Copyright � The Korean Academy
of Medical Sciences
J Korean Med Sci 2007; 22: 518-23
ISSN 1011-8934
텅홱칩캤후캣회즉쥡크캥캄홱크좍후캣홰홱즉크썼쥠크터회캤홱칩캤홱크회즉크텃썼캣홱칩
This paper provides an overview of the Korean Burden of Disease (KBoD) study,
which was the first such study to assess the national burden of disease using disability-adjusted life years (DALYs) in an advanced Asian country. The KBoD study
generally followed the approach utilized in the original Global Burden of Disease
study (GBD), with the exception of the disease classification and epidemiological
data estimation methods used, and the relative weightings of disabilities. The results
of the present study reveal that the burden of disease per 100,000 of the Korean
population originates primarily from; cancer (1,525 Person Years, PYs), cardiovascular disease (1,492 PYs), digestive disease (1,140 PYs), diabetes mellitus (990
PYs), and certain neuro-psychiatric conditions (883 PYs). These results are largely
consistent with those of developed countries, but also represent uniquely Korean
characteristics.
텝홱썼밗폭텁후즉크홈썼썼즉포크텝칩즉쥡폭빔캄홱썼투크좍칩홱*포크
텝칩즉쥡폭텀투크텄홱홱�포크좼컥홱획후즉쥡크빔캄칩즉쥡�포크
좼홱후회크텝후쥡크텁썼�포크텁썼썼폭좼후즉크텝후즉쥡‖포크
텁칩홱폭좼컥후즉크심칩캣밗¶포크텁회즉폭홈썼즉쥡크텄홱홱**포
홈썼후즉쥡캤썼썼크텝캄회즉**
Department of Preventive Medicine, College of Medicine,
Korea University, Seoul; Department of Internal
Medicine*, Division of Rheumatology, College of
Medicine, Hanyang University, Seoul; Department of
�
Preventive Medicine , University of Ulsan, Seoul;
�
Department of Health Sercive Management , Kyung
Hee University College of Business Administration,
�
Seoul; Departments of Health Policy and Management ;
Department of Preventive Medicine‖, College of
Medicine, Kangwon National University, Choncheon;
Research Institute for National Cancer Control and
Evaluation National Cancer Center¶, Goyang;
Department of Health Policy And Management**,
Seoul National University College of Medicine, Seoul,
Korea
Received : 30 August 2006
Accepted : 25 October 2006
탱홰홰캣홱캤캤크쥠썼캣크쥑썼캣캣홱캤툼썼즉홰홱즉쥑홱
Seok-Jun Yoon, M.D.
Department of Preventive Medicine, College of
Medicine, Korea University, 126-1 Anam-dong 5-ga,
Sungbuk-gu, Seoul 136-705, Korea
Tel : +82.2-920-6412, Fax : +82.2-927-7220
E-mail : yoonsj02@korea.ac.kr
*This research was supported by the Korean Health
21 R&D Project, Ministry of Health & Welfare, Republic
of Korea (01-PJ1-PG1-OICH10-0007).
Key Words : Mortality; Morbidity; Korea; Burden of Disease
INTRODUCTION
den of disease issues raised by the GBD (3, 8). In Korea, changing disease trends have been observed over recent years. Specifically, the natures and magnitudes of the threats posed by
contagious diseases have receded, whereas the prevalences of
non-contagious and chronic diseases have increased (9). Moreover, such changes weigh heavily on the national healthcare
system, and make the process of resource allocation a difficult
proposition (10).
In this article, we describe some of the key findings of the
KBoD study, which was initiated in the early 2000s and continues today.
In this study, we provide an overview of the Korean Burden of Disease (KBoD) study, which was the first study of
its type to assess the national burden of disease in an advanced
Asian country, using disability-adjusted life years (DALYs)
as measures of disability.
Burden of disease measurements that employ DALYs have
been previously utilized by several studies conducted at international and national levels (1-5).
