Abstract
Purpose
The first year of the COVID-19 pandemic in Korea elicited changes in healthcare service utilization. This study aimed to report changes in healthcare service utilization among cancer patients during the first year of the COVID-19 pandemic in Korea.
Materials and Methods
We analyzed records from National Health Insurance Service Database and identified cancer patients as those with specific beneficiary codes (“V193” or “V194”) assigned to cancer patients. We calculated percentage changes in the number of patients between 2019 and 2020 based on claims records for outpatient clinic visits, hospitalization, and emergency room visits by month, age group, residential areas, and hospital location.
Results
The number of newly diagnosed cancer patients in 2020 decreased by 3.2%, compared to the previous year. The number of patients who visited an outpatient clinic, were hospitalized, and visited the emergency room decreased by 2.6%, 4.0%, and 3.5%, respectively, in 2020, compared to the year 2019.
Conclusion
During the first year of the COVID-19 pandemic, the number of newly diagnosed cancer patients decreased by 3.2%, compared to the previous year, and their utilization of healthcare services declined significantly after the outbreak of COVID-19.
Keywords: Delivery of health care, neoplasms, COVID-19, pandemics
Graphical Abstract
INTRODUCTION
In December 2019, the first COVID-19 confirmed case was reported in Wuhan, China.1 The Korean government reported the first confirmed COVID-19 case in February 2020 and subsequently implemented strict social-distancing regulations to prevent virus transmission.2 During the first wave of the pandemic, centered in the Daegu and Gyeongbuk region in March of 2020, more than 6000 COVID-19 cases were reported. The government asked the public to refrain from leaving their houses except for urgent situations.3 University hospitals located in areas with surges in COVID-19 infections were turned into COVID-19 designated hospitals to monitor virus-infected cases and to overcome a shortage of beds for COVID-19 patients.4
This reordering of healthcare facilities and workforce to mitigate the COVID-19 pandemic affected the delivery of medical care services for other disease patients.5 Indeed, collateral damage from the COVID-19 pandemic to patients with other diseases who experienced difficulties accessing healthcare facilities or receiving proper care has been reported by several countries.6,7,8,9,10,11 In particular, studies from Turkey and the United States, as well as an international prospective cohort study, have documented disruptions to healthcare systems during the pandemic, which affected cancer patients of all stages, from diagnosis to the administration of palliative care services.12,13,14 A survey conducted in Australia including 3563 medical facilities across 54 countries showed cancer care declined by 88.2% during the pandemic.15
Meanwhile, research has shown that delays in cancer care, including cancer screening, treatment, and surgery, caused by either social-distancing regulations to prevent viral infections or voluntary decisions to postpone medical appointments, can negatively affect a cancer patient’s quality of life or prognosis.16 This study aimed to analyze changes in healthcare utilization among cancer patients in Korea during the first year of the COVID-19 pandemic. We analyzed outpatient clinic visits, hospitalizations, emergency room visits, and cancer treatments for newly diagnosed cancer patients in Korea according to percentage changes between 2019 and 2020.
MATERIALS AND METHODS
Data source
We requested customized research data from the National Health Insurance Service database. The data from the National Health Insurance Service generally includes 2% of the entire Korean population. The requested research data includes claims data for cancer patients assigned specific beneficiary codes, “V193” or “V194,” from 2017 to 2020, including qualification data and treatment data (Supplementary Figs. 1, 2, 3, 4, 5, 6, 7, 8, only online). These two codes are assigned to cancer patients with the following ICD 10 codes; C00–C97, D00–D09, D32–D33, and D37–D48. The qualification data contain general information on fourteen variables, such as age, sex, residence, etc. The treatment data include a Statement Table (20t), consisting of variables related to the diagnosis and date of receiving specific treatment. The Treatment Table (30t) has information on procedures, prescribed medication, and emergency department visits.
Study population
Since the specific beneficiary codes are given to cancer patients for 5 years after they apply for approval for care, we set a wash out period of the 2 previous years. We excluded patients who lacked sex information. Claims records for chemotherapy and surgery of common cancer types, including colorectal, gastric, breast, lung, liver, pancreatic, and bile duct cancer, were analyzed. The lists of chemotherapy drug administration codes, surgical operation codes, and radiation therapy codes are provided in Supplementary Tables 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 (only online).
