한국의 빈곤동태, 의료이용과 의료비

학위논문(박사)--서울대학교 대학원 :보건대학원 보건학과(보건정책관리학전공),2019. 8. 권순만.본 연구는 한국의 빈곤동태와 의료급여의 수급지위변화가 의료이용, 의료비와 미충족 의료에 미치는 영향에 대해 한국의료패널 2008-2014년 자료를 사용하여 2011-2013년에 대한 분석을 하였다. 또한 중위소득 50% 미만의 빈곤선 아래의 빈곤층에서, 재난적 의료비가 첫 번째 빈곤주기의 길이와 총 빈곤기간에 미치는 영향에 대해서 한국복지패널 2008-2016년 자료를 사용하여 분석하였다. 그리고, 중위소득 40% 미만의 빈곤선 아래의 빈곤층에서, 재난적 의료비가 빈곤탈출 (혹은 빈곤지속)에 미치는 영향에 대해서 한국복지패널 2008-2016년 자료를 사용하여 이산시간 사건사 분석을 통해 분석을 하였다. 본 연구는 빈곤동태가 의료이용, 의료비와 미충족 의료에 미치는 영향을 탐색한 첫 번째 시도라는 점에서 의미가 있다. 연구결과, 지속적 빈곤층(the persistent poor)은 응급실 방문과 입원횟수에 어려움이 있었고, 의료비를 낮게 지출하였고, 미충족 의료를 더 많이 보고하였다. 반복적 빈곤층(the recurrent poor)은 입원횟수가 더 적었고, 의료비를 덜 지출하였고, 가장 높은 수준의 경제적 이유로 인한 미충족 의료를 호소하였다. 건강유지와 개인의 안녕에서 질병이 발생하였을 때 적절한 때에 적절한 의료이용을 하는 것의 중요성을 생각해볼 때, 지속적 빈곤층과 반복적 빈곤층은 건강상태와 안녕이 나빠질 위험에 처해 있다고 할 수 있겠다. 또한 의료급여의 수급지위의 변화가 의료이용, 의료비, 미충족 의료에 미치는 영향을 살펴보면, 지속적 의료급여집단은 더 많은 외래이용, 더 적은 건강검진서비스 이용, 더 많은 응급의료 이용과 입원이용을 하였고, 의료비를 덜 지출하였으나 더 많은 미충족 의료를 보고하였다. 신규 의료급여 집단은 본인부담금이 낮아지면서 더 많은 급여혜택을 받게 되어 더 많은 외래이용을 하고 재원일수가 길었다. 신규 건강보험 집단은 본인부담금이 높아지면서 급여혜택이 줄어드는 상황이 되는데, 입원이용을 줄이는 양상을 보였고, 높은 미충족 의료 수준을 보고하였다. 본 연구는 재난적 의료비가 첫 번째 빈곤주기의 길이와 총 빈곤기간, 그리고 빈곤탈출에 미치는 영향을 처음으로 분석한 것에 의의를 가진다. 다른 빈곤기간에 미치는 영향요인들을 통제한 상태에서도, 재난적 의료비가 발생한 가구는 통계적으로 유의하게 첫 번째 빈곤주기(30-40%의 역치 수준)와 총 빈곤기간(30%의 역치 수준)이 길어졌다. 재난적 의료비의 총 빈곤기간에 대한 영향의 크기는 첫 번째 빈곤주기의 길이에 대한 영향보다 다소 줄어들었는데, 이는 재난적 의료비의 영향이 첫 번째 빈곤주기의 길이에서 더 중요하게 작용함을 의미한다고 할 수 있다. 재난적 의료비가 빈곤탈출에 미치는 영향은 빈곤탈출 유형별로 다르게 나타났다. 본 연구에서는 차상위 빈곤층으로 탈출과 완전 빈곤탈출로 나누어 빈곤탈출을 살펴보았다. 재난적 의료비의 발생은 통계적으로 유의하게 차상위 빈곤층으로 탈출과 부적 상관이 있었으나, 완전 빈곤탈출에서는 통계적으로 유의하지 않았다. 빈곤탈출의 대부분(70%)이 차상위 빈곤층으로의 이동임을 고려할 때, 재난적 의료비의 발생은 이미 제한적인 빈곤층의 가계예산에 위협을 주며, 가계의 소득감소와 더불어 빈곤지속의 요인임을 확인할 수 있었다. 의료이용의 접근성 향상과 의료비로 인한 재정적 위험에 대한 보호를 이루기 위한 가장 중요한 접근은 급여항목을 확대하고 본인부담금을 낮추는 선지불체계를 발전시키는 것이다. 다른 분야의 빈곤감소 정책들과 더불어, 건강보장제도를 강화하여 재난적 의료비 발생을 줄이는 것은 빈곤을 감소시키고 국민의 안녕을 향상시키는 실현가능하고 현실적인 방안들 중 하나라고 할 수 있겠다.The aim of the study was to examine the effects of poverty dynamics and the Medical Aid (MA) status change on health care use, health expenditure (out-of-pocket payments), and unmet need, using data from the Korea Health Panel 2008-2014 for the years of 2011-2013. Then, the study aimed to analyze the effect of catastrophic health expenditure (CHE) on the first poverty spell length and the total poverty duration among the poor at the poverty line of less than 50% of the median income level (MIL), using the Korean Welfare Panel Study 2008-2016 through the panel generalized estimating equations population-averaged model. The study then examined the effect of CHE on exit from poverty among the poor at the poverty line of less than 40% of MIL, analyzing data from the Korean Welfare Panel Study 2008-2016 through a discrete time event history analysis. This study was the first attempt to explore the effect of poverty dynamics on health care use, health expenditure, and unmet need. The study showed that the persistent poor had difficulties in access to having emergency visits and hospitalization. The persistent poor spent less total health expenditure at all the poverty lines, and less outpatient health expenditures at some poverty lines and reported more unmet need for all reasons and for the economic reason. The recurrent poor had less inpatient care, spent less total health expenditure, and reported the largest unmet need for the economic reason. Considering how important receiving proper health care services timely to improve and sustain health and well-being is, the results raise some concerns that the persistent poor and potentially the recurrent poor would be at risk of having worse health status and well-being. As for the effects of the MA status change on health care use, health