Analysis of Scoliosis-related Medical Services in South Korea Between 2010 and 2018: A Cross-sectional Study Using Health Insurance Review and Assessment Service Data

Scoliosis is defined as an abnormally laterally curved spine with a Cobb angle of ≥10°.1,2 Scoliosis can occur because of neuromuscular diseases (e.g., cerebral palsy, myelodysplasia, muscular atrophy)3 or congenital spinal malformation, (e.g., hemivertebra, unilateral bar, block vertebra).2 Cases with unknown etiology are known as “idiopathic scoliosis,” which is the most common type and clinically important.4 Studies report scoliosis prevalence in adults as 3.9% to 29.4%5–7 with one study finding the prevalence of 68% for asymptomatic patients aged ≥60 years.8 Idiopathic scoliosis’ prevalence in adolescence may vary according to ethnicity, age, and sex and has been found to range from 0.47% to 5.2%, which differed across studies depending on scoliosis definition, study protocol, and subjects’ age group.2 In South Korea, a 35.5% prevalence was found among those aged ≥60 years,9 whereas in adolescents, the prevalence was 3.26%, with that for girls being 4.65%, approximately 2.4 times higher than for boys.10

Although some studies have proposed treatments for scoliosis according to patients’ age and scoliosis cause,2,3,11–13 data are lacking on which treatments are popular for general scoliosis and which service categories incur the most cost in South Korea. Thus, accurately examining scoliosis’ present prevalence and features and identifying treatment types and cost in clinical practice are necessary.

Thus, this study aims to analyze the types and costs of scoliosis treatment in a 9-year period (2010–2018) to present the general trend in scoliosis care and examine trend changes over time.

MATERIALS AND METHODS Data Source

We used 2010 to 2018 Health Insurance Review and Assessment Service-National Patient Sample (HIRA-NPS) data, which contain information on health insurance claims generated in the process of reimbursing health care providers under the NHI system in South Korea.14 South Korea has a universal health coverage system with approximately 98% of the population enrolled in the National Health Insurance (NHI).15 Low income individuals not enrolled in NHI receive medical aid and recipients of medical aid have most of their medical costs, excluding noncovered items, paid by the government.16 The HIRA-NPS data used in this study contain claims records of a 3% sample (about 1.4 million people) randomly selected from the Republic of Korea's total population registered in the NHI or medical aid system (about 46 million people). They contain sociodemographic information, as well as information about provided health services.15

Inclusion/Exclusion Criteria

Patients who received Western medicine (WM) or Korean medicine (KM) care for scoliosis (ICD-10 code M41) as the principal diagnosis at least once between 2010 and 2018 were included in the sample. Patients with codes for dentistry, community health center, or psychiatry; whose organization type corresponded to long-term care hospital, psychiatric care hospital, dental hospital, maternity center, or community health center; or those with 0 or no data for total cost and number of days in care were excluded.

Study Outcomes and Analysis

All indicators in this study, such as number of patients, number of cases, average annual visits per patient, and total expense, were calculated based on the sample population of this study, that is patients with primary diagnosis of scoliosis who received treatments included in NHI covered items. In cases where patients included in this study received both treatments covered and not covered by NHI, only data related to treatments covered by NHI were calculated.

Participants were classified by age, sex, payer type, visit type, and medical institution to calculate the number of patients or cases and their percentage in each category. The word ‘the number of cases’ in this study is used as the same meaning of the number of insurance claims. Age was classified into eight groups in 10-year units from < 15 years to ≥75 years; payer type was classified into NHI, Medical Aid, and others. Visit type was classified into outpatient and inpatient based on the bill; medical institution type was classified into tertiary hospital/general hospital/hospital, clinic, KM hospital, and KM clinic.

Service categories were classified into nine categories based on the HIRA reimbursement system, and the number of cases and total cost of each category were calculated, and the number of cases and total cost of each category were calculated. Total cost is the patient's incurred cost at a medical institution calculated as the sum of health insurance-paid costs and patients’ out-of-pocket costs.

