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HEALTH SERVICES RESEARCH

Analysis of Scoliosis-related Medical Services in South Korea Between 2010 and 2018

A Cross-sectional Study Using Health Insurance Review and Assessment Service Data

Hong, Doohyun KMDa; Lim, Yu-Cheol PharmDb; Lee, Sook-Hyun PhDb; Sung, Won-Suk KMD, PhDc; Lee, Yoon Jae KMD, PhDb; Kim, Eun-Jung KMD, PhDc; Ha, In-Hyuk KMD, PhDb

Author Information
doi: 10.1097/BRS.0000000000004349

Scoliosis is defined as an abnormally laterally curved spine with a Cobb angle of ≥10°.1,2 Scoliosis can occur because of neuromuscular diseases (e.g., cerebral palsy, myelodysplasia, muscular atrophy)3 or congenital spinal malformation, (e.g., hemivertebra, unilateral bar, block vertebra).2 Cases with unknown etiology are known as “idiopathic scoliosis,” which is the most common type and clinically important.4 Studies report scoliosis prevalence in adults as 3.9% to 29.4%5–7 with one study finding the prevalence of 68% for asymptomatic patients aged ≥60 years.8 Idiopathic scoliosis’ prevalence in adolescence may vary according to ethnicity, age, and sex and has been found to range from 0.47% to 5.2%, which differed across studies depending on scoliosis definition, study protocol, and subjects’ age group.2 In South Korea, a 35.5% prevalence was found among those aged ≥60 years,9 whereas in adolescents, the prevalence was 3.26%, with that for girls being 4.65%, approximately 2.4 times higher than for boys.10

Although some studies have proposed treatments for scoliosis according to patients’ age and scoliosis cause,2,3,11–13 data are lacking on which treatments are popular for general scoliosis and which service categories incur the most cost in South Korea. Thus, accurately examining scoliosis’ present prevalence and features and identifying treatment types and cost in clinical practice are necessary.

Thus, this study aims to analyze the types and costs of scoliosis treatment in a 9-year period (2010–2018) to present the general trend in scoliosis care and examine trend changes over time.

MATERIALS AND METHODS

Data Source

We used 2010 to 2018 Health Insurance Review and Assessment Service-National Patient Sample (HIRA-NPS) data, which contain information on health insurance claims generated in the process of reimbursing health care providers under the NHI system in South Korea.14 South Korea has a universal health coverage system with approximately 98% of the population enrolled in the National Health Insurance (NHI).15 Low income individuals not enrolled in NHI receive medical aid and recipients of medical aid have most of their medical costs, excluding noncovered items, paid by the government.16 The HIRA-NPS data used in this study contain claims records of a 3% sample (about 1.4 million people) randomly selected from the Republic of Korea's total population registered in the NHI or medical aid system (about 46 million people). They contain sociodemographic information, as well as information about provided health services.15

Inclusion/Exclusion Criteria

Patients who received Western medicine (WM) or Korean medicine (KM) care for scoliosis (ICD-10 code M41) as the principal diagnosis at least once between 2010 and 2018 were included in the sample. Patients with codes for dentistry, community health center, or psychiatry; whose organization type corresponded to long-term care hospital, psychiatric care hospital, dental hospital, maternity center, or community health center; or those with 0 or no data for total cost and number of days in care were excluded.

Study Outcomes and Analysis

All indicators in this study, such as number of patients, number of cases, average annual visits per patient, and total expense, were calculated based on the sample population of this study, that is patients with primary diagnosis of scoliosis who received treatments included in NHI covered items. In cases where patients included in this study received both treatments covered and not covered by NHI, only data related to treatments covered by NHI were calculated.

Participants were classified by age, sex, payer type, visit type, and medical institution to calculate the number of patients or cases and their percentage in each category. The word ‘the number of cases’ in this study is used as the same meaning of the number of insurance claims. Age was classified into eight groups in 10-year units from < 15 years to ≥75 years; payer type was classified into NHI, Medical Aid, and others. Visit type was classified into outpatient and inpatient based on the bill; medical institution type was classified into tertiary hospital/general hospital/hospital, clinic, KM hospital, and KM clinic.

