Relationship between continuity of ambulatory care and medication adherence in adult patients with type 2 diabetes in Korea: a longitudinal analysis.

BACKGROUND: Medication adherence is the most important factor in the proper management of patients with diabetes. Considering the importance of informational continuity in a changing world, it could be meaningful to improve institution-level continuity of care and its positive relationship with medication adherence. OBJECTIVES: We examined the relationship between institution-level continuity of ambulatory care and medication adherence in adult patients with type 2 diabetes receiving a new hypoglycemic prescription and sought to determine whether an improvement in medication adherence could be achieved through an ongoing relationship between the patient and the medical care institution. RESEARCH DESIGN AND SUBJECTS: This was a longitudinal study of 23,034 patients aged 20 years and older enrolled in the Korea National Health Insurance (KNHI) program and first diagnosed with type 2 diabetes in 2004. The patients were followed-up for 4 years using claims data to measure continuity of ambulatory care and adherence to oral antihyperglycemic medications. The Continuity of Care Index (COCI) was calculated on the institution level as a measure of continuity and the medication possession ratio (MPR) was used as a measure of adherence. RESULTS: After adjusting for confounding variables, the odds of being medication adherent (MPR ≥ 0.8) increased as the COCI increased [0.2≤COCI<0.4, odds ratio (OR)=2.20; 0.4≤COCI<0.6, OR=3.46; 0.6≤COCI<0.8, OR=4.76; 0.8≤COCI<1.0, OR=4.43; COCI=1.0, OR=7.24]. CONCLUSIONS: Institution-level continuity of ambulatory care was positively associated with medication adherence, which suggested that a high concentration of ambulatory care visits, whether it's a physician or an institution, could facilitate delivery of proper medical services to and increases medication adherence among patients with type 2 diabetes, and that institution-level continuity of ambulatory care could be an effective index for assessing the quality of chronic care in the fragmented health care delivery system as in Korea.

Agent Orange exposure and disease prevalence in Korean Vietnam veterans: the Korean veterans health study.

Between 1961 and 1971, military herbicides were used by the United States and allied forces for military purposes. Agent Orange, the most-used herbicide, was a mixture of 2,4-dichlorophenoxyacetic acid (2,4-D) and 2,4,5-trichlorophenoxyacetic acid, and contained an impurity of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Many Korean Vietnam veterans were exposed to Agent Orange during the Vietnam War. The aim of this study was to evaluate the association between Agent Orange exposure and the prevalence of diseases of the endocrine, nervous, circulatory, respiratory, and digestive systems. The Agent Orange exposure was assessed by a geographic information system-based model. A total of 111,726 Korean Vietnam veterans were analyzed for prevalence using the Korea National Health Insurance claims data from January 2000 to September 2005. After adjusting for covariates, the high exposure group had modestly elevated odds ratios (ORs) for endocrine diseases combined and neurologic diseases combined. The adjusted ORs were significantly higher in the high exposure group than in the low exposure group for hypothyroidism (OR=1.13), autoimmune thyroiditis (OR=1.93), diabetes mellitus (OR=1.04), other endocrine gland disorders including pituitary gland disorders (OR=1.43), amyloidosis (OR=3.02), systemic atrophies affecting the nervous system including spinal muscular atrophy (OR=1.27), Alzheimer disease (OR=1.64), peripheral polyneuropathies (OR=1.09), angina pectoris (OR=1.04), stroke (OR=1.09), chronic obstructive pulmonary diseases (COPD) including chronic bronchitis (OR=1.05) and bronchiectasis (OR=1.16), asthma (OR=1.04), peptic ulcer (OR=1.03), and liver cirrhosis (OR=1.08). In conclusion, Agent Orange exposure increased the prevalence of endocrine disorders, especially in the thyroid and pituitary gland; various neurologic diseases; COPD; and liver cirrhosis. Overall, this study suggests that Agent Orange/2,4-D/TCDD exposure several decades earlier may increase morbidity from various diseases, some of which have rarely been explored in previous epidemiologic studies.

