INTRODUCTION
Family medicine is a medical specialty, which provides comprehensive and continuing health care for the individual and their family members irrespective of age, gender, and disease [1,2]. The holistic nature of family medicine also emphasizes health promotion and disease prevention [1]. In South Korea (hereafter Korea), family medicine was introduced in 1979 and has been functioning as the center of primary care [2]. The number of board-certified family physicians increased to 6,935 (7.8% of all medical specialties) in 2020 [3]. In some countries such as Australia, Canada, Norway, Sweden, and England, primary care is the point of access to other specialists [4]. However, since visits to a primary care physician are not mandatory before consulting a specialist, a designated primary care physician for each patient does not exist systematically in Korea.
The lack of regular primary care physicians may cause several problems [5,6]. When patients visit a specialist based on their own judgement, the choice of specialty or specialist may be incorrect. Patients are more likely to undergo unnecessary examinations because doctors are unaware of the patients’ detailed medical history and previous test results. Consequently, overall medical expenses and social costs also increase [5,6].
The Lifetime Health Maintenance Program (LHMP) is a lifelong health management program that aims to prevent diseases and promote health throughout the lifetime of each individual [7]. It aims to detect diseases at an early asymptomatic period (secondary prevention), prevent disease development by identifying individualized health risk factors and behavior modification (primary prevention), and treat diseases appropriately to improve the quality of life (health promotion) [7]. The concept of LHMP is comparable to that of the clinical preventive health care in Canada and clinical preventive services in the United States [8,9]. In Korea, the LHMP was introduced in 1995 by the Korean Task Force on LHMP [7]. Since 1995, many primary care clinics and hospitals have adopted this program to provide lifelong health management to their patients. This method can overcome the systematic lack of regular primary care physicians in Korea because patients are registered with a single doctor in this program, which ensures continuity of care.
Although the LHMP has been implemented in many clinics and hospitals, very few studies have reported on the management of patients. Therefore, in this study, we present the clinical content of LHMP patients registered with a single family physician who introduced the LHMP in Korea and operated the program in a tertiary hospital for over 30 years.
METHODS
1. Study Participants
We analyzed the electronic medical records of 745 patients, who had registered for more than 3 times with the LHMP under the care of a single family physician (Y.S.K.), between January 1, 2010, and December 31, 2019. The registration period for the LHMP is 2 years. Therefore, patients who wanted to continue participating in the LHMP had to register every 2 years. The institutional review board (IRB) of Asan Medical Center (IRB approval no., 2021-1540) approved the study protocol and waived the requirement for consent to participate statement because this study was conducted through a retrospective review of medical records.
2. Data Collection and Measurement
We reviewed medical records from June 1989, when the hospital was established, to February 2022. Y.S.K., who managed the LHMP, and S.Y.K., a family physician, independently reviewed the medical records for accuracy. Medical records of the hospital were computerized in 2007. Prior to 2007, test results and medication prescriptions were preserved as electronic medical records, while clinical records written by doctors were preserved in optical files. Therefore, we were able to thoroughly investigate the medical records of patients over 30 years. We collected the participants’ age at the time of LHMP enrollment, sex, initial consultation date, and final consultation date. We evaluated whether each participant had visited the outpatient clinic more than once for acute symptoms and chronic diseases while registered with the LHMP. The acute symptoms were as follows: upper respiratory tract infection, abdominal pain, dizziness/vertigo, headache, lower back pain, chest pain, shoulder/elbow/wrist pain, knee pain, sinusitis/tonsillitis, Helicobacter pylori eradication, hip/pelvic pain, pruritus/urticaria, herpes simplex/zoster, ankle/foot/sole pain, urinary tract infection, neck pain, cellulitis/skin infection, and pneumonia. The chronic diseases included dyslipidemia, hypertension, osteoarthritis, osteoporosis/osteopenia, diabetes, benign prostate hyperplasia, tinea/onychomycosis, fatty liver, female menopause, hyperuricemia, alcoholic liver disease, anemia, cancer, chronic hepatitis B/C, testosterone deficiency syndrome, chronic kidney disease, hypothyroidism, ischemic heart disease/stroke, alopecia, hyperthyroidism, atrial fibrillation, cognitive impairment/dementia, and chronic obstructive pulmonary disease/asthma. Furthermore, we evaluated whether each participant had received psychiatric consultation for anxiety, insomnia, and depression, and counseling on health behaviors such as obesity, smoking cessation, and alcohol consumption. Additionally, we evaluated the health checkup items and lists of vaccinations that the participants received. The specific tests of the health checkup were as follows: gastroscopy, colonoscopy, abdominal ultrasound, bone densitometry, chest radiography, low-dose chest computed tomography (CT), Papanicolaou (Pap) smear, mammography, breast ultrasound, serum prostate-specific antigen (PSA) level, serum alpha-fetoprotein (AFP) level, fecal occult blood test (FOBT), 24-hour blood pressure monitoring, and Patient Health Questionnaire–9. The vaccinations administered included influenza, zoster, pneumococcus, hepatitis A, hepatitis B, and tetanus. Consultation content was divided into the following six categories: acute symptoms, chronic diseases, psychiatric consultation, counseling on health behaviors, vaccinations, and health checkups. Among these categories, acute symptoms, chronic diseases, and psychiatric consultations were grouped as illness visits, while counseling on health behaviors, vaccinations, and health checkups were grouped as wellness visits.
