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Almost all preference-based measures (PBMs) have been developed in Western countries, with none having been formulated in Asian countries. In this study, we construct a new generic PBM based on concept elicitation using interview surveys in East and Southeast Asian countries and qualitative analysis.This cross-sectional study included 225 adults recruited from 9 East and Southeast Asian countries or regions (Indonesia, Japan, Korea, mainland China, Malaysia, the Philippines, Singapore, Taiwan, and Thailand). Trained interviewers conducted semistructured interviews with 25 participants from the general population of each country/region. Qualitative data were analyzed using a content analysis approach. The selection of items was determined based on interview surveys and team member discussions. The description of items was considered based on a detailed qualitative analysis of the interview survey.A new region-specific PBM-the Asia PBM 7 dimensions instrument-was designed. It reflects East and Southeast Asian values and comprises 7 items: pain, mental health, energy, mobility, work/school, interpersonal interactions, and burden to others.The new region-specific instrument is one of the first PBMs developed in the context of non-Western countries. The Asia PBM 7 dimensions contains 7 items that address the core concepts of health-related quality of life that are deemed important based on East and Southeast Asian health concepts.

Background: We aimed to verify the validity of the proportional recovery model for the lower extremity. Methods: We reviewed clinical data of patients enrolled in the Korean Stroke Cohort for Functioning and Rehabilitation between August 2012 and May 2015. Recovery proportion was calculated as the amount of motor recovery over initial motor impairment, measured as the Fugl-Meyer Assessment of Lower Extremity score. We used the logistic regression method to model the probability of achieving the full Fugl-Meyer Assessment of Lower Extremity score, whereby we considered the ceiling effect of the score. To show the difference in the prevalence of achieving the full Fugl-Meyer Assessment of Lower Extremity score between 3 and 6 months poststroke, we constructed a marginal model through the generalized estimating equation method. We also performed the propensity score matching analysis to show the dependency of recovery proportion on the initial motor deficit at 3 and 6 months poststroke. Results: We evaluated 1085 patients. The recovery proportions at 3 and 6 months poststroke were 0.67±0.42 and 0.75±0.39, respectively. A 1-unit decrease in the initial neurological impairment and the age at stroke onset increased the probability of achieving the full Fugl-Meyer Assessment of Lower Extremity score, which occurred at both 3 and 6 months poststroke. The prevalence of those who reach full lower limb motor recovery differs significantly between 3 and 6 months poststroke. We also found out that the recovery proportion at both 3 and 6 months poststroke is determined by the initial motor deficits of the lower limb. These results are not consistent with the proportional recovery model. Conclusions: Our results demonstrated that the proportional recovery model for the lower limb is invalid.

Background: The International Classification of Primary Care-2 (ICPC-2) is a classification method designed for primary care. Although previous studies have found that ICPC-2 is a useful tool for demonstrating the relationship between patients’ expectations and health providers’ diagnoses, its utility of ICPC-2 has yet to be fully studied in Korea. This study aimed to evaluate the practicality of ICPC-2 in Korean primary care.Methods: The study was conducted at primary care clinics in Seoul and Gyeonggi areas from October to November 2015. Third-year family medicine residents examined and analyzed the medical records of patients who visited primary care physicians using ICPC-2, and the results were compared with those obtained using the International Classification of Diseases-10 (ICD-10) (Korean version: Korean Standard Classification of Diseases-7).Results: A total of 26 primary care physicians from 23 primary care clinics participated in the study. Furthermore, 2,458 ICD-10 codes and 6,091 ICPC-2 codes were recorded from the data of 1,099 patients. The common disease codes were vasomotor and allergic rhinitis (J30), according to ICD-10, and acute upper respiratory infection (R74) in ICPC-2. Comparing disease status by body systems, the proportion of gastrointestinal disease with ICD-10 codes was significantly higher than that with ICPC-2 codes (P4 diagnoses accounted for 36% of the ICD-10 classifications, whereas those with >4 diagnoses accounted for 4% of the ICPC-2 classifications.Conclusion: Introducing ICPC as a complementary means for diagnosing common diseases could be a practical approach in Korean primary care.