Seasonal variation in case fatality rate in Korean patients with acute myocardial infarction using the 1997-2006 Korean National Health Insurance Claims Database.

OBJECTIVE: Seasonal and monthly variation in the occurrence and case fatality rate (CFR) of acute myocardial infarction (AMI) have been reported. We examined the seasonal variation in hospital admissions and CFR in Korean patients with AMI, and analysed the influence of season on fatality risk for AMI. METHODS: We used the 10-year administrative database of the Korean National Health Insurance covering the entire population of Korea. The data included 265,935 AMI events that occurred in 228,601 patients who were admitted to hospitals across Korea from 1997-2006. RESULTS: Hospital admissions and CFR for AMI were highest in winter and lowest in summer. The fatality risk for AMI was significantly higher in spring (odds ratio [OR]: 1.06, confidence interval [CI]: 1.02-1.10), autumn (OR: 1.08, CI:1.04-1.12), and winter (OR: 1.11, CI:1.07-1.15) than in summer. Interestingly, among the summer months, the fatality risk for men was higher in August (OR: 1.10, CI: 1.01-1.19) than in June. CONCLUSIONS: Our findings support the hypothesis that AMI may be triggered by events external to atherosclerotic plaques. This seasonal evidence supports the idea that a disease forecast system may be developed using temperature information in Korea.

Regular HbA1c examination and health outcomes in adult patients with type 2 diabetes in South Korea: A retrospective cohort study.

Concerns have been raised about the effectiveness of using process-centered indicators to assess the quality of diabetes care in Korea. This study aims to examine the factors influencing the performance of regular HbA1c testing and to explore its association with health outcomes, including hospitalization and mortality. We utilized a retrospective cohort design with a 4-year follow-up period, involving 159,452 adult patients newly diagnosed with type 2 diabetes (E11 in International Classification of Diseases, 10th Edition) in 2011. We established a national population database by merging the Korea National Health Insurance (KNHI) claims database and the KNHI Qualification Database of South Korea. The proportion of diabetic patients who underwent regular HbA1c testing at least once a year in the first 3 years was determined to be 33.8%. In comparison, patients who did not receive regular tests during the same period exhibited significantly increased odds of hospitalization (diabetes/CVD/renal, OR, 1.23, 95% CI, 1.12-1.34; diabetes, OR, 1.36, 95% CI, 1.17-1.57). Additionally, this nonpatient group experienced a higher risk of mortality (OR: 1.56, 95% CI: 1.36-1.80). This study supports the positive impact of regular HbA1c testing on health outcomes for individuals with type 2 diabetes. To increase the current 33% rate of regular HbA1c testing, developing patient-customized management policies is essential. Priority should be given to diabetic patients aged 65 or older, living in rural areas, and those belonging to low-income families (medical aid).

Relationship between the use of new or used computed tomography scanners and image retake rates in South Korea.

BACKGROUND: The use of high-cost imaging has increased worldwide, contributing to increased healthcare expenditures. Without proper quality verification, the installation of used imaging equipment may lead to wasteful increases in cost due to ineffective and poor-quality imaging that requires repeat scans. PURPOSE: To examine the relationship between the use of new or used computed tomography (CT) scanners and image retake rates to evaluate the comparative quality of used and new CT scanners. MATERIAL AND METHODS: This was a retrospective cohort study of patients who first underwent CT from January 1 to June 30, 2008 (n = 258,572). Data were obtained by linking the Health Care Institution Registration Data with the Korean National Health Insurance Claims Database. Image retake rates within 30, 60, 90, and 180 days after the first CT scan were calculated, and differences in the image retake rate by new versus used CT scanners were assessed. RESULTS: After adjusting for confounders, use of a used CT scanner for the first scan increased the odds of retake within 30 days (odds ratio [OR]: 1.34, 95% confidence interval [CI]: 1.22-1.48), 60 days (OR: 1.59, 95% CI: 1.47-1.72), 90 days (OR: 1.48, 95% CI: 1.38-1.59), and 180 days (OR: 1.38, 95% CI: 1.30-1.46) compared with use of a new CT scanner. Such results were evident in scans of the spine, abdomen, chest, and face or skull base. CONCLUSION: The quality control associated with import of used CT scanners should be improved. Moreover, regular and detailed quality inspections of used CT scanners currently operating in healthcare institutions are necessary.

