Trends in Physiotherapy Interventions and Medical Costs for Parkinson’s Disease in South Korea, 2011–2020

Article information

J Mov Disord. 2024;17(3):270-281

Publication date (electronic) : 2024 March 19

doi : https://doi.org/10.14802/jmd.23269

Dong-Woo Ryu¹, Jinse Park², Myung Jun Lee³, Dallah Yoo⁴, Sang-Myung Cheon^5,

¹Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea

²Department of Neurology, Haeundae Paik Hospital, Inje University, Busan, Korea

³Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea

⁴Department of Neurology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea

⁵Department of Neurology, School of Medicine, Dong-A University, Busan, Korea

Corresponding author: Sang-Myung Cheon, MD, PhD Department of Neurology, School of Medicine, Dong-A University, 26 Daesingongwon-ro, Seo-gu, Busan 49201, Korea / Tel: +82-51-240-5266 / Fax: +82-51-244-8338 / E-mail: smcheon@dau.ac.kr

Received 2023 December 22; Revised 2024 March 7; Accepted 2024 March 18.

Abstract

GRAPHICAL ABSTRACT

INTRODUCTION

Among neurological disorders, Parkinson’s disease (PD) is a rapidly growing, chronic, progressive neurodegenerative condition [1]. The global prevalence of PD exceeds 8.5 million patients and has increased more than 2.5 times during the last 30 years [2]. PD accompanied by various motor and nonmotor symptoms can decrease quality of life and lead to disability in patients. Eventually, the socioeconomic burden of PD has increased due to expanding health care utilization and associated costs [3,4]. The increase in medical costs associated with PD is influenced by multiple factors, including patient age, disease severity, type of medical service, frequency of health care utilization, medical insurance, and social support [5,6]. Thus, health care accessibility and medical expenses may vary between countries and regions [7,8]. The analysis of health care utilization and expenses among patients with PD can contribute to the efficient allocation of medical resources and the development of successful health care policies.

The treatment strategies for PD include exercise and physiotherapy (PT), which may influence PD progression [9]. Moreover, PT interventions for PD can alleviate motor symptoms and improve balance, gait, and quality of life [10]. Early PT interventions are recommended for PD management to address the potential increase in disability [11], and they may also help improve motor symptoms and quality of life in patients with advanced-stage PD [12]. However, regardless of the therapeutic benefits, increasing PT interventions can lead to increasing medical costs, which strains national insurance financing. In addition, various factors restrict the application of PT interventions. Due to the increasing societal burden of PD and increasing medical costs, an analysis of the utilization of PT interventions among patients with PD is essential. However, no studies have investigated the health care utilization and medical costs associated with PT interventions for patients with PD in South Korea.

This study investigated the trends in PT interventions for patients with PD in South Korea over the past decade, evaluated health care utilization and costs related to PT interventions, and analyzed factors influencing the implementation of PT interventions.

MATERIALS & METHODS

RESULTS

Prevalence and incidence

Over the 10 years between 2011 and 2020, 169,613 patients with PD were diagnosed, accounting for 0.30% of the entire registered population of 57,148,316 patients under the national health care system. The prevalence rate of PD was 296.79 per 100,000 people over the 10 years. Table 1 presents the annual number and prevalence rate of patients with PD over the 10 years, along with their clinical characteristics. Among them, 71,674 (42.26%) were male, and 97,939 (57.74%) were female. With increasing age, the number of patients with PD gradually increased, with 74,763 (44.08%) patients in their 70s. Subsequently, the number decreased to 40,327 (23.78%) in the 80 or older age group. Among all patients with PD, 47,300 (27.89%) were diagnosed with disabilities, 25,445 (15.00%) of whom were classified as being severely disabled. When regarding the residential areas, patients with PD were distributed as follows: 31,627 (18.65%) in Seoul, 39,883 (23.52%) in metropolitan cities, 75,879 (44.74%) in cities, and 22,194 (13.09%) in other regions. The regional distribution of patients with PD is comparable to that of the total population in South Korea. Excluding 12,333 (7.27%) medical aid recipients, patients with PD were distributed based on personal income quartiles as follows: 28,019 (16.52%) were in the first quartile, 20,908 (12.33%) were in the second quartile, 34,036 (20.07%) were in the third quartile, and the largest group of 74,317 (43.82%) was in the highest fourth quartile.

