Journal of Preventive Medicine and Public Health

Original Articles

Annual Endovascular Thrombectomy Case Volume and Thrombectomy-capable Hospitals of Korea in Acute Stroke Care: Eun Hye Park, Seung-sik Hwang, Juhwan Oh, Beom-Joon Kim, Hee-Joon Bae, Ki-Hwa Yang, Ah-Rum Choi, Mi-Yeon Kang, S.V. Subramanian; J Prev Med Public Health. 2023;56(2):145-153. Published online March 31, 2023; DOI: https://doi.org/10.3961/jpmph.22.318

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Abstract Summary PDF Supplementary Material: Objectives
Although it is difficult to define the quality of stroke care, acute ischemic stroke (AIS) patients with moderate-to-severe neurological deficits may benefit from thrombectomy-capable hospitals (TCHs) that have a stroke unit, stroke specialists, and a substantial endovascular thrombectomy (EVT) case volume.
Methods
From national audit data collected between 2013 and 2016, potential EVT candidates arriving within 24 hours with a baseline National Institutes of Health Stroke Scale score ≥6 were identified. Hospitals were classified as TCHs (≥15 EVT case/y, stroke unit, and stroke specialists), primary stroke hospitals (PSHs) without EVT (PSHs-without-EVT, 0 case/y), and PSHs-with-EVT. Thirty-day and 1-year case-fatality rates (CFRs) were analyzed using random intercept multilevel logistic regression.
Results
Out of 35 004 AIS patients, 7954 (22.7%) EVT candidates were included in this study. The average 30-day CFR was 16.3% in PSHs-without-EVT, 14.8% in PSHs-with-EVT, and 11.0% in TCHs. The average 1-year CFR was 37.5% in PSHs-without-EVT, 31.3% in PSHs-with-EVT, and 26.2% in TCHs. In TCHs, a significant reduction was not found in the 30-day CFR (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.76 to 1.12), but was found in the 1-year CFR (OR, 0.84; 95% CI, 0.73 to 0.96).
Conclusions
The 1-year CFR was significantly reduced when EVT candidates were treated at TCHs. TCHs are not defined based solely on the number of EVTs, but also based on the presence of a stroke unit and stroke specialists. This supports the need for TCH certification in Korea and suggests that annual EVT case volume could be used to qualify TCHs.; Summary

Korean summary
급성 허혈성 뇌졸중 환자에서 “혈관 내 혈전제거술(endovascular treatment, EVT)”의 치료효과는 여러 연구를 통해 증명되었으나, EVT 후보군에서 EVT를 제공하기 위한 의료서비스 연구는 부족한 실정이다. 5~7차 뇌졸중 적정성 평가 자료를 활용하여 연간 EVT 시행횟수와 EVT후보군의 30일, 1년 후 치명률 간의 연관성을 다수준 분석을 통해 확인하였다. 연간 15회 이상 EVT를 시행하면서 뇌졸중 전문치료실과 뇌줄중 관련 전문분과(신경과, 신경외과, 재활의학과) 전문의가 모두 있는 병원(TCHs)에서 치료받은 환자는 EVT를 시행하지 않는 병원(PSHs-without-EVT)에서 치료받는 환자에 비해 치명률이 감소하는 경향을 보였다. 이는 뇌졸중 치료체계에서 EVT가능병원을 정의할 필요성을 잘 보여주고, “연간 EVT 시행횟수”는 TCHs를 정의하는 중요한 지표로 사용될 수 있을 것이다.

Construction of the Mobility to Participation Assessment Scale for Stroke (MPASS) and Testing Its Validity and Reliability in Persons With Stroke in Thailand: Jiraphat Nawarat, Kanda Chaipinyo; J Prev Med Public Health. 2022;55(4):334-341. Published online June 13, 2022; DOI: https://doi.org/10.3961/jpmph.21.605

