Differential characteristics and treatment of psoriasis patients by economic status in South Korea: An analysis of the National Health Insurance Database.

Despite the enormous burden on patients with severe psoriasis, their utilization of medical care is not well understood in Korea.To compare the characteristics and treatment patterns of psoriasis patients by economic status as well as to examine the factors influencing systemic treatments of psoriasis.We conducted a descriptive cross-sectional study using National Health Insurance sample cohort data in 2015. Psoriasis patients were classified as either the "topical treatment only" or the "systemic treatment" group based on the types of treatment. Patients' economic status was defined by the deciles of health insurance premium, which was determined based on income and assets. Multivariate logistic regression analysis was performed to examine the factors influencing systemic treatments of psoriasis.We identified 6041 psoriasis patients; 39.5% were in the bottom 5 deciles of health insurance premium and 60.5% were in the top 5 deciles. Only 1.9% of the low economic status group and 4.0% of the high economic status group were treated with expensive biologics, although the difference was not statistically significant.Overall, psoriasis patients with higher economic status had a lower likelihood of receiving systemic treatments but had a higher probability of being treated with expensive biologics.

Notable Differences in Drug Lag Between Korea and Japan of New Drugs Between 2009 and 2017.

BACKGROUND: Although great efforts have been made to address delays in new-drug approvals between different regions, little is known regarding drug lag in Korea. We compared drug lag in Korea with that in Japan, which is well known through many previous studies. METHODS: We extracted approval information from public data obtained from the regulatory authorities on all new drugs that were listed in both Korea and Japan between 2009 and 2017. Relative drug lag represented the difference between the date of approval in the country of interest and the date of the first global approval. Relative drug lag was measured as median approval lag. Multiple regression models were used to identify the factors associated with drug lag. The factors considered included origin of substance, nationality of manufacturer, original approval date, orphan drug status, and therapeutic class. RESULTS: In total, 394 new drugs were approved in both countries between 2009 and 2017. The median approval lag was 28.2 and 54.1 months in Korea and Japan, respectively. Domestic company drugs were associated with longer median approval lag in Korea ([Formula: see text]), sensory organ drugs were associated with shorter median approval lag in Japan ([Formula: see text]), and orphan drug status was associated with longer duration of drug approval in Japan ([Formula: see text]). CONCLUSIONS: Notable drug lags were observed in both Korea and Japan, but the lag was shorter in Korea. Inclusion of global clinical trials and existence of prior knowledge in new drug development were critical to reduce drug lag.

Comparison of signal detection of tumour necrosis factor-α inhibitors using the Korea Adverse Events Reporting System Database, 2005-2016.

OBJECTIVES: There are no pharmacovigilance studies on adverse event (AE) data for tumour necrosis factor alpha (TNFα) inhibitors in South Korea. We analysed AEs induced by adalimumab, infliximab, and etanercept METHODS: We used data from the Korea Institute of Drug Safety and Risk Management-Korea Adverse Events Reporting System Database (KIDS-KD) collected between 2005 and 2016. We used three different signal detection methods: proportional reporting ratio (PRR), reporting odds ratio (ROR), and information component (IC). The drug was compared with drug labels in the USA and Korea. Logistic regression analysis identified AEs that are more likely to occur with drug use. RESULTS: Of the 5594 AEs identified, 350, 452, and 71 were related to adalimumab, infliximab, and etanercept, respectively. We identified seven new signals, which were not listed on drug labels in either Korea or the USA, for AEs associated with the study drugs: two for adalimumab (medication error and drug failure), two for infliximab (palpitation and temperature sensation change), and three for etanercept (hyperkeratosis, acne, and thyroid neoplasm malignant). Injection site pain (OR 6.14, 95% CI 1.15-32.74) and alopecia (OR 4.54, 95% CI 1.16-17.77) for adalimumab, chest pain (OR 6.01, 95% CI 1.35-26.77) for infliximab, and uveitis (OR 10.11, 95% CI 1.13-90.77) for etanercept were more likely to be reported in patients with each TNFα inhibitor than in those without, respectively. CONCLUSIONS: Seven new signals that were not included in the current label were identified for TNFα inhibitors and should be updated and monitored.Key Points• Large-scale spontaneous AE reporting data and data mining techniques are useful for detecting signals of rare AEs as well as common AEs induced by drugs.• Drug labels should be updated to reflect signals that are newly discovered by continuous monitoring.

