Development of the Korean Standardized Antimicrobial Administration Ratio as a Tool for Benchmarking Antimicrobial Use in Each Hospital

Background@#The Korea National Antimicrobial Use Analysis System (KONAS), a benchmarking system for antimicrobial use in hospitals, provides Korean Standardized Antimicrobial Administration Ratio (K-SAAR) for benchmarking. This article describes K-SAAR predictive models to enhance the understanding of K-SAAR, an important benchmarking strategy for antimicrobial usage in KONAS. @*Methods@#We obtained medical insurance claims data for all hospitalized patients aged ≥ 28 days in all secondary and tertiary care hospitals in South Korea (n = 347) from January 2019 to December 2019 from the Health Insurance Review & Assessment Service. Modeling was performed to derive a prediction value for antimicrobial use in each institution, which corresponded to the denominator value for calculating K-SAAR. The prediction values of antimicrobial use were modeled separately for each category, for all inpatients and adult patients (aged ≥ 15 years), using stepwise negative binomial regression. @*Results@#The final models for each antimicrobial category were adjusted for different significant risk factors. In the K-SAAR models of all aged patients as well as adult patients, most antimicrobial categories included the number of hospital beds and the number of operations as significant factors, while some antimicrobial categories included mean age for inpatients, hospital type, and the number of patients transferred from other hospitals as significant factors. @*Conclusion@#We developed a model to predict antimicrobial use rates in Korean hospitals, and the model was used as the denominator of the K-SAAR.

A Critical Evaluation and International Comparison of Pharmaceutical Consumption and Sales Statistics / 보건행정학회지

Background@#Health statistics of pharmaceutical use and expenditure are essential to make and implement evidence-based pharmaceutical policy. This study aims to demonstrate the methods and results of pharmaceutical consumption and sales in 2018 according to the sources and methods given by the Organization for Economic Cooperation and Development (OECD). @*Methods@#The medication list contains 39,346 medicines both reimbursed and non-reimbursed by the National Health Insurance in 2018. We used the therapeutic categories based on Anatomic Therapeutic Chemical Classification of World Health Organization. This study analyzed National Health Insurance claims data and supply data generated from wholesalers to health care facilities. The indicators are defined daily dose (DDD), per 1,000 inhabitants per day and US$ per capita. @*Results@#In South Korea, the number of medications to which DDD were assigned was 18,055 and it was 45.9% of the total number of medications on the list. The consumption in anti-infective for systemic use (J) and musculo-skeletal system (M) was higher than the mean consumption among the OECD countries. The pharmaceutical sales per person in Korea was also higher than the mean sales per person across the OECD countries. @*Conclusion@#We sought to explain the methods to produce pharmaceutical consumption and sales statistics which we had submitted annually to OECD. Considering the characteristics of pharmaceutical statistics, a direct comparison should be approached with caution. Since the growth in pharmaceutical spending has greatly increased over the past decade, we need to monitor pharmaceutical consumption and expenditure consistently.

Development of Antibiotic Classification for Measuring Antibiotic Usage in Korean Hospitals Using a Modified Delphi Method

In 2019, a project designed to develop a system for measuring and comparing antibiotic usage in hospitals was launched in Korea. As part of this project, we developed a means to classify antibiotic usage in Korean hospitals using a modified Delphi method. In results, the following categories of antibiotic classification were accepted for use in Korean hospitals: 1) broad-spectrum antibacterial agents predominantly used for hospital-onset infections in adults, 2) broad-spectrum antibacterial agents predominantly used for community-acquired infections in adults, 3) antibacterial agents predominantly used for resistant gram-positive infections in adults, 4) narrow-spectrum beta-lactam agents in adults, 5) antibacterial agents predominantly used for extensive antibiotic resistant gram-negative bacteria in adults, and 6) total antibacterial agents.