The DALYs concept was initially developed by Murray
and Lopez, and was applied for the first time in their authoritative Global Burden of Disease (GBD) project (6, 7). This
project commenced in the early 1990s and involved researchers
in many countries. Moreover, its results have been published
in a variety of forms, and researchers in many countries involved, and continue to make, recommendations at the national level and expedite programs that properly address the bur-
MATERIALS AND METHODS
Overview
In general, the KBoD study followed the protocols of the
518
Burden of Disease in Korea
original GBD study (6). However, the KBoD study differs
in terms of the detailed methodology used with respect to;
the disease classification and epidemiological data estimation
methods used, and the relative weighting of disabilities.
Development of disease classification
In order to evaluate burden of disease and health care performance, a measure is needed that can be used to quantify
scientific health status and to create a systematically organized
classification system capable of comprehensibly including
every important disease entity.
DALY is a summary measure that represents health status.
Using DALYs, WHO arranged ICD codes into 3 major groups, 16 sub-categories, and 93 third-level categories. However, decisions concerning the diseases that should be measured and the units of estimation used are as important as
the need for a measurement index. In the present study, we
developed a new disease classification that can be used to fully
adjust the structure of diseases in Korea and health care performance.
First, we collected and addressed the disease classifications
used by WHO and other DALYs yielding procedures. Second, the characteristics of the data sources used to estimate
DALYs were scrutinized. Third, the project units of public
health activity and public health-related medical services that
are in need of the evaluation of public health performances
were comprehensibly grasped. Fourth, representative data
concerning the disease structure in Korea such as major causes
of death and frequent medical service utilizing diseases were
investigated. Fifth, based on the above, we developed a new
disease classification, which included several added disease
entities, and then consulted a team of clinical and public health
specialists about the new disease classification system.
Our disease classification is based on the Global Burden
of Disease as defined by WHO, and adheres to the principle
that a disease classification should be exhaustive and exclusive.
On the other hand, considering the ease of approach offered
by intervention, and attempt was made to avoid overly detailed
disease classifications. In addition, we added diseases included
in the Korean national infectious disease surveillance system
and the national cancer registration project.
The following diseases (all of which are currently included
in the national communicable disease surveillance system)
were added to group I of the GBD classification (communicable diseases); herpes genitalia, cholera, typhoid and paratyphoid, shigellosis, mumps, rubella, and chicken pox. In addition, we also added pneumonia and influenza to the classification system. These were added because they were described
as ‘lower respiratory infections’ in the previous GBD classification. Moreover, these diseases are included in the Korean
Contagious Disease Prevention Act and thus need to be monitored separately. In group 2 (non-communicable diseases),
gallbladder cancer, thyroid cancer, kidney cancer, brain can-
519
cer, and bone and cartilage cancer were added to the ‘Malignant neoplasm’ subcategory. These disease entities have been
under continuous surveillance by the Korean National Cancer Registry project, and are also included in the list of the
236 most frequent causes of death in Korea. Benign brain
neoplasm was added to the ‘other neoplasms’ subcategory,
because the disease process and final results associated with
brain neoplasms are similar to those of other malignancies.
However, neuro-psychiatric diseases were addressed in a somewhat different manner. Instead of simply adding locally important diseases to the current GBD classification, we elected
to change the disease classification hierarchy itself.
Consequently, we added a new disease group, which includes
19 disease entities, namely, 8 communicable diseases, 6 neoplastic diseases, and 5 neuro-psychiatric conditions.
Estimation of epidemiologic parameters
In order to determine the incidences and prevalence of all
disease categories, we constructed a large normative cohort,
representing the Korean population in 1998 as a cooperative
project with the National Health Insurance Corporation of
Korea. The Korean National Health Insurance system is an
obligatory program that covers all 47 million Koreans. Korean National Health Insurance and related data sources have
been previously described in detail (11). We randomly sampled 1,209,693 persons, and stratified them for age into 5-yr
age groups, sex, area of residence (Seoul/large city/other), and
type of insurance (employee/self-governor/medical aid). The
Korean Normative Cohort includes 2.5% of all Koreans, with
and overrepresentation of elderly, to add stability to estimated
parameters (Table 1). For the cohort, morbidity and mortality outcomes were followed using data links to the National
Health Insurance (KNHI) medical claim and Korean National Statistical Office (NSO) databases during the period 1998
until June 2002. ICD-10 codes which are used by both the
KNHI and NSO were reclassified according to disease classification. All prevalence, incidence, and mortality data were
estimated from unit disease classification. Prevalences (per
1,000 persons per year) were calculated after averaging the
total number (person-base) of those who had been diagnosed
during the follow-up period (1998-2002). Incidences were
calculated for 2000 and 2001 after excluding patients who
had visited hospital during the first two years (i.e., 1998-1999).