Pattern of adverse events induced by aflibercept and ranibizumab: A nationwide spontaneous adverse event reporting database, 2007-2016.

Data regarding the safety of anti-vascular endothelial growth factor (anti-VEGF) treatment is limited.To compare the adverse events (AEs) induced by aflibercept and ranibizumab using a spontaneous reporting system and determine the signals.We used data from the Korea Institute of Drug Safety & Risk Management-Korea Adverse Event Reporting System Database (KIDS-KD), collected between 2007 and 2016. Differences in patient demographics, report type, reporter, causality, and serious-AEs between aflibercept and ranibizumab were compared. Metrics including proportional reporting ratio (PRR), reporting odds ratio (ROR), and information component (IC), were used to compare signals with the AEs on the drug labels in the United States of America and Korea. Logistic regression analysis was performed to identify AEs that are more likely to occur with drug use.A total of 32 aflibercept and 103 ranibizumab cases of AEs were identified. The proportion of AEs that were reported voluntarily was higher with aflibercept (50.5%) use than ranibizumab (4.9%), whereas the AEs reported by post-marketing surveillance were higher with ranibizumab (46.6%) use than aflibercept (31.3%). The percentage of AEs in patients >60 years old, reports by consumers, and the ratio of SAEs to AEs associated with aflibercept (84. %, 9.4%, and 75.0%, respectively) were higher than those of ranibizumab (77.7%, 1.9%, and 19.4%, respectively). The number of newly detected AEs after aflibercept and ranibizumab treatment was 3 and 8, respectively. Among these, conjunctivitis and medicine ineffective were not included on the aflibercept and ranibizumab labels, respectively. Endophthalmitis (OR 6.96, 95% CI 2.74-17.73) was more likely to be reported in patients with aflibercept than in patients without aflibercept, whereas medicine ineffective (OR 18.49, 95% CI 2.39-143.29) and retinal disorder (OR 7.03, 95% CI 1.60-30.96) were more likely to be reported in patients with ranibizumab than in patients without ranibizumab.New signals have been identified for aflibercept and ranibizumab. Further research is necessary to evaluate the causality of AEs that were detected as signals in this study.

Comparison of signal detection between statin and statin/ezetimibe fixed-dose combination using the Korea Adverse Events Reporting System Database, 2005 - 2016
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BACKGROUND AND OBJECTIVES: Statin/ezetimibe fixed-dose combination is often used as statin monotherapy; however, no study has analyzed its adverse effect (AE) signals. We comparatively analyzed the AE status of statin and statin/ezetimibe fixed-dose combination and compared the signal information using a 12-year AE reporting database. MATERIALS AND METHODS: We used data from the Korea Adverse Events Reporting System database from 2005 to 2016. Drug-AE pairs corresponded to drugs and AEs for analysis of demographic characteristics, causality, number, and type of serious AEs. Metrics, including proportional reporting ratio (PRR), reporting odds ratio (ROR), and information component (IC) were used to detect signals. Signals were compared with drug labels in the USA and Korea. RESULTS: Of the 4,569 AE cases identified, 4,130 and 442 were of statin and statin/ezetimibe fixed-dose combination, respectively. There were no statistically significant differences in AE report characterization for statin and the statin/ezetimibe fixed-dose combination. The number of AE signal detections for statin, statin/ezetimibe fixed-dose combination, and both, based on PRR and ROR, was 16, 4, and 2, respectively, and the number of cases not included on the label was 3, 2, and 0, respectively. The number of AE signals that only met IC indicators was greater in statin/ezetimibe fixed-dose combination (33) than in statin (4), and 12 of the 33 cases in statin/ezetimibe fixed-dose combination were not included on the drug label. CONCLUSION: The combination of statin and ezetimibe exhibited greater AE signal detection than statin alone, and the inclusion of AEs on the drug label was insufficient.

Factors Associated With the Management of Adverse Drug Reactions Among Community Pharmacists in South Korea.