expenditure, and unmet need, the continuous MA had more outpatient visits, less medical check-ups, more emergency visits, more inpatient care, less health expenditure, and more unmet need; the new MA group who can have relatively high benefit coverage of services by reduction of co-payment compared to the continuous health insurance beneficiaries had more outpatient visits and stayed longer at a hospital; the new HI group who may have relatively low benefit coverage level decreased their inpatient care use, which may also affect the result of unmet need. The study was the first exploratory study to examine the effect of catastrophic health expenditure on the first poverty spell length and the total poverty duration, and on exit from poverty. Households with occurrence of CHE at the thresholds of 30-40% were more likely to be at risk of lengthening their first poverty spell, even after controlling other predictors of poverty duration. Households with occurrence of CHE at the threshold of 30% were likely to stay longer in the total poverty duration, with smaller effect sizes of CHE compared to those at the first poverty spell. This would suggest that effects of CHE were more critical for the first poverty spell. Effects of CHE on poverty exit were different between exit to near-poverty and exit to non-poverty. Households facing CHE were less likely to exit from poverty to near-poverty at the thresholds of 20-30%; however, effects of CHE were not associated with exiting from poverty to non-poverty. Considering the majority of types of exit from poverty were exit to near-poverty (about 70%), this result would raise concerns that occurrences of CHE may pose a big threat to their already limited household budget. Combined loss of income due to ill health, financial burden due to health care use may force the poor to be stuck at poverty. The key approach to achieving better access to care and financial protection should be to develop prepayment systems by extending benefit packages and reducing co-payments. Reduction of incidence of CHE by expanding coverage of the national health insurance may be one of more feasible ways of reducing poverty and improving well-being of the people in a society, along with other sectors policies for poverty reduction.Contents Introduction 1 1. Background 1 2. Research objectives of the study 6 Literature review 8 1. Health care use, health expenditure, and unmet need among the poor 9 2. Poverty dynamics 24 3. Catastrophic health expenditure and poverty persistence 37 Research frameworks and methods 42 1. Research frameworks 42 1.1. The effect of poverty dynamics and the Medical Aid status change on health care use, health expenditure, and unmet need in South Korea 42 1.2. The effect of catastrophic health expenditure on persistence of poverty in South Korea 43 2. Research methods 45 2.1. The effect of poverty dynamics and the Medical Aid status change on health care use, health expenditure, and unmet need in South Korea 45 2.2. The effect of catastrophic health expenditure on persistence of poverty in South Korea 50 The effect of poverty dynamics and the Medical Aid status change on health care use, health expenditure, and unmet need in South Korea 59 1. Results 59 2. Discussions 83 3. Limitations 92 The effect of catastrophic health expenditure on persistence of poverty in South Korea 94 1. The effect of catastrophic health expenditure on poverty duration among the poor 94 1.1. Results 94 2. The effect of catastrophic health expenditure on exit from poverty among the poor 110 2.1. Results 110 3. Discussions 116 4. Limitations 129 Policy implications and conclusion 132 References 141 Appendix 155Docto