Data analysis
We compared percent changes in outpatient clinic visits, hospitalizations, and emergency room visits for newly diagnosed cancer patients according to the month, age group, and geographical region. We compared the number of claims and patients who received chemotherapy, cancer surgery, and radiotherapy before and during the pandemic according to percentage change. To analyze the patients according to different age groups, we divided the cancer patients into three age groups (0–39, 40–64, and over 65). We selected two regions, the Capital and the Daegu Gyeongbuk Region, affected most by the pandemic during the three waves of the pandemic in 2020. All statistical analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC, USA).
Institutional Review Board
The study protocol was exempt from the review by the IRB of Seoul National University College of Medicine/Seoul National University Hospital due to the use of anonymized secondary data only (IRB number: 2010-002-1160).
RESULTS
The number of newly diagnosed patients totaled 292808 in 2019 and 283424 in 2020, which declined 2020 by 3.2%, compared to 2019 (Table 1). The sharpest decline was 21.7% in April (Fig. 1). Similar decreasing trends were observed for patients who visited outpatient clinics, which decreased by 25.9% in April (Fig. 2), and for the number of hospitalized patients (Fig. 3), decreased sharply by 16.0% in April (Fig. 3). Among the newly diagnosed cancer patients, hospitalized patients dropped sharply in August by 10.1%. The number of emergency room visitations patients was 270579 in 2019 and 261224 in 2020. These declined by 3.5% and significantly dropped in April by 21.8% (Fig. 4).
Table 1. Baseline Characteristics of the Newly Diagnosed Cancer Patients (2019–2020).
| 2019 (n=292808) | 2020 (n=283424) | ||
|---|---|---|---|
| Sex | |||
| Male | 142044 (48.5) | 137724 (48.6) | |
| Female | 150764 (51.5) | 145700 (51.4) | |
| Age (yr) | |||
| 0–39 | 26501 (9.1) | 26059 (9.2) | |
| 40–64 | 134627 (46.0) | 127304 (44.9) | |
| Over 65 | 131680 (45.0) | 130061 (45.9) | |
| Insurance type | |||
| Locally provided policyholders | 85417 (29.2) | 83193 (28.4) | |
| Employer-provided policyholders | 194170 (66.3) | 187382 (64.0) | |
| Recipient of medical benefits | 13221 (4.5) | 2849 (4.4) | |
| Residence | |||
| Capital | 139027 (47.5) | 135556 (47.8) | |
| Central | 40383 (13.8) | 38920 (13.7) | |
| Southeastern | 77859 (26.6) | 74403 (26.3) | |
| Southwestern | 35430 (12.1) | 34448 (12.2) | |
| - | 109 (-) | 97 (-) | |
| Location of healthcare facilities | |||
| Capital | 172641 (59.0) | 166186 (58.6) | |
| Central | 27663 (9.4) | 27434 (9.7) | |
| Southeastern | 65303 (22.3) | 63264 (22.3) | |
| Southwestern | 27201 (9.3) | 26540 (9.4) | |
| Income level | |||
| Group 1 (level 0–4) | 62112 (21.2) | 58853 (20.8) | |
| Group 2 (level 5–8) | 35413 (12.1) | 36475 (12.9) | |
| Group 3 (level 9–12) | 45784 (15.6) | 44783 (15.8) | |
| Group 4 (level 13–16) | 58863 (20.1) | 55809 (19.7) | |
| Group 5 (level 17–20) | 86382 (29.5) | 83439 (29.4) | |
| - | 4254 (1.5) | 4065 (1.4) | |
| Cancer type | |||
| Lip, oral cavity, and pharynx | 2776 (0.9) | 2860 (1.0) | |
| Gastrointestinal | 77703 (26.5) | 73093 (25.8) | |
| Lung and intrathoracic | 24263 (8.3) | 23243 (8.2) | |
| Bone and soft tissue | 8711 (3.0) | 8615 (3.0) | |
| Breast | 21959 (7.5) | 21831 (7.7) | |
| Gynecological | 23434 (8.0) | 23797 (8.4) | |
| Genitourinary | 12108 (4.1) | 12159 (4.3) | |
| Eye, brain, and other parts of central nervous system | 1886 (0.6) | 1835 (0.6) | |
| Thyroid | 28674 (9.8) | 27476 (9.7) | |
| Secondary and unspecified site | 16036 (5.5) | 15950 (5.6) | |
| Lymphoma | 11127 (3.8) | 11032 (3.9) | |
| Multiple sites | 17 (-) | 14 (-) | |
| In situ neoplasms | 25587 (8.7) | 24855 (8.8) | |
| Benign neoplasm of brain and other parts of central nervous system | 22668 (7.7) | 21718 (7.7) | |
| Neoplasms of uncertain behavior, polycythemia vera and myelodysplastic syndromes | 15859 (5.4) | 15305 (5.4) | |
Data are presented as n (%).
