STRENGTHS AND LIMITATIONS OF THIS STUDY
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This study described the community treatment centre (CTC), a unique facility operated by Korea to respond to COVID-19.
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Health insurance claim data was used to analyse the actual treatment outcomes of COVID-19 patients and the costs of CTC and inpatient services.
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However, it is difficult to accurately calculate the operating costs of medical institutions, so the costs associated with medical institutions are often limited to treatment costs.
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The study did not consider patients’ underlying conditions or their health status apart from their COVID-19 diagnosis, which could moderate the severity of COVID-19 and impact treatment outcomes.
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The exclusion of patients’ underlying health status may result in overstating the cost-effectiveness of the CTC model, affecting the validity of the study conclusion. A more cautious interpretation of the findings is advised.
Introduction
South Korea’s policy was to hospitalise all COVID-19 patients, regardless of symptom severity. Since the first COVID-19 case was reported in January 2020, South Korea has experienced about seven major outbreaks, and each outbreak has been accompanied by a shortage of beds. To manage limited medical resources, the South Korean government established community treatment centres (CTCs) to monitor people with COVID-19 who had mild or no symptoms and to provide necessary medical care as well as to meet people’s daily needs. In March 2020, the first CTC was set up in Daegu. Later, each local government established a medical support system focusing on tertiary hospitals in cities and provinces.1 Between March 2020 and August 2022, 102 CTCs were opened. The number of hospital beds available at each CTC varied from around 2500 to 3000 during the first three waves (March 2020, August–September and December) to 20 000 beds during the fourth wave after July 2021.2 As the number of confirmed cases began to decline in April 2022, the South Korean government began to shut down CTCs in local governments in June 2022. As of August 2022, only one CTC was operating under the supervision of the Central Disaster Management Headquarters.3
South Korea implemented the 3T (test, trace and treatment) strategy to control the spread of COVID-19 early on in the pandemic.4 CTCs were introduced as a key quarantine measure to help redirect medical resources for critically ill patients and to provide timely treatment for hospitalised patients.5 6 CTCs are unique medical facilities that give patients assistance for their medical and daily needs. Except for a few countries, such as Japan and Singapore, CTCs are rare in the region.
Several studies have been conducted on CTCs; however, most domestic studies focus on methods of operation. For instance, Park et al,7 based on their experience working at the first CTC in Korea and Kim et al,8 based on their experience working at CTCs, proposed strategies for operating CTCs, such as categorising severity based on a patient’s medical history, supplying medical equipment and dispatching experienced medical professionals. For the optimal operation of CTCs, Choi et al suggested increasing home-based treatment for patients with mild or no symptoms and reducing their length of stay at their respective CTCs.9 Although studies on the method of operation in CTCs have been conducted, the effect of CTCs is underexplored.
In this study, we compared the cost-effectiveness of hospital-based treatment and that of CTCs. Specifically, we analysed the cost-effectiveness of operating CTCs compared with in-hospital treatment programmes. The findings can be used as baseline data for operating CTCs during another wave of COVID-19 or a future pandemic.
Community treatment centres
CTCs provide isolated treatment to patients who test positive for COVID-19 but have mild or no symptoms10; they were established to control the spread of infectious disease while providing effective treatment based on severity, and to help regulate medical resources when hospitals cannot manage a large influx of patients.11 During the COVID-19 pandemic, the South Korean government rented college dormitories, privately owned hotels and training centres at public institutions or private companies to open CTCs.
