Effects of private health insurance on medical expenditure and health service utilization in South Korea: a quantile regression analysis.

BACKGROUND: Despite universal health insurance, South Korea has seen a sharp increase in the number of people enrolled in supplemental private health insurance (PHI) during the last decade. This study examined how private health insurance enrollment affects medical expenditure and health service utilization. METHODS: Unbalanced panel data for adults aged 19 and older were constructed using the 2016-2018 Korea Health Panel Survey. Quantile regression for medical cost, and quantile count regression for health service utilization were utilized using propensity score-matched data. We included 17 variables representing demographic, socioeconomic, and health information, as well as medical costs and use of outpatient and inpatient care. RESULTS: We discovered that PHI enrollees' socioeconomic and health status is more likely to be better than PHI non-enrollees'. Results showed that private health insurance had a greater effect on the lower quantiles of the conditional distribution of outpatient costs (coefficient 0.149 at the 10th quantile and 0.121 at the 25th quantile) and higher quantiles of inpaitent care utilization (coefficient 0.321 at the 90th quantile for days of hospitalization and 0.076 at the 90th quantile for number of inpatient visits). CONCLUSIONS: PHI enrollment is positively correlated with outpatient costs and inpatient care utilization. Government policies should consider these heterogeneous distributional effects of private health insurance.

The associations of continuity of care with inpatient, outpatient, and total medical care costs among older adults with urinary incontinence.

INTRODUCTION: Urinary incontinence is a significant health problem with considerable social and economic consequences among older adults. The objective of this study was to investigate the financial impact of continuity of care (CoC) among older urinary incontinence patients in South Korea. METHODS: We used the NHIS-Senior cohort patient data between January 1, 2010, and December 31, 2010. Patients who were diagnosed with urinary incontinence in 2010 were included. Operational definition of CoC included referrals, number of providers, and number of visits. A generalized linear model (GLM) with γ-distributed errors and the log link function was used to examine the relationship between health cost and explanatory variables. Additionally, we conducted a two-part model analysis for inpatient cost. Marginal effect was calculated. RESULTS: Higher CoC was associated with a decrease in total medical cost (-0.63, P < .0001) and in outpatient costs (-0.28, P < .001). Higher Charlson Comorbidity Index (CCI) score was a significant predictor for increasing total medical cost (0.59, P < .0001) and outpatient cost (0.22, P < .0001). Higher CoC predict a reduced medical cost of $360.93 for inpatient cost (P = 0.044) and $23.91 for outpatient cost (P = 0.008) per patient. CONCLUSION: Higher CoC was associated with decrease in total medical costs among older UI patients. Policy initiatives to promote CoC of older UI patients in the community setting could lead to greater financial sustainability of public health insurance in South Korea.

Smoking and passive smoking increases mortality through mediation effect of cadmium exposure in the United States.

Cigarette smoking is one of the leading causes of preventable and premature death worldwide. Even worse, many people are generally exposed to passive smoking, which leads to several respiratory diseases and related mortalities. Considering, more than 7000 compounds are included in cigarettes, their combustion results intoxicants that have deleterious effects on health. However, there is a lack of research analyzing the effects of smoking and passive smoking on all-cause and disease-specific mortality through its chemical compounds including heavy metals. Thus, this study aimed to evaluate the effect of smoking and passive smoking on all-cause and disease-specific mortality mediated by cadmium, one of the representative smoking-related heavy metals using data from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 in the United States. We found that current smoking and passive smoking was related to increased risk of all-cause, CVD-related, and cancer-related mortality. Notably, passive smoking showed a synergistic effect with smoking status on the risk of mortality. In particular, current smokers with passive smoking had the highest risk of all-cause and disease-specific deaths. In addition, the accumulation of cadmium in the blood due to smoking and passive smoking mediates the increased risk of all-cause mortality. Further studies are needed to monitor and treat cadmium toxicity to improve smoking-related mortality rates.

Access to care and satisfaction with care among fee-for-service Medicare beneficiaries by level of care need.

