The costliness index (CI) is an index that is used in various ways to improve the quality of medical care and the management of appropriate treatment in medical institutions. However, the current calculation method for CI has a limitation in reflecting the actual medical cost of the patient unit because the outpatient and inpatient costs are evaluated separately. It is desirable to calculate the CI by integrating the medical cost into the episode unit. We developed an episode-based CI method using the episode classification system of the Centers for Medicare and Medicaid Services to the National Inpatient Sample data in Korea, which can integrate the admission and ambulatory care cost to episode unit. Additionally, we compared our new method with the previous method. In some episodes, the correlation between previous and episode-based CI was low, and the proportion of outpatient treatment costs in total cost and readmission rates are high. As a result of regression analysis, it is possible that the level of total medical costs of the patient unit in low volume medical institute and rural area has been underestimated. High proportion of outpatient treatment cost in total medical cost means that some medical institutions may have provided medical services in the ambulatory care that are ancillary to inpatient treatment. In addition, a high readmission rate indicates insufficient treatment service for inpatients, which means that previous CI may not accurately reflect actual patient-based treatment costs. Therefore, an integrated patient-unit classification system which can be used as a more effective CI indicator is needed.

Background: As the survival rate of cancer patients increases, the clinical importance of rehabilitation provided by healthcare professionals also increases. However, the evidence supporting the relevance of rehabilitation programs is insufficient. This study aimed to review the literature on effectiveness in physical function, quality of life (QOL) or fatigue of supervised physical rehabilitation in patients with advanced cancer. Methods: A systematic review and meta-analysis was conducted following the Cochrane guidelines. We narratively described the results when meta-analysis was not applicable or appropriate. Literature databases including Ovid-MEDLINE, Ovid-EMBASE, and the Cochrane Library, as well as several Korean domestic databases, were searched up to June 2017 for studies that investigated the effectiveness of supervised physical rehabilitation programs on physical function, QOL or fatigue in patients with advanced cancer. The quality of the selected studies was evaluated independently by paired reviewers. Results: Eleven studies with 922 participants were finally selected among 2,459 articles. The meta-analysis revealed that after physical exercise, the physical activity level and strength of patients with advanced cancer increased significantly. The QOL showed a statistically significant improvement after physical rehabilitation according to the European Organization for Research and Treatment of Cancer version C30. Though some of measurements about cardiovascular endurance or strength in several studies were not able to be synthesized, each study reported that they were significantly improved after receiving rehabilitation. Conclusion Supervised physical rehabilitation for patients with advanced cancer is effective in improving physical activity, strength, and QOL. However, more trials are needed to prove the effectiveness of supervised exercise and to strengthen the evidence.

PURPOSE: This study investigated the optimal strategy to minimize budgetary constraints on National Health Insurance (NHI) services, while maximizing the number of diabetic macular edema (DME) patients who receive anti-vascular endothelial growth factor (anti-VEGF) therapy. METHODS: We estimated the potential budget impact of anti-VEGF treatments in DME patients based on perceived upcoming changes in reimbursement fees over the next 5 years (2018–2022). Four scenarios were evaluated: (1) current anti-VEGF treatment patterns, (2) the hypothetical reimbursement fee, (3) the introduction of a new molecule similar to current anti-VEGF treatments, and (4) the prescription of an off-label drug, bevacizumab. The number of patients, anti-VEGF treatments, and medical costs for each scenario were calculated using claims data from the Korean NHI system and anti-VEGF prescription data from a single hospital. RESULTS: The potential budget impact of anti-VEGF injections in patients with DME over the next 5 years was estimated to be about 97.7 billion and 106.2 billion KRW for scenarios 1 and 2, respectively. In scenario 3, in which a biosimilar product to anti- VEGF is used, the estimated budget of the NHI system would be approximately 98.4 billion KRW. If an off-label drug is reimbursed, roughly 79.5 billion KRW will be required for the NHI system's budget. CONCLUSIONS: If the revised fee structure for AMD patients is similarly applied to anti-VEGF injections for DME patients, the NHI fiscal requirements will increase disproportionately over the next 5 years compared to current reimbursement conditions. Given the growth of DME patients in toda's patient population, the use of a biosimilar or off-label drug is a financially viable alternative to reduce the overall burden on the NHI system.
Bevacizumab ; Budgets ; Endothelial Growth Factors ; Fees and Charges ; Humans ; Macular Edema ; National Health Programs ; Prescriptions ; Ranibizumab ; Vascular Endothelial Growth Factor A

