Trends in outpatient rehabilitation practices in Japan: analysis using the National Database of Health Insurance Claims Open Data / Journal of Rural Medicine

Objective: Many countries have recently established registration databases in the field of rehabilitation to clarify their current status. However, these databases are primarily created for inpatients, with only a few large-scale databases for outpatients. The present study aimed to clarify secular changes, age distribution, and regional disparities in the implementation of outpatient rehabilitation in Japan using the National Database of Health Insurance Claims.Materials and Methods: Using the National Database of Health Insurance Claims Open Data published by the Ministry of Health, Labor, and Welfare, the number of outpatient rehabilitation units from 2014 to 2018 were extracted and examined.Results: The total number of units for outpatient rehabilitation increased gradually from 2014 to 2018. Orthopedic rehabilitation accounted for more than 80% of the total number of units for outpatient rehabilitation in 2018. The total number of units for outpatient rehabilitation according to age was highest among those in their late 70s, while cerebrovascular and dysphagia rehabilitation had the highest number of units in children.Conclusion: The total number of units for outpatient rehabilitation gradually increased from 2014 to 2018; whereas the number of total units for outpatient rehabilitation according to age was the highest among those in their late 70s. However, cerebrovascular rehabilitation and dysphagia rehabilitation had the highest number of units in children. The implementation status of rehabilitation in each region varied greatly among prefectures, suggesting the need for policy planning to eliminate regional disparities.

Estimating Nationwide Prevalence of Live Births with Down Syndrome and Their Medical Expenditures in Korea

BACKGROUND: This study aimed to estimate the nationwide prevalence of live births with Down syndrome (DS) and its trends and compare the observed and model-based predicted prevalence rates. Further, we compared the direct medical expenditures among DS and non-DS patients. METHODS: Using the health administrative data of Health Insurance Review and Assessment in Korea, we selected 2,301 children with DS who were born between 2007 and 2016 to estimate the prevalence of live births with DS, and 12,265 non-DS children who were born between 2010 and 2014 to compare the direct medical expenditures among patients. RESULTS: The prevalence of live births with DS was 5.03 per 10,000 births in 9 years, and 13% of children with DS were medical aid recipients during the study period. The medical expenditure of children with DS was about 10-fold higher than that of non-DS children and their out-of-pocket expenditure was about twice as high. CONCLUSION: The prevalence of live birth with DS is high in the low socioeconomic group and the healthcare costs for the children with DS are significantly higher than those for non-DS children. Therefore, health authorities should help mothers at lower socioeconomic levels to receive adequate antenatal care and consider the cost of medical care for children with DS.

Prescription Patterns and Burden of Pediatric Asthma in Korea

PURPOSE: This study aimed to estimate the prevalence, prescription pattern and burden of pediatric asthma in Korea by analyzing the National Health Insurance (NHI) claims data. METHODS: We retrospectively analyzed the insurance claim records from the Korean NHI claims database from January 2010 to December 2014. Asthmatic patients were defined as children younger than 18 years, with appropriate 10th Revision of the International Classification of Diseases codes (J45 or J46) and a prescription for 1 or more asthma maintenance medications at the same date. Hospitalization and emergency department visits for asthma were defined as use of short-acting beta2-agonists during hospital visits among asthmatic patients. RESULTS: There were 1,172,807 asthmatic children in 2010, which increased steadily to 1,590,228 in 2014 in Korea. The prevalence showed an increasing trend annually for all ages. The mean prevalence by age in those older than 2 years decreased during the study period (from 39.4% in the 2–3 year age group to 2.6% in the 15–18 year age group). In an outpatient prescription, leukotriene receptor antagonists were the most commonly prescribed medication for all ages. Patients older than 6 years for whom inhaled corticosteroids were prescribed comprised less than 15% of asthmatic patients. The total direct medical cost for asthma between 2010 and 2014 ranged from $376 to $483 million. Asthma-related medical cost per person reached its peak in $366 in 2011 and decreased to $275 in 2014. CONCLUSIONS: The prevalence of pediatric asthma increased annually and decreased with age. Individual cost of asthma showed a decreasing trend in Korean children.

