Patient Perspectives of Chronic Disease Management and Unmet Care Needs in South Korea: A Qualitative Study

Introduction

The burdens of chronic disease are increasing worldwide. The global share of chronic disease accounted for 60.8% of all deaths in 2000, and increased to 73.6% in 2019 when 7 of the 10 leading causes of death were chronic diseases. ¹ In South Korea, chronic diseases caused 79.9% of all deaths in 2019 and accounted for 8 of the 10 leading causes of death. ² These diseases challenge the current healthcare system, which is oriented to acute services. ³ Since chronic diseases are rarely cured and require continuous, coordinated, comprehensive, and person-centered care, healthcare systems should be redesigned to address the needs and concerns of those with chronic diseases. ⁴ The quality of service delivery should take into account patients’ experiences and perceptions of their care.^5,6

Several frameworks have been proposed for addressing the complex needs of patients with chronic diseases within the healthcare system. One notable example is the Chronic Care Model developed by Wagner, which advocates for collaborative efforts among patients and families, nonphysician personnel, evidence-based proactive providers, and community-based resources.^4,7 Similarly, the innovative care for chronic conditions framework suggests that patients and their families, community partners, and health professionals should be motivated to work together. ⁸ Another study emphasized the significance of care coordination and integration and the utilization of tools such as population management and information technology, with a specific focus on prevention, self-management, and primary health care. ⁹ This chronic care paradigm emphasized the significance of identifying patients’ needs, preferences, and perceptions in designing a successful chronic care strategy.

Korea's healthcare system is not well prepared to meet the changing needs of its population. Tackling chronic diseases requires better coordination, continuation across health care services, and health promotion and prevention. The community health care infrastructure is skewed towards the provision of inpatient and outpatient care services. ¹⁰ Since gate-keeping is not strictly enforced, patients can use healthcare services in any type of hospital with relative ease, which hinders care continuation and coordination ¹⁰ and may result in poor outcomes, such as high rates of diabetes-related hospitalization. ¹¹ A community-based primary-care chronic disease management pilot project was implemented ¹² in response to the emerging challenge of chronic diseases in South Korea. ¹⁰ While the project includes comprehensive services such as care planning and education, it covers only hypertension and diabetes patients in several regions. ¹²

Despite the increasing burden of chronic illness and the recent emphasis on patients’ perspectives in the healthcare system, studies in Korea have conducted limited investigations into the perceptions of patients with chronic diseases, with only 1 study conducted in 2014. ¹³ Understanding and incorporating the public's views and perceptions help to address the emerging challenge of chronic diseases in South Korea. This study aims to analyze patients’ experiences and examine patients’ unmet needs regarding chronic care in South Korea.

Method

Participant Recruitment and Data Collection

Participants were all 45 years of age or older with more than one chronic disease and were mainly using primary care clinics for chronic disease management. The FGIs were conducted from July to September of 2021. Each group consisted of 2 to 4 patients, and a total of 23 people participated. The interviews were conducted face-to-face by inviting participants to an allowed space where quarantine rules such as wearing facial masks and social distancing were strictly observed. We used semistructured questionnaires that were focused on patients’ care experiences and expectations for patient-centered care management. Two researchers participated in the FGIs, and each interview took one hour to one and a half hours. All of the interviews were recorded and transcribed for analysis. Table 1 shows the patient demographics.

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Table 1.

General Characteristics and Illness Information of Participants.

No	Participants	Gender	Age	Type of illness (order of diagnosis)	Duration of illness (years)
1	P1	M	51	Diabetes, hyperlipidemia	4
2	P2	F	45	Diabetes	10
3	P3	M	55	Diabetes, hypertension	3
4	P4	F	67	Hypertension, diabetes, hyperlipidemia	10
5	P5	F	67	Hyperlipidemia	5
6	P6	F	60	Hyperlipidemia	3
7	P7	F	63	Diabetes	6
8	P8	M	63	Hypertension	27
9	P9	F	50	Hypertension, hyperlipidemia	9
10	P10	M	55	Diabetes, hypertension, hyperlipidemia	11
11	P11	M	59	Diabetes, hypertension, hyperlipidemia	9
12	P12	M	55	Diabetes, hypertension, hyperlipidemia	21
13	P13	F	53	Hypertension, diabetes	15
14	P14	M	59	Hypertension, diabetes	7
15	P15	F	63	Hypertension, hyperlipidemia, osteoporosis	7
16	P16	F	65	Hypertension, hyperlipidemia, osteoporosis, arthritis	11
17	P17	M	65	Hypertension, hyperlipidemia	3
18	P18	F	65	Hypertension, hyperlipidemia, diabetes	15
19	P19	F	66	Hypertension, angina	15
20	P20	F	66	Hypertension	16
21	P21	F	57	Hyperlipidemia, osteopenia	3
22	P22	M	60	Hyperlipidemia	3
23	P23	M	55	Chronic neurovascular headache	10

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Table 2.