The Opinion of Experts and Stakeholder on Introduction of Orphan or Anticancer Drugs Funding Program

Background@#& objective: The Korean government has expanded its benefit coverage to enhance patients' access to orphan drugs and cancer medicines. However, the number of new drugs whose indications were not applied to reimbursement in health insurance was increased. This study aimed to understand the perspectives of experts and various stakeholders on the introduction of a new funding program for cancer treatment and orphan drugs. @*Methods@#We conducted email surveys comprising 19 questions, from September 9 to 26, 2016. We distributed questionnaires to members of the Pharmaceutical Benefit Appraisal Committee and Cancer Assessment Committee. We also conducted a qualitative study through group interviews with stakeholders, including pharmaceutical companies and some patient groups for diseases. @*Results@#A total of 35 survey respondents recommended the introduction of a funding program for orphan drugs, whereas 66% recommended the launch of funding for anticancer drugs. In addition, most pharmaceutical companies and patient groups recommended the introduction of new funding programs targeting patients with cancer and rare diseases. However, some participants asserted that it would be more appropriate to modify the existing reimbursement scheme than launch new funding. @*Conclusion@#This study concluded that introducing new funding needs a social consensus to relieve financial hardships at the patient level.

The Opinion of Experts and Stakeholder on Introduction of Orphan or Anticancer Drugs Funding Program

Background@#& objective: The Korean government has expanded its benefit coverage to enhance patients' access to orphan drugs and cancer medicines. However, the number of new drugs whose indications were not applied to reimbursement in health insurance was increased. This study aimed to understand the perspectives of experts and various stakeholders on the introduction of a new funding program for cancer treatment and orphan drugs. @*Methods@#We conducted email surveys comprising 19 questions, from September 9 to 26, 2016. We distributed questionnaires to members of the Pharmaceutical Benefit Appraisal Committee and Cancer Assessment Committee. We also conducted a qualitative study through group interviews with stakeholders, including pharmaceutical companies and some patient groups for diseases. @*Results@#A total of 35 survey respondents recommended the introduction of a funding program for orphan drugs, whereas 66% recommended the launch of funding for anticancer drugs. In addition, most pharmaceutical companies and patient groups recommended the introduction of new funding programs targeting patients with cancer and rare diseases. However, some participants asserted that it would be more appropriate to modify the existing reimbursement scheme than launch new funding. @*Conclusion@#This study concluded that introducing new funding needs a social consensus to relieve financial hardships at the patient level.

Pricing policies for generic medicines in Australia, New Zealand, the Republic of Korea and Singapore: patent expiry and influence on atorvastatin price

Background Little is known about how the different policies available to promote use of genericmedicines affect the price per unit supplied or sold. This study compares the influence of pricingpolicies for generic medicines on atorvastatin prices in Australia, New Zealand, the Republic of Koreaand Singapore, after market entry of generic atorvastatin.Methods The annual price of atorvastatin per defined daily dose supplied (price/DDD) was examinedfor each country from 2006 to 2015 (≥2 years before and ≥4 years after generic market entry). Priceswere converted to international dollars and cumulative percentage price reductions were calculated forthe first 4 years following generic entry.Results Prior to market entry of generic atorvastatin, New Zealand had the lowest price ($0.10/DDD),and the Republic of Korea the highest ($2.89/DDD). The price/DDD fell immediately after generic entryin all countries except New Zealand, which already had low prices. The largest immediate decreasewas observed in Singapore (46%, year 1). By the fourth year after generic entry, the price had fallen by46–80% in all countries; however, large price differences between countries remained.Conclusion New Zealand’s tendering system and use of preferred medicines resulted in verylow atorvastatin prices well before patent expiry. Pricing policies in the other three countries wereeffective in reducing atorvastatin prices, with reductions of between 46% and 80% within 4 years ofgeneric entry. Where tendering and use of preferred medicines were the mechanisms for atorvastatinprocurement (New Zealand), prices were lowest before and after generic entry. Mandatory pricecuts, combined with price-disclosure policies (Australia), produced similar relative price reductions totendering systems (New Zealand, Singapore) at 4 years. By comparison, mandatory price cuts upongeneric entry as the sole measure, while initially effective, were associated with the smallest relativereduction in price after 4 years (Republic of Korea).

