Two Decades of Research Using Taiwan's National Health Insurance Claims Data: Bibliometric and Text Mining Analysis on PubMed

Comparative effectiveness and safety of direct oral anticoagulants in atrial fibrillation patients with dementia

INTRODUCTION

Patients with atrial fibrillation (AF) and dementia face unique challenges in stroke prevention, particularly in selecting appropriate anticoagulation therapy. Direct oral anticoagulants (DOACs) effectively reduce stroke and embolism risks, but evidence comparing their effectiveness and safety in this population remains limited.

METHODS

This retrospective, population-based cohort study used data from Taiwan's National Health Insurance Research Database to evaluate outcomes of four DOACs (dabigatran, apixaban, edoxaban, and rivaroxaban) in AF patients with dementia aged 50 years or older. We used propensity score matching to balance baseline characteristics across six DOAC comparison pairs.

RESULTS

Dabigatran demonstrated superior outcomes, reducing the composite risk of ischemic stroke, acute myocardial infarction, intracranial hemorrhage, major bleeding, and all-cause mortality compared to apixaban (hazard ratio [HR], 0.82; 95 % confidence interval [CI], 0.73-0.92), edoxaban (HR, 0.81; 95 % CI, 0.71-0.92), and rivaroxaban (HR, 0.82; 95 % CI, 0.73-0.91). It also showed lower risks of intracranial hemorrhage and all-cause mortality. Sensitivity analyses excluding patients with nasogastric tubes or severe renal impairment showed smaller differences in overall outcomes but maintained dabigatran's advantage in reducing intracranial hemorrhage risk.

CONCLUSIONS

This study demonstrates the need for tailored anticoagulation strategies in this vulnerable population, with dabigatran emerging as a potentially safer and more effective option for stroke prevention in AF patients with dementia. Future research should examine individual DOAC effects across diverse clinical settings to optimize treatment outcomes.

Cancer publications using real-world data from the Taiwan National Health Insurance Research Database: Conceptual framework and bibliometric analysis

BACKGROUND

Bibliometric analysis often overlooks study-based components such as study aims, design, and statistical methods. In this study, we propose a conceptual framework incorporating these study-based components with disease-based components for the bibliometric analysis of cancer articles using real-world data. This framework is a significant step forward in cancer research. We then investigated the distribution and temporal trends of these components for cancer articles using the Taiwan National Health Insurance Research Database (NHIRD) published from 2006 to 2022.

METHODS

Study- and disease-based components were extracted and cross-validated. The distribution and temporal trends of these components were then presented.

RESULTS

We analyzed 1232 articles and found a noticeable increase in the annual publication count from 2011 onward. This upward trend signified the growing momentum in cancer research. Cancer risk factors were the most studied (52%), followed by cancer outcomes (36%) and incidence/prevalence (3%). Among the publications on risk factors and outcomes, most were cohort studies (85%), followed by case-control studies (10.7%). In both study designs, the use of the propensity score method increased steadily from 2.4% in 2011 to 40% in 2022. The most frequently studied cancer site was "all cancers or multiple cancers" (25.6%), followed by breast (9.6%), hepatobiliary (9.2%), and colorectal cancers (8.8%). Among the top 10 cited articles, the first and fourth focused on whether suppressing hepatitis B viral load with nucleoside analogs could reduce hepatocellular carcinoma recurrence and incidence in chronic hepatitis B patients. The remaining eight examined the association between medications and cancer risk.

CONCLUSION

Beyond citation metrics, our research underscores the importance of considering study-based and disease-based components in bibliometric analysis. These components form the foundation of the real-world data cancer research framework and have practical implications for diseases beyond cancers, providing a broader perspective for researchers and practitioners.

Comparative effectiveness and safety of direct oral anticoagulants and warfarin in atrial fibrillation patients with dementia

INTRODUCTION

Developing an effective stroke prevention strategy is crucial for elderly atrial fibrillation (AF) patients with dementia. This is due to the limited and inconsistent evidence available on this topic. In this nationwide, population-based cohort study, we aim to compare the effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in AF patients with dementia.

