Journal List > J Korean Diabetes Assoc > v.30(5) > 1062400

TOOLS
Kim, Kim, Kim, Min, Park, Park, Park, Baik, Son, Ahn, Oh, Lee, Lee, Chung, Choi, Choi, and Kim: Current Status of the Continuity of Ambulatory Diabetes Care and its Impact on Health Outcomes and Medical Cost in Korea Using National Health Insurance Database
Original Article
The Journal of Korean Diabetes Association

The Journal of Korean Diabetes Association 2006; 30(5): 377-387.

Published online: 30 September 2006

DOI: https://doi.org/10.4093/jkda.2006.30.5.377

Current Status of the Continuity of Ambulatory Diabetes Care and its Impact on Health Outcomes and Medical Cost in Korea Using National Health Insurance Database

Jaiyong Kim*, **, Hyeyoung Kim**, Hwayoung Kim*, **, Kyung Wan Min*, 1, Seok Won Park*, 2, Ie Byung Park*, 3, Jeong Hyun Park*, 4, Sei Hyun Baik*, 5, Hyun Shik Son*, 6, Chul Woo Ahn*, 7, Jee-Young Oh*, 8, Sunhee Lee**, Juneyoung Lee*, 9, Choon Hee Chung*, 10, Kyung Mook Choi*, 5, Injeoung Choi**, Dae Jung Kim*, 11

*Task Force Team for Basic Statistical Study of Korean Diabetes Mellitus of Korean Diabetes Association, Korea.

**Department of Research, Health Insurance Review Agency, Korea.

1Department of Internal Medicine, College of Medicine, Eulji University, Korea.

2Department of Internal Medicine, Pochon CHA University, Korea.

3Department of Endocrinology, Gachon University of Science and Medicine, Gil Medical Center, Korea.

4Department of Internal Medicine, Pusan Paik Hospital, Inje College of Medicine, Korea.

5Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University, Korea.

6Department of Internal Medicine, The Catholic University of Korea, Korea.

7Department of Internal Medicine, Yonsei University College of Medicine, Korea.

8Division of Endocrinology and Metabolism, Ewha Womans University College of Medicine, Korea.

9Department of Biostatistics, College of Medicine, Korea University, Korea.

10Department of Internal Medicine, Wonju College of Medicine, Yonsei University, Korea.

11Department of Endocrinology and Metabolism, Ajou University School of Medicine, Korea.

Received 5 August 2006       Accepted 28 September 2006

Copyright © 2006 Korean Diabetes Association

Abstract

Background

The continuity of care in chronic diseases, especially in diabetes, was emphasized from many studies. But large scale studies with long-term observation which confirm the impact of continuity of care on health outcomes are rare. This study tried national level 3 year observation to find differences in hospitalization, mortality and medical costs among patient groups with different utilization pattern.

Methods

The 1,088,564 patients with diabetes diagnosis and diabetes drug prescription in 2002, from 20 to 79 years old, and survived until the end of 2004 were included. Annual drug prescription days, number of visited clinics and quarterly continuity of care were measured. Gender, age group, living area, health insurance premium level (as a proxy of the income level), years of first DM diagnosis, five co-morbidities (hypertension, heart disease, stroke, renal disease, admission with DM), hospitalization experience and the type of main attending clinic were adjusted. Hospitalization, mortality and high costs group (top quintile) in 2005 were predicted by multiple logistic regression model.

Results

Patients who failed in continuity of care in 2003 and 2004 showed higher hospitalization (OR =1.29), higher mortality (OR =1.75) and they are more likely to be high costs group (OR =1.34) in 2005 than who fulfilled the continuity of care. Patients who have single attending clinic also showed lower hospitalization, lower mortality and lower cost. Completeness in diabetic drug prescription were correlated with lower hospitalization, lower mortality but with higher cost. Possible cost saving from continual care with single attending clinic was estimated at ₩417 billion ($1 = ₩943.7). Possible expenditure from complete drug prescription was ₩228 billion. So, net saving was ₩139 billion in our study population.

Conclusion

Continual care and single attending clinic saves patient's life and national costs. Fragmented primary care system in Korea should be reformed for more effective care of chronic diseases. National Health Insurance Database in Korea enables nationwide long-term observation study which overcomes the many limitations found in hospital-based studies and cross-sectional surveys.

