Epidemiology and Health

COVID-19: Original Article

Worsening of health disparities across COVID-19 pandemic stages in Korea: Hyejin Lee, Hyunwoo Nam, Jae-ryun Lee, Hyemin Jung, Jin Yong Lee; Epidemiol Health. 2024;46:e2024038. Published online March 13, 2024; DOI: https://doi.org/10.4178/epih.e2024038

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Abstract Summary PDF: Abstract
OBJECTIVES
With the end of the coronavirus disease 2019 (COVID-19) pandemic, the health outcomes of this disease in Korea must be examined. We aimed to investigate health outcomes and disparities linked to socioeconomic status during the COVID-19 pandemic in Korea and to identify risk factors for hospitalization and mortality.
METHODS
This nationwide retrospective study incorporated an analysis of individuals with and without COVID-19 in Korea between January 1, 2020 and December 31, 2022. The study period was divided into 4 stages. Prevalence, hospitalization, mortality, and case-fatality rates were calculated per 100,000 population. Multivariate logistic regression was performed to identify risk factors for COVID-19 hospitalization and mortality.
RESULTS
Overall, the incidence rate was 40,601 per 100,000 population, the mortality rate was 105 per 100,000 population, and the case-fatality rate was 259 per 100,000 cases. A total of 12,577,367 new cases (24.5%) were recorded in stage 3 and 8,979,635 cases (17.5%) in stage 4. Medical Aid recipients displayed the lowest 3-year cumulative incidence rate (32,737 per 100,000) but the highest hospitalization (5,663 cases per 100,000), mortality (498 per 100,000), and case-fatality (1,521 per 100,000) rates. Male sex, older age, lower economic status, non-metropolitan area of residence, high Charlson comorbidity index, and disability were associated with higher risk of hospitalization and death. Vaccination was found to reduce mortality risk.
CONCLUSIONS
As the pandemic progressed, surges were observed in incidence, hospitalization, and mortality, exacerbating disparities associated with economic status and disability. Nevertheless, Korea has maintained a low case-fatality rate across all economic groups.; Summary

Korean summary
국민건강보험공단 자료를 이용하여 2020-2022년 후향적 코호트를 구축하여 시기별 코로나19 유병률, 입원률, 사망률, 치명률과 장애, 소득에 따른 건강격차를 확인하였을 때, 코로나19 대유행이 진행됨에 따라 발병률, 입원률, 사망률이 급증하고 건강 격차가 확대되었다. 그러나 이러한 격차에도 불구하고 한국은 다른 국가들과 비교하여 모든 소득수준에서 낮은 치명률을 유지하였다.

Key Message
Using data from the National Health Insurance Service, a retrospective cohort for the years 2020-2022 was established. By examining the COVID-19 prevalence rate, hospitalisation rate, mortality rate, and case-fatality rate, along with health disparities based on disability and economic status, as the pandemic progressed, there was a surge in incidence, hospitalisation, and mortality, widening disparities related to economic status and disability. Despite these disparities, Korea has maintained a low case-fatality rate across all economic groups.

COVID-19: Original Article

Influence of practice location on prescribing, diabetes care, and colorectal cancer screening among Czech general practitioners during the COVID-19 pandemic: Jan Bělobrádek, Luděk Šídlo, Tom Philipp; Epidemiol Health. 2024;46:e2024033. Published online February 23, 2024; DOI: https://doi.org/10.4178/epih.e2024033

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
The provision of primary health care was not interrupted during the coronavirus disease 2019 (COVID-19) pandemic in Czechia, although the capacity and resources of providers changed. We examined how the pandemic affected individual general practices throughout 2017-2021, focusing on differences between urban and rural practices.
METHODS
We analysed data from the largest health insurance company in Czechia, which provides care to 4.5 million people (60% of the population). We evaluated the prescription volume, diabetes care procedures, and faecal immunochemical test (FIT) in preventive care and new pandemic-related procedures (remote consultations, testing, and vaccinations). For the spatial distribution of practices, we adapted the Organisation for Economic Cooperation and Development typology.
RESULTS
We observed minimal declines in 2020 in the rate of prescribing (-1.0%) and diabetes care (-5.1%), with a rapid resumption in 2021, but a substantial decline in FIT (-17.8% in 2020) with slow resumption. Remote consultations were used by 94% of all practices regardless of location, with testing and vaccinations more commonly performed by rural general practitioners (GPs).
CONCLUSIONS
Primary care in Czechia rose to the challenge of the COVID-19 pandemic, as shown by the finding that the volume of healthcare services provided through primary care did not decrease across most of the monitored parameters. This study also confirmed that rural GPs provide more care in-house, both in terms of prescribing and procedures performed in their practices. Future studies will need to focus on preventive care, which the pandemic has dampened in GP practices in Czechia.; Summary

Key Message
Primary care in Czechia has effectively adapted to the changes brought about by the COVID-19 pandemic. Minimal impact was observed in prescribtions and diabetic patient care. There was a significant decline in colorectal cancer screening, with a slow restitution after the pandemic subsided. Rural GPs consistently provided in-house treatment and have higher shares of both prescribing and diabetes care, as well as performing more COVID-19 specific procedures.

