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Comparison of Anterior Segment Features between Groups with or without Glaucoma in Pseudoexfoliation Syndrome (거짓비늘증후군에서 개방각녹내장 병합 유무에 따른 전안부 소견과 생체 계측치에 대한 비교)

  • Gu, Bon Hyeok;Choi, Sangkyung
    • Journal of The Korean Ophthalmological Society
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    • v.59 no.11
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    • pp.1049-1055
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    • 2018
  • Purpose: To investigate the factors associated with glaucoma in patients with pseudoexfoliation syndrome by comparing features of the anterior segments and ocular biometry according to the presence or absence of open-angle glaucoma in pseudoexfoliation syndrome. Methods: We analyzed 96 patients (115 eyes) diagnosed as having pseudoexfoliation syndrome in this study. The patients were divided into two groups of simple pseudoexfoliation syndrome (64 patients, 76 eyes) and pseudoexfoliation glaucoma (32 patients, 39 eyes). We compared the age, sex, underlying disease, location of pseudoexfoliative material, iris change, degree of nuclear cataract, pupil dilatation, corneal endothelial cell counts, central corneal thickness, anterior chamber depth, axial length, corneal curvature, and intraocular pressure (IOP). Results: There were no significant differences between the two groups in terms of age (p = 0.694), sex (p = 0.161), diabetes (p = 0.440), hypertension (p = 0.238), pseudoexfoliative material observed in anterior capsule (p = 0.700), pupillary margin (p = 0.210), iris depigmentation (p = 0.526), pupillary ruff loss (p = 0.708), degree of nuclear cataract (p = 0.617), pupil dilatation (p = 0.526), central corneal thickness (p = 0.097), anterior chamber depth (p = 0.283), axial length (p = 0.095), or horizontal and vertical corneal curvature (p = 0.066 and 0.306, respectively). In pseudoexfoliation glaucoma, significantly higher IOP (p = 0.026), a high frequency of membrane formation (p = 0.047), and decreased corneal endothelial cell counts (p = 0.048) were observed. Conclusions: Pseudoexfoliation syndrome with open-angle glaucoma was shown to be associated with high IOP, decreased corneal endothelial cell counts, and a high frequency of membrane formation. Therefore, when such changes are observed in pseudoexfoliation syndrome patients, a higher risk of open-angle glaucoma should be recognized, and careful attentionis required accordingly.

Comparative Evaluation of 25-OH-VitD and 25-OH-VitD3 by Radioimmunoassay (방사면역 측정법에 의한 25-OH-VitD와 25-OH-VitD3의 비교 평가)

  • Lee, Young-ji;Park, Ji-hye;Lim, Soo-yeon;Cheon, Jun-hong;Lee, Sun-ho
    • The Korean Journal of Nuclear Medicine Technology
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    • v.24 no.1
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    • pp.33-38
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    • 2020
  • Purpose Vitamin D is essential for maintaining bone health, controling cell proliferation or differentiation, strengthening immune function by controlling calcium metabolism in the body. Vitamin D deficiency can lead to increase the risk of rickets, osteoporosis, cardiovascular disease, diabetes and cancer. Especially, South Korea is one of the highest population proportion of vitamin D deficiency. Accurate determination of levels of 25-OH-VitD or 25-OH-VitD3 in blood serum is required for the diagnosis and treatment of vitamin D deficiency. In this study, radioimmunoassay of 25-OH-VitD and 25-OH-VitD3 was performed and compared to evaluate the effectiveness of Vitamin D radioimmunoassay. Materials and Methods Serum 25-OH-VitD and 25-OH-VitD3 levels were measured using radioimmunoassay. The interrelationship, reproducibility and population distribution rate were evaluated. In addition, the internal quality control was performed at Asan Medical Center from April 2017 to June 2019 and the result of external quality control (Interagency proficiency evaluation) of first and second half of 2018 hosted by the Korean Society of Nuclear Medicine Technology (KSNMT). Both tests were measured by same manufacturer's reagent. Results 25-OH-VitD showed a strong positive correlation on 97 samples, as 25-OH-VitD3 x 0.9 + 0.3 (R>0.9). In repeated measurement, the average Diff(%) value of the reproducibility evaluation of 25-OH-VitD and 25-OH-VitD3 were 7.7% and 7.4%, respectively. Population distribution results showed no statistically significant differences(p>0.05). The resultant value of internal quality control, which measured from April, 2017 to June 2019 in Blood test room of Nuclear Medicine at Asan Medical Center, showed average (CV%) 6.2% and 6.8%, respectively. As a result of the external quality control (interagency proficiency evaluation) Z value obtained under 2.0, as shown below; Conclusion The interrelationship, reproducibility, population distribution rate, internal quality control and external quality control between 25-OH-VitD and 25-OH-VitD3 radioimmunoassay shows superior outcome. Radioimmunoassay, which can be alone measured in the blood as 25-OH-VitD or 25-OH-VitD3, is considered suitable screening tests for the diagnosis of vitamin D deficiency.