Analysis of factors affecting antibiotic use at hospitals and clinics based on the defined daily dose

Inappropriate antibiotic use significantly contributes to antibiotic resistance, resulting in reduced antibiotic efficacy and an increased burden of disease. The objective of this study was to investigate the characteristics of prescribers whose antibiotics use was high and to explore factors affecting the use of antibiotics by medical institutions. This study analyzed the National Health Insurance claims data from 2015. Antibiotic prescription data were analyzed in terms of the number of defined daily doses per 1,000 patients per day, according to the World Health Organization anatomical-therapeutic-chemical classification and methodologies for measuring the defined daily dose. We investigated the characteristics of prescribers and medical institutions with high antibiotic use. Multivariate regression analyses were performed on the basis of characteristics of the medical institution (number of patients, type of medical institution [hospital or clinic], age of the physician, etc.). The number of patients and number of beds were found to be significant factors affecting antibiotic use in hospitals, and the number of patients, region, and medical department were significant factors affecting antibiotic use at the level of medical institutions. These findings are expected to help policy-makers to better target future interventions to promote prudent antibiotic prescription.

Analysis of factors affecting antibiotic use at hospitals and clinics based on the defined daily dose

Inappropriate antibiotic use significantly contributes to antibiotic resistance, resulting in reduced antibiotic efficacy and an increased burden of disease. The objective of this study was to investigate the characteristics of prescribers whose antibiotics use was high and to explore factors affecting the use of antibiotics by medical institutions. This study analyzed the National Health Insurance claims data from 2015. Antibiotic prescription data were analyzed in terms of the number of defined daily doses per 1,000 patients per day, according to the World Health Organization anatomical-therapeutic-chemical classification and methodologies for measuring the defined daily dose. We investigated the characteristics of prescribers and medical institutions with high antibiotic use. Multivariate regression analyses were performed on the basis of characteristics of the medical institution (number of patients, type of medical institution [hospital or clinic], age of the physician, etc.). The number of patients and number of beds were found to be significant factors affecting antibiotic use in hospitals, and the number of patients, region, and medical department were significant factors affecting antibiotic use at the level of medical institutions. These findings are expected to help policy-makers to better target future interventions to promote prudent antibiotic prescription.

Assessing Seasonality of Acute Febrile Respiratory Tract Infections and Medication Use / 보건행정학회지

BACKGROUND: Monitoring appropriate medication categories can provide early warning of certain disease outbreaks. This study aimed to present a methodology for selecting and monitoring medications relevant to the surveillance of acute respiratory tract infections, such as influenza. METHODS: To estimate correlations between acute febrile respiratory tract infection and some medication categories, the cross-correlation coefficient (CCC) was used and established. Two databases were used: real-time prescription trend of antivirals, anti-inflammatory drugs, antibiotics using Drug Utilization Review Program between 2012 and 2015 and physicians' number of encounters with acute febrile respiratory tract infections such as influenza outbreaks using the national level health insurance claims data. The seasonality was also evaluated using the CCC. RESULTS: After selecting six candidate diseases that require extensive monitoring, influenza with highly specific medical treatment according to the health insurance claims data and its medications were chosen as final candidates based on a data-driven approach. Antiviral medications and influenza were significantly correlated. CONCLUSION: An annual correlation was observed between influenza and antiviral medications, anti-inflammatory drugs. Suitable models should be established for syndromic surveillance of influenza.