Patients’ Experience for the Chronic Disease Management.

Theme categories	Themes
Patient-provider interaction experience	Doctors only prescribe medicine Doctors who provide conventional advice Doctors who do not respect the patient's opinion Long wait times and inadequate consultations Lack of personalized care Freedom to select another doctor
Community and health system experience	Struggling alone Commercial media and folk remedies Lack of IT technologies for care Demanding visiting services Lack of collaboration in the community

Results

A total of 11 themes emerged and were clustered into 2 categories: Provider-patient interaction experience and community and health system experience (Table 2).

Discussion

Most participants in our study reported poor interactions with their health care providers, especially doctors. In particular, patients reported that healthcare providers were only interested in dispensing medication and providing short, conventional advice and did not listen to their opinions. A previous study suggested that these problems came from acute care-oriented and fragmented healthcare systems. ¹³ More specifically, multiple factors at the provider, organizational, and system levels may cause these problems. At the provider level, most physicians in local clinics are specialists, since primary care provider qualifications are not regulated. ¹⁴ They are less likely to understand the roles of primary care providers and more likely to focus on curative and specialty care, underusing preventive, comprehensive, and community-oriented care. ¹⁵

At the organizational level, physicians need to be more involved with nonphysician professionals to conduct routine assessments and preventive tasks and to provide the counseling and support necessary for self-management.^4,16 However, the majority of local clinics are solo practices in Korea, ¹⁰ which makes it difficult for physicians to work in teams and to provide comprehensive care. At the system level, the current reimbursement mechanism is optimized for acute care rather than chronic care.^4,9 Based on fee-for-service payment, productivity measures focus on the number of visits and technical procedures. ⁴ Providers are generally not rewarded for comprehensive assessments, counseling, and educational activities, ⁴ and positive outcomes.^17,18

Our findings show that community resources are not well mobilized. The care of patients with chronic conditions cannot be limited to their contacts with health care providers. These patients need support at home, work, and in the community, where they spend most of their time. ¹⁶ First, developing self-management skills and lifestyle changes fundamental to chronic disease care^16,19 requires a whole-system approach and community resources beyond individual healthcare providers. ¹⁹ Group and community interventions, such as a weight-loss program, combined with professional support may enhance patients’ self-management skills. ¹⁹ Next, people with chronic conditions living in a community require visiting and social services. ²⁰ Although several programs have been implemented in Korea, they provide services for a limited group, ²¹ and do not have adequate human resources. ²² Lastly, fragmented services and a lack of coordination are more serious problems in Korea, where primary care is not well established than in other countries. ¹⁵ Korean physicians also indicated that coordination and comprehensiveness are lacking in primary care. ²³ Payment and healthcare delivery systems should be developed to enhance community-based coordinated and integrated care.

Some participants in our study emphasized the use of information technology. Information regarding patients, their care, and their outcomes are essential to improving chronic care. ⁴ The electronic patient care record may support communication between health care professionals and reduce errors. ²⁴ In addition, the information can be used to compare provider performance.^24,25 Information technology may enable home care through telecare and telehealth applications. ⁹ In Korea, the National Health Insurance Service has given a financial incentive to providers by reviewing prescriptions and treatment, ²⁶ but other providers such as nurses and clinical nutritionists have limited access to this information, which may prohibit care coordination. Establishing an electronic patient care record may cause privacy concerns, but safeguards could ensure patient benefits.^10,25

This qualitative study explored patients’ experiences of chronic disease management under the current Korean healthcare system, especially primary care. There are several policy-evaluating studies from the perspectives of the policymakers or healthcare providers, but few studies have evaluated the chronic disease care system from the viewpoint of the patients and service users. This approach will help policymakers establish a more patient-centered chronic care system.

Limitations

One limitation of this qualitative study is the small sample size of patients. Future research should aim to gather a larger number of patient perspectives regarding their care experiences and recommendations for enhancing healthcare delivery in alignment with advancements in information technology. In addition, our findings may not represent the diverse perspectives of those with chronic illnesses. Nevertheless, our findings are good evidence for developing future policies.

Conclusion

A fundamental change in the paradigm of the Korean healthcare system is required for successful chronic disease management and desirable health outcomes. Our findings suggest that the existing fee-for-service payment and healthcare delivery system should be more patient-centered. In addition, programs like community-based primary-care chronic disease management initiatives should strive to incorporate the perspectives of patients with chronic diseases. New policies are more likely to succeed when they proactively address the diverse needs of patients with chronic conditions.