Changes in cancer detection and false-positive recall in mammography using artificial intelligence: a retrospective, multireader study

Background Mammography is the current standard for breast cancer screening. This study aimed to develop an artificial intelligence (AI) algorithm for diagnosis of breast cancer in mammography, and explore whether it could benefit radiologists by improving accuracy of diagnosis. Methods In this retrospective study, an AI algorithm was developed and validated with 170 230 mammography examinations collected from five institutions in South Korea, the USA, and the UK, including 36 468 cancer positive confirmed by biopsy, 59 544 benign confirmed by biopsy (8827 mammograms) or follow-up imaging (50 717 mammograms), and 74 218 normal. For the multicentre, observer-blinded, reader study, 320 mammograms (160 cancer positive, 64 benign, 96 normal) were independently obtained from two institutions. 14 radiologists participated as readers and assessed each mammogram in terms of likelihood of malignancy (LOM), location of malignancy, and necessity to recall the patient, first without and then with assistance of the AI algorithm. The performance of AI and radiologists was evaluated in terms of LOM-based area under the receiver operating characteristic curve (AUROC) and recall-based sensitivity and specificity. Findings The AI standalone performance was AUROC 0·959 (95% CI 0·952–0·966) overall, and 0·970 (0·963–0·978) in the South Korea dataset, 0·953 (0·938–0·968) in the USA dataset, and 0·938 (0·918–0·958) in the UK dataset. In the reader study, the performance level of AI was 0·940 (0·915–0·965), significantly higher than that of the radiologists without AI assistance (0·810, 95% CI 0·770–0·850; p<0·0001). With the assistance of AI, radiologists’ performance was improved to 0·881 (0·850–0·911; p<0·0001). AI was more sensitive to detect cancers with mass (53 [90%] vs 46 [78%] of 59 cancers detected; p=0·044) or distortion or asymmetry (18 [90%] vs ten [50%] of 20 cancers detected; p=0·023) than radiologists. AI was better in detection of T1 cancers (73 [91%] vs 59 [74%] of 80; p=0·0039) or node-negative cancers (104 [87%] vs 88 [74%] of 119; p=0·0025) than radiologists. Interpretation The AI algorithm developed with large-scale mammography data showed better diagnostic performance in breast cancer detection compared with radiologists. The significant improvement in radiologists’ performance when aided by AI supports application of AI to mammograms as a diagnostic support tool.ope

남성유방에서 유방암과 유사하게 보이는 과립세포종양: 증례 보고

Granular cell tumor of the breast is a rare tumor arising from Schwann cells. Although it is usually a benign tumor, its characteristics can mimic those of breast carcinoma clinically, radiologically, and macroscopically. The tongue is the single most common anatomic site involved; however, a granular cell tumor may arise in virtually any site of the body. We report on a 67-year-old male patient with a palpable breast mass presenting as an irregular mass on mammography and ultrasound.ope

초음파 유도하 핵생검에서 진단된 유방의 엽상종양 혹은 세포충실성섬유상피병변: 절제생검 결과와 초음파 소견과의 비교

PURPOSE: The purpose of this study was to analyze the histologic concordance of sonographically guided core needle biopsy for phyllodes tumors or fibroepithelial lesions with cellular stroma of the breast by comparing this with the outcomes of excision biopsy and to identify any sonographic features that are helpful to predict phyllodes tumors. MATERIALS AND METHODS: We retrospectively reviewed 60 breast masses that were diagnosed as phyllodes tumors (n = 43) or fibroepithelial lesions with cellular stroma (n = 17) on a sonographically guided core needle biopsy. The tumors were all subsequently excised by surgery. The sonographic features were compared between the phyllodes tumors and the non-phyllodes tumors according to the results of excision biopsy. RESULTS: By the results on excision biopsy, there were 48 (80%) phyllodes tumors and 12 (20%) non-phyllodes tumors. Phyllodes tumors were diagnosed at a rate of 90.7% (39/43) for the nodules with phyllodes tumors on the sonographically guided core needle biopsy, and at a rate of 52.9% (9/17) for the nodules with fibroepithelial lesions with cellular stroma on the sonographically guided core needle biopsy. On sonography, heterogeneous internal echotexture (58% vs. 17%, respectively, p = 0.0239), clefts (56% vs. 17%, respectively, p = 0.0331) and horizontal linear striations (71% vs. 33%, respectively, p = 0.0221) were significantly more frequent in the phyllodes tumors than that in the non-phyllodes tumors. CONCLUSION: Identification of a heterogeneous-internal echotexture, clefts and horizontal linear striations on sonography might help differentiate phyllodes tumors from non-phyllodes tumorsope