The Trend of Acute Respiratory Tract Infections and Antibiotic Prescription Rates in Outpatient Settings using Health Insurance Data

OBJECTIVE: A significant concern has been raised about the emerging resistance that is largely caused by the excessive or inappropriate use of antibacterial agents for viral respiratory infections. This study investigated the trend of respiratory tract infections (RTIs) and the use of antibiotics. METHODS: Utilizing the national level health insurance claims data from 2005 to 2008, we examined encounter days, antibiotic use, and the prescription rate for respiratory tract infections including upper respiratory tract infections (URTIs), lower respiratory tract infections (LRTIs), and otitis media in outpatient settings. The antibiotic use was measured as defined daily dose per 1,000 patients per day (DDD/1,000 patients/day). RESULTS: The visit for URTI increased from 141,693,465 in 2005 to 120,717,966 in 2008 and the visit for LRTI decreased from 61,778,718 to 66,930,122. For RTIs, prescription rates of antibiotics decreased from 65.2% to 58.5% for URTIs and 76.9% to 68.3% for LRTIs from 2005 to 2008. The antibiotic use decreased to 20.85 DDD/1,000 patients/day after a significant increase of 22.01 DDD/1,000 patients/day in 2006. Among antibiotics, J01CR had the highest use- 7.93 DDD/1,000 patients/day followed by J01DC of 3.71 DDD/1,000 patients/day and J01FA of 3.2 DDD/1,000 patients/day. One notable trend is that J01FA presented a continuous increase in antibiotic use from 2.3 in 2005 to 3.26 DDD/1,000 patients/day in 2008. CONCLUSION: The use of antibiotics had poor compliance to guidelines for RTIs. Despite decrease in the use of antibiotics, prescription rates for URTIs were still about 50% indicating that the delayed prescribing antibiotics (or wait-and-see) were not observed.

Towards Actualizing the Value Potential of Korea Health Insurance Review and Assessment (HIRA) Data as a Resource for Health Research: Strengths, Limitations, Applications, and Strategies for Optimal Use of HIRA Data

Health Insurance and Review Assessment (HIRA) in South Korea, also called National Health Insurance (NHI) data, is a repository of claims data collected in the process of reimbursing healthcare providers. Under the universal coverage system, having fee-for-services covering all citizens in South Korea, HIRA contains comprehensive and rich information pertaining to healthcare services such as treatments, pharmaceuticals, procedures, and diagnoses for almost 50 million beneficiaries. This corpus of HIRA data, which constitutes a large repository of data in the healthcare sector, has enormous potential to create value in several ways: enhancing the efficiency of the healthcare delivery system without compromising quality of care; adding supporting evidence for a given intervention; and providing the information needed to prevent (or monitor) adverse events. In order to actualize this potential, HIRA data need to actively be utilized for research. Thus understanding this data would greatly enhance this potential. We introduce HIRA data as an important source for health research and provide guidelines for researchers who are currently utilizing HIRA, or interested in doing so, to answer their research questions. We present the characteristics and structure of HIRA data. We discuss strengths and limitations that should be considered in conducting research with HIRA data and suggest strategies for optimal utilization of HIRA data by reviewing published research using HIRA data.

A Qualitative Study of Antibiotic Prescribing Decision of Physicians and Strategy of Antibiotics Prescription

BACKGROUND: Korea has high prescribing rate and rising antibiotic resistance. This study was conducted to understand why primary physicians prescribe antibiotics for acute respiratory infections and to explore the factors that influence antibiotic resistance, and so to suggest strategy to reduce antibiotic resistance. METHODS: A qualitative exploratory approach was used using 4 focus groups composed of physicians from different area. A semi-structured guide was applied in obtaining the physicians' opinions. Common themes were extracted by authors, which were used to gather results and draw conclusion. RESULTS: Participants acknowledged multiple factors such as clinical factor and competitive environment are involved in physicians' decision of antibiotic prescribing. They identified that causes of rising antibiotic resistance were shortage of information, discontinuation of taking antibiotics, and other system factors. CONCLUSION: Participants were certain that less prescribing antibiotics and selecting appropriate antibiotics might be method to reduce antibiotic resistance. To change the prescribing behavior, it should be provided periodically for community physicians with prescribing information and specific guidelines for antibiotics resistance. Patients should be also noticed about antibiotic medication information more accurately. Including prescription incentive policy, improvement of healthcare system will be carried out at the same time.

