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Background: Deer antlers have been used as strong tonifying medicine in Asian countries, especially for the growth and development of children in pediatrics of Korean medicine. The safety of deer antler in adults cannot be applied directly to children because of their physiological characteristics. To accumulate reliable data on the safety of deer antler in pediatric populations, well-designed clinical studies are required., Methods: This research is a 12-week, randomized, double-blind, placebo-controlled clinical trial evaluating the safety of deer antler extract (DAE) in children. The DAE group received an intervention containing 1586 mg of DAE, whereas the control group received a placebo for 12 weeks. The safety was assessed by monitoring adverse drug reactions (ADRs) and laboratory test results., Results: One hundred participants were included in the safety analysis. Three and 2 participants in the DAE and control groups, respectively, reported ADRs. There was no significant difference in incidence between the 2 groups. ADRs are categorized into gastrointestinal and skin-related symptoms. No serious ADR was observed throughout the study. The laboratory test results were within or outside the normal range at clinically insignificant levels., Conclusion: The research discovered that the DAE is safe in terms of ADRs and laboratory parameters under the conditions studied. Further studies are required to accumulate safety data about DAE dosage adjustment and potential interactions with other medicines., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: The purpose of this study is to determine the level of health equity in relation to cancer incidence., Materials and Methods: We used the National Health Insurance claims data of the National Health Insurance Service between 2005 and 2022 and annual health insurance and medical aid beneficiaries between 2011 and 2021 to investigate the disparities of cancer incidence. We calculated age-sex standardized cancer incidence rates by cancer and year according to the type of insurance and the trend over time using the annual percentage change. We also compared the hospital type of the first diagnosis by cancer type and year and cancer incidence rates by cancer type and region in 2021 according to the type of insurance., Results: The total cancer incidence increased from 255,971 in 2011 to 325,772 cases in 2021. The absolute difference of total cancer incidence rate between the NHI beneficiaries and the medical aid (MA) recipients increased from 510.1 cases per 100,000 population to 536.9 cases per 100,000 population. The odds ratio of total cancer incidence for the MA recipients increased from 1.79 (95% confidence interval [CI], 1.77 to 1.82) to 1.90 (95% CI, 1.88 to 1.93). Disparities in access to hospitals and regional cancer incidence were profound., Conclusion: This study examined health inequities in relation to cancer incidence over the last decade. Cancer incidence was higher in the MA recipients, and the gap was widening. We also found that regional differences in cancer incidence still exist and are getting worse. Investigating these disparities between the NHI beneficiaries and the MA recipients is crucial for implementing of public health policies to reduce health inequities.

Individuals with autism spectrum disorders (ASD) have difficulty accessing dental care. We aim to verify whether individuals with ASD are properly managed by checking the frequency of dental visits, cost and severity of dental treatment compared with those without ASD. This cross-sectional study used the Korean Health Insurance Database to analyze the frequency, cost and severity of dental treatment in 209,780 people under the age of 19 with or without ASD in 2020. The average frequency of dental visits for individuals without ASD was 2.98 times, which was significantly higher ( p < 0.001) than the 2.89 times for those with ASD. However, the average dental cost for individuals with ASD was USD 132.63, which was significantly higher ( p < 0.001) than USD 116.57 for those without ASD. Additionally, the average number of times that individuals without ASD received severe dental treatment was 1.23 times, significantly higher than the 1.15 times for those with ASD. Further, per 10,000 people, we found that trauma treatment was recorded for an average of 21.90 individuals with ASD, significantly higher than the 7.75 recorded for those without ASD ( p < 0.001). Individuals with ASD encounter significant disparities in accessing dental care, as evidenced by their relatively infrequent dental visits. This discrepancy can be attributed to various barriers including the financial burden compared with those without ASD., Competing Interests: The authors declare no conflict of interest., (©2024 The Author(s). Published by MRE Press.)

Objectives: With the end of the coronavirus disease 2019 (COVID-19) pandemic, the health outcomes of this disease in Korea must be examined. We aimed to investigate health outcomes and disparities linked to socioeconomic status during the COVID-19 pandemic in Korea and to identify risk factors for hospitalization and mortality., Methods: This nationwide retrospective study incorporated an analysis of individuals with and without COVID-19 in Korea between January 1, 2020 and December 31, 2022. The study period was divided into 4 stages. Prevalence, hospitalization, mortality, and case-fatality rates were calculated per 100,000 population. Multivariate logistic regression was performed to identify risk factors for COVID-19 hospitalization and mortality., Results: Overall, the incidence rate was 40,601 per 100,000 population, the mortality rate was 105 per 100,000 population, and the case-fatality rate was 259 per 100,000 cases. A total of 12,577,367 new cases (24.5%) were recorded in stage 3 and 8,979,635 cases (17.5%) in stage 4. Medical Aid recipients displayed the lowest 3-year cumulative incidence rate (32,737 per 100,000) but the highest hospitalization (5,663 cases per 100,000), mortality (498 per 100,000), and case-fatality (1,521 per 100,000) rates. Male sex, older age, lower economic status, non-metropolitan area of residence, high Charlson comorbidity index, and disability were associated with higher risk of hospitalization and death. Vaccination was found to reduce mortality risk., Conclusions: As the pandemic progressed, surges were observed in incidence, hospitalization, and mortality, exacerbating disparities associated with economic status and disability. Nevertheless, Korea has maintained a low case-fatality rate across all economic groups.

Objectives: In Korea, the National Health Insurance Service (NHIS) covers essential healthcare expenses, including cataract surgery. To address concerns that private health insurance (PHI) might have inflated the need for such procedures, we investigated the extent of the PHI-attributable increase in cataract surgery and its impact on NHIS-reimbursed expenses., Methods: This retrospective, observational study uses nationwide claims data for cataract surgery from 2016 to 2020. We examined trends in utilization and cost, and we estimated the excess numbers of (1) cataract operations attributable to PHI and (2) types of intraocular lenses used for cataract surgery in 2020., Results: Between 2016 and 2020, a 36.8% increase occurred in the number of cataract operations, with increases of 63.5% and 731.8% in the total healthcare costs reimbursed by NHIS and PHI, respectively. Over a 5-year period, the surgical rate per 100,000 people doubled for patients aged <65 years (from 328 in 2016 to 664 in 2020). Among the 619,771 cases in 2020 of cataract surgery reimbursed by the Korean diagnosis-related group system, more non-NHIS-covered intraocular lenses were used for patients aged <65 years than ≥65 years (68.1 vs. 14.2%). In 2020 alone, an estimated 129,311 excess operations occurred, accounting for an excess cost of US$115 million., Conclusions: A dramatic increase in the number and cost of cataract operations has occurred over the last 5 years. The PHI-related increase in operations resulted in increased costs to NHIS. Measures to curtail the non-indicated use of cataract surgery should be implemented regarding PHI.

Background: Digital therapeutics (DTx) are therapeutic interventions driven by software and directly provided to patients, allowing them to manage their health with ease in any setting. A growing interest in DTx has spurred a discussion concerning their reimbursement pathways. However, DTx are still at a premature stage, with insufficient evidence on effectiveness, efficiency, and safety. Currently, although industries desire to quickly enter the market, especially by getting their products reimbursed by the National Health Insurance (NHI) fund, the NHI is cautious about DTx due to their uncertainties. Thus, public discussion and social consensus are crucial in deciding whether to reimburse DTx by the NHI fund., Objective: This study examined multiple stakeholders' awareness and attitudes toward DTx and perceptions of regulatory pathways for adopting DTx., Methods: In-depth interviews were conducted with 11 stakeholders in South Korea (industry: n=4, health care: n=3, academia: n=2, and consumer: n=2) using semistructured guidelines. They were purposively sampled to identify individuals with expertise in DTx and NHI policies. The interviews were conducted either in person or via a videoconference for 45-70 minutes. Qualitative data were analyzed using directed content analysis, which uses interview guidelines as an analytical framework., Results: Findings were divided into three categories: (1) awareness and attitude toward DTx, (2) perception of whether DTx are worth entering the market and being reimbursed by the NHI fund, and (3) perception of how to enter the market and how to reimburse DTx by the NHI fund if they are worth it. Although consumer stakeholders were not familiar with the basic concept of DTx, the other stakeholders understood it thoroughly. However, all participants showed positive attitudes and acceptance of DTx. Most of them responded that DTx are worth entering the market, but they could not reach an agreement on the pathways for DTx to enter the market. Although participants were in favor of the reimbursement of DTx in principle, they responded that a conservative approach is required due to insufficient clinical evidence for DTx., Conclusions: We found that stakeholders in South Korea had positive attitudes toward DTx, perceived them as worth using, and agreed to allow them to enter the market. The main issue was not the problem of the technology itself but the difference in opinion as to the pathways for reimbursement. Therefore, this study concluded that the NHI fund, which is operated very conservatively, is insufficient to quickly adopt and implement DTx. Various reimbursement methods, including tax-based financing, raising innovation funds for new technologies, and pilot studies using the NHI fund, should be used to rapidly generate clinical evidence and reduce the uncertainties of DTx to secure a stable market., (© Boram Sim, Jin Han Ju, Byungsoo Kim, Jin Yong Lee. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org).)