Original Articles

Adherence to the American Cancer Society guidelines on nutrition and physical activity for cancer survivors and biomarkers of inflammation among breast cancer survivors: Minji Kang, Sihan Song, Hyun Jeong Cho, Zisun Kim, Hyun Jo Youn, Jihyoung Cho, Jun Won Min, Yoo Seok Kim, Sang-Woon Choi, Jung Eun Lee; Epidemiol Health. 2024;46:e2024026. Published online January 25, 2024; DOI: https://doi.org/10.4178/epih.e2024026

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
This study investigated whether adherence to the overall lifestyle recommendations in the American Cancer Society (ACS) guidelines on nutrition and physical activity for cancer survivors was associated with inflammation in breast cancer survivors.
METHODS
The study included 409 women who had undergone breast cancer surgery at least 1 year before enrollment. A generalized linear model was used to estimate the least square means and 95% confidence intervals of plasma levels of inflammatory markers according to lifestyle factors defined in terms of adherence to the ACS guidelines.
RESULTS
Higher overall adherence scores were associated with lower levels of high-sensitivity C-reactive protein (hs-CRP) (p for trend=0.015) and higher levels of adiponectin (p for trend=0.009). Similar significant associations of hs-CRP (p for trend= 0.004) and adiponectin (p for trend=0.010) levels were observed with the score for the body mass index (BMI) component of the adherence score. A higher diet component score was associated with a higher adiponectin level (p for trend=0.020), but there was no significant association for the physical activity component score.
CONCLUSIONS
The present study’s findings suggest that maintaining a healthy lifestyle according to the ACS guidelines was associated with beneficial effects on inflammatory marker levels, especially hs-CRP and adiponectin, among breast cancer survivors. Among the 3 components of lifestyle guidelines, the BMI component exhibited the most similar tendency to the overall adherence score in relation to inflammatory indicators. Further prospective and intervention studies are needed to investigate longitudinal associations between lifestyle factors and inflammatory markers among breast cancer survivors.; Summary

Korean summary
- 한국인 유방암 생존자를 대상으로 한 연구에서, 암 생존자를 위한 영양 및 신체 활동에 관한 미국암협회 (American Cancer Society, ACS) 지침을 따라 건강한 생활 습관을 유지하는 것이 혈중 염증 마커 수준, 특히 낮은 hs-CRP와 높은 adiponectin 수준과 관련이 있었습니다. - 체질량지수 (Body Mass Index, BMI)를 적절한 수준 (18.5-23 kg/m²)으로 유지하는 것은 낮은 hs- CRP 수준과 높은 adiponectin 수준과 관련이 있는 것으로 나타났습니다. - 또한, 과일, 야채 및 통곡물이 풍부하고 적색육 및 가공육을 적게 섭취하는 건강한 식단은 혈중 adiponectin 수치가 높은 것과 관련이 있었습니다.

Association between dietary and behavioral-based oxidative balance score and phenotypic age acceleration: a cross-sectional study of Americans: Dongzhe Wu, Yulin Shen, Chaoyi Qu, Peng Huang, Xue Geng, Jianhong Zhang, Zhijian Rao, Qiangman Wei, Shijie Liu, Jiexiu Zhao; Epidemiol Health. 2024;46:e2024023. Published online January 18, 2024; DOI: https://doi.org/10.4178/epih.e2024023

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Abstract Summary PDF Supplementary Material

Abstract

OBJECTIVES
In light of the rise in the global aging population, this study investigated the potential of the oxidative balance score (OBS) as an indicator of phenotypic age acceleration (PhenoAgeAccel) to better understand and potentially slow down aging.

METHODS

Utilizing data from the National Health and Nutrition Examination Survey collected between 2001 and 2010, including 13,142 United States adults (48.7% female and 51.2% male) aged 20 and above, OBS and PhenoAgeAccel were calculated. Weighted generalized linear regression models were employed to explore the associations between OBS and PhenoAgeAccel, including a sex-specific analysis.

RESULTS

The OBS demonstrated significant variability across various demographic and health-related factors. There was a clear negative correlation observed between the higher OBS quartiles and PhenoAgeAccel, which presented sex-specific results: the negative association between OBS and PhenoAgeAccel was more pronounced in male than in female. An analysis using restricted cubic splines revealed no significant non-linear relationships. Interaction effects were noted solely in the context of sex and hyperlipidemia.

CONCLUSIONS

A higher OBS was significantly associated with a slower aging process, as measured by lower PhenoAgeAccel. These findings underscore the importance of OBS as a biomarker in the study of aging and point to sex and hyperlipidemia as variables that may affect this association. Additional research is required to confirm these results and to investigate the biological underpinnings of this relationship.

Summary

Key Message
• The study found a significant negative correlation between the oxidative balance score (OBS) and phenotypic age acceleration (PhenoAgeAccel), with higher OBS associated with slower biological aging. This association was more pronounced in males, and significant in individuals with high cholesterol. • OBS can serve as an effective biomarker for studying the aging process and its association with lifestyle and dietary factors.

