Arch. Pharm. Res. (2015) 38:1389–1396 DOI 10.1007/s12272-014-0406-5
RESEARCH ARTICLE
Patient factors affecting frequent potential unnecessary injection use in outpatient care setting Hyun Soon Sohn • Sunmee Jang • Euna Han Eun-Ju Lee • Soon-ae Shin • Ju-Yeun Lee
•
Received: 2 February 2014 / Accepted: 23 April 2014 / Published online: 17 May 2014 Ó The Pharmaceutical Society of Korea 2014
Abstract This study aimed to investigate the prevalence of potential unnecessary injection (PUNI) and to identify factors associated with frequent PUNI uses. Populationbased National Health Insurance claims data for outpatient health care settings during the six month period from July to December 2011 were retrospectively reviewed. Patients aged 18–80 without severe diseases and visited healthcare centers more than 25 times during study period were included. PUNI was defined as injection used where substitutable oral agents were available and where injection uses are not warranted. A total of 801,532 patients were included for this analysis. Among them, 29.0 % were frequent PUNI user defined as C10 PUNI used during the study period. In multivariate logistic regression results revealed significant associations between frequent PUNI use and several patient and healthcare utilization factors. H. S. Sohn College of Pharmacy, Ajou University, Suwon, Korea S. Jang College of Pharmacy, Gachon University, Incheon, Korea E. Han College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Korea E.-J. Lee School of Public Health, Seoul National University, Seoul, Korea S. Shin Big Data Steering Department, National Health Insurance Service, Seoul, Korea J.-Y. Lee (&) College of Pharmacy, Institute of Pharmaceutical Science and Technology, Hanyang University, Gyeonggi, Korea e-mail:
[email protected]
Women than men, elderly than younger people, residents in rural areas than in big cities, and more frequent visitors to healthcare centers than less frequent visitors were more likely to be frequent PUNI users. Larger number of healthcare center utilized and higher out-of-pocket expense level showed significant lower risks of frequent PUNI uses. Identified factors associated with frequent PUNI use in this study could be the targets to develop programs for reducing injection overuse. Keywords Outpatient
Potential unnecessary injection Overuse
Introduction Injection should be used only in a situation where a definitive guideline for choosing parenteral route is established or there is no available oral formulation (Simonsen et al. 1999; Shatsky 2009), as numbers of risks are reported to be associated with parenteral administration. The potential risks range from local to systemic, including injection site bleeding, inflammation, atrophy, nerve injury, anaphylactic shock, as well as transmission of blood borne infection (Abkar et al. 2013; Gupta et al. 2013; Kahn and Styrt 1997; Fiechter et al. 2005; Barnes et al. 2012; Ramtahal et al. 2006). Therefore, in outpatient settings, nonparenteral administration is recommended in principle, whereas in a practice, injections are frequently used in situations where patient’s symptoms or disease status do not warrant injection treatment or when oral alternatives are available. We may consider those cases as potential unnecessary injection (hereafter ‘‘PUNI’’) uses, even though some healthcare professionals may not agree with the terms of ‘unnecessary use’. This PUNI use may be
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derived from common belief of health care professionals and patients on superiority of injection formulation in terms of drug effect and faster onset time compared to oral medication (Schwartz et al. 2000; Hwang et al. 2007). Number of other factors such as patient or physician characteristics, physician’s knowledge, patient’s demand for injection, and competitive medical environments to retain patient may contribute in prescribing injection over oral formulation (Hwang et al. 2007; Dong et al. 2011). PUNI is also associated with increased medical expenditure as drug acquisition and administration cost of injection is usually higher than oral formulation. Thus, in both clinical and economic aspects, PUNI, especially in outpatient setting, should be minimized where possible. However, PUNI use and overuse in outpatient settings are being continuously reported, especially in developing countries, and it is of concern (Logez et al. 2004; Rajasekaran et al. 2003; Vong et al. 2005; McLaws et al. 2014). There are growing consensuses on possible achievement of appropriate injection use, through behavioral changes of both patient and healthcare professional. Enhancing public awareness for the risks of unsafe and unnecessary injection use is one of measures that World Health Organization (WHO) recommended for safe and appropriate use of injection, expecting behavioral changes to reduce number of unnecessary injection uses (Dziekan et al. 2003). Even though discussion on proper management of injection use is ongoing to reduce risks to patients and health workers and indirect risks to the community via the environment (Kaipilyawar 2005; Gyawali et al. 2013), an alarming number of unnecessary and