Fig. 1. The number of newly diagnosed cancer patients and % differences between 2019 and 2020.
Fig. 2. The number of newly diagnosed cancer patients who visited outpatient clinics and % differences between 2019 and 2020.
Fig. 3. The number of newly diagnosed cancer patients who were hospitalized and % differences between 2019 and 2020.
Fig. 4. The number of newly diagnosed cancer patients who visited emergency rooms and % differences between 2019 and 2020.
Analyzing patient numbers according to residence, we noted significant decreases of 49.3% and 40.6% in March and April, respectively, in the Daegu · Gyeongbuk region and of 21.8% in April in the Capital region (Table 2). When we analyzed according to hospital location, we identified the sharpest decline in March at 36.3% in the Daegu · Gyeongbuk region and a significant drop in April of 23.4% in the Capital region (Table 2). The number of newly diagnosed cancer patients declined most significantly in April in all age groups (0–39 year group: 17.1%, 40–64 year group: 24.3%, over 65 year group: 20.1%) in 2020, compared to the same months in 2019 (Table 3).
Table 2. The Number of Newly Diagnosed Cancer Patients by Hospital Location.
| Location | Year | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | Total |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Nationwide | 2019 | 27546 | 20444 | 24052 | 25253 | 24557 | 22785 | 26594 | 24055 | 22205 | 24209 | 25003 | 26105 | 292808 |
| 2020 | 25820 | 22869 | 21086 | 19774 | 21796 | 25027 | 25927 | 22505 | 22885 | 23316 | 25512 | 26907 | 283424 | |
| % Difference | -6.3% | 11.9% | -12.3% | -21.7% | -11.2% | 9.8% | -2.5% | -6.4% | 3.1% | -3.7% | 2.0% | 3.1% | -3.2% | |
| Capital Region | 2019 | 16369 | 11885 | 14065 | 14872 | 14586 | 13436 | 15677 | 14259 | 12969 | 14232 | 14747 | 15544 | 172641 |
| 2020 | 15345 | 13579 | 12505 | 11399 | 12573 | 14499 | 15164 | 13288 | 13173 | 13643 | 15160 | 15858 | 166186 | |
| % Difference | -6.3% | 14.3% | -11.1% | -23.4% | -13.8% | 7.9% | -3.3% | -6.8% | 1.6% | -4.1% | 2.8% | 2.0% | -3.7% | |
| Daegu-Gyeongbuk Region | 2019 | 2438 | 1775 | 2027 | 2123 | 2072 | 1841 | 2274 | 2110 | 1948 | 2102 | 2200 | 2238 | 25148 |
| 2020 | 2176 | 1853 | 1292 | 1561 | 1783 | 2161 | 2258 | 1858 | 2036 | 1963 | 2152 | 2441 | 23534 | |
| % Difference | -10.7% | 4.4% | -36.3% | -26.5% | -13.9% | 17.4% | -0.7% | -11.9% | 4.5% | -6.6% | -2.2% | 9.1% | -6.4% |
Table 3. The Number of Newly Diagnosed Cancer Patients by Age Group.