Survey of Drug Prescription Patterns Among Patients with Nontuberculous Mycobacterial Disease Using the Database of Health Insurance Claims / 薬剤疫学

In recent years, the number of patients with non-tuberculosis mycobacteria (NTM) has rapidly increasing.According to the nationwide survey conducted in 2014, the number of patients with NTM was reported to increase 9.7 times compared to the survey in 1980. Among them, the patients with Mycobacterium avium complex (MAC) account for about 88.8% of them. It is the main cause of the rapid increase of NTM patients mainly in middle-aged and elderly woman. To treat patients with MAC, it is common to do chemotherapy over one year after the bacteria becomes negative. Among experts of NTM, it is recommended to do chemotherapy preventing generation of resistant bacteria by using clarithromycin (CAM) and rifampicin and ethambutol (EB) in combination. Meanwhile, a monotherapy of CAM and high-dose EB administration over a long period are not currently recommended due to side effects. However, it has not been clarified so far how many such drug prescriptions had existed. Therefore, in this study, we investigated the actual drug prescription of 571 patients who were presumed to be NTM in health insurance data collected from 2015 to 2016. As a result, about 5.1% (29 cases) of CAM monotherapy and 4.4% (15 cases) of EB high-dose prescription over 3 months were observed. In general, because NTM is a case where a long-term antibiotic treatment is required, it increases the possibility of any disadvantages exerting on patients. Hence, we consider it is an important and urgent matter to inform the correct information widely to clinical workers and sites.

Surveillance to Determine Adverse Reactions to Carbamazepine and Lamotrigine: / 医薬品情報学

<b>Objective: </b>We previously showed that interstitial lung disease, pneumonia, abnormal liver function, and anaphylactic reactions were frequent adverse events, and we analyzed outcomes, suspected causative drugs, and the onset of adverse events using information derived from the “Japanese Adverse Drug Event Report” (JADER) database.  Here, we aimed to determine the status of actual adverse reactions to carbamazepine (CBZ) and lamotrigine (LTG) using national public databases.<br><b>Methods: </b>Data from the “Information on Decision on Payment/non-payment of Adverse Reaction Relief Benefits” (IARRB; April 2012-March 2016) and JADER (April 2012-March 2016) databases were downloaded from the website of the Pharmaceuticals and Medical Devices Agency.  Information from the national database of the “Health Insurance Claims and Specific Health Checkups of Japan” (NDB) (April 2014-March 2015) was downloaded from the website of the Ministry of Health, Labour and Welfare.<br><b>Results: </b>The numbers of females and males in the IARRB were 169 and 229, respectively, for CBZ and 135 and 56, respectively, for LTG.  Those in JADER were 1,152 and 1,352, respectively, for CBZ and 1,358 and 806, respectively, for LTG.  The respective ratios of males and females prescribed CBZ and LTG in the NDB were 46.2 and 53.8%, and 56.3 and 43.7%, respectively.  Both CBZ and LTG were identified as very high-risk drugs associated with extreme skin reactions such as drug-induced hypersensitivity syndrome (DIHS), toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome (SJS), erythema multiforme type drug eruption (EM), and disseminated papuloerythematous drug eruption (DPE).  CBZ induced DIHS, EM, and DPE more frequently among elderly men (over 60 years old), whereas LTG induced these reactions in women of reproductive age.<br><b>Conclusions: </b>Elderly men prescribed CBZ and women of reproductive age prescribed LTG should be advised about extreme adverse skin reactions.

Geographical distribution of primary care clinics for elderly ambulatory diabetic patients in Ibaraki Prefecture / 日本プライマリ・ケア連合学会誌

<b>Introduction</b> : The appropriate size of the regional coverage area for primary care in Japan has been unclear. The aim of this study was to determine the geographical distribution of primary care clinics for elderly ambulatory diabetic patients.<br><b>Methods</b> : Using an insurance claims database, we extracted data of patients aged 75 years and older requiring ambulatory diabetic care in May 2010 in Ibaraki prefecture. The geographical distance from each municipal office to the clinics was analyzed.<br><b>Results</b> : A total of 17,717 data points were extracted from the database. Data points that could not be mapped due to coding errors were eliminated, resulting in 17,144 (96.8%) data points that were ultimately analyzed. The median [25th-75th percentile] geographical distance was 5.5 [2.3-9.9] km. The distance was not related to municipal population, aging rate, or area size.<br><b>Conclusion</b> : The coverage area for diabetic care in this primary care setting was estimated. For most elderly ambulatory diabetic patients, clinics are distributed within a 10-km radius area. Further investigation is needed to clarify primary care coverage areas that result in the most efficient use of medical resources.