Citations

Citations to this article as recorded by

Association of oxidative balance score with chronic kidney disease: NHANES 1999-2018
Haibin Wen, Xianhua Li, Jiangming Chen, Yi Li, Nailong Yang, Ning Tan
Frontiers in Endocrinology.2024;[Epub] CrossRef

The effect of public hospital closure on the death of long-term inpatients in Korea: Taeuk Kang, Minsung Sohn, Changwoo Shon; Epidemiol Health. 2024;46:e2024022. Published online January 17, 2024; DOI: https://doi.org/10.4178/epih.e2024022

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Abstract Summary PDF: Abstract
OBJECTIVES
This study aimed to examine the changes in health outcomes and the patterns of medical institution utilization among patients with long-term stays in public hospitals following the closure of a public medical center. It also sought to present a proposal regarding the role of public hospitals in countries with healthcare systems predominantly driven by private entities, such as Korea.
METHODS
To assess the impact of a public healthcare institution closure on health outcomes in a specific region, we utilized nationally representative health insurance claims data. A retrospective cohort study was conducted for this analysis.
RESULTS
An analysis of the medical utilization patterns of patients after the closure of Jinju Medical Center showed that 67.4% of the total medical usage was redirected to long-term care hospitals. This figure is notably high in comparison to the 20% utilization rate of nursing hospitals observed among patients from other medical facilities. These results indicate that former patients of Jinju Medical Center may have experienced limitations in accessing necessary medical services beyond nursing care. After accounting for relevant mortality factors, the analysis showed that the mortality rate in closed public hospitals was 2.47 (95% confidence interval, 0.85 to 0.96) times higher than in private hospitals.
CONCLUSIONS
The closure of public medical institutions has resulted in unmet healthcare needs, and an observed association was observed with increased mortality rates. It is essential to define the role and objectives of public medical institutions, taking into account the distribution of healthcare resources and the conditions of the population.; Summary

Korean summary
본 연구는 사회보험제도를 기반으로 하고 있는 한국의 상황에서 지방의 공공의료기관 폐쇄가 환자들의 건강에 어떠한 영향을 미쳤는지를 확인하고자 국민건강보험 청구자료를 기반으로 후향적코호트 자료를 구축하여 분석을 시행하였다. 연구결과 장기 입원 환자의 67.4%가 장기요양병원을 의료를 이용하였고, 이는 비교집단의 장기요양 이용비율인 20% 수준보다 3배 가량 높은 수치로, 의료이용에 일부 제약이 발생하였을 가능성을 시사하는 것이다. 폐업 후 1년 이내 사망률을 비교한 결과, 인근지역 내 민간병원 환자와 비교하여 공공의료기관 입원환자의 사망확률은 2.67배였고, 의료급여 수급권자들의 사망확률은 고소득 5분위에 비해 2.24배 높은 것으로 나타났다.

Key Message
Even in Korea's healthcare system with high medical accessibility, adverse health impacts have been observed due to the closure of public healthcare institutions. Systematic policy development is necessary to evaluate essential medical service provision and allocate medical resources comprehensively.

Association of plain water intake with self-reported depression and suicidality among Korean adolescents: Jung Woo Lee, Yookyung Kim; Epidemiol Health. 2024;46:e2024019. Published online January 9, 2024; DOI: https://doi.org/10.4178/epih.e2024019

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
Adolescent depression and suicidality are serious health problems worldwide. Lower plain water intake has been proposed as a risk factor for depression in adults. This study investigated the association of daily plain water intake with self-reported depression and suicidality among Korean adolescents.
METHODS
We used nationwide data from 112,250 students aged 12-18 years who participated in the Korean Youth Risk Behavior Web-based Surveys in 2019 and 2020. Daily plain water intake was categorized as <1 glass, 1-2 glasses, and ≥3 glasses. The adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for self-reported depression and suicidality were calculated using multiple regression analyses.
RESULTS
The weighted prevalence rates of self-reported depression, suicidal ideation, suicide planning, and suicide attempts were 26.7%, 12.0%, 3.8%, and 2.5%, respectively. Of the participants, 3.9%, 18.5%, and 77.7% were categorized into the <1 glass/day, 1-2 glass/day, and ≥3 glass/day groups, respectively. Compared to the reference group (≥3 glass/day), the lowest level of water intake (<1 glass/day) was associated with higher odds of self-reported depression (aOR, 1.30; 95% CI, 1.20 to 1.39), suicidal ideation (aOR, 1.39; 95% CI, 1.27 to 1.55), suicide planning (aOR, 1.46; 95% CI, 1.25 to 1.69), and suicide attempts (aOR, 1.38; 95% CI, 1.15 to 1.67). Moderately lower water intake (1-2 glass/day) showed slightly increased odds of self-reported depression (aOR, 1.05; 95% CI, 1.01 to 1.10) and suicidal ideation (aOR, 1.08; 95% CI, 1.03 to 1.14).
CONCLUSIONS
Lower plain water intake was significantly associated with a higher risk of self-reported depression and suicidality among Korean adolescents. Since this cross-sectional study is unable to establish a causal relationship, it underscores the need for additional longitudinal research.; Summary

Korean summary
- 한국 청소년들에서 하루 물 섭취량이 적을수록 스스로 느끼는 우울감과 자살성향 위험이 증가하였다. - 이 연구는 하루 물 섭취량 측정이 청소년 우울증과 자살성향을 선별할 수 있음을 시사한다.

Key Message
- Lower daily plain water intake is significantly associated with a higher risk of self-reported depression and suicidality in Korean adolescents. - It suggests that daily plain water consumption could potentially serve as a screening indicator to identify depression and suicidality in adolescents.

