Journal of Preventive Medicine and Public Health

Original Articles

Evaluation of Geographic Indices Describing Health Care Utilization: Agnus M. Kim, Jong Heon Park, Sungchan Kang, Yoon Kim; J Prev Med Public Health. 2017;50(1):29-37. Published online December 19, 2016; DOI: https://doi.org/10.3961/jpmph.16.099

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Objectives
The accurate measurement of geographic patterns of health care utilization is a prerequisite for the study of geographic variations in health care utilization. While several measures have been developed to measure how accurately geographic units reflect the health care utilization patterns of residents, they have been only applied to hospitalization and need further evaluation. This study aimed to evaluate geographic indices describing health care utilization.
Methods
We measured the utilization rate and four health care utilization indices (localization index, outflow index, inflow index, and net patient flow) for eight major procedures (coronary artery bypass graft surgery, percutaneous transluminal coronary angioplasty, surgery after hip fracture, knee replacement surgery, caesarean sections, hysterectomy, computed tomography scans, and magnetic resonance imaging scans) according to three levels of geographic units in Korea. Data were obtained from the National Health Insurance database in Korea. We evaluated the associations among the health care utilization indices and the utilization rates.
Results
In higher-level geographic units, the localization index tended to be high, while the inflow index and outflow index were lower. The indices showed different patterns depending on the procedure. A strong negative correlation between the localization index and the outflow index was observed for all procedures. Net patient flow showed a moderate positive correlation with the localization index and the inflow index.
Conclusions
Health care utilization indices can be used as a proxy to describe the utilization pattern of a procedure in a geographic unit.

Summary

Citations

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Development and Evaluation of Rehabilitation Service Areas for the United States
Timothy A. Reistetter, Julianna M. Dean, Allen M. Haas, John D. Prochaska, Daniel C. Jupiter, Karl Eschbach, Yong-Fang Kuo
BMC Health Services Research.2023;[Epub] CrossRef
Factors Associated with End-Of-Life Health Care Use and Spending in Korea in Comparison with the General Population
Agnus M. Kim, Yoon Kim
Journal of Aging & Social Policy.2023; : 1. CrossRef
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
Journal of Preventive Medicine and Public Health.2021; 54(6): 385. CrossRef
An ecological study of geographic variation and factors associated with cesarean section rates in South Korea
Agnus M. Kim, Jong Heon Park, Sungchan Kang, Tae Ho Yoon, Yoon Kim
BMC Pregnancy and Childbirth.2019;[Epub] CrossRef
Geographic variation and factors associated with rates of knee arthroplasty in Korea-a population based ecological study
Agnus M. Kim, Sungchan Kang, Jong Heon Park, Tae Ho Yoon, Yoon Kim
BMC Musculoskeletal Disorders.2019;[Epub] CrossRef
Factors associated with the rates of coronary artery bypass graft and percutaneous coronary intervention
Agnus M. Kim, Jong Heon Park, Seongcheol Cho, Sungchan Kang, Tae Ho Yoon, Yoon Kim
BMC Cardiovascular Disorders.2019;[Epub] CrossRef

Seasonal Variation of Pre-term Births in Korea.: Duk Hee Lee, Sang Hyeok Ma, Hai Rim Shin; Korean J Prev Med. 2000;33(4):402-408.

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Abstract PDF: OBJECTIVES
To investigate possible seasonal patterns of pre-term birth in Korea. METHODS: A total number of 2,669,357 single live births reported to the National Statistical Office from 1995 to 1998 were analyzed. Composite monthly cohorts of ongoing pregnancies were constructed for each month of the year and the probability of pre-term birth was estimated. RESULTS: Increases in the probability of a pre-term birth occurred during winter for the birth of first child and during summer for the birth of second or later child. This seasonal variation was similar among groups divided by sex, residency, age of mother, and education of mother. CONCLUSIONS: These findings suggests that some environmental factors related to season may partially explain the incidence of premature births.; Summary

A study on the Statistical Distribution and Testing of Variation Indicies at the Small Area Variation Analysis .: Jungmo Nam, Sunhee Lee, Woohyun Cho; Korean J Prev Med. 1999;32(1):80-87.