Table 1.

Annual number of patients with Parkinson’s disease (PD) and their characteristics

The number of patients with PD increased from 49,417 (prevalence rate: 97.40) in 2011 to 91,841 (prevalence rate: 177.20) in 2020. During this time period, the proportion of male patients increased from 38.13% in 2011 to 41.51% in 2020. As age increased, the increasing trend in the annual number of patients with PD became more pronounced. Notably, the percentage of PD patients aged 80 years or older significantly increased from 18.67% in 2011 to 34.22% in 2020. The proportion of patients with PD with severe disability increased from 17.08% in 2011 to 22.02% in 2020, whereas the percentage of patients with PD with total disability decreased from 41.80% in 2011 to 33.30% in 2020.

Table 2 displays the annual number and incidence rate of new patients with PD according to sex and age. Excluding the first year of the study period, the incidence of patients with PD gradually increased from 11,105 (incidence rate: 21.80) in 2012 to 15,281 (incidence rate: 29.51) in 2017. The incidence remained relatively stable in 2018 but declined to 14,137 and 13,229 in 2019 and 2020, respectively. The PD incidence in males increased from 4,632 (41.71%) in 2012 to 6,306 (47.67%) in 2020, thus representing a greater increase than that in females. This trend was significant in older patients. The incidence of patients with PD aged 80 years or older increased from 2,237 (20.14%) in 2012 to 4,251 (27.82%) in 2017.

Table 2.

Incidence of patients with Parkinson’s disease according to clinical characteristics

PT interventions

Figure 1 displays the annual number of patients with PD who underwent PT interventions and the corresponding number of prescriptions. Over 10 years, a total of 45,737 patients with PD (26.97%) received PT interventions. The number of patients with PD receiving PT interventions exhibited a progressive increase from 4,847 (9.81%) in 2011 to 13,163 (14.33%) in 2020. Among patients with PD, 31,921 received specialized rehabilitation PTs, which constituted 69.79% of the patients receiving PT interventions. The number of patients with PD receiving specialized rehabilitation PTs gradually increased, starting at 3,017 in 2011 and reaching 8,357 in 2019. Among the patients with PD undergoing PT interventions, the proportion increased from 62.24% in 2011 to 78.87% in 2018, subsequently reaching 66.48% and 60.62% in 2019 and 2020, respectively (Supplementary Table 1 in the online-only Data Supplement).

Figure 1.

Annual number of patients with Parkinson’s disease (PD) receiving physiotherapy (PT) interventions and prescriptions for PT interventions between 2011 and 2020. A: Total number of patients with PD receiving PT interventions over the 10 years. B: Total number of prescriptions for PT interventions for patients with PD over the 10 years. C: Annual number of patients with PD receiving PT interventions. D: Annual number of prescriptions for PT interventions for patients with PD.

Over a decade, 7,080,020 prescriptions were provided for patients with PD. The number of prescriptions for patients with PD increased from 384,755 in 2011 to 918,668 in 2019. Among patients with PD, the prescription rate increased from 7.79 in 2011 to 10.17 in 2020. Among patients with PD, the total number of prescriptions for PT interventions was 2,605,922, with the annual number significantly increasing from 81,220 (21.11%) in 2011 to 371,022 (42.20%) by 2020. Among patients with PD who received PT interventions, the number of prescriptions increased from 16.76 in 2011 to 28.19 in 2020. The total number of prescriptions for specialized rehabilitation PTs was 1,771,276, thus constituting 67.97% of all PT intervention prescriptions. The number of prescriptions for specialized rehabilitation PTs increased from 46,436 in 2011, which accounted for 57.17% of the PT intervention prescriptions, to 249,471 in 2018, which accounted for 74.18% (Supplementary Table 1 in the online-only Data Supplement).

The number of prescriptions for each PT intervention is displayed in Supplementary Table 2 (in the online-only Data Supplement). Among PT interventions, the most frequently prescribed treatments were as follows: rehabilitative development therapy for disorders of the central nervous system (18.88%), gait training (13.72%), complex occupational therapy (9.61%), mattress or mobilization training (7.47%), and special occupational therapy (7.25%) in specialized rehabilitation PTs; deep heat therapy (7.22%), superficial heat therapy with deep heat (6.84%), and transcutaneous electrical nerve stimulation (4.77%) in basic PTs; and interferential current therapy (4.26%) in others.