Socioeconomic inequality in health-related quality of life among Korean adults with chronic disease: an analysis of the Korean Community Health Survey: Thi Huyen Trang Nguyen, Thi Tra Bui, Jinhee Lee, Kui Son Choi, Hyunsoon Cho, Jin-Kyoung Oh; Epidemiol Health. 2024;46:e2024018. Published online January 8, 2024; DOI: https://doi.org/10.4178/epih.e2024018

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Abstract Summary PDF: Abstract
OBJECTIVES
Health-related quality of life is crucial for people dealing with chronic illness. This study investigated the quality of life in individuals with 5 common chronic conditions in Korea. We also analyzed socioeconomic factors such as education, income, occupation, and urbanization to identify determinants of inequality.
METHODS
Using 2016 Korea Community Health Survey data, we examined individuals aged 30 or older with chronic diseases (diabetes, hypertension, cardiovascular disease, hyperlipidemia, arthritis) using the EuroQol 5-Dimension 3 Level tool. We analyzed the associations between socioeconomic factors (education, income, occupation, urbanization) and quality of life using descriptive statistics and regression analysis. Inequality indices (relative inequality index, absolute inequality index) were used to measure inequality in quality of life.
RESULTS
Individuals with higher income levels showed a 1.95-fold higher likelihood of a better quality of life than those with the lowest income. The lowest income group had higher odds of mobility (adjusted odds ratio [aOR], 2.2), self-care (aOR, 2.1), activity limitations (aOR, 2.4), pain/discomfort (aOR, 1.8), and anxiety/depression (aOR, 2.3). Educational disparities included a 3-fold increase in mobility and daily activity problems for those with elementary or lower education. Well-educated participants had a 1.94 times higher quality of life, with smaller differences in anxiety/depression and self-management. The income gap accounted for 14.1% of variance in quality-of-life disparities.
CONCLUSIONS
Addressing socioeconomic disparities in the quality of life for individuals with chronic diseases necessitates tailored interventions and targeted health policies. This research informs policymakers in developing focused initiatives to alleviate health inequities. It emphasizes the importance of mental health support and ensuring affordable, accessible healthcare services.; Summary

Korean summary
- 지역사회건강조사 자료를 통해 확인한 한국인에게 호발하는 만성질환자(당뇨, 고혈압, 심혈관질환, 고지혈증, 관절염)에서 삶의 질 점수(EQ-5D)는 평균 0.7점으로, 남성에서 높고, 연령이 높을수록 낮다. - 소득이 낮거나 교육수준이 낮은 군에서 삶의 질이 상대적으로 낮으며, 특히 운동능력, 자기관리, 통증/불편, 불안/우울 각각에서 두배 가량 어려움을 겪는 것으로 나타났다. - 만성질환자에서 삶의 질은 사회경제적 여건에 따라 격차가 존재하므로, 취약한 계층 발굴과 지원이 필요하다.

Key Message
- Quality of life score (EQ-5D) in patients with chronic diseases (i.e., diabetes, hypertension, cardiovascular disease, hyperlipidemia, and arthritis) that are prevalent in Koreans identified through data from community health surveys averaged 0.7, lower in women than in men, and decreased by age. - Low-income or low-educated patients have relatively low quality of life, and they have more than twice as much problem in mobility, self-care, pain/discomfort, and anxiety/depression. - Disparities in quality of life in patients with chronic diseases according to socioeconomic conditions have been found, and support for the vulnerable is needed.

An epidemic of cataract surgery in Korea: the effects of private health insurance on the National Health Insurance Service: Hyejin Lee, Soo-Hee Hwang, Choon-Seon Park, Seol-Hee Chung, Catherine L. Chen, Jin Yong Lee, Jin Soo Lee; Epidemiol Health. 2024;46:e2024015. Published online January 6, 2024; DOI: https://doi.org/10.4178/epih.e2024015

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
In Korea, the National Health Insurance Service (NHIS) covers essential healthcare expenses, including cataract surgery. To address concerns that private health insurance (PHI) might have inflated the need for such procedures, we investigated the extent of the PHI-attributable increase in cataract surgery and its impact on NHIS-reimbursed expenses.
METHODS
This retrospective, observational study uses nationwide claims data for cataract surgery from 2016 to 2020. We examined trends in utilization and cost, and we estimated the excess numbers of (1) cataract operations attributable to PHI and (2) types of intraocular lenses used for cataract surgery in 2020.
RESULTS
Between 2016 and 2020, a 36.8% increase occurred in the number of cataract operations, with increases of 63.5% and 731.8% in the total healthcare costs reimbursed by NHIS and PHI, respectively. Over a 5-year period, the surgical rate per 100,000 people doubled for patients aged <65 years (from 328 in 2016 to 664 in 2020). Among the 619,771 cases in 2020 of cataract surgery reimbursed by the Korean diagnosis-related group system, more non-NHIS-covered intraocular lenses were used for patients aged <65 years than ≥65 years (68.1 vs. 14.2%). In 2020 alone, an estimated 129,311 excess operations occurred, accounting for an excess cost of US$115 million.
CONCLUSIONS
A dramatic increase in the number and cost of cataract operations has occurred over the last 5 years. The PHI-related increase in operations resulted in increased costs to NHIS. Measures to curtail the non-indicated use of cataract surgery should be implemented regarding PHI.; Summary

Korean summary
백내장 수술에서 실손보험으로 인한 의료비 증가 수준을 확인하고 건강보험급여 비용에 미치는 영향을 조사했을 때 2016년과 2020년 사이에 백내장 수술 건수는 36.8% 증가했으며, 건강보험과 실손보험에서 지급한 총 의료 비용은 각각 63.5%와 731.8% 증가했다. 백내장 수술은 65세 미만에서 주로 증가하였으며, 이 연령층은 공단에서 급여하지 않는 고가의 인공수정체를 더 많이 사용하였다. 추정 초과 수술 건수는 2020년에만 129,311건으로 1억 1,500만 달러의 초과 비용이 발생했다.