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Abstract PDF: OBJECTIVES
The Study of Small Area Variation(SAV) is most interesting issue in the health care researches. Most studies of SAV have been concluded the existences of variation on the basis of the magnitude of variation without statistical testing. But it is difficult to explain the existence of variation with this way because variation indicies are easily influenced by several parameters and also their distribution are skewed. So, it needs for the study to investigate the distribution of these indices and develop the statistical testing model. METHODS: This study was planned to analyze on the distribution of variation indices such as Extremal Quotient(EQ), Coefficient of Variation(CV), Systematic Component of Variation(SCV) and compare the statistical power among indicies. The simulations was performed on the basis of several assumptions and compared to the empirical data. RESULTS: Main findings can be summarized as follows. 1. If other conditions are constant, the more number of regions, the larger 95 percentile of EQ. But under same situation, 95 percentile of CV and SCV were slightly decreased. 2. If the size of regional population or utilization rate were increased, 95 percentile of all statistics were decreased. Also in the cases of small population size and low utilization rate, 95 percentiles of EQ showed various change contrast to the little change of CV. 3. If the difference at the size of regional population were increased, 95 percentiles of EQ and SCV were increased contrast to the little difference of CV 4. If the utilization rate were increased, 95 percentiles of all indicies were increased. But under the same difference of utilization rate, the power of CV and SCV were increased comparing to no change of the power of EQ. 5. Usually the power of EQ were lower than that of CV or SCV and it is similar between CV and SCV. CONCLUSIONS: Therefore, we suggest that in selecting the variation indicies at the SAV, CV or SCV are superior than EQ in terms of significance level and power.; Summary

A Variation of Health Service Utilization in Wonju City.: Kinam Jin; Korean J Prev Med. 1996;29(2):385-395.

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Abstract PDF: This study intends to examine the behavioral pattern and small area variations of health service utilization within Wonju city. We selected three small areas in Wonju city as the study site: Haksung-dong(central area of the city), Moonmak-myun (industrial area which is located 25km away from the center of the city), and Gure-myun (agricultural area which is located 32km away from the center). The data were collected by administering questionnaire interviews with 526 people in three areas. The questionnaire include the items on health service utilization behaviors, sociodemographic characteristics, health status, and perceptions. The statistical methods used for the analysis were ANOVA and hierarchical logistic regression. From the analysis, it was found that there was a variation of health service utilization by areas. Compared to those of other areas, the respondents from agricultural area showed a high probability of using health services. When respondents' personal characteristics were taken into account, the effect of dummy variables representing areas disappeared. Instead, the perceived health status became the prime factor of health service utilization. This result showed that the small area variations of health service utilization is due to the demand factor rather than the supply factor.; Summary

An Analysis of Small Area Variations of Hospital Services Utilization in Korea.: Woo Hyun Cho, Sun Hee Lee, Eun Cheol Park, Myong Sei Sohn, Se Ra Kim; Korean J Prev Med. 1994;27(3):609-626.