South Korea’s policy was to hospitalise all COVID-19 patients, regardless of symptom severity. However, when medical resources such as beds became scarce, asymptomatic or mild cases were admitted to CTC. At this time, even asymptomatic or mild cases, such as patients with cancer undergoing treatment and pregnant women with symptoms, were recommended for hospitalisation. Asymptomatic or mildly symptomatic COVID-19 patients who met the following criteria were considered for hospitalisation: (1) confusion or disorientation, (2) shortness of breath, (3) fever of 38°C or higher that is not relieved by fever-reducing medications, (4) uncontrolled diabetes, (5) end-stage renal disease patients, (6) patients receiving chemotherapy or immunosuppressive therapy, (7) mental health patients with symptoms that are not relieved by medication, (8) patients with bedridden conditions, (9) obesity (body mass index >30), (10) pregnant women with symptoms (abdominal pain, labour pain, vaginal bleeding, etc), (11) paediatric severe and high-risk groups, (12) patients with chronic lung diseases, asthma, heart failure or coronary artery disease that are being treated. Once admitted to a CTC, patients self-monitored their symptoms by checking their oxygen saturation and body temperature two times a day. When necessary, patients were given a physician’s prescription or transferred to a hospital-based on their condition. Medical staff in charge of CTC patients would transfer them to other duties if they met any of the following criteria or were judged to be at a similar risk level: (1) oxygen saturation less than 94%, (2) worsening clinical symptoms such as dyspnoea and decreased consciousness, (3) fever of 37.8℃ for more than 72 hours, (4) clear evidence of pneumonia on a chest X-ray with worsening radiological findings. Patients were discharged after a 7-day quarantine or after testing negative for COVID-19.
Methods
Participants and data collection
To calculate the costs incurred for hospitalised and CTC patients, we divided the costs into treatment costs and operating costs.
To calculate the treatment costs for inpatients and CTC patients, we used billing data from the Health Insurance Review and Assessment Service (HIRA), to which medical institutions submit health insurance billing information in order to receive compensation for the medical services rendered. The billing data contain details about the medical treatment provided.
From the 2020–2021 health insurance billing data (reviewed between January 2020 and June 2022), we extracted 415 270 hospital claims and 244 776 CTC claims related to COVID-19. To select the data on confirmed COVID-19 patients, we used the following criteria: a primary diagnostic code for positive cases (U071); a specific code that makes a person eligible for financial assistance during national disasters (MT043); and a specific code for COVID-19 (3/02). Among the confirmed cases, we screened hospitalised patients using the code for ‘inpatient’ based on the coding assignment for ‘cases of COVID-19 patients who are admitted to a hospital and outpatient claims’. To screen the CTC patients, we used the insurance code numbers that included ‘patient care at a CTC’ or ‘CTC’ in their insurance claims. As for patients who originally checked in at a CTC and were later transferred to a hospital, we used the insurance code numbers (Preventive care for new infectious disease syndrome, overnight care for COVID-19 patients and hospital care in an isolated ward.) related to the hospital claims followed by the CTC claims.
To collect the data on the operating expenses for CTCs, we used the budget report by the Ministry of Strategy and Finance (2021 and 2022) and the actual budget execution for operating CTCs by the HIRA (2021 and 2022).
Classification of the participants
To analyse the medical expenses based on the severity of hospitalised COVID-19 patients, we categorised the patients based on gender, age and severity. Using ‘COVID-19 treatment’, a guideline published by the South Korean government, we divided severity into four categories: ‘mild illness’, ‘moderate illness’, ‘critical illness’ and ‘death’.12 When a patient manifested more than two levels of severity simultaneously, we classified the patient under the highest level of severity.
Data analysis
To analyse the medical expenses of COVID-19 patients, we divided healthcare usage among COVID-19 patients into three types: hospitalisation, discharge from a CTC with no hospitalisation and transfer from a CTC to a hospital for admission. For COVID-19 patients who were hospitalised, we calculated their severity based on the medical treatment they received. Using severity, we calculated the probability of the length of hospitalisation and medical expenses. Moreover, we calculated the average hospital stay and average medical expenses by dividing the total number of days and total medical expenses by the number of patients. For statistical analysis, we used the SAS Enterprise Guide V.9.4.
Patient and public involvement
It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research.