PATIENTS AND METHODS

We identified AF patients with dementia, aged 50 years or older, from Taiwan's National Health Insurance Research Database between 2010 and 2019. The primary outcome was a composite of hospitalizations due to ischemic stroke, acute myocardial infarction, intracranial hemorrhage, or major bleeding, as well as all-cause mortality. We used 1:1 propensity score matching and Cox proportional hazard models to adjust for confounding factors when comparing outcomes between warfarin and DOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) users or warfarin and each individual DOAC.

RESULTS

There were 2952 patients in the DOAC-warfarin matched cohort. The apixaban-, dabigatran-, edoxaban-, and rivaroxaban-warfarin matched cohorts had 2346, 2554, 1684, and 2938 patients, respectively. The DOAC group, when compared to warfarin, was associated with a lower risk of both the composite outcome (hazard ratio (HR), 0.81; 95% confidence interval (CI) 0.69-0.95) and ischemic stroke (HR 0.65; 95% CI 0.48-0.87). Apixaban (HR 0.79; 95% CI 0.66-0.94), dabigatran (HR 0.64; 95% CI 0.53-0.77), and rivaroxaban (HR 0.82; 95% CI 0.70-0.97) were also associated with a lower risk of the composite outcome.

DISCUSSION AND CONCLUSION

Compared to warfarin, DOACs, whether as a group or apixaban, dabigatran, or rivaroxaban individually, were associated with a reduced risk of the composite outcome in elderly patients with concurrent AF and dementia.

Poststroke seizures and epilepsy increase the risk of dementia among stroke survivors: A population-based study

OBJECTIVE

With global aging, the occurrence of stroke and associated outcomes like dementia are on the rise. Seizures and epilepsy are common poststroke complications and have a strong connection to subsequent dementia. This study examines the relationship between poststroke seizures (PSS) or poststroke epilepsy (PSE) and dementia using a national health care database.

METHODS

We conducted a retrospective study using data from the Taiwan National Health Insurance Research Database from 2009 to 2020. We identified acute stroke patients from 2010 to 2015, excluding those with pre-existing neurological conditions. Based on age, sex, stroke severity level, and the year of index stroke, patients with PSS or PSE were matched to those without. The main outcome was incident dementia.

RESULTS

This study included 62 968 patients with an average age of 63 years, with males accounting for 62.9%. Of them, 60.3% had ischemic strokes, and 39.7% had hemorrhagic strokes. After an average follow-up period of 5.2 years, dementia developed in 15.9% of patients who had PSS or PSE, as opposed to 8.4% of those without these conditions. A time-dependent Fine and Gray competing risk analysis showed that PSS and PSE were significantly associated with dementia across all stroke types. Subgroup analyses revealed significantly increased risk of dementia across all age groups (<50, 50-64, and ≥65 years), sexes, and various stroke severity levels. The link between PSS or PSE and dementia was particularly pronounced in men, with a less distinct correlation in women.

SIGNIFICANCE

The risk of incident dementia was higher in patients with PSS or PSE. The potential for therapeutic interventions for seizures and epilepsy to reduce poststroke dementia underscores the importance of seizure screening and treatment in stroke survivors.

Traditional Chinese Medicine Herbs for Breast Cancer Prevention and Survival: A Narrative Review of Epidemiological Studies from Taiwan

PURPOSE OF REVIEW

This review aims to describe the association of integrating traditional Chinese medicine (TCM) herbs into conventional medicine (CM) in preventing breast cancer and improving survival rates among breast cancer patients of Taiwan.

RECENT FINDINGS

Of 7 relevant studies, spanning 2014-2023, 4 investigated breast cancer risk in women with menopausal symptoms and other comorbidities. All 4 reported that TCM herbal use was associated with lower risks of developing breast cancer. Three studies investigated survival in newly-diagnosed breast cancer patients receiving CM. All reported that adjunctive TCM users had lower mortality rates than CM-only patients. However, the heterogeneity of study designs, populations, and interventions may limit the generalizability and robustness of the findings. TCM herbs may promote breast cancer prevention and survival when used alongside CM. More rigorous observational research and clinical trials in specific patient populations are needed to guide clinical decision-making.