Determinants of unhealthy living by gender, age group, and chronic health conditions across districts in Korea using the 2010-2017 Community Health Surveys: Thi Tra Bui, Thi Huyen Trang Nguyen, Jinhee Lee, Sun Young Kim, Jin-Kyoung Oh; Epidemiol Health. 2024;46:e2024014. Published online January 4, 2024; DOI: https://doi.org/10.4178/epih.e2024014

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
We investigated the prevalence and determinants of unhealthy living by gender, age, and comorbidities across Korean districts.
METHODS
For 806,246 men and 923,260 women from 245 districts who participated in the 2010-2017 Korean Community Health Surveys, risk scores were calculated based on obesity, physical inactivity, smoking, and high-risk alcohol consumption, each scored from 0 (lowest risk) to 2 (highest risk). A risk score ≥4 was defined as indicating unhealthy living, and weighted proportions were calculated for each district. Using multivariate regression, an ecological model including community socioeconomic, interpersonal, and neighborhood factors was examined by gender, age, and comorbidities.
RESULTS
The mean age-standardized rate of unhealthy living was 24.05% for men and 4.91% for women (coefficients of variation, 13.94% and 29.51%, respectively). Individuals with chronic diseases more frequently exhibited unhealthy lifestyles. Unhealthy lifestyles were associated with educational attainment (β-coefficients: men, -0.21; women, -0.15), high household income (β=0.08 and 0.03, respectively), pub density (β=0.52 and 0.22, respectively), and fast-food outlet density (β=2.81 and 1.63, respectively). Negative associations were observed with manual labor, social activity participation, and hospital bed density. Unhealthy living was positively associated with living alone among women and with being unemployed among middle-aged men. Access to parks was negatively associated with unhealthy living among young men and women. The ecological model explained 32% of regional variation in men and 41% in women.
CONCLUSIONS
Improving the neighborhood built and socioeconomic environment may reduce regional disparities in lifestyle behaviors; however, the impacts may vary according to socio-demographic traits and comorbidities.; Summary

Korean summary
- 시군구 지역단위의 불건강생활(흡연, 음주, 비만, 신체활동 부족 각 0-2점, 합 4점 이상 불건강) 유병률은 여자보다 남자에서 높고, 연령이 높아지면서 감소한다. - 지역사회 환경개선(술집 개수, 패스트푸드점 밀도, 공원 면적, 병상밀도)과 사회경제적 수준 강화(교육수준, 가구소득, 고용)를 통해 생활습관적 건강행태의 지역 격차를 줄일 수 있다. - 이러한 향상 노력의 효과는 지역의 건강상태 수준이나 사회인구학적 특성에 따라 다를 수 있다.

Key Message
• District prevalence rates of unhealthy living were higher among men than women and decreased with advancing age. • Efforts to reduce regional disparities in lifestyle behaviors could benefit from enhancements to the neighborhood environment and the socioeconomic status of the area. • The effectiveness of such improvements may vary based on socio-demographic characteristics and health conditions.

Systematic Review

Effectiveness of community-based interventions for older adults living alone: a systematic review and meta-analysis: Inhye Kim, Hyunseo An, Sohyeon Yun, Hae Yean Park; Epidemiol Health. 2024;46:e2024013. Published online January 3, 2024; DOI: https://doi.org/10.4178/epih.e2024013

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
This study examined the effectiveness of community-based interventions designed for older adults living alone through a systematic review and meta-analysis.
METHODS
The study incorporated 4 randomized controlled trials (RCTs) and 5 non-RCTs to evaluate various interventions. The methodological quality of these studies was assessed using the Downs and Black checklist, while Q-statistic and I-square tests were performed to examine statistical heterogeneity. Additionally, visual inspection of funnel plots and the trim-and-fill method were employed to investigate potential publication bias. Of the 2,729 identified studies, 9 met the criteria for inclusion in this review. Independent variables were categorized into 5 groups (physical activity, nutrition, social relationships, social participation, and combined intervention) to examine their effects. Dependent variables were similarly classified into 5 subgroups to identify the specific effects of the interventions.
RESULTS
Interventions focusing on nutrition and combined approaches were the most effective, yielding effect sizes of 0.96 (95% confidence interval [CI], 0.66 to 1.25) and 0.43 (95% CI, 0.26 to 0.60), respectively. The interventions had the greatest impacts on the health behavior and mental health of the participants, with effect sizes of 0.98 (95% CI, 0.73 to 1.22) for health behavior and 0.67 (95% CI, 0.19 to 1.16) for mental health.
CONCLUSIONS
This study suggests a direction for the development of community-based interventions tailored to the needs of older adults living alone. Additionally, it provides evidence to inform policy decisions concerning this demographic.; Summary

Korean summary
본 연구는 독거 노인들 대상으로 한 지역사회 기반 중재의 효과에 대하여 탐색하고 그 효과 크기를 확인하기 위하여 체계적고찰 및 메타분석을 실시하였다. 영양 및 복합 중재가 특히 효과적이었으며, 이는 건강 행동과 정신건강에 있어 중요한 긍정적 효과를 나타내어 추후 개별적 맞춤 중재의 잠재적 효과성을 나타낸다. 이러한 발견은 독거노인 집단의 웰빙 향상을 위한 프로그램과 정책 입안에 근거로 활용될 수 있다.