Introduction Many countries have established their own EQ-5D value sets proceeding on the basis that health preferences differ among countries/populations. So far, published studies focused on comparing value set using TTO data. This study aims to compare the health preferences among 11 Asian populations using the DCE data collected in their EQ-5D-5L valuation studies. Methods In the EQ-VT protocol, 196 pairs of EQ-5D-5L health states were valued by a general population sample using DCE method for all studies. DCE data were obtained from the study PI. To understand how the health preferences are different/similar with each other, the following analyses were done: (1) the statistical difference between the coefficients; (2) the relative importance of the five EQ-5D dimensions; (3) the relative importance of the response levels. Results The number of statistically differed coefficients between two studies ranged from 2 to 16 (mean: 9.3), out of 20 main effects coefficients. For the relative importance, there is not a universal preference pattern that fits all studies, but with some common characteristics, e.g. mobility is considered the most important; the relative importance of levels are approximately 20% for level 2, 30% for level 3, 70% for level 4 for all studies. Discussion Following a standardized study protocol, there are still considerable differences in the modeling and relative importance results in the EQ-5D-5L DCE data among 11 Asian studies. These findings advocate the use of local value set for calculating health state utility.

The purpose of this study is to identify the factors associated with the burden on primary family caregivers of stroke patients at home without care services. For this study, the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) data were used. Of the total 8010 caregivers, 1133 family caregiver burden was assessed with the shortened Caregiver Burden Inventory (CBI) 3 months after stroke. Patient and caregiver-related factors affecting the heavier burden of caregivers were identified by comparing the heavier caregiver burden group and the lighter caregiver burden group, which divided according to the CBI scores. The 719 (63.5%) family caregiver cared for patients at home without care services. Logistic regression analysis showed that four or more comorbidities (p = 0.002), neurological impairment at early onset (p < 0.001), dependence on daily life (p < 0.001), aphasia (p = 0.024), and depression(p < 0.001) were associated with a heavier burden of care. According to the shortened CBI, caregivers tended to be concerned more about psychological stress than physical strain. The findings suggest the importance of proactively guiding the emotional support services to caregivers who are at high risk of the heavier burden of patient care.

ImportanceBecause stroke causes diverse functional deficits, understanding the long-term recovery pattern of each functional domain may inform prognosis and therapeutic strategies.ObjectiveTo observe long-term changes in functional status and residual disability in survivors of first-time stroke.Design, Setting, and ParticipantsThis cohort study was an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation. Between August 2012 and May 2015, 7858 of 10 636 screened patients with first-time strokes from 9 district hospitals in Korea provided informed consent to participate. Data were analyzed from September 2021 through February 2022.ExposureFirst-time stroke.Main Outcomes and MeasuresStudy data include multifaceted face-to-face functional assessments obtained at 8 to 9 points until 60 months after stroke onset. The Korean Mini-Mental State Examination (K-MMSE), Fugl-Meyer Assessment, Functional Ambulatory Category, American Speech-Language-Hearing Association National Outcome Measurement System Swallowing Scale, and Short Korean version of the Frenchay Aphasia Screening Test were performed from 7 days to 60 months after stroke. The Korean Modified Barthel Index was measured from 3 months to 60 months after stroke.ResultsA total of 4443 patients (2649 men [59.62%]; mean [SD] age 62.13 [12.43] years) who underwent repeated functional assessments for 60 months after stroke (3508 patients with ischemic and 935 patients with hemorrhagic stroke) were included. Overall, functions plateaued between 12 and 18 months after stroke and declined after 30 months; for example, mean (SD) K-MMSE improved from 7 days (22.89 [7.89]) to 12 months (26.03 [5.48]) (P P P for interaction P for interaction P for interaction P P = .004), and hemorrhagic stroke type (β vs ischemic stroke = 2.35; SE, 0.81; P = .004).Conclusions and RelevanceThis study found that long-term recovery patterns in multifaceted functional domains differed from one another and varied by patient age, stroke severity, and stroke type. Understanding the diversity of long-term functional recovery patterns and factors associated with these outcomes in survivors of stroke may help clinicians develop strategies for effective stroke care and rehabilitation.