<b>Assessment of Medical Information Databases to Estimate Patient Numbers</b> / 薬剤疫学

<b>Objective</b>: Medical information databases provide useful Real World Evidence (RWE) and a comprehensive view of medical activities. However, since each database has limited coverage and cannot be self-sufficient, combining information from multiple databases is a useful research technique. In this study, we examined methods of estimating patient numbers by combining information from multiple databases in order to assess the respective databases and identify the respective characteristics, biases and idiosyncrasies. This process also allowed us to propose improvements in the grand design of medical information databases in Japan.<br><b>Design</b>: Retrospective observational cohort study<br><b>Methods</b>: We attempted to estimate the numbers of patients treated for certain diseases and the numbers prescribed a drug by three methods: i) We estimated patient numbers for seven diseases using an insurance claims database, adjusting the proportion of elderly patients according to a hospital medical records database; ii) Sales information for drug X was combined with the prescribed volume per person estimated from pharmacy claims databases to estimate the number of patients administered X; this number was divided by the prescription rate obtained from a medical claims database to calculate patient numbers for the associated disease; and iii) We examined two surveys of the National Institute of Infectious Diseases (NIID) for timely estimation of patient numbers for influenza, referring to estimates from an insurance claims database.<br><b>Results</b>: In Method i)-iii), we proved that it is possible to estimate patient numbers for many diseases and administered drugs by effectively combining multiple medical information databases. Validation could be claimed when multiple methods lead to similar results.<br><b>Conclusion</b>: These databases provided by government agencies and private corporations are separately managed, and there is no grand plan to integrate them into one platform. It is crucial that databases, rather than being designed to stand alone, are standardized according to widely used systems under a solid master data management strategy. This will make it easier to combine information from multiple databases and to maximize their values. Mutual use of these databases by academic researchers for epidemiological and clinical studies and by government policy makers and data scientists of pharmaceutical companies may improve the usefulness of these databases and expand their application in research.

<b>3. Legal Bases of the National Claims Database </b> / 薬剤疫学

Japan's national claims database(NDB) was established and its data became available for research purposes. However its potential for research use is considerably limited due to privacy protection requirements and security rules. For example, tabulations containing figures smaller than 10 are not allowed to be published due to the minimal cell size rules. Strangely enough, a similar statistical survey named Health Insurance Claims Survey(HICS) is not subject to such restrictions. Such difference in research use derives from different legal bases: NDB based on the Administrative Personal Data Protection Law while the HICS based on the Statistics Law. The vectors of the two laws are opposite: the Administrative Personal Data Protection Law intends to protect privacy while the Statistics Law intends to enhance data use. Application of the Statistics Law to NDB would be desirable to enhance research use but that would also restrict the government from using NDB data for other purposes such as detection of fraud and abuses. The government has multiple and mutually overlapping statistical surveys on health insurance claims since long before, all of which are subject to the Statistics Law and there is a call for unifying them with a single NDB to avoid duplication and waste. The author proposes, however, that it would be desirable to maintain multiple databases subject to different legal bases to enhance both research use while securing the discretion of the government to use NDB data effectively. Hindrance against effective use of national databases due to legal constraintsfor privacy protection is not limited to Japan. An excerpt of a recent survey results by OECD on national databases and legal restrictions on their secondary use was added for reference. (Jpn J Pharmacoepidemiol 2012; 17(2): 117-134)