To reduce possible over-estimations of morbidity rates caused
by using medical claim data, an operational definition for
each disease category was made by specialists. For example,
cancer cases were counted only when the diagnosis was made
in a general hospital, and there were two or more claims for
the same disease category. Moreover, all bona vide cancer cases
deemed to have required more than one admission event. In
terms of mortality, causes of death as reported by the NSO
were used as was.
To further refine morbidity rates, 3,678 cases in 9 typical
S.-J. Yoon, S.-C. Bae, S.-I. Lee, et al.
520
Table 1. Characteristics of the representative Korean Normative Cohort
Cohort
Age group
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95-99
100+
Total
Korean population (2000)
Sampling rate
Male
Female
Total
Male
Female
Total
Male
Female
Total
42,345
47,821
41,357
48,191
50,586
56,885
57,771
56,073
53,023
38,530
30,177
25,022
20,905
14,190
8,521
5,189
3,040
1,640
879
501
370
603,016
38,256
41,887
37,222
45,161
48,420
53,941
55,392
53,333
50,945
37,251
29,545
26,420
24,518
19,621
14,106
9,569
6,542
5,138
3,322
2,729
3,359
606,677
80,601
89,708
78,579
93,352
99,006
110,826
113,163
109,406
103,968
75,781
59,722
51,442
45,423
33,811
22,627
14,758
9,582
6,778
4,201
3,230
3,729
1,209,693
1,689,517
1,903,325
1,659,786
1,926,753
2,021,488
2,260,009
2,303,166
2,242,344
2,125,313
1,532,344
1,195,544
1,003,925
840,681
568,990
336,557
209,170
98,983
34,080
8,957
984
172
23,962,088
1,538,491
1,676,991
1,490,692
1,805,403
1,922,269
2,162,330
2,206,046
2,123,583
2,035,562
1,492,612
1,178,793
1,068,758
971,217
777,065
568,539
387,997
218,104
104,093
33,216
6,658
2,048
23,770,467
3,228,008
3,580,316
3,150,478
3,732,156
3,943,757
4,422,339
4,509,212
4,365,927
4,160,875
3,024,956
2,374,337
2,072,683
1,811,898
1,346,055
905,096
597,167
317,087
138,173
42,173
7,642
2,220
47,732,558
2.51
2.51
2.49
2.50
2.50
2.52
2.51
2.50
2.49
2.51
2.52
2.49
2.49
2.49
2.53
2.48
3.07
4.81
9.81
50.91
215.12*
2.52
2.49
2.50
2.50
2.50
2.52
2.49
2.51
2.51
2.50
2.50
2.51
2.47
2.52
2.53
2.48
2.47
3.00
4.94
10.00
40.99
164.01*
2.55
2.50
2.51
2.49
2.50
2.51
2.51
2.51
2.51
2.50
2.51
2.52
2.48
2.51
2.51
2.50
2.47
3.02
4.91
9.96
42.27
167.97*
2.53
*This age group included those who died between 1998 and 2001, which resulted in oversampling compared with the surviving cross-sectional population.
In an effort to generate a stable epidemiological indicator, weights of 3% or more were given to age groups of 80 or older as follows: 3% (80-84), 5%
(85-89), 10% (90-94), 50% (95-99), 100% (100 or older).
disease groups (asthma, epilepsy, stroke, myocardial infarction, herniated intervertebral disk, rheumatoid arthritis, systemic lupus erythematosus, lung cancer, and common surgical conditions) were sampled to validate the KNHI diagnosis based on a medical record review. The concordance rate,
which was defined based on ‘‘probable cases’’ and ‘‘confirmed
cases’’, was as low as 52.6% for asthma (298 acceptable cases
out of 567 claims) and as high as 84.1% for a herniated intervertebral disk (132 acceptable cases out of 157 claims). Several
factors were found to be associated with validity, i.e., admission/outpatient, patient age, type of hospital, whether operations were performed or not, total cost, and length of admission. Models were constructed to predict the probability of
validity of each case, using the above medical utilization factors. Original prevalence and incidences were recalculated
by summing predicted probabilities to yield adjusted morbidity rates. Adjusted morbidity rates were compared to those
in previous independent Korean reports when possible.