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Abstract PDF: This study was conducted to investigate whether variations in hospital services utilization across small geographic areas in Korea existed, and if so, what factors are responsible for the variation. The claims data of the fiscal year 1992 obtained from the regional health insurance societies were used for the study. Main finding of the research can be summarized as follows: 1. External Quotients (EQ) of hospital expenditure per capita and hospital days per capita were 2.69 and 2.73, and coefficient of variation (CV) were 0.14,both, respectively. The EQ and the CV of admission rate were also 2.71, 0.15. The EQ and the CV of expenditure per admission were 1.73, 0.10 and those of hospital days per admission were 1.29, 0.06. All these statistics were statistically significant and this result provides strong evidence for the existence of small area variations. 2. Comparing patterns of variation among areas, the area which showed higher utilization amounts is cbansungp'o. Koje area, whereas the areas which showed lower utilization amounts are Yongju, Changhung, Miryang, Mokp'o, Koch'ang area. 3. Multivariate analytic methods were used to examine factors related to the variation across areas. In terms of the health resource availability variables, beds per capita or physicians per capita were positively associated with all utilization indices. As for the health service market structure variables, the proportion of health care institutions operating for less than 5 years was positively related to the expenditure per capita, hospital days per capita and expenditure per admission. In addition the proportion of lhe private health care institutions also had a negative relationship with total utilization amount and admission rate and the proportion of physicians under age 40 was negatively associated with expenditure per capita and expenditure per admission. With regard to the socio-demographic characteristics, proportion of medicaid population was positively related to hospital days per capita, and percentage of paved road was positively related to hospital days per admission. As a conclusion, wide variations existed across small areas in Korea and supply factors were found to be important in explaining the variation.; Summary

Geographic variations in tonsillectomy and adnoidectomy (T & A) and appendectomy in Korea.: Hong Ki Lee, Ok Ryun Moon, Key Hyo Lee; Korean J Prev Med. 1993;26(3):430-441.

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Abstract PDF: The objectives of this study are two-fold : to identify geographic variations in the rate of tonsillectomy and adenoidectomy(T and A) and appendectomy and analyze the socioeconomic variables and health resources which affect geographic variation in the rate. The nationwide three month's cases of the two surgical procedures in 1991 are obtained from the record of the National Federation of Medical Insurance. The analysis shows two to ten-fold variations in the regional rates for the performance of two common procedures such as T and A and appendectomy. T and A shows a bigger regional variations than appendectomy. As a result of multiple regression, the factor of bed supply has been found significant for the dependent variable of the rate of T and A. The findings of large variations in the rate of surgical procedures throughout the country would have important implications for allocating scarce resources and managing quality of care. Further analysis is needed for the elaboration of the above implications.; Summary

An analysis an dassessment of diagnostic and therapeutic process in some freqent admissions and operations.: Chang Yup Kim, Yoon Kim, Young Dae Kwon, Yong Ik Kim, Young Soo Shin; Korean J Prev Med. 1993;26(3):400-411.

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Abstract PDF: The aim of this study is to analyze the variations among hospitals and hospital groups in resource use and procedures of diagnostic and therapeutic process, such as laboratory tests, radiologic examinations, tissue diagnosis, timing of surgery after admission, the time required for operation. The study was performed for five procedures including cesarean section(C/S), appendectomy, cholecystectomy, cataract extraction, and pediatric pneumonia. The 2,316 subjects were selected from medical insurance claims list, and from this list 413 cases were sampled for medical record review. The patterns of resource utilization and process of treatment were described according to hospitals and characteristics of hospital groups. The major results were as follows: 1. The numbers of laboratory and radiologic tests showed significant difference among hospitals and hospital groups. In case of hospital groups, we could find tendencies of more tests with increasing hospital bed size. 2. In general, the proportion of operative cases evaluated by tissue diagnosis postoperatively among all operations ranged from 28.3% to 1005. The proportion varied among hospital groups, of which general hospital A group(more than 15 specially) showed the highest proportion. 3. Post-admission delay until operation and the time required for operative procedure were not invariable among hospitals and hospital groups. The duration of operation in tertiary hospitals was slightly shorter than general hospitals, with varying statistical significance. We could find that probably there were differences of quality among hospitals in some components of procedures, which suggested that the implementation of quality assurance activities would be mandatory. In this study, we simply described the patterns of resource utilization and some features of clinical process, with institution of the need for advanced studies with in-depth analyses for each component of diagnosis and treatment procedures.; Summary

Regional Variations in the Cesarean Section Rate and It's Determinants in Korea.: Hye Kyung Kim, Jeon Un Lee, Kang Won Park, Ok Ryun Moon; Korean J Prev Med. 1992;25(3):312-329.