Medical Service Utilization with Osteoporosis

BACKGROUND: Although osteoporosis is increasing in the elderly population, attempts to analyze the patterns of medical service utilization for osteoporosis are currently not sufficient. The medical services and treatment patterns were investigated using Korea's National Health Insurance claims data, which includes all of the Korean population. METHODS: Through the patient identification algorithm developed by using the administrative claims data in 2007, the adult patients (between 50-100 years) with osteoporosis were identified. The age and gender of the patients who used medical service for osteoporosis were described, in relation with six dichotomous variables. The medical service use patterns such as the type of medical institution and conducting bone mineral density measurement were investigated. RESULTS: The number of patients who used medical service were 1,230,580 (females 89.9%). Sixty one point six percent of the patients were prescribed osteoporosis medicine (indicated for osteoporosis only), and 12.9% of the patients had experienced osteoporotic fracture. The primary medical institutions for treatment were clinics (54.3%), while hospitals were mainly used among the patients with a history of fracture and disease or drug use that may induce secondary osteoporosis. The number of visited medical institutions was 6.4 (as an outpatient) and 0.2 (as admissions) during 6 months. The proportion of patients who conducted bone mineral density measurements within one year before and after the diagnosis of osteoporosis was 66.7% and DXA was the most frequently used densitometry (46.3%). The average number of days for the prescriptions for osteoporosis medicine was 70 days. CONCLUSION: In order to prevent further osteoporotic fractures, appropriate management and treatment should be implemented for osteoporosis patients. To do this, we need to understand the current state of medical service utilization and the treatment of osteoporosis using the National Health Insurance claims data.

Development of the National Database by the Government and its Potential for Pharmacoepidemiology / 薬剤疫学

As the number of electronically submitted health insurance claims increases, so does the potential for the effective use of such valuable health data to improve quality health care. The Ministry of Health, Labor & Welfare (MHLW), thanks to the IT reform initiative in 2006 calling for creation of a national database (NDB) and its effective use for epidemiological studies, is developing NDB containing health insurance claims data as well as health checks and guidance data individually linked by encryption techniques. Procurement of the software (system development) and the hardware will be completed by the end of FY2008, and gradual collection of data will start in FY2009. In the first phase (FY2009-10), the analysis of the evaluation of Health Care Cost Containment Plans (HCCCP) will be the top priority and the economic evaluation of health checks and guidance may pose methodological challenges. In the second phase (FY2011-), after a full on-line submission of health insurance claims, MHLW will start to publish the findings of the analysis. Although the governing law limits the purpose of NDB to "development, implementation and evaluation of HCCCP", a report by the committee studying the use of health insurance claims data for the improvement of quality health care called for wider use of NDB for public interests in February 2008. Also, JSPE submitted a statement to the Minister in late 2007 calling for the use of NDB for pharmacoepidemiological purposes. For the opinions and demands of JSPE to materialize, continued support and effort from the members is greatly appreciated.

Data Mining Technique for Signal Detection of Drug Adverse Events Using Health Insurance Claims / 薬剤疫学

Objective : To detect signals of potential drug adverse events (DAEs) through data mining of health insurance claims.<BR>Design and Data : Retrospective observational study. The data used were the database of health insurance claims collected and maintained by the Japan Medical Data Center consisting of 312, 797 medical and pharmaceutical claims in one year (August 2003 through July 2004) linked uniquely for 35, 410 patients using an encryption technique to ensure privacy.<BR>Methods : We counted all combinations (cross product or Cartesian product) of drugs and diagnoses appearing in the same claims and counted the number of times a given drug was prescribed preceding the suspected diagnosis in all combinations of the drug and the diagnosis appearing in a claim, i.e., the prescription date precedes the diagnosing date (the preceding number). We calculated the expected preceding number from the overall prevalence of drugs and diagnoses, and then calculated the observed and expected ratio, which was used as the signal indices. We calculated the signal indices on the health insurance claims data to detect DAEs of psychiatric drugs.<BR>Results : Amoxapine and trazodone HCL showed high signal indices with paralytic ileus and convulsion (epilepsy) as documented in their package inserts. However, paroxetine HCL and etizolam showed high signal indices with these potential adverse events although no such DAEs are documented in their package inserts.<BR>Conclusions : The undocumented high signal indices observed between the drugs and diagnoses indicate the potential DAEs and warrant in-depth pharmacovigilance. Given the strength of health insurance claims with a well-defined source population and accurate drug exposure, the proposed signal index will likely prove to be an effective data mining technique when combined with nested case-control analysis and counter-matching.