Comparison of Health Outcomes by Care Provider Type for Newly Diagnosed Mild Type 2 Diabetes Patients in South Korea: A Retrospective Cohort Study.

(1) Background: Although the beneficial impacts of primary care on patients' health outcomes have been reported, it is still difficult to limit patients' herd behavior in seeking tertiary or large hospital services in South Korea. The purpose of this study was to examine whether the use of primary care clinics was longitudinally beneficial for mild diabetes. (2) Methods: Using claims data from the National Health Insurance (NHI) program, this population-based retrospective cohort study compared health outcomes over a 4-year period from 2011 to 2015 by type of health care institution as a usual source of care in diabetic patients who were newly diagnosed in 2011, i.e., without any diagnosis between 2005 and 2010. (3) Results: Compared to those attending hospitals, general hospitals (GHs), or tertiary general hospitals (TGHs), patients who visited primary clinics were more likely to experience better health outcomes such as the lower risk of hospitalization and death. (4) Conclusions: These results provide additional evidence that higher-value from primary care clinics would be highly expected for early and mild type 2 diabetics. Promoting the Informed, patient-centered decision toward primary care clinics would contribute to improving the value of the healthcare delivery system.

Body mass index and all-cause mortality in patients with newly diagnosed type 2 diabetes mellitus in South Korea: a retrospective cohort study.

OBJECTIVES: The lower risk of death in overweight or obese patients, compared with normal-weight individuals, has caused confusion for patients with diabetes and healthcare providers. This study investigated the relationship between body mass index (BMI) and mortality in patients with type 2 diabetes. DESIGN: A retrospective cohort study. SETTING: We established a national population database by merging the Korea National Health Insurance (KNHI) claims database, the National Health Check-ups Database and the KNHI Qualification Database of South Korea. PARTICIPANTS: A total of 53 988 patients who were newly diagnosed with type 2 diabetes (E11 in International Classification of Diseases, 10th Edition) in 2007, had available BMI data, lacked a history of any serious comorbidity, received diabetes medication and did not die during the first 2 years were followed up for a median of 8.6 years. PRIMARY OUTCOME MEASURES: All-cause mortality. RESULTS: The mean BMI was 25.2 (SD 3.24) kg/m2, and the largest proportion of patients (29.4%) had a BMI of 25-27.4 kg/m2. Compared with a BMI of 27.5-29.9 kg/m2 (the reference), mortality risk continuously increased as BMI decreased while the BMI score was under 25 (BMI <18.5 kg/m2: adjusted HR (aHR) 2.71, 95% CI 2.24 to 3.27; BMI 18.5-20.9 kg/m2: aHR 1.94, 95% CI 1.70 to 2.22; BMI 21-22.9 kg/m2: aHR 1.51, 95% CI 1.34 to 1.70; and BMI 23-24.9 kg/m2: aHR 1.14, 95% CI 1.01 to 1.28). For patients aged ≥65 years, the inverse association was connected up to a BMI ≥30 kg/m2 group (aHR 0.76, 95% CI 0.59 to 0.98). However, the associations for men, patients aged <65 years and ever smokers resembled a reverse J curve, with a significantly greater risk of death in patients with a BMI ≥30 kg/m2. CONCLUSIONS: This study suggests that, for patients with type 2 diabetes at a normal weight, distinct approaches are needed in terms of promoting muscle mass improvement or cardiorespiratory fitness, rather than maintaining weight status. Improved early diagnosis considering the inverse association between BMI and mortality is also needed.