| Age | Year | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | Total |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Total | 2019 | 27546 | 20444 | 24052 | 25253 | 24557 | 22785 | 26594 | 24055 | 22205 | 24209 | 25003 | 26105 | 292808 |
| 2020 | 25820 | 22869 | 21086 | 19774 | 21796 | 25027 | 25927 | 22505 | 22885 | 23316 | 25512 | 26907 | 283424 | |
| % Difference | -6.3% | 11.9% | -12.3% | -21.7% | -11.2% | 9.8% | -2.5% | -6.4% | 3.1% | -3.7% | 2.0% | 3.1% | -3.2% | |
| 0–39 | 2019 | 2410 | 1812 | 1961 | 2201 | 2122 | 2174 | 2417 | 2205 | 2114 | 2213 | 2339 | 2533 | 26501 |
| 2020 | 2266 | 2085 | 1925 | 1825 | 1805 | 2108 | 2318 | 2033 | 2250 | 2191 | 2495 | 2758 | 26059 | |
| % Difference | -6.0% | 15.1% | -1.8% | -17.1% | -14.9% | -3.0% | -4.1% | -7.8% | 6.4% | -1.0% | 6.7% | 8.9% | -1.7% | |
| 40–64 | 2019 | 13032 | 9045 | 10602 | 11096 | 10930 | 9966 | 12095 | 11266 | 10423 | 11401 | 11970 | 12801 | 134627 |
| 2020 | 11853 | 10431 | 9259 | 8400 | 9150 | 10608 | 11366 | 10231 | 10744 | 10462 | 11906 | 12894 | 127304 | |
| % Difference | -9.0% | 15.3% | -12.7% | -24.3% | -16.3% | 6.4% | -6.0% | -9.2% | 3.1% | -8.2% | -0.5% | 0.7% | -5.4% | |
| 2019 | 12104 | 9587 | 11489 | 11956 | 11505 | 10645 | 12082 | 10584 | 9668 | 10595 | 10694 | 10771 | 131680 | |
| Over65 | 2020 | 11701 | 10353 | 9902 | 9549 | 10841 | 12311 | 12243 | 10241 | 9891 | 10663 | 11111 | 11255 | 130061 |
| % Difference | -3.3% | 8.0% | -13.8% | -20.1% | -5.8% | 15.7% | 1.3% | -3.2% | 2.3% | 0.6% | 3.9% | 4.5% | -1.2% |
The number of claims by patients receiving chemotherapy for common cancer types was 1239925 in 2019 and 1300379 in 2020 (Table 4). Claims for chemotherapy declined in May and October by 3.6% and 2.0%, respectively. Claims by patients who underwent surgery for common cancer types totaled 138457 in 2019 and 121289 in 2020 (Table 4), respectively, declining 12.4% during the pandemic. In February, the number of cancer surgery claims significantly dropped by 23.9%. The number of claims by patients who received radiation therapy was 1323879 in 2019 and 1369795 in 2020, increasing by 3.5% (Table 4). These dropped sharply in April and August by 4.8% and 4.7%, respectively.
Table 4. The Number of Claims and the Patients Receiving Chemotherapy, Surgery, or Radiotherapy (2019–2020).
| Year | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | Total | ||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Chemotherapy | |||||||||||||||
| Claims | 2019 | 108982 | 89689 | 98773 | 104806 | 107188 | 96939 | 111751 | 104714 | 101472 | 108605 | 100987 | 106019 | 1239925 | |
| 2020 | 109095 | 97939 | 109337 | 107959 | 103282 | 110688 | 114390 | 105430 | 108099 | 106398 | 109999 | 117763 | 1300379 | ||
| % Difference | 0.1% | 9.2% | 10.7% | 3.0% | -3.6% | 14.2% | 2.4% | 0.7% | 6.5% | -2.0% | 8.9% | 11.1% | 4.9% | ||
| Patients | 2019 | 70132 | 65100 | 67715 | 69728 | 70148 | 68597 | 72017 | 70652 | 70517 | 71675 | 70199 | 71020 | 837500 | |
| 2020 | 72116 | 69644 | 72516 | 72143 | 71815 | 73587 | 74576 | 71956 | 72892 | 73201 | 74265 | 75876 | 874587 | ||
| % Difference | 2.8% | 7.0% | 7.1% | 3.5% | 2.4% | 7.3% | 3.6% | 1.8% | 3.4% | 2.1% | 5.8% | 6.8% | 4.4% | ||
| Surgery | |||||||||||||||
| Claims | 2019 | 12376 | 11058 | 11944 | 10579 | 11332 | 12147 | 12325 | 10404 | 11128 | 11696 | 12009 | 11459 | 138457 | |
| 2020 | 11567 | 8410 | 10218 | 10039 | 10025 | 9635 | 10668 | 9871 | 9448 | 9970 | 10924 | 10514 | 121289 | ||
| % Difference | -6.5% | -23.9% | -14.5% | -5.1% | -11.5% | -20.7% | -13.4% | -5.1% | -15.1% | -14.8% | -9.0% | -8.2% | -12.4% | ||
| Patients | 2019 | 7279 | 5301 | 6443 | 6291 | 6227 | 6062 | 6670 | 6126 | 5777 | 5969 | 6661 | 6136 | 74942 | |
| 2020 | 6980 | 6354 | 6753 | 5598 | 6135 | 6755 | 6763 | 5728 | 6175 | 6403 | 6724 | 6444 | 76812 | ||
| % Difference | -4.1% | 19.9% | 4.8% | -11.0% | -1.5% | 11.4% | 1.4% | -6.5% | 6.9% | 7.3% | 0.9% | 5.0% | 2.5% | ||
| Radiotherapy | |||||||||||||||
| Claims | 2019 | 113871 | 91717 | 112675 | 118295 | 112856 | 102713 | 123936 | 112280 | 100486 | 117929 | 110035 | 107086 | 1323879 | |