unwarranted injection formulas are being used possibly due to still existing popular demand for injections (Kotwal 2005). The prescription rate of injections for outpatients in South Korea was 20.5 % in 2012, according to a semiannual report (Health Insurance Review and Assessment Service 2012). This statistic carefully indicates patient’s higher demand for injection coming from their misunderstanding better effects of injection than oral formula as the above-mentioned (Hwang et al. 2007; Kim et al. 2012; McLaws et al. 2014). This may also be interlinked with current national regulatory environment to make parenteral administration more convenient, that injections are allowed to be administered inside the medical institution whereas oral formulation drugs should be dispensed outside the medical institution. Tagging along the practice of WHO, South Korea has initiated a measure to yield such behavioral changes. This includes public disclosure of injection prescribing rates for outpatients at individual healthcare institution level implemented by National Health Insurance Service (NHIS) since 2006. The injection prescribing rate was used as one of indicators of appropriateness of healthcare services and its public
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disclosure was subsequently expected to lead behavioral changes of healthcare providers. But, in addition to healthcare provider-focused strategies, patient-focused strategies would be necessary in order to achieve rational drug uses. It is not exceptional for the PUNI uses. In this respect, investigations on PUNI use pattern and patient factors contributing frequent PUNI are compulsory, and they will be of help in designing practical programs to minimize PUNI uses. The aims of this study were to investigate the prevalence of PUNI uses and to identify patient factors associated with frequent PUNI uses.
Materials and methods Database and patient selection In this retrospective study, we used population-based national health insurance (NHI) claims data for outpatients provided by the NHIS, a single public health insurance payer in South Korea. NHIS claims data comprised of patient’s socio-demographic information and healthcare utilization information including diagnoses, physician visits, medical care services, and drug prescriptions, etc. for all the NHIS beneficiaries covering about 97 % of the Korean populations (National Health Insurance Service, Health Insurance Review & Assessment Service 2013). Target patients were adult aged 18–80 who visited to outpatient setting of general hospitals, hospitals, clinics or public health centers at least 25 times during the 6 month study period from July 1, 2011 to December 31, 2011. The frequency of 25 times was equivalent to one physician visit every week. We considered that frequent injection uses were highly prevalent in frequent healthcare user such as every week visitors. The database provided by NHIS excluded patients younger than 18 and extreme elderly patients aged 80 above, and patients with severe diseases such as cancer, cardio-or cerebrovascular disease, rare disease, incurable disease and dementia being managed by national registries. These several diseases were not included because we could not judge patient’s medical conditions whether injection use was necessary or not, using claims data alone. De-identified data were provided in compliance with the NHIS regulations to protect personal information. This study was reviewed and approved by the Institutional Review Board of NHIS.
Potential unnecessary injection use All the drug prescriptions during six months from July to December 2011 for individual patients were integrated to investigate overall injection uses. PUNI was defined as an
Factors affecting potential unnecessary injection use
injection prescribed even where clinically substitutable oral formula medications with the same active ingredient were available. Available oral form medications equivalent to injection form were verified based on the national formulary list effective on May 1, 2012, notified by the Korean health authority. Injection prescriptions conforming to the following drug-based criteria were excluded in counting PUNI uses, based on the predefined drug codes: 1) injection prescribed at the emergency room; 2) injection which had less than two substitutable oral formulas of same ingredient within the national formulary list; 3) injection prescribed in a clinical situation requiring prompt onset of drug effect, such as heart stimulants, anti-arrhythmics, antihypertensives, vasodilators and electrolytes, and so forth.; 4) injection indicated for severe conditions such as cancer, hemophilia, chronic renal failure and organ transplantation, and antiemetic injections used for auxiliary purpose in patients undergoing surgery or anticancer therapy; 5) injection corresponding antipsychotics and anti-epileptics, controlled substances, and psychotropic drugs and narcotics; and 6) regulatory approved indication of injection was not equivalent to same ingredient oral medications. A dummy indicator was generated for frequent PUNI, defined by PUNI uses more than 10 times during 6 months of study period.