COVID-19 vaccination certificates (CVCs) have played a key role in safe reopening of borders for international travel and trade, so understanding key stakeholder perceptions of enablers and barriers for their effective use is critical. The COVID-19 Vaccination Policy Research and Deci-sion-Support Initiative in Asia (CORESIA) was established to address policy questions related to CVCs. We conducted two online surveys, i.e., one for the public and one for health and non-health sector experts, from June to October 2021 in nine Asian countries. Descriptive analysis identified participants, enablers, and barriers. Most participants (78% public, 89% experts) accepted the use of CVCs, primarily to resume international travel (76%). Most respondents in both surveys wanted the minimum vaccination coverage to be 60% before CVCs were implemented nation-wide. Most of the public (82%) agreed to maintain existing non-pharmaceutical interventions, while most experts wanted risk-based testing and quarantine policy for incoming travellers (51%) and both digital and paper format CVCs (64%). Support for CVCs for international travel remains high in Asia. Recognising key enablers and barriers for effective use of CVCs from COVID-19 pandemic may help policymakers draft effective border policies for future epidemics.

Smoking is a leading cause of diseases and death, with significant socioeconomic consequences. The purpose of this study was to evaluate the health and economic effectiveness of a workplace smoking cessation program. A total of 89 smokers from seven workplaces in Korea were the participants of the program. For 4 months, individual counseling based on the transtheoretical model (TTM) was conducted and interpersonal and organizational components were applied to encourage entire workplaces to encourage employee smoking cessation. The primary outcome was whether participants quit smoking or not. We also evaluated the changes in attitude and perceptions related to smoking cessation before and after the program and estimated the program's economic effects. Economic effects were defined as reductions in productivity losses and medical expenses. We calculated the return on investment (ROI) values representing the averted cost through the program compared to program cost. At the end of the program, 40.4% of participants quit smoking. Improvements were observed in TTM-based attitudes and perceptions. The mean reduction in productivity losses was estimated to be $187,609.94 for 2 yr and the mean reduction in medical expenses was $3,136.49 at 20 yr among seven workplaces. When accounting for these reductions, the ROI was 15.39 (ranging from -1.00 to 44.53). These effects were robust under various scenarios. The smoking cessation program should be expanded to a wider variety of workplaces. In the future, more sophisticated economic assessment methods should be developed and applied to facilitate workplace recruitment and attract management support.Smoking is a major cause of disease and death with large socioeconomic costs. This study examined the effect of a workplace smoking cessation program on health perspective, and on productivity and profit. A total of 40.4% of participants quit smoking, and the perceptions on smoking were improved. Also, the program was revealed to have an average return on investment (ROI) of 15.39. This can be deemed as the program’s economic effect is 15.39 times the program cost. We believe this kind of evaluation may help with the dissemination of workplace health promotion programs.

General anesthesia induces changes in dendritic spine number and synaptic transmission in developing mice. These changes are rather disturbing, as similar changes are seen in animal models of neurodevelopmental disorders. We previously suggested that mTor-dependent upregulation of mitochondrial function may be involved in such changes. To further understand the significance of mitochondrial changes after general anesthesia during neurodevelopment, we exposed young mice to 2.5 % sevoflurane for 2 h followed by injection of rotenone, a mitochondrial complex I inhibitor. In postnatal day 17 (PND17) mice, intraperitoneal injection of rotenone not only blocked sevoflurane-induced increases in mitochondrial function, it also prevented sevoflurane-induced changes in excitatory synaptic transmission. Interestingly, similar changes were not observed in younger, neonatal mice (PND7). We next assessed whether the mitochondrial unfolded protein response (UPRmt) acted as a link between anesthetic exposure and mitochondrial function. Expression of UPRmt proteins, which help maintain protein-folding homeostasis and increase mitochondrial function, was increased 6 h after sevoflurane exposure. Our results show that a single, brief sevoflurane exposure induces age-dependent changes in mitochondrial function that constitute an important mechanism for the increase in excitatory synaptic transmission in late postnatal mice, and also suggest mitochondria and UPRmt as potential targets for preventing anesthesia toxicity.