BACKGROUND: Variation among fee-for-service (FFS) Medicare beneficiaries by level of care need for access to care and satisfaction with care is unknown. OBJECTIVE: We examined access to care and satisfaction with care among FFS Medicare beneficiaries by level of care need. METHODS: We employed a cross-sectional study design. Using the Medicare Current Beneficiary Survey, we categorized 17,967 FFS Medicare beneficiaries into six groups based on level of care need: the relatively healthy (11.0%), those with simple chronic conditions (26.1%), those with minor complex chronic conditions (28.6%), those with major complex chronic conditions (14.2%), the frail (6.2%), and the non-elderly disabled or end-stage renal disease (ESRD) (13.9%). Outcome measures included multiple indicators for access to care and satisfaction with care. For each outcome, we conducted a linear probability model while adjusting for individual-level and county-level characteristics and estimated the adjusted value of the outcome by level of care need. RESULTS: The non-elderly disabled or ESRD were more likely to experience limited access to care and poor satisfaction with care than other five care need groups. Particularly, the rates of reporting trouble accessing needed medical care were the highest among the non-elderly disabled or ESRD (12.4% [95% CI: 9.6-15.3] vs. 2.1 [95% CI: 1.5-2.8] to 2.5 [95% CI: 1.6-3.5]). The leading reason for trouble accessing needed care among the non-elderly disabled or ESRD was attributable to affordability (59.6%). CONCLUSIONS: Policymakers need to develop targeted approaches to improve access to care and satisfaction with care for the non-elderly with a disability or ESRD.

Association between body shape index and risk of mortality in the United States.

The body mass index (BMI) neither differentiates fat from lean mass nor does it consider adipose tissue distribution. In contrast, the recently introduced z-score of the log-transformed A Body Shape Index (LBSIZ) can be applied to measure obesity using waist circumference (WC), height, and weight. We aimed to investigate the association between LBSIZ and mortality. We used data from the National Health and Nutrition Examination Survey 1999-2014 and linked the primary dataset to death certificate data from the National Death Index with mortality follow-up through December 31, 2015. A multiple Cox regression analysis was performed to evaluate the hazard ratio (HR) of all-cause and cardiovascular disease (CVD) mortalities with adjustment for baseline characteristics. LBSIZ, WC, and BMI showed positive association with total fat percentage (P < 0.001); however, only WC and BMI were positively associated with appendicular skeletal mass index (ASMI) (P < 0.001). In the multiple Cox regression analysis, only LBSIZ showed a significant HR for all-cause and CVD mortalities. Under restricted cubic spline regression, mortality risk increased with LBSIZ. However, BMI and WC showed a U-shape association. In conclusion, LBSIZ is strongly associated with all-cause and CVD mortalities. Since LBSIZ is independent of BMI, LBSIZ complements BMI to identify high-risk groups for mortality even in individuals with low or normal BMI.

Pain and mortality among older adults in Korea.

OBJECTIVES: With the increasing elderly population with chronic disease, understanding pain and designing appropriate policy interventions to it have become crucial. While pain is a noted mortality risk factor, limited studies exist due to the various causes of pain and the subjectivity of pain expression. This study aimed to examine the relationship between pain and mortality, controlling for other diseases and socio-cultural factors. METHODS: We analyzed 6,258 individuals aged 45 years or older, the population with the highest prevalence of pain, using the Korean Longitudinal Study of Aging (2006-2016) data and the Cox proportional-hazards model. Further subgroup analyses were conducted by sex and education level to examine differences in the relationship between pain and mortality. RESULTS: The adjusted hazard ratios of mortality were 1.16 (95% confidence interval [CI], 1.00 to 1.34, model 1) and 1.12 (95% CI, 0.97 to 1.29, model 2) for the individuals in pain depending on the models used, where additional socio-cultural factors were accounted for in model 2. For individuals in severe pain, ratios were significantly higher with 1.23 (95% CI, 1.08 to 1.41, model 1) and 1.16 (95% CI, 1.02 to 1.32, model 2). Further subgroup analyses showed that severe pain was more associated with mortality for males and more educated individuals, with adjusted hazard ratios of 1.29 (95% CI, 1.08 to 1.55, model 2) and 1.62 (95% CI, 1.15 to 2.28, model 2), respectively. CONCLUSIONS: Pain showed a statistically significant relationship with mortality risk. Family members or medical staff should pay proper attention to pain, particularly severe pain in males and highly educated individuals.

Fluoroquinolone and no risk of Achilles-tendinopathy in childhood pneumonia under eight years of age-a nationwide retrospective cohort.

