Abstract
This retrospective, cross-sectional, and descriptive study aimed to analyze the trend of utilizing traditional Korean medicine services in patients with lumbar disc herniation (LDH) and/or lumbar spinal stenosis (LSS). In this study, based on the national patient sample data provided by Health Insurance Review and Assessment Service (HIRA), the trend of Korean medicine service utilization was investigated, including the following information: demographic characteristics of the patients, the total expenditure, number of claim statements per category, medical care expenditure per category, and routes of visiting traditional Korean medicine institutions. The study population comprised patients who visited Korean medicine institutions at least once from January 2010 to December 2019, with LSS and LDH as the primary diagnosis. LDH patients who used traditional Korean medicine services for treatment increased by about 1.36 times. LDH and LSS patients under 45 years of age were more likely to be males, but women accounted for a higher percentage among those over 45 years of age. Overall, women accounted for a slightly higher percentage than their counterparts for both diseases. From details of treatments received that were extracted from the claims data, acupuncture treatment accounted for the highest percentage for both disorders. Moreover, 50.7% of the patients who visited Korean medicine institutions to treat the two diseases also visited conventional Western medicine institutions. These patients, who were diagnosed with their condition at a Korean medicine institution, visited a conventional institution and then returned; the conventional institutions were primarily used for examination (40.5%). Increased utilization of traditional Korean medicine services was confirmed among patients with LDH and/or LSS; in particular, a sharp increase was noted among patients with LSS. The results of this study will be useful as basic research data for clinicians, researchers, and policy makers.
Keywords: cost of care, HIRA claims data, Korean medical service utilization, lumbar disc herniation, national patient sample, spinal stenosis
1. Introduction
Spinal diseases are among the most common health problems in clinical medicine, presenting with various clinical symptoms and conditions. It has been reported that about 2-thirds of adults suffer from low back pain (LBP) at some point during their lifetime.[1] Lumbar disc herniation (LDH) and lumbar spinal stenosis (LSS) are the 2 leading causes of musculoskeletal pain in the affected area.[2] LDH is a disease that causes inflammatory responses in which part or all of the nucleus pulposus prolapses through tearing of the ligamentous fibers of the annulus fibrosus by degenerative or traumatic changes in the intervertebral disc.[3] In LSS, herniated disks and hypertrophy of the osseous and soft tissue structures surrounding the lumbar spinal canal cause compression of the nerve roots, resulting in radiating pain from the gluteal area down to the leg and possibly into the foot.[4]
According to recent Korean research, the incidence of LDH among Koreans over 60 increased from 36.0% in 2008 to 41.6% in 2016, and the incidence among those in their 80s continued to rise.[5] In Europe, the mean prevalence estimates of LSS based on clinical diagnoses ranged from 11% to 39%.[6] The socioeconomic burden of spine disorders has been rising in recent years owing to increased work limitations and medical costs associated with these disorders.[7] The total cost estimate of direct medical expenditures for spine care in the U.S. in 2006 was more than $85 billion, and the data indicates an alarming rate of increase in utilization and costs of spine care in recent years, signifying an added burden to patients with spine-related disorders.[8]
Current treatment options for spine disorders include non-surgical treatments such as exercise, heat, cold, acupuncture, corsetry, radio frequency/shock waves, local anesthetic and steroid injections, and surgical treatments.[9] As a result of the wide range of treatment options, the number of lumbar surgery cases related to LSS and LDH is on the rise, both at home and abroad.[10,11] However, there have been reports of complications in 10% to 24% of participants receiving surgical treatments, and there is no clear advantage for surgical treatments over more conservative management options.[12,13]
South Korea has maintained a dual healthcare delivery system in which traditional Korean medicine (KM) and conventional Western medicine (WM) are practiced independently. Therefore, patients can choose between WM and KM services. However, with a recent increase in the long-term management of chronic conditions and rising costs, an increasing number of patients opt for conservative treatments based on KM.[14] According to the Korea Health Panel data from 2008 to 2009, patients with musculoskeletal disorders visited KM institutions more frequently than WM institutions. Furthermore, the 2011 National Survey of oriental (Korean) medicine utilization and herbal drug consumption revealed that treatment of musculoskeletal disorders was the most common reason for visiting KM institutions (50.2%). Among musculoskeletal disorders, treatment of LBP accounted for the highest percentage of 6.6%.[14]
As such, LSS and LDH are representative diseases that cause LBP, and are also diseases for which KM treatment is often used. Also, previous studies have shown that KM treatments are effective in treating patients with LDH, and LSS. Acupuncture and acupotomy therapy have been reported to be able reduce LBP and radiating pain in patients with LDH,[15,16] and integrative KM treatment reportedly improves LBP and functional disability among LSS patients.[17] There have, however, been relatively few studies examining the macroscopic trends in KM service utilization for the treatment of spine disorders. Therefore, we decided to examine trends in the use of KM in patients with LSS and LDH.
Therefore, this study analyses the trend of KM service utilization for patients with LDH and/or LSS in South Korea using the 10-year Health Insurance Review & Assessment Service (HIRA) data of national health insurance (NHI) claims from 2010 to 2019, thereby providing useful basic research data for clinicians, researchers, and policymakers.
2. Methods
2.1. Data source
This study used a 10-year dataset (2010–2019) from National Patient Sample (NPS) provided by HIRA of South Korea. The health security system in South Korea has 2 components: the National Health Insurance Service (NHIS), a social insurance system of mandatory subscription covering about 97% of the national population, and the remaining 3% of the population is covered by medical aid, a form of public assistance supported by government subsidies. Under the NHIS, reimbursements are based on claims submitted by healthcare providers. HIRA requires all hospitals and clinics to submit their medical records, including diagnosis and surgery codes, to receive reimbursement for any healthcare services provided. The HIRA database ensures the representativeness of the nation population and contains data for multiple key variables of epidemiological research, namely diagnosis, treatment, procedures, surgical history, and prescribed medications, thus providing valuable resources for healthcare service research.[5] In this study, secondary data was statistically sampled annually from raw data using stratified randomized sampling methods with all personal information and information about the associated corporate bodies de-identified.