Previous studies have investigated the predictors for home discharge without considering stroke severity. To develop a practical assessment tool that predicts home discharge for moderate stroke patients after subacute rehabilitation therapy in the tertiary hospitals. Stroke patients with National Institutes of Health Stroke Scale scores of 6 to 13 were included in this prospective cohort study. Various demographic, clinical, and functional factors were analyzed as potential predictive factors. A weighted scoring model was developed through the following three-step process: 1) selection of the factors by logistic regression analyses, 2) development of a weighted scoring model, and 3) validation of the generalizability of the model. The home discharge rate was 51% (n = 372), and the overall mean length of stay of hospitalization was 32.5 days. 1) The Cognitive Functional Independence Measure, 2) the Functional Ambulation Categories, 3) the modified Charlson Comorbidity Index, and 4) marital status were independent predictors of home discharge. The coefficient value for marital status was adjusted to 1 in the scoring system, and the values of the other parameters were proportionally converted to the nearest integer. Possible total scores ranged from 0 to 13 in the model, with a higher score indicating a higher probability of home discharge. With a cutoff point of 7, this model showed 87.0% sensitivity and 86.2% specificity (area under the curve = 0.90). This novel assessment tool can be useful in predicting home discharge after subacute rehabilitation of moderate stroke patients.

Background and Purpose— The theory of cognitive reserve (CR) was introduced to account for individual differences in the clinical manifestation of neuropathology. This study investigated whether CR has a modulating effect on cognitive impairment and recovery after stroke. Methods— This study is an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation. A total of 7459 patients with first-ever stroke were included for analysis. Education, occupation, and composite CR scores derived from those 2 variables were used as CR proxies. Scores from the Korean version of the Mini-Mental State Examination analyzed for 30 months after stroke onset were analyzed. Results— Lower CR increased the risk of cognitive impairment after stroke. The odds ratio was 1.89 (95% CI, 1.64–2.19) in patients with secondary education and 2.42 (95% CI, 2.03–2.90) in patients with primary education compared with patients with higher education. The odds ratio was 1.48 (95% CI, 1.23–1.98) in patients with a skilled manual occupation and 2.01 (95% CI, 1.42–2.83) in patients with a nonskilled manual occupation compared with patients with a managerial or professional occupation. In the multilevel model analysis, the Korean version of the Mini-Mental State Examination total score increased during the first 3 months (1.93 points per month) and then plateaued (0.02 point per month). The slopes were moderated by the level of education, occupation, and composite CR score: the higher the level of education, occupation, or CR score, the faster the recovery. In the older adult group, the Korean version of the Mini-Mental State Examination scores showed a long-term decline that was moderated by education level. Conclusions— Education and occupation can buffer an individual against cognitive impairment caused by stroke and promote rapid cognitive recovery early after stroke. In addition, higher education minimizes long-term cognitive decline after stroke, especially in older patients. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT03402451.