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Abstract PDF: Objectives
This study was conducted to develop the Mobility to Participation Assessment Scale for Stroke (MPASS) and assess its content validity, internal consistency, inter-rater and intra-rater reliability, and convergent validity in people with stroke living in the community.
Methods
The MPASS was developed using published data on mobility-related activity and participation timing in elderly individuals, and then reviewed by community physical therapists. Content validity was established by reaching a consensus of experienced physical therapists in a focus group. The MPASS was scored for 32 participants with stroke (mean age 61.75±4.92 years) by 3 individual testers. Reliability was examined using the intraclass correlation coefficient (ICC), internal consistency using the Cronbach alpha coefficient (α), and convergent validity using the Pearson correlation coefficient (r) to compare the MPASS to the Modified Rivermead Mobility Index as a referent test of mobility.
Results
The MPASS consists of 8 items, and its scoring system provides information on the ability of people with stroke to reach a movement level enabling them to live in society, including interactions with other people and safe living in the community. The inter-rater and intra-rater reliability were excellent (ICC, 0.948; 95% confidence interval [CI], 0.893 to 0.982 and ICC, 0.967; 95% CI, 0.933 to 0.989, respectively). Internal consistency was good (α=0.877). The convergent validity was moderate (r=0.646; p<0.001).
Conclusions
The newly developed MPASS showed acceptable construct validity and high reliability. The MPASS is suitable for use in people with stroke, especially those who have been discharged and live in the community with the ability to initiate sitting.; Summary

Presence of Thrombectomy-capable Stroke Centers Within Hospital Service Areas Explains Regional Variation in the Case Fatality Rate of Acute Ischemic Stroke in Korea: Eun Hye Park, Yong Jin Gil, Chanki Kim, Beom Joon Kim, Seung-sik Hwang; J Prev Med Public Health. 2021;54(6):385-394. Published online October 22, 2021; DOI: https://doi.org/10.3961/jpmph.21.329

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Abstract Summary PDF Supplementary Material

Objectives
This study aimed to explore the status of regional variations in acute ischemic stroke (AIS) treatment and investigate the association between the presence of a thrombectomy-capable stroke center (TSC) and the case fatality rate (CFR) of AIS within hospital service areas (HSAs).
Methods
This observational cross-sectional study analyzed acute stroke quality assessment program data from 262 hospitals between 2013 and 2016. TSCs were defined according to the criteria of the Joint Commission. In total, 64 HSAs were identified based on the addresses of hospitals. We analyzed the effects of structure factors, process factors, and the presence of a TSC on the CFR of AIS using multivariate logistic regression.
Results
Among 262 hospitals, 31 hospitals met the definition of a TSC. Of the 64 HSAs, only 20 had a TSC. At hospitals, the presence of a stroke unit, the presence of stroke specialists, and the rate of endovascular thrombectomy (EVT) treatment were associated with reductions in the CFR. In HSAs, the rate of EVT treatment (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99) and the presence of a TSC (OR, 0.93; 95% CI, 0.88 to 0.99) significantly reduced the CFR of AIS.
Conclusions
The presence of a TSC within an HSA, corresponding to structure and process factors related to the quality of care, contributed significantly to lowering the CFR of AIS. The CFR also declined as the rate of treatment increased. This study highlights the importance of TSCs in the development of an acute stroke care system in Korea.

Summary

Korean summary
혈관 내 재개통술(endovascular thrombectomy, EVT)는 많은 전문인력과 장비등 상당한 자원을 필요로 하는 특성으로 인해 상대적으로 자원이 부족한 지역에 치료 공백이 발생할 수 있다. EVT 가능 병원(Thrombectomy capable stroke center, TSC)를 "연간 EVT 15회 이상 시행, 뇌졸중 전문치료실 운영 그리고 뇌졸중 관련 전문의(신경과, 신경외과, 재활의학과)가 모두 근무하는 병원으로 정의하고 진료권 단위로 분석한 결과 진료권 내 TSC의 존재는 허혈성 뇌졸중 환자군의 치명률를 유의하게 감소시켰다. 그러므로 급성 허혈성 뇌졸중 치료의 지역 간 변이를 줄이기 위해서 진료권 내 TSC 를 정의하고 설치하는 것의 중요하며, 이러한 결과는 향후 70개 진료권 단위 지역책임의료기관을 구축하는 과정에 중요한 근거자료로 활용될수 있을 것이다.