2.2. Study design and study population
In this retrospective, cross-sectional, and descriptive study, HIRA-NPS data were used for the period January 2010 through December 2019. To extract information related to patients with LSS and/or LDH from the HIRA-NPS data, the disease codes were selected based on the seventh revision of the Korean standard classification of diseases (KCD-7). The KCD-7 is the Korean version mapping of the International Classification of Disease and Causes of Death-10 (ICD-10).
The disease code of LSS in this study was defined as M480_(spinal stenosis), and all subtypes of the code were included.
As for disease codes of LDH, the 3 codes that are most commonly diagnosed among subtypes of M51_(Other intervertebral disc disorders), which are M51.1 Lumbar and other intervertebral disc disorders with radiculopathy, M51.8 Other specified intervertebral disc disorders, and M51.9 Intervertebral disc disorder, unspecified, were used.
All patients who used KM services at least once with spinal stenosis (KCD-7 CODE M480_) and LDH (KCD-7 CODE M511, M518, M519) as the primary diagnosis were included in the sample data used in this study. KM service utilization trends were analyzed for patients with LSS and LDH, respectively. Patients with both LSS and LDH as their primary diagnoses were included in both groups.
If demographic information or information about medical institutions was missing, data were excluded from the analysis of this study. In addition, data where the total expenditure or the number of days of treatment was zero, or claims without relevant information, were excluded from the study.
2.3. Study outcomes
In this study, the general demographic characteristics of patients were classified as age, sex, payer type, type of visit, and medical institutions. Age groups comprised 5 groups of ten years from under 45 to 75 years and older. Payer type was classified into NHI and other, and the kind of visit was classified into outpatient and inpatient. For categories of age, sex, payer type, and type of visit, the number of patients was counted for analysis. The type of medical institutions was classified into tertiary general hospitals, KM hospitals, and KM clinics; for this category, the number of claim statements was counted for analysis. All categories in these general demographic characteristics indicate analysis for patients visiting KM institutions. From 2010 to 2019, the number of patients, total expenditures, number of claims by category of KM services, and expenditures by type of KM services were analyzed for each year of the analysis period.
The total expenditure included expenditure of inpatient and outpatient care, and KM services were classified into the following 5 categories based on the information on the claim statements: Procedure, Consultation, Medication, Hospitalization, and Examination. In addition, for the Procedure category, which appeared the most on the claims, subtypes were further classified for analysis. Also, the pathway of patients who utilized KM institutions was analyzed. The WM claims of patients who initially visited KM institutions, then WM institutions, and then again visited KM institutions for treatment were classified into the following 6 categories for analysis: examination, procedure, consultation, hospitalization, medication, NHI, and non-reimbursable services.
2.4. Statistical analysis
For each year in the analysis period, the total number of patients who used KM services with LSS/LDH as their primary diagnosis, the total number of claims, the total expenditure, the average spending per patient, and the average spending per claim were presented with classification into total, outpatient, and inpatient patients. In addition, the ratio of the number of inpatients to the total number of patients for each year was expressed in percentage (%). Yearly trend was expressed with P value, which was calculated using a simple linear regression model with the year variable as the independent variable. Furthermore, the number of patients by age, sex, payer type, and type of medical institutions and the ratio to the total number of patients were presented along with a classification into total, outpatient, and inpatient. Finally, the annual trends in the number of patients by sex and age were visually presented using graphs.
The number of claims for each category and the ratio to the total number of claims were expressed in percentage, as was the expenditure by category and the ratio to the total spending. The annual trends of changes in the proportions of the number of claims and spending for each category were presented with graphs. Details on the subtypes of treatments for the Procedure category were given in terms of the number of claims and expenditures. The respective ratios to the total number of claims and the total costs were also presented in percentages.
All expenditures were converted with base currency adjustments (KRW-USD) each year. In addition, the expenses was adjusted based on the consumer price index in the healthcare sector in 2019. All statistical analyses in this study were performed using SAS 9.4 (SAS Institute Inc., Cary, NC).
2.5. Ethics approval
The study protocol was approved by the HIRA Deliberative Committee for public data provision, and the study was conducted in accordance with relevant guidelines and regulations. The current study was reviewed and qualified for an exemption by the Institutional Review Board of Jaseng Hospital of Korean Medicine, Seoul, Korea (JASENG 2022-10-023). Because the study analyzed publicly available data, no informed consent was obtained from the subjects by the authors. Moreover, all personal information was de-identified by the NHIS prior to public release.
3. Results
3.1. Participants
This study utilized the HIRA-NPS data provided by HIRA in South Korea and the data of 42,246 patients (303,284 claims) who used KM services at least once a year with the primary diagnosis codes of M480_(Spinal Stenosis) or M511, M518, M519 (LDH) in terms of KCD-10 CODE were included in the analysis. Out of these, the cases without demographic information or information regarding medical institutions (2851 claims, 623 patients), those with total expenditure or number of days of treatment as zero, or claims without relevant information (313 claims, 147 patients) were excluded from the analysis. Finally, a total of 300,120 claims of 41,476 patients were included in the analysis, of which there were 13,880 patients (117,438 claims) with LSS (M480_) and 28,334 patients (182,682 claims) with LDH (M511, M518, M519) (Fig. 1).
Figure 1.
Number of patients who visited KM institutions with LSS and LDH as a primary diagnosis from 2010 to 2019. In each year, those who had both LSS and LDH as the primary diagnosis were counted twice, as duplication. LSS = lumbar spinal stenosis, LDH = lumbar disc herniation.
3.2. Annual trend of KM service utilization in patients with LSS/LDH
The annual trends in the total number of patients with LDH/LSS and the ratio of inpatients are shown in Table 1, Figures 2A and 3A. The number of patients with LSS using KM services continuously increased during the analysis period (from 369 in 2010 to 2895 in 2019). However, the number of patients with LDH using KM services showed a mixed trend, with an increase from 2425 in 2010 to 3023 in 2013, then a gradual decrease to 2635 up to 2018, followed by a rise to 3301 in 2019. In addition, the ratio of inpatients varied within a small range from 4.6% to 7.2% for the 10-year period in the case of patients with LSS, whereas in the case of patients with LDH, the ratio showed a continuous increase from 7.3% in 2010 to 18.7% up to 2017, followed by a slight decrease after 2017.