Land subsidence is the gradual or sudden dropping of the ground surface developed by increasing the total stress. Most studies have discussed the relationship between land subsidence with groundwater level. However, there is a lack of discussion on groundwater environmental changes after occurring land subsidence. This study aimed to evaluate the hydrogeological and water chemistry characteristics of construction sites with land subsidence. Land subsidence in the Yangyang coastal area occurred suddenly on August 3, 2022, when the retaining wall of the construction collapsed. The groundwater level was measured three times, and water samples were collected twice between August 5, 2022, and September 5, 2022, for laboratory analysis. After land subsidence occurred, the average groundwater level was - 19.91 m ground level (GL) on August 9, 2022, and finally decreased to - 19.21 m GL on September 05, 2022. The groundwater levels surrounding the construction site gradually increased for a month. The electrical conductivity value measured at the monitoring wells ranged from 89 to 7800 μS/cm, and four wells exceeded the measurement limit near the groundwater leaked points. The highest mixing ratio of leaked water samples, collected on August 9, 2022, was 27.6%. Furthermore, the fresh groundwater-saltwater interface depth was estimated to be above the construction bottom. Although groundwater levels recovered, the groundwater quality continuously is affected by saltwater. This finding could contribute to understanding the hydrogeological characteristics surrounding construction sites with land subsidence and provide insight into the hydrochemical evolution process during declined groundwater levels in coastal aquifers., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Risk perception research, targeting the general public, necessitates the study of the multi-faceted aspects of perceived risk through a holistic approach. This study aimed to investigate the association between the two dimensions of risk perception of COVID-19, i.e., risk as a feeling and analysis, trust in the current government, political ideologies, and socio-demographic factors in South Korea. This study used a year-long repeated cross-sectional design, in which a national sample (n = 23,018) participated in 23 consecutive telephone surveys from February 2020 to February 2021. Most factors differed in the magnitude and direction of their relationships with the two dimensions of risk perception. However, trust in the current government, alone, delineated an association in the same direction for both dimensions, i.e., those with a lower level of trust exhibited higher levels of cognitive and affective risk perception. Although these results did not change significantly during the one-year observation period, they are related to the political interpretation of risk. This study revealed that affective and cognitive risk perceptions addressed different dimensions of risk perception. These findings could help governments and health authorities better understand the nature and mechanisms of public risk perception when implementing countermeasures and policies in response to the COVID-19 pandemic and other public health emergencies., Competing Interests: Jang DH is affiliated with Gallup Korea (https://www.gallup.co.kr/), but did not receive any funding from them for this. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Lee et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Microplastic (MPs) contamination in groundwater has received massive attention since plastic waste has been released directly into the environment. This study investigates MPs contamination in groundwater on the Jeju volcanic Island, Korea. To the best of our knowledge, this is the first study to identify MPs in groundwater from volcanic islands. A total of 21 sites were sampled for groundwater wells and springs in July and September (2021). Sampling was performed without cross-contamination through quality assurance and quality control. The results showed that MPs abundance ranged from 0.006 to 0.192 particles/L in groundwater samples. Additionally, MPs were detected in deep groundwater wells where the groundwater level was 143 m below ground surface. Eight MPs polymer types, including polypropylene, polyethylene, polyethylene terephthalate, polyvinyl chloride, polystyrene, polyamide, acrylonitrile butadiene styrene, and polyurethane, were detected using Micro-Fourier Transform Infrared Spectroscopy (μ-FT-IR). Most of the detected MPs size ranged from 20 to 100 μm, accounting for 95% of the total. Fragments and fiber shaped MPs were detected, with the majority of them being fragmented in groundwater samples. The concentrations of MPs and major ions in groundwater showed a positive correlation. A negative correlation was observed between MPs concentration and topographic elevation (r = -0.59, p = 0.01). The source of MPs contamination is most likely attributed to agricultural activities, such as plastic mulching and greenhouses, which account for most of the land use in the study area. In this study, MPs entered the aquifer through the soil at the surface and seeped through cracks in fractured rock on basalt with sealed groundwater wells. This study takes 500 L of samples to prevent sample bias, reveal plastic contamination in groundwater, and indicating the characteristics and sources of contaminated plastics., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: The coronavirus disease 2019 (COVID-19) pandemic has led to a global shortage of medical resources; therefore, we investigated whether COVID-19 impacted the quality of non-COVID-19 hospital care in Korea by comparing hospital standardized mortality rates (HSMRs) before and during the pandemic., Methods: This retrospective cohort study analyzed Korean National Health Insurance discharge claim data obtained from January to June in 2017, 2018, 2019, and 2020. Patients' in-hospital deaths were classified according to the most responsible diagnosis categories. The HSMR is calculated as the ratio of expected deaths to actual deaths. The time trend in the overall HSMR was analyzed by region and hospital type., Results: The final analysis included 2 252 824 patients. In 2020, the HSMR increased nationwide (HSMR, 99.3; 95% confidence interval [CI], 97.7 to 101.0) in comparison to 2019 (HSMR, 97.3; 95% CI, 95.8 to 98.8). In the COVID-19 pandemic zone, the HSMR increased significantly in 2020 (HSMR, 112.7; 95% CI, 107.0 to 118.7) compared to 2019 (HSMR, 101.7; 95% CI, 96.9 to 106.6). The HSMR in all general hospitals increased significantly in 2020 (HSMR, 106.4; 95% CI, 104.3 to 108.5) compared to 2019 (HSMR, 100.3; 95% CI, 98.4 to 102.2). Hospitals participating in the COVID-19 response had a lower HSMR (HSMR, 95.6; 95% CI, 93.9 to 97.4) than hospitals not participating in the COVID-19 response (HSMR, 124.3; 95% CI, 119.3 to 129.4)., Conclusions: This study suggests that the COVID-19 pandemic may have negatively impacted the quality of care in hospitals, especially general hospitals with relatively few beds. In light of the COVID-19 pandemic, it is necessary to prevent excessive workloads in hospitals and to properly employ and coordinate the workforce.

Background: The epidemiology of influenza is commonly used to understand and establish relevant health policies for emerging respiratory infections, including coronavirus disease 2019 (COVID-19). However, Korea has no confirmed nationwide data on influenza incidence, severity, and mortality rate., Methods: We conducted a cross-sectional study to obtain epidemic data on influenza at the national level using National Health Insurance claims data during 2010 to 2020. Influenza cases were defined as 90-day timeframe episodes based on all inpatient and outpatient claims data with disease code J09, J10, and J11. Influenza incidence, severity, and mortality rate were calculated, and logistic regressions were performed to assess the associations of demographic characteristics and comorbidity with influenza-related hospitalization, severe illness, and death., Results: There were 0.4-5.9% influenza cases in the population from 2010 to 2020, with 9.7-18.9%, 0.2-0.9%, and 0.03-0.08% hospitalized, used in the intensive care unit, and dead, respectively. Age-standardized incidence and mortality rates were 424.3-6847.4 and 0.2-1.9 per 100,000 population, respectively. While more than half of the influenza cases occurred in populations aged younger than 20 years, deaths in older than 60 years accounted for more than two-thirds of all deaths., Conclusion: This study provided the simplest but most important statistics regarding Korean influenza epidemics as a reference. These can be used to understand and manage other new acute respiratory diseases, including COVID-19, and establish influenza-related policies., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2023 The Korean Academy of Medical Sciences.)

Background: There is limited quantitative evidence to investigate short-term suicide rates although the risk of suicide in psychiatric patients is exceptionally high in the early post-discharge period. This study aimed to explore the trends of the 30 days suicide rate after discharge using population-based data from Korea., Methods: This study was conducted on psychiatric patients aged 15 years or older discharged between 2010 and 2018. Patients were extracted from the National Health Insurance Claim Database (NHICD) and information on suicide was obtained from the National Statistical Office. Age-standardized suicide rate (ASR) and Standardized Mortality Ratio (SMR) within 30 days after discharge was estimated and tested using joinpoint regression., Results: Of the 1,576,028 patients discharged from hospitals from 2010 to 2018, 53.9 % were male and 47.9 % were aged between 40 and 59 years. The 30 days ASRs for psychiatric patients after discharge varied from 174.9 to 218.0 per 100,000 patients with no clear trend excluding patients with schizophrenia and anxiety disorder. The SMR for suicide within 30 days after discharge was 66.8 in 2016-2018, and patients aged 20 to 39, female, and patients with depression had high SMRs compared to other groups., Limitations: Factors that may impact the suicide were not considered in this study. Since the NHICD data is collected for payment of medical expenses, there may be scope for inaccuracies., Conclusions: The 30 days suicide rate after psychiatric discharge has failed to decrease between 2010 and 2018. This study recommends early interventions after discharge and intensive interventions for patient groups who may be vulnerable to suicide., Competing Interests: Conflict of interest The authors declare that they have no competing interests., (Copyright © 2022. Published by Elsevier B.V.)