Service categories were classified into nine categories based on the HIRA reimbursement system, and the number of cases and total cost of each category were calculated, and the number of cases and total cost of each category were calculated. Total cost is the patient's incurred cost at a medical institution calculated as the sum of health insurance-paid costs and patients’ out-of-pocket costs.

Scoliosis service codes were classified into WM and KM; service codes with a frequency of ≥0.1% (top 121 codes) were considered for WM, and those with a frequency of ≥0.01% (top 84 codes) were considered for KM. Service codes were categorized into 12 categories for WM and into 11 categories for KM. The number of cases and total cost, the total number of patients, the average annual number of cases per patient, and average annual per-patient cost for each code were analyzed. There were fewer KM-related service codes covered by the NHI, so instead of using the same criterion (≥0.1%), which would only qualify the top 39 codes, a broader criterion of ≥0.01% was used.

Prescriptions filled at private pharmacies and hospitals were categorized according to their Anatomical Therapeutic Chemical codes (ATC-codes) (Supplemental Table 1, https://links.lww.com/BRS/B858), and the number of cases, total cost, the total number of patients, the average annual cost per case, and average annual per-patient cost of each category were analyzed. ATC-codes and their categorization are shown in Supplemental Table 1, https://links.lww.com/BRS/B858. Packaged herbal medicine was excluded, as it is not presently covered by insurance.

We also analyzed the number of patients, total cases, total expense, per-patient expense, per-case expense, total care, average days in care per patient, total visits, and average visits per patient by year for the entire sample and by WM and KM (Supplemental Table 2, https://links.lww.com/BRS/B858). All cost-related results presented in this study were converted to the 2018 level based on health care and medical service price index adjusted for health care inflation rate and KRW:USD exchange rate (Supplemental Table 3, https://links.lww.com/BRS/B858). Data were analyzed using SAS software (version 9.4, SAS Institute, Cary, NC).

Ethical Statement

Study protocol was approved by the HIRA public data provision deliberation committee, and the study was conducted according to relevant guidelines/regulations. The present study was exempted by Jaseng Hospital of Korean Medicine's Institutional Review Board (JASENG 2021–02024). Declaration of Helsinki principles were adhered to in the analysis.

RESULTS

Study Sample Flowchart

Of the 109,633 cases of scoliosis (M41), 887 cases with an excluded code, 35 with an excluded organization type, and 68 with 0 or no data for total cost and number of days in care were not considered for analysis. Thus, 108,643 total cases for 32,362 patients were included in the final analysis (Figure 1).

F1
Figure 1:
Flowchart of the study sample.

Basic Patient Characteristics

Most patients who visited a medical institution for scoliosis were <15 years (n = 9020; 27.87%) and 15 to 24 years’ old (n = 9925; 30.67%); health care utilization tended to decrease with age. Patients were predominantly female (64.84%). The payer was NHI in most cases (96.20%). Although 92.18% of patients only sought WM, 6.56% only sought KM, showing that 98.73% (31,952) of patients only visited one type of medical institution. Sex and health insurance type varied little between the two care type groups (Table 1).

TABLE 1 - Basic Patient Characteristics
Total (2010–2018) Western Medicine (2010–2018) Korean Medicine (2010–2018) Both Care Types (2010–2018)
Category No of Patients Percentage No. of Patients Percentage No. of Patients Percentage No. of Patients Percentage
Total 32,362 100.00 29,830 100.00 2122 100.00 410 100.00
Age, y <15 9020 27.87 8509 28.52 355 16.73 156 38.05
15–24 9925 30.67 9240 30.98 518 24.41 167 40.73
25–34 3433 10.61 3094 10.37 293 13.81 46 11.22
35–44 2546 7.87 2277 7.63 252 11.88 17 4.15
45–54 2412 7.45 2150 7.21 253 11.92 9 2.20
55–64 2056 6.35 1841 6.17 211 9.94 4 0.98
65–74 1812 5.60 1656 5.55 149 7.02 7 1.71
≥75 1158 3.58 1063 3.56 91 4.29 4 0.98
Sex Male 11,378 35.16 10,461 35.07 778 36.66 139 33.90
Female 20,984 64.84 19,369 64.93 1344 63.34 271 66.10
Payer type NHI 31,133 96.20 28,683 96.15 2053 96.75 397 96.83
Medical aid 1228 3.79 1146 3.84 69 3.25 13 3.17
Others 1 0 1 0
NHI indicates National Health Insurance.