OBJECTIVES: Community pharmacists dispensed 68.4% of all drugs used in Korea, but reported only 2.0% of adverse drug reactions (ADRs) in 2011. This study compared community pharmacists' understanding of the importance of ADR management and their actual practice of it, and identified relevant factors related to their management of ADR. METHODS: With the use of a modified health belief model (HBM), 800 community pharmacists were surveyed via social network service messaging. A total of 200 usable responses were obtained for an effective response rate of 25.0%. Descriptive analysis was used to quantify the differences between community pharmacists' understanding of the importance of ADR prevention and their practice. A hierarchical regression was performed with the following predictors: (1) demographic factors, (2) social impact of ADR prevention, (3) importance of social support, and (4) cognition about the importance of ADR prevention. RESULTS: Although community pharmacists clearly recognized the importance of ADR management, their performance was very low. The disparity between cognition and performance was more pronounced for ADR reporting than for patient counseling. Social support was the most powerful predictor of ADR prevention practice, explaining 18.5% of the variance in ADR prevention practice. Social impact of ADR prevention, demographic factors, and cognition about the importance of ADR prevention explained 12.6%, 6.2%, and 1.8% of the variance, respectively. CONCLUSIONS: Strengthening community pharmacists' performance of population-based ADR management should be prioritized over patient-oriented ADR management. To improve public health, community pharmacists should make an effort at ADR reporting. This can be done with appropriate government support, such as incentives to community pharmacists, public awareness campaigns, education, and establishment of feedback systems.

Healthcare utilization and medical expenditure of Korean psoriasis patients: A descriptive result using a health insurance database.

BACKGROUND: Epidemiological evidence regarding healthcare utilization and medical expenditure of patients with psoriasis in Korea is needed. To analyze the differences in healthcare utilization and financial burdens between patients with and without psoriasis and compare these patterns according to the disease severity. METHODS: We conducted a descriptive cross-sectional study using a sample of the National Health Insurance database between January 1, 2012 and December 31, 2013. We included patients diagnosed with psoriasis and those with nonpsoriasis skin diseases, matched for age, sex, income, and geographical region. The patients with psoriasis were further divided into mild and moderate-to-severe psoriasis groups. Each patient was followed up for 1 year to estimate their healthcare utilization and medical expenditure since their initial diagnosis. Healthcare utilization was defined as the sum of outpatient visits and inpatient stays per person. We conducted McNemar test or Bowker test of symmetry to compare the baseline characteristics and used the Wilcoxon matched-pair signed-rank test to compare the healthcare utilization and direct costs with a 5% significance level. RESULTS: Our study subjects were 4016 patients with psoriasis and equally matched 4016 patients with nonpsoriasis skin diseases. Compared with patients without psoriasis, those with psoriasis had more days of healthcare service use (5.26 vs 4.19, P < .001) and higher medical expenditures within 1 year per person (209,320 vs 117,968 won, P < .001). Patients with moderate-to-severe psoriasis had more days of healthcare service use (12.71 vs 3.25, P < .001) and higher medical expenditures within 1 year per person (611,688 vs 107,445 won, P < .001) than those with mild psoriasis. CONCLUSION: Patients with psoriasis had higher burdens of healthcare utilization than those without psoriasis, and patients with moderate-to-severe psoriasis had the greatest burdens.

Projection of future pharmacy service fees using the dispensing claims in hospital and clinic outpatient pharmacies: national health insurance database between 2006 and 2012.

BACKGROUND: Predicting pharmacy service fees is crucial to sustain the health insurance budget and maintain pharmacy management. However, there is no evidence on how to predict pharmacy service fees at the population level. This study compares the status of pharmacy services and constructs regression model to project annual pharmacy service fees in Korea. METHODS: We conducted a time-series analysis by using sample data from the national health insurance database from 2006 and 2012. To reflect the latest trend, we categorized pharmacies into general hospital, special hospital, and clinic outpatient pharmacies based on the major source of service fees, using a 1% sample of the 2012 data. We estimated the daily number of prescriptions, pharmacy service fees, and drugs costs according to these three types of pharmacy services. To forecast pharmacy service fees, a regression model was constructed to estimate annual fees in the following year (2013). The dependent variable was pharmacy service fees and the independent variables were the number of prescriptions and service fees per pharmacy, ratio of patients (≥ 65 years), conversion factor, change of policy, and types of pharmacy services. RESULTS: Among the 21,283 pharmacies identified, 5.0% (1064), 4.6% (974), and 77.5% (16,340) were general hospital, special hospital, and clinic outpatient pharmacies, respectively, in 2012. General hospital pharmacies showed a higher daily number of prescriptions (111.9), higher pharmacy service fees ($25,546,342), and higher annual drugs costs ($215,728,000) per pharmacy than any other pharmacy (p <  0.05). The regression model to project found the ratio of patients aged 65 years and older and the conversion factor to be associated with an increase in pharmacy service fees. It also estimated the future rate of increase in pharmacy service fees to be between 3.1% and 7.8%. CONCLUSIONS: General hospital outpatient pharmacies spent more on annual pharmacy service fees than any other type of pharmacy. The forecast of annual pharmacy service fees in Korea was similar to that of Australia, but not that of the United Kingdom.