Background: COVID-19 has brought changes in daily life and increased the medical burden. This study aims to evaluate the delays in healthcare services and related factors in the general population during the COVID-19 pandemic., Methods: We took a nationally representative sample and conducted a mobile phone-based survey. The study was conducted anonymously. Of the 3377 subjects who consented to participate, a total of 2097 finished the survey. The primary outcome was respondents' experiences with delayed (1) health screenings, (2) non-urgent medical visits, (3) medical visits for chronic disease, and (4) emergency visits during the COVID-19 pandemic., Results: Of 2097 respondents, females, residents of the Seoul metropolitan area, those with private insurance, those without chronic diseases, smokers, and drinkers had higher risk of delays in health screening and non-urgent medical visits after adjustment. Among chronic disease patients, those who were over 60 years old (adjusted odds ratio 0.36, 95% CI 0.14-0.92) showed lower risk of delayed medical visit. Residents of the Seoul metropolitan area, those with private insurance, smokers, and drinkers were all associated with experiencing delayed health screening and non-urgent medical visits had higher risk of delays in chronic disease visits and emergent medical visits., Conclusions: Delayed access to healthcare services is associated with poor outcomes and may cause different complications. Efforts are needed to prevent delays in medical use due to infectious diseases such as COVID-19. Considering the possibility of the emergence of infectious diseases, various countermeasures are needed to prevent delays in medical visit., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Integrative traditional Korean medicine (TKM) treatment including herbal medicine and acupuncture has been used frequently by parents in South Korea for the treatment of children with idiopathic short stature (ISS). We aimed to report the TKM treatments currently being used for children with ISS and explore their therapeutic effects. The medical records of children who met the criteria for ISS and who had been treated with TKM for the management of ISS were retrospectively reviewed. In total, 116 patients (mean [standard deviation] age, 8.07 [3.08] years; 52.6% girls) enrolled in the study. Their mean height percentile was 1.45 and body mass index was 16.19 kg/m2. During the study period of 5 years, participants visited the outpatient clinic an average of 2.93 times; the mean number of days to the next visit was 101 days. All patients received herbal medicine treatment, and the formulation was mainly decoction type. Additional treatments including ear acupuncture and moxibustion were also used. After treatment with TKM, the height percentile and standard deviation scores increased in both girls and boys (P < .001 and P < .01, respectively). Additionally, the predicted adult height, estimated based on bone age, increased in girls (P < .05). This study provided preliminary data for future research in TKM use in children with ISS., Competing Interests: The authors have no conflict of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

In this study, two geothermal wells (PX-1 and PX-2) exhibiting abnormal groundwater levels and microbial communities were examined at the Enhanced Geothermal System site before and after the Pohang earthquake (November 2017). Furthermore, the EXP-1 well level, water temperature, microbial communities and their association with earthquakes, as well as the possibility of future earthquakes were explored. The primary objectives of this research were to: (1) perform correlation and cluster analyses of hydrophysical parameters for earthquakes using next-generation sequencing; (2) analyze pre-, co-, and post-seismic changes in groundwater levels, temperatures, and microbial communities; and (3) further assess the analyzed results of the post-earthquake changes in the groundwater levels and temperatures to interpret their implications. Although the pre-earthquake water levels in the three wells were unknown, their depth-to-water levels post-earthquake ranged from 50.33-98.20 m, 570.91-735.00 m, and 47.70-56.04 m for wells PX-1 (depth 4362 m), PX-2 (4348 m), and EXP-1 (180 m), respectively. In particular, the water levels of PX-2 were abnormally low compared with the surrounding area. Moreover, the geothermal wells demonstrated unstable microbial communities prior to the earthquake. However, while the microbial communities of PX-1 recovered relatively quickly post-earthquake, those of PX-2 failed to stabilize even within two years after the earthquake. Thus, it was inferred here that the PX-2 well is more closely related to seismic activity, the effects of which can still be seen. Accordingly, it is important that PX-2 is continuously monitored until June 2024, the minimum period predicted for the water levels to reach stability., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: The aim of this study was to estimate the 8-year prevalence and mortality statistics of autism spectrum disorder (ASD) according to birth year (2002-2012)., Methods: We used the National Health Insurance Service database with 4,989,351 children born from 2002 to 2012 including 35,529 children diagnosed with ASD until 8 years of age. The 8-year cumulative prevalence of ASD was calculated annually (2010-2020) with 8 years of follow-up. The 8-year mortality was estimated using Cox models adjusted for sex, household income, area of residence, and year of birth., Results: Of the 473,494 children born in 2002, 2,467 (5.2 per 1,000 births) were diagnosed with ASD until 2010. The ASD prevalence was 2.6 times higher among boys (1,839; 7.4 per 1,000 boy births) than girls (628; 2.8 per 1,000 girl births). Of the 467,360 children born in 2012, 4,378 (9.4 per 1,000 births) were diagnosed with ASD until 2020. The ASD prevalence was 2.7 times higher among boys (3,246; 13.5 per 1,000 boy births) than girls (1,132; 5.0 per 1,000 girl births). The risk of all-cause mortality was higher among children with ASD than those without (hazard ratio [HR], 2.340; 95% confidence interval [CI], 2.063-2.654), which is substantially higher among girls (HR, 4.223; 95% CI, 3.472-5.135) than boys (HR, 1.774; 95% CI, 1.505-2.090)., Conclusion: The present study demonstrated that national-level prevalence and mortality statistics of ASD can be estimated effectively using claims data comprising newborns born each year and followed up for to the age of interest. Because this information is essential to establish evidence-based policies, health authorities need to consider producing epidemiological information of ASD continuously using the same methodology., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2022 The Korean Academy of Medical Sciences.)

Objectives: We investigated the awareness, experience, approval, intention to use, and the desired type of telemedicine among Korean general public., Methods: From November to December 2020, we conducted an online self-reported survey on awareness, experience, approval, and intent to use telemedicine services among Korean residents aged 20 years or older. A total of 2,097 participants completed the survey., Results: Of the 2,097 participants, 1,558 (74.3%) were aware of, 1,198 (57.1%) approved of, and 1,474 (70.3%) had the intention to use telemedicine. Participants from regions other than the Seoul metropolitan area and Daegu-Gyeongbuk Province (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.02 to 1.63), households with a monthly household income of US$6,000 or more (aOR, 1.44; 95% CI, 1.01 to 2.08), participants who had a college/university or associate's degree (aOR, 1.35. 95% CI, 1.04 to 1.75) or a master's degree or above (aOR, 1.73; 95% CI, 1.20 to 2.50), and housewives (aOR, 1.30; 95% CI, 1.03 to 1.64) had higher odds of approval. Elderly participants, those with a chronic disease (aOR, 1.26; 95% CI, 1.04 to 1.54), those who had experienced delays of healthcare services (aOR, 1.94; 95% CI, 1.27 to 2.96), and those who had experience with telemedicine (aOR, 4.28; 95% CI, 1.69 to 10.82) were more likely to intend to use telemedicine services. Regarding types of telemedicine, teleconsultation between doctors showed the highest approval rate (73.1%)., Conclusions: In the context of the coronavirus disease 2019 pandemic, more than 70% of participants had already used or intended to use telemedicine at some point. Groups with a substantial need for telemedicine were more in favor of telemedicine.

