Journal of Preventive Medicine and Public Health

Scoping Review

Reporting Quality for Comorbidity Adjustment in Studies Using Korean Health Insurance Claim Data: A Scoping Review: Kyoung-Hoon Kim; J Prev Med Public Health. 2026;59(2):123-131. Published online January 6, 2026; DOI: https://doi.org/10.3961/jpmph.25.839

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Abstract Summary PDF: Objectives
Adjustment for comorbidity is essential in observational studies using administrative data to ensure the reproducibility and transparency of research findings. However, the reporting quality of comorbidity adjustment in studies using the National Health Insurance Claim Data (NHICD) has not yet been evaluated. This study aimed to assess the reporting quality of comorbidity adjustment in health outcome studies that used the NHICD.
Methods
We conducted a PubMed search in April 2025 using the terms “(Korea OR Korean) AND (‘health insurance claim*’ OR claims data OR NHIS OR HIRA) AND (2024).” Of the 239 retrieved studies, 82 outcome studies that exclusively used the NHICD and adjusted for comorbidities as confounding variables were included. Reporting quality was evaluated across 3 domains: (1) scope of data, (2) range of diagnostic codes, and (3) length of the look-back period.
Results
Among the 82 studies, 33 (40.2%) used ad hoc selection, 33 (40.2%) used the Charlson comorbidity index, and 13 (15.9%) applied both methods. The Elixhauser comorbidity measure was rarely used, appearing in only 3 studies. Only 3 studies explicitly described the scope of data used, and 6 reported the diagnostic code range. The look-back period was specified in 26 studies (31.7%), with 1 year being the most commonly reported duration.
Conclusions
The reporting quality of comorbidity adjustment in studies using the NHICD remains suboptimal. Transparent and standardized reporting of data scope, diagnostic code range, and look-back period is essential to improve the reproducibility and comparability of research findings.; Summary

Korean summary
건강보험 청구자료를 활용한 관찰연구에서 동반질환 보정은 연구 결과의 타당성을 확보하는 데 중요한 요소이나, 그 보고 수준은 충분히 평가되지 않았다. 본 연구는 2024년에 발표된 건강보험 청구자료 기반 연구를 대상으로 문헌검색을 수행하고, 데이터 범위, 진단코드 범위, 관찰기간 측면에서 동반질환 보정의 보고 수준을 평가하였다. 그 결과, 대부분의 연구에서 이러한 핵심 방법론적 정보가 충분히 보고되지 않았으며, 보고 방식에도 상당한 변이가 존재하였다. 이러한 결과는 연구의 재현성과 비교 가능성을 제한할 수 있음을 의미하며, 향후 행정자료 기반 연구의 신뢰성과 방법론적 정확성을 높이기 위해 표준화되고 투명한 보고가 필요함을 시사한다.

Key Message
The reporting quality of comorbidity adjustment in studies using Korean health insurance claims data remains suboptimal. Key methodological elements, including the scope of data, diagnostic code range, and look-back period, are frequently omitted or insufficiently described, limiting the reproducibility and comparability of findings. Transparent and standardized reporting of these components is essential to improve methodological rigor and support more reliable evidence generation in administrative data research.

Original Articles

Comorbid Conditions in Persons Exposed to Ionizing Radiation and Veterans of the Soviet–Afghan War: A Cohort Study in Kazakhstan: Saule Sarkulova, Roza Tatayeva, Dinara Urazalina, Ekaterina Ossadchaya, Venera Rakhmetova; J Prev Med Public Health. 2024;57(1):55-64. Published online November 1, 2023; DOI: https://doi.org/10.3961/jpmph.23.333