Key Message
This systematic review and meta-analysis evaluated the impact of community-based interventions for older adults living alone, incorporating 9 studies to assess effectiveness in areas like nutrition and combined strategies. Results indicated significant benefits, particularly in health behavior and mental health, demonstrating the potential of tailored interventions. These findings support the development of targeted programs and policy decisions aimed at improving the well-being of this demographic.

Original Articles

Identifying pregnancy episodes and estimating the last menstrual period using an administrative database in Korea: an application to patients with systemic lupus erythematosus: Yu-Seon Jung, Yeo-Jin Song, Jihyun Keum, Ju Won Lee, Eun Jin Jang, Soo-Kyung Cho, Yoon-Kyoung Sung, Sun-Young Jung; Epidemiol Health. 2024;46:e2024012. Published online December 19, 2023; DOI: https://doi.org/10.4178/epih.e2024012

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
This study developed an algorithm for identifying pregnancy episodes and estimating the last menstrual period (LMP) in an administrative claims database and applied it to investigate the use of pregnancy-incompatible immunosuppressants among pregnant women with systemic lupus erythematosus (SLE).
METHODS
An algorithm was developed and applied to a nationwide claims database in Korea. Pregnancy episodes were identified using a hierarchy of pregnancy outcomes and clinically plausible periods for subsequent episodes. The LMP was estimated using preterm delivery, sonography, and abortion procedure codes. Otherwise, outcome-specific estimates were applied, assigning a fixed gestational age to the corresponding pregnancy outcome. The algorithm was used to examine the prevalence of pregnancies and utilization of pregnancy-incompatible immunosuppressants (cyclophosphamide [CYC]/mycophenolate mofetil [MMF]/methotrexate [MTX]) and non-steroidal anti-inflammatory drugs (NSAIDs) during pregnancy in SLE patients.
RESULTS
The pregnancy outcomes identified in SLE patients included live births (67%), stillbirths (2%), and abortions (31%). The LMP was mostly estimated with outcome-specific estimates for full-term births (92.3%) and using sonography procedure codes (54.7%) and preterm delivery diagnosis codes (37.9%) for preterm births. The use of CYC/MMF/MTX decreased from 7.6% during preconception to 0.2% at the end of pregnancy. CYC/MMF/MTX use was observed in 3.6% of women within 3 months preconception and 2.5% during 0-7 weeks of pregnancy.
CONCLUSIONS
This study presents the first pregnancy algorithm using a Korean administrative claims database. Although further validation is necessary, this study provides a foundation for evaluating the safety of medications during pregnancy using secondary databases in Korea, especially for rare diseases.; Summary

Korean summary
임산부의 약물 사용 안전성에 대한 근거 제공을 위해 실제 인구집단에서의 임신 중 약물 치료 안전성을 평가하는 청구자료 기반 연구가 중요하다. 본 연구에서는 국내 청구자료에 적용할 수 있는 임신 정의 및 임신 결과 조작적 정의 알고리즘을 개발하였다. 본 알고리즘은 임신 결과 간의 우선순위를 고려한 계층 구조를 활용하며, 조기 분만 및 초음파 검사 코드 등을 통해 최종 월경 기간을 추정하였다. 또한 알고리즘을 전신홍반루푸스 환자에 적용하여 유산, 사산 등의 유병률을 산출하고 임신 중 잠재적으로 부적절한 면역억제제 사용을 파악하여 국내 청구자료의 특성을 고려한 임신 중 약물 사용 연구의 기반을 마련하였다.

Key Message
Limited safety data for pregnant women prompted recent studies on medication during pregnancy using real-world databases. This study developed a tailored algorithm for Korean healthcare claims database, employing a hierarchy of pregnancy outcomes and incorporating pre-term delivery and sonography codes for last menstrual period estimation. Applied to systemic lupus erythematosus (SLE) patients, this study presented the prevalence and drug utilization pattern of pregnancy-incompatible immunosuppressants from preconception to pregnancy end, laying a foundation for further claims database studies on medication pregnancy safety.

Folate, vitamin B12, and homocysteine status in the Korean population: data from the 2013-2015 Korea National Health and Nutrition Examination Survey: Sihan Song, Bo Mi Song, Hyun-Young Park; Epidemiol Health. 2024;46:e2024007. Published online December 11, 2023; DOI: https://doi.org/10.4178/epih.e2024007

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
We aimed to assess the serum folate, vitamin B12, and homocysteine status in Korean adolescents and adults using national data.
METHODS
Blood samples were collected from participants aged ≥10 years in the Korea National Health and Nutrition Examination Survey 2013-2015. The stored serum samples were used to measure folate, vitamin B12, and homocysteine concentrations. A total of 8,016 participants were included in this analysis. Unweighted descriptive statistics and adjusted geometric means of the B vitamins and homocysteine concentrations were estimated.
RESULTS
Females had higher serum folate and vitamin B12 concentrations and lower serum homocysteine concentrations than males. Folate deficiency (<6.8 nmol/L) and hyperhomocysteinemia (>15 μmol/L) were found in 8.6% and 11.8% of males, respectively. Approximately 3% of males had low or marginally low vitamin B12 status (≤221 pmol/L). Folate and vitamin B12 deficiencies and hyperhomocysteinemia were found in <2% of females. Suboptimal folate status was prevalent among adolescents and young adults, while suboptimal vitamin B12 status and hyperhomocysteinemia were relatively higher in older adults. Adjusted mean homocysteine concentrations were sharply decreased from the first to second decile of serum folate in males.
CONCLUSIONS
In the Korean population, the proportion of males who achieved desirable folate and homocysteine concentrations were lower than those of females. Although most Koreans have adequate vitamin B12, a suboptimal folate status is common, particularly among adolescents and young adults. These findings could establish a foundation for public health initiatives aimed at improving folate levels in the Korean population.; Summary

