National Health Insurance Service-Senior Research Articles

Changes in Cardiovascular Health Status and Risk of Sudden Cardiac Death in Older Adults.

PurposeCardiovascular health (CVH) status is associated with several cardiovascular outcomes; however, correlations between changes in CVH status and risk of sudden cardiac death (SCD) are unknown. We aimed to evaluate associations between changes in CVH status and risk of SCD and all-cause death in older adults.Materials and MethodsWe used data from the Korea National Health Insurance Service-Senior cohort database (2005–2012). Six metrics from the American Heart Association (smoking, body mass index, physical activity, blood pressure, total cholesterol, and fasting blood glucose) were used to calculate CVH scores. Changes in CVH status between two health checkups were categorized as low to low, low to high, high to low, and high to high.ResultsWe included 105200 patients whose CVH status for an initial and follow-up health checkup (2-year interval) was available. During a median of 5.2 years of follow-up after a second health checkup, 688 SCDs occurred. Compared to patients with a persistent low CVH status, those with a consistently high CVH status had a reduced risk of SCD [adjusted hazard ratio (HR), 0.69; 95% confidence interval (CI), 0.56–0.86] and all-cause death (adjusted HR, 0.74; 95% CI, 0.69–0.78). The risk of all-cause death followed similar trends. However, an inconsistent linear relationship was observed for changes in CVH status and the risk of SCD, but not of all-cause death.ConclusionMaintaining a high CVH status was associated with future risks of SCD and all-cause death among an older adult population.

Benefit of high cardiovascular health for incident cardiovascular events and mortality in elderly population

Abstract Background There is consistent evidence of the association between ideal cardiovascular health and lower incident cardiovascular disease (CVD); however, most studies used a single measure of cardiovascular health. Purpose To examine the association of change in cardiovascular health with subsequent incident CVD and mortality in elderly population. Methods In the Korea National Health Insurance Service-Senior (≥60 years) cohort, 312,736 participants who received national health check-ups between 2005–2012 were assessed for eligibility. Using the 7metrics of the American Heart Association (nonsmoking; and ideal levels of body mass index, physical activity, diet, blood pressure, fasting blood glucose, and total cholesterol), participants with 0 to 2, 3 to 4, and 5 to 7 ideal metrics were categorized as having low, moderate, and high cardiovascular health. Change in cardiovascular health over 2 years between 2005 and 2006 was considered. Results The study population included 162,149 participants without prior CVD or malignancy (median age at baseline, 69 [IQR 66–73] years; 91,408 [56.2%] women), of whom 59,887 had data about cardiovascular health change. Over a median follow-up of 5.8 (5.5–8.0) years, 5346 incident CVD events and 6035 death occurred. In multivariable analysis and compared with individuals with persistently low cardiovascular health (consistently low group, 7.9% of participants; CVD incident rate per 1000 person-years, 21.1 [95% CI, 19.4–23.0]), a lower CVD risk was observed in the consistently moderate group (38.7% of participants; absolute rate difference per 1000 person-years, −4.8 [95% CI, −5.5 to −4.1]; HR, 0.77 [95% CI, 0.70–0.85]), the moderate to high group (11.6% of participants; absolute rate difference per 1000 person-years, −7.7 [95% CI, −8.8 to −5.5]; HR, 0.62 [95% CI, 0.55–0.70]), the high to moderate group (11.2% of participants; absolute rate difference per 1000 person-years, −7.2 [95% CI, −8.3 to −5.9]; HR, 0.64 [95% CI, 0.56–0.72]), and the consistently high group (11.3% of participants; absolute rate difference per 1000 person-years, −10.2 [95% CI, −11.2 to −9.1]; HR, 0.51 [95% CI, 0.44–0.58]). A lower mortality risk was observed in the consistently moderate group, the moderate to high group, and the high to moderate or high groups. Conclusion Among a group of elderly participants without CVD, there was benefit of moderate or high cardiovascular health for incident cardiovascular events and mortality. Funding Acknowledgement Type of funding source: None

What Is the Ideal Blood Pressure Threshold for the Prevention of Atrial Fibrillation in Elderly General Population?