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Objectives
This study investigated the prevalence and characteristics of comorbid conditions in patients exposed to ionizing radiation and those who were involved in the Soviet–Afghan war.
Methods
This study analyzed the frequency and spectrum of morbidity and comorbidity in patients over a long-term period (30-35 years) following exposure to ionizing radiation at the Semipalatinsk nuclear test site or the Chornobyl nuclear power plant, and among participants of the Soviet–Afghan war. A cohort study, both prospective and retrospective, was conducted on 675 patients who underwent comprehensive examinations.
Results
Numerical data were analyzed using the Statistica 6 program. The results are presented as the mean±standard deviation, median, and interquartile range (25-75th percentiles). The statistical significance of between-group differences was assessed using the Student t-test and Pearson chi-square test. A p-value of less than 0.05 was considered statistically significant. We found a high prevalence of cardiovascular diseases, including hypertension (55.0%) and cardiac ischemia (32.9%); these rates exceeded the average for this age group in the general population.
Conclusions
The cumulative impact of causal occupational, environmental, and ultra-high stress factors in the combat zone in participants of the Soviet–Afghan war, along with common conventional factors, contributed to the formation of a specific comorbidity structure. This necessitates a rational approach to identifying early predictors of cardiovascular events and central nervous system disorders, as well as pathognomonic clinical symptoms in this patient cohort. It also underscores the importance of selecting suitable methods and strategies for implementing treatment and prevention measures.

Summary

Key Message
This study investigated the long-term health effects on 675 individuals exposed to ionizing radiation at Semipalatinsk and Chornobyl, and those involved in the Soviet–Afghan war. Results showed a higher prevalence of cardiovascular diseases, notably hypertension (55%) and cardiac ischemia (32.9%), compared to the general population. The findings highlight the need for early detection of cardiovascular and central nervous system disorders in these groups, emphasizing tailored treatment and prevention strategies.

Citations

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Global trends in research on Semipalatinsk nuclear testing health effects: A bibliometric analysis and short review
Nailya Chaizhunussova, Lyudmila Pivina, Dariya Shabdarbayeva, Andrey Orekhov, Raushan Dosmagambetova, Galiya Alibayeva, Meruyert Massabayeva, Alexandra Lipikhina, Gulshara Abildinova, Askar Kassymov, Zhanargul Smailova, Rauan Kissina, Diana Ygiyeva, Ernar
Journal of Environmental Radioactivity.2025; 290: 107793. CrossRef
Long-Term Consequences of Combat Stress in Afghan War Veterans: Comorbidity of PTSD and Physical and Mental Health Conditions
Ekaterina Ossadchaya, Roza Tatayeva, Zhibek Sembayeva, Akmaral Nursafina, Mira Zhakenova, Gaukhar Slamkhanova
Psychiatry International.2025; 6(4): 141. CrossRef

Sleep Duration, Comorbidities, and Mortality in Korean Health Examinees: A Prospective Cohort Study: Sukhong Min, Woo-Kyoung Shin, Katherine De la Torre, Dan Huang, Hyung-Suk Yoon, Aesun Shin, Ji-Yeob Choi, Daehee Kang; J Prev Med Public Health. 2023;56(5):458-466. Published online September 26, 2023; DOI: https://doi.org/10.3961/jpmph.23.311

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Abstract Summary PDF Supplementary Material

Objectives
The association between long sleep duration and mortality is frequently attributed to the confounding influence of comorbidities. Nevertheless, past efforts to account for comorbidities have yielded inconsistent outcomes. The objective of this study was to evaluate this relationship using a large prospective cohort in Korea.
Methods
The study included 114 205 participants from the Health Examinees Study, who were followed for a median of 9.1 years. A composite comorbidity score was developed to summarize the effects of 21 diseases. Using Cox proportional hazards regression, hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause, cancer, and cardiovascular mortality associated with sleep duration were estimated. These estimates were adjusted for socio-demographic factors, lifestyle factors, body mass index, and comorbidity score. Additionally, a stratified analysis by subgroups with and without comorbidities was conducted.
Results
Throughout the follow-up period, 2675 deaths were recorded. After all adjustments, an association was observed between a sleep duration of 8 hours or more and all-cause mortality (HR, 1.10; 95% CI, 1.01 to 1.20). However, no such association was detected in the stratified analysis for the subgroups based on comorbidity status.
Conclusions
Long sleep duration was found to be associated with all-cause mortality among Koreans, even after adjusting for comorbidities. Additional studies are required to explore the mechanism underlying the association between sleep duration and major causes of mortality.