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Abstract PDF: The purpose of this study is to estimate cesarean section rate in Korea and analyze the socioeconomic variables and health resources which affect regional variation in the rate. Samples were drawn from the record of vaginal and cesarean section deliveries based upon insurance claim bills which have been submitted to the National Federation of Medical Insurance for the first three months, January through March, 1991. The results are obtained as follows: It was found that, cesarean section rate was increasing rapidly up to 23.1% in 1991. Cesarean section per 10 thousand insured people was 4.8 and the number of cesarean section per 10 thousand insured eligible(15-49 years old) female was 7.6. The fee for normal delivery was 109,489 won and that for cesarean section was 390,024 won. The average days of hospitalization in normal delivery was 2.3 days, and those in cesarean section was 7.6 days. On the average cesarean section has a longer of stay as much as by 4.3 days and cost 3.6 times more than normal deliveries. Cesarean section rates vary among medical facilities: 19.8% at clinics 37.6% in small-scale hospitals, and 29.1% in general hospitals. The regional variation of cesarean section rates was also fairly prominent. The South Cheju Gun has the highest rate of cesarean section, 56.2%. Meanwhile no cesarean section cases has been reported in Sunchang Gun during the period of this study. The variation is noted among provinces. The rate for Cheju province has been 3.4 times higher than that for Chunnam. The number of cesarean section per 10 thousand insured people vary greatly among regions, too. This study has found that there exists significant regional variations among various geographic units in terms of average length of stay, average cost, number of obsretricians and number of beds. Multiple regression analysis was done to identify factors explaining the regional variance of various cesarean section rates: In the urban areas, no significant explaining variables were noted except the number of beds for the dependent variable of cesarean section cases per 10 thousand insured eligible females. The smaller the number of bed, the more cases of cesarean section was noted for an urban area. The is mostly because the rate of cesarean section is higher in medium-size hospitals than in large general hospitals. In the rural areas, the factor of education has been found significant for all three dependent variables. The higher the educational level, the rate of cesarean section is most likely to rise. An income variable measured by the amount of monthly insurance contribution has been identified a powerful predictor in explaining the variance of cesarean section rates. The same has been noted for the number of obstetricians. Similar findings are observed for the country as a whole. The income level has been found as the most powerful explaining factor in the regional variance of cesarean section rates. In general the rate is higher in the urban areas, and lower in the area with more small hospitals. As this is the initial attempt to identify the factors relevant to the regional difference in the rates of cesarean section, more elaborated study is urgently required.; Summary

Variation in resource utilization for inpatients among university teaching hospitals in city.: Hayoung Park, Euichul Shin, Kwongho Meng; Korean J Prev Med. 1990;23(4):451-464.

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Abstract PDF: The variation in resource utilization for hospitalized patients who had a group of similar disease -- a Korean Diagnosis Related Group (KDRG) -- among the same type of hospitals was studied to assess the utilization variation due to the practice pattern of hospitals. Information about inpatients who were beneficiaries of the medical insurance for teachers and government officials discharged from 20 large university teaching hospitals in Seoul during 1986 and information about the hospitals were analyzed to achieve the study objective. A total of 20,223 non-outlier patients in 100 most frequent KDRGs were included in the analysis. Case charges after the review and length of stay (LOS) were used as measures of resource utilization during a hospitalization. A substantial variation among hospitals was found in most KDRGs: the ratio of the maximum and the minimum among the mean case charges of hospitals was greater than 2 in 83 KDRGs; the difference between the maximum and the minimum among the mean case charges of hospitals was greater than 100,000 Won in 94 KDRGs; the ratio of the maximum and the minimum among the mean LOS of hospitals was greater than 2 in 82 KDRGs; the difference between the maximum and the minimum among the mean LOS of hospitals was greater than 3 days in 94 KDRGs. The practice pattern of hospitals explained more than 20% of charge variation in 49 KDRGs and more than 20% of LOS variation in 43 KDRGs. The study results indicated need for a new health policy initiative for cost containment and quality assurance.; Summary

Seasonal variation of water qualities in the upper and middle reaches of the Han River(1998.8~1989.9).: Sang Jun Lee, Kyou Chull Chung; Korean J Prev Med. 1990;23(1):106-116.