Results
General characteristics of hospitalised and CTC patients
Between January 2020 and December 2021, the number of confirmed COVID-19, hospitalised and CTC patients was 630 794, 411 530 and 243 349, respectively.13 Among the patients who checked in at a CTC, those who were transferred to a hospital for admission were categorised as ‘hospitalised patients’. Thus, the sum of hospitalised and CTC patients was greater than the total number of COVID-19 patients.
Among 411 530 hospitalised patients, 51.1% were male and 48.9% were female. Regarding age group, most patients were in their 50s, followed by 60s and 70s. In terms of region, Seoul and Gyeonggi had the highest number of hospitalised patients, followed by Chungnam-Sejong.
Among 243 349 people who checked in at a CTC, male and female patients constituted 53.3% and 46.7%, respectively. As for age group, most patients were in their 20s, followed by 40s and 50s. In terms of region, the number of CTC patients was the highest in Gyeonggi, followed by Seoul and Chungnam-Sejong.
Comparing hospitalised patients with CTC patients, the percentage of male patients was higher than that of female patients in both groups. In terms of region, Seoul, Gyeonggi and Chungnam-Sejong had a greater proportion of patients than other regions. As for age, the average CTC patients were younger than hospitalised patients. These findings are illustrated in online supplemental table 1.
Supplemental material
Healthcare usage
Hospitalised patients
In accordance with the severity criteria (online supplemental table 2), we classified patients hospitalised between 2020 and 2021 under mild illness, moderate illness, critical illness and death. Then, we examined the length of hospitalisation and medical expenses for each severity category. First, we divided 411 530 confirmed COVID-19 patients who were hospitalised based on severity level: 359 989 patients with mild illness (87.5%), 37 184 patients with moderate illness (9.0%), 9433 patients with a critical illness (2.3%) and 4924 patients who died of the disease (1.2%). As for hospital stay, hospitalised COVID-19 patients stayed in the hospital for 11.7 days on average, 10.8 days for mild illness, 16.2 days for moderate illness and 25.3 days for critical illness. Patients who died during hospitalisation stayed 19.8 days on average. As for medical expenses, hospitalised COVID-19 patients incurred 2 710 000 KRW on average, 1 790 000 KRW for mild illness, 5 440 000 KRW for moderate illness and 19 580 000 KRW for critical illness. Patients who died during hospitalisation incurred 17 070 000 KRW on average.
Supplemental material
We compared 2020 with 2021 in terms of hospital stays and medical expenses based on the patient’s severity. While the rate of confirmed patients with mild illness was higher in 2021 than in 2020, the rate of patients who had a moderate illness, critical illness or who died decreased in 2021. Regarding average hospital stay, hospitalised patients stayed for 15.8 days on average in 2020, whereas the average hospital stay for COVID-19 patients fell to 11.0 days in 2021. Across all severity levels, the average hospital stay in 2021 was shorter than that in 2020. As for medical expenses, hospitalised patients incurred 3 660 000 KRW on average in 2020, but the average medical expenses declined to 2 540 000 KRW in 2021. However, COVID-19 patients who had a critical illness and those who died incurred high medical expenses on average compared with 2020 (online supplemental table 3).
Supplemental material
Community treatment centres
We classified the COVID-19 patients who checked in at a CTC between 2020 and 2021 under mild illness, moderate illness, critical illness and death. Then, we examined the length of stay and medical expenses for each severity category.
We compared 2020 with 2021 in terms of the length of stay and medical expenses at CTCs based on severity among patients with COVID-19. The share of admission among CTC patients rose from 13.6% in 2020 to 14.6% in 2021. In addition, patients who were transferred from a CTC to a hospital in 2021 had more severe conditions than in 2020. As for hospital stay, CTC patients who were admitted to a hospital in 2020 and 2021 stayed for 18.4 days and 14.0 days on average, respectively. The overall hospital stay in 2021 was shorter than in 2020, except for critical cases. As for medical expenses, patients who were transferred to a hospital in 2020 and 2021 incurred 3 880 000 KRW and 4 210 000 KRW on average, respectively. Consequently, the average medical expenses among transfer patients increased in 2021, including cases of critical illness and death (online supplemental table 4).