Background There are ongoing calls to harmonise and increase the use of COVID-19 vaccination certificates (CVCs) in Asia. Identifying groups in Asian societies who oppose CVCs and understanding their reasons can help formulate an effective CVCs policy in the region. However, no formal studies have explored this issue in Asia. Method The COVID-19 Vaccination Policy Research and Decision-Support Initiative in Asia (CORESIA) was established to address policy questions related to CVCs. An online cross-sectional survey was conducted from June to October 2021 in nine Asian countries. Multivariable logistical regression analyses were performed to identify potential opposers of CVCs. Results Six groups were identified as potential opposers of CVCs: (i) unvaccinated (Odd Ratio (OR): 2.01, 95% Confidence Interval (CI): 1.65-2.46); vaccine hesitant and those without access to COVID-19 vaccines; (ii) those not wanting existing NPIs to continue (OR: 2.97, 95% CI: 2.51-3.53); (iii) those with low level of trust in governments (OR: 1.25, 95% CI: 1.02-2.52); (iv) those without travel plans (OR: 1.58, 95% CI: 1.31-1.90); (v) those expecting no financial gains from CVCs (OR: 2.35, 95% CI: 1.98-2.78); and (vi) those disagreeing to use CVCs for employment, education, events, hospitality, and domestic travel. Conclusions Addressing recurring public health bottlenecks such as vaccine hesitancy and equitable access, adherence to policies, public trust, and changing the narrative from ‘societal-benefit’ to ‘personal-benefit’ may be necessary and may help increase wider adoption of CVCs in Asia.

We aimed to estimate the socioeconomic burden of pneumonia due to multidrug-resistant Acinetobacter baumannii (MRAB) and Pseudomonas aeruginosa (MRPA).We prospectively searched for MRAB and MRPA pneumonia cases and matched them with controls with susceptible-organism pneumonia and non-infected cases from ten hospitals over a 6-month period. The matching criteria were: same principal diagnosis, same surgery or intervention during hospitalization, age (years ± 10), sex, and admission date within 60 days. The total additional direct medical cost was estimated by the multistate model. A total of 108 cases of MRAB pneumonia [MRAB-P] and 28 cases of MRPA pneumonia [MRPA-P] were identified. The 90-day mortality rate was 37.0% and 39.3% for MRAB-P and MRPA-P, respectively. The additional medical costs were $42,203 and $35,556 for MRAB-P and MRPA-P, respectively. The estimated number of MRAB-P and MRPA-P cases were 1,309–2,483 and 339–644, respectively with estimated deaths being 485–920 and 133–253 in a year, respectively. The annual socioeconomic burden was $12,053,593–$22,898,271 and $15,241,883–$28,994,008, respectively. We estimated that MRAB-P and MRPA-P occurred in 1,648–3,172 patients, with 618–1,173 deaths, and caused $27,295,476–$51,892,279 in socioeconomic burden nationwide. It is time to investigate and invest in prevention of multidrug-resistant bacterial pneumonia.

Background: Although many studies about survival rates and functional outcomes after stroke have been published, studies on gender differences have reported conflicting results. Aims: To determine whether there are differences in mortality and functional outcomes during the first 5 years after a first-ever ischemic stroke in Korean males and females. Method: This is an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation, a prospective multicenter cohort study. Multifaceted functional assessments were performed repeatedly from 7 days to 60 months after stroke onset to test motor, ambulatory, cognitive, language, and swallowing functions as well as activities of daily living (ADLs) in patients with first-ever stroke. Of 10,636 first-ever-stroke patients admitted to nine representative hospitals in Korea, 8210 were ischemic stroke patients included in the mortality analysis. Among them, 6258 patients provided informed consent and 3508 completed functional assessments for 60 months. Gender-related differences in 5-year mortality and functional recovery were analyzed. Result: Women showed a significantly higher 5-year mortality rate than men after correction for possible covariates ( p Conclusion: Five-year mortality rate, functional outcomes, and recovery patterns after first-ever ischemic stroke differed significantly by gender. These results suggest the need for gender-specific stroke care and long-term management strategies.