Citations

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Prioritization of Injury Prevention and Management Programs and Research and Development (R&D) Projects: Survey Using the Delphi Technique and Analytic Hierarchy Process
Won Kyung Lee, Minsu Ock, Ju Ok Park, Changsoo Kim, Beom Sok Seo, Jeehee Pyo, Hyun Jin Park, Ui Jeong Kim, Eun Jeong Choi, Shinyoung Woo, Hyesook Park
Asia Pacific Journal of Public Health.2024; 36(1): 78. CrossRef
Patterns in the number of interventionalists for endovascular treatment of acute ischemic stroke in the US
Ankita Tripathi, Laura K. Stein, Mandip S. Dhamoon
Journal of Stroke and Cerebrovascular Diseases.2023; 32(2): 106943. CrossRef
Thrombectomy-Capable Stroke Centre—A Key to Acute Stroke Care System Improvement? Retrospective Analysis of Safety and Efficacy of Endovascular Treatment in Cardiac Cathlab
Krzysztof Pawłowski, Artur Dziadkiewicz, Anna Podlasek, Jacek Klaudel, Alicja Mączkowiak, Marek Szołkiewicz
International Journal of Environmental Research and Public Health.2023; 20(3): 2232. CrossRef
COVID-19 case-fatality variations with application to the Middle East countries
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The Burden of Stroke in Kurdistan Province, Iran From 2011 to 2017: Shahram Moradi, Ghobad Moradi, Bakhtiar Piroozi; J Prev Med Public Health. 2021;54(2):103-109. Published online February 1, 2021; DOI: https://doi.org/10.3961/jpmph.20.335

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Abstract PDF: Objectives
The aim of this study was to calculate the burden of stroke in Kurdistan Province, Iran between 2011 and 2017.
Methods
Incidence data extracted from the hospital information system of Kurdistan Province and death data extracted from the system of registration and classification of causes of death were used in a cross-sectional study. The World Health Organization method was used to calculate disability-adjusted life years (DALYs).
Results
The burden of stroke increased from 2453.44 DALYs in 2011 to 5269.68 in 2017, the years of life lost increased from 2381.57 in 2011 to 5109.68 in 2017, and the years of healthy life lost due to disability increased from 71.87 in 2011 to 159.99 in 2017. The DALYs of ischaemic stroke exceeded those of haemorrhagic stroke. The burden of disease, new cases, and deaths doubled during the study period. The age-standardised incidence rate of ischaemic stroke and haemorrhagic stroke in 2017 was 21.72 and 20.72 per 100 000 population, respectively.
Conclusions
The burden of stroke is increasing in Kurdistan Province. Since health services in Iran are based on treatment, steps are needed to revise the current treatment services for stroke and to improve the quality of services. Policy-makers and managers of the health system need to plan to reduce the known risk factors for stroke in the community. In addition to preventive interventions, efficient and up-to-date interventions are recommended for the rapid diagnosis and treatment of stroke patients in hospitals. Along with therapeutic interventions, preventive interventions can help reduce the stroke burden.; Summary

Modeling Survival in Patients With Brain Stroke in the Presence of Competing Risks: Solmaz Norouzi, Mohammad Asghari Jafarabadi, Seyed Morteza Shamshirgaran, Farshid Farzipoor, Ramazan Fallah; J Prev Med Public Health. 2021;54(1):55-62. Published online December 7, 2020; DOI: https://doi.org/10.3961/jpmph.20.463

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Abstract PDF: Objectives
After heart disease, brain stroke (BS) is the second most common cause of death worldwide, underscoring the importance of understanding preventable and treatable risk factors for the outcomes of BS. This study aimed to model the survival of patients with BS in the presence of competing risks.
Methods
This longitudinal study was conducted on 332 patients with a definitive diagnosis of BS. Demographic characteristics and risk factors were collected by a validated checklist. Patients’ mortality status was investigated by telephone follow-up to identify deaths that may be have been caused by stroke or other factors (heart disease, diabetes, high cholesterol, etc.). Data were analyzed by the Lunn-McNeil approach at alpha=0.1.
Results
Older age at diagnosis (59-68 years: adjusted hazard ratio [aHR], 2.19; 90% confidence interval [CI], 1.38 to 3.48; 69-75 years: aHR, 5.04; 90% CI, 3.25 to 7.80; ≥76 years: aHR, 5.30; 90% CI, 3.40 to 8.44), having heart disease (aHR, 1.65; 90% CI, 1.23 to 2.23), oral contraceptive pill use (women only) (aHR, 0.44; 90% CI, 0.24 to 0.78) and ischemic stroke (aHR, 0.52; 90% CI, 0.36 to 0.74) were directly related to death from BS. Older age at diagnosis (59-68 years: aHR, 21.42; 90% CI, 3.52 to 130.39; 75-69 years: aHR, 16.48; 90% CI, 2.75 to 98.69; ≥76 years: aHR, 26.03; 90% CI, 4.06 to 166.93) and rural residence (aHR, 2.30; 90% CI, 1.15 to 4.60) were directly related to death from other causes. Significant risk factors were found for both causes of death.
Conclusions
BS-specific and non-BS-specific mortality had different risk factors. These findings could be utilized to prescribe optimal and specific treatment.; Summary