Medical costs

Table 3 displays the annual medical costs associated with hospitalization and outpatient visits among patients with PD. Medical costs per patient increased from 1,686 USD in 2011 to 3,202 USD in 2020. The number of hospitalized patients with PD increased annually, from 10,228 in 2011 to 24,233 in 2018. Hospitalizations for patients with PD remained within the range of 1.4 to 1.5 times per year over the 10 years. However, the number of days per hospitalization gradually increased from 62.13 days in 2011 to 103.95 days in 2020. Therefore, medical costs per hospitalization increased from 3,989 USD in 2011 to 8,161 USD in 2020. Hospitalization costs per patient with PD increased significantly, starting at 5,648 USD in 2011 and doubling to 12,011 USD in 2020. The actual number of hospitalized patients accounted for approximately 20% of the total patients with PD and consistently increased in accordance with the overall increase in PD incidence. Consequently, among the total population with PD, including hospitalized patients, the hospitalization costs for each patient with PD significantly increased from 1,169 USD in 2011 to 2,889 USD in 2020.

Table 3.

Annual medical costs in patients with Parkinson’s disease

The number of patients with PD who visited outpatient departments exhibited an upward trend, increasing from 46,600 in 2011 to 81,448 in 2020. The number of outpatient visits per patient with PD remained relatively stable at between approximately six and seven visits per year. However, medical costs per outpatient visit decreased from 90 USD in 2011 to 59 USD in 2020. Consequently, the cost per patient with PD visiting the outpatient department progressively decreased from 549 USD in 2011 to 353 USD in 2020. Furthermore, outpatient costs per patient with PD decreased over the years, starting at 522 USD in 2011 and decreasing to 315 USD in 2020.

Table 4 presents the annual medical costs of patients with PD receiving PT intervention. The medical expenses for each patient with PD receiving PT increased steadily from 6,582 USD in 2011 to 13,475 USD in 2020, which surpassed the expenses for a PD patient by approximately fourfold during this time period. Hospitalization costs per patient with PD receiving PT interventions increased from 6,172 USD in 2011 to 13,055 USD in 2020, thus contributing significantly to the overall increase in medical expenses among patients with PD. Figure 2 displays the increase in the annual medical costs of patients with PD and those receiving PT interventions. The annual medical costs per patient with PD receiving PT interventions were greater and increased more steeply than those of patients with PD. The increase in hospitalization costs significantly contributed to the overall increase in medical expenses for both patients with PD and those undergoing PT interventions.

Table 4.

Annual medical costs in patients with Parkinson’s disease receiving physiotherapy interventions

Figure 2.

Annual medical costs per patient with Parkinson’s disease associated with hospitalizations and outpatient visits. Due to rounding differences in the conversion of medical costs into USD, total medical cost and the sum of individuals may show discrepancies at the level of one dollar. PD, Parkinson’s disease; PT, physiotherapy; USD, United States dollar.

Approximately 70% of patients with PD receiving PT interventions were hospitalized, and the number of hospitalized patients increased from 3,743 in 2011 to 10,722 in 2020. Hospitalizations for patients with PD receiving PT interventions were more frequent and longer than those for patients with PD. The number of hospital days per patient with PD receiving PT increased from 74.94 days in 2011 to 125.53 days in 2020. The medical costs per hospitalization of patients with PD undergoing PT increased from 5,034 USD in 2011 to 10,097 USD in 2020. Therefore, the costs per hospitalized patient with PD receiving PT increased from 7,992 USD in 2011 to 16,027 USD in 2020.

The increase in outpatient-visited patients with PD receiving PT was less significant than that in hospitalized patients with PD receiving PT. Except in 2011, outpatient-visited patients with PD receiving PT had more than 20 visits per year, which exceeded the annual number of visits. The annual medical costs per outpatient visit for patients with PD who received PT interventions were lower than those for patients with PD. However, the costs per outpatient-visited patient with PD receiving PTs increased from 534 USD in 2011 to 859 USD in 2019, thus surpassing those of outpatient-visited patients with PD.