BackgroundMultidrug-resistant organisms (MDROs), including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), multidrug resistant Acinetobacter baumannii (MRAB), multidrug resistant Pseudomonas aeruginosa (MRPA), and carbapenem-resistant Enterobacteriaceae (CRE) are particularly important public health threats, but their detailed clinical outcomes and socioeconomic burden are adequately addressed.MethodsWe prospectively searched for these MDROs bacteraemia cases with matched controls from 10 hospitals across Korea, in a 6-month period, in 2017. Patients were classified into the MDRO, susceptible organism, and no-infection groups. The corresponding susceptible or no-infection controls had similar principal diagnosis at admission time, major surgery or intervention during hospitalization, age (± 10 years), sex, and within ± 60 days of admission date. We collected detailed clinical information and estimated the total additional direct medical cost of each MDRO bacteraemia case using the multistate model. ResultsOf 486 MDRO bacteraemia cases identified for MRSA, MRAB, MRPA, CRE, and VRE, at 260, 87, 18, 20, and 101, respectively, their 90-day mortality rates (overall, 40.3%) were 30.4%, 63.2%, 16.7%, 55.0%, and 47.5%, respectively. Their additional medical costs (overall, $27,700) were $15,768, $35,682, $39,908, $72,051, and $33,662 (compared to the no-infection group), respectively. Overall, these five MDRO bacteraemia cases occurred in 7,979 patients, caused 3,280 deaths, and cost $294,505,002 (range, $170,627,020 to $416,094,679) socioeconomic loss. ConclusionsTremendous clinical and economic burden occurred with MDRO bacteraemia compared with those of antibiotic-susceptible and no-infection groups. Substantial investment and efforts by related government agencies and medical staffs are needed to urgently prevent the increase, spread and expansion of antibiotic-resistant bacteria.

Background: We conducted a comparative survival analysis between primary androgen deprivation therapy (PADT) and radical prostatectomy (RP) based on nationwide Korean population data that included all patients with prostate cancer. Materials and Methods: This study enrolled 4,538 patients with prostate cancer from the National Health Insurance Service (NHIS) database linked with Korean Central Cancer Registry data who were treated with PADT or RP between January 1, 2007, and December 31, 2014. Kaplan-Meier and multivariate survival analyses stratified by stage (localized and locally advanced) and age (Results: Among 18,403 patients from the NHIS database diagnosed with prostate cancer during the study period, 4,538 satisfied inclusion criteria and were included in the analyses. Of these, 3,136 and 1,402 patients underwent RP or received PADT, respectively. Risk of death was significantly increased for patients who received PADT compared with those who underwent RP in the propensity score–matched cohort. In subgroup analyses stratified by stage and age, in every subgroup, patients who received PADT had a significantly increased risk of death compared with those who underwent RP. In particular, a much greater risk was observed for patients with locally advanced prostate cancer. Conclusions: Based on a nationwide survival analysis of nonmetastatic prostate cancer, this study provides valuable clinical implications that favor RP over PDAT for treatment of Asian populations. However, the possibility that survival differences have been overestimated due to not accounting for potential confounding characteristics must be considered.

Stroke in young adults has catastrophic consequences and has increased in prevalence, contrary to the trends of most other diseases. This study aimed to determine the major characteristics and risk factors for stroke in younger adults compared with older adults. From the Korean Stroke Cohort for Functioning and Rehabilitation, 10,584 patients with first-ever stroke between August 2012 and March 2015 were enrolled retrospectively and divided into younger (age ≤ 45) and older groups (age > 45). The clinical characteristics and risk factors of stroke were compared between the younger and older groups. The younger group comprised 915 patients (8.6%). The proportion of hemorrhage strokes in the younger group (42.3%) was significantly higher than in the older group (20.0%) (p < 0.001). Obesity, current smoking, and heavy alcohol consumption were significantly more common risk factors in the younger group than in the older group for all stroke types, whereas hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, and coronary heart disease were significantly more frequent in the older group (both p < 0.001). The major risk factors in the younger group may be lifestyle-related. Therefore, increasing awareness of lifestyle-related risk factors may be necessary to prevent stroke in young adults.