Background: The COVID-19 pandemic has radically shifted living practices, thereby influencing changes in the health status and behaviors of every person., Objective: The aim of this study was to investigate the impact of COVID-19 on the self-reported health status and health behaviors along with any associated factors in adults in the Republic of Korea wherein no stringent lockdown measures were implemented during the pandemic., Methods: We conducted a web-based self-reported survey from November 2020 to December 2020. The study participants (N=2097) were identified through quota sampling by age, sex, and geographical regions among residents aged 19 years or older in Korea. The survey collected information on basic demographics, changes in self-reported health status, and health behaviors during the COVID-19 pandemic. Self-reported health status and health behaviors were categorized into 3 groups: unchanged, improved, or worsened. A chi-square test and logistic regression analyses were conducted., Results: With regard to changes in the self-reported health status, the majority (1478/2097, 70.5%) of the participants reported that their health was unchanged, while 20% (420/2097) of the participants reported having worser health after the COVID-19 outbreak. With regard to changes in health behaviors, the proportion of participants who increased tobacco consumption was similar to that of those who decreased tobacco consumption (110/545, 20.2% vs 106/545, 19.5%, respectively), while the proportion of those who decreased their drinking frequency was more than twice as many as those who increased their drinking frequency (578/1603, 36.1% vs 270/1603, 16.8%, respectively). Further, those who decreased their exercising frequency were more than those who increased their exercising frequency (333/823, 15.9% vs 211/823, 10%, respectively). The factor that had the greatest influence on lifestyle was age. In the subgroup analysis, the group aged 20-29 years had the highest number of individuals with both a worsened (100/377, 26.5%) and an improved (218/377, 15.7%) health status. Further, individuals aged 20-29 years had greater odds of increased smoking (6.44, 95% CI 2.15-19.32), increased alcohol use (4.64, 95% CI 2.60-8.28), and decreased moderate or higher intensity aerobic exercise (3.39, 95% CI 1.82-6.33) compared to individuals aged 60 years and older. Younger adults showed deteriorated health behaviors, while older adults showed improved health behaviors., Conclusions: The health status and the behavior of the majority of the Koreans were not found to be heavily affected by the COVID-19 outbreak. However, in some cases, changes in health status or health behavior were identified. This study highlighted that some groups were overwhelmingly affected by COVID-19 compared to others. Certain groups reported experiencing both worsening and improving health, while other groups reported unchanged health status. Age was the most influential factor for behavior change; in particular, the younger generation's negative health behaviors need more attention in terms of public health. As COVID-19 prolongs, public health interventions for vulnerable groups may be needed., (©EunKyo Kang, Hyejin Lee, Jee Hoon Sohn, Jieun Yun, Jin Yong Lee, Yun-Chul Hong. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 26.11.2021.)

This study aimed to assess the correlation between political ideologies, government trust, and COVID-19 vaccine hesitancy in South Korea during the COVID-19 pandemic. A cross-sectional survey was conducted among South Korea's general population and 1000 respondents (aged 18 years and older) were included. We used multivariate logistic regression models to identify the factors associated with vaccine hesitancy. Respondents who self-identified as liberal or held "no political opinion" had higher rates of vaccine hesitancy than conservative respondents. People's trust in the government's countermeasures was associated with vaccination. Respondents who had risk perceptions (affective and cognitive) of COVID-19 had lower rates of vaccine hesitancy. Perceptions that the vaccine was not safe and being aged 18-29, 30-39, or 40-49 were associated with a higher probability of vaccine hesitancy. This study found that even if vaccine safety and risk perceptions toward COVID-19 were adjusted, self-rated political ideologies and government trust was associated with COVID-19 vaccine hesitancy. More effort to communicate with those who are *liberal or "no political opinion", younger, and have lower level of trust in the government are required to dissolve vaccine hesitancy. Further studies should analyze the mechanism of COVID-19 vaccine uptake for effective herd immunity.

Background: Excess all-cause mortality is helpful to assess the full extent of the health impact, including direct and indirect deaths of coronavirus disease 2019 (COVID-19). The study aimed to estimate overall and regional excess all-cause mortality during the pandemic in Korea., Methods: We obtained all-cause death data and population statistics from January 2010 to December 2020. The expected mortality in 2020 was estimated using a quasi-Poisson regression model. The model included death year, seasonal variation, cold wave (January), average death counts in the previous month, and population. Excess mortality was defined as the difference between the observed mortality and the expected mortality. Regions were classified into three areas according to the numbers of COVID-19 cases., Results: There was no annual excess all-cause mortality in 2020 at the national and regional level compared to the average death for the previous ten years. The observed mortality in 2020 was 582.9 per 100,000 people, and the expected mortality was 582.3 per 100,000 people (95% confidence interval, 568.3-596.7). However, we found monthly and regional variations depending on the waves of the COVID-19 pandemic in Korea. While the mortality in August, October, and November exceeded the expected range, the mortality in September was lower than the expected range. The months in which excess deaths were identified differed by region., Conclusion: Our results show that the mortality in 2020 was similar to the historical trend. However, in the era of the COVID-19 pandemic, it would be necessary to regularly investigate COVID-19-related mortality and determine its direct and indirect causes., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2021 The Korean Academy of Medical Sciences.)

Purpose: This study aimed to investigate the association between autism spectrum disorder (ASD) diagnosis and mortality among children using the data from a large-scale national cohort of Korean infants and children. We also explored the association between hearing impairment detected during early infancy and mortality., Materials and Methods: We performed a retrospective cohort study using the nationwide claims data of the Republic of Korea. Children born between 2007 and 2014 (n=3598904) were followed up until 2020. Cox proportional hazard models were used to examine the association between ASD diagnosis and mortality among children. Then, in order to evaluate the association between hearing impairment and mortality, Cox proportional hazard models were built using the responses related to hearing impairment asked during the first health screening (at age 4-6 months)., Results: Of the 3598904 children born between 2007 and 2014, 32878 children (0.9%) were diagnosed with ASD until the end of 2020. We identified that ASD diagnosis was associated with higher mortality among children [hazard ratio (HR)=2.5, 95% confidence interval (CI): 2.2-2.9]. This association was stronger among girls (HR=4.8, 95% CI: 3.9-5.8) compared to boys (HR=1.9, 95% CI: 1.6-2.2). We found that hearing impairment detected during infancy was associated with higher mortality among children with ASD diagnosis., Conclusion: ASD diagnosis was associated with higher mortality among Korean children. This association was stronger in girls than in boys. Hearing impairment detected during infancy was also associated with higher mortality among children diagnosed with ASD., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2021.)

The epidemiological characteristics of women living with human immunodeficiency virus (HIV) infection have gained little attention as the numbers are small compared with men living with HIV in the Republic of Korea. However, these data are important to achieve effective HIV infection control and to consider the influence of socioeconomic status on HIV transmission. This study utilized the claims database of the Korean National Health Insurance system to analyze women with a newly diagnosed HIV infection during the period 2009-2016. Adherence to antiretroviral agents was calculated using the medication possession ratio. Among 677 women with a newly diagnosed HIV infection, 219 (32.4%) were over 50 years of age; 291 (43.0%) were identified as having acquired immune deficiency syndrome (AIDS). A total of 99 women (14.6%) were National Medical Aid beneficiaries. Optimal medical adherence >95% was found in 62.2% of subjects. Teenage years (odds ratio(OR) 14.9, 95% confidence interval (95CI) 4.9-44.8), AIDS (OR 1.7, 95CI 1.2-2.3), and low economic status requiring National Medical Aid (OR 3.0, 95CI 2.0-4.6) were associated to adherence. Diagnosis prior to 2012 was also associated with poor adherence. In women, particularly young patients with low economic status, extra attention is required to enhance adherence to prescribed medication.

Background: Healthcare quality assessment is being conducted in many countries. Although improving health equity is one of the major objectives of medical quality assessment, it is not clear whether different socio-economic statuses show the same health outcomes even in the same medical quality hospitals. No study has directly compared the health outcomes of different socio-economic statuses in the same hospitals nationwide., Objective: To determine whether the mortality rate of acute stroke patients differs according to socioeconomic status., Methods: This study was a retrospective, observational study of patients who were subject to acute stroke quality assessment in 2013. A total of 10 399 stroke cases were included in the study. When evaluating the mortality rate, the researchers analysed 10 228 cases, after excluding 171 cases that were measured twice for the same person. The levels of socio-economic status were divided according to the use of medical benefits, either National Health Insurance (NHI) for general population or Medical Aid (MA) for the vulnerable. The primary outcomes measured according to socio-economic status were in-hospital mortality rate and 1-year follow-up mortality rate of stroke patients. The secondary outcome was the composite performance score., Results: MA recipients had a higher in-hospital mortality rate (12.5 vs. 8.3%, P < 0.001) and 1-year follow-up mortality rate (14.9 vs. 10.8%, P < 0.001) than NHI subscribers. MA recipients had slightly lower scores than NHI subscribers (83.2 vs. 84.4, P = 0.02). In hospitals of the same grade, MA recipients had lower performance scores than NHI subscribers, although the difference was not statistically significant., Conclusions: There is a difference in mortality and healthcare performance according to socio-economic status in stroke patients in Korea. Efforts to improve equity are needed, including the development and monitoring of equality indicators and developing policies for healthcare equity., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Inflammatory bowel disease (IBD) presents with various extraintestinal manifestations. As part of them, various skin diseases are suggested to be related to IBD. We aimed to identify the epidemiology and risk of developing skin manifestations in patients with IBD. We used Korean insurance claims data and selected patients with IBD and age/sex-matched non-IBD subjects between 2013 and 2017 using the diagnosis code and prescription records of IBD-specific medications. The prevalence and risk of concurrent skin diseases were estimated. We identified 64 837 patients with IBD. Reactive skin eruptions including pyoderma gangrenosum and erythema nodosum were associated with IBD with highest odds ratios among three categories of reactive, inflammatory, and autoimmune skin diseases. Inflammatory skin diseases including rosacea, psoriasis, atopic dermatitis, hidradenitis suppurativa, and acne conglobata were significantly associated with IBD, but the association was less marked compared to reactive skin eruptions. The patients with IBD also had a higher risk of autoimmune skin diseases including vitiligo and alopecia areata than non-IBD subjects. We determined that IBD was related to various skin diseases including reactive, inflammatory, and autoimmune skin diseases. Considering these relationships can allow better management of patients with IBD and comorbid skin diseases., (© 2021 Japanese Dermatological Association.)