Relationship between oral antihyperglycemic medication adherence and hospitalization, mortality, and healthcare costs in adult ambulatory care patients with type 2 diabetes in South Korea.

BACKGROUND: Medication adherence has been identified as a major factor influencing health outcomes in patients with type 2 diabetes. OBJECTIVES: We assessed the relationship between initial adherence to oral antihyperglycemic medications and subsequent health outcomes. RESEARCH DESIGN AND SUBJECTS: This was a retrospective cohort study of 40,082 patients enrolled in Korea's national health insurance program, who were 20 years of age or older and first diagnosed with type 2 diabetes in 2004. The patients were followed up for 3 years using claims data to measure adherence to oral antihyperglycemic medications for the initial 2 years after diagnosis and to investigate hospitalization, mortality, and healthcare costs in the third year of follow-up. RESULTS: After adjusting for confounders, nonadherence in the first 2 years after prescription increased the risk for hospitalization in the third year compared with adherence over the same period [odds ratio (OR)=1.26, 95% confidence interval=1.08-1.47]. Nonadherence in at least one of the 2 years increased the risk for hospitalization compared with adherence in both years. In addition, nonadherence during both the first and second years was associated with statistically significantly greater risks for mortality during this period than was adherence (odds ratio=1.40, 95% confidence interval=1.01-1.95). Medication adherence decreased healthcare costs compared with nonadherence (ß=-0.127; P<0.001). CONCLUSIONS: Because improved medication adherence can produce better health outcomes for diabetes patients and also save national healthcare resources, government-sponsored healthcare policies to improve medication adherence among newly diagnosed diabetes patients are urgently required.

Do differences in profiling criteria bias performance measurements? Economic profiling of medical clinics under the Korea National Health Insurance program: an observational study using claims data.

BACKGROUND: With a greater emphasis on cost containment in many health care systems, it has become common to evaluate each physician's relative resource use. This study explored the major factors that influence the economic performance rankings of medical clinics in the Korea National Health Insurance (NHI) program by assessing the consistency between cost-efficiency indices constructed using different profiling criteria. METHODS: Data on medical care benefit costs for outpatient care at medical clinics nationwide were collected from the NHI claims database. We calculated eight types of cost-efficiency index with different profiling criteria for each medical clinic and investigated the agreement between the decile rankings of each index pair using the weighted kappa statistic. RESULTS: The exclusion of pharmacy cost lowered agreement between rankings to the lowest level, and differences in case-mix classification also lowered agreement considerably. CONCLUSIONS: A medical clinic may be identified as either cost-efficient or cost-inefficient, even when using the same index, depending on the profiling criteria applied. Whether a country has a single insurance or a multiple-insurer system, it is very important to have standardized profiling criteria for the consolidated management of health care costs.

Comparison of case fatality rates for acute myocardial infarction in weekday vs weekend admissions in South Korea.

BACKGROUND: According to recent reports, reduced weekend staffing in hospitals may lead to a lower intensity of management of patients with acute conditions such as acute myocardial infarction (AMI). The present study evaluated differences in the case fatality rate of Korean patients admitted with AMI on weekdays vs those admitted on weekends. METHODS AND RESULTS: The dataset was constructed from the Korea National Health Insurance Claims Database. The study population was 97,466 patients who were admitted to a hospital in Korea from 2003 to 2007 with AMI. Patients admitted on weekends had a higher 30-day fatality rate (20.1% vs 17.3%) than did those admitted on weekdays. Differences in the 30-day fatality rate were significant after adjusting for baseline characteristics and the severity of disease (odds ratio (OR), 1.21; 95% confidence interval (CI), 1.16-1.26). However, the 30-day fatality rate was insignificantly different after additional adjustment for medical or invasive management (OR 1.05; 95%CI 0.99-1.11). CONCLUSIONS: Differences in the case fatality rate of AMI patients admitted on weekdays and on weekends in Korea are caused by differences in the rate of performance of medical or invasive procedures.