Intensive blood pressure (BP) lowering in patients with hypertension at increased risk of cardiovascular disease has been associated with a lowered risk of incident atrial fibrillation (AF). It is uncertain whether maintaining the optimal BP levels can prevent AF in the general elderly population. We included 115,866 participants without AF in the Korea National Health Insurance Service-Senior (≥60 years) cohort from 2002 to 2013. We compared the influence of BP on the occurrence of new-onset AF between octogenarians (≥80 years) and non-octogenarians (<80 years) subjects. With up to 6.7 ± 1.7 years of follow-up, 4393 incident AF cases occurred. After multivariable adjustment for potentially confounding clinical covariates, the risk of AF in non-octogenarians was significantly higher in subjects with BP levels of <120/<80 and ≥140/90 mm Hg, with hazard ratios of 1.15 (95% confidence interval (CI), 1.03–1.28; p < 0.001) and 1.14 (95% CI, 1.04–1.26; p < 0.001), compared to the optimal BP levels (120–129/<80 mm Hg). In octogenarians, the optimal BP range was 130–139/80–89 mm Hg, higher than in non-octogenarians. A U-shaped relationship for the development of incident AF was evident in non-octogenarians, and BP levels of 120–129/<80 mm Hg were associated the lowest risk of incident AF. Compared to non-octogenarians, the lowest risk of AF was associated with higher BP levels of 130–139/80–89 mm Hg amongst octogenarians.

What Is the Difference in the Risk of Suicide Death Between Spine Fracture in Patients Older Than 65 Years and Matched Controls? A Large-database Study from South Korea.

Pain and kyphotic deformity after spinal fractures can result in a decrease in a patient's physical function and quality of life. Furthermore, physical illness, such as respiratory compromise, or mental illness, including depression, may be exacerbated by a spinal fracture. Complications caused by spinal fractures and old age are risk factors for suicide, but studies on these patients are rare. (1) What is the incidence rate of death by suicide after a spinal fracture in patients older than 65 years? (2) How much does the risk of death by suicide increase in patients older than 65 years who have spine fractures compared with well-matched controls? (3) How does this risk change as a function of increasing time after injury? Spinal fractures in patients older than 65 years and matched controls were selected from the National Health Insurance Service-Senior cohort (NHIS-Senior) of South Korea. The NHIS-Senior consists of 558,147 people selected by 10% simple random sampling method from a total of 5.5 million people 60 and older in 2002; all people were followed through 2015. A total of 31,357 patients with spine fractures and their 62,714 matched controls remained in the study. The mean follow-up time was 4.3 ± 3.0 years (135,229 person-years) in the spine fracture group and 4.6 ± 3.0 years (290,096 person-years) in the matched control group. We matched the groups for demographic factors such as age, gender, Charlson Comorbidity Index score, medication history, medical history, preoperative disability, number of hospital admissions, as well as socioeconomic factors such as household income level, residential district, and type of national health insurance using a 1:2 risk set propensity score matching by a nearest-neighbor matching algorithm with a maximum caliber of 0.1 of the hazard components. The incidence rate of suicide and the 95% confidence interval were calculated based on a generalized linear model with a Poisson distribution. The effect size was presented as a hazard ratio (HR) using Cox's proportional hazard model with robust variance estimator that accounts for clustering within matched pairs. The overall risk of death by suicide throughout the surveillance period, expressed as an incidence rate, was 116 per 100,000 person-years in spinal fracture (157 deaths by suicide over 135,229 person-years). Throughout the entire surveillance period, the risk of death by suicide was greater among patients with spinal fractures than it was in the control group (HR 1.8 [95% CI 1.5 to 2.2]; p < 0.01). This difference was greatest in the first 365 days after the fracture (HR 2.5 [95% CI 1.6 to 3.8]; p < 0.01) (45 deaths by suicide, incidence rate: 156 per 100,000 person-years in spinal fracture). The risk of suicide death in patients with spine fracture from 365 days to the last follow-up was also higher than that of matched controls (HR 1.6 [95% CI 1.3 to 2.1]; p < 0.01). Considering the substantially increased risk of death by suicide in patients with spine fractures who are older than 65 years, surgeons should consider offering psychiatric evaluation and management more frequently, particularly in patients with chronic pain, functional disability, and depressive mood. Future studies should investigate the underlying causes of suicide, such as deteriorating socioeconomic support or depression, and whether early initiation of psychological support after injury can reduce the suicide rate. Level III, prognostic study.