| 2020 | 112433 | 113813 | 121921 | 112671 | 108927 | 119578 | 122402 | 106948 | 111373 | 103547 | 116260 | 119922 | 1369795 | ||
| % Difference | -1.3% | 24.1% | 8.2% | -4.8% | -3.5% | 16.4% | -1.2% | -4.7% | 10.8% | -12.2% | 5.7% | 12.0% | 3.5% | ||
| Patients | 2019 | 13030 | 11885 | 12879 | 13346 | 12875 | 12263 | 13671 | 12806 | 12492 | 13375 | 13078 | 12684 | 154384 | |
| 2020 | 13343 | 13040 | 13683 | 12872 | 13082 | 13674 | 13446 | 12576 | 12298 | 12520 | 13285 | 13195 | 157014 | ||
| % Difference | 2.4% | 9.7% | 6.2% | -3.6% | 1.6% | 11.5% | -1.6% | -1.8% | -1.6% | -6.4% | 1.6% | 4.0% | 1.7% | ||
DISCUSSION
During the COVID-19 pandemic, there was a change in healthcare service utilization among cancer patients in Korea. The number of newly diagnosed patients declined in 2020, compared to 2019. This result corresponds with the report published by the Health and Review Assessment showing decreases in cancer screening rates followed by declines in cancer diagnoses.17 Screening rates for four major cancer types, colorectal, gastric, breast, and cervical cancer, dropped significantly during the first and third wave of the pandemic in Korea in March and in December, respectively.18 The decrease in the number of the newly diagnosed cancer patients may be associated with reductions in cancer screening rates during the first year of the pandemic.
The reduced cancer screening rates correspond to the results of another study conducted in the New England region of the United States. There was a sharp decline in the number of patients as 15456 patients underwent any of the five cancer screening examinations (low-dose computed tomography, Papanicolaou test, colonoscopy, prostate-specific antigen screening, or mammography) during the 3-month study period (March–June, 2020), compared with 60344 patients who had undergone screening during the same 3 months of the previous year.19 A study using real-time international systemic anticancer therapy delivery data from National Health Service (NHS) Scotland reported a decrease in hospitalized patients. There was a rapid decrease in adult patient attendance in March, a week after the announcement of the UK lockdown. A decrease of by 28.7% was seen from March 2 to April 19, 2020 compared to January 20 to March 1, 2020.20
It has been suggested that a shorter duration from diagnosis to surgery could improve patient survival that delayed visits to the clinic for cancer treatment due to late diagnoses could negatively affect patient survival.21 During the pandemic, there was a significant increase in stage III diagnosed colorectal cancer patients (68.42% change; p<0.001) at two tertiary hospitals in Japan.22 A study conducted at seven cancer centers in France indicated that newly diagnosed cancer patients delayed visiting hospitals during the pandemic period from January to July 2020 (2019-47159; 2020-43947, -6.8%).23 The hazard ratio of estimated excess cancer death rate was 1.06 for a 1-month delay in therapeutic intervention. A systemic review and meta-analysis, including seven studies and 314560 colorectal cancer patients, showed a delay in 1 month of elective colorectal cancer surgery led to poorer overall survival and disease-free survival with a hazard ratio of 1.57 (95% CI 1.16–2.12, p=0.004).24
According to the Cancer Statistics conducted by the Korean Central Cancer Registry, the number of newly diagnosed cancer in 2020 decreased 3.6%, compared to 2019, which may reflect a low cancer screening participation rate.25 Before the pandemic, the number of newly diagnosed cancer patients in Korea had increased since 2019. The lower rate of cancer screening participation during the pandemic may lead to decreases in new cancer diagnoses and healthcare service utilization by cancer patients during the pandemic. Another report showed decreases in new cancer diagnoses are attributed to low cancer screening participation rates and healthcare facility visits.26 During the first pandemic wave from March to April 2020, the number of new cancer diagnoses and utilization of healthcare services for cancer treatment sharply decreased, and we expect the long-term effect of the delayed screening on cancer prognosis should be monitored.