Summary

Korean summary
- 한국의 대규모 코호트 자료를 이용, 긴 수면 시간과 사망률 간의 연관성이 동반 상병으로 인한 교란 효과로 인한 것인지를 검토하였다. - 수면 시간과 총 사망률, 암 사망률, 심혈관질환 사망률 간의 연관성을 확인하였고, 이 중 총 사망률과 긴 수면 시간이 동반 상병 지수로 보정 한 뒤에도 유의한 연관성을 보였다.

Key Message
Using a large prospective cohort in Korea, the association between long sleep duration and mortality was evaluated, after adjusting for the confounding influence of comorbidities. When 114,205 participants from the Health Examinees Study were followed for a median of 9.1 years, sleep duration of 8 hours or more were found to be associated with all-cause mortality (HR, 1.10; 95% CI, 1.01 to 1.20). Additional studies are required to explore the mechanism underlying the association between sleep duration and major causes of mortality.

Citations

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Imbalanced sleep increases mortality risk by 14–34%: a meta-analysis
Zoltan Ungvari, Mónika Fekete, Péter Varga, János Tibor Fekete, Andrea Lehoczki, Annamaria Buda, Ágnes Szappanos, György Purebl, Anna Ungvari, Balázs Győrffy
GeroScience.2025; 47(3): 4545. CrossRef
Non-linear association of sleep duration with osteoarthritis among U.S. middle-aged and older adults
Guoliang Ma, Bo Xu, Zhizhuang Wang, Weili Duan, Xin Chen, Liguo Zhu, Bowen Yang, Dian Zhang, Xiaokuan Qin, He Yin, Xu Wei
BMC Public Health.2024;[Epub] CrossRef

Brief Report

Characteristics and Health Care Spending of Persistently and Transiently High-cost Older Adults in Korea: Sungchul Park, Giryeon Bae; J Prev Med Public Health. 2023;56(5):475-480. Published online September 4, 2023; DOI: https://doi.org/10.3961/jpmph.23.270

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Abstract Summary PDF

Objectives
This study examined differences in health care spending and characteristics among older adults in Korea by high-cost status (persistently, transiently, and never high-cost).
Methods
We identified 1 364 119 older adults using data from the Korean National Insurance Claims Database for 2017-2019. Outcomes included average annual total health care spending and high-cost status for 2017-2019. Linear regression was used to estimate differences in the outcomes while adjusting for individual-level characteristics.
Results
Persistently and transiently high-cost older adults had higher health care spending than never high-cost older adults, but the difference in health care spending was greater among persistently high-cost older adults than among transiently high-cost older adults (US$20 437 vs. 5486). Despite demographic and socioeconomic differences between transiently high-cost and never high-cost older adults, the presence of comorbid conditions remained the most significant factor. However, there were no or small differences in the prevalence of comorbid conditions between persistently high-cost and transiently high-cost older adults. Rather, notable differences were observed in socioeconomic status, including disability and receipt of Medical Aid.
Conclusions
Medical risk factors contribute to high health care spending to some extent, but social risk factors may be a source of persistent high-cost status among older adults in Korea.

Summary

Korean summary
- 한국에서 65세 이상의 고령층 고비용 환자 그룹 내에서 두 개의 이질적인 그룹을 발견하였다. - 지속적으로 고비용인 환자는 일시적으로 고비용인 환자보다 의료비 지출이 유의미하게 더 많았다. - 두 그룹의 특성을 비교한 결과, 건강요인의 차이도 있었지만 그보다는 사회적 요인의 차이가 더 컸다.

Key Message
- High-cost older adults are heterogeneous in terms of health care spending and sample characteristics in Korea. - Persistently high-cost older adults had significantly higher health care spending than transiently high-cost older adults. - Medical risk factors contribute to high health care spending to some extent, but social risk factors may be a source of persistent high-cost status among older adults.