In order to determine disability duration and average age
at onset, we used the DisMod II model (12). Prevalence,
incidences, and specific mortality rates were required to estimate disability duration and average age at onset.
Disability weight
When developing our new classification system, it was
found necessary to standardize and quantify a number of social
preferences, in order to accurately deduce a set of disability
weightings. Multiple measurement methods were used to
perform this task, these included person trade off (PTO), time
trade off, visual analogue scale, and standard gamble. In the
GBD study, however, a protocol was developed based on the
PTO measurement scheme (6). In the present study, we selected 16 indicator conditions that fit the Korean context, using
three selection criteria as follows: health state should be meaningful in terms of public health, health status is most popular, and health status can be represented on a scale from 0
(representing a good state) to 1 (representing a fatal state of
health). After conducting a pilot test of the method using a
group of medical students, the PTO protocol was revised in
order to render it more appropriate for this study. The 16 indicator conditions are as follows: Chronic back pain, Colon
and rectum cancers, Down syndrome, Diabetes mellitus, Peptic ulcer disease, Stomach cancer, Hepatitis B and hepatitis
C, Influenza, pneumonia, Unipolar major depression, Dementia, Low birth weight, Schizophrenia, Iron-deficiency anemia,
Ischemic heart disease, Epilepsy, and Rheumatoid arthritis.
We then assigned preference weights to selected indicator
conditions using the following procedure. First, 30 doctors
were grouped into three panels of 10 individuals. The proportions of physicians and preventive medicine specialists
were almost same in each panel.
Burden of Disease in Korea
521
The first measurement group contained one female doctor
and the 2nd and 3rd groups two apiece. Second, each of the
three panels was then assigned preference weighting for the
16 indicator conditions, each group taking a different date.
Third, panel members took approximately 30 min to assign
preference weightings to each of the health states, using a
form developed for this study and by following a coordinator’s instructions, were based on PTO1 and PTO2 protocols,
respectively. Panel members recorded values to the questions
asked in these variants, provided reasons for their answers,
and discussed results with other members. After this process
had been repeated three times, each of the members provided
final values for PTO 1 and PTO2 variants. Forth, disability
weightings (DW) were calculated for each of the health states
using the PTO values obtained from the panels, as follows:
DW=1-1000/PTO1=1000/PTO2. Fifth, median disability
weights were recorded on the disability scale, for each of the
16 indicator conditions.
Then, for health states other than those covered by the 16
indicator conditions, each panel member was presented with
a set of 37 health states; 30 of which were selected from different categories and 7 from a list of common core diseases.
Panel members then assigned preference weights to a total
of 123 health states, including the indicator conditions, by
interpolation, using the disability scale that had been developed for the indicator conditions.
Finally, the study employed generalizability theory, which
is commonly used in the reliability behavior theory, to estimate the relative magnitudes of various components of mea-
surements (generalizability study or G study), by analyzing
the reliability coefficient (G coefficient) and ensuring the
desired level of reliability (decision study or D study) (13, 14).
The results of this G study revealed that the degree of contribution made by the 16 indicator conditions was 78.3%.
This indicates that the total variance could be explained by
the indicator conditions, and that the measurement errors
associated with panels and panel members were essentially
insignificant. In terms of total variance, 5.2% was explained
by all of the other interactions among the sources of error. The
D study showed that the generalizability coefficient was greater
than 0.9 in all nine, which suggests a high level of reliability. The generalizability coefficient associated with research
design (i.e., indicator conditions, taking triplicorte measurements, 10 respondents for each panel) was also found to be
high, at 0.973.
After completing this process, we estimated DALYs with
regard to disease burden in the Korean population.