Scoliosis service codes were classified into WM and KM; service codes with a frequency of ≥0.1% (top 121 codes) were considered for WM, and those with a frequency of ≥0.01% (top 84 codes) were considered for KM. Service codes were categorized into 12 categories for WM and into 11 categories for KM. The number of cases and total cost, the total number of patients, the average annual number of cases per patient, and average annual per-patient cost for each code were analyzed. There were fewer KM-related service codes covered by the NHI, so instead of using the same criterion (≥0.1%), which would only qualify the top 39 codes, a broader criterion of ≥0.01% was used.

Prescriptions filled at private pharmacies and hospitals were categorized according to their Anatomical Therapeutic Chemical codes (ATC-codes) (Supplemental Table 1, https://links.lww.com/BRS/B858), and the number of cases, total cost, the total number of patients, the average annual cost per case, and average annual per-patient cost of each category were analyzed. ATC-codes and their categorization are shown in Supplemental Table 1, https://links.lww.com/BRS/B858. Packaged herbal medicine was excluded, as it is not presently covered by insurance.

We also analyzed the number of patients, total cases, total expense, per-patient expense, per-case expense, total care, average days in care per patient, total visits, and average visits per patient by year for the entire sample and by WM and KM (Supplemental Table 2, https://links.lww.com/BRS/B858). All cost-related results presented in this study were converted to the 2018 level based on health care and medical service price index adjusted for health care inflation rate and KRW:USD exchange rate (Supplemental Table 3, https://links.lww.com/BRS/B858). Data were analyzed using SAS software (version 9.4, SAS Institute, Cary, NC).

Ethical Statement

Study protocol was approved by the HIRA public data provision deliberation committee, and the study was conducted according to relevant guidelines/regulations. The present study was exempted by Jaseng Hospital of Korean Medicine's Institutional Review Board (JASENG 2021–02024). Declaration of Helsinki principles were adhered to in the analysis.

RESULTS Study Sample Flowchart

Of the 109,633 cases of scoliosis (M41), 887 cases with an excluded code, 35 with an excluded organization type, and 68 with 0 or no data for total cost and number of days in care were not considered for analysis. Thus, 108,643 total cases for 32,362 patients were included in the final analysis (Figure 1).

F1Figure 1:

Flowchart of the study sample.

Basic Patient Characteristics

Most patients who visited a medical institution for scoliosis were <15 years (n = 9020; 27.87%) and 15 to 24 years’ old (n = 9925; 30.67%); health care utilization tended to decrease with age. Patients were predominantly female (64.84%). The payer was NHI in most cases (96.20%). Although 92.18% of patients only sought WM, 6.56% only sought KM, showing that 98.73% (31,952) of patients only visited one type of medical institution. Sex and health insurance type varied little between the two care type groups (Table 1).

TABLE 1 - Basic Patient Characteristics Total (2010–2018) Western Medicine (2010–2018) Korean Medicine (2010–2018) Both Care Types (2010–2018) Category No of Patients Percentage No. of Patients Percentage No. of Patients Percentage No. of Patients Percentage Total 32,362 100.00 29,830 100.00 2122 100.00 410 100.00 Age, y <15 9020 27.87 8509 28.52 355 16.73 156 38.05 15–24 9925 30.67 9240 30.98 518 24.41 167 40.73 25–34 3433 10.61 3094 10.37 293 13.81 46 11.22 35–44 2546 7.87 2277 7.63 252 11.88 17 4.15 45–54 2412 7.45 2150 7.21 253 11.92 9 2.20 55–64 2056 6.35 1841 6.17 211 9.94 4 0.98 65–74 1812 5.60 1656 5.55 149 7.02 7 1.71 ≥75 1158 3.58 1063 3.56 91 4.29 4 0.98 Sex Male 11,378 35.16 10,461 35.07 778 36.66 139 33.90 Female 20,984 64.84 19,369 64.93 1344 63.34 271 66.10 Payer type∗ NHI 31,133 96.20 28,683 96.15 2053 96.75 397 96.83 Medical aid 1228 3.79 1146 3.84 69 3.25 13 3.17 Others 1 0 1 0 — — — —

NHI indicates National Health Insurance.