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Status of health and nutritional intake of the elderly in long-term care facilities: focus on Gwangju Metropolitan City (노인의료복지시설 입소 노인의 건강 상태 및 영양소 섭취 현황: 광주광역시를 중심으로)

  • Han, Gyusang;Yang, Eunju
    • Journal of Nutrition and Health
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    • v.53 no.1
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    • pp.27-38
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    • 2020
  • Purpose: This study assessed the food intake and nutritional status of the elderly in long-term care facilities in order to provide adequate food services and improve the nutritional status. Methods: The survey was carried out from August 2019 to October 2019 for the elderly in long-term care facilities located in Gwangju Metropolitan City. The survey was conducted to collect data from 199 elderly persons (34 males and 165 females) aged over 65 years old. The food intake was assessed using a 1-day 24-hour recall method. Results: More than 90% of the subjects were over 75 years old. Forty five percent of the subjects were active, 44.2% of the subjects perceived themselves as not being healthy. Dementia and Parkinson's disease were the most common diseases, followed by hypertension, musculo-skeletal disease, diabetes, and stroke. Only 25.6% of the subjects had most of their teeth intact, and 44.7% of the subjects had difficulty in chewing and swallowing. The total food intake was 1,127 g in males and 1,078 g in females. The most frequently consumed foods were kimchi, cooked rice with multi-grains, soybean soup, cooked rice with white rice, yogurt, pumpkin porridge, soy milk, and duck soup. The average energy intake of the subjects was 1,564.9 kcal in males and 1,535.5 kcal in females. The overall nutritional status of the elderly in the long-term care facilities was poor. In particular, the intake of vitamin D and calcium, vitamin C, riboflavin, and potassium were very low. The intake of vitamin D was 5 ㎍, and 86.4% of the elderly were below the estimated average requirement, while the intake of sodium was high. Conclusion: The results of this study can be used to understand the health and nutritional status and to improve the food services and nutrition management for the elderly in longterm care facilities.

Antimicrobial, Antioxidant, and Anti-diabetic Activities of Rodgersia podophylla (도깨비부채의 항균, 항산화 및 항당뇨 활성)

  • Pyo, Su-Jin;Lee, Yun-Jin;Kang, Deok-Gyeong;Son, Ho-Jun;Park, Gwang Hun;Park, Jong-Yi;Sohn, Ho-Yong
    • Journal of Life Science
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    • v.30 no.3
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    • pp.298-303
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    • 2020
  • This study aimed to investigate possible applications of Rodgersia podophylla in the food and cosmetic industry. Ethanol extracts of leaves (RP-L), branches (RP-B), and root (RP-R) were prepared, and their antimicrobial, antioxidant, and anti-diabetic activities were evaluated. The polyphenol content in the RP-R, RP-L, and RP-B extracts was 79.6, 30.4, and 16.9 mg/g, respectively. An antimicrobial activity assay showed that the RP-L and RP-R extracts exhibited strong growth inhibition of pathogenic and food spoilage Gram-positive bacteria. Furthermore, the RP-R extract inhibited the growth of the Gramnegative E. coli and P. vulgaris bacteria. All extracts showed strong scavenging activity for DPPH, ABTS, nitrite, and reducing power determined by A 700 nm. In particular, the RC50s of the RP-R extract for the DPPH anion and ABTS cation were 23.0-29.7 and 15.0-18.2 ㎍/ml, respectively, which are comparable to those of vitamin C (9.8 and 8.0 ㎍/ml, respectively). An activity assay of α-glucosidase and β-amylase suggested a high potential for the RP-R extract as an anti-diabetic agent. Its inhibition levels of α-glucosidase and β-amylase at 0.5 mg/ml were 6.9 and 48.5%, respectively. This is the first report of the antimicrobial and anti-diabetic activities of R. podophylla. Our results suggest that RP-L and RP-R extracts could be developed as novel cosmeceutical and functional food resources.