Validating ICD-10 Diagnosis Codes for Guillain-Barré Syndrome in Taiwan's National Health Insurance Claims Database

Purpose

To validate the International Classification of Diseases, 10th Revision (ICD-10) codes for Guillain-Barré syndrome (GBS) in Taiwan's insurance claims database.

Methods

We identified adult patients hospitalized at any Chang Gung Memorial Foundation branch hospital between January 1st, 2017, and December 31st, 2022, with ICD-10 code G61.0 in any of the five discharge diagnosis positions, indicating possible Guillain-Barré syndrome. We then validated the possible GBS diagnosis using data from electronic medical records of the identified patients, based on the diagnostic criteria established by the National Institute of Neurological Disorders and Stroke. We determined the positive predictive values (PPV) of various operational definitions, including the position (primary or other) where the code was recorded in the discharge diagnosis, nerve conduction study (NCS) claims, and / or specific GBS treatments.

Results

The final validation cohort of 484 patients with ICD-10 code for GBS in the discharge diagnosis was found to include 368 true GBS patients. Identifying inpatients using only the ICD-10 code for GBS in any of the five positions for discharge diagnosis yielded a PPV of 76.0%. With more restrictive definitions (primary diagnosis only, or requiring additional claims for NCS and/or treatments), the PPV tended to increase, but with fewer true GBS patients identified. Using ICD-10 GBS code in the primary diagnosis plus NCS and treatment claims yielded the highest PPV (98.3%); however, 140 (38.0%) of the true GBS patients were missed using this definition. In contrast, using the ICD-10 GBS code in any position, plus claims for NCS, achieved a relatively good PPV (85.8%) with minimal loss of true GBS patients (13, ie, 3.5%).

Conclusion

In Taiwan's NHI claims data, identifying true GBS patients using only the ICD-10 code yielded a PPV of 76.0%; however, adding claims for diagnostic procedure and GBS treatment increased the PPV to 98.3%.

Age, sex, and pre-arrest comorbidities shape the risk trajectory of sudden cardiac death- Patterns highlighted by population data in Taiwan

OBJECTIVES

Few reports have indicated the secular trend in the sudden cardiac death (SCD) incidence and pre-arrest comorbidities. This study aimed to comprehensively analyze the trend of SCD incidence and its association with pre-arrest comorbidities.

METHODS

This population-based cohort study analyzed Taiwan's National Health Insurance (NHI) research database and identified SCD incidents by inspecting data from all emergency department visits from 2011 to 2018. The inclusion criteria were ICD-9:427.5 or 427.41, or ICD-10:I46.9, I46.8, or I46.2. Pre-existing comorbidities were confirmed based on medication use. Multivariable logistic regression was adopted with covariates age, sex, and pre-existing comorbidities.

RESULTS

This study reviewed a total of 184,164,969 person-year records, and identified 92,138 SCD incidents. From 2011 to 2018, the SCD incidence rate increased from 36.3 to 55.4 per 100,000 enrollees in Taiwan. The top five pre-arrest comorbidities were stable, while the prevalence of chronic kidney disease rose significantly. Compared to those aged 20-29, enrollees aged >65 years had significantly higher odds of SCD (aOR:27.30, 95% CI:26.05-28.61). Higher odds of SCD were noted in the enrollees who had a seizure (aOR:2.24, 95% CI:2.12-2.38), parkinsonism (aOR:1.81, 95% CI:1.73-1.89), psychological disorders (aOR:1.59, 95% CI:1.56-1.62), diabetes mellitus (aOR:1.44, 95% CI:1.41-1.46), heart diseases (aOR:1.41, 95% CI:1.38-1.44).

CONCLUSIONS

The incidence of SCD steadily increased in Taiwan from 2011 to 2018. Hypertension, diabetes mellitus, heart disease, psychological disorders, and arthritis were major pre-arrest comorbidities. Age is the most important risk factor for SCD. Further large-scaled population-based study that investigated in diverse ethnicities from countries in addition to Asians would be warranted.