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Health Care Spending Increases and Value in South Korea
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Assessing differences among persistent, episodic, and non- high-need high-cost hospitalized children in China after categorization by an unsupervised learning algorithm
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COVID-19: Original Article

Association of Comorbidities With Pneumonia and Death Among COVID-19 Patients in Mexico: A Nationwide Cross-sectional Study: Akram Hernández-Vásquez, Diego Azañedo, Rodrigo Vargas-Fernández, Guido Bendezu-Quispe; J Prev Med Public Health. 2020;53(4):211-219. Published online May 28, 2020; DOI: https://doi.org/10.3961/jpmph.20.186

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Abstract PDF

Objectives
The goal of this study was to identify chronic conditions and multimorbidity patterns in patients with coronavirus disease 2019 (COVID-19) and to examine their associations with pneumonia and death.
Methods
This cross-sectional study analyzed the official data of COVID-19 patients in Mexico through May 18, 2020 (released by the Secretaría de Salud de México). Adjusted logistic regression models were applied to assess the associations of comorbidities with pneumonia and death. The marginal effects were estimated, and the probability of pneumonia or death according to the number of comorbidities was graphed for each year of age.
Results
Of the 51 053 COVID-19 patients enrolled in the final analysis, 27 667 (54.2%) had no chronic conditions, while 13 652 (26.7%), 6518 (12.8%) and 3216 (6.3%) were reported to have 1, 2, and 3 or more simultaneous conditions, respectively. Overall, a significant incremental gradient was observed for the association between multimorbidity and pneumonia (p<0.001); for 2 chronic conditions, the adjusted odds ratio (aOR) was 2.07 (95% confidence interval [CI], 1.95 to 2.20), and for ≥3 conditions, the aOR was 2.40 (95% CI, 2.22 to 2.60). A significant incremental gradient was also found for the relationship between multimorbidity and death (p<0.001); an aOR of 2.51 (95% CI, 2.30 to 2.73) was found for 2 chronic conditions and an aOR of 3.49 (95% CI, 3.15 to 3.86) for ≥3 conditions.
Conclusions
Underlying chronic conditions and multimorbidity are associated with pneumonia and death in Mexican COVID-19 patients. Future investigation is necessary to clarify the pathophysiological processes behind this association, given the high burden of chronic diseases in various countries, including Mexico.

Summary

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Original Article

Increased Prevalence of Chronic Disease in Back Pain Patients Living in Car-dependent Neighbourhoods in Canada: A Cross-sectional Analysis: Amy Zeglinski-Spinney, Denise C. Wai, Philippe Phan, Eve C. Tsai, Alexandra Stratton, Stephen P. Kingwell, Darren M. Roffey, Eugene K. Wai; J Prev Med Public Health. 2018;51(5):227-233. Published online August 10, 2018; DOI: https://doi.org/10.3961/jpmph.18.038

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Abstract PDF

Objectives
Chronic diseases, including back pain, result in significant patient morbidity and societal burden. Overall improvement in physical fitness is recommended for prevention and treatment. Walking is a convenient modality for achieving initial gains. Our objective was to determine whether neighbourhood walkability, acting as a surrogate measure of physical fitness, was associated with the presence of chronic disease.
Methods
We conducted a cross-sectional study of prospectively collected data from a prior randomized cohort study of 227 patients referred for tertiary assessment of chronic back pain in Ottawa, ON, Canada. The Charlson Comorbidity Index (CCI) was calculated from patient-completed questionnaires and medical record review. Using patients’ postal codes, neighbourhood walkability was determined using the Walk Score, which awards points based on the distance to the closest amenities, yielding a score from 0 to 100 (0- 50: car-dependent; 50-100: walkable).
Results
Based on the Walk Score, 134 patients lived in car-dependent neighborhoods and 93 lived in walkable neighborhoods. A multivariate logistic regression model, adjusted for age, gender, rural postal code, body mass index, smoking, median household income, percent employment, pain, and disability, demonstrated an adjusted odds ratio of 2.75 (95% confidence interval, 1.16 to 6.53) times higher prevalence for having a chronic disease for patients living in a car-dependent neighborhood. There was also a significant dose-related association (p=0.01; Mantel-Haenszel chi-square=6.4) between living in car-dependent neighbourhoods and more severe CCI scores.
Conclusions
Our findings suggest that advocating for improved neighbourhood planning to permit greater walkability may help offset the burden of chronic disease.

