Hee-Chung Kang

Continuity of ambulatory care and health outcomes in adult patients with type 2 diabetes in Korea.

OBJECTIVES Continuity of ambulatory care in chronic disease affects the quality of care and the efficiency of healthcare spending. We assessed the relationship between initial continuity of ambulatory care and subsequent health outcomes (hospitalization, mortality and healthcare costs). METHODS This was a retrospective cohort study of 68,469 patients enrolled in the Korean National Health Insurance Program, who were 20 years of age or older and first diagnosed with type 2 diabetes in 2004. Patients were followed for 4 years using claims data to measure continuity of ambulatory care for the initial 3 years after first diagnosis and to investigate hospitalization, mortality, and healthcare costs in the fourth year of follow-up. RESULTS In the group of patients with COCI<0.4, the risk of hospitalization for all causes was higher (odds ratio: 1.37, 95% CI: 1.28-1.47) and healthcare costs increased (β=0.037, P<0.001) compared with the reference group (COCI=1.0), after adjusting for patient risk factors, such as age, gender, and comorbidity index. CONCLUSIONS Policies that promote a continuing relationship with the same physician seem to enhance the quality of care and the efficiency of spending in the treatment of diabetic patients.

Regional differences in treatment frequency and case-fatality rates in korean patients with acute myocardial infarction using the Korea national health insurance claims database: findings of a large retrospective cohort study.

AbstractIssues regarding healthcare disparity continue to increase in connection with access to quality care for acute myocardial infarction (AMI), even though the case-fatality rate (CFR) continues to decrease.We explored regional variation in AMI CFRs and examined whether the variation was due to disparities in access to quality medical services for AMI patients.A dataset was constructed from the Korea National Health Insurance Claims Database to conduct a retrospective cohort study of 95,616 patients who were admitted to a hospital in Korea from 2003 to 2007 with AMI. Each patient was followed in the claims database for information about treatment after admission or death.The procedure rate decreased as the region went “down” from Seoul to the county level, whereas the AMI CFR increased as the county level as a function of proximity to the county level (30-day AMI CFRs: Seoul, 16.4%; metropolitan areas, 16.2%, cities; 18.8%, counties, 39.4%). Even after adjusting for covariates, an identical regional variation in the odds of patients receiving treatment services and dying was identified. After adjusting for invasive and medical management variables in addition to earlier covariates, the death risk in the counties remained statistically significantly higher than in Seoul; however, the degree of the difference decreased greatly and the significant differences in metropolitan areas and cities disappeared.Policy interventions are needed to increase access to quality AMI care in county-level local areas because regional differences in the AMI CFR are likely caused by differences in the performance of medical and invasive management among the regions of Korea. Additionally, a public education program to increase the awareness of early symptoms and the necessity of visiting the hospital early should be established as the first priority to improve the outcome of AMI patents, especially in county-level local areas.

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

BackgroundWith a greater emphasis on cost containment in many health care systems, it has become common to evaluate each physicians 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.MethodsData 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.ResultsThe exclusion of pharmacy cost lowered agreement between rankings to the lowest level, and differences in case-mix classification also lowered agreement considerably.ConclusionsA 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.

Oral Antihyperglycemic Medication Adherence and Its Associated Factors among Ambulatory Care with Adult Type 2 Diabetes Patients in Korea

Objectives : This study aims to estimate the oral antihyperglycemic medications adherence among ambulatory care with adult type 2 diabetes patients and to identify factors affecting the medication adherence in Korea. Methods : This study used the Korean National Health Insurance Database. Study population was 40,082 patients who were 20 years of age or older and first diagnosed with type 2 diabetes (ICD-10: E11) in 2004. The patients were followed up for two years in order to measure adherence with oral antihyperglycemic medications. The level of medication adherence was measured by the medication possession ratio (MPR). Results : The average MPR in the study population was 49.5%. The appropriate adherence rate (MPR80%) was 29.4% and showed variation according to the characteristics of individual patients. Multiple logistic regression analysis revealed that the odds of appropriate adherence increased with female (OR:1.21, CI:1.14-1.27), older age, increasing ambulatory care visits, health insurance (OR:1.53, CI:1.33-1.76), decreasing ambulatory care providers, using a specialized general hospital as their main attending medical institution (OR:10.08, CI:8.96-11.33), having co-morbidity, using polytherapy (OR:1.07, CI:1.01-1.13). Conclusions : The medications adherence for patient with type 2 diabetes is low in Korea, and shows variation according to the characteristics of patients. For proper management of diabetes, health care policy is expected to be enacted to improve medications adherence continuously. In particular, more intensive management is needed for patients with low medications adherence. Also, health care policy makers need to develop the program to induce health care utilization by a patient to be more concentrated with the same provider.