The Relationship between the Progression of Chronic Kidney Disease and Beta Cell Function in Non-Diabetic Korean Adults (대한민국 비당뇨 성인에서 만성신장질환과 인슐린저항성 및 베타세포기능의 관련성)

  • Kim, Hyung Rag
    • Korean Journal of Clinical Laboratory Science
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    • v.52 no.3
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    • pp.165-171
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    • 2020
  • This study examined the relationship between chronic kidney disease (CKD) and the homeostasis model assessment of insulin resistance (HOMA-IR) and beta-cell function (HOMA-B) in non-diabetic Korean adults. This study included 4,380 adults aged 20 or older (50.32±16.14) using the 2015 Korea National Health and Nutrition Examination Survey (KNHANES) data, which represents the national data in Korea. The present study had several key findings. First, in terms of HOMA-IR, after adjusting for the related variables (Model 4), the HOMA-IR (M±SE, 95% confidence interval [CI]) in group 1 (G1; estimated glomerular filtration rate [eGFR], ≥90 mL/min/1.73 ㎡), group 2 (G2; eGFR, 60~89 mL/min/1.73 ㎡), group 3a (G3a; eGFR, 30~59 mL/min/1.73 ㎡), and ≥group 3b (≥G3b; eGFR, <30 mL/min/1.73 ㎡) were 1.78±0.03 (1.73~1.83), 1.87±0.03 (1.81~1.93), 2.16±0.13 (1.91~2.42), and 2.59±0.24 (2.12~3.06), respectively. The HOMA-IR was positively associated with the progression of CKD (P<0.001). Second, in terms of the HOMA-B, after adjusting for the related variables (Model 4), the HOMA-B (M±SE, 95% CI) in G1, G2, G3a, and ≥G3b were 87.46±1.21 (85.08~89.84), 89.11±1.38 (86.40~91.81), 104.82±5.91 (93.23~116.42), and 123.97±10.87 (102.66~145.29), respectively. HOMA-B was positively associated with the progression of CKD (P<0.001). Both insulin resistance and the beta-cell function were positively associated with CKD in non-diabetic Korean adults.

Clinical Features and Treatment Response in 18 Cases with Idiopathic Nonspecific Interstitial Pneumonia (특발성 비특이성 간질성 폐렴 18례의 임상상 및 치료반응)

  • Kang, Eun-Hae;Chung, Man-Pyo;Kang, Soo-Jung;An, Chang-Hyeok;Ahn, Jong-Woon;Han, Joung-Ho;Lee, Kyung-Soo;Lim, Si-Young;Suh, Gee-Young;Kim, Ho-Joong;Kwon, O-Jung;Rhee, Chong-H.
    • Tuberculosis and Respiratory Diseases
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    • v.48 no.4
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    • pp.530-542
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    • 2000
  • Background : Nonspecific interstitial pneumonia (NSIP) has been reported recently to have shown much better response to medical treatment and better prognosis compared with idiopathic UIP. However, clinical characteristics of idiopathic NSIP discriminating it from UIP have not been clearly defined. Method : Among 120 patients with biopsy-proven diffuse interstitial lung diseases admitted to the Samsung Medical Center between July 1996 and March 2000, 18 patients with idiopathic NSIP were included in this study. Retrospective chart review and radiographic analysis were performed. Results : 1) At diagnosis, 17 patients were female and the average age was $55.2{\pm}8.4$ years (44~73 years). The average duration from development of respiratory symptom to surgical lung biopsy was $9.9{\pm}17.1$ months. Increase in bronchoalveolar lavage fluid lymphocytes ($23.0{\pm}13.1%$) was noted. On HRCT, ground glass and irregular linear opacity were observed, but honeycombing was absent in all patients. 2) Corticosteroids were initially given to 13 patients, but the medication was stopped in 3 patients due to severe side effects. Further medical therapy was not possible in 1 patient who experienced streroid-induced psychosis. Herpes zoster (n=3), tuberculosis (n=1), avascular necrosis of the hip (n=1), cataract (n=2) and diabetes mellitus (n=1) developed during prolonged corticosteroid administration. Of the 7 patients receiving oral cyclophosphamide therapy, hemorrhagic cystitis hindered one patient from continuing with the medication. 3) After medical treatment, 14 of 17 patients improved, and 3 patients remained stable (mean follow-up ; $24.1{\pm}11.2$ months). FVC increased by $20.2{\pm}11.2%$ of predicted value and the extent of ground glass opacity on HRCT decreased significantly ($15.7{\pm}14.7%$). 4) Of the 14 patients who had stopped medication, 5 showed recurrence of NSIP and 2 became aggravated during steroid tapering. All patients with recurrence showed deterioration within one year after completion of initial treatment. Conclusion : Since idiopathic NSIP has unique clinical profiles and shows good prognosis, diagnosis different from UIP, and aggressive medical treatment are needed.