Development of a Decision Support Program to minimize Health Insurance Claims Reject: 20% albumin infusion and perineal care procedure / 대한의료정보학회지

This study was focused on developing a computerized decision support program for physician order entry of 20% albumin infusion and perineal care procedures in order to minimize inpatients'insurance claims rejects. The frequency of inpatients health insurance reimbursement claims rejects of a 800-bed tertiary care teaching university hospital in Seoul area was reviewed and the most common two orders of the reject were chosen for the study. The order decision support program was designed on the basis of Korean Health Insurance Reimbursement Guidelines. The server system used for the study was ProLiant 7000 and Pentium III was used for the program development. Windows 2000 was used as the operating system, MS SQL v7.o was used for the database. The software development languages were Visual basic V6.0 and Spread v3.0. This Decision Support Program was proven to be very useful when doctors and nurses wanted to reflect the Health Insurance Reimbursement Guidelines in their ordering practices.

Reduction of Influenza-related Outpatient Visits Among Community-dwelling Elderly Who Received Influenza Vaccination / 薬剤疫学

Objective : To evaluate the difference in utilization of influenza-related outpatient visits of the community-dwelling elderly between recipients and non-recipients of influenza vaccination using health insurance claims with the main purpose of appraising the effectiveness of a community-wide vaccination program<BR>Design : A retrospective observational study<BR>Methods : Outpatient health insurance claims of elderly enrollees of Natori city National Health Insurance program in February 2002 were matched with the list of influenza vaccination recipients in previous year. Comparison was made between vaccinated and non-vaccinated groups with respect to the share of influenza and related respiratory diseases in aggregate number of days (= outpatient visits).<BR>Results : Influenza accounted for 0.319% of outpatient days of the non-vaccinated group while it accounted for 0.053% of the vaccinated group, or 83.4% reduction in the aggregate number of outpatient visits purely attributable to influenza. The difference was statistically significant.<BR>Discussions : The observed difference in utilization of outpatient visits attributable to influenza was consistent with proven vaccine effectiveness of approximately 80% established in RCTs. Due to the non-randomization nature of this method, it cannot provide a valid evaluation of vaccine effectiveness. However, the observed reduction of outpatient visits attributable to influenza will yield a reasonable appraisal method to retrospectively evaluate the efficacy of a community-wide mass vaccination program particularly in view of the possible adverse selection of vaccine recipients as evidenced by the high percent of institutionalized elderly and higher per claim cost. Retrospective analysis of health insurance claims, though not a substitution of RCTs by any means, can serve as a practical method for program appraisal where RCTs are not feasible.

Sensitivity of Medical Insurance Claims Data Using Population-based Cancer Registry Data / 대한의료정보학회지

Although medical insurance claims data provide an increasingly accessible and widely used source of data for health care research, there are few studies about their sensitivity. This study was conducted to investigate the sensitivity of diagnosed cancers in medical insurance claims data. Every case of Kwangju Cancer Registry registered during 1998-1999 was checked for its status in medical insurance claims. The sensitivity of medical insurance claims was expressed as the proportion of cases who were reported as having cancer among cancer registry cases. The sensitivities of Kwangju and nationwide medical insurance claims data for overall cancer were 87.2% and 92.8%, respectively. For cancer sites, the sensitivity of medical insurance claims data was the highest for breast, followed by thyroid, lymphoma and colorectum, and the lowest for pancreas and kidney. Medical insurance claims data would provide reasonably high sensitivity for the detection of cancer, especially if nationwide medical insurance claims are included. Further studies should examine false positive cases to measure other dimensions of accuracy, such as specificity and predictive value.

Computerization of Health Insurance Claims and its Application to Pharmacoepidemiological Studies / 薬剤疫学

Objective : To elucidate the availability and applicability of the information contained in health insurance claims to pharmacoepidemiological studies with particular reference to the computerization of insurance claims submitted by dispensing pharmacies.<BR>Data Sources : Outpatient insurance claims of two health insurance societies based in the Kanto region. The survey, funded by the Federation of Health Insurance Societies, was undertaken as part of a demonstration project to develop methodologies for insurers to evaluate the clinical performance of providers.<BR>Study Selection : Disease-specific, provider-specific and clinical procedure specific comparison of the per-claim cost. All claims from pharmacies were matched with the prescribing hospitals or clinics to capture the entire medication.<BR>Data Extraction : All claims were reviewed by trained reviewers and procedure specific costs were classified into five disease categories to obtain the best estimate of disease-specific cost.<BR>Results : Inter-provider variations were assessed based on overlapping of the overall average and the confidence interval of the doubled standard error after adjusting for age. Contrary to popular belief, academic medical centers showed significantly lower medication cost than clinics for the treatment of acute upper respiratory infection. Prescription pattern to favor high cost antibiotics accounted for higher per-claim medication cost of clinics with concentration of high cost claims.<BR>Conclusion : Based on the authors' experience and methodologies developed, computerization of insurance claims will achieve consistency, efficiency and timelines which are of utmost importance for pharmacoepidemiological studies. On the other hand, insurers may preempt the claims review and reimbursement organizations by appealing to the pharmacy claims through electronically matching the prescribing claims. The nature of evidence sought by both pharmacoepidemiological researchers and insurers, whether it be for the purpose of post-marketing survey or cost cutting, would eventually converge.