BackgroundLong-term usage of glucocorticoids results in a loss of bone mass and a higher risk of fracture, and the most common cause of secondary osteoporosis is glucocorticoid-induced osteoporosis (GIOP). For preventing GIOP, bisphosphonate (BP) is widely used. However, analysis on BP’s effect on the prevention of re-fracture is insufficient. The purpose of the present study is to evaluate the comparative treatment effect and prevention of re-fracture according to the type of BP in GIOP as the basis for a reliable clinical strategy for patients.Methods and analysisWe will search electronic databases of the PubMed, Cochrane Library and EMBASE using a comprehensive search strategy in December 2021 with no language restriction. Randomised controlled trials (RCTs), quasi-RCTs, controlled trials and cohort studies evaluating the effectiveness of BP to the patients with GIOP will be included in this study. The primary outcome will be the incidence of hip, vertebral and other fractures. The secondary outcome will include percentage changes on the bone mineral density and incidence of re-fracture. Assessing risk of bias for included studies is done using the Cochrane Risk of Bias tool and Risk Of Bias In Non-randomized Studies–of Intervention tool. If quantitative synthesis is possible, a meta-analysis will be performed. A subgroup analysis will be conducted to compare re-fracture rate on the patients with GIOP who experience previous fractures. This study’s result will provide evidence for the effectiveness of BP in the prevention of re-fracture on patients with GIOP.Ethics and disseminationThe results will be disseminated through publishing in a peer-reviewed journal or public presentations. Ethical approval is not required as this is a systematic review of publicly available data.PROSPERO registration numberCRD42022343787.

Background and Purpose: The aim of this study was to verify the validity of the proportional recovery model in view of the ceiling effect of the Fugl-Meyer Assessment. Methods: We reviewed the medical records of patients enrolled in the Korean Stroke Cohort for Functioning and Rehabilitation between August 2012 and May 2015. Recovery proportion was defined as the actual change in Fugl-Meyer Assessment score of the upper extremity between 7 days and 6 months poststroke, relative to the initial neurological impairment. We then used logistic regression to identify clinical factors attributable to a ceiling effect of the Fugl-Meyer Assessment score of the upper extremity and propensity score matching to verify the validity of the proportional recovery rule. Results: We screened 10 636 patients and analyzed 849 patients (mean age, 65.4±11.9 years; female, 320 [37.7%]) with first-ever ischemic stroke. We found, through logistic regression analysis, that a one-unit increase in the initial neurological impairment and the age at stroke onset affected the odds ratio (1.0386 and 0.9736, respectively) of achieving the full Fugl-Meyer Assessment score of the upper limb at 6 months poststroke. We also demonstrated, through propensity score matching, that the difference in initial neurological impairment of the upper extremity resulted in discrepancy of the recovery proportion (0.92±0.20 [0–1] versus 0.81±0.31 [0–1], P Conclusions: We demonstrated that the ceiling effect of the Fugl-Meyer Assessment score of the upper extremity is pronounced in patients with mild initial motor deficits of the upper extremity and that the recovery proportion varies according to the initial motor deficit of the upper limb using logistic regression analysis and propensity score matching, respectively. These results suggest that the proportional recovery model is not valid.

There is growing interest globally in using real-world data (RWD) and real-world evidence (RWE) for health technology assessment (HTA). Optimal collection, analysis, and use of RWD/RWE to inform HTA requires a conceptual framework to standardize processes and ensure consistency. However, such framework is currently lacking in Asia, a region that is likely to benefit from RWD/RWE for at least two reasons. First, there is often limited Asian representation in clinical trials unless specifically conducted in Asian populations, and RWD may help to fill the evidence gap. Second, in a few Asian health systems, reimbursement decisions are not made at market entry; thus, allowing RWD/RWE to be collected to give more certainty about the effectiveness of technologies in the local setting and inform their appropriate use. Furthermore, an alignment of RWD/RWE policies across Asia would equip decision makers with context-relevant evidence, and improve timely patient access to new technologies. Using data collected from eleven health systems in Asia, this paper provides a review of the current landscape of RWD/RWE in Asia to inform HTA and explores a way forward to align policies within the region. This paper concludes with a proposal to establish an international collaboration among academics and HTA agencies in the region: the REAL World Data In ASia for HEalth Technology Assessment in Reimbursement (REALISE) working group, which seeks to develop a non-binding guidance document on the use of RWD/RWE to inform HTA for decision making in Asia.