Reordering of healthcare resources and workforce may have affected the decline in healthcare utilization among cancer patients. In March 2020, hospitals located in areas where COVID-19 cases surged were converted into dedicated COVID-19 hospitals and COVID-19 emergency centers.27 A total of 67 hospitals were selected, and non-COVID-19 infected patients diagnosed with other diseases were not allowed to access these or receive care. When COVID-19 infected cases were reported, hospitals and emergency rooms were temporally closed to prevent infections from COVID-19.28 Any planned operation had to be postponed or transferred to another clinic during the shutdown period.29 The results of our study highlight declines in the number of claims for patients who underwent cancer surgery in March and April of 2020 when there were temporarily closed hospitals.
Decreases in cancer patient visits to the hospital may stem from fear of infection at the clinic. In Korea, Middle East Respiratory Syndrome outbreaks occurred at 16 healthcare facilities in 2015.30 Since then, people have feared being infected with viruses at clinics. One study that analyzed emergency room visits among children during the COVID-19 pandemic posited that fear of being exposed to the virus at the clinic may have been a cause of a decrease in the number of emergency room visits during the pandemic.31 Among 397 breast cancer patients from the General Hospital of Western Theater Command, China, 19.1% of patients delayed their treatment and showed higher scores on both anxiety and depression subscales than those who did not postpone the treatment.32
During the pandemic, the total number of claims by cancer patient for chemotherapy, surgery, and radiotherapy increased. However, the number of patients who received chemotherapy, surgery, or radiotherapy all declined in April when there was a surge of COVID-19 cases and when strong social-distancing regulations were implemented. The increase in the number of claims and patients who received cancer care differed from the results of other studies conducted in other countries: most studies reported a decline in the number of cancer patients who received proper cancer care during the pandemic period, and there was significant decline during the lockdown periods.14,16,33 Unlike other countries, the Korean government did not implement a national lockdown during the pandemic.27 One study conducted at the largest tertiary hospital in Seoul reported that outpatient clinic visits and hospitalizations, except emergency room visits, were mostly unaffected during the pandemic.34 This indicates the availability if proper cancer treatment at university-affiliated hospitals, where most cancer patients would be served during the pandemic, may have elicited increases in the number of cases of chemotherapy and radiotherapy for cancer.
This study has several limitations. First, the customized data from the National Health Insurance Service do not have a variable indicating the first date of cancer diagnosis. We sorted the newly diagnosed cancer patients’ claims data based on primary cancer diagnosis. We then rearranged the data according to the patient’s treatment date and deleted the beneficiaries’ ID numbers to count the number of newly diagnosed patients without duplicates. Second, the operational definition of cancer patients in this study was solely based on given beneficiary codes. This could lead to underestimation of true cancer incidence. Ideally, cancer registration data would reflect accurate cancer incidence. However, lack of details on cancer treatment, as well as lag between the registration and release of the data for research purposes, limits the utility of cancer registry data for the current study. Third, the stage of cancer diagnosis was not considered in this study due to lack of stage information in health insurance claim data. If the decrease in cancer screening during the pandemic led to a decline in the number of newly diagnosed cancer patients, cancer stage migration among the patients could possibly be detected. Therefore, future studies must focus on monitoring the health status of patients who are newly diagnosed with cancer during the outbreak of infectious disease so that we can evaluate how a pandemic affects overall health and quality of life.
The strength of this study is the use of nationwide claims data that cover the entire Korean population, benefiting the generalizability of the results of the study. Furthermore, to the best of our knowledge, this study is the first study to document changes in health care utilization among cancer patients using various indicators. This study also reveals regional inequalities in utilization of healthcare services. Cancer patients residing in provincial areas are likely to visit hospitals in the Capital region.35 The regional disparities stemming from the lack of facilities or workforce should be managed meticulously with cooperation among the central government, policymakers, and healthcare professionals. During the pandemic, the role of the local government and healthcare institutions became crucial to meeting the local needs for COVID-19 response.36 Improving regional healthcare systems will benefit residing patients and provide guidelines to manage other emerging infectious diseases more effectively in the future.