Table 1.
Annual trend in the total number of patients and inpatients with LSS/LDH.
| Yr | LSS | LDH | ||
|---|---|---|---|---|
| All | Inpatient(%) | All | Inpatient(%) | |
| 2010 | 369 | 25 (6.8) | 2425 | 178 (7.3) |
| 2011 | 611 | 36 (5.9) | 2917 | 255 (8.7) |
| 2012 | 714 | 36 (5.0) | 2866 | 316 (11.0) |
| 2013 | 1006 | 64 (6.4) | 3023 | 386 (12.8) |
| 2014 | 1250 | 72 (5.8) | 2994 | 446 (14.9) |
| 2015 | 1425 | 97 (6.8) | 2856 | 466 (16.3) |
| 2016 | 1581 | 113 (7.2) | 2723 | 495 (18.2) |
| 2017 | 1912 | 115 (6.0) | 2596 | 485 (18.7) |
| 2018 | 2119 | 144 (6.8) | 2635 | 444 (16.9) |
| 2019 | 2895 | 133 (4.6) | 3301 | 490 (14.8) |
| All | 13882 | 835 (6.0) | 28336 | 3961 (14.0) |
| P value | <.01 | <.01 | .47 | <.01 |
The P value was calculated using a simple linear regression model with the year variable as the independent variable.
LDH = Lumbar disc herniation, LSS = Lumbar spinal stenosis.
Figure 2.
Ten-yr (2010–2019) trend in Korean medicine service utilization owing to LSS. (A) Trend in the total number of patients and the ratio of inpatients. (B) Trend in the total expenditure and ratio of inpatient expenditure. LSS = lumbar spinal stenosis.
Figure 3.
Ten-yr (2010–2019) trend in Korean medicine service utilization owing to LDH. (A) Trend in the total number of patients and the ratio of inpatients (B) Trend in the total expenditure and ratio of inpatient expenditure. LDH = lumbar disc herniation.
In addition, the trends in the expenditure related to KM service utilization due to LSS and LDH are presented in Figures 2B and 3B. In both LSS and LDH, the total expenditure of using KM services showed a steadily increasing trend annually. For example, the total spending for patients with LSS increased from $61,326.78 in 2010 to $85,0176.06 in 2019, and that for patients with LDH increased from $371,511.24 in 2010 to $1532,499.68 in 2019.
The spending ratio on inpatient care out of the total cost varied within a relatively small range from 26.4% to 36.9% in patients with LSS. In contrast, the ratio of patients with LDH continuously increased from 42.1% in 2010 to 66.9% in 2016, followed by a slight decrease. Thus, inpatient expenditure showed a similar trend to the number of inpatients for each disease. Overall, the ratio of inpatient expenditure was higher in patients with LDH than in patients with LSS. The total number of patients, the total number of claims, the total spending, the average expenditure per patient, and the average expenditure per claim for LSS and LDH are presented in Supplemental Tables 1 and 2, http://links.lww.com/MD/N238 respectively.
Additionally, analysis of yearly trends is presented in Table 1 and Supplemental Table 3 http://links.lww.com/MD/N238. The number of patients using KM services with LSS, the number of claims, aadnd total expenditure all increased statistically significantly over time. The results were the same when categorized into inpatients and outpatient. The total number of patients using KM services with LDH tended to increase over time, but this was not statistically significant. However, when limited to inpatients, there was a statistically significant increase. Likewise, the total number of claims increased significantly over time only for inpatients. Total expenditure increased significantly over time for all patients.
3.3. Trends in KM utilization according to general characteristics of patients with LSS/LDH
Table 2 presents the distribution of general characteristics of patients with LSS/LDH that used KM services during the 10-year (2010–2019) period: age, sex, payer type, and type of medical institutions visited. Regarding the age group distribution of these patients, for patients with LSS, the number of those under 45 years was the smallest (N = 536; 3.9%), and the number of patients increased with age. LDH patients showed the opposite tendency, with the largest number of patients under 45 years of age (N = 8908; 31.4%) and the smallest number of patients 75 years of age or older (N = 2479; 8.8%). As for the sex distribution of the patients, the ratio of women was higher at 67.6% (N = 9377) and 59.1% (N = 16,733) for patients with LSS and LDH, respectively. In terms of payer type, most of the patients used NHI (for LSS, N = 13,037, 93.9%; for LDH, N = 27,193, 96%). In terms of the types of medical institutions, the patients visited, both of the patient groups (LSS/LDH) visited KM clinics (for LSS, N = 107,761, 87.5%; for LDH, N = 141,045, 74.8%), primary care providers, which was the most utilized, followed by KM hospitals and tertiary general hospitals.
Table 2.
Number of patients with LSS/LDH according to general characteristics.