The Impact of Korean Medicine Treatment on the Incidence of Parkinson's Disease in Patients with Inflammatory Bowel Disease: A Nationwide Population-Based Cohort Study in South Korea.

We aimed to investigate the association between Korean medicine (KM) treatment and the risk of Parkinson’s Disease (PD) in patients with inflammatory bowel disease (IBD) in South Korea. This study analyzed data from the National Health Insurance Service-Senior cohort in South Korea. The 1816 IBD patients enrolled in the analysis comprised 411 who received only conventional treatment (monotherapy group) and 1405 who received both conventional and KM treatments (integrative therapy group). The risk of PD in patients with IBD was significantly lower in the integrative therapy group than in the monotherapy group after adjusting for confounding variables (adjusted hazard ratio (HR), 0.56; 95% confidence interval (CI) = 0.34–0.92). In the mild Charlson Comorbidity Index (CCI) group, the risk of PD in patients with IBD in the integrative therapy group was 0.39 times lower (adjusted HR, 95% CI = 0.20–0.77) than that in the monotherapy group. However, there was no significant difference in the risk of PD in patients with IBD between the integrative therapy and monotherapy groups among individuals with severe CCI (adjusted HR, 0.90; 95% CI = 0.41−1.96). IBD patients are at a decreased risk of PD when they receive integrative therapy. KM treatment may prevent PD in IBD patients.

Effects of Statin Use for Primary Prevention among Adults Aged 75 Years and Older in the National Health Insurance Service Senior Cohort (2002-2015).

BackgroundThis study aimed to identify adverse events and mortality in adults aged 75 years and older who were initially prescribed statins for primary prevention.MethodsThis retrospective study analyzed the data from the National Health Insurance Corporation–Senior Cohort from 2002 to 2015. An exact block matched model was constructed from statin user and statin non-user groups. ResultsThe study sample comprised 1,370 older adults (mean age, 78 years), with 685 statin non-users matched to 685 new statin users. Compared to non-users, the adjusted hazard ratios (HRs) of new statin users were 0.83 (p=0.04) for all-cause mortality, 1.24 (p=0.03) for major adverse cardiovascular events, and 1.18 (p=0.06) for new-onset diabetes mellitus. In a sub-analysis of statin use duration, longer statin use (>5 years) was associated with a significantly lower risk of all-cause mortality (HR=0.76, p=0.01) but not with major adverse cardiovascular events (HR=0.88, p=0.36) or new-onset diabetes mellitus (HR=0.95, p=0.78) after adjusting for age, sex, body mass index, diabetes mellitus, hypertension, aspirin use, and antiplatelet use. ConclusionOur findings suggested that statins started for primary prevention in older adults aged 75 years and older had an advantageous effect on all-cause mortality only if used for at least 5 years.

Potentially Avoidable Hospitalization among Long-Term Care Insurance Beneficiaries with Dementia.

BackgroundThis study investigated the differences in the risk of potentially avoidable hospitalization (PAH) among eligible long-term care insurance (LTCI) beneficiaries with dementia for LTCI services in Korea. Nested case-control study was conducted using the National Health Insurance Service–Senior claim database.MethodsCases of individuals who had a PAH incident diagnosis and controls were selected by incidence density sampling and matched to cases based on age, sex, and difficulty of daily living among dementia patients. We conducted incidence density sampling three times by PAH type.ResultsOur main results were presented by conditional logistic regression analysis for the matched case–control studies. Out of the 7,352 eligible LTCI beneficiary patients, there were 1,231 cases (16.7%) in overall PAH, 132 cases (19.0%) in acute PAH and 1,114 cases (16.7%) in chronic PAH categories. In terms of individual risk of overall and chronic PAH, the odds ratios of those who did not receive any services were 1.336 time higher (95% confidence interval [CI], 1.159–1.540) and 1.280 time higher (95% CI, 1.103–1.485) compared to those who received home care, respectively. For risk of acute PAH, the odds ratios of those who did receive institutional care were 2.046 time higher (95% CI, 1.170–3.578) compared to those who received home care.ConclusionThis study identified the differences in risk of PAH incidents according to the type of LTCI service in the elderly population in Korea. Therefore, it will require substantial effort and strategy from health policy makers to improve care quality.