Continuity of care for elderly patients with diabetes mellitus, hypertension, asthma, and chronic obstructive pulmonary disease in Korea.

We sought to assess continuity of care for elderly patients in Korea and to examine any association between continuity of care and health outcomes (hospitalization, emergency department visits, health care costs). This was a retrospective cohort study using the Korea National Health Insurance Claims Database. Elderly people, 65-84 yr of age, who were first diagnosed with diabetes mellitus (n=268,220), hypertension (n=858,927), asthma (n=129,550), or chronic obstructive pulmonary disease (COPD, n=131,512) in 2002 were followed up for four years, until 2006. The mean of the Continuity of Care Index was 0.735 for hypertension, 0.709 for diabetes mellitus, 0.700 for COPD, and 0.663 for asthma. As continuity of care increased, in all four diseases, the risks of hospitalization and emergency department visits decreased, as did health care costs. In the Korean health care system, elderly patients with greater continuity of care with health care providers had lower risks of hospital and emergency department use and lower health care costs. In conclusion, policy makers need to develop and try actively the program to improve the continuity of care in elderly patients with chronic diseases.

Association between years since manufacture and utilization of computed tomography scanner in South Korea: A cross-sectional study (a STROBE-compliant article).

Health care institutions that acquire an expensive, brand-new computed tomography (CT) scanner are likely to perform excessive scanning in an attempt to recover their investment as early as possible. We examined the association between the age of CT scanners and the number of CT scans at small-sized hospitals and clinics in Korea and assessed the notable increase in scanning quantity at health care institutions with a recently manufactured CT scanner.A cross-sectional study designed to analyze whether the age of CT scanners was associated with the number of scans at small-sized hospitals and clinics that were operating a CT scanner for the full year 2008 (n = 703). Data were obtained by linking the National Health Insurance Claims Database and Health Care Institution Statistics.A multiple regression analysis found that the older a CT scanner was, the fewer CT scans were performed in terms of annual total (ß = -34.8; P < .001) and patient average (ß = -0.0018; P = <.001).Health care institutions with newer CT scanners administered more CT scans in terms of annual total and scans per patient. Because this may indicate the practice of excessive scanning with newly acquired equipment, it is necessary to have a system of regularly monitoring the quantity and retake rate of CT scanning in these health care institutions so as to prevent unnecessary use of CT.

Body mass index and mortality in South Korean men resulting from cardiovascular disease: a Kangwha cohort study.

PURPOSE: The purpose of this study was to examine the association of body mass index (BMI) with death caused by total cardiovascular disease in a long-term follow-up study. METHODS: We followed a total of 2608 men who were 55 years or older in 1985 from March 1985 through December 2001 to investigate their mortality. The hazard ratios of mortality as the result of cardiovascular disease by BMI level were estimated with the Cox proportional hazards model, adjusting for relevant covariates. RESULTS: For the group with a BMI >/= 27 kg/m(2) compared with the reference group (BMI, 21.0-22.9), the adjusted hazard ratio of death resulting from total cardiovascular disease was 2.4 (95% confidence interval [CI], 1.5-3.9) and that of death resulting from cerebrovascular disease was 3.6 (95% CI, 2.0-6.3). Observing nonsmoking subjects only, the BMI <18.5 kg/m(2) group had a 4.6 times (95% CI, 1.8-11.8) greater risk of death attributed to total cardiovascular disease than the reference group and a 4.7 times (95% CI, 1.4-16.2) greater risk of death from cerebrovascular disease. CONCLUSION: This study defined that BMI is related to Korean male deaths caused by total cardiovascular disease. The risk of death attributed to total cardiovascular disease and cerebrovascular disease was significantly increased in the group, with a BMI >/=27 kg/m(2). In our study, in the case of nonsmokers, low BMI was shown to be related to deaths from cardiovascular disease. Such result is different from those of previous studies.

Age at menopause and cause-specific mortality in South Korean women: Kangwha Cohort Study.