Supplemental material
Cost-effectiveness analysis
Cost-effectiveness analysis model
Model design for cost-effectiveness analysis
In this study, we compared the expenses for treating COVID-19 patients at CTCs and hospitals, respectively, and we examined which medical facility is more cost-effective to operate. For analysis, we used the model shown in figure 1 that depicts cases of COVID-19 patients who were admitted to hospitals and CTCs. As for COVID-19 patients who were admitted to hospitals, we divided them into ‘discharge’ and ‘death’. We classified those who were discharged from a hospital-based on severity: mild illness, moderate illness and critical illness. Then, we calculated the cost and probability for each severity category. In terms of patients who checked into a CTC, we categorised them into ‘check out’ and ‘admission to a hospital’. We divided COVID-19 patients admitted to a hospital into ‘discharge’ and ‘death’. We classified those discharged from the hospital-based on severity: mild illness, moderate illness and critical illness. Then, we calculated the cost and probability for each severity category.
Decision tree model for analysing the cost-effectiveness of community treatment centres.
Analysis criteria
To conduct a cost-benefit analysis on COVID-19 patients admitted to hospitals and CTCs, we used the probability of the possible outcomes based on the model displayed in figure 1 and calculated the expected costs for hospital and CTC care. To analyse the probability and expected medical costs based on the severity of the COVID-19 patients who were admitted to a hospital, we used the data from online supplemental table 5. For CTC patients who were admitted to a hospital, we added the hospital costs to the medical expenses that they had incurred at their respective CTC. To determine the status of check out and probability based on the severity of CTC patients and medical expenses per person, we used the data from online supplemental table 6.
Supplemental material
Supplemental material
Of 243 349 patients who checked in at a CTC, 207 682 patients checked out (85.3%), while the rest of them were transferred to a hospital due to mild illness (68.6%), moderate illness (26.1%), critical illness (4.8%) or death (0.4%). Regarding stay, CTC patients stayed at their respective CTC for 10.4 days on average. The average stay of patients who checked out without being transferred to a hospital was 9.7 days, whereas the average stay of patients who were transferred to a hospital was 14.5 days (including length of stay at the CTC). CTC patients who developed a critical condition stayed for 24.5 days on average, whereas CTC patients who did not survive stayed for 31.8 days on average. This shows that increased severity is closely related to longer stays. In terms of medical expenses, CTC patients incurred 1 060 000 KRW on average. Those who checked out without being transferred to a hospital incurred 520 000 KRW, while those who were transferred to a hospital incurred 4 230 000 KRW. Those who developed a critical condition incurred about 17 000 000 KRW. CTC patients who died incurred about 43 000 000 KRW. This shows that increased severity is closely linked to higher medical expenses (online supplemental table 6).
When calculating the expenses for COVID-19 patients who were admitted to a hospital and for patients who checked into a CTC, we included only medical expenses directly related to treatment. The medical costs included infection prevention management fees, such as the use of negative pressure facilities, diagnostic tests and isolation costs. The operating costs of the CTC included general operating expenses, personnel expenses, medical supplies expenses, etc. We excluded indirect costs—non-medical expenses incurred during healthcare use, such as transportation and caregiver costs, or an individual patient’s productivity loss costs due to disease—because the expected costs may vary greatly depending on the inclusion criteria.14 The details are illustrated in table 1.
Analysis criteria for this study
Results of the cost-effectiveness analysis
Medical expenses
Employing healthcare usage as a criterion, we compared the cases of COVID-19 patients admitted to a hospital with those of COVID-19 patients at a CTC. The average amount of medical expenses incurred by a COVID-19 patient at a hospital and a CTC was approximately 2 710 000 KRW and 1 080 000 KRW, respectively. That is, COVID-19 patients using a hospital service incurred greater medical expenses than COVID-19 patients using a CTC by 1 630 000 KRW.