Annual Trends in Ultrasonography-Guided 14-Gauge Core Needle Biopsy for Breast Lesions

OBJECTIVE: To examine time trends in ultrasonography (US)-guided 14-gauge core needle biopsy (CNB) for breast lesions based on the lesion size, Breast Imaging-Reporting and Data System (BI-RADS) category, and pathologic findings. MATERIALS AND METHODS: We retrospectively reviewed consecutive US-guided 14-gauge CNBs performed from January 2005 to December 2016 at our institution. A total of 22,297 breast lesions were included. The total number of biopsies, tumor size (≤ 10 mm to > 40 mm), BI-RADS category (1 to 5), and pathologic findings (benign, high risk, ductal carcinoma in situ [DCIS], invasive cancer) were examined annually, and the malignancy rate was analyzed based on the BI-RADS category. RESULTS: Both the total number of US scans and US-guided CNBs increased while the proportion of US-guided CNBs to the total number of US scans decreased significantly. The number of biopsies classified based on the tumor size, BI-RADS category, and pathologic findings all increased over time, except for BI-RADS categories 1 or 2 and category 3 (odds ratio [OR] = 0.951 per year, 95% confidence interval [CI]: 0.902, 1.002 and odds ratio = 0.979, 95% CI: 0.970, 0.988, respectively). Both the unadjusted and adjusted total malignancy rates and the DCIS rate increased significantly over time. BI-RADS categories 4a, 4b, and 4c showed a significant increasing trend in the total malignancy rate and DCIS rate. CONCLUSION: The malignancy rate in the results of US-guided 14-gauge CNB for breast lesions increased as the total number of biopsies increased from 2005 to 2016. This trend persisted after adjusting for the BI-RADS category.ope

반지세포 위암의 유방 전이: 증례 보고

Metastasis of signet ring cell gastric carcinoma to the breast is extremely rare. The common clinical findings are redness, edematous skin and pain, and these findings are similar to those of inflammatory breast cancer. We describe here a case of metastatic signet ring cell gastric carcinoma to the bilateral breasts, and this presented as bilateral palpable breast lumps after the patient had undergone radical total gastrectomy two years previouslyope

갑상선암의 18F-Fluorodeoxyglucose PET 섭취 유무에 따른 임상소견, 병리소견 및 초음파 소견의 비교에 대한 고찰

PURPOSE: We wanted to investigate the incidence and the clinicopathologic and sonographic characteristics of thyroid cancers that exhibit positive PET scans. MATERIALS AND METHODS: From January 2007 to February 2008, 156 patients with thyroid cancer underwent both sonography and FDG-PET for the purpose of staging the cancer. We conducted a retrospective review of their clinical, radiologic and pathologic records and we evaluated the incidence of PET-positive thyroid cancer, as well as the associated clinicopathologic aggressiveness and the sonographic features. RESULTS: The incidence of PET-positive thyroid carcinoma was 78.2% (122/156). On univariate analysis, PET-positive thyroid cancer was significantly associated with tumor size, extracapsular invasion and central lymph node metastasis, but there was no association between the sonographic features of the thyroid cancer or the sonographic features of the 2 groups of tumor (1. probably benign and 2. suspicious for malignancy) and the FDG uptake. Multivariate logistic regression analysis showed a significant association between PET positivity and both extrathyroidal extension and a higher cancer stage (III/IV) (p < 0.05). CONCLUSION: The incidence of PET positive thyroid carcinoma is high (78.2%) and PET positivity is significantly associated with tumor size, extracapsular extension and a higher stage. However, there is no significant association between PET positivity and the sonographic features of thyroid carcinomaope