BACKGROUND: The emergence of macrolide-resistant Mycoplasma pneumoniae pneumonia (MRMP) has made its treatment challenging. A few guidelines have recommended fluoroquinolones (FQs) as second-line drugs of choice for treating MRMP in children under the age of eight, but concerns about potential adverse events (i.e., Achilles tendinopathy; AT) have been raised. The aim of this study was to investigate the relationship between the use of FQs and the risk of AT in pneumonia in children under eight years of age. METHODS: Children hospitalized with pneumonia (total of 2,213,807 episodes) from 2002 to 2017 were enrolled utilizing the Korean National Health Insurance Sharing Service (NHISS) database. The independent risk of FQs for AT was analyzed by a generalized estimating equation with adjustment for age, sex, and underlying diseases. RESULTS: Among 2,213,807 episodes of pneumonia hospitalization, children in a total of 6,229 episodes (0.28%) were treated with FQs (levofloxacin 40.9%, ciprofloxacin 36.1%, moxifloxacin 11.6%, and others 11.4%). The FQ-exposure group showed a 0.19% (12/6,229) incidence of AT within 30 days after the first administration of FQ. The use of FQs increased the risk of AT (OR 3.00; 95% CI: 1.71-5.29), but became null after adjusting for age, sex, and underlying diseases (aOR 0.85; 95% CI: 0.48-1.51). All AT related to the use of FQs occurred after the use of ciprofloxacin or levofloxacin, and not in children under eight years of age. CONCLUSIONS: AT was a rare adverse event of FQ use for childhood pneumonia, particularly under eight years of age. Clinicians could consider using FQs as a second-line option in the treatment of childhood pneumonia when there are no alternative therapeutic options.

Self-rated health as a predictor of mortality according to cognitive impairment: findings from the Korean Longitudinal Study of Aging (2006-2016).

OBJECTIVES: Self-rated health is an instrumental variable to assess the overall health status of a population. However, it remains questionable whether it is still useful for cognitively impaired individuals. Therefore, this study aims to analyze whether self-rated health by the cognitively impaired predicts mortality reliably. METHODS: This study used 7,881 community-dwelling individuals, aged 45 and above, from the Korean Longitudinal Study of Aging (2006-2016). It used the Cox proportional hazard models for analysis. Cognitive status was classified based on the Korean Mini Mental State Examination score and a stratified analysis was used to determine whether the predictability of self-rated health varies according to cognitive status. RESULTS: For cognitively intact individuals, the adjusted hazard ratios (aHR) of mortality were 2.00 (95% confidence interval [CI], 1.18 to 3.41, model 4) for those with 'bad' self-rated health and 2.40 (95% CI, 1.35 to 4.25, model 4) for those with 'very bad' self-rated heath, respectively, compared with those with 'very good' health. The results remain statistically significant even after adjusting for socio-demographic factors, health status, and health-related behaviors. For cognitively impaired individuals, the aHR of mortality was statistically significant for those with 'very bad' self-rated health, compared with those with 'very good' health, when socio-demographic factors were accounted for (aHR, 3.03; 95% CI, 1.11 to 8.28, model 2). CONCLUSIONS: Self-rated health by cognitively impaired individuals remains useful in predicting mortality. It appears to be a valid and reliable health indicator for the rising population with cognitive impairment, especially caused by aging population.

Effect of Sarcopenia and Body Shape on Cardiovascular Disease According to Obesity Phenotypes.

Background: This study aimed to assess the effects of sarcopenia and A Body Shape Index (ABSI) on cardiovascular disease (CVD) risk according to obesity phenotypes. Methods: We used data from the National Health and Nutrition Examination Survey 1999 to 2012. A total of 25,270 adults were included and classified into the following groups: metabolically healthy normal weight (MHNW), metabolically healthy overweight/obese (MHO), metabolically unhealthy normal weight (MUNW), and metabolically unhealthy overweight/obese (MUO). Sarcopenia was defined as the appendicular skeletal mass index <7 kg/m2 in men and <5.5kg/m2 in women. A multivariate logistic regression analysis was performed to evaluate the odds ratio (OR) of sarcopenia and ABSI for CVD events according to the obesity phenotype. Results: The MHNW participants with sarcopenia had higher risk for CVD than those without sarcopenia (OR, 2.69; 95% confidence interval [CI], 1.56 to 4.64). In the analysis with MHNW participants without sarcopenia as a reference, the participants with sarcopenia showed a higher OR for CVD than those without sarcopenia in both MHO (OR in participants without sarcopenia, 3.31; 95% CI, 1.94 to 5.64) (OR in participants with sarcopenia, 8.59; 95% CI, 2.63 to 28.04) and MUO participants (OR in participants without sarcopenia, 5.11; 95% CI, 3.21 to 8.15) (OR in participants with sarcopenia, 8.12; 95% CI, 4.04 to 16.32). Participants within the second and third tertiles of ABSI had higher ORs for CVDs than the counterpart of obesity phenotypes within the first tertile. Conclusion: These results suggest that clinical approaches that consider muscle and body shape are required.