Medical and operating expenses
In addition to medical expenses for treating COVID-19 patients at a CTC, we examined the operating expenses of a CTC. We calculated the operating expenses based on the budget execution15–17 for running a CTC. Additionally, we used the data on CTC budgets allocated by the HIRA in the following categories of operating expenses: general expenses, labour and rental fees. We also studied the execution of each budget. The expenses for operating a CTC between 2020 and 2021 were estimated to be about 446.2 billion KRW. The categories with the highest expenses were in the order of general expenses, labour and rental fees (online supplemental table 7).
Supplemental material
Among the categories of operating expenses for CTCs, we excluded labour because it was generated when dispatching and hiring medical professionals from the private sector. Instead, we included the categories of operating expenses that were directly related to running a CTC such as general expenses and rental fees. To calculate average operating expenses, we divided the total annual expenses by the total number of patients who checked into a CTC.
Furthermore, we calculated the expected costs of using the respective medical facility by adding the medical expenses to the operating expenses. COVID-19 patients admitted to a hospital and CTC incurred approximately 2 710 000 KRW and 2 220 000 KRW on average, respectively. That is, using a hospital service led patients to incur about 480,000 KRW more than going to a CTC.
When substituting the expected costs from table 2 and online supplemental table 8 in the decision tree model in figure 1, the outcome is as shown in figure 2. When a CTC patient was transferred to a hospital, the average medical expenses that the patient incurred were higher than the medical expenses for COVID-19 patients who were directly admitted to the hospital. However, it was less likely for a CTC patient’s symptoms to worsen and to need to be transferred to a hospital; thus, the total expected cost for a CTC patient was lower than that for a hospital patient.
Supplemental material
Results of cost-effectiveness analysis on community treatment centres.
Comparison of expected costs: medical expenses+operating expenses (2020–2021) (unit: KRW)
Sensitivity analysis
The expected costs we discussed earlier can vary based on the change in the selected variables. Consequently, we conducted a one-way sensitivity analysis using the variable range and selection criteria in the cost analysis. For sensitivity analysis, we used the factors that had been chosen for calculating the expected costs for 2020–2021: medical expenses, operating expenses and probability. At this time, we used average medical expenses. For the maximum and minimum values of the medical expenses, we used the SD in online supplemental tables 5 and 6, with a 95% CI as the variation range. As for operating expenses, we used the CTC operation costs shown in online supplemental table 9 as the base input, with the average operating costs in 2020 as the high input, and with the average operating costs in 2021 as the low input. We calculated the probability by ±10% of the corresponding average values within a range between 0 and 1. The sensitivity analysis results are detailed in table 3.
Supplemental material
Sensitivity analysis (unit: KRW)
The results of the sensitivity analysis showed that any changes in operating expenses had a great impact on costs, and that the change in probability also had an impact on total expenses. Besides operating expenses, the range of variation declined in the following order: the probability of COVID-19 patients admitted to a hospital with mild or no symptoms, those with moderate symptoms, those with critical symptoms and those checking out from a CTC. To comprehensively indicate the shifting pattern according to the change in the variable’s input, we presented a range of expected costs in a Tornado diagram (online supplemental figure 1).
Supplemental material
Discussion
Unlike other countries that implemented home-based quarantine policies for curbing COVID-19, South Korea enforced inpatient treatment for all confirmed COVID-19 patients regardless of the severity of the symptoms. However, when the number of confirmed patients skyrocketed in March 2020 around the Daegu-Gyeongbuk region, there was a shortage of hospital beds for COVID-19 patients. As an alternative, the South Korean government established CTCs for COVID-19 patients with mild or no symptoms to manage the limited number of hospital beds for patients with severe symptoms. CTCs are one of the key measures to prevent the spread of COVID-19 because they enable the reallocation of medical resources for patients who need more support by categorising them based on severity level. However, few scholars have evaluated the effects of CTCs.