OBJECTIVE: The purpose of this study was to examine the relation between age at natural menopause and all-cause and cause-specific mortality among women. METHODS: This study used the data of the Kangwha Cohort that was followed up from 1985 to 2001, in particular, for the group of 55 years or older women (n=2658). We calculated the hazard ratio of mortality by the group of age at menopause using the Cox proportional hazards model with adjustment for age, alcohol consumption, education, age at first birth, self-cognitive health level, chronic disease, marital partner, parity, age at menarche, oral contraceptive use and hypertension. RESULTS: The mean (standard deviation) age at menopause was 46.9 (4.9) years, and the median age was 48 years. After adjusting for the relevant variables, the risk of total death in the early menopause group (<40 years at menopause) was 1.32 times higher than that of the reference group (45-49 years at menopause) (95% confidence interval [CI], 1.05-1.66, p=0.02). For the early menopause group, relative to the reference group, the adjusted hazard ratios of death due to cardiovascular disease and cancer were 1.53 (95% CI, 1.00-2.39, p=0.04) and 2.01 (95% CI, 1.06-3.82, p=0.03), respectively. CONCLUSION: Through this study, the age at menopause was found to be different between Asian and Caucasian women and the association of age at menopause with death, particularly caused by cardiovascular disease and cancer, was validated. Our study is one of rare studies regarding the age at menopause of Asian women and their risk of mortality, which could be considered to be meaningful.

Association between costs and quality of acute myocardial infarction care hospitals under the Korea National Health Insurance program.

If cost reductions produce a cost-quality trade-off, healthcare policy makers need to be more circumspect about the use of cost-effective initiatives. Additional empirical evidence about the relationship between cost and quality is needed to design a value-based payment system. We examined the association between cost and quality performances for acute myocardial infarction (AMI) care at the hospital level.In 2008, this cross-sectional study examined 69 hospitals with 6599 patients hospitalized under the Korea National Health Insurance (KNHI) program. We separately estimated hospital-specific effects on cost and quality using the fixed effect models adjusting for average patient risk. The analysis examined the association between the estimated hospital effects against the treatment cost and quality. All hospitals were distributed over the 4 cost × quality quadrants rather than concentrated in only the trade-off quadrants (i.e., above-average cost and above-average quality, below-average cost and below-average quality). We found no significant trade-off between cost and quality among hospitals providing AMI care in Korea.Our results further contribute to formulating a rationale for value-based hospital-level incentive programs by supporting the necessity of different approaches depending on the quality location of a hospital in these 4 quadrants.

Impact of alcohol consumption and body mass index on mortality from nonneoplastic liver diseases, upper aerodigestive tract cancers, and alcohol use disorders in Korean older middle-aged men: Prospective cohort study.

Alcohol use is a leading risk factor for the global disease burden including liver diseases. However, the combined effect of alcohol use and body mass index (BMI) on alcohol-related diseases has seldom been examined. We examined whether alcohol consumption and BMI could act together to increase mortality from nonneoplastic liver diseases, upper aero-digestive tract (UADT) cancers, and alcohol use disorders (AUD) in middle-aged Korean men.107,735 men (mean age, 58.8 years) participated in a postal survey in 2004 and were followed until 2010, by linkage to national death records. Hazard ratios (HRs) of cause-specific death were calculated after adjustment for confounders.Each 5-drink (approximately 45 g alcohol) higher weekly alcohol consumption was associated with increased mortality, by approximately 70% for nonneoplastic liver disease mortality (HR = 1.70, P < 0.001), approximately 60% for UADT cancer mortality (HR = 1.64, P < 0.001), and approximately 70% for AUD mortality (HR = 1.71, P < 0.001). Generally, BMI was inversely associated with these alcohol-related diseases (HR per each 5 kg/m higher BMI = 0.18-0.46, P < 0.001 for each cause), while, in participants with BMI ≥25 kg/m, each 5 kg/m higher BMI was also associated with an elevated mortality from nonneoplastic liver diseases of approximately 150% (HR = 2.52, P = 0.001). Men with BMI < 21 kg/m and weekly alcohol consumption ≥14 drinks showed markedly higher mortality from nonneoplastic liver diseases (HR = 5.7), alcoholic liver diseases (HR = 9.3), UADT cancers (HR = 10.5), and esophageal cancer (HR = 15.5), compared to men drinking less than 1 drink/wk with BMI ≥25 kg/m. The combined effect of low BMI and high weekly alcohol consumption was 2.25- to 3.29-fold greater than the additive effect of each factor for these alcohol-related diseases (P < 0.05 for each cause).Alcohol consumption and low BMI were related to deaths from nonneoplastic liver diseases, UADT cancers, and AUD, with evidence of a supra-additive combined effect of both factors. High BMI was also related to deaths from nonneoplastic liver diseases. Men with a low BMI (<23 kg/m) are suggested to be prone to the harmful effects of alcohol.