Regular PT interventions

Table 5 displays the number of patients with PD who received regular PT and the corresponding ORs. Over 10 years, 31,782 patients with PD (18.74%) had undergone regular PT interventions. Supplementary Table 3 (in the online-only Data Supplement) displays the annual number of patients with PD receiving regular PT. The annual increase in the number of patients with PD receiving regular PT interventions increased from 61.36% in 2011 to 69.54% in 2020. During this time period, all of the patients with PD who underwent regular PT were hospitalized. Among them, approximately 10% received regular PT interventions, both via hospitalizations and outpatient visits, and no patients underwent those interventions solely via outpatient services.

Table 5.

The odds ratios for clinical characteristics associated with receiving regular physiotherapy interventions among patients with Parkinson’s disease

According to the univariate logistic regression analysis, age, disability status, and residential region influenced the OR for receiving regular PT interventions among patients with PD. Patients with PD in their 50s had a greater OR of 1.347, whereas those in their 70s and 80s had lower ORs of 0.852 and 0.868, respectively, than PD patients in their 50s. The ORs of patients with mild and severe disabilities were 1.234 and 1.059, respectively. Compared to Seoul, metropolitan cities had an OR of 0.906, cities had an OR of 0.572, and other regions had an OR of 0.440. This indicates that residents in areas outside of Seoul had a low OR for receiving regular PT interventions in patients with PD, with small regional units exhibiting a low OR. These results were confirmed by multivariate analysis, which demonstrated that patients with PD in their 50s and those with PD had a high OR, whereas patients aged 80 years or older who resided outside of Seoul had a low OR.

DISCUSSION

Based on NHIS data, this study demonstrated that the economic burden of PD has increased over the past 10 years in South Korea. During this period of time, the prevalence and incidence of PD in South Korea increased annually, and the population aged. These results correspond with the global increase in PD burden, thus highlighting the fact that the prevalence of PD in South Korea is high throughout the world [8]. Health care utilization and associated expenses, particularly those associated with PT interventions and hospitalizations, were significantly increased among patients with PD. Regional and age-based differences in PT interventions for patients with PD exhibit health care accessibility disparities, thus emphasizing the need for efficient cost management and health care policies.

According to a systematic analysis of the Global Disease of Burden Study 2019, the global PD incidence in 2019 was 106.28 per 100,000 individuals, with variations across countries [8]. Notably, the prevalence in East Asia was the highest at 145.44 per 100,000 individuals [8]. Between 1990 and 2019, an increase in the number of male and aging patients with PD was observed, with a steady increase in the prevalence and disease burden. In this study, PD exhibited a high prevalence and demographic changes. In the United States, the increasing PD incidence contributes to the increasing social burden of neurological disorders [1]. This increase in social burden is not only due to the increase in the number of patients with PD but can also be attributed to the aging population. In old age, PD can aggravate the burden of dementia, and comorbidities (such as frailty) can negatively affect the disease trajectory [15,16]. A population-based cohort in South Korea demonstrated high mortality rates among older patients with PD, with an annual mortality rate of 149.6 per 1,000 individuals aged 80 years or older [17]. In this study, the proportion of severely disabled patients with PD increased annually, thus indicating an increased disease burden.

During the study period, health care utilization among patients with PD increased significantly. Despite the number of patients with PD doubling, prescriptions nearly tripled, thus indicating a substantial increase in the number of prescriptions per patient. This increase can be attributed to the remarkable increase in PT prescriptions, which did not align proportionally with the increase in non-PT prescriptions. The proportion of patients with PD receiving PT increased from approximately 10% to approximately 15% of all patients with PD, and the number of PT prescriptions per patient with PD receiving PTs also increased. A significant proportion of PT prescriptions were specialized rehabilitative prescriptions that could only be prescribed by rehabilitation specialists. When considering the situation in which prescriptions for specialized rehabilitative and general PTs coincide in a patient, most PT interventions for PD patients are administered by rehabilitation specialists.