| LSS | LDH | |||||
|---|---|---|---|---|---|---|
| All | Inpatient | Outpatient | All | Inpatient | Outpatient | |
| No.(%) | No.(%) | No.(%) | No.(%) | No.(%) | No.(%) | |
| All | 13880 | 834 | 13046 | 28334 | 3959 | 24375 |
| Age group | ||||||
| <45 years | 536 (3.9) | 61 (7.3) | 475 (3.6) | 8908 (31.4) | 1533 (38.7) | 7375 (30.3) |
| 45–54 | 1296 (9.3) | 183 (21.9) | 1113 (8.5) | 5912 (20.9) | 1167 (29.5) | 4745 (19.5) |
| 55–64 | 3220 (23.2) | 289 (34.7) | 2931 (22.5) | 5991 (21.1) | 948 (24.0) | 5043 (20.7) |
| 65–74 | 5280 (38.0) | 186 (22.3) | 5094 (39.1) | 5044 (17.8) | 225 (5.7) | 4819 (19.8) |
| ≥75 yr | 3548 (25.6) | 115 (13.8) | 3433 (26.3) | 2479 (8.8) | 86 (2.2) | 2393 (9.8) |
| Sex | ||||||
| Male | 4503 (32.4) | 252 (30.2) | 4251 (32.6) | 11601 (40.9) | 1390 (35.1) | 10211 (41.9) |
| Female | 9377 (67.6) | 582 (69.8) | 8795 (67.4) | 16733 (59.1) | 2569 (64.9) | 14164 (58.1) |
| Payer type | ||||||
| NHI | 13037 (93.9) | 766 (91.9) | 12271 (94.1) | 27193 (96) | 3771 (95.3) | 23422 (96.1) |
| Others | 843 (6.1) | 68 (8.2) | 775 (5.9) | 1141 (4) | 188 (4.8) | 953 (3.9) |
| Medical institutions | ||||||
| All | 123096 | 3769 | 119327 | 188568 | 15492 | 173076 |
| General hospital-tertiary | 937 (0.8) | 194 (5.2) | 743 (0.6) | 1143 (0.6) | 429 (2.8) | 714 (0.4) |
| KM hospital | 14398 (11.7) | 2613 (69.3) | 11785 (9.9) | 46380 (24.6) | 13204 (85.2) | 33176 (19.2) |
| KM clinic | 107761 (87.5) | 962 (25.5) | 106799 (89.5) | 141045 (74.8) | 1859 (12.0) | 139186 (80.4) |
The numbers according to age, sex, and payer type were counted based on the number of patients, and for the type of medical institutions, the number was counted based on claims.
KM = Korean medicine, LDH = Lumbar disc herniation, LSS = Lumbar spinal stenosis, NHI = National Health Insurance
In patients with LSS, the proportion of young and middle-aged patients under the age of 64 was higher in inpatients than in outpatients, and this ratio was also high in patients with LDH. Among inpatients, there was a higher proportion of female patients, and the difference was greater among those with LSS than in those with LDH.
Figure 4 shows the trends in KM service utilization due to LSS/LDH by sex and age. Figure 3A shows that for the patient age group under 45 years, the ratio of males was slightly higher than their counterparts, while for all other age groups, the ratio of female patients was higher. The number of patients gradually increased from 2010 to 2019 in all age groups and sexes. In the case of patients with LDH, as in the case of those with LSS, the ratio of male patients was higher than their counterparts in the patient age group under 45 years, but for all the other age groups (45 years and older), the female patients accounted for a higher percentage. As for the trend in the number of patients over time, it is noteworthy that the number of male patients has not changed much; however, the number of female patients has steadily decreased from 410 patients (16.9%) in 2010, while the number of older patients (75 years or older) has increased from 101 patients (4.2%) in 2010 to 255 patients (9.7%) in 2018 (Fig. 3B). Supplemental Tables 4 and 5 http://links.lww.com/MD/N238 provide additional details regarding the data shown in Figure 3.
Figure 4.
Ten-yr trend (2020–2019) of Korean medicine service utilization by age and sex for patients with LSS or LDH. (A) LSS. (B) LDH. LSS = lumbar spinal stenosis, LDH = lumbar disc herniation.
3.4. Details of KM treatments received
Table 3 shows the number of patients, expenditure, and average expenditure per claim for each category based on claims received from KM institutions for patients with LSS and/or LDH. In both LSS and LDH, the number of claims was in the order of Procedure, Consultation, Medication, Hospitalization, and Examination. In terms of total expenditure, Hospitalization expenditure accounted for 37.4%, the second highest ratio after Procedure for patients with LDH. In the case of patients with LSS, Consultation expenditure accounted for 25.0%, the second highest ratio after Procedure. Examining the annual trends in the number of claims and expenditures by category of KM services, the number of claims for all categories showed an overall increase from 2010 to 2019. Still, when the ratios were compared among categories, the claims in the Procedure category showed a decreasing trend from 73.9% in 2010 to 66.8% in 2017, followed by a slight increase to 68.9% up to 2019. The claims in the Consultation category also slightly decreased from 22.6% in 2010 to 18.2% in 2019. On the other hand, the claims in the Medication category showed a steady increase from 1.5% in 2010 to 10.4% in 2019 (Fig. 5A, Supplemental Table 6) http://links.lww.com/MD/N238.
Table 3.
Number of claims and total expenditure by category of Korean medicine service utilization for patients with LSS/LDH.
| LSS | LDH | |||||
|---|---|---|---|---|---|---|
| N(%) | Total expenditure(%) | Avg. | N(%) | Total expenditure(%) | Avg. | |
| All | 648,072 | 3597700.5 | 5.6 | 1047,551 | 9544,442.7 | 9.1 |
| Procedure | 431,789 (66.6) | 1909,253.5 (53.1) | 4.4 | 749,066 (71.5) | 4499,894.1 (47.2) | 6.0 |
| Consultation | 130,142 (20.1) | 899,910.4 (25.0) | 6.9 | 197,784 (18.9) | 1389,636.6 (14.6) | 7.0 |
| Medication | 77,581 (12.0) | 62,830.7 (1.8) | 0.8 | 62,448 (6.0) | 83,379.1 (0.9) | 1.3 |
| Hospitalization | 8150 (1.3) | 724,105.6 (20.1) | 88.9 | 37,114 (3.5) | 3566,918.2 (37.4) | 96.1 |
| Examination | 410 (0.1) | 1600.2 (0.0) | 3.9 | 1139 (0.1) | 4614.8 (0.1) | 4.1 |
“Avg.” indicates average expenditure by the claim.
LDH = Lumbar disc herniation, LSS = Lumbar spinal stenosis.
Figure 5.
Trends by category of Korean medicine service utilization for patients with LSS and LDH. (A) Annual trends in the number of claims by category. (B) Annual trends in expenditure by category. LSS = lumbar spinal stenosis, LDH = lumbar disc herniation.