3. Statistical Analysis
Descriptive statistics were used to present the number and proportion of participants for each consultation content. We conducted subgroup analysis according to sex. Chi-square tests were conducted to evaluate the association between age at the time of registration, sex, duration of LHMP enrollment, and each category of consultation content (acute symptoms, chronic diseases, psychiatric consultation, counseling on health behaviors, vaccinations, and health checkups). Furthermore, the number and proportion of participants according to the number of categories were presented. Chi-square test was performed to evaluate the association of age at the time of registration, sex, and duration of LHMP enrollment with the number of categories of consultation content. Statistical analyses were performed using IBM SPSS Statistics for Windows ver. 27.0 (IBM Corp., Armonk, NY, USA). Two-tailed P-values <0.05 were considered statistically significant.
RESULTS
1. General Characteristics of Patients in the Lifetime Health Maintenance Program
Table 1 shows the basic characteristics of the 745 participants enrolled in the LHMP. The mean age at the time of registration was 53.1±11.6 years. Among them, 54.5% were female. The mean duration of LHMP enrollment was 17.3±6.7 years; 13.8%, 46.6%, 35.6%, and 4.0% of the participants had registered for <10, 10–19, 20–29, and ≥30 years, respectively.
2. Content Analysis of Illness Visits
Table 2 shows the consultation content for illness visits. Among the acute symptoms, the top five diagnoses were upper respiratory infection, abdominal pain, dizziness/vertigo, headache, and lower back pain. More than 60% of the patients had visited the LHMP more than once for upper respiratory infections. Among the chronic diseases, the top five diagnoses for LHMP visits were dyslipidemia, hypertension, osteoarthritis, osteoporosis/osteopenia, and diabetes. In men, the top five diagnoses were dyslipidemia, hypertension, benign prostate hyperplasia, diabetes, and osteoarthritis, whereas in women the top five diagnoses were dyslipidemia, osteoporosis/osteopenia, hypertension, and osteoarthritis. More than 95% of the patients diagnosed with dyslipidemia, hypertension, tinea/onychomycosis, hypothyroidism, ischemic heart disease/stroke, alopecia, hyperthyroidism, and atrial fibrillation received pharmacotherapy (data not shown). Approximately 28%, 23%, and 20% of the patients received psychiatric consultation more than once for anxiety, insomnia, and depression, respectively. More women received psychiatric consultations than men.
3. Content Analysis of Wellness Visits
Table 3 shows the consultation content for wellness visits. The results of counseling on health behaviors showed that 32.5%, 20.8%, and 11.0% consulted more than once for obesity, alcohol consumption, and smoking cessation, respectively. More men received counseling on health behaviors than women. Pharmacotherapy was provided to ≥70% of the patients who received consultations for obesity and smoking cessation. However, only 21.9% of the patients received pharmacotherapy during alcohol counseling (data not shown). The top five tests for health checkups were chest radiography, gastroscopy, abdominal ultrasound, colonoscopy, and bone densitometry. In men, the top five investigations were serum PSA level, abdominal ultrasonography, gastroscopy, chest radiography, and colonoscopy, whereas in women, they were chest radiography, bone densitometry, gastroscopy, abdominal ultrasonography, and mammography. Influenza was the most common vaccination followed by pneumococcus and zoster.