Between 2011 and 2020, medical expenses per patient with PD doubled, and overall medical costs surged by 3.5 times. The increase in medical expenses per patient with PD was driven by an increase in hospitalization costs, which is attributed to the increased number of hospitalized patients and long admission days. Moreover, the increase in medical costs per hospitalization compared to the increase in hospital days suggested the influence of the increase in health care utilization or unit costs for medical services. Supplementary Table 2 (in the online-only Data Supplement) displays the widespread increase in most individual PT prescriptions, with a notable increase in less commonly prescribed PT interventions. This scenario suggests that a broader spectrum of PT interventions may have been administered to hospitalized patients with PD.

However, the outpatient costs per patient with PD decreased between 2011 and 2020. During this time period, the total number of outpatient visits of patients with PD increased approximately twofold, whereas the overall outpatient costs remained relatively unchanged. Decreasing medical costs per outpatient visit can lead to a decrease in outpatient costs per patient with PD. The decrease in outpatient visit costs may be linked to changes in health care services; however, it is likely tied to a reduction in drug expenses, which constitute the majority of outpatient costs [18]. The reduction in drug costs may be associated with government-regulated pricing and the increased availability of generic medications.

Medical expenses per patient were greater and exhibited a steeper increase in patients with PD undergoing PT than in all patients with PD. The increase in costs among patients receiving PT could be a major contributing factor to the increase in overall medical expenses associated with PD. Similar to the trends observed among all patients with PD, the increase in medical costs among patients with PD receiving PT was mainly due to the increase in hospitalization costs caused by an increase in hospitalized patients, long hospital stays, and overall health care utilization. According to a cohort study using medical claims data from Singapore, medical expenses related to PD increased significantly from 2008 to 2017. Among these expenses, costs associated with hospitalization and intermediate- and long-term care facilities, including PT interventions, exhibited a substantial increase [19]. In our study, the number of outpatient visits of patients with PD receiving PT interventions increased in accordance with the number of patients, whereas the medical costs per outpatient visit remained relatively stable and did not impact the increase in the overall medical expenses for patients with PD.

The increase in medical costs for patients with PD may be associated with the increase in costs associated with PT interventions during hospitalization. However, this cost increase may not be solely attributable to PT. Although it is challenging to precisely analyze the cost of individual prescriptions from billing data, it is speculated that the surge in costs is closely related to an increase in the number of patients receiving PT, the number and length of admission, and the quantity of PT prescriptions.

Over the past 10 years in South Korea, medical expenses for patients with PD have significantly increased, which is mainly due to the increase in the number of patients and the medical costs for hospitalized patients receiving PT interventions. A Swedish observational study demonstrated that patients with severe PD had increased medical expenses and required more hospitalizations and formal care than those with less severe PD [20]. Although this study did not analyze the association with PD severity, the increase in health care utilization, including hospitalization and PT interventions, may be attributed to aging and the increasing severity of disabilities. Furthermore, the utilization of medical services can be influenced by social support, and the long-term care insurance system in South Korea has increased health care utilization [5,21]. The observed increase in health care utilization for PD in this study could have been influenced by health care insurance services and public medical aid. Although not included in this study’s findings, medical aid recipients among patients with PD demonstrated a high OR of 4.50 for undergoing regular PT interventions in the univariate analysis. An increase in health care utilization, including outpatient services, hospitalization, and PT interventions, can directly increase medical costs and impact household budgets and national insurance finances. However, in the long-term, health care utilization may reduce medical costs by reducing complications and mortality [22-24]. Therefore, an analysis of the cost-effectiveness of PT interventions for patients with PD, which is mainly associated with increased medical costs, is necessary.

PD clinical trials for PT interventions typically involve conventional PT therapies conducted between 4 and 12 weeks [10]. In our study, regular PT interventions were defined as PTs that were performed at least twice weekly for more than 4 weeks, which could represent a strategically administered valid treatment. Although the number of patients undergoing regular PT interventions has been consistently increasing, the number remains relatively low among patients with PD. Furthermore, all patients receiving regular PT interventions were hospitalized, with no patient receiving them only via outpatient services. The lack of regular PT interventions in outpatient departments could be due to physical limitations, such as mobility or distance constraints. Additionally, the current health care system may not adequately provide outpatient-based PT services for patients with PD. Outpatient-based planned PT interventions could facilitate access to treatment for more patients with PD and potentially contribute to reduced medical expenses by decreasing hospitalization costs.