As for the annual trends in total expenditure by category, the spending in the Procedure category showed little change in the 47% to 49% range from 2010 to 2018 but slightly increased to 53.3% in 2019. Expenditure in the Hospitalization category gradually increased from 26.9% in 2011 to 35.1% in 2016 and decreased slightly thereafter. The spending in the Consultation category showed a decreasing trend from 24.2% in 2010 to 16.0% in 2019, while the expenditure in the Medication category slightly increased from 0.5% in 2010 to 1.3% in 2019 (Fig. 5B, Supplemental Table 7) http://links.lww.com/MD/N238.
Table 4 presents the details of treatment items in the Procedure category. For patients with LSS, the number of claims in the Procedure category of KM services was the largest in Acupuncture_general (119,381 claims (25.9%)), and treatment items related to acupuncture, consisting of Acupuncture_general, Acupuncture_special, and electroacupuncture, accounted for the highest percentage at 59.3%. For patients with LDH, the number of claims was also the largest in Acupuncture_general (187,968 claims (24.4%)), and the sum of the treatment items related to acupuncture accounted for the highest percentage at 67.9%. For both patient groups, infrared therapy and cupping (dry cupping, wet cupping) were the treatment items of the second and third largest number of claims after those related to acupuncture.
Table 4.
Number of claims and total expenditure by treatment item of KM procedure.
| M480_ | M51_ | |||
|---|---|---|---|---|
| No. of claims(%) | Total exp(%) | No. of claims(%) | Total exp(%) | |
| 461861 (100.0) | 1840613.7 (100.0) | 771387 (100.0) | 4303426 (100.0) | |
| KM examinations | ||||
| Yangdorak test | 12 (0.0) | 36.7 (0.0) | 35 (0.0) | 106.6 (0.0) |
| Pulse electrocardiogram | 49 (0.0) | 151.1 (0.0) | 91 (0.0) | 307.1 (0.0) |
| Meridian function test | 346 (0.1) | 1399.7 (0.1) | 1003 (0.1) | 4197.2 (0.1) |
| Acupuncture_general | 119381 (25.9) | 552651.5 (30.0) | 187968 (24.4) | 1201354.3 (27.9) |
| Acupuncture_special | ||||
| Intraperitoneal | 1362 (0.3) | 4249.4 (0.2) | 805 (0.1) | 3439.6 (0.1) |
| Intra-articular | 30390 (6.6) | 98524.8 (5.4) | 45456 (5.9) | 168927.5 (3.9) |
| Intravertebral | 28424 (6.2) | 95225.0 (5.2) | 30576 (4.0) | 120050 (2.8) |
| Piercing | 53199 (11.5) | 290723.5 (15.8) | 106291 (13.8) | 835393.1 (19.4) |
| Intranasal | 31 (0.0) | 80.0 (0.0) | 51 (0.0) | 155.03 (0.0) |
| Intraorbital | 68 (0.0) | 213.9 (0.0) | 83 (0.0) | 145.6 (0.0) |
| Others | 487 (0.1) | 1847.7 (0.1) | 621 (0.1) | 3893.5 (0.1) |
| Electroacupuncture | 40314 (8.7) | 199084.4 (10.8) | 85351 (11.1) | 590692.1 (13.7) |
| Moxibustion | 26269 (5.7) | 104962.9 (5.7) | 33589 (4.4) | 197474.6 (4.6) |
| Cupping | ||||
| Dry cupping | 36075 (7.8) | 177664.7 (9.7) | 47836 (6.2) | 377007.2 (8.8) |
| Wet cupping | 20273 (4.4) | 182894.8 (9.9) | 47758 (6.2) | 492618.5 (11.5) |
| Diagnosis based on the patient symptoms and conditions | 14598 (3.2) | 42453.9 (2.3) | 44192 (5.7) | 128722.4 (3.0) |
| Infrared therapy | 58054 (12.6) | 69322.3 (3.8) | 112410 (14.6) | 158957.3 (3.7) |
| Dispensing and medication | 32503 (7.0) | 18713.9 (1.0) | 27247 (3.5) | 19521.6 (0.5) |
| Other treatments | 26 (0.0) | 413.7 (0.0) | 22 (0.0) | 427.2 (0.0) |
| KM psychotherapy | . | . | 2 (0.0) | 35.5 (0.0) |
KM = Korean medicine.
As a result of comparing total expenditure for each treatment item, Acupuncture_general accounted for the largest expense (for LSS $552,651.5, 30%; for LDH $1201,354.3, 27.9%), and acupuncture-related items consisting of Acupuncture_general, Acupuncture_special, and electroacupuncture items accounted for the highest percentage at 67.5% for patients with LSS and at 67.9% for patients with LDH.
In addition, the treatment items of wet cupping, infrared therapy, dispensing, and medication management were representative items that showed discrepancies between the ratio in terms of the number of claims and the ratio in terms of total expenditure. In both patient groups of LDH and LSS, wet cupping was associated with fewer claims than dry cupping, but total expenditure was higher with wet cupping. Infrared therapy and dispensing & medication management showed a considerable decrease in the ratio in terms of total expenditure compared to the ratio in terms of the number of claims. This is because wet cupping has a higher average expenditure per claim than dry cupping, and infrared therapy and dispensing & medication management have lower average expenditures per claim than other treatment items.
3.5. Routes of KM service utilization
Table 5 summarizes the patient pathways to KM institutions according to age and sex. Among the patients of KM institutions, the K group, which used KM treatments only, accounted for the highest percentage at 49.3%, followed by the WKW + group, whose pathway involved being diagnosed at a WM institution followed by visiting a KM institution and then revisiting of a WM institution. The pathway for the WK group involved visiting a KM institution after diagnosis at a conventional WM institution. Patients in the KW group visited a conventional WM institution after being diagnosed at a KM institution. In contrast, those in the KWK + were initially diagnosed at a KM institution, visited a conventional institution, and then returned to the KM institution. Since the K group that used KM treatment only accounted for 49.3%, among the patients with LDH and/or LSS that used KM services, those using collaborative treatments with WM services accounted for 50.7%, more than half of the total number of patients. Similarly to the previously present results in this study, there were more male patients in the age group under 45 years and more female patients in the age groups of 45 years or older. Moreover, the number of male patients decreased with age, while the number of female patients increased.