Suicide in Elderly Patients with Hip Fracture: A South Korean Nationwide Cohort Study.

The purpose of the present study was to evaluate the incidence rate (IR) of suicide in elderly patients with hip fracture on the basis of a nationwide cohort and to analyze the change in the hazard ratio for suicide after hip fracture over time in comparison with a control group. Patients with hip fracture and their matched controls were selected from the National Health Insurance Service-Senior cohort (NHIS-Senior) of the Republic of Korea. The NHIS-Senior consists of 558,147 people selected by a 10% simple random-sampling method from a total of 5.5 million subjects ≥60 years of age in 2002. Risk-set matching (1:2) on the propensity score was performed with use of a nearest neighbor matching algorithm with a maximum caliper of 0.1 for the hazard components. The IR of suicide and 95% confidence interval (CI) were calculated on the basis of a generalized linear model with a Poisson distribution. The effect size was presented as a hazard ratio (HR) with use of the Cox proportional-hazard model with a robust variance estimator that accounts for clustering within matched pairs. A total of 11,477 patients with hip fracture and 22,954 matched controls were included. The mean duration of follow-up was 4.59 years, generating 158,139 person-years. During follow-up, a total of 170 suicides were identified. Comparisons at up to 180 days and 365 days showed that patients with hip fracture were at higher risk for suicide than matched controls (p = 0.009 and 0.004, respectively; stratified log-rank test). During the first 180 days of follow-up, 14 suicides were identified in patients with hip fracture during 11,152 person-years (IR, 266.1 per 100,000 person-years; 95% CI, 157.6 to 449.4). Patients with hip fracture were 2.97 times more likely to kill themselves than their matched controls during the same period (HR = 2.97; 95% CI, 1.32 to 6.69). Hip fracture in elderly patients increased suicide risk within a year. A new approach to psychiatric evaluation and management is needed in elderly patients with hip fracture. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Retrospective Cohort Study of Risk of Gallbladder Disease in Acute Cerebral Infarction Patients

Background: Gallbladder diseases after acute cerebral infarction are relatively rare, but could have a serious impact on mortality and morbidity of patients. The purpose of this study was to investigate the risk of gallbladder disease in patients with acute cerebral infarction.Methods: This study analyzed a population-based matched cohort constructed using National Health Insurance Service-Senior cohort dataset in South Korea. Subjects after acute cerebral infarction during 2002-2015 were identified as the exposed group, and up to four individual matched for age, sex, and index years were as the controls. The difference of the risk of gallbladder disease between the exposed and control group was evaluated using Cox regression adjusting for hypertension, diabetes, liver diseases, and the modified Charlson Comorbidity Index (mCCI). The risk of gallbladder disease of the exposed group was evaluated using Cox regression analyses to identify the risk factors.Results: The occurrence of the gallbladder disease was significantly associated with the acute cerebral infarction (&lt;i&gt;p&lt;/i&gt;&lt;0.0001). The presence of acute cerebral infarction was associated with a higher risk of gallbladder disease (adjusted hazard ratio=1.44, 95% confidence interval=1.26-1.66). The subjects with higher CCI showed higher risk of gallbladder disease. Among acute cerebral infarction patients, the oldest group, subjects having liver diseases, or subjects with the mCCI higher than two were found significant on the risk of gallbladder disease.Conclusions: Our study showed that the acute cerebral infarction has a significant association with gallbladder disease. These results suggested that the possibility of developing of gallbladder disease in patients with acute cerebral infarction should be considered.

The Influence of Renal Dialysis on All-Cause Mortality in Older Patients with Hip Fracture: a Korean Nationwide Cohort Study.