Bibliographic analysis of psychiatric publications in Taiwan: An analysis of Web of Science subject category from 1970 to 2023

BACKGROUND

Mental diseases continue to rank among the top 10 leading causes of global burden. Psychiatric research is a crucial avenue through which mental healthcare can be enhanced. Taiwanese academics have constantly concentrated their efforts on psychiatric research and published their findings. A systematic examination of these papers will provide an assessment of the present state and contribute to the formulation of future policies for psychiatric research in Taiwan. We assessed psychiatric papers from Taiwan using the Web of Science (WoS) database.

METHODS

Academic papers in the Psychiatry category of the WoS database from Taiwan were retrieved and evaluated. The analysis included papers published in Science Citation Index-Expanded and Social Science Citation Indexed journals between 1970 and 2023, excluding meeting abstracts and corrections.

RESULTS

Of the 1 049 281 papers published globally in the Psychiatry category of the WoS system between 1970 and 2023, 6117 (0.58%) were published in Taiwan. Taiwan ranked 26th globally in terms of number of papers published. These publications have received 150 519 citations. Over the past 53 years, both the annual number of psychiatric papers from Taiwan and their citations received have significantly and rapidly increased. However, the average impact factor of publications remained constant over time.

CONCLUSION

Over the last five decades, the number of psychiatric publications from Taiwan has increased. However, the average impact factor of these published papers did not increase over time. Investing in advanced research infrastructure and interdisciplinary projects may improve the quality and relevance of Taiwanese psychiatric research publications, potentially increasing their global citations and impact.

Bridging Real-World Data Gaps: Connecting Dots Across 10 Asian Countries

The economic trend and the health care landscape are rapidly evolving across Asia. Effective real-world data (RWD) for regulatory and clinical decision-making is a crucial milestone associated with this evolution. This necessitates a critical evaluation of RWD generation within distinct nations for the use of various RWD warehouses in the generation of real-world evidence (RWE). In this article, we outline the RWD generation trends for 2 contrasting nation archetypes: "Solo Scholars"-nations with relatively self-sufficient RWD research systems-and "Global Collaborators"-countries largely reliant on international infrastructures for RWD generation. The key trends and patterns in RWD generation, country-specific insights into the predominant databases used in each country to produce RWE, and insights into the broader landscape of RWD database use across these countries are discussed. Conclusively, the data point out the heterogeneous nature of RWD generation practices across 10 different Asian nations and advocate for strategic enhancements in data harmonization. The evidence highlights the imperative for improved database integration and the establishment of standardized protocols and infrastructure for leveraging electronic medical records (EMR) in streamlining RWD acquisition. The clinical data analysis and reporting system of Hong Kong is an excellent example of a successful EMR system that showcases the capacity of integrated robust EMR platforms to consolidate and produce diverse RWE. This, in turn, can potentially reduce the necessity for reliance on numerous condition-specific local and global registries or limited and largely unavailable medical insurance or claims databases in most Asian nations. Linking health technology assessment processes with open data initiatives such as the Observational Medical Outcomes Partnership Common Data Model and the Observational Health Data Sciences and Informatics could enable the leveraging of global data resources to inform local decision-making. Advancing such initiatives is crucial for reinforcing health care frameworks in resource-limited settings and advancing toward cohesive, evidence-driven health care policy and improved patient outcomes in the region.

Alcohol abuse may increase the risk of autoimmune connective tissue disease: a nationwide population-based cohort study

Objectives

Altered immune and inflammatory responses resulting from alcohol abuse have been implicated in increasing the risk of autoimmune connective tissue disease (ACTD). However, limited research has been conducted on this topic in the Asian population. Therefore, this study was undertaken to investigate and address this knowledge gap.

Methods

Using data from Taiwan's National Health Insurance Research Database, we identified all patients with alcohol abuse between 2000 and 2017. We selected a comparison cohort without alcohol abuse, matching them in terms of age, sex, and index date at a 3:1 ratio. We collected information on common underlying comorbidities for analysis. Both cohorts were followed up until the diagnosis of ACTD or the end of 2018.