Effect of body shape on the development of cardiovascular disease in individuals with metabolically healthy obesity.

Studies about the effects of metabolically healthy obesity on cardiovascular disease (CVD) have yielded conflicting results. These heterogeneous results could be due to the limited usefulness of BMI in measuring general adiposity, as body mass index (BMI) does not accurately reflect body composition. This study aimed to evaluate the effect of body shape on CVD outcomes across different obesity phenotypes, and to provide an explanation for the heterogeneous effects of metabolically healthy obese (MHO) phenotype on CVD.We analyzed data from the Korean Genome and Epidemiology Study, a population-based cohort study conducted between 2001 and 2012. We divided the participants into 4 groups: metabolically healthy non-obese (MHNO), MHO, metabolically unhealthy non-obese (MUNO), and metabolically unhealthy obese (MUO). To assess body shape, we calculated the z-score of the log-transformed a body shape index (LBSIZ). We computed Pearson correlation coefficients to examine the association of LBSIZ with muscle mass index, percentage of total fat mass (%Total FM), and percentage of abdominal fat mass (%Abdominal FM). We also used Cox proportional hazards regression to evaluate the effect of LBSIZ on CVD events according to the obesity phenotypes.A total of 9460 participants were assessed in this study. The incidence of CVD was 8.53 cases per 1000 person-year. LBSIZ showed strong positive correlation with %Total FM and %Abdominal FM, but negative correlation with muscle mass index. In Cox regression, MHO individuals did not show increased risk of CVD compared with MHNO individuals (hazard ratio [HR], 1.29; 95% confidence interval [CI], 0.96-1.73). However, MHO individuals in the 3rd (HR, 2.40; 95% CI, 1.28-4.51) and 4th (HR, 3.67; 95% CI, 1.99-6.74) quarters of LBSIZ showed significantly higher risk of CVD compared with MHNO individuals in the 1st quarter of LBSIZ. Moreover, LBSIZ showed a linear relationship with CVD among MHO individuals.While the MHO individuals showed similar CVD risk to the MHNO individuals, CVD risk increases with LBSIZ among the MHO individuals. LBSIZ appears to be a useful measure for CVD risk assessment in clinical practice and epidemiologic studies, especially for MHO patients.

The Association between Z-Score of Log-Transformed A Body Shape Index and Cardiovascular Disease in Korea.

BACKGROUND: In order to overcome the limitations of body mass index (BMI) and waist circumference (WC), the z-score of the log-transformed A Body Shape Index (LBSIZ) has recently been introduced. In this study, we analyzed the relationship between the LBSIZ and cardiovascular disease (CVD) in a Korean representative sample. METHODS: Data were collected from the Korea National Health and Nutrition Examination VI to V. The association between CVD and obesity indices was analyzed using a receiver operating characteristic curve. The cut-off value for the LBSIZ was estimated using the Youden index, and the odds ratio (OR) for CVD was determined via multivariate logistic regression analysis. ORs according to the LBSIZ value were analyzed using restricted cubic spline regression plots. RESULTS: A total of 31,227 Korean healthy adults were analyzed. Area under the curve (AUC) of LBSIZ against CVD was 0.686 (95% confidence interval [CI], 0.671 to 0.702), which was significantly higher than the AUC of BMI (0.583; 95% CI, 0.567 to 0.599) or WC (0.646; 95% CI, 0.631 to 0.661) (P<0.001). Similar results were observed for stroke and coronary artery diseases. The cut-off value for the LBSIZ was 0.35 (sensitivity, 64.5%; specificity, 64%; OR, 1.29, 95% CI, 1.12 to 1.49). Under restricted cubic spline regression, LBSIZ demonstrated that OR started to increase past the median value. CONCLUSION: The findings of this study suggest that the LBSIZ might be more strongly associated with CVD risks compared to BMI or WC. These outcomes would be helpful for CVD risk assessment in clinical settings, especially the cut-off value of the LBSIZ suggested in this study.