Estimation of cost savings between 2011 and 2014 attributed to infliximab biosimilar in the South Korean healthcare market: real-world evidence using a nationwide database.

AIM: The introduction of biosimilars is expected to reduce the cost of biologic drugs, but the actual cost savings have not yet been quantified in Korea. The aim of this study was to estimate the annual cost savings attributed to the introduction of infliximab biosimilar. METHODS: We conducted a retrospective analysis using data from the Health Insurance Review and Assessment Service-National Patients Sample (HIRA-NPS) between 2011 and 2014. The study subjects were patients who were treated with infliximab, adalimumab or etanercept. We compared the drug costs before and after the introduction of infliximab biosimilar in December 2012 (2011-2012 and 2013-2014) to estimate the annual drug cost savings attributed to this and the number of patients who could additionally benefit from the biosimilar in 2013 and 2014. RESULTS: A total of 10 986 prescriptions were identified: 2620 for infliximab. The cost savings were estimated at $262 270 for 133 patients in 2013 and $395 220 for 174 patients in 2014. Among the patients who underwent a 1-year maintenance course of infliximab therapy, the annual expenditure on infliximab was lower in 2014 than in 2011. If the cost savings were used to treat additional patients, 13.3%-38.6% more patients per year could be treated by indication. CONCLUSION: The introduction of infliximab biosimilar reduced direct medical costs for both patients and the payer, which could then be used to increase patient access to biologic medicines. The entry of infliximab biosimilar could result in further reductions in healthcare costs.

Prevalence and predictors of tricyclic antidepressant use among elderly Koreans in primary-care and specialty clinics.

OBJECTIVES: Tricyclic antidepressants (TCAs) are prescribed with caution in the elderly due to diverse side effects. We analyzed the patterns of TCA use in elderly patients in primary-care and specialty clinics and investigated factors influencing TCA prescriptions. MATERIALS AND METHODS: Elderly patients (≥ 65 years old) prescribed antidepressants in primary-care clinics in 2013 were included from the Health Insurance Review and Assessment Service-Aged Patient Sample (HIRA-APS). Prevalence of TCA prescriptions was assessed by insurance coverage status, clinical specialty, and region. Multiple logistic regression analysis was performed to compute odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with TCA prescriptions. RESULTS: TCAs and selective serotonin reuptake inhibitors (SSRIs) comprised 45.2% and 15.0% of all antidepressant prescriptions, respectively. TCAs comprised 61.5% and 20.7% of antidepressant prescriptions for pain and depression, respectively. Patients aged ≥ 85 years were less likely to be treated with TCAs (OR 0.81, 95% CI 0.79 - 0.84) than those aged 65 - 69 years. The odds for being prescribed TCAs were higher for patients residing in cities (OR 1.20, 95% CI 1.18 - 1.23), treated in nonpsychiatric clinics (OR 5.64, 95% CI 5.53 - 5.76), and those covered by Veteran's Health (OR 1.62, 95% CI 1.37 - 1.90) when compared to patients residing in the Seoul metropolitan area, treated in psychiatric clinics, or covered by National Health Insurance, respectively. The prescriptions of TCAs with pain diagnoses were much higher than prescriptions for depression (OR 1.87, 95% CI 1.82 - 1.93). CONCLUSIONS: Compared with a 2005 report, the prevalence of TCA prescriptions in elderly patients in Korea has decreased substantially, but remains high. Various efforts should be considered to reduce TCA prescriptions in the elderly.
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Use pattern and predictors of use of highly caffeinated energy drinks among South Korean adolescents: a study using the Health Belief Model.