Independent variables Independent variables included patient’s socio-demographics and healthcare utilization characteristics. Patient’s socio-demographic characteristics included age, gender, residence area, nationality, insurance premium level and family size. Age was divided into elderly and non-elderly with fifteen years intervals and corresponding dummy indicator was generated with 18–34 years old as the reference. Residence areas were grouped by size including big city, medium/small city and rural area, with big city residence as the reference. Nationality was divided with Korean and foreigner with Korean as the reference. Family sizes were divided by number of family members into three groups of 1–5 ? with 1–2 as the reference. As a variable presenting patient’s economic level, health insurance premium levels were divided into quartile-based four groups of high, high to medium, medium to low, and with low as the reference. Healthcare utilization variables included type and number of healthcare center visited, frequency of outpatient visit, total medical expenditure and out-ofpocket expense. Types of healthcare centers were divided into five groups by the size including teaching hospital, general hospital, hospital, clinic and public health center, with teaching hospital as the reference. Frequencies of outpatient care setting visits, and total medical
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Subjects aged 18-80 with more than 25 visits for outpatient care during 6 months (2011.7-12) (N= 2,1113,939) PUNI users (N=801,532)
Frequent PUNI users (at least 10 times) (N=232,370)
Infrequent PUNI users (N=569,162)
Fig. 1 Patient selection scheme. PUNI, potential unnecessary injection
expenditures and out-of-pocket money level were divided into four groups respectively, discretionally considering their median values in all the patient group. Statistical analysis Descriptive analysis was performed to summarize patient characteristics and healthcare utilizations in PUNI users who frequently visited outpatient care settings. Accumulative number of PUNI use per patient was counted and frequently used PUNI drug classes among PUNI users were analyzed. Comparisons between groups (frequent PUNI users vs. infrequent PUNI users) were conducted using a t test or a Chi square test for continuous or categorical variables. Multivariate logistic regression model was used to determine odds ratios and the 95 % confidence interval for independent variables to identify factors associated with frequent PUNI uses. Value of p \ 0.05 was considered to be statistically significance. An SAS version 9.1 was used for all statistical analyses (SAS Institute, Cary, NC).
Results PUNI use pattern A total of 801,532 patients were PUNI users with at least one prescription of PUNI during 6 months in outpatient settings who eligible for patient selection criteria, and 29.0 % (232,370 patients) of these PUNI users were frequent PUNI users who had 10 or more PUNI prescriptions during the study period (Fig. 1). An average prescribing rate of PUNI per visit was 20.4 %, and 9.4 % of PUNI users showed more than 50 % injection prescribing rate per visit. Their average visit number of healthcare center was 40.0 times (Table 1). The national formulary included a total of 868 ingredients and 3,438 products of injection formula. Of them, 61 (7.0 %) ingredients and 443 (12.9 %)
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1392 Table 1 Potential unnecessary injection use pattern
H. S. Sohn et al.
PUNI uses
N
Total number of PUNI user Frequency of PUNI use
Prescribing rate of PUNI per visit (%)
801,532
(100.0)
1–5
415,083
(51.8)
6–10
180,493
(22.5)
11–15
92,761
(11.6)
16–20
50,669
(6.3)
C21
62,526
Mean ± SD
(7.8) 20.4 ± 18.2
0 \ % \ 50
734,111
(91.6)
50 B % \ 80
57,935
(7.2)
C80 %
9,486
(1.2)
Frequency of outpatient care visit of PUNI users
Mean ± SD
Drug class of PUNI
Analgesics
3,807,644
(57.9)
NSAIDs
1,837,971
(28.0)
Mucolytics
297,098
(4.5)
Muscle relaxant Spasmodics
201,215 91,292
(3.1) (2.9)
Propulsives
39,664
(2.1)
Antibacterials
39,943
(0.6)
H2 blockers
31,234
(0.5)
Cephalosporins
22,396
(0.3)
Corticosteroids
13,202
(0.2)
Penicillins
10,022
(0.2)
Quinolones
7,489
(0.1)
Diuretics
5,003
(0.1)
Vitamins
4,909
(0.1)
Anti-dementia drugs
4,907
(0.1)
Other
2,660
(0.0)
Total
6,576,706
(100.0)
PUNI, potential unnecessary injection; SD, standard deviation
products were included in PUNIs (Data not shown). The top ranked drug class of PUNIs was analgesics (57.9 %), followed by nonsteroidal anti-inflammatory drugs (NSAIDs) (28.0 %)(Table 1). Frequent PUNI users: patient characteristics and healthcare utilizations Patient socio-demographics and healthcare utilizations in the frequent PUNI user group (at least 10 prescriptions of PUNI) and infrequent PUNI user group (less than 10 prescriptions of PUNI) during the study period were summarized in Table 2. In the frequent PUNI user group, women accounted for 71.3 %, the average age was 65.5 years old, and the elderly aged 65 or more accounted for 63.0 %. Approximately one third (30.1 %) of patients lived in rural areas, and non-Koreans accounted for 0.3 %. The average number of family members was 3.5, and those with 5 or more accounted for 31.6 %. The average number of healthcare centers they visited during the study period was 5.6 and they mainly visited clinics to use UNI (97.2 %).