Table 5.
Routes of visiting KM institutions.
| Routes | Age group | All | Sex | |
|---|---|---|---|---|
| Male | Female | |||
| N(%) | N(%) | N(%) | ||
| (1) K | <45 yr | 5280 (12.7) | 2978 (18.8) | 2302 (9.0) |
| 45–54 | 3583 (8.6) | 1438 (9.1) | 2145 (8.4) | |
| 55–64 | 4160 (10.0) | 1385 (8.7) | 2775 (10.8) | |
| 65–74 | 4674 (11.3) | 1384 (8.7) | 3290 (12.8) | |
| ≥75 yr | 2753 (6.6) | 746 (4.7) | 2007 (7.8) | |
| All | 20450 (49.3) | 7931 (50.0) | 12519 (48.9) | |
| (2) KW | <45 yr | 1055 (2.5) | 612 (3.9) | 443 (1.7) |
| 45–54 | 879 (2.1) | 295 (1.9) | 584 (2.3) | |
| 55–64 | 1157 (2.8) | 359 (2.3) | 798 (3.1) | |
| 65–74 | 1164 (2.8) | 376 (2.4) | 788 (3.1) | |
| ≥ 75 yr | 702 (1.7) | 190 (1.2) | 512 (2.0) | |
| All | 4957 (12.0) | 1832 (11.6) | 3125 (12.2) | |
| (3) KWK+ | < 45 yr | 762 (1.8) | 424 (2.7) | 338 (1.3) |
| 45–54 | 573 (1.4) | 185 (1.2) | 388 (1.5) | |
| 55–64 | 669 (1.6) | 187 (1.2) | 482 (1.9) | |
| 65–74 | 735 (1.8) | 230 (1.5) | 505 (2) | |
| ≥ 75 yr | 434 (1.1) | 137 (0.9) | 297 (1.2) | |
| All | 3173 (7.7) | 1163 (7.3) | 2010 (7.9) | |
| (5) WK | < 45 yr | 1056 (2.6) | 629 (4.0) | 427 (1.7) |
| 45–54 | 896 (2.2) | 358 (2.3) | 538 (2.1) | |
| 55–64 | 1161 (2.8) | 368 (2.3) | 793 (3.1) | |
| 65–74 | 1328 (3.2) | 396 (2.5) | 932 (3.6) | |
| ≥ 75 yr | 714 (1.7) | 214 (1.4) | 500 (2.0) | |
| All | 5155 (12.4) | 1965 (12.4) | 3190 (12.5) | |
| (6) WKW+ | < 45 yr | 1245 (3.0) | 783 (4.9) | 462 (1.8) |
| 45–54 | 1173 (2.8) | 450 (2.8) | 723 (2.8) | |
| 55–64 | 1838 (4.4) | 617 (3.9) | 1221 (4.8) | |
| 65–74 | 2170 (5.2) | 695 (4.4) | 1475 (5.8) | |
| ≥ 75 yr | 1315 (3.2) | 426 (2.7) | 889 (3.5) | |
| All | 7741 (18.7) | 2971 (18.7) | 4770 (18.6) | |
| All | 41476 (100.0) | 15862 (100.0) | 25614 (100.0) | |
K: Use of Korean medicine services only, KW: Visiting of a conventional WM institution after diagnosis at a KM institution, KWK+: Route of diagnosis at a KM institution followed by visiting a conventional institution and then revisiting of a KM institution, WK: Visiting of a KM institution after diagnosis at a conventional WM institution, WKW+: Route of diagnosis at a WM institution followed by visiting of a KM institution and then revisiting of a WM institution
For the routes and age group, the Chi-Square statistic with 16 degrees of freedom is 438.7052, and the associated probability is <0.0001. This highly significant P value indicates that there is a very strong likelihood that the observed frequencies are not due to chance, implying a relationship between the variables. For the routes and sex, the Chi-Square statistic is 9.4776 with 4 degrees of freedom, and the associated probability is 0.0502. This P value is just above the commonly used significance level of 0.05, suggesting that the relationship between the variables is marginally significant.
Table 6 shows which procedures were received at conventional WM institutions for the KWK + group with the route of being diagnosed with LSS or LDH at a KM institution followed by visiting a conventional institution and then revisiting a KM institution. The category with the most number of claims was examination (40.5%), followed by Procedure (33.7%) and Consultation (21.6%). Among the patients in the KWK + group, for those who revisited a KM institution within 7 days, 69.7% of the patients underwent Examination at a WM institution, and 66.0% of the patients who revisited a KM institution within 14 days underwent Examination at a WM institution.
Table 6.
Ratio of WM claims concerning the period of revisiting KM institutions.
| Category | A. Number of total WM claims of KWK + patients | B. Number of WM claims for patients who revisited KM institutions within 7 d | C. Number of WM claims for patients who revisited KM institutions within 14 d |
|---|---|---|---|
| N(%) | N(%) | N(%) | |
| All | 127,702 (100.0) | 8122 (100.0) | 17,957 (100.0) |
| Examination | 51,752 (40.5) | 5664 (69.7) | 11,849 (66.0) |
| Procedure | 42,967 (33.7) | 1547 (19.1) | 4387(24.4) |
| Consultation | 27,613 (21.6) | 850 (10.5) | 1537(8.6) |
| Hospitalization | 3606(2.8) | 27 (0.3) | 108 (0.6) |
| Medication | 1205(0.9) | 20 (0.3) | 46 (0.3) |
| Others | 559 (0.4) | 14 (0.2) | 30 (0.2) |
WM: Use of Western medicine services only, KM: Use of Korean medicine services only, KWK+: Route of diagnosis at a KM institution followed by visiting a conventional institution and then revisiting a KM institution.