OBJECTIVES: Concerns about the use of highly caffeinated energy drinks among Korean adolescents remains. We compared adolescents' perceptions regarding the use of drinks to their behaviours and factors. DESIGN: A structured questionnaire based on the Health Belief Model was administered to 850 freshmen and sophomores at three high schools in Bucheon, South Korea. Benefits were defined as beneficial effects from the use of highly caffeinated energy drinks (eg, awakening from sleepiness) and harms as adverse effects of the drinks (eg, cardiac palpitation). Likelihood of action represents the likelihood of taking actions that are perceived to be more beneficial after comparison of the benefits and harms of caffeine use. Descriptive analysis was used to quantify the relationship between their beliefs about highly caffeinated energy drinks and their use. We conducted hierarchical logistic regression to compute ORs and 95% CIs for: (1) demographic factors, (2) health threat, (3) likelihood of action and (4) cues to act. RESULTS: Altogether, 833 students responded to the questionnaire (effective response rate=98.0%). About 63.0% reported use of highly caffeinated energy drinks and 35.2% had used them as needed and habitually. The more susceptible the respondents perceived themselves to be to the risk of using these drinks, the less likely they were to use them (OR: 0.73, 95% CI 0.50 to 1.06). The more severe the perception of a health threat, the less that perception was associated with use (OR: 0.44, 95% CI 0.29 to 0.67). Likelihood of action was the strongest predictor of use, explaining 12.5% in use. Benefits and harms (OR: 4.43, 95% CI 2.77 to 7.09; OR: 1.86, 95% CI 1.16 to 2.99) also were significant predictors. CONCLUSIONS: Enhancing adolescents' perceptions of benefits and harms regarding using highly caffeinated energy drinks could be an effective way to influence the use of these drinks.

Trends in the prescribing of atypical antipsychotics in elderly patients with dementia in Korea
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OBJECTIVE: In 2005, the Food and Drug Administration warned that atypical antipsychotics (AAPs) increased mortality in elderly patients with dementia. We investigated AAP prescribing in elderly patients with dementia in the ambulatory setting in Korea and the factors affecting AAP prescribing in elderly patients with dementia. METHODS: Subjects ≥ 65 years of age with at least one diagnosis of dementia (ICD-10: F00-F03, G30, G31.8) from January 1 to December 31, 2013 were identified from a health insurance database. Using multiple logistic regression analysis to estimate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for AAP prescribing in elderly patients with dementia, AAP user prevalence was estimated and presented by dementia type, individual AAP, medical institution, and region. RESULTS: A total of 61,550 elderly patients with dementia were identified: 6,504 (9.8%) received AAPs, 12.3% of them had Alzheimer's disease; only 2 patients with vascular dementia were prescribed AAPs (0.04%). Female patients were less likely to be prescribed AAPs than male patients. The likelihood of AAP prescribing was higher for patients aged 70 years and older than for those < 70 years. AAP prescribing was higher for patients visiting secondary care institutions (OR, 1.12; 95% CI, 1.65 - 1.74) than for those visiting primary care institutions, and for patients in cities (OR, 1.57; 95% CI, 1.52 - 1.62) than for those in metropolitan regions. CONCLUSIONS: Although the prevalence of AAP prescribing has decreased, especially among patients with vascular dementia, it remains high. Efforts to reduce AAP use should focus on secondary care institutions in nonmetropolitan regions.
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Development of a transformation model to derive general population-based utility: Mapping the pruritus-visual analog scale (VAS) to the EQ-5D utility.

RATIONALE, AIMS, AND OBJECTIVES: Although nonpreference-based disease-specific measures are widely used in clinical studies, they cannot generate utilities for economic evaluation. A solution to this problem is to estimate utilities from disease-specific instruments using the mapping function. This study aimed to develop a transformation model for mapping the pruritus-visual analog scale (VAS) to the EuroQol 5-Dimension 3-Level (EQ-5D-3L) utility index in pruritus. METHODS: A cross-sectional survey was conducted with a sample (n = 268) drawn from the general population of South Korea. Data were randomly divided into 2 groups, one for estimating and the other for validating mapping models. To select the best model, we developed and compared 3 separate models using demographic information and the pruritus-VAS as independent variables. The predictive performance was assessed using the mean absolute deviation and root mean square error in a separate dataset. RESULTS: Among the 3 models, model 2 using age, age squared, sex, and the pruritus-VAS as independent variables had the best performance based on the goodness of fit and model simplicity, with a log likelihood of 187.13. The 3 models had similar precision errors based on mean absolute deviation and root mean square error in the validation dataset. No statistically significant difference was observed between the mean observed and predicted values in all models. CONCLUSIONS: In conclusion, model 2 was chosen as the preferred mapping model. Outcomes measured as the pruritus-VAS can be transformed into the EQ-5D-3L utility index using this mapping model, which makes an economic evaluation possible when only pruritus-VAS data are available.