4. Relationship between Patients’ Characteristics and Consultation Contents
Table 4 shows the general characteristics of patients according to the six categories of consultation content. More than 90% of the 745 patients visited the LHMP for management of acute symptoms, chronic diseases, and health checkups, whereas <50% visited the LHMP for psychiatric consultations and counseling on health behaviors. The proportion of patients who visited the LHMP for chronic diseases and psychiatric consultations increased with age at the time of registration. Conversely, the proportion of patients who visited the LHMP for counseling on health behaviors and vaccinations increased as the age at the time of registration decreased. The proportion of patients who visited the LHMP for acute symptoms, vaccinations, and health checkups increased as the duration of program enrollment increased. Table 5 shows the general characteristics of patients according to the number of categories of consultation content. Generally, the number of categories increased as the duration of program enrollment increased.
DISCUSSION
In this observational study of outpatient primary care over a 30-year period, patients visited the LHMP for various reasons, including acute symptom management, chronic disease management, psychiatric consultation, counseling on health behaviors, health checkups, and vaccination. The top five diagnoses for acute symptom management were upper respiratory infection, abdominal pain, dizziness/vertigo, headache, and lower back pain, whereas those for chronic disease management were dyslipidemia, hypertension, osteoarthritis, osteoporosis/osteopenia, and diabetes. More than one in five patients received psychiatric consultation and counseling on health behaviors. Patients who were older at the time of registration visited more frequently for chronic disease management and psychiatric consultation; patients who were younger at the time of registration received counseling on health behaviors and vaccinations. Female patients had more psychiatric consultations, while their male counterparts received more counseling on health behaviors. As the duration of the program enrollment increased, the proportion of patients visiting the LHMP for acute symptoms, vaccinations, and health checkups also increased. Furthermore, the number of categories of consultation content increased for each patient.
In this study, the top five diagnoses for acute symptom management were upper respiratory infection, abdominal pain, dizziness/vertigo, headache, and lower back pain, whereas those for chronic disease management were dyslipidemia, hypertension, osteoarthritis, osteoporosis/osteopenia, and diabetes. According to a systematic review of primary care data from 12 countries, the top diagnoses in developed countries were hypertension, upper respiratory infection, back pain, arthritis, dermatitis, acute otitis media, diabetes, cough, and urinary tract infection, which are similar to the findings of this study [10]. The top diagnoses in developing countries were somewhat different as many of those were related to infections such as pneumonia, tuberculosis, parasites, bronchitis, and tonsillitis [10]. The prevalence of hypertension and diabetes in this study was 61.2% and 34.4%, respectively, which was similar to the national prevalence among those aged ≥65 years in 2020 (61.4% for hypertension and 30.1% for diabetes) [11]. However, the prevalence of dyslipidemia (69.7%) in this study was much higher than the national prevalence of hyperlipidemia (40.8%) and hypertriglyceridemia (10.2%) among those aged ≥65 years [11]. The difference in the prevalence of dyslipidemia between patients in this study and the general population is due to different definitions of dyslipidemia. Dyslipidemia in this study was defined based on the cardiovascular risk: lowdensity lipoprotein cholesterol (LDL-C) ≥160 mg/dL for the low-risk group, LDL-C ≥130 mg/dL for the moderate-risk group, LDL-C ≥100 mg/dL for the high-risk group, and LDL-C ≥70 mg/dL for the very high-risk group, whereas hyperlipidemia in the national data was defined universally as total cholesterol ≥240 mg/dL or the intake of lipid lowering medications [11,12].
This study identified the reasons for patients’ visits to the LHMP. Patients visited for both illness and wellness, similar to the observations of previous studies [10,13-15]. Remarkably, approximately 45% of the participants received psychiatric consultations during the LHMP in this study. According to a Primary Care Network Survey in the United States, visits for mental disorders were approximately 5% [13]. Furthermore, in an international comparative study conducted in the Netherlands, Malta, and Serbia, the prevalence of depression in primary care was <4% [14]. The high proportion of psychiatric consultations in our study could be due to the following reasons: First, patients who had received psychiatric consultations in this study implied those who had ≥1 psychiatric consultations, and the mean enrollment duration was 17.3 years; thus, the proportions were not the same as the point prevalence. Additionally, the attending physician (Y.S.K.) had extensive experience and interest in psychiatric consultations. Furthermore, individuals with psychiatric problems more likely registered with the LHMP. Our study showed that psychiatric consultations can be effectively conducted by primary care physicians.