Results

A total of 57,154 patients with alcohol abuse and 171,462 patients without alcohol abuse were included in the study. The age and sex distributions were similar in both cohorts, with men accounting for 89.8% of the total. After adjusting for underlying comorbidities, patients with alcohol abuse had a higher risk of developing ACTD [adjusted hazard ratio (AHR): 1.12, 95% confidence interval (CI): 1.01-1.25]. The stratified analysis revealed that this increased risk was specific to the male population. Additionally, besides alcohol abuse, liver disease, renal disease, coronary artery disease, and chronic obstructive pulmonary disease were identified as independent predictors for ACTD.

Conclusion

This study demonstrates that alcohol abuse increases the risk of developing ACTD in the Asian population, particularly among men. Therefore, it is important to implement alcohol cessation, especially in individuals with liver disease, renal disease, coronary artery disease, and chronic obstructive pulmonary disease.

Real-world data analysis on effectiveness of integrative therapies: A practical guide to study design and data analysis using healthcare databases

Real world data (RWD) is increasingly used to investigate health outcomes and treatment efficacy in the field of integrative medicine. Due to the fact that the majority of RWDs are not intended for research, their secondary use in research necessitates complex study designs to account for bias and confounding. To conduct a robust analysis of RWD in integrative medicine, a comprehensive study design process that reflects the characteristics of integrative therapies is necessary. In this paper, we present a guide for designing comparative effectiveness RWE research in integrative medicine. We discuss key factors to consider when selecting RWDs for research on integrative medicine. We provide practical steps for developing a research question, formulating the PICOT objectives (population, intervention, comparator, outcome, and time horizon), and selecting and defining covariates with a summary table. Specific study designs are depicted with corresponding diagrams. Finally, data analysis procedures are introduced. We hope this article clarifies the importance of RWE research design and related processes in order to improve the rigor of RWD studies in the field of integrative medicine research.

Association between chronic pain and acute coronary syndrome in the older population: a nationwide population-based cohort study

BACKGROUND

Chronic pain (CP) may increase the risk of acute coronary syndrome (ACS); however, this issue in the older population remains unclear. Therefore, this study was conducted to clarify it.

METHODS

We used the Taiwan National Health Insurance Research Database to identify older patients with CP between 2001 and 2005 as the study cohort. Comparison cohort was the older patients without CP by matching age, sex, and index date at 1:1 ratio with the study cohort in the same period. We also included common underlying comorbidities in the analyses. The risk of ACS was compared between the two cohorts by following up until 2015.

RESULTS

A total of 17241 older patients with CP and 17241 older patients without CP were included in this study. In both cohorts, the mean age (± standard deviation) and female percentage were 73.5 (± 5.7) years and 55.4%, respectively. Spinal disorders (31.9%) and osteoarthritis (27.0%) were the most common causes of CP. Older patients with CP had an increased risk for ACS compared to those without CP after adjusting for all underlying comorbidities (adjusted sub-distribution hazard ratio [sHR] 1.18; 95% confidence interval: 1.07-1.30). The increasement of risk of ACS was more when the follow-up period was longer (adjusted sHR of < 3 years: 1.8 vs. <2 years: 1.75 vs. <1 year: 1.55).

CONCLUSIONS

CP was associated with an increased risk of ACS in the older population, and the association was more prominent when the follow-up period was longer. Early detection and intervention for CP are suggested in this population.

Validation of ICD-10-CM Diagnostic Codes for Identifying Patients with ST-Elevation and Non-ST-Elevation Myocardial Infarction in a National Health Insurance Claims Database

Purpose

Distinguishing ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) is crucial in acute myocardial infarction (AMI) research due to their distinct characteristics. However, the accuracy of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for STEMI and NSTEMI in Taiwan's National Health Insurance (NHI) database remains unvalidated. Therefore, we developed and validated case definition algorithms for STEMI and NSTEMI using ICD-10-CM and NHI billing codes.