Summary

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English Abstracts

Comparative Study on Three Algorithms of the ICD-10 Charlson Comorbidity Index with Myocardial Infarction Patients.: Kyoung Hoon Kim; J Prev Med Public Health. 2010;43(1):42-49.; DOI: https://doi.org/10.3961/jpmph.2010.43.1.42

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Abstract PDF

OBJECTIVES
To compare the performance of three International Statistical Classification of Diseases, 10th Revision translations of the Charlson comorbidities when predicting in-hospital among patients with myocardial infarction (MI). METHODS: MI patients > or =20 years of age with the first admission during 2006 were identified(n=20,280). Charlson comorbidities were drawn from Heath Insurance Claims Data managed by Health Insurance Review and Assessment Service in Korea. Comparisions for various conditions included (a) three algorithms (Halfon, Sundararajan, and Quan algorithms), (b) lookback periods (1-, 3- and 5-years), (c) data range (admission data, admission and ambulatory data), and (d) diagnosis range (primary diagnosis and first secondary diagnoses, all diagnoses). The performance of each procedure was measured with the c-statistic derived from multiple logistic regression adjusted for age, sex, admission type and Charlson comorbidity index. A bootstrapping procedure was done to determine the approximate 95% confidence interval. RESULTS: Among the 20,280 patients, the mean age was 63.3 years, 67.8% were men and 7.1% died while hospitalized. The Quan and Sundararajan algorithms produced higher prevalences than the Halfon algorithm. The c-statistic of the Quan algorithm was slightly higher, but not significantly different, than that of other two algorithms under all conditions. There was no evidence that on longer lookback periods, additional data, and diagnoses improved the predictive ability. CONCLUSIONS: In health services study of MI patients using Health Insurance Claims Data, the present results suggest that the Quan Algorithm using a 1-year lookback involving primary diagnosis and the first secondary diagnosis is adequate in predicting in-hospital mortality.

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A Comparative Study on Comorbidity Measurements with Lookback Period using Health Insurance Database: Focused on Patients Who Underwent Percutaneous Coronary Intervention.: Kyoung Hoon Kim, Lee Su Ahn; J Prev Med Public Health. 2009;42(4):267-273.; DOI: https://doi.org/10.3961/jpmph.2009.42.4.267

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Abstract PDF

OBJECTIVES
To compare the performance of three comorbidity measurements (Charlson comorbidity index, Elixhauser's comorbidity and comorbidity selection) with the effect of different comorbidity lookback periods when predicting in-hospital mortality for patients who underwent percutaneous coronary intervention. METHODS: This was a retrospective study on patients aged 40 years and older who underwent percutaneous coronary intervention. To distinguish comorbidity from complications, the records of diagnosis were drawn from the National Health Insurance Database excluding diagnosis that admitted to the hospital. C-statistic values were used as measures for in comparing the predictability of comorbidity measures with lookback period, and a bootstrapping procedure with 1,000 replications was done to determine approximate 95% confidence interval. RESULTS: Of the 61,815 patients included in this study, the mean age was 63.3 years (standard deviation: +/-10.2) and 64.8% of the population was male. Among them, 1,598 (2.6%) had died in hospital. While the predictive ability of the Elixhauser s comorbidity and comorbidity selection was better than that of the Charlson comorbidity index, there was no significant difference among the three comorbidity measurements. Although the prevalence of comorbidity increased in 3 years of lookback periods, there was no significant improvement compared to 1 year of a lookback period. CONCLUSIONS: In a health outcome study for patients who underwent percutaneous coronary intervention using National Health Insurance Database, the Charlson comorbidity index was easy to apply without significant difference in predictability compared to the other methods. The one year of observation period was adequate to adjust the comorbidity. Further work to select adequate comorbidity measurements and lookback periods on other diseases and procedures are needed.