This article aims to introduce the inception and operation of the COVID-19 International Collaborative Research Project, the world's first coronavirus disease 2019 (COVID-19) open data project for research, along with its dataset and research method, and to discuss relevant considerations for collaborative research using nationwide real-world data (RWD). COVID-19 has spread across the world since early 2020, becoming a serious global health threat to life, safety, and social and economic activities. However, insufficient RWD from patients was available to help clinicians efficiently diagnose and treat patients with COVID-19, or to provide necessary information to the government for policy-making. Countries that saw a rapid surge of infections had to focus on leveraging medical professionals to treat patients, and the circumstances made it even more difficult to promptly use COVID-19 RWD. Against this backdrop, the Health Insurance Review and Assessment Service (HIRA) of Korea decided to open its COVID-19 RWD collected through Korea's universal health insurance program, under the title of the COVID-19 International Collaborative Research Project. The dataset, consisting of 476 508 claim statements from 234 427 patients (7590 confirmed cases) and 18 691 318 claim statements of the same patients for the previous 3 years, was established and hosted on HIRA's in-house server. Researchers who applied to participate in the project uploaded analysis code on the platform prepared by HIRA, and HIRA conducted the analysis and provided outcome values. As of November 2020, analyses have been completed for 129 research projects, which have been published or are in the process of being published in prestigious journals.

In 2020, the coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented disruptions to global health systems. The Korea has taken full-fledged actions against this novel infectious disease, swiftly implementing a testing-tracing-treatment strategy. New obligations have therefore been given to the Health Insurance Review and Assessment Service (HIRA) to devote the utmost effort towards tackling this global health crisis. Thanks to the universal national health insurance and state-of-the-art information communications technology (ICT) of the Korea, HIRA has conducted far-reaching countermeasures to detect and treat cases early, prevent the spread of COVID-19, respond quickly to surging demand for the healthcare services, and translate evidence into policy. Three main factors have enabled HIRA to undertake pandemic control preemptively and systematically: nationwide data aggregated from all healthcare providers and patients, pre-existing ICT network systems, and real-time data exchanges. HIRA has maximized the use of data and pre-existing network systems to conduct rapid and responsive measures in a centralized way, both of which have been the most critical tactics and strategies used by the Korean healthcare system. In the face of new obligations, our promise is to strive for a more responsive and resilient health system during this prolonged crisis.

Background: Emerging data suggest that inflammatory bowel disease (IBD) and psoriasis are associated, sharing common genetic predispositions and immunological mechanisms. However, concrete data on psoriasis risk in IBD patients compared to the general population are limited., Objective: We investigated the risk of developing psoriasis in IBD patients compared to controls without IBD., Methods: Using the Korean National Health Insurance Database, patients diagnosed with Crohn's disease (CD) or ulcerative colitis (UC) between 2005 and 2008 were age- and sex-matched 1:4 to non-IBD subjects from 2003 to 2018. IBD patients were defined by combining the International Classification of Diseases 10th revision code and at least one prescription of IBD-specific medications. Disease phenotypes, including psoriasis severity and psoriatic arthritis, were also identified. We investigated newly diagnosed psoriasis from 2009 to 2018. Incidence rates and risk of psoriasis were assessed with multivariate Cox regression models. Subgroup analyses for age and sex, and sensitivity analysis involving tumor necrosis factor (TNF) inhibitor-naïve patients were performed., Results: During nearly a decade of follow-up, 20,152 IBD patients were identified (14,619 [72.54%] UC and 5,533 [27.46%] CD). Among them, 439 patients were newly diagnosed with psoriasis (incidence rate of 217.68 per 100,000 person-years and 228.62 per 100,000 person-years for UC and CD, respectively). The psoriasis risk was higher in IBD patients than in the matched controls (adjusted hazard ratio, aHR, 2.95, 95% confidence interval, CI, 2.60-3.33). Moreover, IBD patients aged <30 years were at an increased risk (aHR 3.35, 95% CI 2.58-4.35), a trend that was unchanged across all psoriasis phenotypes. Sensitivity analysis of TNF inhibitor-naïve patients revealed consistent results., Conclusions: IBD patients were more likely to develop psoriasis compared to non-IBD subjects, including younger patients at an elevated risk regardless of TNF inhibitor use. This advocates the interplay between IBD and psoriasis; thus, inspection of cutaneous manifestation and dermatological consultation may be helpful in IBD patients at risk., (© 2021 The Author(s) Published by S. Karger AG, Basel.)

Background: Following the coronavirus disease 2019 (COVID-19) outbreak in Wuhan, China, a total of 637 patients had been diagnosed with the disease in Seoul as of May 2, 2020. Our study aimed to describe the impact of the 3T strategies (preemptive testing, prompt tracing and proper treatment) on the epidemiological characteristics of COVID-19 in Seoul., Methods: The descriptive and explanatory analysis was carried out on critical indicators such as epidemiological characteristics and key duration of patient status change from January 24 to May 2 in Seoul before and after preemptive testing for patients under investigation associated with COVID-19 clusters., Results: Preemptive testing increased the positive test rate (3.9% to 4.2%), an asymptomatic case at diagnosis (16.9% to 30.6%), and reduced the time from symptom onset to quarantine (4.0 to 3.0 days). Prompt tracing decreased unknown sources of infection (6.9% to 2.8%), the mean number of contacts (32.2 to 23.6), and the time-varying reproduction number R(t) (1.3 to 0.6). With proper treatment, only 2 cases of mortality occurred, resulting in a fatality rate of just 0.3%., Conclusion: In the first wave of the COVID-19 pandemic lasting 100 days, the effect of the 3T strategies flattened the curve and decreased the time during which infected individuals were contagious, thereby lowering the R(t) below 1 in Seoul., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2020 The Korean Academy of Medical Sciences.)

Background: There is no general agreement on underlying pathophysiology explaining the high burden of cardiovascular disease on people at low socioeconomic status (SES). This study was conducted to investigate the association between healthcare systems and arterial stiffness., Methods: A total of 8,929 subjects (60 years old and 55% were male) who underwent brachial-ankle pulse wave velocity (baPWV) measurement were retrospectively analyzed. There were 8,237 National Health Insurance (NHI) beneficiaries (92.2%) and 692 medical aid (MA) beneficiaries (7.8%). The median value of baPWV was 1,540 cm/s., Results: Subjects with higher baPWV values (≥1,540 cm/s) were older, and more frequently had cardiovascular risk factors and unfavorable laboratory findings than those with lower values baPWV (<1,540 cm/s). The baPWV values were significantly higher in MA beneficiaries than in NHI beneficiaries (1,966 ± 495 vs. 1,582 ± 346 cm/s, P < 0.001). The proportion of MA beneficiaries was significantly higher in subjects with higher baPWV than those with lower baPWV (13.1% vs. 2.3%, P < 0.001). In multivariable analysis, MA beneficiaries were significantly associated with higher baPWV values even after controlling for potential confounders (odds ratio, 5.41; 95% confidence intervals, 4.02-7.27; P < 0.001)., Conclusions: The baPWV values were significantly higher in MA beneficiaries than in NHI beneficiaries. The result of this study provides additional evidence on the association between low SES and arterial stiffening., (© American Journal of Hypertension, Ltd 2020. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: The absence of effective antiviral medications and vaccines increased the focus on non-pharmaceutical preventive behaviors for mitigating against the coronavirus disease 2019 (COVID-19) pandemic. To examine the current status of non-pharmaceutical preventive behaviors practiced during the COVID-19 outbreak and factors affecting behavioral activities, we compared to the 2015 Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in Korea., Methods: This was a serial cross-sectional population-based study in Korea with four surveys conducted on June 2 and 25, 2015 (MERS-CoV surveys), and February 4, and April 2, 2020 (COVID-19 surveys). Of 25,711 participants selected using random digit dialing numbers, 4,011 participants (aged ≥ 18 years) were successfully interviewed, for the 2020 COVID-19 (n = 2,002) and 2015 MERS-CoV (n = 2,009) epidemics were included. Participants were selected post-stratification by sex, age, and province. The total number of weighted cases in this survey equaled the total number of unweighted cases at the national level. We measured the levels of preventive behaviors (social distancing [avoiding physical contact with others]), and practicing transmission-reducing behaviors such as wearing face mask and handwashing., Results: Between the surveys, respondents who reported practicing social distancing increased from 41.9%-58.2% (MERS-CoV) to 83.4%-92.3% (COVID-19). The response rate for the four surveys ranged between 13.7% and 17.7%. Practicing transmission-reducing behaviors (wearing face masks and handwashing) at least once during COVID-19 (78.8%, 80.2%) also increased compared to that during MERS-CoV (15.5%, 60.3%). The higher affective risk perception groups were more likely to practice transmission-reducing measures (adjusted odds ratio, 3.24-4.81; 95 confidence interval, 1.76-6.96) during both COVID-19 and MERS-CoV., Conclusion: The study findings suggest markedly increased proportions of non-pharmaceutical behavioral practices evenly across all subgroups during the two different novel virus outbreaks in Korea. Strategic interventions are needed to attempt based on preventive behavior works., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2020 The Korean Academy of Medical Sciences.)