Patients and Methods

We obtained claims data and medical records of inpatient visits from 2016 to 2021 from the hospital's research-based database. Potential STEMI and NSTEMI cases were identified using diagnostic codes, keywords, and procedure codes associated with AMI. Chart reviews were then conducted to confirm the cases. The performance of the developed algorithms for STEMI and NSTEMI was assessed and subsequently externally validated.

Results

The algorithm that defined STEMI as any STEMI ICD code in the first three diagnosis fields had the highest performance, with a sensitivity of 93.6% (95% confidence interval [CI], 91.7-95.2%), a positive predictive value (PPV) of 89.4% (95% CI, 87.1-91.4%), and a kappa of 0.914 (95% CI, 0.900-0.928). The algorithm that used the NSTEMI ICD code listed in any diagnosis field performed best in identifying NSTEMI, with a sensitivity of 82.6% (95% CI, 80.7-84.4%), a PPV of 96.5% (95% CI, 95.4-97.4), and a kappa of 0.889 (95% CI, 0.878-0.901). The algorithm that included either STEMI or NSTEMI ICD codes listed in any diagnosis field showed excellent performance in defining AMI, with a sensitivity of 89.4% (95% CI, 88.2-90.6%), a PPV of 95.6% (95% CI, 94.7-96.4%), and a kappa of 0.923 (95% CI, 0.915-0.931). External validation confirmed these algorithms' efficacy.

Conclusion

Our results provide valuable reference algorithms for identifying STEMI and NSTEMI cases in Taiwan's NHI database.

Sodium-glucose co-transporter 2 inhibitor add-on therapy for metformin delays diabetic retinopathy progression in diabetes patients: a population-based cohort study

To investigate how sodium-glucose co-transporter 2 inhibitors (SGLT2is) add-on therapy for metformin affects diabetic retinopathy (DR) progression in patients with type 2 diabetes mellitus (T2DM). This nationwide population-based study conducted from January 1, 2016, to December 31, 2018 involved 3,432,911 adults with T2DM in Taiwan. To adjust for potential confounders, data on sex, age, income, comorbidities, diabetes complication severity index score, staging of kidney disease, anti-diabetic medications, and index year were included. The outcome was DR progression, determined by procedure codes or the addition of ICD-9-CM or ICD-10-CM codes to the medical records of the patients during the study. Sensitivity analyses were performed to validate the findings. The adjusted hazard ratio (aHR) of DR progression was 0.89 for the SGLT2is add-on group, relative to the control group [95% confidence interval (CI) 0.81-0.99, P = 0.026]. The Kaplan-Meier curve of the cumulative incidence rate showed that the cumulative incidence of DR progression was considerably decreased in the SGLT2is cohort (log-rank P = 0.0261). The use of SGLT2is for less than 1 year and 1-2 years were associated with a significant increase in the risk of DR progression (aHR 1.56 and 1.88, respectively); however, the risk markedly reduced if the SGLT2is regimen was used for more than 2 years (aHR 0.41, 95% Cl 0.35-0.48; P < 0.001). The serial sensitivity analysis showed consistent findings. The aHR of DR progression was 0.82 for the SGLT2is cohort relative to the non-SGLT2is cohort based on the fundoscopy or indirect ophthalmoscopy findings within 1 year before the outcome date (95% Cl 0.71-0.95; P = 0.009). Co-administration of metformin and SGLT2is may reduce the risk of DR progression. Short-term use of SGLT2is may markedly increase the risk of DR, whereas prolonged use SGLT2is may significantly decrease it.