In this study, we first categorised COVID-19 patients based on severity and examined the probability of their condition developing into each severity level. CTC patients were less likely to develop worse conditions (moderate, critical or death) compared with hospitalised patients. As for COVID-19 patients admitted to a hospital, the likelihood of their condition becoming moderate, critical and of them dying was 9%, 2.3% and 1.2%, respectively. Moreover, the likelihood of COVID-19 patients who checked into CTCs and later transferred to a hospital developing worse conditions (moderate illness: 3.8%, critical illness: 0.7%, death: 0.1%) was minimal.
To compare the expenses incurred by COVID-19 patients for hospital care with those of CTC care, we examined probability, medical expenses and operating expenses for each severity group. Using a CTC was more cost-effective than a hospital service. Comparing only the medical expenses, COVID-19 patients admitted to hospitals and CTCs incurred 2 710 000 KRW and 1 080 000 KRW on average, respectively. Given the operating expenses for CTCs, CTC patients incurred 2 220 000 KRW on average, which was less than the expenses incurred by hospitalised COVID-19 patients.
This study has the following limitations. First, when evaluating the effect of using a CTC, we did not consider other options such as treatment at home. As home-based COVID-19 treatment implementation started in 2022, we excluded it from the analysis period.
However, a follow-up study could ensure a comprehensive comparative analysis by including home-based treatment and treatment at a medical facility.
Second, we did not include COVID-19 patients who became reinfected. Between 2020 and 2021, only 142 people were reinfected with COVID-19.18 As this figure was negligible and its impact on the research outcomes was insignificant, we did not consider such patients.
Third, it was difficult to calculate the exact amount of operating expenses due to limited data. Aside from the medical expenses for treating COVID-19 patients, medical facilities appear to have incurred additional expenses related to installing negative pressure rooms and recruiting medical staff. Moreover, it was difficult to determine the amount of operating expenses because most medical facilities exclusively treating COVID-19 patients did not disclose their data, and even disclosed data did not itemise each operating expense. The cost-benefit of using CTCs will increase if the operating expenses of hospitals can be added.
Additionally, while our analysis controlled for COVID-19 severity, we did not account for patients’ underlying conditions or their health status apart from their COVID-19 diagnosis. This is an important limitation, as the health status and underlying conditions of patients could moderate the severity of COVID-19 and impact treatment outcomes. Failure to control for the health status may result in overstating the cost-effectiveness of the CTC model and hence affect the validity of the study conclusion. A more cautious interpretation of the findings is advised, as the conclusion that ‘using a CTC is more cost-effective than hospital services alone’ may be beyond what the data suggest.
Despite these limitations, treatment at CTCs is more cost-effective than in-hospital treatment. Particularly when there is a highly infectious and fatal disease similar to COVID-19 prior to the Omicron variant, operating CTC in parallel with inpatient treatment is necessary to concentrate resources on patients who need more medical services. We hope that this analysis on the effect of CTCs will be used as baseline data for establishing guidelines for more effective operation of CTCs during COVID-19 waves or future pandemics.
Data availability statement
Data are available in a public, open access repository.
Ethics statements
Patient consent for publication
Ethics approval
This study received approval from the Institutional Review Board (IRB) without deliberation (IRB of Health Insurance Review and Assessment Service (No.2022-063-001) approved this study. HIRA anonymised and de-identified the patient information according to South Korean privacy law. Informed consent was not required because the data used in this study were all anonymised and unidentifiable.
Acknowledgments
We thank that Health Insurance Review and Assessment Service (HIRA) for providing the insurance claim data and their administrative and technical support.
This post was originally published on https://bmjopen.bmj.com