BackgroundThe purpose of this study was to analyze the all-cause mortality rate over time after elderly hip fracture in end-stage renal disease (ESRD) patients with dialysis, using a Korean nationwide claims database.MethodsThis retrospective nationwide study identified subjects from the Korean National Health Insurance Service-Senior cohort (NHIS-Senior). The NHIS-Senior (total of 588,147 participants) was constructed by 10% random sampling and was designed to represent the elderly living in Korea. Subjects were patients aged 65–99 years who underwent surgical treatment for femoral neck fractures or intertrochanteric fractures. A generalized estimating equation model with Poisson distribution and logarithmic link function was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) to measure associations between renal dialysis and cumulative mortality in various time frames.ResultsThe total number of patients included in this study was 16,818. These patients were divided into two groups: 116 (0.69%) in the dialysis group and 16,702 (99.31%) in the no-dialysis group. The mean length of hospital stay was 43.87 ± 48.45 days in the dialysis group and 36.29 ± 37.49 days in the no-dialysis group (P = 0.095). The effect of renal dialysis on all-cause mortality was 2.29-fold (aRR; 95% CI, 1.29–4.06; P = 0.005) within 30 days and 1.72-fold (aRR; 95% CI, 1.34–2.21; P < 0.001) within 1-year after hip fracture compared to the no-dialysis group. And, the effect of renal dialysis of in-hospital mortality was 2.72-fold (aRR; 95% CI, 1.71–4.33; P < 0.001) compared to the no-dialysis group.ConclusionElderly patients who underwent dialysis have very high mortality rates after hip fracture. Therefore, it is considered that postoperative care through multidisciplinary management and understanding of pathophysiology for the ESRD patients is necessary.

Association between Timed Up and Go Test and Subsequent Functional Dependency.

BackgroundThis study aimed to evaluate the association between baseline results of the Timed Up and Go (TUG) test and subsequent functional dependency occurrence.MethodsFrom the National Health Insurance Service-Senior Cohort database, we identified 39,519 people who participated in the National Screening Program for Transitional Ages at the age of 66 during 2007–2008. Impaired mobility was defined as taking 10 seconds or longer to perform the TUG test. Functional dependency occurrence was defined as the initiation of receiving national Long-Term Care Insurance services—home care or admission to long-term care facilities. Cox proportional hazard regression models were used to assess the hazard ratios (HRs) for dependency occurrence according to baseline TUG test results.ResultsThe mean follow-up period was 5.7 years. Occurrence rates of dependency were 2.0 and 3.4 cases per 1,000 person-years in the normal and impaired TUG groups, respectively. Impaired mobility was associated with a higher risk of functional dependency occurrence (adjusted HR [aHR], 1.65; 95% confidence interval [CI], 1.40–1.95; P < 0.001). Additionally, in the subgroup analysis for the participants with intact baseline activities of daily living, impaired mobility was associated with a higher risk of dependency occurrence (aHR, 1.65; 95% CI, 1.33–2.04; P < 0.001).ConclusionThe TUG test might be a useful predictive marker of subsequent functional dependency occurrence. Intervention to prevent functional dependency may be helpful for older adults with impairment on the TUG test.

Blood Transfusion for Elderly Patients with Hip Fracture: a Nationwide Cohort Study.