Risk of rapid progression to dialysis in patients with type 2 diabetes mellitus with and without diabetes-related complications at diagnosis

Many adults with diabetes mellitus are unaware worldwide. The study objectives aimed to evaluate the risk of dialysis within 5 years of diagnosis between patients with newly diagnosed diabetes with and without diabetes-related complications. A retrospective longitudinal nationwide cohort study was conducted. Patients diagnosed with diabetes between 2005 and 2013 were followed up until 2018. They were categorized based on the presence or absence of complications, the number of complications, and the diabetes complications severity index (DCSI) scores. Dialysis outcomes were determined through the Registry of Catastrophic Illness from the National Health Insurance Research Database. Among the analyzed patients, 25.38% had complications at diagnosis. Patients with complications at diagnosis had a significantly higher risk of dialysis within 5 years (adjusted hazard ratio: 9.55, 95% confidence interval CI 9.02-10.11). Increasing DCSI scores and the number of complications were associated with higher dialysis risks. Patients with one complication had a 7.26-times higher risk (95% CI 6.83-7.71), while those with ≥ 3 complications had a 36.12-times higher risk (95% CI 32.28-40.41). In conclusion, newly diagnosed diabetes patients with complications face an increased risk of dialysis within 5 years. The severity and number of complications are directly linked to the risk of dialysis within this timeframe.

Ablation of atrial fibrillation and dementia risk reduction during long-term follow-up: a nationwide population-based study

AIMS

This study investigated the epidemiological characteristics of new-onset dementia in patients with atrial fibrillation (AF) and the association of catheter ablation with different subtypes of dementia.

METHODS AND RESULTS

We conducted a population-based, retrospective cohort study using data from the Taiwan National Health Insurance Research Database. In total, 136 774 patients without a history of dementia were selected after 1:1 propensity score matching based on age (with AF vs. without AF). A competing risk model was used to investigate the three subtypes of dementia: Alzheimer's disease, vascular dementia, and other/mixed dementia. Inverse probability of treatment weighting (IPTW) was performed to minimize the impact on dementia risk due to the imbalanced baseline characteristics. After a median follow-up period of 6.6 years, 8704 events of new-onset dementia occurred. Among all AF patients developing dementia, 73% were classified as having Alzheimer's disease, 16% as having vascular dementia, and 11% as having other/mixed dementia. The cumulative incidence of dementia in AF patients was higher than those without AF (log-rank test: P < 0.001 for both before and after IPTW). In patients with AF undergoing catheter ablation, the total dementia risk decreased significantly [P = 0.015, hazard ratio (HR): 0.74, 95% confidence interval (CI): 0.58-0.94] after multivariable adjustment, but not for the subtype of vascular dementia (P = 0.59, HR: 0.86, 95% CI: 0.49-1.50).

CONCLUSION

Patients with AF have a higher incidence of all types of dementia, including Alzheimer's disease, vascular dementia, and a mixed type of dementia. Alzheimer's disease is less likely to occur in patients with AF undergoing catheter ablation.

Atrial fibrillation as a contributor to the mortality in patients with dementia: A nationwide cohort study

Background

Knowledge of the risk of death in patients with dementia is essential for planning preventive strategies. This study aimed to evaluate the effect of atrial fibrillation (AF) on death risks and other factors associated with death in patients with dementia and AF.

Methods

We conducted a nationwide cohort study using Taiwan's National Health Insurance Research Database. We identified subjects with dementia diagnosed for the first time and AF diagnosed concomitantly between 2013 and 2014. Subjects under the age of 18 years were excluded. Age, sex, and CHA2DS2-VASc scores were 1: 4 matched for AF patients (N = 1,679) and non-AF controls (N = 6,176) using the propensity score technique. The conditional Cox regression model and competing risk analysis were applied. The risk of mortality was tracked till 2019.

Results

AF history was associated with higher risks of all-cause death (hazard ratio [HR]: 1.208; 95% confidence interval [CI]: 1.142–1.277) and cardiovascular death (subdistribution HR: 1.210; 95% CI: 1.077–1.359) in dementia patients than patients without a diagnosis of AF. For patients with both dementia and AF, they had a higher risk of death due to higher age, diabetes mellitus, congestive heart failure, chronic kidney disease, and prior stroke. Anti-arrhythmic drugs and novel oral anticoagulants significantly reduced the risk of death in patients with AF and dementia.

Conclusion

This study found that AF is a risk factor for mortality in patients with dementia and explored several risk factors for AF-related mortality. This study highlights the importance of controlling AF especially in patients with dementia.