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(%)
40.0 ± 18.9
Frequent PUNI user group showed a higher frequency of outpatient care clinic visits during the study period than infrequent UNI user group (average 48.1 times versus 36.7 times). The total medical expenditure of the frequent PUNI user group was an average of US $724 while the infrequent user group consumed a total of US $624 for the same time period. On the other hand, out-of-pocket expense was US $180–US $184 for the frequent and the infrequent PUNI user groups, respectively. The proportion of out-of-pocket expenses in the total medical expenditure was lower in the frequent user group (24.6 %) than the infrequent user group (28.8 %) (Table 2). Factors affecting frequent PUNI use Multivariate logistic regression analysis results revealed significant associations between frequent PUNI use and some patient factors. Positive demographic determinants of the PUNI use included gender, age, area of residence and nationality. Women (odds ratio, OR = 1.22, 95 % confidence interval, CI 1.20–1.23) and elderly patients
Factors affecting potential unnecessary injection use Table 2 Patient characteristics and healthcare utilization in PUNI users
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Characteristics
Total no. of patients
p value1
Infrequent PUNI users
Frequent PUNI users
N
(%)
N
(%)
569,162
(100.0)
232,370
(100.0)
Socio-demographics Gender Age (years)
Area of residence
Insurance premium level (quartile)
Men
186,111
(32.7)
66,750
(28.7)
Women
383,051
(67.3)
165,620
(71.3)
\0.001
Mean ± SD
61.0 ± 13.1
65.5 ± 10.9
\0.001
18–34
28,302
(5.0)
3,535
(1.5)
\0.001
35–49 50–64
74,066 191,826
(13.0) (33.7)
17,390 65,072
(7.5) (28.0)
C65
(63.0)
274,968
(48.3)
146,373
Big city
234,799
(41.3)
69,595
(30.0)
Medium/ small city
229,044
(40.2)
92,742
(39.9)
Rural area
105,200
(18.5)
69,976
(30.1)
1 (low)
102,090
(17.9)
43,204
(18.6)
2
101,264
(17.8)
42,188
(18.2)
3
138,663
(24.4)
57,115
(24.6)
\0.001
\0.001
4 (high)
205,949
(36.2)
80,622
(34.7)
Nationality
Korean
566,345
(99.5)
231,734
(99.7)
No. of family members
Non-Korean Mean ± SD
2,817 (0.5) 3.4 ± 2.1
636 (0.3) 3.5 ± 1.9
\0.001
1
90,076
(15.8)
35,669
(15.4)
\0.001
2-4
324,165
(57.0)
123,205
(53.0)
C5
154,802
(27.2)
73,439
(31.6)
Teaching hospital
2,358
(0.4)
87
(0.0)
General hospital Hospital
8,900
(1.6)
1,211
(0.5)
11,764
(2.1)
3,757
(1.6)
\0.001
Healthcare utilization during 6 months Type of healthcare center patient utilized
Total no. of healthcare center utilized per patient
1
t-test or Chi square test
PUNI, potential unnecessary injection; SD, standard deviation; OOP, out-of-pocket
Clinic
530,452
(93.2)
225,879
(97.2)
Public health center
15,688
(2.8)
1,436
(0.6)
Mean ± SD
6.0 ± 2.6
\0.001
\0.001
5.6 ± 2.8
1
8,086
(1.4)
6,886
(3.0)
2
28,730
(5.0)
18,393
(7.9)
3 4
57,116 81,251
(10.0) (14.3)
29,340 35,908
(12.6) (15.5)
(69.2)
141,843
(61.0)
\0.001
5?