RESULTS
The burdens imposed by major disease groups (DALYs
lost per 100,000 of the population) are shown in Fig. 1. Cancer was found to be the most prominent cause of disease burden, with a score of 1,525, followed by cardiovascular diseases
Diabetes mellitus
CV A
Cirrhosis of the liver
Cancer
Asthma
Cardiovascular disease
Ischemic heart disease
Digestive disease
Peptic ulcer disease
Diabetes mellitus
Liver cancer
Respiratory disease
Trachea, bronchus, and lung cancers
Neuro-psychiatric conditions
Stomach cancer
Musculo-skeletal disease
COPD
Infectious and parastitic disease
Unipolar major depression
Respiratory infection
Schizophrenia
Skin disease
Skin disease
Genito-urinary disease
Reumatoid arthritis
Sensory organ disease
Tuberculosis
YLD
Oral condition
Glomerulonephritis
DALYs per 100,000 population
Fig. 1. Burden of disease (years of life lost to premature mortality
[YLL], years of life lost due to disability [YLD] and total disabilityadjusted life years [DALYs]) for broad disease groups in Korea
in 2002.
Note: DALYs due to injuries are excluded.
0
Epilepsy
0
20
0
40
0
60
0
80
0
1,0
00
1,2
00
1,4
00
1,6
00
1,8
00
Marternal condition
1,2
00
Hepatitis B and hepatitis C
1,0
00
YLD
80
0
YLL
Endocrine disorders
60
0
YLL
Colon and rectum cancers
40
0
Otitis media
Congenital anomalies
20
0
Conditions arising during perinatal period
DALYs per 100,000 population
Fig. 2. Top twenty diseases as determined by burden of disease
(years of life lost to premature mortality [YLL], years of life lost due
to disability [YLD] and total disability-adjusted life years [DALYs])
for major diseases in Korean men in 2002.
Note: DALYs due to injuries are excluded.
S.-J. Yoon, S.-C. Bae, S.-I. Lee, et al.
522
at 788, followed by diabetes mellitus (740) and asthma (710)
(Fig. 3).
The burden attributable to unipolar major depression was
determined to be twice as high in women than in men, whereas the disability burden associated with cirrhosis of the liver
was determined to be 3.7 times as high in men than in women
(Fig. 2, 3).
Diabetes mellitus
Cardiovascular disease
Peptic ulcer disease
Asthma
Reumatoid arthritis
Unipolar major depression
Ischemic heart disease
Osteoarthritis
Skin disease
DISCUSSION
Chronic obstructive pulmonary disease
Stomach cancer
Schizophrenia
Otitis media
Breast cancer
Cirrhosis of the liver
Trachea, bronchus and lung cancers
Liver cancer
YLL
Glomerulonephritis
YLD
Colon and rectum cancers
1,0
00
80
0
60
0
40
0
20
0
0
Epilepsy
DALYs per 100,000 population
Fig. 3. Top twenty diseases as determined by burden of disease
(years of life lost to premature mortality [YLL], years of life lost due
to disability [YLD] and total disability-adjusted life years [DALYs])
for primary diseases in Korean women in 2002.
Note: DALYs due to injuries are excluded.
(1,492), digestive diseases (1,140), diabetes mellitus (970),
respiratory diseases (951), and neuro-psychiatric conditions
(883). The mortality burden of cancer (YLLs lost per 100,000
of the population) was determined to be the leading cause
of premature mortality, with a score of 1,222, and this was
followed by cardiovascular diseases (768), digestive diseases
(368) and diabetes mellitus (291). Digestive diseases were
determined to be the leading causes of disability in Korea
(injuries not included), with a YLD of 853 per 100,000 individuals, followed by respiratory diseases (841), neuro-psychiatric conditions (768), and cardiovascular diseases (735) (Fig.
1). A list of the top twenty leading causes of disease burden
among men (DALYs lost per 100,000 of the population) is
shown in Fig. 2. Diabetes mellitus was found to be associated with the highest burden of disease with 1,020 DALYs,
followed by CVA (937), cirrhosis of the liver (671), asthma
(663), and ischemic heart disease (601). By individual disease, in men, diabetes mellitus exhibited the highest YLD,
at 801 per 100,000 individuals, followed by asthma (610)
and peptic ulcer disease (547) (Fig. 2).