Utility of the Z-score of log-transformed A Body Shape Index (LBSIZ) in the assessment for sarcopenic obesity and cardiovascular disease risk in the United States.

Body mass index (BMI) has limited accuracy for predicting cardiovascular diseases (CVD) and is not capable of identifying sarcopenic obesity, the combination of sarcopenia (an age-associated decline in muscle mass and physical function) and obesity. To overcome this, the z-score of the log-transformed A Body Shape Index (LBSIZ) was recently introduced as a measure of obesity using waist circumference, height, and weight. We aimed to investigate the association of LBSIZ with sarcopenic obesity and CVD, and propose appropriate cut-off values using the National Health and Nutrition Examination Survey 1999-2016 data. Of 92,062 participants, 40,468 adults (≥20 years) were included. Overall area under curve (AUC) of LBSIZ was 0.735 (95% confidence interval [CI]: 0.716-0.754) for sarcopenic obesity, and 0.695 (95% CI: 0.687-0.703) for CVD. The subgroup analysis of ethnicity/race showed similar results. Waist circumference (WC), BMI, conicity index, body roundness index (BRI), Clinica Universidad de Navarra-Body Adiposity Estimator (CUN-BAE), new BMI, and waist to height ratio (WHtR) showed a negative association with sarcopenic obesity, while LBSIZ and conicity index showed a positive association. The AUC of LBSIZ was significantly higher for sarcopenic obesity than that of conicity index (p < 0.001). The AUC of LBSIZ was significantly higher for CVD than those of parameters including WC, BMI, BRI, CUN-BAE, new BMI, and WHtR (p < 0.001). The AUC for conicity index alone was comparable to that of LBSIZ for CVD. Overall LBSIZ cut-off was 0.35 for both sarcopenic obesity (sensitivity, 65.3%; specificity, 71.5%) and CVD (sensitivity, 63.3%; specificity, 66.6%). These results may be useful not only to identify sarcopenic obesity, but also to conduct CVD risk assessment in the clinical setting.

Impact of Regional Cardiocerebrovascular Centers on Myocardial Infarction Patients in Korea: A Fixed-effects Model.

OBJECTIVES: The Regional Cardiocerebrovascular Center (RCCVC) Project designated local teaching hospitals as RCCVCs, in order to improve patient outcomes of acute cardiocerebrovascular emergencies by founding a regional system that can adequately transfer and manage patients within 3 hours. We investigated the effects of RCCVC establishment on treatment volume and 30-day mortality. METHODS: We constructed a panel dataset by extracting all acute myocardial infarction cases that occurred from 2007 to 2016 from the Health Insurance Review and Assessment Service claims data, a national and representative source. We then used a panel fixed-effect model to estimate the impacts of RCCVC establishment on patient outcomes. RESULTS: We found that the number of cases of acute myocardial infarction that were treated increased chronologically, but when the time effect and other related covariates were controlled for, RCCVCs only significantly increased the number of treatment cases of female in large catchment areas. There was no statistically significant impact on 30-day mortality. CONCLUSIONS: The establishment of RCCVCs increased the number of treatment cases of female, without increasing the mortality rate. Therefore, the RCCVCs might have prevented potential untreated deaths by increasing the preparedness and capacity of hospitals to treat acute myocardial infarction patients.

Cost-effectiveness and health-related outcomes of screening for hepatitis C in Korean population.