Body Mass Index and Cancer Mortality Among Korean Older Middle-Aged Men: A Prospective Cohort Study.

The association of body mass index (BMI; kg/m) with overall and site-specific cancer mortality in Asians is not well understood. A total of 113,478 men from the Korean Veterans Health Study who returned a postal survey in 2004 were followed up until 2010. The adjusted hazard ratios (HRs) of cancer mortality were calculated using a Cox model. During 6.4 years of follow-up, 3478 men died from cancer. A reverse J-curve association with a nadir at 25.0 to 27.4 kg/m was observed. Below 25 kg/m, the HRs of death for each 5 kg/m decrease in BMI were 1.72 (95% confidence interval = 1.57-1.90) for overall cancer; 3.63 (2.57-5.12) for upper aerodigestive tract (UADT) cancers, including oral cavity and larynx [HR = 4.21 (2.18-8.12)] and esophagus [HR = 2.96 (1.82-4.81)] cancers; 1.52 (1.35-1.71) for non-UADT and non-lung cancers, including stomach [HR = 2.72 (2.13-3.48)] and large intestine [HR = 1.68 (1.20-2.36)] cancers; and 1.93 (1.59-2.34) for lung cancer. In the range of 25 to 47 kg/m, the HRs for each 5 kg/m increase in BMI were 1.27 (1.03-1.56) for overall cancer mortality and 1.57 (1.02-2.43) for lung cancer mortality. In individuals <25 kg/m, inverse associations with mortality from overall cancer and non-UADT and non-lung cancer were stronger in never-smokers than in current smokers. Both low and high BMI were strong predictors of mortality from overall and several site-specific cancers in Korean men. Further research is needed to evaluate whether interventions involving weight change (loss or gain) reduce the risk of cancer or improve the survival.

Sex Differences in the Treatment and Outcome of Korean Patients With Acute Myocardial Infarction Using the Korean National Health Insurance Claims Database.

Evidence showing higher acute myocardial infarction (AMI) mortality rates among female compared with male inpatients has stimulated interest in whether this disparity is the result of biological factors or differences in the provision of healthcare services. We investigated the impact of sex on in-hospital mortality rates due to AMI, and evaluated the contribution of differences in the delivery of optimal medical services for AMI.We retrospectively constructed a dataset of 85,329 new patients admitted to Korean hospitals with AMI between 2003 and 2007 from the Korea National Health Insurance Claims Database. We used the claims database to provide information about treatment after admission or death for each patient.Proportionally more female than male patients aged 65 years or older had complications; however, proportionally fewer female patients underwent invasive procedures. Female patients had a higher in-hospital mortality rate than males (21.2% vs 14.6%, odds ratio [OR] 1.58, 95% confidence interval [CI] 1.52-1.64). The probability of death within 30 days after admission remained higher for females than males after adjusting for demographic characteristics and severity (OR 1.08, 95% CI 1.04-1.13). After additionally adjusting for invasive and medical management, the probability of death within 30 days did not differ between males and females (OR 1.04, 95% CI 0.99-1.08). A similar trend was revealed by an additional analysis of patients according to younger (<65 years) and older (≥65 years) age groups.The higher in-hospital mortality rates after AMI in Korean female patients was associated with a lower procedure rate. Evidence indicating that AMI symptoms differ according to sex highlights the need for health policies and public education programs that raise awareness of sex-related differences in early AMI symptoms to increase the incidence of appropriate early treatment in females.