4. Discussion
This study analyzed the trends of KM service utilization based on HIRA-NPS data from 2010 to 2019. Furthermore, we examined the number of patients with LDH/LSS, expenditure of KM services and characteristics, frequently used categories and treatment items in KM service utilization, and the pathways taken to accessing services provided at KM institutions. Overall, the number of patients visiting KM institutions, the total number of claims, and the total expenditure of KM services due to LDH and LSS showed an increasing trend. According to the analysis, the number of patients with LDH increased by approximately 1.36 times in 2019 compared to 2010, and the number of patients with LSS increased by approximately 7.85 times. This trend of an increase in the incidence of LDH/LSS has already been reported in several previous studies.[7,8]
Examining the annual trends in more detail, the number of patients with LSS visiting KM institutions showed a persistent trend of an annual increase, but the number of patients with LDH has decreased since 2013. Conversely, the ratio of inpatients remained relatively constant for 10 years in the case of patients with LSS, but the ratio continued to increase until 2017 for patients with LDH. The cause of this trend may be associated with problems of over-diagnosis and unnecessary treatment of spinal diseases for which media have raised issues since the early 2000s, as reported by Jung et al.[5] In particular, in 2013, the problem was pointed out by a number of media outlets, emerging as a social issue and resulting in a decrease in the number of patients with LDH. Meanwhile, with reports and publications of positive outcomes for patients with LDH who received KM inpatient treatments,[18,19] the preference for KM treatment increased among patients with spinal diseases, and with an increase in the ratio of treatments for LDH in KM hospitals, it is reasoned that the ratio of inpatient treatment also increased accordingly.[5,14]
The number of patients with LSS visiting KM institutions also showed a steady trend of an annual increase, resulting in an increase of 7.8 times over ten years. LSS is a symptom caused by compression of nerves with narrowing of the spinal canal, and it is mainly attributable to degenerative changes in the spine.[20] A previous study reported that 21% of adults aged 60 years or older were diagnosed with LSS based on radiological findings,[10] and a number of prior studies[10,12,20–22] also reported the association between LSS with aging and degenerative changes. In line with the trend of an aging society, the number of LSS patients in South Korea also increased by more than twice over ten years, from 830,000 in 2010 to 1.72 million in 2019.[23] Even with consideration of the increase in the total number of patients with LSS, there has been a substantial increase in the number of patients visiting KM institutions for the treatment of LSS.
Previous studies have continuously reported the effectiveness and safety of KM treatment for patients with LSS. Through integrative KM treatment such as acupuncture, electroacupuncture, pharmacopuncture, herbal medicine, and Chuna manual therapy, improvements were reported in terms of pain, walking time. Oswestry Disability Index for quantitative representation of functional disability for patients with LSS, and these effects were maintained during the follow-up period of 1–3 years.[17,24,25] In addition, Oka et al[26] reported that acupuncture was more effective than exercise in terms of improvement in physical function scores and showed higher treatment satisfaction scores compared to medication (acetaminophen) for patients with LSS. Hadianfard et al[27] reported that acupuncture was effective not only in reducing pain for patients with LSS but also in a significant improvement in the quality of life of these patients in dimensions of emotions, vitality, general health, and physical well-being. Furthermore, KM treatments are non-surgical, conservative treatments with the advantages of minimal side effects and risks compared to invasive approaches.[12] As described in the previous studies above, it is reasoned that KM treatments are an appropriate means of treatment for management and treatment of symptoms and discomfort of LSS, and due to high treatment satisfaction of patients, the number of patients using KM services for treatment has continuously increased over time.
Examining trends by sex and age of patients with LDH/LSS during the 10-year period from 2010 to 2019, among patients with LDH, the number of female patients (N = 16,733, 59.1%) was about 1.44 times larger than male patients (N = 11,601, 40.9%), Among patients with LSS, there were approximately 2.08 times more female patients (N = 9377, 67.6%) than their counterparts (N = 4503, 32.4%). Also, in both patient groups of LDH and LSS, the ratio of male patients was slightly higher than the ratio of female patients in the age group under 45 years but for older age groups, female patients considerably outnumbered male patients. A previous study[5] also reported that among patients with LDH, male patients outnumbered female patients under the age of 30 years. However, for middle-aged (patients in their 30s or 40s) and older patients, female patients outnumbered their counterparts, and the number of female patients was larger by 1.5 to 1.6 times higher for patients in their 60s. Furthermore, in another study, among patients with LSS that underwent inpatient treatment in KM institutions from 2015 to 2018, there were about twice as many female patients as male patients.[17]
Although the exact cause of this sex-specific difference has not been elucidated. Bailey et al[28] reported that when standing, female patients had a greater lumbar angle indicative of lordotic curvature between L1 and S1, as well as a greater sacral slope, which indicated that a greater range of motion in the spines, resulting in an increased risk of degenerative changes in lumbar spine conditions with age. Freidin et al[29] reported that due to higher genetic correlation with chronic back pain in female patients than in male patients. Female patients usually exhibit greater morbidity, severity, and poorer treatment responses than male. In a previous study conducted in South Korea,[30] female patients showed more utilization of healthcare services due to factors such as pregnancy and childbirth and higher morbidity; therefore, an understanding of sex differences in recognizing a disease or symptoms is sought for further information related to an illness or its prevention. As an example of the sex differences, the average number of outpatient visits between 2009 and 2016 in South Korea was also reported to be higher in female patients than in male patients.