BackgroundThis nationwide study aimed to investigate the blood transfusion status of elderly hip fracture patients and to examine the effect of packed red blood cell transfusion on all-cause mortality.MethodsFrom the Korean National Health Insurance Service-Senior cohort consisting of 588,147 participants aged over 60 years in 2002, a total of 14,744 new-onset hip fracture patients aged 65–99 years were followed up for 11 years. The adjusted hazard ratios (aHRs), risk ratios, and their 95% confidence intervals were estimated by the Cox proportional hazard model and Poisson regression model.ResultsThere were 10,973 patients (74.42%) in the transfusion group and 3,771 (25.58%) patients in the non-transfusion group. The mean volume of blood transfusion was 1,164.51 mL (± 865.25; median, 800 mL; interquartile range, 640–1,440). In the multivariable-adjusted Cox proportional hazard model, the transfusion group had 1.34-fold more risk of all-cause mortality than the non-transfusion group (aHR, 1.34; 95% confidence interval [CI], 1.26–1.42). In the multivariate-adjusted Poisson regression model, hip fracture patients in the transfusion group were 1.43 (adjusted risk ratio [aRR], 1.43; 95% CI, 1.09–1.87; P = 0.009) folds more likely to die within 30 days than those in the non-transfusion group. The mortality risk was highest at 90 days (aRR, 1.64; 95% CI, 1.40–1.93; P < 0.001) and slightly decreased at 180 days (aRR, 1.58; 95% CI, 1.40–1.79; P < 0.001) and 1 year (aRR, 1.43; 95% CI, 1.31–1.58; P < 0.001).ConclusionIn this nationwide representative cohort study, blood transfusion was performed in 75% of hip fracture patients. Even after adjusting for comorbidity and anticoagulant use, the postoperative results (hospitalization, mortality) of the transfusion group did not show significantly worse results than the non-transfusion group. Therefore, adequate patient blood management can only improve the patient's outcome after hip fracture surgery.

Poststroke suicide risk among older adults in South Korea: A retrospective longitudinal cohort study.

The present study evaluated suicide risk within 1 year after discharge among older adults with stroke as a function of depression onset. We used the Korean National Health Insurance Service-Senior cohort data and included first discharged patients with a stroke as the principal diagnosis. The comparison group was selected by a 1:2 case-control propensity score matching for age, sex, Charlson comorbidity index, and diagnosis year between 2005 and 2012. Suicide deaths were measured by code for causes of death from Statistics Korea, and the main outcome was suicide death within 1 year following discharge. An adjusted hazard ratio (AHR) of suicidal risk was measured using a Cox proportional hazard model. In the total sample of 128 286 older adults (aged 63-114 years), the higher suicidal risk was examined for stroke patients vs the comparison group (AHR = 1.4; 95% confidence interval [CI], 1.1-1.8). Stroke patients with depression had an increased suicide risk (AHR = 2.9; 95% CI, 1.8-4.8) but only for poststroke depression (AHR = 4.1; 95% CI, 1.8-9.5). Pre and poststroke depression suicidality (AHR = 4.8; 95% CI, 2.1-11.1) was also higher when compared to stroke patients without depression. Poststroke patients are at increased suicidal risk during 1 year following discharge. Furthermore, patients who were diagnosed with depression after a stroke are more likely to commit suicide than stroke patients without depression. This suggests a necessity for early suicide preventive intervention for stroke patients while considering depressive symptomology.

Suicide risk after cancer diagnosis among older adults: A nationwide retrospective cohort study

ObjectivesCancer increases suicide risk, but little is known about associations between cancer and suicide among older adults. We aimed to investigate suicide risk within 1 year after cancer diagnosis in older adults. MethodsUsing National Health Insurance Service-Senior Cohort data, we included newly diagnosed older patients with cancer and older adults without cancer, selected by a 1:3 propensity score matching using sex, age, Charlson comorbidity index, and index year from 2004 to 2012 and followed them up throughout 2013. We used Cox proportional hazard models to estimate adjusted hazard ratios (AHR) of suicide risk. ResultsIn the total sample of 259,688 older adults (aged 62–115 years), the highest proportion of observed suicide deaths occurred within one year after cancer diagnosis (36.1% of total); 64,922 older patients with cancer showed higher suicide risk after cancer diagnosis compared to non-cancer participants (AHR 2.05; 95% CI 1.64–2.56). Patients with mental disorder diagnosis before cancer diagnosis (AHR 2.98; 95% CI 2.12–4.18) had increased suicide risk than those without mental disorder diagnosis (AHR 1.78; 95% CI 1.38–2.29) compared to non-cancer participants. Suicide risk among older patients with bladder, head and neck, liver, lung, and stomach cancers was higher than in non-cancer participants (AHR 4.77, 2.28, 2.99, 1.98, 2.40; 95% CI 2.53–8.99, 1.47–3.54, 1.63–5.49, 1.15–3.40, 1.57–2.24), respectively. ConclusionsOlder patients with cancer have a higher suicide risk. Early mental health support needs to be provided with consideration of prediagnosis mental disorders during follow-up after cancer diagnosis.