Basic Medical Usage Characteristics

Most scoliosis treatment cases in a medical institution (99.37%) were outpatient cases. Of all cases, 32.27% and 52.43% of them were from a WM hospital (tertiary/general/ hospital) and WM clinic, respectively, whereas 1.39% and 13.91% of them were from a KM hospital and KM clinic, respectively (Table 2).

TABLE 2 - Basic Medical Usage Characteristics Total (2010–2018) Western Medicine (2010–2018) Korean Medicine (2010–2018) Category No. of Cases % No. of Cases % No. of Cases % Total 108,643 100.00 92,358 100.00 16,285 100.00 Type of visit Outpatient 107,960 99.37 91,719 99.31 16,241 99.73 Inpatient 683 0.63 639 0.69 44 0.27 Medical institution Tertiary/general/hospital 35,058 32.27 34,997 37.89 61 0.37 Clinic 56,965 52.43 56,965 61.68 — — Korean medicine hospital 1511 1.39 396 0.43 1115 6.85 Korean medicine clinic 15,109 13.91 — — 15,109 92.78
Number of Medical Cases and Medical Costs Per Service Category

Treatment accounted for the greatest percentage of service categories (145,397 cases; 27.62%), followed by examination, special equipment and radiologic diagnosis, and injection. In WM, treatment was highest (145,254 cases, 32.48%), and in KM, injection was highest (57,907 cases, 73.11%). Overall, examination cost accounted for the greatest percentage of total cost (992,173 USD, 28.70%), followed by treatment and special equipment and radiologic diagnosis. In WM, examination cost was highest (875,859 USD, 28.03%). In KM, injection cost was highest (196,333 USD, 59.03%) (Table 3).

TABLE 3 - Number of Medical Cases and Medical Costs Per Service Category Service Category Total Western Medicine Korean Medicine No. of Cases % Total Cost % No. of Cases % Total Cost % No. of Cases % Total Cost % Treatment∗ 145,397 27.62 580,987 16.81 145,254 32.48 580,412 18.58 143 0.18 575 0.17 Examination† 136,886 26.00 992,173 28.70 119,290 26.67 875,859 28.03 17,596 22.22 116,314 34.97 Special equipment and radiologic diagnosis 98,718 18.75 631,651 18.27 98,718 22.07 631,651 20.22 — — — — Injection 90,762 17.24 381,653 11.04 32,855 7.35 185,320 5.93 57,907 73.11 196,333 59.03 Test 33,358 6.34 230,400 6.66 33,358 7.46 230,400 7.37 — — — — Medication preparation and administration 13,067 2.48 41,520 1.20 9747 2.18 38,741 1.24 3320 4.19 2778 0.84 Hospitalization 4594 0.87 343,865 9.95 4359 0.97 327,274 10.47 235 0.30 16,592 4.99 Procedure and surgery 3015 0.57 242,142 7.00 3015 0.67 242,142 7.75 — — — — Other 603 0.11 12,181 0.35 603 0.13 12,181 0.39 — — — — Noncovered services 3 <0.01 371 0.01 3 <0.01 371 0.01 — — — —

∗For the treatment category, all items except injection among all treatments covered by NHI for patients with primary diagnosis of scoliosis were included. Specifically, physical therapy, anesthesia, casts, blood transfusion, palliative care, psychotherapy, and other treatments were included.

†Examination corresponds to consultation fee, which includes fees incurred during the process of a patient meeting a physician for examination and consultation; All cost-related results presented in this study were converted to the 2018 level based on health care and medical service price index adjusted for health care inflation rate and KRW: USD exchange rate (see Supplemental Table 3,
https://links.lww.com/BRS/B858).
Frequently Used Service Codes

From 2010 to 2018, physiotherapy was the most frequently used service code (130,337 cases), followed by examination and imaging for WM versus acupuncture (31,191 cases), examination, and Korean medicine physiotherapy for KM. Regarding total cost, examination was the highest (816,147 USD), followed by imaging and physiotherapy for WM versus examination (121,078 USD), acupuncture, and cupping therapy for KM. (Table 4).