Korean summary
엽산과 비타민B12는 전 생애에 걸쳐 건강에 영향을 미치는 필수 비타민이다. 그러나 해당 비타민 상태에 대한 국내 자료는 부족한 실정이다. 본 연구는 국민건강영양조사 참여자로부터 수집된 혈청으로부터 엽산, 비타민B12, 그리고 이들의 기능성 지표인 호모시스테인 농도를 측정하였고 성별과 연령별 분포와 적합 상태를 평가하였다. 엽산 결핍과 고호모시스테인혈증은 남성에서 높은 유병률을 가졌다. 적정 엽산 상태를 충족하지 못하는 비율은 청소년과 젊은 성인에서 흔하게 관찰되었다. 대부분의 한국인은 충분한 비타민B12 수준을 가졌으나, 노인의 경우 정기적인 평가가 필요하다. 본 연구는 한국인이 최적의 엽산과 비타민B12 상태를 유지하기 위한 기반적 근거를 제공한다.

Key Message
Folate and vitamin B12 have significant health impacts throughout the life cycle. However, national-level data on B vitamins in Korea are limited. Serum folate, vitamin B12, and homocysteine concentrations were measured from samples stored during the national survey. In our study, the proportions of folate deficiency and hyperhomocysteinemia were higher in men than in women.Suboptimal folate status was common among adolescents and young adults. Most Koreans had adequate levels of vitamin B12; however, regular monitoring is warranted, especially in the older population. The current data provide a future direction for achieving optimal B vitamin status in the Korean population.

Regional disparities in the availability of cancer clinical trials in Korea: Jieun Jang, Wonyoung Choi, Sung Hoon Sim, Sokbom Kang; Epidemiol Health. 2024;46:e2024006. Published online December 11, 2023; DOI: https://doi.org/10.4178/epih.e2024006

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
Unequal access to cancer clinical trials is an important issue, given the potential benefits of participation for cancer patients. We evaluated regional disparities in access to cancer clinical trials in Korea.
METHODS
From the Ministry of Food and Drug Safety database, we extracted 2,465 records of all cancer clinical trials approved between January 2012 and April 2023. To measure disparities in cancer clinical trial access, we calculated the ratio of clinical trials open to non-capital areas relative to those open to capital areas. We then analyzed temporal trends in this ratio, which we termed the trial geographical equity index (TGEI).
RESULTS
Disparities in access to cancer clinical trials, as indicated by the TGEI, did not significantly improve during the study period (regression coefficient, 0.002; p=0.59). However, for phase II/III trials sponsored by global pharmaceutical companies, the TGEI improved significantly (regression coefficient, 0.021; p<0.01). In contrast, the TGEI deteriorated for trials initiated by investigators or those testing domestically developed therapeutics (regression coefficient, -0.015; p=0.05). Furthermore, the increasing trend of TGEI for phase II/III trials sponsored by global companies began to reverse after 2019, coinciding with the outbreak of coronavirus disease 2019 (COVID-19).
CONCLUSIONS
Over the past decade, access to cancer clinical trials has improved in Korea, particularly for phase II/III trials evaluating therapeutics from global companies. However, this increase in accessibility has not extended to trials initiated by investigators or those assessing domestically developed therapeutics. Additionally, the impact of COVID-19 on disparities in clinical trial access should be closely monitored.; Summary

Korean summary
본 연구는 개시된 암 임상시험 수가 국내 수도권에 비해 비수도권에서 절대적으로 부족하고, 이러한 부족이 지난 10년간 개선되지 않았음을 보여줍니다. 다만, 글로벌 제약회사의 치료제를 검증하는 2상/3상 암 임상시험의 경우 임상시험 접근성에 대한 이러한 지역적 격차가 의미 있게 감소했으나 이러한 개선 또한 2019년 이후로는 정체되었을 수 있습니다. 상기 결과들은 임상시험 가용성의 형평성을 향상시키기 위해서는 국내 임상시험 개시 규모가 지역적 불균형을 이루고 있음에 대한 인식이 높아져야 하고, 비수도권 지역에서 임상시험 개시를 방해하는 장벽을 식별하는 데 추가적인 노력이 필요함을 강조합니다.

Key Message
The findings in this study indicate scarcity of cancer clinical trials in non-capital areas compared to that in capital areas of Korea, which has not improved over the past decade. However, this regional disparity in the access to clinical trials meaningfully decreased for phase II/III trials testing therapeutics from global pharmaceutical companies, though this progress may have stalled after 2019. This study highlights that increasing awareness of the regional imbalance in clinical trial access is vital and further efforts are needed to identify the barriers impeding the initiation of clinical trials in non-capital areas to improve the equity of availability.