Background Despite strong evidence of clinical benefit, cardiac rehabilitation (CR) programs are currently underutilized and smartphone-based CR strategies are thought to address this unmet need. However, data regarding the detailed process of development are scarce. Objective This study focused on the development of a smartphone-based, patient-specific, messaging app for patients who have undergone percutaneous coronary intervention (PCI). Methods The AnSim app was developed in collaboration with a multidisciplinary team that included cardiologists, psychiatrists, nurses, pharmacists, nutritionists, and rehabilitation doctors and therapists. First, a focus group interview was conducted, and the narratives of the patients were analyzed to identify their needs and preferences. Based on the results, health care experts and clinicians drafted messages into 5 categories: (1) general information regarding cardiovascular health and medications, (2) nutrition, (3) physical activity, (4) destressing, and (5) smoking cessation. In each category, 90 messages were developed according to 3 simplified steps of the transtheoretical model of behavioral change: (1) precontemplation, (2) contemplation and preparation, and (3) action and maintenance. After an internal review and feedback from potential users, a bank of 450 messages was developed. Results The focus interview was conducted with 8 patients with PCI within 1 year, and 450 messages, including various forms of multimedia, were developed based on the transtheoretical model of behavioral change in each category. Positive feedback was obtained from the potential users (n=458). The mean Likert scale score was 3.95 (SD 0.39) and 3.91 (SD 0.39) for readability and usefulness, respectively, and several messages were refined based on the feedback. Finally, the patient-specific message delivery system was developed according to the baseline characteristics and stages of behavioral change in each participant. Conclusions We developed an app (AnSim), which includes a bank of 450 patient-specific messages, that provides various medical information and CR programs regarding coronary heart disease. The detailed process of multidisciplinary collaboration over the course of the study provides a scientific basis for various medical professionals planning smartphone-based clinical research.

BACKGROUND Despite strong evidence of clinical benefit, cardiac rehabilitation (CR) programs are currently underutilized and smartphone-based CR strategies are thought to address this unmet need. However, data regarding the detailed process of development are scarce. OBJECTIVE This study focused on the development of a smartphone-based, patient-specific, messaging app for patients who have undergone percutaneous coronary intervention (PCI). METHODS The AnSim app was developed in collaboration with a multidisciplinary team that included cardiologists, psychiatrists, nurses, pharmacists, nutritionists, and rehabilitation doctors and therapists. First, a focus group interview was conducted, and the narratives of the patients were analyzed to identify their needs and preferences. Based on the results, health care experts and clinicians drafted messages into 5 categories: (1) general information regarding cardiovascular health and medications, (2) nutrition, (3) physical activity, (4) destressing, and (5) smoking cessation. In each category, 90 messages were developed according to 3 simplified steps of the transtheoretical model of behavioral change: (1) precontemplation, (2) contemplation and preparation, and (3) action and maintenance. After an internal review and feedback from potential users, a bank of 450 messages was developed. RESULTS The focus interview was conducted with 8 patients with PCI within 1 year, and 450 messages, including various forms of multimedia, were developed based on the transtheoretical model of behavioral change in each category. Positive feedback was obtained from the potential users (n=458). The mean Likert scale score was 3.95 (SD 0.39) and 3.91 (SD 0.39) for readability and usefulness, respectively, and several messages were refined based on the feedback. Finally, the patient-specific message delivery system was developed according to the baseline characteristics and stages of behavioral change in each participant. CONCLUSIONS We developed an app (AnSim), which includes a bank of 450 patient-specific messages, that provides various medical information and CR programs regarding coronary heart disease. The detailed process of multidisciplinary collaboration over the course of the study provides a scientific basis for various medical professionals planning smartphone-based clinical research. CLINICALTRIAL