Background: Studies that examine the growth effects of massage at ages beyond infancy are rare. A recently developed massage chair (BEG-100) targets teenagers who want to increase their growth. The chair can stretch areas around the knee after fixating the knee and ankle areas., Methods: This is a clinical study that included 38 children aged 11 years whose heights ranged from 145.0 to 155.0 cm. We aim to observe the potential of a 24-week massage for growth promotion. We will also evaluate the changes in height percentile, height, height standard deviation score, bone age, height standard deviation score for bone age, growth rate, predicted height estimated from bone age, seated height-to-standing height ratio, weight, and body mass index. To confirm safety, the associated adverse events will be investigated., Objective: The aim of this study was to investigate the growth-promoting effect of BEG-100 in children with average height., Trial Registration: KCT0004673 (Clinical Research Information Service).

Condomless sex is not totally discouraged after achieving undetectable human immunodeficiency virus (HIV) load, but the prevalence of sexually transmitted diseases (STDs) in the group is unknown. This study was retrospective in nature, using the claims database of the National Health Insurance system from 2008 to 2016. The clinical characteristics of people living with HIV with or without syphilis coinfection were analyzed. People with HIV and syphilis coinfection were divided into two groups according to antiretroviral therapy adherence, as optimal and suboptimal adherence groups by a medication possession ratio of 95%. Of the 9393 people living with HIV, 4536 (48.3%) were diagnosed with syphilis coinfection. Optimal adherence was associated with syphilis coinfection (odds ratio [OR] 1.18; 95% confidence interval [95CI] 1.08-1.30; p  = .001). This suggests that unsafe sex occurs regardless of medication adherence. Being male, bacterial/protozoa STDs, and genital herpes virus infection were also risk factors for HIV-syphilis coinfection. Although HIV is unlikely to be transmittable when viral load is controlled, consistent use of condoms is necessary to prevent infection with syphilis.

Objectives: This study aimed to assess the affective and cognitive risk perceptions in the general population of Middle East respiratory syndrome (MERS) during the 2015 MERS coronavirus (MERS-CoV) outbreak in South Korea and the influencing factors., Design: Serial cross-sectional design with four consecutive surveys., Setting: Nationwide general population in South Korea., Participants: Overall 4010 respondents (aged 19 years and over) from the general population during the MERS-CoV epidemic were included., Primary and Secondary Outcome Measures: The main outcome measures were (1) affective risk perception, (2) cognitive risk perception, and (3) trust in the government. Multivariate logistic regression models were used to identify factors (demographic, socioeconomic, area and political orientation) associated with risk perceptions., Results: Both affective and cognitive risk perceptions decreased as the MERS-CoV epidemic progressed. Proportions of affective risk perception were higher in all surveys and slowly decreased compared with cognitive risk perception over time. Females (adjusted OR (aOR) 1.72-2.00; 95% CI 1.14 to 2.86) and lower self-reported household economic status respondents were more likely to perceive the affective risk. The older the adults, the higher the affective risk perception, but the lower the cognitive risk perception compared with younger adults. The respondents who had low trust in the government had higher affective (aOR 2.19-3.11; 95 CI 1.44 to 4.67) and cognitive (aOR 3.55-5.41; 95 CI 1.44 to 9.01) risk perceptions., Conclusions: This study suggests that even if cognitive risk perception is dissolved, affective risk perception can continue during MERS-CoV epidemic. Risk perception associating factors (ie, gender, age and self-reported household economic status) appear to be noticeably different between affective and cognitive dimensions. It also indicates that trust in the government influences affective risk perception and cognitive risk perception. There is a need for further efforts to understand the mechanism regarding the general public's risk perception for effective risk communication., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Statistical data of undiagnosed people living with human immunodeficiency virus (PLHIV) are of great importance to human immunodeficiency virus (HIV) infection control. This study estimated the total number of PLHIV using nationwide claims data., Methods: This study used data of the incident HIV cases identified by the National Health Insurance System between 2009 and 2015. The number of patients with acquired immune deficiency syndrome (AIDS) was identified by diagnoses or prescription records. The estimated number of PLHIV and the time to diagnosis were calculated from the incident numbers of HIV and AIDS cases using the HIV Modeling Tool of the European Center for Disease Prevention and Control., Results: Between 2009 and 2015, a total of 7,033 PLHIV and 2,899 AIDS patients were diagnosed. In 2009, the number of incident HIV cases was 873 (460 AIDS patients), increasing to 995 (337 AIDS patients) in 2015. Besides, the estimated number of prevalent cases was 10,753 in 2009, compared to 14,880 in 2015. Patients visiting health facilities accounted for 42.9% (4,616/10,753) in 2009 and 64.1% (9,544/14,880) in 2015. In 2009, there were 8,363 (77.8%) undiagnosed HIV cases, experiencing a decline to 6,215 (41.8%) in 2015. It took a mean of 6.96 years to diagnose after HIV infection., Conclusion: This study estimates the total burden of HIV infection in Korea for the first time using an internationally recognized HIV modeling tool. Claims data can be used to estimate the number of undiagnosed cases by identifying the total number of PLHIV and AIDS patients visiting health facilities., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2020 The Korean Academy of Medical Sciences.)