Efficacy of Aspirin in the Primary Prevention of Cardiovascular Diseases and Cancer in the Elderly: A Population-Based Cohort Study in Korea.

Aspirin is widely used to prevent cardiovascular diseases (CVDs). However, the balance of its benefits and risks in the primary prevention of CVDs and cancer is unclear, especially in elderly Asians. The present study aimed to evaluate the efficacy of aspirin in the primary prevention of major adverse cardiac and cerebrovascular events (MACCE), bleeding risk, and cancer in elderly Koreans with cardiovascular (CV) risk factors. This retrospective cohort study used data from the Korean National Health Insurance Service-Senior cohort database (2002-2015). Patients aged 60-90years with hypertension, type 2 diabetes mellitus (T2DM), or dyslipidemia were identified. Aspirin users were compared with non-users using propensity score matching at a 1:3 ratio. The primary outcome was MACCE, a composite of CV mortality, myocardial infarction, and ischemic stroke. The secondary outcomes were the components of MACCE, all-cause mortality, angina pectoris, heart failure, the incidence and mortality of cancer, and the risks of hemorrhagic stroke and gastrointestinal bleeding. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using a Cox proportional hazard model. A total of 3366 aspirin users and 10,089 non-users were finally included in the study. During a mean follow-up of 7.8years, the incidence of MACCE was 15.2% in aspirin users and 22.4% in non-users. The risk of MACCE was significantly lower in aspirin users than in non-users (HR 0.76; 95% CI 0.69-0.85), and this risk was significantly reduced in patients using aspirin over 5years (HR 0.52; 95% CI 0.46-0.60). Aspirin use was associated with a 21% reduction in the risk of primary cancer (HR 0.79; 95% CI 0.70-0.88) and cancer-related mortality (HR 0.72; 95% CI 0.61-0.84). No significant differences in bleeding risks were observed between the two groups. Aspirin reduced the risks of MACCE and cancer without increasing the bleeding risk in elderly Koreans with hypertension, T2DM, or dyslipidemia. Moreover, the benefits of the long-term use of aspirin in reducing the risks of MACCE were demonstrated. However, the decision of using aspirin for primary prevention must be carefully made on an individual basis, while estimating the benefit-risk balance of aspirin.

Hypoglycemia and Dementia Risk in Older Patients with Type 2 Diabetes Mellitus: A Propensity-Score Matched Analysis of a Population-Based Cohort Study.

BackgroundType 2 diabetes mellitus (T2DM) is associated with an increased risk for dementia. The effects of hypoglycemia on dementia are controversial. Thus, we evaluated whether hypoglycemia increases the risk for dementia in senior patients with T2DM.MethodsWe used the Korean National Health Insurance Service Senior cohort, which includes >10% of the entire senior population of South Korea. In total, 5,966 patients who had ever experienced at least one episode of hypoglycemia were matched with those who had not, using propensity score matching. The risk of dementia was assessed through a survival analysis of matched pairs.ResultsPatients with underlying hypoglycemic events had an increased risk for all-cause dementia, Alzheimer's dementia (AD), and vascular dementia (VaD) compared with those who had not experienced a hypoglycemic event (hazard ratio [HR], 1.254; 95% confidence interval [CI], 1.166 to 1.349; P<0.001 for all-cause dementia; HR, 1.264; 95% CI, 1.162 to 1.375; P<0.001 for AD; HR, 1.286; 95% CI, 1.110 to 1.490; P<0.001 for VaD). According to number of hypoglycemic episodes, the HRs of dementia were 1.170, 1.201, and 1.358 in patients with one hypoglycemic episode, two or three episodes, and more than three episodes, respectively. In the subgroup analysis, hypoglycemia was associated with an increased risk for dementia in both sexes with or without T2DM microvascular or macrovascular complications.ConclusionOur findings suggest that patients with a history of hypoglycemia have a higher risk for dementia. This trend was similar for AD and VaD, the two most important subtypes of dementia.

Fracture Experiences and Long-Term Care Initiation among Older Population: Analysis of Korean National Health Insurance Service-Senior Cohort Study.