수술 전 항암화학요법을 시행받는 유방암 환자에서 초음파유도하 클립삽입술의 타당성 연구

Purpose: The purpose of our study was to investigate the feasibility of US-guided clip implantation in patients receiving neoadjuvant chemotherapy for treatment of breast cancer. Materials and Methods: From January to May 2012, marker clips were inserted with US guidance in or adjacent to 23 tumors in 20 female patients receiving neoadjuvant chemotherapy for treatment of breast cancer at our institution. One radiologist performed a retrospective review of the identification of tumors on US, mammography, and breast MRI, and MRI artifact caused by a marker clip. Clip migration was evaluated using the clip-to-nipple distance on mammography obtained immediately after clip insertion and within one week before breast surgery. Complication associated with clip insertion was also observed. Results: After completion of neoadjuvant chemotherapy, all tumors showed a decrease in size, and 13 of 23 (56.5%) tumors were no longer palpable and thus required preoperative localization. In addition, marker clips were the only remaining evidence of the original tumor site in three of 23 (13.0%) tumors at the time of preoperative localization. All signal voids caused by a marker clip on breast MRI were less than 1 cm, which did not have a significant effect on detection and evaluation of the extent of the breast cancer. The mean change of the clip-to-nipple distance was 2.11 mm on a craniocaudal, and 2.67 mm on a mediolateral mammogram. No complication associated with clip insertion was observed in any case. Conclusion: US-guided clip implantation in or adjacent to a breast cancer is safe and feasible for patients with anticipation of complete or near complete response to neoadjuvant chemotherapy.ope

Radiomics in predicting mutation status for thyroid cancer: A preliminary study using radiomics features for predicting BRAFV600E mutations in papillary thyroid carcinoma

PURPOSE: To evaluate whether if ultrasonography (US)-based radiomics enables prediction of the presence of BRAFV600E mutations among patients diagnosed as papillary thyroid carcninoma (PTC). METHODS: From December 2015 to May 2017, 527 patients who had been treated surgically for PTC were included (training: 387, validation: 140). All patients had BRAFV600E mutation analysis performed on surgical specimen. Feature extraction was performed using preoperative US images of the 527 patients (mean size of PTC: 16.4mm±7.9, range, 10-85 mm). A Radiomics Score was generated by using the least absolute shrinkage and selection operator (LASSO) regression model. Univariable/multivariable logistic regression analysis was performed to evaluate the factors including Radiomics Score in predicting BRAFV600E mutation. Subgroup analysis including conventional PTC <20-mm (n = 389) was performed (training: 280, validation: 109). RESULTS: Of the 527 patients diagnosed with PTC, 428 (81.2%) were positive and 99 (18.8%) were negative for BRAFV600E mutation. In both total 527 cancers and 389 conventional PTC<20-mm, Radiomics Score was the single factor showing significant association to the presence of BRAFV600E mutation on multivariable analysis (all P<0.05). C-statistics for the validation set in the total cancers and the conventional PTCs<20-mm were lower than that of the training set: 0.629 (95% CI: 0.516-0.742) to 0.718 (95% CI: 0.650-0.786), and 0.567 (95% CI: 0.434-0.699) to 0.729 (95% CI: 0.632-0.826), respectively. CONCLUSION: Radiomics features extracted from US has limited value as a non-invasive biomarker for predicting the presence of BRAFV600E mutation status of PTC regardless of size.ope

Sonographic predictors of aggressive behavior in medullary thyroid carcinomas

Objective: To identify the clinical and sonographic risk factors for aggressive behavior of Medullary Thyroid Carcinomas (MTCs). Material and methods: This is a retrospective analysis. The informed consents were waived. Totally, 127 patients were selected from the database. Two radiologists were invited to review the clinical records and ultrasonic images and scored all the cases according to ACR TI-RADS, retrospectively. Kappa test was used to evaluate the consistency between the two reviewers. Logistic regression analysis was carried to identify the risk factors for aggressive behaviors of MTCs. Comparison of survival proportions between different groups were calculated by Kaplan-Meier method and log-rank test. Results: Female patients with MTCs were more commonly seen than male (1.7:1), male sex was a risk factor for both metastasis (OR: 4.471, P = 0.001) and perithyroidal invasion (OR = 4.674, P = 0.004). Consistency between the two reviewers were quite high (K value, 0.797-0.988). On sonograms, typical MTCs manifest as hypoechoic (96.9%) solid nodules (94.5%). Sex of patients (P = 0.001), margin (P = 0.003) and focality (P = 0.01) of the nodule were independent risk factors for metastasis, whereas sex of the patients (P = 0.004) and margin (P = 0.000) were independent risk factors for perithyroidal invasion. By Kaplan-Meier analysis, survival proportions different between groups with/without perithyroidal extension (P = 0.000) but not between groups with/without metastasis (P = 0.473). Conclusion: High frequency ultrasound and TI-RADS were effective methods for preoperative diagnosis of MTC. Sex of the patients and margin of the nodule are common risk factors for both metastasis and perithyroidal invasion. Focality of the tumor is another independent risk factor for metastasis.ope