Background: Ethnic differences exist in relation to culprit drugs for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). We wanted to determine culprit drugs for SJS and TEN in Korean population., Objective: To evaluate culprit drugs for SJS and TEN by applying an algorithm for assessment of drug causality for epidermal necrolysis (ALDEN) in a nationwide administrative database., Methods: We used the claims database, which included claims data for the entire South Korean population. A retrospective cohort study was conducted by collecting subjects who were first diagnosed with SJS and TEN in 2011. All drugs prescribed to the subjects were reviewed and scored according to the ALDEN score. Drugs with an ALDEN score ≥2 were considered culprit drugs., Results: A total of 187 subjects were included in the culprit drug analysis; 33 very probable, 101 probable, and 57 possible culprit drugs were identified for SJS and TEN according to the ALDEN score. The most frequently suspected culprit drug was allopurinol (19 cases), followed by carbamazepine (17 cases), lamotrigine (13 cases), amoxicillin (9 cases), and dorzolamide (9 cases). Most cases (78.8%, 52 of 66) associated with the use of allopurinol, carbamazepine, lamotrigine, dorzolamide, and methazolamide occurred between 13 and 44 days after initiating the drug., Conclusion: We applied the ALDEN score to the claims database to identify possible culprit drugs for SJS and TEN in South Korea. This approach could shed light on research and policymaking for drug adverse reactions., (Copyright © 2019 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Several reports suggested that radiotherapy (RT) was related to an increased risk of cerebrovascular disease (CVD) in head and neck cancer (HNC) patients, but other risk factors of CVD were not properly considered in estimating the risk of RT. The purpose of this study is to analyze the effect of RT on the risk of CVD in HNC patients., Materials and Methods: The Korean Central Cancer Registry data and Korean National Health Insurance Service data were used. A total of 5570 patients with newly diagnosed HNC between the years 2003-2005 was included in our study cohort. We analyzed the effect of treatment modality and other socioeconomic variables on ischemic CVD incidence using the Cox proportional hazard regression model both in the entire cohort (n = 5570) and in the propensity score matching (PSM) cohort (n = 3310)., Results: RT increased the CVD risk by 40.8% (aHR: 1.408, p = 0.006) in the entire cohort and by 44.3% (aHR: 1.443, p = 0.047) in the PSM cohort, respectively., Conclusion: The risk of ischemic CVD increased by RT after adjusting for other socioeconomic and clinical risk factors. Regular follow up and appropriate screening for CVD are required for HNC patients who received RT, and focus should be on advanced-age patients with a low socioeconomic status and known clinical risk factors of CVD., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The spatial synoptic classification (SSC) scheme is a daily weather-type classification scheme that is widely used in climatological and epidemiological investigations. We investigated the modification effect of temperature on respiratory disease-related hospital admissions (RAs) in children based on the SSC type., Methods: Data on RAs among children aged ≤19 years were collected from the National Inpatient Sample (NIS) database between 2011 and 2015 in Seoul, Korea. In this time-series study, we used Poisson generalized linear models allowing for over-dispersion, with stratification by season and each of the seven distinctive SSC types (Dry moderate [DM], Dry polar [DP], Dry tropical [DT], Moist moderate [MM], Moist polar [MP], Moist tropical [MT], and Transition [T]). We investigated the modification effects of temperature by SSC type through seasonal stratification, adjusting for other meteorological conditions, air pollution, and time trends, and considered the delayed effect for up to four consecutive days. We reported the relative risk percentage change with 95% confidence intervals (CIs) of RAs for every 1 °C increase in ambient temperature, by season and SSC type., Results: Of the 8346 RAs overall investigated between 2011 and 2015, there were 5271 [63.2%] RAs in children aged 0-4 years. Overall, on majority of the days, the SSC types were DM (665 days [36.4%]), and DP (371 days [20.3%]). With regard to seasons, the different SSC types were distributed as follows: spring, DM (193 days [42.0%]); summer, MT (193 days [42.0%]); fall, DM (241 days [53.0%]); and winter, DP (228 days [50.6%]). A stronger association between RAs and temperature was observed overall (1.28% [95% CI; 0.04%, 2.53%]), and in spring (2.10% [0.62%, 3.60%]). According to SSC type, increased associations between RAs and temperature were detected with DM (2.20% [0.47%, 3.97%]) condition during spring and DT (2.41% [0.22%, 4.64%]) during fall. In addition, on re-categorizing the SSC types from a temperature or humidity standpoint, a modified association was observed especially in children aged ≤4 years and 5-9 years during spring., Conclusions: Using temperature variability to distinguish seasonal characteristics, we found that the relationship between temperature and RAs in children varied by SSC type. Application of the SSC scheme as an integrative approach may assist in gaining an understanding of seasonal characteristics and health effects due to temperature change., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Access to a delivery unit is a major factor in determining maternal morbidity and mortality. However, there is little information about the optimal access time to a delivery unit. This study aimed to establish the optimal hospital access time (OHAT) for pregnant women in South Korea., Design: Nationwide cross-sectional study., Setting: We used the National Health Insurance System database of South Korea., Participants: We analysed the data of 371 341 women who had experienced pregnancy in 2013., Primary and Secondary Outcome Measures: Access time to hospital was defined as the time required to travel from the patient's home to the delivery unit. The incidence of obstetric complications was plotted against the access time to hospital. Change-point analysis was performed to identify the OHAT by determining a point wherein the incidence of obstetric complications changed significantly. As a final step, the risk of obstetric complications was compared by type among pregnant women who lived within the OHAT against those who lived outside the OHAT., Results: The OHAT associated with each adverse pregnancy outcomes were as follows: inadequate prenatal care, 41-50 min; preeclampsia, 51-60 min; placental abruption, 51-60 min; preterm delivery, 31-40 min; postpartum transfusion, 31-40 min; uterine artery embolisation, 31-40 min; admission to intensive care unit, 31-40 min; and caesarean hysterectomy, 31-40 min. Pregnant women who lived outside the OHAT had significantly higher risk for obstetric complications than those who lived within the OHAT., Conclusions: Our results showed that the OHAT for each obstetric complication ranged between 31 and 60 min. The Korean government should take the OHAT under consideration when establishing interventions for pregnant women who live outside OHAT to reduce maternal morbidity and mortality., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Although effective care for type 2 diabetes (T2DM) is well known, considerable inadequate care has been still existed. Variations in achievement of the recommended quality indicators inT2DM care among small areas are not well known in Korea. This study examined the quality of care T2DM care and its geographical variations., Methods: We used the national health insurance database and national health screening database. Seven quality indicators were used to evaluate continuity of care (medication possession ratio), process of care (hemoglobin A1c test, lipid profile, microalbuminuria test, and eye examination), and intermediate outcome (blood pressure control, and low-density lipoprotein control). Crude and age-standardized proportions were calculated for each 252 districts in Korea., Results: All quality indicators failed to achieve the recommended level. Only about 3% and 15% of the patients underwent eye examination and microalbuminuria test, respectively. Other indicators ranged from 48% to 68%. Wide variation in the quality existed among districts and indicators. Eye examination and microalbuminuria test varied the most showing tenfold (0.9%-9.2%) and fourfold (6.3%-28.9%) variation by districts, respectively. There were 32.4 and 42.7 percentage point gap between the best and the worst districts in hemoglobin A1c test and blood pressure control, respectively., Conclusion: Considerable proportion of T2DM patients were not adequately managed and quality of care varied substantially district to district. To improve the quality of diabetes care, it is necessary to identify the poor performance areas and establish a well-coordinated care system tailored to the need of the district., Competing Interests: The authors have no potential conflicts of interest to disclose. This article was based on a KNHIS Atlas Project 2016, final report submitted by the authors to Korean National Health Insurance Service., (© 2019 The Korean Academy of Medical Sciences.)

Background: Autism spectrum disorder (ASD) is characterized by continuous impairment in communication and social interaction and by limited and repetitive behaviors, interests, or activities. Behavioral, educational, and pharmaceutical interventions have been shown to reduce behavioral disabilities, improve verbal/non-verbal communication, and help patients acquire self-reliance skills. However, there has been a lack of systematic verification and consensus regarding the treatment of the core symptoms of ASD because of its unclear etiology. Ukgansangajinpibanha (UGSJB), a legitimately prescribed herbal medicine for nervousness, insomnia, night crying, and malnutrition in South Korea and Japan, has been used for angry, sensitive, nervous, and unsettled children with ASD., Methods/design: This trial is a prospective, multicenter, randomized, double-blinded, placebo-controlled, parallel-group, clinical trial. The 4- to 6-year-old children with ASD will be randomly assigned to following groups: 1. A UGSJB granule with acupuncture, twice daily (n = 120) 2. A placebo group with acupuncture, twice daily (n = 120). The following outcome measures will be used: behavior by the Childhood Autism Rating Scale, Autism Behavior Checklist, and Aberrant Behavior Checklist; social maturity by the Social Maturity Scale; quality of life by the Child Health Questionnaire and EuroQoL Five-dimension Five-level Youth; and parental stress by the Parenting Stress Index at baseline and at 6, 12, and 24 weeks after the beginning of treatment. In addition, to evaluate safety, we will investigate the adverse reactions that may be caused by UGSJB granule. Finally, we will make an economic evaluation of UGSJB for the treatment of ASD., Discussion: We prepared a well-designed clinical trial to investigate the safety and effectiveness of UGSJB on ASD symptoms compared with placebo treatment. The results from this study will provide clinical evidence on the safety, effectiveness, and economic value of UGSJB combined with acupuncture in children with ASD., Trial Registration: Clinical Research Information Service: KCT0003007 (registered on April 5, 2018).

This study examined the public's preventive behavioral responses during the 2015 Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak in Korea and the influencing factors. Two cross-sectional telephone surveys were conducted by Gallup Korea using random digit dialing in June 2015 ( n = 2004). The main outcome variables were nonpharmaceutical preventive measures (survey (1): Measures for reducing transmission (handwashing, face masks); and survey (2): Measures for avoiding contact with others). Multiple logistic regression was used to identify the factors influencing preventive behaviors. In survey (1), 60.3% of respondents reported more frequent handwashing and 15.5% reported wearing face masks at least once due to the MERS-CoV epidemic. In survey (2), 41-56% of respondents reported practicing avoidance measures. The concerned group was more likely to practice reducing transmission measures (odds ratio (OR) 4.5; 95% confidence interval (CI) 3.3-6.1) and avoidance measures (OR = 9.6; 95% CI, 6.4-14.4). The respondents who had low trust in president or ruling party had a higher practice rate of reducing transmission measures (OR = 1.7; 95% CI, 1.2-2.6) and avoidance measures (OR = 2.1; 95% CI, 1.2-3.5). Cooperative prevention measures need appropriated public concern based on effective risk communication., Competing Interests: The authors declare no conflict of interest.