PURPOSE: To evaluate the current use of intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) in patients with diabetic retinopathy. METHODS: We determined the current number of diabetic retinopathy patients and their medical expenditure using National Health Insurance Service claims data (2007-2016). We also analyzed the medical costs of patients with diabetic retinopathy who received anti-VEGF treatment, including ranibizumab and aflibercept. We then evaluated aspects of the use of anti-VEGF injections, such as frequency and intervals, in newly diagnosed diabetic retinopathy patients who received anti-VEGF treatment, along with their medical costs. RESULTS: The number of patients with diabetic retinopathy was 397,956 in 2009 and 721,310 in 2016, a 1.8-fold increase over 8 years. Of these, the number of patients undergoing anti-VEGF therapy was 4,283 in 2015 and 4,270 in 2016. Of the diabetic retinopathy patients in 2016, the total medical cost of those treated with anti-VEGF was 1.5 billion won, and the average medical cost per person was 3,531,064 won. CONCLUSIONS: Based on the National Health Insurance claims data, the use of ranibizumab and aflibercept is increasing. The results of this study suggest that diabetic retinopathy will become an important public health issue.
Diabetic Retinopathy ; Endothelial Growth Factors ; Health Expenditures ; Humans ; Intravitreal Injections ; National Health Programs ; Public Health ; Ranibizumab

PURPOSE: To evaluate the current use of intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) in patients with age-related macular degeneration (AMD). METHODS: We analyzed the number and medical costs of patients with AMD diagnosed by the National Health Insurance Corporation (2007–2016). We also analyzed the number and medical costs of such patients who received anti-VEGF treatment, and analyzed the frequency, period of use, and average medical cost of anti-VEGF use in AMD patients. Finally, we evaluated the use of anti-VEGF injections for new AMD patients. RESULTS: The number of patients with AMD was 236,158 in 2009 and 537,528 in 2016, which represented a 2.3-fold increase over 8 years. Of these, the number of patients undergoing anti-VEGF therapy increased steadily from 9,961 in 2009 to 35,762 in 2016. The mean number of cycles of ranibizumab or aflibercept per patient was 4.87 ± 3.37, and the mean interval between treatments was 2.89 months. On average, 6.2 injections were performed in the first year of diagnosis, and the frequency of use decreased with time, with an average of 1.2 cycles after 4 years of diagnosis. Among all AMD patients in 2016, the total medical cost of those treated with anti-VEGF was 76.9 billion won, and the average medical cost per person was 2,162,145 won. CONCLUSIONS: The use of two drugs, ranibizumab and aflibercept, as reflected in public health insurance claims, steadily increased over the study period. Notably, there was a tendency to substitute aflibercept for ranibizumab.
Diagnosis ; Endothelial Growth Factors ; Humans ; Insurance ; Intravitreal Injections ; Macular Degeneration ; National Health Programs ; Public Health ; Ranibizumab

PURPOSE: To compare the efficacy and safety of intravitreal injections of bevacizumab, ranibizumab, and aflibercept for the treatment of new patients with age-related macular degeneration (AMD). METHODS: We conducted an update of the most recent and high quality systematic reviews (Canadian Agency for Drug Technology in Health [CADTH] 2016). Three randomized clinical trials were added to 13 trials identified from the CADTH report. The efficacy outcomes were 1) average improvement in visual acuity, 2) proportion of patients who experienced an improvement in vision (an increase in best-corrected visual acuity (BCVA) of ≥ 15 on Early Treatment Diabetic Retinopathy Study [ETDRS] letters), and 3) proportion of patients who experienced worsening of vision (decrease in BCVA of ≥ 15 ETDRS letters). In addition, safety outcomes included systemic adverse events and ocular-related adverse events. To analyze the outcomes of 16 randomized controlled trials, we conducted meta-analyses on the outcome measures. RESULTS: There was no significant difference in efficacy outcomes among anti-vascular endothelial growth factor (anti-VEGF) drugs. The mean difference in BCVA between ranibizumab and bevacizumab was 0.33 (95% confidence interval [CI]: −1.29, 1.95), and the odds ratio (OR) for a vision gain in the BCVA of ≥ 15 ETDRS letters for the ranibizumab versus aflibercept treatment was 1.02 (95% CI: 0.80, 1.30). There was also no significant difference in safety outcomes, except in terms of arterial thromboembolic events (ranibizumab vs. bevacizumab; OR: 2.15; 95% CI: 1.04, 4.41). CONCLUSIONS: The efficacy of anti-VEGF drugs for AMD patients was not significantly different. The safety of the drugs was also not significantly different, except in terms of arterial thromboembolic events.
Bevacizumab ; Diabetic Retinopathy ; Endothelial Growth Factors ; Humans ; Intravitreal Injections ; Macular Degeneration ; Odds Ratio ; Outcome Assessment (Health Care) ; Ranibizumab ; Visual Acuity