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Abstract PDF: This study was conducted to investigate of water qualities in the upper and middle reaches of the Han River. For this purpose, water was sampled at Kwangjin and 1st Han-River Bridges of the Han River in Seoul and analysed from August, 1988 to September, 1989. The results are summarized as follows: 1. Water quality at 1st Han-River Bridge was more polluted than that at Kwangjin Bridge. 2. Except biological oxygen demand (BOD), turbidity, suspended solid (SS), dissolved oxygen (DO), DO saturation (DOS), ammonia nitrogen (NH3-N), nitrite nitrogen (NO2-N) and chloride ion (Cl-) at Kwangjin and 1st Han-River Bridges were lower as compared with the previous data before redevelopment of the Han River. 3. SS, DO and pH at Kwangjin and 1st Han-River Bridges could be classified to the 1st grade in environmental water quality standard. DOS at Kwangjin Bridge was over 100% and that at 1st Han-River Bridge was below 100% in the Han River. BOD at Kwangjin Bridge could be classified to 2nd grade and that at 1st Han-River Bridge to 3rd grade in environmental water quality standard. 4. The higher the level of water was, the lower the levels of turbidity and SS, and NH3-N was decreased with increasing water level at 1st Han-River Bridge. DO was decreased as water temperature went up but DOS was increased with DO. BOD was positively correlated with nitrite-nitrogens. 5. Turbidity and SS at the both sites and Chloride ion (Cl-) at Kwangjin Bridge were increased in July and August. And DO at the both sites and NH3-N at 1st Han-River Bridge were decreased in at July and August.; Summary

Circadian Disruptions of Heart Rate Variability among Weekly Consecutive-12-hour 2 Shift Workers in the Automobile Factory in Korea.: Mia Son, Juhon Sung, Myunggul Yum, Jung Ok Kong, Hye Un Lee, In A Kim, Jung Yeon Kim; J Prev Med Public Health. 2004;37(2):182-189.

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Abstract PDF: OBJECTIONS: The objective of this study is to compare the circadian patterns of heart rate variability assessed by 24-hour ambulatory electrocardiographic (ECG) recordings during day shift and night shift among the workers in the 5 days-concecutive- 12-hour shift in an automobile factory in Korea. METHODS: The study population consisted 300 workers, who were randomly selected among the 8700 total workers in one car factory. To analyse circadian variation, the 24-hour ECG recordings (Marquette) were measured during day shift (08: 00-20: 00 h) and night shift (20: 00-08: 00 h). Analysis was performed for all time and frequency domain measures of HRV. 233 workers completed taking 24-hour ECG recordings. RESULTS: This study shows that the 24 hourcircadian variation mainly follows work/sleep cycle rather than day/night cycle among shift workers. This study also shows that among the night shift, the circadian variation between work and sleep cycle decreased compared to the work/sleep cycle among day shift workers. All time and frequency domain parameters (except LF/HF ratio) show significantly different between work and sleep in the day shift and night shift. CONCLUSION: These changes in heart rate variability circadian rhythms reflect significant reductions in cardiac parasympathetic activity with the most marked reduction in normal vagal activity among the shift workers. Especially, it suggests the circadian rhytm has blunted among the night workers. The quantification of the circadian variation in HRV can be a surrogates of workers' potential health risk, as well as suggests possible mechanisms through which the shift works compromise workers' health.; Summary

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