Basic Medical Usage Characteristics

Most scoliosis treatment cases in a medical institution (99.37%) were outpatient cases. Of all cases, 32.27% and 52.43% of them were from a WM hospital (tertiary/general/ hospital) and WM clinic, respectively, whereas 1.39% and 13.91% of them were from a KM hospital and KM clinic, respectively (Table 2).

TABLE 2 - Basic Medical Usage Characteristics
Total (2010–2018) Western Medicine (2010–2018) Korean Medicine (2010–2018)
Category No. of Cases % No. of Cases % No. of Cases %
Total 108,643 100.00 92,358 100.00 16,285 100.00
Type of visit Outpatient 107,960 99.37 91,719 99.31 16,241 99.73
Inpatient 683 0.63 639 0.69 44 0.27
Medical institution Tertiary/general/hospital 35,058 32.27 34,997 37.89 61 0.37
Clinic 56,965 52.43 56,965 61.68
Korean medicine hospital 1511 1.39 396 0.43 1115 6.85
Korean medicine clinic 15,109 13.91 15,109 92.78

Number of Medical Cases and Medical Costs Per Service Category

Treatment accounted for the greatest percentage of service categories (145,397 cases; 27.62%), followed by examination, special equipment and radiologic diagnosis, and injection. In WM, treatment was highest (145,254 cases, 32.48%), and in KM, injection was highest (57,907 cases, 73.11%). Overall, examination cost accounted for the greatest percentage of total cost (992,173 USD, 28.70%), followed by treatment and special equipment and radiologic diagnosis. In WM, examination cost was highest (875,859 USD, 28.03%). In KM, injection cost was highest (196,333 USD, 59.03%) (Table 3).

TABLE 3 - Number of Medical Cases and Medical Costs Per Service Category
Service Category Total Western Medicine Korean Medicine
No. of Cases % Total Cost % No. of Cases % Total Cost % No. of Cases % Total Cost %
Treatment 145,397 27.62 580,987 16.81 145,254 32.48 580,412 18.58 143 0.18 575 0.17
Examination 136,886 26.00 992,173 28.70 119,290 26.67 875,859 28.03 17,596 22.22 116,314 34.97
Special equipment and radiologic diagnosis 98,718 18.75 631,651 18.27 98,718 22.07 631,651 20.22
Injection 90,762 17.24 381,653 11.04 32,855 7.35 185,320 5.93 57,907 73.11 196,333 59.03
Test 33,358 6.34 230,400 6.66 33,358 7.46 230,400 7.37
Medication preparation and administration 13,067 2.48 41,520 1.20 9747 2.18 38,741 1.24 3320 4.19 2778 0.84
Hospitalization 4594 0.87 343,865 9.95 4359 0.97 327,274 10.47 235 0.30 16,592 4.99
Procedure and surgery 3015 0.57 242,142 7.00 3015 0.67 242,142 7.75
Other 603 0.11 12,181 0.35 603 0.13 12,181 0.39
Noncovered services 3 <0.01 371 0.01 3 <0.01 371 0.01
For the treatment category, all items except injection among all treatments covered by NHI for patients with primary diagnosis of scoliosis were included. Specifically, physical therapy, anesthesia, casts, blood transfusion, palliative care, psychotherapy, and other treatments were included.
Examination corresponds to consultation fee, which includes fees incurred during the process of a patient meeting a physician for examination and consultation; All cost-related results presented in this study were converted to the 2018 level based on health care and medical service price index adjusted for health care inflation rate and KRW: USD exchange rate (see Supplemental Table 3, https://links.lww.com/BRS/B858).

Frequently Used Service Codes

From 2010 to 2018, physiotherapy was the most frequently used service code (130,337 cases), followed by examination and imaging for WM versus acupuncture (31,191 cases), examination, and Korean medicine physiotherapy for KM. Regarding total cost, examination was the highest (816,147 USD), followed by imaging and physiotherapy for WM versus examination (121,078 USD), acupuncture, and cupping therapy for KM. (Table 4).