PURPOSE: To evaluate the effects of anti-vascular endothelial growth factor (VEGF) treatment on the healthcare-related finances of patients with age-related macular degeneration. METHODS: Changes in health care financing due to newly introduced benefit standards were predicted over the coming 5-year period (2018–2022). We also analyzed the financial impact of scenarios in which agents similar to anti-VEGF, such as the over-licensed drug bevacizumab, were introduced. For this purpose, the future number of patients receiving anti-VEGF treatments was estimated for various scenarios based on National Health Insurance Corporation claims data followed by an estimate of the financial burden. RESULTS: In the case of age-related macular degeneration, the current standard of care (14 times in a lifetime) was maintained in scenario 1. In 2018, the insurance budget for the coming 5-year period was estimated at approximately 440.3 billion won. The insurance cost for that period was estimated at approximately 560.1 billion won under the revised standard of December 2017 (scenario 2). For scenarios wherein, after 2020, similar treatments (scenario 3) and bevacizumab (scenario 4) were introduced, the estimated health insurance costs were 521 billion won and 419.7 billion won, respectively. CONCLUSIONS: Health insurance costs are projected to increase substantially due to the elimination of the 14 time pay standard; however, the actual budget will only moderately increase, due to new limitations of visual acuity ≤ 0.1 or in case of scarring/ atrophic lesions. Clinically similar agents and bevacizumab could be considered as alternatives to anti-VEGF treatment for age-related macular degeneration.
Bevacizumab ; Budgets ; Delivery of Health Care ; Endothelial Growth Factors ; Humans ; Insurance ; Insurance, Health ; Macular Degeneration ; National Health Programs ; Ranibizumab ; Standard of Care ; Visual Acuity

PURPOSE: Intravitreal aflibercept, ranibizumab, bevacizumab, and dexamethasone are the most widely used drugs in the treatment of diabetic macular edema (DME). The aim of this study was to compare the efficacy and safety of anti-vascular endothelial growth factors and dexamethasone for the treatment of DME. METHODS: There were nine previous systematic reviews on this topic; we updated these high-quality reviews. Seven studies were added to two studies following a literature search. Efficacy outcomes were 1) average improvement in visual acuity, 2) proportion of patients who experienced an improvement in vision (an increase in best-corrected visual acuity (BCVA) of ≥ 15 in the Early Treatment Diabetic Retinopathy Study [ETDRS]), and 3) proportion of patients who experienced worsening vision (a decrease in BCVA of ≥ 15 in the ETDRS). Safety outcomes included systemic adverse events and ocular-related adverse events. RESULTS: The mean difference in the BCVA for ranibizumab versus bevacizumab treatment was 0.16 (95% confidence interval [CI]: −0.02, 0.34), and that for ranibizumab versus aflibercept was −0.08 (95% CI: −0.26, 0.10). The mean difference in the change of BCVA for aflibercept versus ranibizumab was −0.20 (95% CI: −0.40, −0.01), and that for aflibercept versus bevacizumab was −0.34 (95% CI: −0.53, −0.14). Other efficacy outcomes showed similar trends, and there was no significant difference between treatments. There was also no significant difference in both systemic and ocular adverse events rates between the treatments. CONCLUSIONS: In DME patients, the efficacy of aflibercept was found to be higher with respect to BCVA changes compared with ranibizumab or bevacizumab. However, there were no significant difference in terms of visual acuity improvement or visual acuity of more than 15 letters, nor in terms of anti-vascular endothelial growth factors (as a safety outcome).
Bevacizumab ; Dexamethasone ; Diabetic Retinopathy ; Endothelial Growth Factors ; Humans ; Intravitreal Injections ; Macular Edema ; Ranibizumab ; Visual Acuity

Background: The International Classification of Primary Care-2 (ICPC-2) is a classification method designed for primary care. Although previous studies have found that ICPC-2 is a useful tool for demonstrating the relationship between patients’ expectations and health providers’ diagnoses, its utility of ICPC-2 has yet to be fully studied in Korea. This study aimed to evaluate the practicality of ICPC-2 in Korean primary care. Methods: The study was conducted at primary care clinics in Seoul and Gyeonggi areas from October to November 2015. Third-year family medicine residents examined and analyzed the medical records of patients who visited primary care physicians using ICPC-2, and the results were compared with those obtained using the International Classification of Diseases-10 (ICD-10) (Korean version: Korean Standard Classification of Diseases-7). Results: A total of 26 primary care physicians from 23 primary care clinics participated in the study. Furthermore, 2,458 ICD-10 codes and 6,091 ICPC-2 codes were recorded from the data of 1,099 patients. The common disease codes were vasomotor and allergic rhinitis (J30), according to ICD-10, and acute upper respiratory infection (R74) in ICPC-2. Comparing disease status by body systems, the proportion of gastrointestinal disease with ICD-10 codes was significantly higher than that with ICPC-2 codes (P<0.001). Furthermore, patients with >4 diagnoses accounted for 36% of the ICD-10 classifications, whereas those with >4 diagnoses accounted for 4% of the ICPC-2 classifications. Conclusion Introducing ICPC as a complementary means for diagnosing common diseases could be a practical approach in Korean primary care.