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A Clinical Study of Corrosive Esophagitis (식도부식증에 대한 임상적 고찰)

  • 조진규;차창일;조중생;최춘기
    • Proceedings of the KOR-BRONCHOESO Conference
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    • pp.7-8
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    • 1981
  • Authors observed clinically 34 cases of the corrosive esophagitis caused by various corrosive agents at Kyung Hee University Hospital from Aug. 1978 to Dec. 1980. The results obtained were as follows; 1. Among the 34 patients, male was 19 (55.9%) and female 15(44.1%). Most frequently found age was 3rd decade. 2. 18 cases(52.9%) came to the hospital within 24 hours after ingestion of the agents, and 13 cases(38.2%) within 2 to 7 days. 3. Seasonal distribution showed most frequently in spring(35.3%). 4. The moment of the accident was suicidal attempt in 27 cases(79.4%) and misdrinking in 7 cases(20.6%). 5. Acetic acid was a most commonly used agent, showing 23 cases(67.6%), lye and insecticides were next in order. 6. Common chief complaints were swallowing difficulty and sore throat. 7. The average hospital days was 14.8 days. 8. Esophagogram was performed between 3 to 7 days after ingestion in 13 cases(38.2 %), findings were constrictions on the 1st narrowing portion in 4 cases(30.8%) and within normal limits in 3 cases(23.1%). 9. Esophagoscopy was performed in 31 cases(91.2%) between 2 to 7 days after ingestion, which revealed edema and coating on entrance of the esophagus in 9 cases (29.0 %). Diffuse edema on entire length of the esophagus and within normal limits were next in order. 10. Laboratory results were as follows: Anemia was in 1 cases(2.9%), leukocytosis. in 21 cases (61.8%), increase ESR in 9 cases (26.5%), markedly increased BUN and creatinine in 3 cases (8.8%), and hypokalemia in 1 cases(2.9%). Proteinuria in 10 cases(29.4%) hematuria in 4 cases(l1.8%), and coca cola urine in 3 cases (8.8%). 11. Associated diseases were 3 cases(8.8%) of cancer, 1 cases (2.9%) of diabetes mellitus, and 1 cases(2.9%) of manic depressive illness. 12. Various treatment was given: Esophageal and gastric washing in 23 cases(67.6%) for the emergent treatment, antibiotics in 32 cases(94.1%), steroids in 30 cases(88.2%), bougienation in 5 cases(14.7%), hemodialysis in 1 case(2.9%), and partial esophagectomy with gastrostomy and gastroileal anastomosis in 1 cases(2.9%). 13. Serious complications were observed in 9 cases (26.5%), consisted of 6 cases(17.6%) of esophageal stricture, 1 cases(2.9%), of aute renal failure, 1 cases (2.9%) of pneu momediastinum with pneumonia, and 1 cases (2.9%) of pneumonia.

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Utilization Pattern of Complementary Therapy in Hypertension, Diabetes and Chronic Arthritis Patients Visited to Local Health Center (일개 보건소를 방문하는 고혈압, 당뇨 및 관절염환자의 보완요법 이용실태)