Keywords: Continuity of care, Diabetes, Health outcome, Medical cost, Observation study

Figures and Tables

Fig. 1
Distribution of cumulative medical cost in 2005.
jkda-30-377-g001
Fig. 2
Medical cost in 2005 by the continuity of ambulatory care.
jkda-30-377-g002
Fig. 3
Medical cost in 2005 by the number of visited clinics in 2004.
jkda-30-377-g003
Fig. 4
Medical cost in 2005 by the drug prescription days for DM in 2004.
jkda-30-377-g004
Table 1
Selection Processes of Ambulatory Diabetes Patients
jkda-30-377-i001

*One or more claims with ICD-10 code E10, E11, E12, E13, E14 either in principal or subsequent diagnosis from general hospitals or clinics.

Table 2
Factors associated with Continuity of Ambulatory Care in 2004
jkda-30-377-i002

*Proportion is a proportion of patient to total study population (N = 1,088,564).

†Odd ratios and 95% confidence intervals (CIs) were calculated from multiple logistic regression models.

‡Having co-morbidity means more then 1 hospital admission or more then 3 ambulatory visits in hypertension, heart disease, stroke and renal disease in 2002. This table shows only disease (+) number of patients.

§AUC(area under the receiver operating characteristic curve) means discrimination ability of prediction model. It ranges from 0.5 to 1 and 1 means perfect discrimination.

Table 3
Correlations between Risk Factors and Health Outcomes (admission, death & cost) in '2005
jkda-30-377-i003

*Proportion is a proportion of patient to total study population (N = 1,088,564).

†Odd ratios and 95% confidence intervals (CIs) were calculated from multiple logistic regression models.

‡Having co-morbidity means more then 1 hospital admission or more then 3 ambulatory visits in hypertension, heart disease, stroke and renal disease in 2002. This table shows only disease (+) number of patients.

§AUC (area under the receiver operating characteristic curve) means discrimination ability of prediction model. It ranges from 0.5 to 1 and 1 means perfect discrimination.

Table 4
Annual Ambulatory Visit Days of Study Population in '2004
jkda-30-377-i004

*Q1-Q3 means inter-quantile range.

Table 5
Possible cost Savings by Utilization Pattern Change*
jkda-30-377-i005

*Unit of cost is 1,000 Won.

†Possible sum of cost difference is (mean-minimum) in number of visited clinics & continuity and (mean-maximum) in annual drug prescription days.

‡Medical cost in this study include about 11 month's cost. Adjusted difference = difference × 12(month) ÷ 11 (month).

References

1. International Diabetes Federation. Diabetes Atlas. 2003. 2nd ed.
2. Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000. 321:405–412.
3. Vijan S, Stevens DI, Herman WH, Funnel MN, Stanford CJ. Screeing, preventing, counseling, and treatment for the complications of type II diabetes mellitus: putting evidence into practice. J Gen Intern Med. 1997. 12:567–580.
4. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993. 329:977–986.
5. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998. 352:837–853.
6. Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, Rhodes S, Shekelle P. Meta-analysis: Chronic disease self-management programs for older adults. Ann Intern Med. 2005. 143:427–438.
7. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2001. 24:S33–S43.
9. Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH. Improving the quality of health care for chronic conditions, Qual Saf Healt. Care. 2004. 13:299–305.
10. Ibrahim MA, Saviz LA, Carey TS, Wagner EH. Population-based health principles in medical and public health practice. Journal of Public Health Management and Practice. 2001. 7:75–81.
11. Norris SL, Glasgow RE, Engelgau MM, O'Connor PJ, McCulloch D. Chronic Disease Management -A Definition and Systematic Approach To Component Interventions. Dis Manage Health Outcomes. 2003. 11:477–488.
12. Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V, Wagner EH. Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetics and heart failure teams. Ann Behav Med. 2002. 27:80–87.
13. WHO Noncommunicable Disease and Mental Health. Innovative care for chronic conditions: building blocks for action: global report. 2002. WHO.
14. Desai J, Geiss L, Mukhtar Q, Harwell T, Benjamin S, Bell R, Tierney E. Public health surveillance of diabetes in United States. Journal of Public Health Management and Practice. 2003. Suppl. S44–S51.
16. National Quality Forum. Pay-for-performance programs: Guiding principles and design strategies-Conference proceedings. 2005.
17. Darden PM, Ector W, Moran C, Quattlebaum TG. Comparison of continuity in resident versus private practice. Pediatrics. 2001. 108:1263–1268.
21. Starfield B. Longitudinality and Managed Care. Primary Care: Concepts, Evaluation, and Policy. 1992. New York: Oxford University Press. Inc;41–55.
22. Center for Chronic Disease Prevention and Control. Diabetes in Canada. 2002. Health Canada.
23. American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care. 2004. 27:S15–S35.
26. Diabetes care analysis-savings estimate. Bridges to Excellence. 2005. Available at http://www.bridgestoexcellence.org/pdf/DCL_analysis1207051.pdf.
TOOLS
Similar articles