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Prognostic Impact of Charlson Comorbidity Index Obtained from Medical Records and Claims Data on 1-year Mortality and Length of Stay in Gastric Cancer Patients.: Min Ho Kyung, Seok Jun Yoon, Hyeong Sik Ahn, Se min Hwang, Hyun Ju Seo, Kyoung Hoon Kim, Hyeung Keun Park; J Prev Med Public Health. 2009;42(2):117-122.; DOI: https://doi.org/10.3961/jpmph.2009.42.2.117

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OBJECTIVES
We tried to evaluate the agreement of the Charlson comorbidity index values (CCI) obtained from different sources (medical records and National Health Insurance claims data) for gastric cancer patients. We also attempted to assess the prognostic value of these data for predicting 1-year mortality and length of the hospital stay (length of stay). METHODS: Medical records of 284 gastric cancer patients were reviewed, and their National Health Insurance claims data and death certificates were also investigated. To evaluate agreement, the kappa coefficient was tested. Multiple logistic regression analysis and multiple linear regression analysis were performed to evaluate and compare the prognostic power for predicting 1 year mortality and length of stay. RESULTS: The CCI values for each comorbid condition obtained from 2 different data sources appeared to poorly agree (kappa: 0.00-0.59). It was appeared that the CCI values based on both sources were not valid prognostic indicators of 1-year mortality. Only medical record-based CCI was a valid prognostic indicator of length of stay, even after adjustment of covariables (beta = 0.112, 95% CI = [0.017-1.267]). CONCLUSIONS: There was a discrepancy between the data sources with regard to the value of CCI both for the prognostic power and its direction. Therefore, assuming that medical records are the gold standard for the source for CCI measurement, claims data is not an appropriate source for determining the CCI, at least for gastric cancer.

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Evaluation Studies

Usefulness of Comorbidity Indices in Operative Gastric Cancer Cases.: Se Min Hwang, Seok Jun Yoon, Hyeong Sik Ahn, Hyong Gin An, Sang Hoo Kim, Min Ho Kyeong, Eun Kyoung Lee; J Prev Med Public Health. 2009;42(1):49-58.; DOI: https://doi.org/10.3961/jpmph.2009.42.1.49

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Abstract PDF

OBJECTIVES
The purpose of the current study was to evaluate the usefulness of the following four comorbidity indices in gastric cancer patients who underwent surgery: Charlson Comorbidity Index (CCI), Cumulative Illness rating scale (CIRS), Index of Co-existent Disease (ICED), and Kaplan-Feinstein Scale (KFS). METHODS: The study subjects were 614 adults who underwent surgery for gastric cancer at K hospital between 2005 and 2007. We examined the test-retest and inter-rater reliability of 4 comorbidity indices for 50 patients. Reliability was evaluated with Spearman rho coefficients for CCI and CIRS, while Kappa values were used for the ICED and KFS indices. Logistic regression was used to determine how these comorbidity indices affected unplanned readmission and death. Multiple regression was used for determining if the comorbidity indices affected length of stay and hospital costs. RESULTS: The test-retest reliability of CCI and CIRS was substantial (Spearman rho=0.746 and 0.775, respectively), while for ICED and KFS was moderate (Kappa=0.476 and 0.504, respectively). The inter-rater reliability of the CCI, CIRS, and ICED was moderate (Spearman rho=0.580 and 0.668, and Kappa=0.433, respectively), but for KFS was fair (Kappa=0.383). According to the results from logistic regression, unplanned readmissions and deaths were not significantly different between the comorbidity index scores. But, according to the results from multiple linear regression, the CIRS group showed a significantly increased length of hospital stay (p<0.01). Additionally, CCI showed a significant association with increased hospital costs (p<0.01). CONCLUSIONS: This study suggests that the CCI index may be useful in the estimation of comorbidities associated with hospital costs, while the CIRS index may be useful where estimatation of comorbiditie associated with the length of hospital stay are concerned.

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