  • Park, Ae-Ju;Park, Jae-Yong;Han, Chang-Hyun
    • Journal of agricultural medicine and community health
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    • v.28 no.2
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    • pp.107-122
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    • 2003
  • Objectives: The objective of this study is to investigate the use rate and some aspect of complementary therapies used by patients with chronic illness(hypertension, diabetic mellitus and chronic arthritis). Methods: 600 patients visiting the health center for one month(Jan. 2001) were interviewed on their complementary therapies used by the subjects for the previous year. Results: About fourteen-eight percent of the respondents used therapies; 35% of patients with hypertension, 44.6% of patients with diabetic mellitus and 62.9% of patients with chronic arthritis, which shows the highest rate among patients with three chronic disease. The use rate of complementary therapies indicates few meaningful differences according to the general characteristics of the interviewees. Hypertension patients used herb medication(31.0%) acupuncture(29.6%) and most of all the other therapies. Diabetic patients used dietary therapy(57.5%) and herb medication(35.1%). Chronic arthritis patients used acupuncture(85%) and herb medication(34.7%). 36.8% of all the patients who used complementary therapies tried more than two therapies. 18.3% of hypertension patients, 24.1% of diabetic patients and 55.9% of chronic arthritis patients used more than two therapies. Acupuncture(47%) was used most frequently, followed by herb medications(26.3%), health assistance utensils(21.8%). oriental therapy(21.8%), physical therapy(9.5%), health assistance food(8.4%), herb(7.7%), Korea hand acupuncture(3.2%), abdomen respiration(1.1%), and pore therapy(0.7%) Oriental clinic was visited most frequently(42.8%), which was used to cure diseases(61.8%), and to relieve symptoms(26.0%). (p<0.001) The cost spent on complementary therapies last year was 90,000 won(40.3%) and there are some cases of more than 500,000 won(31.2%). Most of the patients(56.1%) were satisfied with the complementary therapies, with 6% of them having side effects. 74% of the patients used complementary therapies answered that they would continue them and 56.1% of them also answered that they would continue them and 56.1% of them also answered that they would advise other patients to do them. Advantages(compared with those of orthodox medical treatment) are psychological comfort(28.1%), body protection(26.0%), effectiveness(20.0%). 34% of the patients using complementary therapies wanted to have informational orientation on complementary therapies. These findings reveal that a considerable number of patients with chronic illness(47.5%) tried a variety of complementary therapies. Though 6% of the patients using therapies had side effects, most of the subjects seemed satisfied with them and they are supposed to continue them. Conclusions: In conclusion, health center personnels and medical doctors should pay more attention to the complementary therapies used by patients with chronic illness. They also have to try their best to advise more scientific and informative complementary programs with less side effects and more help to improve their conditions.

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A Study on Perception and Attitudes of Health Workers Towards the Organization and Activities of Urban Health Centers (도시보건소 직원의 보건소 업무에 대한 인식 및 견해)

  • Lee, Jae-Mu;Kang, Pock-Soo;Lee, Kyeong-Soo;Kim, Cheon-Tae
    • Yeungnam University Journal of Medicine
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    • v.12 no.2
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    • pp.347-365
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    • 1995
  • A survey was conducted to study perception and attitudes of health workers towards health center's activities and organization of health services, from August 15 to September 30, 1994. The study population was 310 health workers engaged in seven urban health centers in Taegu City area. A questionnaire method was used to collect data and response rate was 81.3 percent or 252 respondents. The following are summaries of findings: Profiles of study population: Health workers were predominantly female(62.3%); had college education(60.3%); and held medical and nursing positions(39.6%), technicians(30.6%) and public health/administrative positions(29.8%). Perceptions on health center's resources: Slightly more than a half(51.1%) of respondents expressed that physical facilities of the centers are inadequate; equipments needed are short(39.0%); human resource is inadequate(44.8%); and health budget allocated is insufficient(38.5%) to support the performance of health center's activities. Decentralization and health services: The majority revealed that the decentralization of government system would affect the future activities of health centers(51.9%) which may have to change. However, only one quarter of respondents(25.4%) seemed to view the decentralization positively as they expect that it would help perform health activities more effectively. The majority of the respondents(78.6%) insisted that the function and organization of the urban health centers should be changed. Target workload and job satisfaction: A large proportion (43.3%) of respondents felt that present target setting systems for various health activities are unrealistic in terms of community needs and health center's situation while only 11.1 percent responded it positively; the majority(57.5%) revealed that they need further training in professional fields to perform their job more effectively; more than one third(35.7%) expressed that they enjoy their professional autonomy in their job performance; and a considerable proportion (39.3%) said they are satisfied with their present work. Regarding the personnel management, more worker(47.3%) perceived it negatively than positive(11.5%) as most of workers seemed to think the personnel management practiced at the health centers is not fair or justly done. Health services rendered: Among health services rendered, health workers perceived the following services are most successfully delivered; they are, in order of importance, Tb control, curative services, and maternal and child health care. Such areas as health education, oral health, environmental sanitation, and integrated health services are needed to be strengthening. Regarding the community attitudes towards health workers, 41.3 percent of respondents think they are trusted by the community they serve. New areas of concern identified which must be included in future activities of health centers are, in order of priority, health care of elderly population, home health care, rehabilitation services, and such chronic diseases control programs as diabetes, hypertension, school health and mental health care. In conclusion, the study revealed that health workers seemed to have more negative perceptions and attitudes than positive ones towards organization and management of health services and activities performed by the urban health centers where they are engaged. More specifically, the majority of health workers studied revealed to have the following areas of health center's organization and management inadequate or insufficient to support effective performance of their health activities: Namely, physical facilities and equipments required are inadequate; human and financial resources are insufficient; personnel management is unsatisfactory; setting of service target system is unrealistic in terms of the community needs. However, respondents displayed a number of positive perceptions, particularly to those areas as further training needs and implementation of decentralization of government system which will bring more autonomy of local government as they perceived these change would bring the necessary changes to future activities of the health center. They also displayed positive perceptions in their job autonomy and have job satisfactions.