393,979
Frequency of outpatient care visit
Mean ± SD
36.7 ± 14.6
48.1 ± 24.9
\0.001
Total medical expenditure (US$)
Mean ± SD
624 ± 326
724 ± 398
\0.001
Out-of-pocket expense (US$)
Mean ± SD
184 ± 132
180 ± 129
\0.001
Percentage of OOP expense in total medical expenditure (%)
Mean ± SD
28.8 ± 9.3s
24.6 ± 8.8
\0.001
(OR = 1.74 in 35–49 years, OR = 2.49 in 50–64 years, OR = 2.93 in elderly aged 65 or older, comparing to young adults aged 18–34 years) were more likely to be frequent
PUNI users. Patients living in rural areas showed higher probability of frequent PUNI use than big city residents (OR = 2.09, 95 % CI 2.06–2.11) while foreigners were less
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Table 3 Factors affecting frequent potential unnecessary injection use: multivariate logistic regression
H. S. Sohn et al.
Variables
Adjusted OR
Gender Age (years)
Area of residence
Insurance premium level (quartile)
Nationality No. of family member
Type of healthcare center patient utilized
Total no. of healthcare center utilized per patient
Frequency of outpatient care visit
Total medical expenditure (US$)
Out-of-pocket expense (US$) PUNI, potential unnecessary injection; OR, odds ratio; CI, confidence interval
likely to use frequent PUNI than Koreans. But, the insurance premium level and number of family members were not variables showing constant associations with frequent PUNI uses, even though patients at the highest insurance premium level less likely used frequent PUNI comparing to the lowest level (OR = 0.87, 95 % CI 0.86–0.89), and patients with larger family size more than 5 used more frequently PUNI than smaller sized family (OR = 1.10, 95 CI 1.08–1.12). For the healthcare utilization variables such as type of healthcare center and number and frequency of healthcare center utilized by patient, frequent PUNI uses were more
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Men
1
Women
1.22
18–34
1
95 % CI
p value
1.20
\0.0001
1.23
35–49
1.74
1.68
1.81
\0.0001
50–64
2.49
2.40
2.58
\0.0001
C65
2.93
2.82
3.04
\0.0001
Big city
1
Medium/small city
1.36
1.34
1.37
\0.0001
Rural area
2.09
2.06
2.11
\0.0001 0.0029
1 (Low)
1
2
1.03
1.01
1.05
3
0.99
0.98
1.01
0.4601
4 (High)
0.87
0.86
0.89
\0.0001
Korean
1
Foreigner
0.90
0.83
0.99
0.0277
1–2
1
3–4
1.00
0.98
1.01
0.7597
C5
1.10
1.08
1.12
\0.0001
Teaching hospital
1
General hospital
2.28
1.82
2.85
\0.0001
Hospital
6.47
5.19
8.06
\0.0001
Clinic
7.65
6.16
9.50
\0.0001
Public health center
1.00
0.80
1.25
0.9685
1
1
2
0.80
0.77
0.83
\0.0001
3
0.65
0.63
0.68
\0.0001
4
0.57
0.55
0.59
\0.0001
C5
0.43
0.41
0.44
\0.0001
25–29
1
30–34
1.56
1.53
1.58
\0.0001
35–40
2.17
2.13
2.21
\0.0001
C40
4.28
4.21
4.36
\0.0001
B364
1
364 \ B 545
0.91
0.89
0.93
\0.0001
545 \ B 727
0.85
0.83
0.87
\0.0001
[727
1.06
1.03
1.09
\0.0001
B91
1
91 \ B136
0.91
0.90
0.93
\0.0001
136 \ B 182
0.81
0.79
0.82
\0.0001
[182
0.64
0.63
0.66
\0.0001
likely occurred in clinics than teaching hospitals (OR = 7.65, 95 % CI 6.16–9.50). But the total number of healthcare centers patients utilized showed negative associations with frequent PUNI uses, while patients with frequent healthcare utilizations (?40 times) showed higher probability of PUNI uses than with 25–29 times utilization during the study period (OR = 4.28, 95 % CI 4.21–4.36). Total medical expenditure was not constantly associated with frequent PUNI uses, but out-of-pocket expenses was associated. Patients who paid out-of-pocket expense more than US $182 showed less likely PUNI use than patients who
Factors affecting potential unnecessary injection use
paid less than US $91 (OR = 0.64, 95 % CI 0.63–0.66) (Table 3).