TABLE 4 - Frequently Used Service Codes Western Medicine Korean Medicine Service Code Total Cases Total Cost Total Patients Average Annual Case Per Patient Average Annual Cost Per Patient Service Code Total Cases Total Cost Total Patients Average Annual Case Per Patient Average Annual Cost Per Patient Physiotherapy∗ 130,337 256,307 10,072 1.97 25.45 Acupuncture 31,191 120,442 2372 3.86 50.78 Examination† 94,260 816,147 29,242 8.66 27.91 Examination 19,600 121,078 2526 6.18 47.93 Imaging 76,868 380,346 24,374 4.95 15.60 Korean medicine physiotherapy 8961 7631 1524 0.85 5.01 Clinical pathology 21,453 65,796 1001 3.07 65.73 Cupping therapy 7819 34,267 1384 4.38 24.76 Other 18,069 9182 6409 0.51 1.43 Electroacupuncture 4865 19,399 834 3.99 23.26 Injection 11,202 36,585 3547 3.27 10.31 Direct moxibustion 2921 7976 479 2.73 16.65 Exercise therapy 4505 22,194 1266 4.93 17.53 Medication preparation 1288 535 273 0.42 1.96 Treatment-nerve block 3141 132,078 1239 42.05 106.60 Hospitalization 174 11,301 35 64.95 322.90 Hospitalization 859 28,444 292 33.11 97.41 Korean medicine testing 142 572 131 4.03 4.37 Medication preparation and instruction 727 7075 470 9.73 15.05 Treatment-other 113 473 111 4.19 4.26 Treatment-other 709 8918 296 12.58 30.13 Other 10 80 4 7.98 19.96 ECG 600 3297 525 5.50 6.28

Service codes with a frequency of ≥0.1% (top 121 codes) were considered for WM, and those with a frequency of ≥0.01% (top 84 codes) were considered for KM.

∗For physiotherapy, service codes with a frequency of 0.1% or higher consisted of superficial heat therapy, deep heat therapy, interferential current therapy (ICT), transcutaneous electric nerve stimulation (TENS), rehabilitative low-level laser therapy (LLLT), and intermittent traction therapy.

†Examination corresponds to consultation fee, which includes fees incurred during the process of a patient meeting a physician for examination and consultation. All cost-related results presented in this study were converted to the 2018 level based on health care and medical service price index adjusted for health care inflation rate and KRW:USD exchange rate (see Supplemental Table 3,
https://links.lww.com/BRS/B858).
Frequently Prescribed Medicine

The most frequently prescribed medication in private pharmacies was anti-inflammatory analgesics (nonsteroidal anti-inflammatory drugs [NSAIDs]; 13,693 cases), followed by antacids and skeletal muscle relaxers. Total cost was highest for NSAIDs (54,122 USD), followed by antacids and other cardiovascular drugs. Among hospital prescriptions, the most frequently prescribed medication was blood products (4661 cases), other central nervous system drugs, and antipyretic analgesics. Total cost was highest for blood products (19,825 USD), other, and narcotics (Table 5).

TABLE 5 - Frequently Prescribed Medicine Category Private Pharmacy Hospital Total Case Total Cost ($) Total Patients Average Annual Cost Per Case ($) Average Annual Cost Per Patient($) Total Case Total Cost ($) Total Patients Average Annual Cost Per Case ($) Average Annual Cost Per Patient ($) Anti-inflammatory analgesics (NSAIDs) 13,693 54,122 7097 3.95 7.63 3073 6367 1581 2.07 4.03 Antacids 10,512 32,628 5271 3.10 6.19 1216 3389 422 2.79 8.03 Skeletal muscle relaxers 8886 15,897 5276 1.79 3.01 1060 3474 485 3.28 7.16 Gastrointestinal drugs 5446 8574 2713 1.57 3.16 674 1127&

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