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A Comparative Study on the Pattern of Outpatient Department Utilization at a Tertiary Level Hospital before and after Implementation of the Patient Referral System (의료전달체계 실시 전후의 3차 진료기관 외래환자 이용양상 비교)

  • Lee, Kyeong-Soo;Kim, Chang-Yoon;Kang, Pock-Soo
    • Journal of Preventive Medicine and Public Health
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    • v.25 no.1
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    • pp.88-100
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    • 1992
  • This study was conducted to assess the effects of implementation of the patient referral system started July 1st, 1989. A comparison on the pattern of outpatient services of the Departments of Internal Medicine, General Surgery, and Pediatrics at the Yeungnam University Hospital was conducted for each one year period before and after implementation of the patient referral system. The pre-implementation period was from July 1, 1988 to June 30, 1989 and the post-implementation period was from July 1, 1989 to June 30, 1990. The information used for this study was obtained from official forms, prepared by the Yeungnam University Hospital, and submitted to the Korean Medical Insurance Cooperatives. After implementation of the patient referral system, the number of outpatient cases in the Department of Internal Medicine decreased 36.1% from 9,669 cases to 6,181 cases a year. Cases in the Department of General Surgery decreased 23.7% from 1,864 cases to 1,422 cases a year. The number of cases in the Department of Pediatrics decreased 36.9% from 3,372 cases to 2,128 cases a year. After implementation of the patient referral system, the average age of cases in the Departments of Internal Medicine and General Surgery was 52.5 and 49.7 years old, respectively. This was a significant increase in comparison with the pre-implementation period. After implementation of patient referral system, the proportion of new outpatients in the Department of Internal Medicine decreased from 24.1% to 14.6%, the Department of General Surgery from 36.0% to 23.4%, and the Department of Pediatrics from 15.5% to 8.3%. The number of visits per case decreased significantly in the Department of Internal Medicine(from 1.74 to 1.61), but there was no significant change in the Departments of General Surgery and Pediatrics. The length of treatment per case increased significantly in all three departments(from 16.1 days to 19.3 days in the Department of Internal Medicine, from 12.0 days to 15.2 days in the Department General Surgery, and 8.9 days to 11.2 days in the Department of Pediatrics). The number of clinical tests per case increased significantly in the Department of Internal Medicine (from 2.2 to 2.5), in the Department of Pediatrics(from 0.8 to 1.1) and increased in the Department of General Surgery(from 6.4 to 6.6). The average medical cost per case decreased from 43,900 Won to 42,500 Won in the Department of Internal Medicine, while the cost increased from 75,900 Won to 78,500 Won in the Department of General Surgery and from 12,700 Won to 13,500 Won in the Department of Pediatrics. In case-mix, the chronic degenerative disease(i. e. hypertension, diabetes mellitus, angina pectoris, malignant neoplasm, and pulmonary tuberculosis) ranked higher and acute infectious diseases and simple cases(i. e. gastritis and duodenitis, haemorrhoids, anal fissure, carbuncle, acute URI, and bronchitis) ranked lower after implementation of the patient referral system compared to before implementation.

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