The effects of the fraud and abuse enforcement program under the National Health Insurance program in Korea.

OBJECTIVE To examine the general deterrence effect of the Korean governments fraud and abuse enforcement program on medical clinics in the country. The effects were evaluated by analyzing the association between the fear of penalty from a potential onsite investigation and the costliness index (CI). METHOD Using a stratified proportional systematic sampling method, 800 out of the 15,443 clinics in Korea that had not had an onsite investigation before June 2007 were selected. Perceived deterrence was measured via face-to-face interviews with the chief doctor of each clinic; these were conducted in July and August 2007. CI was calculated by dividing observed costs by expected costs based on National Health Insurance Claims from January to October 2007. RESULTS Clinics with a high fear of penalty had a significantly lower CI than did other clinics after adjusting for factors related to the providers perception of onsite investigation, the providers service experiences, and general characteristics such as providers sex and age. CONCLUSION Designing effective fraud and abuse control programs can improve the efficiency of providing services to patients.

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

AbstractEvidence 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.

The Variation of HbA1c Examination Performance Rates among Diabetic Patients Using Ambulatory Care in South Korea

Background: The appropriate management of diabetes mellitus(DM) can help reduce its relapse and economic burden, but the level of management of DM in Korea is reported to be insufficient. This study aims to identify the management level of DM by figuring out the HbA1c examination performance rate of the diabetics and analyzing the variation according to the characteristic of a diabetic. Methods: This study used the Korean National Health Insurance Database which includes E10-14(ICD-10 code) as a primary or secondary disease as of 2006. Study population is 1,892,062 diabetics excluding 393,784 patients with the first attack of DM in 2006, 33,440 diabetics who died in 2006, and 21,299 patients with DM having no record of ambulatory care among the 2,340,585 DM patients in total. Results: The HbA1c examination performance rate of all DM patients in our country is estimated to be 41.5% as of 2006 and shows variation according to the characteristic of individual DM patients. The highest performance odds was shown by the patients who were below 19 of age, insured for health insurance, attended more than 3 ambulatory care providers, made ambulatory care visits more than 10 times annually, attended a specialized general hospital as their main attending medical institution, had a record of hospitalization or had co-morbidity. Conclusion: This study propose that is necessary to make politic preparations for the appropriate management of diabetes at a national level, and particularly, the patients with advanced age, the ones dependent on Medical Aid, and the ones using hospitals or clinics, whose appropriate management seems vulnerable, demand a careful management.

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.

Development of Peer-Group-Classification Criteria for the Comparison of Cost Efficiency among General Hospitals under the Korean NHI Program

OBJECTIVES To classify general hospitals into homogeneous systematic-risk groups in order to compare cost efficiency and propose peer-group-classification criteria. DATA SOURCES Health care institution registration data and inpatient-episode-based claims data submitted by the Korea National Health Insurance system to the Health Insurance Review and Assessment Service from July 2007 to December 2009. STUDY DESIGN Cluster analysis was performed to classify general hospitals into peer groups based on similarities in hospital characteristics, case mix complexity, and service-distribution characteristics. Classification criteria reflecting clustering were developed. To test whether the new peer groups better adjusted for differences in systematic risks among peer groups, we compared the R(2) statistics of the current and proposed peer groups according to total variations in medical costs per episode and case mix indices influencing the cost efficiency. DATA COLLECTION A total of 1,236,471 inpatient episodes were constructed for 222 general hospitals in 2008. PRINCIPAL FINDINGS New criteria were developed to classify general hospitals into three peer groups (large general hospitals, small and medium general hospitals treating severe cases, and small and medium general hospitals) according to size and case mix index. CONCLUSIONS This study provides information about using peer grouping to enhance fairness in the performance assessment of health care providers.

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

Abstract 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.