Depressive symptoms and other risk factors predicting suicide in middle-aged men: a prospective cohort study among Korean Vietnam War veterans.

Background. Few studies have prospectively examined whether depressive symptoms and other risk factors are associated with a higher risk of suicide death in individuals other than high-risk populations such as psychiatric patients and individuals with self-harm histories. The purpose of the study is to prospectively examine whether depressive symptoms assessed by the Beck Depression Inventory (BDI) are associated with greater risk of suicide death and whether depressive symptoms and other risk factors are independent predictors of suicide in general-risk populations. Another aim is to evaluate the sensitivity of the BDI for predicting suicide death. Methods. 10,238 Korean Vietnam War veterans (mean age: 56.3 years) who participated in two surveys in 2001 were followed up for suicide mortality over 7.5 years. Results. 41 men died by suicide. Severely depressed participants had a higher adjusted hazard ratio (aHR = 3.4; 95% CI [1.5-7.7]) of suicide than non-to-moderately depressed ones. Higher suicide risk was associated with more severe depressive symptoms (p for trend = 0.009). After adjustment for depressive symptoms and other factors, very poor health, low education, and past drinking were associated with higher suicide risk, while good health, body mass index, and marital status were not associated with suicide. The sensitivity at the cut-off score of 31 for detecting suicide was higher during the earlier 3.5 years of the follow-up (75%; 95% CI [50-90]) than during the latter 4 years (60%; 95% CI [41-76]). Conclusions. Depressive symptoms are a strong independent predictor and very poor health, low education, and drinking status may be independent predictors of future suicide. The BDI may have acceptable diagnostic properties as a risk assessment tool for identifying people with depression and suicidal potential among middle-aged men.

Body mass index and mortality among Korean elderly in rural communities: Kangwha Cohort Study.

BACKGROUND: The relationship between body mass index (BMI) and mortality may differ by ethnicity, but its exact nature remains unclear among Koreans. The study aim was to prospectively examine the association between BMI and mortality in Korean. METHODS: 6166 residents (2636 men; 3530 women) of rural communities (Kangwha County, Republic of Korea) aged 55 and above were followed up for deaths from 1985-2008. The multivariable-adjusted hazard ratios were calculated using the Cox proportional hazards model. RESULTS: During the 23.8 years of follow-up (an average of 12.5 years in men and 15.7 years in women), 2174 men and 2372 women died. Men with BMI of 21.0-27.4 and women with BMI of 20.0-27.4 had a minimal risk for all-cause mortality. A lower BMI as well as a higher BMI increased the hazard ratio of death. For example, multivariable-adjusted hazard ratios associated with BMI below 16, and with BMI of 27.5 and above, were 2.4 (95% CI = 1.6-3.5) and 1.5 (95% CI = 1.1-1.9) respectively, in men, compared to those with BMI of 23.0-24.9. This reverse J-curve association was maintained among never smokers, and among people with no known chronic diseases. Higher BMI increased vascular mortality, while lower BMI increased deaths from vascular diseases, cancers, and, especially, respiratory diseases. Except for cancers, these associations were generally weaker in women than in men. CONCLUSIONS: A reverse J-curve association between BMI and all-cause mortality may exist. BMI of 21-27.4 (rather than the range suggested by WHO of 18.5-23 for Asians) may be considered a normal range with acceptable risk in Koreans aged 55 and above, and may be used as cut points for interventions. More concern should be given to people with BMI above and below a BMI range with acceptable risk. Further studies are needed to determine ethnicity-specific associations.