Pharmacodynamic Drug-Drug Interactions Considered to be Added in the List of Contraindications with Pharmacological Classification in Korea

OBJECTIVES: Drug utilization review program in Korea has provided 'drug combinations to avoid DCA)' alerts to physicians and pharmacists to prevent potential adverse drug events or inappropriate drug use. Seven hundred and six DCA pairs have been announced officially by the Ministry of Food and Drug Safety (MFDS) by March, 2015. Some DCA pairs could be grouped based on the drug interaction mechanism and its consequences. This study aimed to investigate the drug-drug interaction (DDI) pairs, which may be potential DCAs, generated by the drug class-drug class interaction method METHODS: Eleven additive/synergistic and one antagonistic drug class-drug class interaction groups were identified. By combining drugs of two interacting drug class groups, numerous DDI pairs were made. The status and severity of DDI pairs were examined using Lexicomp and Micromedex. Also, the DCA listing rate was calculated. RESULTS: Among 258 DDI pairs generated by the drug class-drug class interaction method, only 142 pairs were identified as official DCA pairs by the MFDS. One hundred and four pairs were identified as potential DCA pairs to be listed. QT prolonging agents-QT prolonging agents, triptans-ergot alkaloids, tricyclic antidepressants-monoamine oxidase inhibitors, and dopamine agonists-dopamine antagonists were identified as drug class-drug class interaction groups which have less than 50 % DCA listing rate. CONCLUSION: To improve the clinicians' adaptability to DCA alerts, the list of DCA pairs needs to be continuously updated.

Survey on Physician Attitude of Antibiotic Prescription for Upper Respiratory Tract Infections

BACKGROUND: There are significant concerns about emerging antibiotic resistance that are largely due to the inappropriate use of antibacterial agents for viral respiratory infections. We explored clinicians' attitude on antibiotic prescription for patients with respiratory tract infections (RTIs) using survey. METHODS: A random, stratified sample of physicians in Seoul, Gyeonggi, and Incheon was surveyed with a mailed questionnaire, and 353 clinicians completed information. A total of 344 were included in the final dataset after excluding incomplete data with missing information (response rate 34.4%). RESULTS: Among 344 physicians, those who would prescribe antibiotics in scenario patient were 39.2%, wait and prescribe 30.5% and not prescribe antibiotics 30.2%. Those who believed antibiotics would help treatment of acute sinusitis were 83.7%, acute pharyngitis 36%, acute tonsillitis 86.3%, acute bronchitis 64% and acute lower respiratory diseases 66.9%. In logistic regression analysis, those who were located in Gyeonggi region and those who believed antibiotics help treatment of tonsillitis and suppurative otitis media would prescribe antibiotics in scenario patient significantly more, whereas those who believe antibiotics help treatment of acute pharyngitis and lower respiratory disease prescribe antibiotics less. CONCLUSIONS: Physicians' attitude to antibiotics in respiratory disease has a significant effect on antibiotic prescription for RTIs. Interventions such as practice guidelines and patient education to optimize antibiotic prescription should take this effect into account.

Impact of Health Insurance Type on the Quality of Hemodialysis Services: A Multilevel Analysis / 예방의학회지