TABLE 4 - Frequently Used Service Codes
Western Medicine Korean Medicine
Service Code Total Cases Total Cost Total Patients Average Annual Case Per Patient Average Annual Cost Per Patient Service Code Total Cases Total Cost Total Patients Average Annual Case Per Patient Average Annual Cost Per Patient
Physiotherapy 130,337 256,307 10,072 1.97 25.45 Acupuncture 31,191 120,442 2372 3.86 50.78
Examination 94,260 816,147 29,242 8.66 27.91 Examination 19,600 121,078 2526 6.18 47.93
Imaging 76,868 380,346 24,374 4.95 15.60 Korean medicine physiotherapy 8961 7631 1524 0.85 5.01
Clinical pathology 21,453 65,796 1001 3.07 65.73 Cupping therapy 7819 34,267 1384 4.38 24.76
Other 18,069 9182 6409 0.51 1.43 Electroacupuncture 4865 19,399 834 3.99 23.26
Injection 11,202 36,585 3547 3.27 10.31 Direct moxibustion 2921 7976 479 2.73 16.65
Exercise therapy 4505 22,194 1266 4.93 17.53 Medication preparation 1288 535 273 0.42 1.96
Treatment-nerve block 3141 132,078 1239 42.05 106.60 Hospitalization 174 11,301 35 64.95 322.90
Hospitalization 859 28,444 292 33.11 97.41 Korean medicine testing 142 572 131 4.03 4.37
Medication preparation and instruction 727 7075 470 9.73 15.05 Treatment-other 113 473 111 4.19 4.26
Treatment-other 709 8918 296 12.58 30.13 Other 10 80 4 7.98 19.96
ECG 600 3297 525 5.50 6.28
Service codes with a frequency of 0.1% (top 121 codes) were considered for WM, and those with a frequency of 0.01% (top 84 codes) were considered for KM.
For physiotherapy, service codes with a frequency of 0.1% or higher consisted of superficial heat therapy, deep heat therapy, interferential current therapy (ICT), transcutaneous electric nerve stimulation (TENS), rehabilitative low-level laser therapy (LLLT), and intermittent traction therapy.
Examination corresponds to consultation fee, which includes fees incurred during the process of a patient meeting a physician for examination and consultation. All cost-related results presented in this study were converted to the 2018 level based on health care and medical service price index adjusted for health care inflation rate and KRW:USD exchange rate (see Supplemental Table 3, https://links.lww.com/BRS/B858).

Frequently Prescribed Medicine

The most frequently prescribed medication in private pharmacies was anti-inflammatory analgesics (nonsteroidal anti-inflammatory drugs [NSAIDs]; 13,693 cases), followed by antacids and skeletal muscle relaxers. Total cost was highest for NSAIDs (54,122 USD), followed by antacids and other cardiovascular drugs. Among hospital prescriptions, the most frequently prescribed medication was blood products (4661 cases), other central nervous system drugs, and antipyretic analgesics. Total cost was highest for blood products (19,825 USD), other, and narcotics (Table 5).

TABLE 5 - Frequently Prescribed Medicine
Category Private Pharmacy Hospital
Total Case Total Cost ($) Total Patients Average Annual Cost Per Case ($) Average Annual Cost Per Patient($) Total Case Total Cost ($) Total Patients Average Annual Cost Per Case ($) Average Annual Cost Per Patient ($)
Anti-inflammatory analgesics (NSAIDs) 13,693 54,122 7097 3.95 7.63 3073 6367 1581 2.07 4.03
Antacids 10,512 32,628 5271 3.10 6.19 1216 3389 422 2.79 8.03
Skeletal muscle relaxers 8886 15,897 5276 1.79 3.01 1060 3474 485 3.28 7.16
Gastrointestinal drugs 5446 8574 2713 1.57 3.16 674 1127 298 1.54 3.78
Antipyretic analgesics (acetaminophen) 4858 18,136 2293 3.73 7.91 3952 4141 1614 1.05 2.57
Enzymes 3556 2797 2260 0.79 1.24 180 212 95 1.18 2.23
Other central nervous system drugs 2226 10,932 790 4.91 13.84 4582 5417 1785 1.18 3.03
Other cardiovascular drugs 1569 19,423 598 12.38 32.48 254 1807 148 7.12 12.21
Other 1175 5730 456 4.88 12.57 2051 18,560 472 9.26 39.32
Adrenal hormone 405 131 179 0.32 0.73 1827 734 1013 0.40 0.72
Blood products 4661 19,825 1282 4.21 15.46
Narcotics 609 7282 231 11.96 31.52
Oxygen 553 1187 190 2.15 6.25
Autonomic nervous system drugs 387 412 170 1.25 2.42
All cost-related results presented in this study were converted to the 2018 based on health care and medical service price index adjusted for health care inflation rate and KRW:USD exchange rate (see Supplemental Table 3, https://links.lww.com/BRS/B858). NSAIDs indicates nonsteroidal anti-inflammatory drugs.