Incidence, Risk Factors, and Prediction of Myocardial Infarction and Stroke in Farmers: A Korean Nationwide Population-based Study: Solam Lee, Hunju Lee, Hye Sim Kim, Sang Baek Koh; J Prev Med Public Health. 2020;53(5):313-322. Published online July 14, 2020; DOI: https://doi.org/10.3961/jpmph.20.156

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Abstract PDF

Objectives
This study was conducted to determine the incidence and risk factors of myocardial infarction (MI) and stroke in farmers compared to the general population and to establish 5-year prediction models.
Methods
The farmer cohort and the control cohort were generated using the customized database of the National Health Insurance Service of Korea database and the National Sample Cohort, respectively. The participants were followed from the day of the index general health examination until the events of MI, stroke, or death (up to 5 years).
Results
In total, 734 744 participants from the farmer cohort and 238 311 from the control cohort aged between 40 and 70 were included. The age-adjusted incidence of MI was 0.766 and 0.585 per 1000 person-years in the farmer and control cohorts, respectively. That of stroke was 0.559 and 0.321 per 1000 person-years in both cohorts, respectively. In farmers, the risk factors for MI included male sex, age, personal history of hypertension, diabetes, current smoking, creatinine, metabolic syndrome components (blood pressure, triglycerides, and high-density lipoprotein cholesterol). Those for stroke included male sex, age, personal history of hypertension, diabetes, current smoking, high γ-glutamyl transferase, and metabolic syndrome components (blood pressure, triglycerides, and high-density lipoprotein cholesterol). The prediction model showed an area under the receiver operating characteristic curve of 0.735 and 0.760 for MI and stroke, respectively, in the farmer cohort.
Conclusions
Farmers had a higher age-adjusted incidence of MI and stroke. They also showed distinct patterns in cardiovascular risk factors compared to the general population.

Summary

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Journal of Preventive Medicine and Public Health.2021; 54(6): 385. CrossRef

Climate Change: Perspective

Characteristics of Heat Waves From a Disaster Perspective: Do-Woo Kim, Chaeyoung Kwon, Jineun Kim, Jong-Seol Lee; J Prev Med Public Health. 2020;53(1):26-28. Published online January 31, 2020; DOI: https://doi.org/10.3961/jpmph.19.315

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Abstract Summary PDF

In September 2018, heat waves were declared to be a type of natural disaster by the Framework Act on the Management of Disasters and Safety. The present study examined the characteristics of heat waves from the perspectives of meteorological phenomena and health damage. The government’s efforts to minimize the damages incurred by heat waves are summarized chronologically. Furthermore, various issues pertaining to heat waves that are being raised in our society despite the government’s efforts are summarized by analyzing big data derived from reported news and academic articles.

Summary

Korean summary
2018년 9월, 폭염이 재난 및 안전 관리 기본법 상 자연재난의 한 유형으로 명시되었다. 본 연구는 다른 자연재난들과 구별되는 폭염 재난의 특징들을 기상학적과 보건학적 측면으로 나누어 제시하였다. 또한 폭염 피해를 줄이기 위한 그간 정부의 각종 노력들을 시간순서대로 정리하였으며, 뉴스와 논문 빅데이터 분석을 통해 최근에 우리사회에서 폭염과 관련된 어떤 이슈들이 떠오르고 있는지도 살펴보았다.