The top twenty leading causes of disease burden among
women (DALYs lost per 100,000 of the population) are shown
in Fig. 3. Diabetes mellitus was associated with the highest
DALY rate, with a score of 919, followed by cardiovascular
disease (900), peptic ulcer disease (794), and asthma (755)
(Fig. 3). In women, peptic ulcer disease had the highest YLD,
In this study, the authors attempted to measure the burden
of disease in Korea, using DALYs. This study represents one
of the first examples of such calculations using epidemiologic
data and disability weights derived in an Asian country.
DALY, as applied in this study, is a single measurement that
consists of a summation of time lost as a result of premature
death and time lived under disabling conditions. The primary
reason why this indicator has attracted the attentions of researchers in the public health area is that it can be used as a tool
for simultaneously measuring the level of death and prevalence
(8, 15).
The developed classification described above has been found
to be a useful tool for many health related studies in Korea
and allows comparative studies to be conducted between countries. WHO recommends that a summary measure should
correctly reflect the characteristics of a country or region, and
that to achieve an intensive study concentrated on a targeted nation should take priority over any other procedures.
The results are expected to provide us with supportive data
for evidence-based decision-making and health resource allocation. The results obtained reveal that the burden of disease
in Korea originates primarily from cancers, cardiovascular
disease, digestive disease, diabetes mellitus, and neuro-psychiatric conditions (Fig. 1). Our findings in this regard are
comparable with, but clearly different from, a similar study
conducted in Australia (3). In Australia, the burden of disease ranking in men per 100,000 persons using DALY (not
including injuries) was found to be cardiovascular disease,
cancer, mental disorders, nervous system diseases, and chronic respiratory diseases (3).
Our findings also clearly differ from those of the GBD study
for the EME (3, 6), in which the top ranked diseases using
DALYs (not including injuries) were ischemic heart disease,
cerebrovascular disease, dementia, tracheal, bronchial and
lung cancer, unipolar major depression, and osteoarthritis (3,
6), whereas in Korea, the top leading causes were diabetes
mellitus, cerebrovascular disease, asthma, peptic ulcer disease,
ischemic heart disease, and cirrhosis of the liver.
These results indicate that the burden of digestive diseases,
such as, peptic ulcer disease and cirrhosis of the liver, are higher
in Korea than in Australia. Korea’s higher level of digestive
disease burden, especially its higher mortality is explained
by a high prevalence of hepatitis B infection and the dietary
Burden of Disease in Korea
habits of Koreans, who traditionally consume great quantities of salty, highly spiced food (16, 17).
The present study has several limitations. First, some degree
of uncertainty was introduced by estimating epidemiologic
parameters using medical utilization data. Especially, this
study did not have exact information regarding utilization
data of oriental medicine, pharmacy. However, we found that
our results are in line with previous studies on estimated disease incidence in Korea (8, 18). Nevertheless, no prevalences
or incidences were available for most disease categories, and
thus, there remains a possibility that morbidity rates could
have been over- or under- estimated (8). Especially, the possibility remains that morbidity rates of older age group could
have been overestimated due to the over-sampling method
in this study (Table 1). Moreover, the cohort approach used
in the present study provided direct estimates and representative morbidity rates for all disease categories, with a certain
degree of reliability. Second, computerized data regarding
cause of death is not entirely accurate. This is because death
certificates are not always issued by physicians, and even when
a diagnosis is rendered by a physician, discrepancies sometimes exist between recorded causes of death and actual causes
(19). Third, it has also been found to be impossible to determine the burden of disease attributable to injuries in Korea
because resulting insurance claims do not contain details of
injury type. Moreover, given that the attributable burden of
injuries is substantial, this failure to incorporate the influence
of injuries into DALY calculations constitutes a major limitation of this study. Finally, the Korean Burden of Disease
study is limited by its lack of adjustment for comorbidities,
which are likely to affect diseases like diabetes and ischemic
heart disease and thus increase the burden of disease (5).
In conclusion, despite the limitations of the data utilized
in this study, we are confident that DALY is an appropriate
and reasonably accurate tool in the public health area, as has
been found in the Netherlands and Australia. Moreover, the
present study also provided the basic epidemiologic data to
establish an evidence-based health policy.
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