General Medical Service Use

Except for 2011 and 2014, total number of patients tended to decrease from the preceding year (Supplemental Figure 1, https://links.lww.com/BRS/B858, Supplemental Table 2, https://links.lww.com/BRS/B858). Furthermore, per-patient expense tended to increase compared to the preceding year except for 2014 (Supplemental Figure 2, https://links.lww.com/BRS/B858, Supplemental Table 2, https://links.lww.com/BRS/B858). There were no notable trends in total expense, total cases, and per-patient average visits (Supplemental Figures 3, 4, 5, https://links.lww.com/BRS/B858).

DISCUSSION

From a 3% sample of Korea's NHI or medical aid subscribers, 32,362 people utilized health care services for scoliosis over 9 years. Even assuming that there were no overlapping counts, approximately 2.31% of the 1.4 million sample utilized health care services for scoliosis. Compared to the prevalence of scoliosis in adults (3.9%–29.4%),3,5–7 people aged ≥60years (68%),8 and adolescents (0.47%– 5.2%),2 the percentage of individuals needing treatment or who actually seek treatment was low. Considering the prevalence of adult idiopathic scoliosis is higher than that among adolescents and that idiopathic scoliosis is the most common scoliosis type,4 we can predict scoliosis prevalence is higher among adults. However, in this study, patients aged <15 (27.87%) and 15 to 24years (30.67%) most frequently visited a medical institution for scoliosis, and health care utilization tended to decline with increasing age. This suggests medical intervention needs are actually greater among younger patients or there are factors promoting younger patients to seek care. In fact, earlier initiation of scoliosis treatment enables more effective use of nonsurgical techniques17,18 and can lower complications like diminished pulmonary functions, pain, and deformity.19 However, as older patients generally have other musculoskeletal comorbidities, other diagnoses may have been used for insurance claims and thus were not included in this study even if scoliosis treatment was performed. Moreover, it is unclear whether there is a tendency to receive less treatment at older age as a result of successful therapeutic intervention for scoliosis at an earlier age. As a cross-sectional study, this study could not compare the difference in subsequent health care utilization between patients who received intervention at younger and older age.

Regarding sex, the percentages of male and female patients who visited a medical institution for scoliosis were 35.16% and 64.84%, respectively, which is in line with previous findings that scoliosis is more common among women.2,4 The total number of patients who received scoliosis treatment tended to decrease compared to the preceding year with the exception of 2011 and 2014, which may be because over half of the patients receiving scoliosis care are younger than 15 years or between 15 and 24 years, and the juvenile population is gradually shrinking in South Korea.20

Regarding service category frequency, treatment was frequent for WM because conservative and non-surgical treatments are generally performed for scoliosis in WM. Examination is common for WM because medical care begins with an examination, which is billed even when patients visit the hospital for treatment or follow-up. Furthermore, special equipment and radiologic diagnosis likely accounted for a high percentage for WM, as it is commonly ordered to diagnose or observe scoliosis progress.21 Conversely, acupuncture is the most basic treatment performed in KM,22 so injection is commonly billed for. The examination in KM is also a common category for the same reason as WM.