In our study, approximately 99% of the patients underwent a health checkup. An Irish study of general practitioner consultations found that 60% and 37% of patients underwent health checkups in a general medical service and private clinic, respectively [15]. The socioeconomic status of the patients in this study was higher than that of the general population because they could afford to visit a tertiary hospital. The high socioeconomic status of patients may have led to higher health checkup rates. Furthermore, individuals who required a health examination were probably registered with the LHMP and the attending physician might have recommended it during consultation. There are differences between health examinations in Korea and Western countries. Due to the high prevalence of gastric and liver cancer in Korea, the national health screening program provides biennial gastroscopy for those ≥40 years and serum AFP and liver ultrasound for those with hepatitis B virus infection, hepatitis C virus infection, or liver cirrhosis [16-18]. Furthermore, an annual FOBT is provided for those ≥50 years, and if, positive, a colonoscopy is included. Biennial low-dose chest CT for lung cancer screening is provided for those aged between 54 and 74 years with a history of ≥30-pack-years of cigarette smoking. A biennial mammography is provided for women ≥40 years; a biennial Pap smear is provided for those ≥20 years [18]. Primary care physicians recommend individualized health checkups to patients based on the national health screening program.
Our analysis identified sex-related differences in several categories of consultation content. First, female patients were more likely to receive psychiatric consultations than male patients. This may be due to a higher prevalence of mood or anxiety disorders among women than men [19]. It could also be due to sex-related differences in the utilization of mental health services. In previous studies, females with mental health problems were more likely to visit outpatient clinics than males [20,21]. It is important to create a healthcare environment in which individuals with mental health problems have easy access to physicians to prevent delayed diagnosis and undertreatment of psychiatric disorders. In this study, health promotion counseling was conducted more frequently among male patients. The prevalence of obesity, alcohol consumption, and smoking is higher among men than among women in Korea [22,23]. Due to the higher prevalence of poor lifestyle factors among men, male patients received more health promotion counseling than females. Previous studies have reported sex-based differences in the clinical content of primary care. In a Swedish study, cystitis, fatigue, hypothyroidism, depression, and acute sinusitis were significantly higher among women, and diabetes and multiple wounds were higher among men [24]. Furthermore, an Irish study reported a higher prevalence of central nervous system, gastrointestinal, urinary tract, and endocrine conditions among women and cancer and renal conditions among men [15]. In this study, the prevalence of cancer and diabetes was higher among men, and urinary tract infection, hypothyroidism, and sinusitis were higher among women, which is consistent with the findings of previous studies.
Furthermore, patients who were older at the time of registration were more likely to have chronic disease management and psychiatric consultations because age is the main risk factor for chronic diseases [25]. However, patients who were younger at the time of registration were more likely to receive counseling on health behaviors and vaccination. In Korea, the prevalence of alcohol consumption and smoking is higher among young adults compared to the general population [26]. Therefore, younger adults underwent more lifestyle interventions than older adults. The duration of LHMP enrollment was associated with the categories of consultation content, emphasizing the importance of regular primary care physicians. This proves that comprehensiveness, which is an advantage and a characteristic of primary care, is achieved through the continuity of care.
This is the first study to report the contents of LHMP in Korea. Although the LHMP was introduced in 1995, its real-world clinical data has not been reported. The average duration of program enrollment was approximately 17 years. Patients visit the LHMP for various health issues, including acute symptoms, chronic diseases, psychiatric issues, counseling on health behaviors, vaccinations, and health checkups. Furthermore, the number of categories of consultation content generally increased as the duration of program enrollment increased. In this context, our study demonstrates the diversity of the clinical content and continuity of care provided by the LHMP. We showed that the LHMP can be a good method to achieve the “4Cs (first contact, comprehensiveness, coordination, and continuity)” of primary care in places where regular primary care physicians do not exist [27]. Moreover, this study emphasizes the need for systematizing regular primary care physicians in Korea. We showed the various types of clinical content of the LHMP run by a single primary care physician and demonstrated the importance of continuity of care. The continuity of primary care physician is important because it is associated with lower medical expenditure, hospitalization rates, and mortality [28,29]. Therefore, it is important to modify the policies that hinder primary care in Korea.
One limitation of this study is the generalizability of the findings. As the study participants were patients who had registered with the LHMP under the care of a single family physician in a tertiary hospital, the findings do not represent the entire primary care environment in Korea. Multicenter studies, including small private and primary outpatient clinics in both secondary and tertiary hospitals, should be conducted to evaluate the overall clinical content of the LHMP. Furthermore, long-term outcomes, such as medical costs, hospitalization rates, and mortality of those registered with the LHMP, should be examined to evaluate the efficacy of the program.
Currently, a “regular, designated” primary care physician does not exist in Korea. The LHMP serves as an intermediate step in the systematization of regular primary care physicians. Because primary care is an essential part of the healthcare system, policy changes are necessary to strengthen it.
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