Risk factors for early-onset lung cancer in Korea: analysis of a nationally representative population-based cohort: Jihun Kang, Taeyun Kim, Kyung-Do Han, Jin-Hyung Jung, Su-Min Jeong, Yo Hwan Yeo, Kyuwon Jung, Hyun Lee, Jong Ho Cho, Dong Wook Shin; Epidemiol Health. 2023;45:e2023101. Published online November 21, 2023; DOI: https://doi.org/10.4178/epih.e2023101

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
We examined the associations of socioeconomic factors, health behaviors, and comorbidities with early-onset lung cancer.
METHODS
The study included 6,794,287 individuals aged 20-39 years who participated in a Korean national health check-up program from 2009 to 2012. During the follow-up period, 4,684 participants developed lung cancer. Multivariable Cox regression analysis was used to estimate the independent associations of potential risk factors with incident lung cancer.
RESULTS
Older age (multivariable hazard ratio [mHR], 1.13; 95% confidence interval [CI], 1.12 to 1.14) and female sex (mHR, 1.62; 95% CI, 1.49 to 1.75) were associated with increased lung cancer risk. Current smoking was also associated with elevated risk (<10 pack-years: mHR, 1.12; 95% CI, 1.01 to 1.24; ≥10 pack-years: mHR, 1.30; 95% CI, 1.18 to 1.45), but past smoking was not. Although mild alcohol consumption (<10 g/day) was associated with lower lung cancer risk (mHR, 0.92; 95% CI, 0.86 to 0.99), heavier alcohol consumption (≥10 g/day) was not. Higher income (highest vs. lowest quartile: mHR, 0.86; 95% CI, 0.78 to 0.94), physical activity for at least 1,500 metabolic equivalent of task-min/wk (vs. non-exercisers: mHR, 0.83; 95% CI, 0.69 to 0.99) and obesity (vs. normal weight: mHR, 0.89; 95% CI, 0.83 to 0.96) were associated with lower lung cancer risk, whereas metabolic syndrome was associated with increased risk (mHR, 1.13; 95% CI, 1.03 to 1.24).
CONCLUSIONS
In young adults, age, female sex, smoking, and metabolic syndrome were risk factors for early-onset lung cancer, while high income, physical activity, and obesity displayed protective effects.; Summary

Korean summary
나이, 여성, 흡연, 그리고 대사 증후군은 조기 발생 폐암의 위험도 증가와 연관이 있었다. 반면에 높은 소득, 신체 활동, 비만은 젊은 성인에서 폐암 발생의 위험도 감소와 연관성을 나타내었다.

Key Message
Age, female sex, smoking, and metabolic syndrome were risk factors for early-onset lung cancer. While, high income, physical activity, and obesity displayed protective effects on the development of lung cancer in young adults.

Performance pressure and mental health among finance workers in Korea: a cross-sectional study: Yu Min Lee, Hyoung-Ryoul Kim; Epidemiol Health. 2023;45:e2023099. Published online November 7, 2023; DOI: https://doi.org/10.4178/epih.e2023099

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Abstract Summary PDF Supplementary Material: Abstract
OBJECTIVES
While issues related to mental health, including suicide, have been frequently reported among finance workers, no formal investigation has been undertaken. This study was conducted to analyze correlations between indicators of performance pressure, which is a characteristic of the finance sector, and mental health.
METHODS
An online survey was administered to 1,181 participants. Brief questionnaires were employed to ask general questions about participant characteristics, work environment, and the presence of performance pressure, suicidal thoughts/plans/attempts, depression (indicated by the Patient Health Questionnaire-9), and anxiety (measured with the Generalized Anxiety Disorder-7). Frequency analysis, chi-square testing, and multivariate logistic regression analysis were performed.
RESULTS
Of the 1,181 respondents, 797 (83.5%) reported feeling pressure to perform at work, while 252 (26.4%) admitted to occasional willingness to achieve results even through illegal activities. Multivariate logarithmic regression analysis was employed to examine the correlation between performance pressure and mental health. This analysis revealed that those expressing willingness to achieve results through illegal activities exhibited higher levels of suicidal ideation (adjusted odds ratio [aOR], 1.63; 99% confidence interval [CI], 1.04 to 2.55), plans (aOR, 1.75; 99% CI, 1.01 to 3.01), and attempts (aOR, 2.72; 99% CI, 1.06 to 6.98). Additionally, these individuals demonstrated higher levels of depression (aOR, 2.02; 99% CI, 1.34 to 3.06) and anxiety (aOR, 2.84; 99% CI, 1.81 to 4.46).
CONCLUSIONS
Performance pressure is prevalent within the finance industry. This pressure serves as a major source of stress for employees and is evident in 3 representative indicators of mental health: suicide, depression, and anxiety.; Summary

Korean summary
현대사회에서 많은 조직이 성과에 따른 보상과 처벌규정을 사용하여 인적자원을 관리함으로써 조직의 성장을 꾀한다. 특히 금융업의 경우 성과평가가 평가를 위한 가시적이고 단순한 지표들과 연계되면서, 근로자들은 부여된 실적만을 달성하기 위한 과도한 노력을 기울이게 된다. 이 연구를 통해 그 과정에서 개인들은 과도한 성과압박을 느끼고, 성과압박을 많이 느낄수록 다양한 업무상 정신질환(불안, 우울, 자살생각 및 시도 등)을 경험한다는 것을 보여주었다.

Key Message
Inappropriately selected performance indicators cause performance pressure, which is related to the occurrence of work-related mental disorders. This paper is meaningful in showing the current status of performance pressure in the Korean financial industry and showing the relationship between performance pressure and work-related mental health.

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