By type of medical institutions, the patients visited, most of the KM services were provided by primary care institutions. Among the claims for patients with LDH, 78.4% were claimed by KM clinics, which are primary care providers, and 87.5% of the claims for patients with LSS were from KM clinics. Also, the ratio of outpatient care was higher than inpatient treatment, and about 86% (24,375/28,334) of patients with LDH and about 94% (13,046/13,880) of patients with LSS received outpatient treatment. The results indicate that in many cases, LSS and LDH are managed with conservative treatment methods in an outpatient setting. In fact, with the exception of some indications of surgical treatment, there have been a number of reports of improvement through conservative treatment in many cases.[10,16,31]
For both patient groups of LDH and LSS, the category of KM services with the highest number of claims over ten years was Procedure, and among the treatment items in the Procedure category, [Acupuncture_general] had the highest number of claims in both diseases. In particular, the number of claims related to acupuncture, including [Acupuncture_general], [Acupuncture_special], and [electroacupuncture], accounted for 67.9% of patients with LDH and 59.3% of patients with LSS, representing more than half of the claims. As a result, acupuncture-related treatment is most often used for the treatment of LDH and LSS among KM services. This was followed by infrared therapy and cupping (dry cupping, wet cupping). Both LDH and LSS cause chronic LBP, and in relation to the treatment of LBP, according to the 2016 CDC Guidelines for Prescribing Opioids for Chronic Pain, and 2017 clinical practice guidelines for chronic pain from the American College of Physicians, acupuncture can be a first-line treatment for patients with chronic LBP, and it was also reported that acupuncture showed promising outcomes for chronic LBP in a number of studies.[32] In addition, infrared therapy was also reported to relieve LBP by enhancing wound healing, relieving pain from inflammation, increasing endorphin levels, and bioactivation of neuromodulators.[33] Cupping was also reported to be effective in treating chronic LBP through metabolic and neuronal activation.[34] Therefore, it is considered reasonable to recommend acupuncture, infrared therapy, and cupping for the treatment of LBP caused by LDH and LSS. In addition, herbal medicine is also commonly used for the treatment of LDH/LSS,[18,19,24,25,35,36] but since herbal medicine treatment is a non-reimbursable service, related statistics could not be obtained from the HIRA-NPS data.
The results showed that more than half of the patients visiting KM institutions for treatment of LDH and LSS received concurrent treatment provided by conventional WM institutions (Table 5). According to the analysis of healthcare service utilization details of patients in the KWK + group who were diagnosed at KM institutions, visited conventional WM institutions, and then returned to KM institutions, the examination claims accounted for the highest percentage, 40.5%. In particular, the ratio of claims in the examination category was very high at 69.7% among the group of patients who revisited KM institutions within a short period of 7 days. This indicates that many of the patients of KM institutions visit conventional WM institutions for examination and then revisit KM institutions for treatment. In general, the diagnosis of LDH or LSS is usually made based on clinical symptoms, physical examination, radiographic findings, and other diagnostic imaging techniques, such as computed tomography or magnetic resonance imaging.[22,31,37] However, under the dual healthcare delivery system of WM and KM in South Korea, doctors who practice KM are not permitted to use these diagnostic imaging techniques. Therefore, patients are generally required to visit conventional WM institutions when such examinations are required. Patients may experience inconvenience as a result of this and may incur additional healthcare costs.
4.1. Strengths and limitations
This study has the following limitations. First, because this study is based on the claims data of HIRA-NPS, a type of secondary data, the scope of analysis was limited to the information on utilized healthcare services that can be identified on the statement of NHI claims. Therefore, it was not possible to obtain information on the clinical symptoms of patients or the severity of their conditions. Further studies are needed to perform an analysis of trends in KM service utilization according to clinical signs of patients or the severity of their conditions.
Furthermore, due to the limitations of the data used in this study, it was not possible to analyze the status of non-reimbursable services such as pharmacoacupuncture and herbal medicine treatments that are not covered by the NHI. Chuna manual therapy, which the NHI currently covers to some extent, was also a non-reimbursable service during the present study period, and this limited analysis of utilization and expenditure of Chuna manual therapy. As a result, the actual expenditures of KM services may have been underestimated.
In addition, although the patient sample data used in this study included patients with LSS and/or LDH as the primary diagnosis for the applicable year, all treatments and services under the procedure category described on the claim statements may not have been solely performed for LSS and LDH, the primary diagnosis. In other words, it may be possible that even though the primary diagnosis of a patient is LDH and/or LSS, the patient may have had other comorbidities, and treatments and procedures performed for conditions other than LDH/LSS may have been included in the statistics of this study.
Lastly, this study used cross-sectional data collected annually, which restricted the ability to examine changes in individual patients, although analyses of the overall status and trends were possible. Additionally, it would have been nice to be able to look at trends over a longer period of time than 10 years.
Nevertheless, the present study is significant in that it presents the latest analysis of 10-year trends (2010–2019) in KM service utilization for patients with LDH/LSS based on data provided by the HIRA, thus ensuring a representative sample of the South Korean population as a whole.
5. Conclusions
This study examined trends in KM service utilization for patients with LDH and/or LSS in South Korea based on HIRA-NPS data from 2010 to 2019. A trend of an overall increase in utilization of traditional KM services was confirmed among patients with LDH and/or LSS, and in particular, a sharply increasing trend in the use of KM services was identified among patients with LSS. However, the limitations of the claims data and patient samples need to be improved in future studies.
Author contributions
Conceptualization: Myeong Yeol Yang, Doori Kim.
Data curation: Eun-Jung Kim.
Formal analysis: Dongwoo Nam.
Funding acquisition: Yoon Jae Lee.
Investigation: Yeoncheol Park.
Supervision: In-Hyuk Ha.
Writing – original draft: Myeong Yeol Yang.
Writing – review & editing: Doori Kim, Yoon Jae Lee.
Supplementary Material
Abbreviations:
- HIRA
- Health Insurance Review and Assessment Service
- KCD-7
- Korean standard classification of diseases
- KM
- Korean medicine
- LBP
- low back pain
- LDH
- lumbar disc herniation
- LSS
- lumbar spinal stenosis
- NHI
- national health insurance
- NHIS
- National Health Insurance Service
- NPS
- National Patient Sample
- WM
- western medicine
This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HF21C0111).
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Supplemental Digital Content is available for this article.
How to cite this article: Yang MY, Kim E-J, Nam D, Park Y, Ha I-H, Kim D, Lee YJ. Trends of Korean medicine service utilization for lumbar disc herniation and spinal stenosis: A 10-year analysis of the 2010 to 2019 data. Medicine 2024;103:30(e38989).
Contributor Information
Myeong Yeol Yang, Email: didaudduf5@naver.com.
Eun-Jung Kim, Email: hanijjung@naver.com.
Dongwoo Nam, Email: hanisanam@daum.net.
Yeoncheol Park, Email: icarus08@hanmail.net.
In-Hyuk Ha, Email: hanihata@gmail.com.
Doori Kim, Email: doori.k07@gmail.com.
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