BackgroundLong-term care is a burden on individuals, families, and society. It is important to find ways to delay the onset of disability to lessen the burden of long-term care in aging societies. Fracture is one of the risk factors that affect physical functions and make older people dependent. This study aimed to examine how much more often older adults who experienced fractures initiated long-term care compared to those who did not, and whether the risk of entering long-term care differed significantly by fracture site. MethodsThe analyses included insurants aged 65 years and over from the Korean National Health Insurance Service-senior cohort study (2002–2013). Cox proportional hazard models were used to calculate the hazard ratios of the first certification of initiation of long-term care after fracture, by fracture site, and for multiple recurrent fractures. ResultsThe incidence rate of initial long-term care beneficiaries was approximately 2.5 times higher when older people had experienced fractures; these individuals entered long-term care beneficiary status 3 years earlier compared to those who had no fracture events. Lower extremity fracture and multiple recurrent fractures more than doubled the risk for long-term care.ConclusionAdditional attention to fracture sites in prevention and rehabilitation settings is warranted to reduce disability and the related long-term care burden.

Poverty and suicide risk in older adults: A retrospective longitudinal cohort study.

We aimed to identify the impact of poverty on suicide risk in older adults. The data used in this study was obtained from the National Health Insurance Service-Senior claims database from 2002 to 2013. A total of 558147 individuals were followed for up to 12years. Poverty was assessed from insurance premium levels, and causes of death were analysed by linking individuals' deaths to the data for causes of death from the National Statistics Office in South Korea. Cox proportional hazard models were used to analyse the associations between poverty and suicide deaths after adjustments for possible confounders. Among 558147 older adults (aged 60-119years), the poverty group had an increased risk of suicide compared with the high-income group (adjusted hazard ratio [AHR], 1.34; 95% confidence interval [CI], 1.22-1.47), and poverty-group males had a significantly higher risk of suicide than males in the high-income group (AHR, 1.50; 95% CI, 1.33-1.68). Adults aged 60 to 74years in the poverty group had a higher risk of suicide than those with a high income in the same age group (AHR, 1.41; 95% CI, 1.27-1.57). However, no statistically significant income gradient was found for females or adults aged 75years or older. Our findings revealed that poverty is a risk factor for death by suicide in older adults. Suicide prevention strategies for older adults should be specifically tailored by income level.

The effect of surgery type on mortality in elderly patients with pertrochanteric femoral fracture: A Korean nationwide cohort study

The purpose of this study is to analyze the effect of surgical methods on mortality and the relative risk of patients who underwent internal fixation (IF) or hemiarthroplasty (HA) after being diagnosed as a pertrochanteric fracture over 65 years old in a Korean nationwide cohort with a single insurance medical system. The Korean National Health Insurance Service-Senior cohort (NHIS-Senior, NHIS-2018-2-111) was used in this study. The eligibility criteria for incident hip fracture patients were the following: (1) first-time admission to acute care hospitals (index admission) with pertrochanteric fracture (ICD-10 S721), (2) three years of hip fracture-free period, (3) recipients of typical surgeries including IF, HA, (4) age between 65 and 99. a total of 7223 patients were enrolled in the cohort. There were 1662 patients (23%) in the HA group and 5561 patients (77%) in the IF group. Mortality rates of the IF group and HA group were 13.46 and 17.94 cases per 100 person-years, respectively. In the multivariable-adjusted Cox proportional hazard model, the HA group had 1.22 times more hazard of all-cause mortality than IF group (aHR 1.22, 95% CI 1.13-1.32). In subgroup analysis, aged 65-79 and female patients showed a prominent association between surgery type and mortality (aHR 1.52, 95% CI 1.29-1.79). In patients with pertrochanter fracture over 65 years, 1.22-fold mortality rate was observed when HA was performed compared to that of IF, and the difference in mortality was particularly prominent within 1-year after surgery.

Cohort Profile: National health insurance service-senior (NHIS-senior) cohort in Korea

PurposeThe National Health Insurance Service (NHIS)-Senior was set up to provide high-quality longitudinal data that can be used to explore various aspects of changes in the socio-economical and health status...