During the first year of the COVID-19 pandemic, there was a change in healthcare service utilization among cancer patients in Korea. Overall, the total number of newly diagnosed patients declined in 2020, compared to 2019. The declines in cancer screening rates may account for decreases in some newly diagnosed cancer patients. Outpatient clinic visits, hospitalizations, and emergency room visits also declined during the pandemic. During the first wave of the pandemic in Korea, the number of cancer patients who live in the Capital or Daegu Gyeongbuk regions sharply declined in March. We found a similar decreasing trend when we compared hospital locations that the patients visited.
In the aftermath of the first year of the pandemic, responses to the infectious disease and government strategies to prevent virus transmission changed. Measures to manage infected cases during the initial phase of the pandemic, which were “trace, test, and treat,” became a relatively aggressive method. Moreover, closing entire facilities because of infected cases is not applied today as a preventive method. Therefore, patients would have easier access to healthcare facilities than in the first year of the pandemic. Considering the change after 2020, further studies are needed to check current health status and the availability of healthcare services among cancer patients. This may provide helpful guidelines for cancer patients and preparing healthcare workers for future pandemics.
ACKNOWLEDGEMENTS
This research was supported by a Korea Health Technology R&D Project grant from the Korea Health Industry Development Institute (KHIDI). This study was also funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HC20C0005).
Footnotes
The authors have no potential conflicts of interest to disclose.
- Conceptualization: all authors.
- Data curation: Aesun Shin and Seung Hee Seo.
- Formal analysis: Aesun Shin and Seung Hee Seo.
- Funding acquisition: Aesun Shin and Bhumsuk Keam.
- Investigation: Aesun Shin and Seung Hee Seo.
- Methodology: all authors.
- Project administration: Aesun Shin, Shin Hye Yoo, and Bhumsuk Keam.
- Resources: Aesun Shin and Seung Hee Seo.
- Software: Seung Hee Seo and Sooyoung Cho.
- Supervision: Aesun Shin, Shin Hye Yoo, and Bhumsuk Keam.
- Validation: all authors.
- Visualization: Aesun Shin and Sooyoung Cho.
- Writing—original draft: Seung Hee Seo.
- Writing—review & editing: all authors.
- Approval of final manuscript: all authors.
SUPPLEMENTARY MATERIALS
The Number of Claims and the Patients Receiving Chemotherapy for Five Major Cancer Types
The Number of Claims and the Patients Who Underwent Surgery for Five Major Cancers Type
The Number of Claims and the Patients Who Underwent Radiation Therapy
Drugs Used for Colorectal Cancer Treatment
Drugs Used for Gastric Cancer Treatment
Drugs Used for Breast Cancer Treatment
Drugs Used for the Treatment of Lung Cancer
Drugs Used for Pancreatic Cancer Treatment
Operation Codes for Cancer Surgery
Codes for Radiation Therapy
Monthly number of claims by cancer patients (2017–2020).
Monthly number of outpatient claims by cancer patients (2017–2020).
Monthly number of inpatient claims by cancer patients (2017–2020).
Monthly number of emergency department claims by cancer patients (2017–2020).
The number of cancer patients by month (2017–2020).
The number of cancer who visited outpatient clinic by month (2017–2020).
The number of cancer patients who are hospitalized by month (2017–2020).
The number of cancer patients who visited emergency department by month (2017–2020).
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The Number of Claims and the Patients Receiving Chemotherapy for Five Major Cancer Types
The Number of Claims and the Patients Who Underwent Surgery for Five Major Cancers Type
The Number of Claims and the Patients Who Underwent Radiation Therapy
Drugs Used for Colorectal Cancer Treatment
Drugs Used for Gastric Cancer Treatment
Drugs Used for Breast Cancer Treatment
Drugs Used for the Treatment of Lung Cancer
Drugs Used for Pancreatic Cancer Treatment
Operation Codes for Cancer Surgery
Codes for Radiation Therapy
Monthly number of claims by cancer patients (2017–2020).
Monthly number of outpatient claims by cancer patients (2017–2020).
Monthly number of inpatient claims by cancer patients (2017–2020).
Monthly number of emergency department claims by cancer patients (2017–2020).
The number of cancer patients by month (2017–2020).
The number of cancer who visited outpatient clinic by month (2017–2020).
The number of cancer patients who are hospitalized by month (2017–2020).
The number of cancer patients who visited emergency department by month (2017–2020).