OBJECTIVES: This study aims to compare quality indicators for the hemodialysis services between patients with health insurance and those with medical aid. METHODS: This study used data from sampled hospitals that provided a hemodialysis service. A total of 2287 patients were selected, and the information for hemodialysis service has been granted from medical record reviews. A multi-level regression analysis was used to examine the differences in process and outcome indicators for hemodialysis between patients with health insurance and those with medical aid. Process indicators were defined as: frequency of hemodialysis, hemodialysis time, erythropoietin (EPO) use, measurement of hemodialysis dose at least once a month, measurement of phosphate at least once every three months, and measurement of albumin at least once every three months. Outcome indicators were defined as: hemodialysis adequacy, anemia management, blood pressure management, and calcium, phosphate and nutrition management. The total scores for outcome indicators ranged from 0 (worst) to 4 (best). RESULTS: There was a significant difference in the measurement of hemodialysis dose at least once a month between patients with health insurance and those with medical aid (OR 0.66, 95% CI=0.43-0.99). However, frequency of hemodialysis, hemodialysis time, EPO use, measurement of phosphate at least once every three months, measurement of albumin at least once every three months, hemodialysis adequacy management, Hb> or =11 g/dL, blood pressure within the range of 100-140/60-90 mmHg, calcium x phosphate or =4 g/dL were not significantly different between the groups. CONCLUSIONS: There were no significant differences in outcome indicators for hemodialysis between the groups. Further studies are warranted into the mechanism that results in no differences in the outcome indicators for hemodialysis.

Development of a List of Potentially Inappropriate Drugs for the Korean Elderly Using the Delphi Method / 대한의료정보학회지

OBJECTIVES: This study aimed to develop a list of potentially inappropriate drugs for the elderly in Korea using the Delphi technique. METHODS: A Delphi evaluation with a two-round survey was used to reach a consensus on the criteria for inappropriate medications for the elderly in an outpatient setting. The expert panel consisted of 7 family medicine specialists, 3 psychiatrists, 1 neurologist and 3 clinical pharmacists. The level of inappropriateness was determined by considering clinical importance of the risk and availability of alternative therapy, and was rated on a scale of 1 (very low) to 4 (very high). The drugs were categorized into three groups. The first group (Group 1) was drugs that should be avoided. The second (Group 2) was for drugs that need to be monitored. And the third (Group 3) was for drugs with a low level of risk. RESULTS: We took a list of 60 ingredients for drugs and created a list of 57 potentially inappropriate ingredients for the elderly, independent of diagnosis. Forty-two drugs were classified as Group 1. 13 drugs were classified as Group 2. And 2 drugs were classified as Group 3. Ninety-three drugs were potentially inappropriate for the elderly with 29 diagnoses. Groups 1, 2, and 3 included 63, 28, and 3 drugs, respectively. CONCLUSIONS: This study is an important development of a list of drugs potentially inappropriate for the elderly in Korea. The application of this list may be useful for identifying potentially inappropriate medication uses and decreasing drug-related problems.

Developing Quality Indicators for In-Center Hemodialysis Patients / 대한신장학회지

PURPOSE:This study was a pilot study to develop structure, clinical performance and outcome measurement and criteria for increasing number of dialysis facilities and patients to provide quality of care. METHODS:The six components of developing quality indicators for hemodialysis were as follows: 1) Organizing expert panel members. 2) Selecting the area: to reflect stakeholders' opinion, structured interviews were done. And literature reviews were performed to investigate guidelines and quality measurements of foreign countries. 3) Selecting clinical performance indicators: From experts' opinions and literature review. 4) Developing candidate indicators. 5) Performing demonstration survey: Systemic sampling was performed and 43 facilities were participated in self-answered medical record survey. 6) Based on preliminary evaluation model, final indicators were selected from expert panel reviews. RESULTS:Eleven measures of structure, thirteen performance measures of process and nine monitoring measures of outcome were developed based on literature review and clinical practice guideline. As for criterion-related validity, those of process and outcome were most high and in case of face validity, those of structure and process were most high. The most valid quality indicators were the rate of internal medicine specialist, dialysis frequency per doctor, whether or not keeping emergency equipment, examination of water quality, hemodialysis adequacy (Kt/V), monitoring arterial venous graft for stenosis maintenance of iron storage, and administration of supplemental iron. CONCLUSION:By developing quality indicators of hemodialysis and performing demonstration evaluation, quality of care for hemodialysis patients is expected to be improved, so as to promote hemodialysis patients' health and improve on quality of life.