The accuracy of myocardial infarction diagnosis in medical insurance claims. Korean Research Group for Cardiovascular Disease Prevention and Control

We attempted to assess the accuracy of the International Classification of Diseases (ICD) codes for myocardial infarction (MI) in medical insurance claims, and to investigate the reasons for any inaccuracy. This study was designed as a preliminary study to establish a surveillance system for cardiovascular diseases in Korea. A sample of 258 male patients who were diagnosed with MI from 1993 to 1997 was selected from the Korea Medical Insurance Corporation cohort (KMIC cohort: 183,461 people). The registered medical record administrators were trained in the survey technique, and gathered data by investigating the medical records of the study subjects from March 1999 to May 1999. The definition of MI for this study included symptoms pursuant to the diagnostic criteria of chest pain, electrocardiogram (ECG) findings, cardiac enzyme and results of coronary angiography or nuclear scan. We asked the record administrators for the reasons of incorrectness for cases where the final diagnosis was 'not MI'. The accuracy rate of the ICD codes for MI in medical insurance claims was 76.0% (196 cases) of the study sample, and 3.9% (ten cases) of the medical records were not available due to hospital closures, non-computerization or missing information. Nineteen cases (7.4%) were classified as insufficient due to insufficient records of chest pain, ECG findings, or cardiac enzymes. The major reason of inaccuracy in the disease code for MI in medical insurance claims was 'to meet the review criteria of medical insurance benefits (45.5%)'. The department responsible for the inaccuracy was the department of inspection for medical insurance benefit of the hospitals.

The Accuracy of ICD codes for Cerebrovascular Diseases in Medical Insurance Claims / 예방의학회지

OBJECTIVES: We attempted to assess the accuracy of ICD codes for cerebrovascular diseases in medical insurance claims (ICMIC) and to investigate the reasons for error. This study was designed as a preliminary study to establish a nationwide surveillance system. METHODS: A total of 626 patients with medical insurance claims who indicated a diagnosis of cerebrovascular diseases during the period from 1993 to 1997 was selected from the Korea Medical Insurance Corporation cohort (KMIC cohort: 115,600 persons). The KMIC cohort was 10% of those insured who had taken health examinations in 1990 and 1992 consecutively. The registered medical record administrators were trained in the survey technique and gathered data from March to May 1999. The definition of cerebrovascular diseases in this study included cases which met one of two criteria (Minnesota, WHO) or 'definite stroke' in CT/MRI finding. We questioned the medical record administrators to explain the error if the final diagnoses were not coded as stroke. RESULTS: The accuracy rate of the ICMIC was 83.0% (425 cases). Medical records were not available for 8.2% (51 cases) due to the closing of hospitals, the absence of a computer system or omission of medical record, etc. Sixty-three cases (10.0%) were classified as impossible to interpret due to insufficient records in 'major clinical symptoms' or 'neurological deficits'. The most common reason was 'to meet review criteria of medical insurance benefits (52.9%)'. The department where errors in the ICMIC occurred most frequently was the department for medical insurance claims in the hospital. CONCLUSION: The accuracy rate of the ICMIC was 83.0%.