BACKGROUND/AIM: In the era of direct-acting antivirals (DAA), active screening for hidden hepatitis C virus (HCV) infection is important for HCV elimination. This study estimated the cost-effectiveness and health-related outcomes of HCV screening and DAA treatment of a targeted population in Korea, where anti-HCV prevalence was 0.6% in 2015. METHODS: A Markov model simulating the natural history of HCV infection was used to examine the cost-effectiveness of two strategies: no screening vs screening and DAA treatment. Screening was performed by integration of the anti-HCV test into the National Health Examination Program. From a healthcare system's perspective, the cost-utility and the impact on HCV-related health events of one-time anti-HCV screening and DAA treatment in Korean population aged 40-65 years was analysed with a lifetime horizon. RESULTS: The HCV screening and DAA treatment strategy increased quality-adjusted life years (QALY) by 0.0015 at a cost of $11.27 resulting in an incremental cost-effectiveness ratio (ICER) of $7435 per QALY gained compared with no screening. The probability of the screening strategy to be cost-effective was 98.8% at a willingness-to-pay of $27 205. Deterministic sensitivity analyses revealed the ICERs were from $4602 to $12 588 and sensitive to screening costs, discount rates and treatment acceptability. Moreover, it can prevent 32 HCV-related deaths, 19 hepatocellular carcinomas and 15 decompensated cirrhosis per 100 000 screened persons. CONCLUSIONS: A one-time HCV screening and DAA treatment of a Korean population aged 40-65 years would be highly cost-effective, and significantly reduce the HCV-related morbidity and mortality compared with no screening.

Cost-effectiveness of sofosbuvir plus ribavirin therapy for hepatitis C virus genotype 2 infection in South Korea.

BACKGROUND AND AIM: For genotype 2 chronic hepatitis C (CHC), the efficacy and safety of sofosbuvir plus ribavirin therapy (SOF + RBV) was better than pegylated interferon plus ribavirin therapy (PR) at a greater drug cost. This study investigated the cost-effectiveness of SOF + RBV compared with PR for treatment-naïve genotype 2 CHC in South Korea. METHODS: Using a decision analytic Markov model, a cost-effectiveness analysis comparing SOF + RBV with PR or no treatment for treatment-naïve genotype 2 CHC was performed with probabilistic and deterministic sensitivity analyses from the payer's perspective in 2017. Three cohorts of patients aged 40-49, 50-59, and 60-69 years were simulated to progress through the fibrosis stages F0-F4 to end-stage liver disease, hepatocellular carcinoma, or death. Published and calculated data on the clinical efficacy of the regimen, health-related quality of life, costs, and transition probabilities were used. RESULTS: While the incremental cost-effectiveness ratio for PR was dominant over no treatment, the incremental cost-effectiveness ratios for SOF + RBV were $20 058 for the patients in their 40s, $19 662 for those in their 50s, and $22 278 for those in their 60s compared with PR. Probabilistic sensitivity analysis indicated an 89.0% probability for the SOF + RBV to be cost-effective at a willingness to pay of $29 754.4 (per-capita gross domestic product in 2017) for the patients in their 40s and 94.1% and 89.1% for the patients in their 50s and 60s, respectively. CONCLUSIONS: The SOF + RBV is a cost-effective option for genotype 2 treatment-naïve CHC patients, especially for the patients with liver cirrhosis in Korea.

Effectiveness of Z-score of log-transformed A Body Shape Index (LBSIZ) in predicting cardiovascular disease in Korea: the Korean Genome and Epidemiology Study.

Body mass index (BMI) and waist circumference (WC) have limitations in stratifying cardio-metabolic risks. Another obesity measure, A Body Shape Index (ABSI), has been introduced but its applicability remains limited. To address this, the z-score of the log-transformed ABSI (LBSIZ) was recently developed. This study aimed to examine the ability of LBSIZ, compared to that of WC and BMI, to predict cardiovascular disease (CVD) risk. The study included 8,485 participants aged 40-69 years (mean age = 52.1) who were followed for 10 years and recruited from the Korean Genome and Epidemiology Study, a population-based cohort study. The area under the curve was 0.635 (95% confidence interval [CI]: 0.614-0.657) for LBSIZ, 0.604 (95%CI: 0.580-0.627) for WC, and 0.538 (95%CI: 0.514-0.562) for BMI. The AUC of the Framingham risk score (FRS) was 0.680 (95%CI: 0.659-0.701) in comparison. When we added LBSIZ to the model, the integrated AUC significantly improved from 0.680 to 0.692 (95%CI: 0.672-0.713; p value, 0.033), whereas there were no changes with BMI (AUC, 0.678; 95%CI: 0.656-0.699) or WC (AUC, 0.679; 95%CI: 0.658-0.701). In the multivariate Cox regression analysis, LBSIZ but not BMI or WC showed a significant hazard ratio of CVD event compared to 1st decile of each parameter. In the restricted cubic spline regression, BMI and WC showed an overall J-shaped relationship with CVD events whereas LBSIZ showed a linear relationship. LBSIZ is strongly associated with CVD risk and should predict CVD risk better than BMI and WC in the general population.