Increased health care utilization related to PD and the subsequent increase in medical costs are inevitable outcomes driven by advanced treatments and epidemiological changes. However, they must be managed with limited financial resources, and ensuring that these resources are allocated effectively is crucial. The current increase in medical costs can be predominantly attributed to PT interventions and hospitalization, whereas outpatient services and medication-related expenses rarely contribute. When considering the limited accessibility of new-to-market medications due to their high costs, there is a need to provide financial resources for new treatments [25].

In this study, patients with PD who were older or resided outside of Seoul had limitations in receiving regular PT interventions. Older patients usually have distinct medical needs compared to younger patients because of their high risk of mortality.26 Common problems such as falls, dementia, and neuropsychiatric complications among older patients with PD can exacerbate symptoms and increase medical costs, thus requiring aggressive management [27,28]. Moreover, a cross-sectional study in Canada [7] indicated that rural areas exhibited lower utilization rates for specialist visits, rehabilitation admissions, and long-term care than did urban areas, potentially due to reduced accessibility. Consequently, efficient management of the increasing health care burden requires alleviating the unequal distribution of medical resources, fulfilling unmet needs among older patients, and enhancing regional accessibility.

In our study, a reduction in the incidence of PD was observed since 2018. Similarly, the incidence of PD in Germany has decreased since 2013 [29]. Regardless of this declining trend, the decline after 2019 was attributed to the coronavirus disease 2019 (COVID-19) pandemic. Especially in 2020, a decrease in prescriptions and hospital admissions among patients with PD was observed, thus indicating reduced health care utilization. During this period of time, a decrease was observed in the number of patients receiving PT interventions and prescriptions for patients with PD. The COVID-19 pandemic has interrupted health care utilization, physical activity, and social engagement among patients with PD, which could negatively affect motor symptoms and mental health [30-32]. Further studies are required to assess the impact of these changes on the health status and health care utilization of patients with PD. Additionally, considerable caution is needed in interpreting the results of health care utilization from 2019, and these results may need to be assessed independently of the continuity of previous changes.

Our study had some limitations that require consideration. First, PD diagnoses based on claims data may have been inaccurate. However, in this study, patients with PD were defined by diagnostic codes and rare incurable disease classifications based on the UK PD Brain Bank criteria [33]. Additionally, patients with atypical parkinsonism or no health care utilization among those with PD were excluded. Second, we did not investigate the origins or implementation patterns beyond the number of PT prescriptions or patients receiving PT interventions. Detailed specifics of individual prescriptions can provide more concrete insights into health care utilization patterns. This study aimed to address this limitation by analyzing the factors associated with regular PT interventions. Third, this study did not evaluate disease severity, which may have affected health care utilization among patients with PD. However, age and degree of disability may partially reflect disease severity. Finally, the analysis of medical costs in this study did not include the annual inflation rate or unit cost of health care services. Except for medication expenses, no significant changes were observed in the unit costs of health care services in South Korea during the study time period. Additionally, as of 2020, the health care price index for 2011 was 93.252, thus exhibiting a slight variance compared to 2020. When considering the health care price index, the actual increase in medical expenses could be greater.

In conclusion, this study demonstrated an increase in the PD burden in South Korea from 2011 to 2020, which was characterized by an increase in the number and age of patients. Along with this trend, health care utilization has significantly increased. Additionally, medical costs related to PD have surged, especially concerning PT interventions and hospital admissions. However, outpatient service costs have remained stable, thus indicating a disproportionate increase in medical expenses.

Although PT interventions among patients with PD have considerably increased, regular PT interventions are limited to a small subset of patients and are only conducted through hospitalization. Despite the proven effectiveness in managing PD symptoms, access to PT remains limited. Barriers to accessing regular PT interventions include factors such as patient age and residential location. An enhancement of the diversity of PT interventions, which encompasses both the prescription and execution phases, could mitigate these barriers. Diversification of PT interventions may also contribute to alleviating the PD disease trajectory, reducing its overall burden, and minimizing the escalation of health care costs, mainly by reducing the necessity for hospital-based PT. Community-based outpatient services, new technologies, and institutional support can enhance the diversification of health care services and efficient resource allocation in PD care.

Supplementary Materials

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