Discussion This study investigated the prevalence of PUNI use among frequent ambulatory visitors and determinants of frequent PUNI use. 76.7 % of frequent adult ambulatory visitors without severe diseases used at least one PUNI and 29.0 % of them were frequent PUNI users with 10 or more prescriptions during the 6 month study period. Most prevalent PUNI drugs (86 %) were analgesics and NSAIDs. In this study, increased age and increased frequency of outpatient care visit demonstrated positive correlations with frequent PUNI uses (p \ 0.0001). Patients at the highest economic level paying the 4th level of health insurance premium showed less likely use frequent PUNI compared with the lowest level. Increased out-of-pocket expense showed negative association with frequent PUNI uses (p \ 0.0001). In summary, elderly woman patients who lived in rural area with big family members, utilized clinics frequently and paid lower out-of-pocket expense were revealed as a possible higher risk group of frequent UNI uses. The phenomenon of higher injection use in the elderly had been reported recently by Choi KH et al. who investigated injection overuse in Korea (Choi et al. 2012). They demonstrated that younger patients, living in urban area and visited bigger sized hospitals tended to use oral formula more than injection, while the elderly group wanted prescription of injections for fast relief of symptoms. The association with different healthcare utilization between urban and rural populations was reported in other countries as well (Logez et al. 2004) likely this study. Another study to investigate the utilization of injections for oral-injection dual-dose-form ingredients in Korea reported a higher likelihood of injection use in the elderly living in rural areas (Lee et al. 2014). For safe and appropriate use of medicine, reduction in PUNI use should be considered and leading behavioral changes of patient can be one of the important step. For the patient group with identified as risk factors related with PUNI use, several interventions could be developed in reducing injections (Kim et al. 2012). Education is discussed as an essential element to influence prescribing behavior and provide a foundation of knowledge that will enhance and increase the acceptance of strategies. Hwang et al. also emphasized the necessity of community–based education in a study reporting that patient’s lack of awareness of risks associated with injections and their strong believes in fast action of injections were driving factors of injection overuse (Hwang et al. 2007). However, education alone without the incorporation of active intervention, may not sufficiently achieve sustained effects to change injection prescription practices, thus, financial
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incentives and development of clinical criteria and guidelines which recommend conversion of injection to oral formulas in outpatient settings are suggested to facilitate PUNI use reduction (Reynolds and McKee 2011). Accordingly, development of interventions to reduce injection overuse in frequent PUNI user groups with higher risks identified in this study seemed to be necessary. This study was conducted using national insurance claims data covering majority of population in Korea. Although the results of this study can be applied to the other countries having similar healthcare systems but we do not guarantee generalizability in other countries where they have different healthcare systems and patient behaviors. The findings from this study could be an important evidence to identify PUNI use risk groups who would be the primary target group to change behaviors, as the first step in making a systematic plan for conversion from injection to oral formulas by healthcare decision makers in actual outpatient settings in South Korea. However, this population based retrospective study has some limitations and the study result should be interpreted with caution. First, in defining PUNI, we could not consider individual patient’s medical conditions, so this study result possibly included clinical discrepancies in judging unnecessary or necessary injection use. Second, in screening oral form interchangeable injection use, we included only injections that there were two or more substitutable oral form drugs of same ingredient within the national formulary. It meant that all the injections of products which there were available only one oral form medicine substitutable to injection were not counted as PUNI use. This conservative approach possibly led to be underestimated PUNI uses. Third, patients with more than 25 times outpatient care setting visit were included in this analysis. The findings from these frequent ambulatory visitors group may weaken generalizability to all the outpatient group. Despite the fact that this study presents PUNI use patterns and some factors associated with frequent PUNI uses from analyses based on frequent ambulatory healthcare users who may not be suitable to represent entire population, it is meaningful as the first whole population based study to investigate PUNI use pattern in outpatient settings nationwide. It could provide important and valuable evidence to support necessity of strategies to minimize PUNI uses.
Conclusion This study demonstrated significant amounts of PUNI use in real-world outpatient settings in South Korea. It becomes imperative to develop strategies evidenced from current situations. Especially frequent PUNI users with risk factors identified in this study could be the target group for
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designing future programs to reduce injection overuse in South Korea. Acknowledgments We thank the National Health Insurance Service for providing us with the NHI data for this study. This work was supported by the NHIS (2012). Conflict of interest All authors certify that there is no conflict of interest with any financial, personal or other relationships with other people or organizations that could inappropriately influence or be perceived to influence this study.
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