Liver cirrhosis and cancer: comparison of mortality.

BACKGROUND: Liver cirrhosis is known to have low survival rate, and its assessment in relation with other fatal diseases will help us design appropriate health interventions. This study compares the mortality of liver cirrhosis with that of five major cancers (lung, colorectal, stomach, liver, and breast cancers). METHODS AND RESULTS: We used the National Health Insurance Service-National Sample Cohort (NHIS-NSC) which provides data for 1,025,340 representative samples of the 46,605,433 people in Korea from 2002 to 2010. During the 8 years, 800 out of 2609 liver cirrhosis patients died and 1316 out of 4852 patients with the five major cancers died. When we estimated the mortality between liver cirrhosis and five major cancers, the relative mortality for liver cirrhosis was greater [hazard ratio 1.47 (95% CI 1.28-1.67) after age, gender, area of residence, type of insurance, insurance premium level (proxy for income level), and comorbidities were adjusted for]. When a sensitivity analysis was performed by excluding patients with both liver cirrhosis and one of the five cancers, the relative mortality was still greater for liver cirrhosis [hazard ratio 1.27 (95% CI 1.10-1.47)]. Furthermore, when we limited liver cirrhosis patients to those with decompensated liver cirrhosis, the relative mortality of decompensated liver cirrhosis was even greater than that of the five cancers [hazard ratio 1.82 (95% CI 1.51-2.20)]. CONCLUSIONS: The mortality of liver cirrhosis is greater than that of the five major cancers. This implies the need to prioritize appropriate health interventions for liver cirrhosis.

Screening for latent and active tuberculosis infection in the elderly at admission to residential care homes: A cost-effectiveness analysis in an intermediate disease burden area.

BACKGROUND: Tuberculosis (TB) in the elderly remains a challenge in intermediate disease burden areas like Hong Kong. Given a higher TB burden in the elderly and limited impact of current case-finding strategy by patient-initiated pathway, proactive screening approaches for the high-risk group could be optimal and increasingly need targeted economic evaluations. In this study, we examined whether and under what circumstance the screening strategies are cost-effective compared with no screening strategy for the elderly at admission to residential care homes. METHODS: A decision analytic process based on Markov model was adopted to evaluate the cost-effectiveness of four strategies: (i) no screening, (ii) TB screening (CXR) and (iii) TB screening (Xpert) represent screening for TB in symptomatic elderly by chest X-ray and Xpert® MTB/RIF respectively, and (iv) LTBI/TB screening represents screening for latent and active TB infection by QuantiFERON®-TB Gold In-Tube and chest X-ray. The target population was a hypothetical cohort of 65-year-old people, using a health service provider perspective and a time horizon of 20 years. The outcomes were direct medical costs, life-years and quality-adjusted life-years (QALYs) measured by incremental cost-effectiveness ratio (ICER). RESULTS: In the base-case analysis, no screening was the most cost-saving; TB screening (CXR) was dominated by TB screening (Xpert); LTBI/TB screening resulted in more life-years and QALYs accrued. The ICERs of LTBI/TB screening were US$19,712 and US$29,951 per QALY gained compared with no screening and TB screening (Xpert), respectively. At the willingness-to-pay threshold of US$50,000 per QALY gained, LTBI/TB screening was the most cost-effective when the probability of annual LTBI reactivation was greater than 0.155% and acceptability of LTBI/TB screening was greater than 38%. In 1,000 iterations of Monte Carlo simulation, the probabilities of no screening, TB screening (CXR), TB screening (Xpert), and LTBI/TB screening to be cost-effective were 0, 1.3%, 20.1%, and 78.6% respectively. CONCLUSIONS: Screening for latent and active TB infection in Hong Kong elderly people at admission to residential care homes appears to be highly effective and cost-effective. The key findings may be the next key factor to bring down TB endemic in the elderly population among intermediate TB burden areas.