As patients in South Korea play the main role in choosing healthcare providers, understanding their attitudes and beliefs toward medical institutions is essential. This study evaluated the public's perspectives on doctors and local clinics. A face-to-face interview survey was conducted with 1000 participants who represent the South Korean adult population. The questionnaire consisted of four domains: personal information; trust level for nine professionals, including doctors; healthcare utilization behavior and attitudes regarding local clinics; and assessment of local clinics. The trust level of the doctor was highest (3.16 out of 4) among nine professionals. 85.3% of the participants frequently visited local clinics because of accessibility. The main reason for visiting hospitals over local clinics was the belief that doctors employed at hospitals would be better qualified. People were generally satisfied with the service of local clinics but wanted more facilities and equipment. Among six attributes of primary care, "first contact" and "accessibility" got higher scores in importance and current performance. Lastly, the participants suggested that improving the quality of doctors was most important for the reinforcement of primary care. Efforts to consider public opinion should be made before establishing healthcare policies for primary care.

On September 12, 2018, President Jae-In Moon announced the Comprehensive Plan for Lifelong Care for People with Developmental Disabilities, with representatives from the associated government branches (Ministry of Health and Welfare, Ministry of Education, and Ministry of Employment and Labor) in attendance. The goals of this plan are to provide health, medical, rehabilitative, special education, and social welfare services according to the life-stages of the affected individuals; to reduce parental pressure; to promote social interventions; and to enhance community-level participation in order to create a 'welfare society in harmony.' However, in order for the plan to succeed, additional efforts must be made in the following areas. First, an epidemiological survey is needed to understand the scale, prevalence, and incidence of developmental disabilities and to establish an evidence base to support policy development. Second, accurate definitions of developmental disabilities must be established in order to avoid policy discrimination based on impairment type and age. Third, personal evaluations to assess disabled individuals' unmet needs and customized service designs to deliver those needs are required. Fourth, the plan must fulfill the goals of accessibility and fairness that the government intends to provide. Fifth, the government should consider an integrated financial support system and to propose a detailed plan for monetary distributions. Finally, an integrated system that links health, medical, employment, educational, and welfare services must be constructed.

Objectives: To investigate the prevalence and incidence of Parkinson's disease (PD) and provide evidence for preventive strategy of vertebral, hip, and femoral fractures (VF, HF, and FF) in PD patients., Design: Retrospective cohort study., Setting and Participants: Using a nationwide medical service utility database from 2009 to 2014, we enrolled PD patients with diagnosis of G20 as per ICD-10 who used medical services. Overall, the number of PD patients was 97,311, 106,072, 115,762, 127,647, 137,782, and 144,757 through 2009-2014, respectively. We followed 35,663 patients diagnosed with PD in 2010 without prior fracture., Measures: We estimated the annual PD prevalence and incidence and used Cox proportional hazards model to estimate the hazards ratio (HR) for factures based on demographic characteristics, underlying disease, and socioeconomic status according to fracture type (osteoporosis-related fracture, VF, HF/FF). Furthermore, we investigated the cumulative incidence of those fractures by month during the 5-year follow-up., Results: The standardized PD prevalence increased from 238 to 279 between 2009 and 2014, and its incidence decreased from 86 to 72 between 2010 and 2014 per 100,000 population based on 2015 census data. We followed 35,663 PD patients: women, 20,732 (58.1%); aged ≥60 years, 29,264 (82.1%); with osteoporosis, 6542 (18.3%); VF experience, 4242 (11.9%); and HF/FF experience, 2112 (5.9%). Osteoporosis was a significant risk factor for VF [HR 1.75, 95% confidence interval (CI) 1.64-1.87] and HF/FF (HR 1.37, 95% CI 1.24-1.51). The cumulative incidence of VF and HF/FF was the highest at 6 months and increased more than half in the coming 2 years after PD diagnosis., Conclusions/implications: VF and HF/FF are common among PD patients. VF and HF/FF risks were high for female PD patients aged ≥60 years with osteoporosis. Fracture prevention strategies should be focused on older, women, and osteoporosis patients within 3 years of PD diagnosis., (Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background and Aim: Alcoholic hepatitis (AH) ranks among the most costly diseases in South Korea. However, accurate hospitalization incidence rates, mortality rates, and contributing factors have not been investigated in South Korea. This study aimed to provide the nationwide incidence of hospitalization, inhospital mortality, and readmission rates for South Korean patients with AH., Methods: Using the Korean Health Insurance Review and Assessment service database, a total of 39 800 inpatient cases from 2008 to 2012 were identified based on the International Classification of Diseases, 10th Revision diagnosis code for AH (K70.1). Standardized hospitalization incidence and mortality rates were calculated, and logistic regression analysis was performed to identify risk factors for inhospital mortality and readmission. Follow-up data for those admitted in 2008 were collected to assess readmissions., Results: The standardized incidence rate for AH hospitalization per 10 5 person/year decreased from 19 in 2008 to 14 in 2012 (P = 0.001). The annual inhospital mortality rate ranged from 0.2% to 0.5%. Inhospital mortality was significantly higher in older patients (odds ratio [OR], 1.36) and those with cirrhosis (OR, 4.40). The readmission rate for patients admitted in 2008 was 34.0%. Male sex (OR, 1.21) and low economic status (OR, 2.35) were significantly associated with readmission, whereas older age (OR, 0.96), cirrhosis (OR, 0.77), and urban residency (OR, 0.68) were inversely associated with readmission., Conclusions: This study captured a 5-year epidemiologic period in South Korea of patients with AH to reflect the real burden of AH and to provide valuable information to policy-makers assessing public health priorities., (© 2018 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: The epidemiology of the association between psoriasis and inflammatory bowel disease is poorly defined and remains controversial., Aim: To evaluate the prevalence of inflammatory bowel disease in patients with psoriasis compared with the general population., Methods: We searched the nationwide health claims database between 2011 and 2015 and evaluated the prevalence of inflammatory bowel disease, including Crohn's disease and ulcerative colitis., Results: Prevalence of inflammatory bowel disease, Crohn's disease and ulcerative colitis in patients with psoriasis vs the general population in 2011 were 0.16, 0.05 and 0.12% vs 0.08, 0.03 and 0.06%, respectively, which increased significantly with time between 2011 and 2015. Patients with psoriasis consistently revealed higher standardized prevalence (age and sex adjusted) of inflammatory bowel disease, Crohn's disease and ulcerative colitis compared with the general population. Subgroup analysis revealed the highest risk of prevalent inflammatory bowel disease in patients younger than 19 years (crude odds ratio 5.33, 95% confidence interval 3.74-7.59). Severe psoriasis demonstrated higher odds of inflammatory bowel disease (odds ratio 2.96, 95% confidence interval 2.54-3.45) than mild psoriasis (odds ratio 1.68, 95% confidence interval 1.51-1.88)., Limitations: Limited data for doing adjustment and cross-sectional study design., Conclusions: Psoriasis patients revealed higher risk of inflammatory bowel disease. In particular, young patients and those with severe psoriasis may require closer monitoring and comprehensive management., Competing Interests: None

This study aimed to investigate the prevalence pattern of pressure injuries (PIs), or 'sores', in South Korea and investigate the factors affecting its development. We estimated the annual prevalence of PIs using the National Inpatient Sample (NIS) data extracted from the Health Insurance Review and Assessment Service (HIRA) database from 2009 to 2015. Multivariable logistic regression was performed to examine the association between hospitalization and socio-demographic characteristics, such as sex, age, type of health insurance, Charlson Comorbidity Index (CCI), and plegia comorbidity. We found that inpatients with PIs make up to 0.86% of the total population in South Korea in 2015, which had shown a steady increase from the previous years. And male, old age, low socioeconomic status (SES), and the patients' severity such as high CCI and the plegia comorbidity were strongly associated with hospitalization due to PI. Based on our results, it would be anticipated that the medical cost for treatment and management of PIs will increase in the future, and it will be accelerated due to the rapidly aging society. In addition, patients in low SES and patients with severe comorbidities would be relatively more burdensome, threatening their household economy and further reducing the quality of life. Therefore, PIs should not be overlooked as the responsibility of just the nursing care professionals but should be recognized as one of the serious societal problems. The establishment of an intense medical care system is needed not only to reduce the prevalence of PIs but also to increase the awareness in people with PI patients.