Regarding the frequency of scoliosis service codes, as mentioned, the high total cost for examination and imaging for WM is because they are billed when patients visit a hospital for treatment or follow-up. Physiotherapy probably incurred a high cost for WM because it is the most commonly used treatment in WM. In KM, the high examination cost was probably for the same reason as for WM, whereas for acupuncture and cupping therapy, high cost is likely because acupuncture is the most frequently performed treatment in KM, and cupping therapy is also common, with a higher per-case cost than the similarly common Korean medicine physiotherapy. Regarding the different physiotherapy types in WM, there were insurance claims for superficial heat therapy, deep heat therapy, interferential current therapy (ICT), transcutaneous electric nerve stimulation (TENS), rehabilitative low-level laser therapy (LLLT), and intermittent traction therapy. Past studies have reported superficial heat therapy, deep heat therapy, TENS, and rehabilitative LLLT reduce low back pain.23–27 ICT and traction therapy for scoliosis have also been reported to reduce Cobb angle and pain.28,29 However, there are few high-quality studies identifying a specific physiotherapy type to be particularly effective for scoliosis. Thus, we can infer physiotherapy can reduce overall low back pain, as opposed to specifically target scoliosis. In WM, the epidural nerve block was also frequently performed, and studies have reported this produces temporary relief of scoliosis-caused radicular pain.25,30,31 All surgery codes were excluded from the service code analysis (Table 4) because they were claimed at a rate of below 0.1% over nine years, with 191 cases of spinal fusion (0.046%), 54 cases of lumbar discectomy (0.013%), and 22 cases of laminectomy (0.005%). In fact, there are findings suggest only a small percentage of patients with scoliosis have a large angle or progressive deformity requiring surgical treatment.32–35

Regarding KM, some studies have reported acupuncture therapy is significantly effective on scoliosis.36–38 However, there are concerns about the lack of high-quality studies examining acupuncture's effectiveness on scoliosis.39,40 Although cupping therapy is effective in reducing overall low back pain,38,41,42 high-quality studies on cupping therapy for scoliosis are scarce. Multiple studies have confirmed Chuna therapy or combining Chuna therapy with a different therapy is effective in reducing Cobb angle.43–45 However, Chuna therapy was not included in this study because health insurance coverage of Chuna therapy began after 2018.

In private pharmacies, the most frequently prescribed drug was NSAIDs, and total cost was highest for NSAIDs. NSAIDs are widely used to relieve acute and chronic pain. Further, antacids are frequently used to alleviate NSAIDs’ gastrointestinal side effects.46 Skeletal muscle relaxers have also been reported to lower overall low back pain.47 Other cardiovascular drugs probably had a high total cost because of high perdrug cost. Considering 99.37% of cases in this study were from outpatient care, we can infer NSAIDs and skeletal muscle relaxers are most frequently used to mitigate scoliosis symptoms and that antacids are also commonly prescribed.

Limitations

This study included patients with a principal diagnosis of scoliosis. The true diagnostic accuracy is unknown, but the accuracy in health insurance claims data is about 70%.48 Furthermore, we did not examine scoliosis severity indices, such as Numeral Rating Scale, Oswestry Disability Index, and Cobb angle, so the findings only show overall health care utilization for scoliosis and not disease severity or changes in health care utilization according to disease severity. In addition, the 2010 to 2018 HIRA-NPS data do not include codes not covered by insurance, such as Chuna therapy or herbal medicine, or indirect medical costs. This omission may have led to an underestimation of the number of patients who actually seek treatment. Finally, as a cross-sectional study, this study determined the health care utilization status of applicable years, but could not observe changes in health care utilization by patients according to the status and time point of past interventions. Nevertheless, this study is significant in that it presents scoliosis-related health care utilization in South Korea over a 9-year period and simultaneously analyzed the utilization of WM and KM services.

CONCLUSION

As we comparatively analyzed the present treatment trends, and cost of treatments by analyzing health care utilization using the nationally representative HIRA-NPS data, the findings will be useful for relevant experts, such as health policymakers, clinicians, and researchers.

Key Points

  • Patients aged 24 years or younger most frequently utilized insurance-covered health care services, and the treatments were predominantly outpatient.
  • Regarding service category, treatment and surgery, examination, and special equipment and radiologic diagnosis accounted for a high percentage.
  • Regarding service code, cost of examination, imaging, and physiotherapy accounted for a high percentage of Western medicine care, while cost of examination, acupuncture, and cupping therapy accounted for a high percentage of Korean medicine care.
  • Anti-inflammatory analgesics, antacids, and skeletal muscle relaxers were most frequently prescribed for scoliosis in private pharmacies.
  • Between 2010 and 2018, the total number of patients tended to decrease compared to the preceding year with the exception of 2011 and 2014, and per-patient expense tended to increase compared to the preceding year with the exception of 2014.

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Keywords:

cost of care; HIRA claims data; Korean medicine; medical service utilization; medication for scoliosis; National Patients Sample; scoliosis; service category for scoliosis; service code for scoliosis; Western medicine

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