Impacts of DRG Payment System on Behavior of Medical Insurance Claimants / 예방의학회지

OBJECTIVES: To evaluate the impacts of the DRG payment system on the behavior of medical insurance claimants. Specifically, we evaluated the case-mix index, the numbers of diagnosis and procedure codes utilized, and the corresponding rate of diagnosis codes before, during and after implementation of the DRG payment system. METHODS: In order to evaluate the case-mix index, the number of diagnosis and procedure codes utilized, we used medical insurance claim data from all medical facilities that participated in the DRG-based Prospective Payment Demonstration Program. This medical insurance claim data consisted of both pre-demonstration program data (fee-for-service, from November, 1998 to January, 1999) and post-demonstration program data (DRG-based Prospective Payment, from February, 1999 to April, 1999). And in order to evaluate the corresponding rate of diagnosis codes utilized, we reviewed 820 medical records from 20 medical institutes that were selected by random sampling methods. RESULTS: The case-mix index rate decreased after the DRG-based Prospective Payment Demonstration Program was introduced. The average numbers of different claim diagnosis codes used decreased (new DRGs from 2.22 to 1.24, and previous DRGs from 1.69 to 1.21), as did the average number of claim procedure codes used (new DRGs from 3.02 to 2.16, and previous DRGs from 2.97 to 2.43). With respect to the time of participation in the program, the change in number of claim procedure codes was significant, but the change in number of claim diagnosis codes was not. The corresponding rate of claim diagnosis codes increased (from 57.9% to 82.6%), as did the exclusion rate of claim diagnosis codes (from 16.5% to 25.1%). CONCLUSIONS: After the implementation of the DRG payment system, the corresponding rate of insurance claim codes and the corresponding exclusion rate of claim diagnosis codes both increased, because the inducement system for entering the codes for claim review was changed.

Incorrect Disease Coding in Medical Insurance Claims and the Effect of Official Intervention: Based on Medical Insurance Claims of 6 Notifiable Acute Communicable Diseases / 한국역학회지

BACKGROUND: Because of their large size and excellent computerized records of illness and services rendered, the importance of national insurance program is getting much attentions from the public health researchers and the national and local health authorities. In reality, however, most health records from medical insurance program suffer very much from inaccurate disease coding, and therefore, they are practically in no use. METHODS: Pattern of incorrect disease coding of 6 Notifiable Acute Communicable Diseases that believed not to have been occurred in Korea lately was reviewed. The reasons of such incorrect codings in different level of medical institutions were studied. This study also attempted to see how an official intervention asking the medical institutions to correct their coding behavior works by comparing the frequencies of incorrect disease coding before and after the intervention. RESULTS: Study results showed that more incorrect disease codings came from clinics than hospitals, and non-physician personnel in clinics and hospitals seemed to be responsible for most of the incorrect disease codings. Most frequent diseases coded incorrectly such as cholera and poliomyelitis were the ones that physicians and non-physician personnel in the clinics and hospitals had been familiar with for a long time period. CONCLUSION: Even a simple official intervention asking the clinics and hospitals to correct their coding behavior was very effective : total number of incorrect disease codings before intervention (398 cases from 144 institutions) dramatically decreased (14 cases from 8 institutions) after intervention. Significant decrease in incorrect disease coding was found more in small institutions such as clinics and public health facilities than large institutions.

Activity Report of the Liaison Meetings of Reserchers Interested in Health Insurance Claims as Data Source / 薬剤疫学

Background : Health insurance claims contain invaluable data for epidemiological survey. However their use for research purposes has been hampered by both bureaucratic red-tape and technical limitations. These include the lack of legal rationale for disclosure and the lack of electronic data transfer. In response to the recent advancement in these field, such as the governmental policy change to allow disclosure of the claims to patients and a rapid computerization of the claims, researchers interested in health insurance claims held liaison meetings to exchange views and know-hows to facilitate the epidemiological research using health insurance claims.<BR>Reports on the Meeting : The liason meetings have so far been held twice as part of Japan Public Health Association annual assembly, at Yamagata in 1995 and at Yokohama in 1997, both sponsored by the author. Fourteen researchers presented their research activities using health insurance claims and discussed with the attendants on their experience to overcome the bureaucratic red-tape and technical limitations. Two of the presenters beside the author were pharmacoepidemiologists : Dr. Hayashi addressed the value and possibilities of the claims as data source for pharmacoepidemiology and Dr. Kubota proposed PEM (Prescription Event Monitoring) using health insurance claims as triggers to complement the present voluntary ADR reporting.<BR>Implications : Since the bureaucratic and technical obstacles may be better handled through a coordinated and liaisoned action of the researchers, it is necessary to form a consortium of researchers and professionals who have any interest in health insurance claims regardless of their purposes and make guidelines and recommendations to assure legitimate and appropriate utilization of the potentially sensitive but useful individual information.