A comparison of discontinuation rates of tofacitinib and biologic disease-modifying anti-rheumatic drugs in rheumatoid arthritis: a systematic review and Bayesian network meta-analysis.

OBJECTIVES: The purpose of this study was to compare the discontinuation rates of tofacitinib and biologics (tumour necrosis factor inhibitors (TNFi), abatacept, rituximab, and tocilizumab) in rheumatoid arthritis (RA) patients considering inadequate responses (IRs) to previous treatment(s). METHODS: Randomised controlled trials of tofacitinib and biologics - reporting at least one total discontinuation, discontinuation due to lack of efficacy (LOE), and discontinuation due to adverse events (AEs) - were identified through systematic review. The analyses were conducted for patients with IRs to conventional synthetic disease-modifying anti-rheumatic drugs (cDMARDs) and for patients with biologics-IR, separately. Bayesian network meta-analysis was used to estimate rate ratio (RR) of a biologic relative to tofacitinib with 95% credible interval (CrI), and probability of RR being <1 (P[RR<1]). RESULTS: The analyses of 34 studies showed no significant differences in discontinuation rates between tofacitinib and biologics in the cDMARDs-IR group. In the biologics-IR group, however, TNFi (RR 0.17, 95% CrI 0.01-3.61, P[RR<1] 92.0%) and rituximab (RR 0.20, 95% CrI 0.01-2.91, P[RR<1] 92.3%) showed significantly lower total discontinuation rates than tofacitinib did. Despite the difference, discontinuation cases owing to LOE and AEs revealed that tofacitinib was comparable to the biologics. CONCLUSIONS: The comparability of discontinuation rate between tofacitinib and biologics was different based on previous treatments and discontinuation reasons: LOE, AEs, and total (due to other reasons). Therefore, those factors need to be considered to decide the optimal treatment strategy.

A comparative analysis of the impact of a positive list system on new chemical entity drugs and incrementally modified drugs in South Korea.

BACKGROUND: Medical costs in South Korea have risen, in part due to increased demand and consumption of pharmaceutical products by an aging population and also because of the introduction of newer, more expensive drugs. In an effort to stabilize the financing of health insurance and alleviate the financial burden on individuals, the government implemented a policy changing the national health insurance drug-listing system from a negative list system to a positive list system (PLS). OBJECTIVES: The goal of this study was to compare differences in drug-listing rates for new chemical entities (NCEs) and incrementally modified drugs (IMDs) after South Korea introduced the PLS in December 2006. Parameters significantly affecting NCE and IMD listings were also identified. METHODS: New drug-listing data for 2007 and 2008 were obtained from the databases of the Health Insurance Review Agency and the Ministry of Health and Welfare. Descriptive analyses on the reimbursement rate and logistic regression analysis were conducted. Statistical significance was tested for all results, and P < 0.05 was considered statistically significant. RESULTS: A total of 150 reimbursement applications (79 for NCEs, 71 for IMDs) were examined for this study. The overall drug-listing rate was lower than before the introduction of the PLS. Drug reimbursement rates for NCEs (50.6%) were lower than those for IMDs (74.6%) (P = 0.0025). However, the price negotiation rate was 85.0% for NCEs compared with 73.6% for IMDs (P = 0.1847). The time required for both reimbursement and drug pricing was significantly longer for NCE than for IMD listings (P < 0.05). Cost-effectiveness and budget impact were 2 significant variables affecting the listing of NCEs. However, no significant variable was identified for IMDs. CONCLUSIONS: The PLS challenges the drug-listing system by decreasing the drug-listing rate and lengthening the period for reimbursement determinations. These effects were more pronounced for NCE listings than for IMD listings.