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Original Articles

Validity of Self-reported Stroke and Myocardial Infarction in Korea: The Health Examinees (HEXA) Study: Sunho Choe, Joonki Lee, Jeeyoo Lee, Daehee Kang, Jong-Koo Lee, Aesun Shin; J Prev Med Public Health. 2019;52(6):377-383. Published online November 12, 2019; DOI: https://doi.org/10.3961/jpmph.19.089

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Abstract PDF

Objectives
Self-reported disease history is often used in epidemiological studies. In this study, we acquired the hospital records of subjects who self-reported stroke or myocardial infarction (MI) and evaluated the validity of the participants’ self-reported disease history. We also determined the level of agreement between specialists and non-specialists.
Methods
Among the participants in the Health Examinees study, 1488 subjects self-reported stroke or MI during 2012-2017, and medical records were acquired for the 429 subjects (28.8%) who agreed to share their medical information. Each record was independently assigned to 2 medical doctors for review. The records were classified as ‘definite,’ ‘possible,’ or ‘not’ stroke or MI. If the doctors did not agree, a third doctor made the final decision. The positive predictive value (PPV) of self-reporting was calculated with the doctors’ review as the gold standard. Kappa statistics were used to compare the results between general doctors and neurologists or cardiologists.
Results
Medical records from 208 patients with self-reported stroke and 221 patients with self-reported MI were reviewed. The PPV of self-reported disease history was 51.4% for stroke and 32.6% for MI. If cases classified as ‘possible’ were counted as positive diagnoses, the PPV was 59.1% for stroke and 33.5% for MI. Kappa statistics showed moderate levels of agreement between specialists and non-specialists for both stroke and MI.
Conclusions
The validity of self-reported disease was lower than expected, especially in those who reported having been diagnosed with MI. Proper consideration is needed when using these self-reported data in further studies.

Summary

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The Incidence of Stroke by Socioeconomic Status, Age, Sex, and Stroke Subtype: A Nationwide Study in Korea: Su Ra Seo, Su Young Kim, Sang-Yi Lee, Tae-Ho Yoon, Hyung-Geun Park, Seung Eun Lee, Chul-Woung Kim; J Prev Med Public Health. 2014;47(2):104-112. Published online March 31, 2014; DOI: https://doi.org/10.3961/jpmph.2014.47.2.104

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Abstract PDF

Objectives

To date, studies have not comprehensively demonstrated the relationship between stroke incidence and socioeconomic status. This study investigated stroke incidence by household income level in conjunction with age, sex, and stroke subtype in Korea.

Methods

Contributions by the head of household were used as the basis for income levels. Household income levels for 21 766 036 people were classified into 6 groups. The stroke incidences were calculated by household income level, both overall within income categories and further by age group, sex, and stroke subtype. To present the inequalities among the six ranked groups in a single value, the slope index of inequality and relative index of inequality were calculated.

Results

In 2005, 57 690 people were first-time stroke patients. The incidences of total stroke for males and females increased as the income level decreased. The incidences of stroke increased as the income level decreased in those 74 years old and under, whereas there was no difference by income levels in those 75 and over. Intracerebral hemorrhage for the males represented the highest inequality among stroke subtypes. Incidences of subarachnoid hemorrhage did not differ by income levels.

Conclusions

The incidence of stroke increases as the income level decreases, but it differs according to sex, age, and stroke subtype. The difference in the relative incidence is large for male intracerebral hemorrhage, whereas the difference in the absolute incidence is large for male ischemic stroke.

Summary

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The Effects of Temperature on Heat-related Illness According to the Characteristics of Patients During the Summer of 2012 in the Republic of Korea: Wonwoong Na, Jae-Yeon Jang, Kyung Eun Lee, Hyunyoung Kim, Byungyool Jun, Jun-Wook Kwon, Soo-Nam Jo; J Prev Med Public Health. 2013;46(1):19-27. Published online January 31, 2013; DOI: https://doi.org/10.3961/jpmph.2013.46.1.19

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Abstract PDF

Objectives

This study was conducted to investigate the relationship between heat-related illnesses developed in the summer of 2012 and temperature.

Methods

The study analyzed data generated by a heat wave surveillance system operated by the Korea Centers for Disease Control and Prevention during the summer of 2012. The daily maximum temperature, average temperature, and maximum heat index were compared to identify the most suitable index for this study. A piecewise linear model was used to identify the threshold temperature and the relative risk (RR) above the threshold temperature according to patient characteristics and region.

Results

The total number of patients during the 3 months was 975. Of the three temperature indicators, the daily maximum temperature showed the best goodness of fit with the model. The RR of the total patient incidence was 1.691 (1.641 to 1.743) per 1℃ after 31.2℃. The RR above the threshold temperature of women (1.822, 1.716 to 1.934) was greater than that of men (1.643, 1.587 to 1.701). The threshold temperature was the lowest in the age group of 20 to 64 (30.4℃), and the RR was the highest in the ≥65 age group (1.863, 1.755 to 1.978). The threshold temperature of the provinces (30.5℃) was lower than that of the metropolitan cities (32.2℃). Metropolitan cities at higher latitudes had a greater RR than other cities at lower latitudes.

Conclusions

The influences of temperature on heat-related illnesses vary according to gender, age, and region. A surveillance system and public health program should reflect these factors in their implementation.

Summary

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Changes in Air Temperature and Its Relation to Ambulance Transports Due to Heat Stroke in All 47 Prefectures of Japan: Shoko Murakami, Nobuyuki Miyatake, Noriko Sakano; J Prev Med Public Health. 2012;45(5):309-315. Published online September 28, 2012; DOI: https://doi.org/10.3961/jpmph.2012.45.5.309

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Abstract PDF

Objectives

Changes in air temperature and its relation to ambulance transports due to heat stroke in all 47 prefectures, in Japan were evaluated.

Methods

Data on air temperature were obtained from the Japanese Meteorological Agency. Data on ambulance transports due to heat stroke was directly obtained from the Fire and Disaster Management Agency, Japan. We also used the number of deaths due to heat stroke from the Ministry of Health, Labour and Welfare, Japan, and population data from the Ministry of Internal Affairs and Communications. Chronological changes in parameters of air temperature were analyzed. In addition, the relation between air temperature and ambulance transports due to heat stroke in August 2010 was also evaluated by using an ecological study.

Results

Positive and significant changes in the parameters of air temperature that is, the mean air temperature, mean of the highest air temperature, and mean of the lowest air temperature were noted in all 47 prefectures. In addition, changes in air temperature were accelerated when adjusted for observation years. Ambulance transports due to heat stroke was significantly correlated with air temperature in the ecological study. The highest air temperature was significantly linked to ambulance transports due to heat stroke, especially in elderly subjects.

Conclusions

Global warming was demonstrated in all 47 prefectures in Japan. In addition, the higher air temperature was closely associated with higher ambulance transports due to heat stroke in Japan.

Summary

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English Abstract

Socioeconomic Costs of Stroke in Korea: Estimated from the Korea National Health Insurance Claims Database.: Seung ji Lim, Han joong Kim, Chung mo Nam, Hoo sun Chang, Young Hwa Jang, Sera Kim, Hye Young Kang; J Prev Med Public Health. 2009;42(4):251-260.; DOI: https://doi.org/10.3961/jpmph.2009.42.4.251

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Abstract PDF

OBJECTIVES
To estimate the annual socioeconomic costs of stroke in Korea in 2005 from a societal perspective. METHODS: We identified those 20 years or older who had at least one national health insurance (NHI) claims record with a primary or a secondary diagnosis of stroke (ICD-10 codes: I60-I69, G45) in 2005. Direct medical costs of the stroke were measured from the NHI claims records. Direct non-medical costs were estimated as transportation costs incurred when visiting the hospitals. Indirect costs were defined as patients' and caregivers' productivity loss associated with office visits or hospitalization. Also, the costs of productivity loss due to premature death from stroke were calculated. RESULTS: A total of 882,143 stroke patients were identified with prevalence for treatment of stroke at 2.44%. The total cost for the treatment of stroke in the nation was estimated to be 3,737 billion Korean won (KRW) which included direct costs at 1,130 billion KRW and indirect costs at 2,606 billion KRW. The per-capita cost of stroke was 3 million KRW for men and 2 million KRW for women. The total national spending for hemorrhagic and ischemic stroke was 1,323 billion KRW and 1,553 billion KRW, respectively, which together consisted of 77.0% of the total cost for stroke. Costs per patient for hemorrhagic and ischemic stroke were estimated at 6 million KRW and 2 million KRW, respectively. CONCLUSIONS: Stroke is a leading public health problem in Korea in terms of the economic burden. The indirect costs were identified as the largest component of the overall cost.

Summary

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