Standardized rate of hospitalization for violent injuries among different generations in counties and cities in Taiwan from 2000 to 2015

This study aimed to understand the distribution of the standardized rate of hospitalization for violent injuries in counties and cities in Taiwan. The ICD-9 diagnosis code N-codes 995.5 (abused child) and 995.8 (abused adult) or E-code E960-E969 (homicide and intentional injury by others) were defined as research cases. The study analyzed the standardized medical treatment rate of children and adolescents aged 0 to 17, adults aged 18 to 64, and older adults over 65 years old suffering from violence for the first time. During the 15-year period, the counties and cities with the highest rate of medical treatment for violent injuries among children (unit: per 105 people) were Pingtung County (33.1 males, 22.9 females), Lienchiang County (8.8 males, 9.8 females), and New Taipei City (8.2 males, 8.8 females). For adults, Pingtung County (73.2 males, 36.8 females), New Taipei City (26.0 males, 14.3 females), and Yunlin County (19.7 males, 7.7 females) registered the highest rates. For older adults, Pingtung County (33.6 persons), New Taipei City (12.5 persons), Yun Lin County (11.2 persons), and Taichung City (9.2 persons) registered the highest rates. The highest rates of older female adults receiving treatment were recorded in Pingtung County (15.1 persons), Yunlin County (9.0 persons), Taichung City (5.5 persons), and New Taipei City (5.1 persons). With the Poisson regression model, the relative risk ratio of seeking medical care owing to violence in Pingtung County (reference: Taipei City) was 25.1 times for children, 20.1 times for adults, and 11.7 times for older adults. The counties and cities with higher rates of violent medical treatment for adults and older adults during the 15-year period were Pingtung County, New Taipei City, and Yunlin County. For children and adolescents, Pingtung County, Lienchiang County, and New Taipei City recorded the highest rates. Pingtung County had the highest risk of sexual violence. These results may be related to the local industrial structure, demographic composition, and other characteristics explained in the text.

Benefit of Uracil-Tegafur Used as a Postoperative Adjuvant Chemotherapy for Stage IIA Colon Cancer

Background and Objectives: Postoperative adjuvant therapy with uracil and tegafur (UFT) is often used for stage II colon cancer in Japan, but a limited number of studies have investigated the effects of UFT in these patients. Materials and Methods: We conducted a population-based cohort study in patients with resected stage II colon cancer comparing the outcomes after postoperative adjuvant chemotherapy with UFT with an observation-only group. The data were collected from the Taiwan National Health Insurance Research Database from 2000 to 2015. The outcomes of the study were disease-free survival (DFS) and overall survival (OS). The hazard ratios (HRs) were calculated using multivariate Cox proportional hazard regression models. Results: No differences in the DFS and OS were detected between the UFT (1137 patients) and observation (2779 patients) cohorts (DFS: adjusted HR 0.702; 95% confidence interval (CI) 0.489-1.024; p = 0.074) (OS: adjusted HR 0.894; 95% CI 0.542-1.186; p = 0.477). In the subgroup analyses of the different substages, UFT prolonged DFS in patients with stage IIA colon cancer (adjusted HR 0.652; 95% CI 0.352-0.951; p = 0.001) compared with DFS in the observation cohort, but no differences in the OS were detected (adjusted HR 0.734; 95% CI 0.475-1.093; p = 0.503). Conclusions: Our results show that DFS improved significantly in patients with stage IIA colon cancer receiving UFT as a postoperative adjuvant chemotherapy compared with DFS in the observation group.

Prevalence of exposure to benzodiazepines among pregnant women in Taiwan: A nationwide longitudinal study

Although more than one hundred studies have examined the prevalence of the use of benzodiazepines and benzodiazepine-like Z-hypnotics (BZDs) among pregnancy events, further analysis of the effects of dosage or type of BZDs is needed. The aim of this study was to examine the prevalence rate of BZDs use in pregnancy events, stratified by trimester over time, with characteristics of the dosage and type of BZDs. This is a retrospective population study based on linking three national databases. We examined the prevalence rates from 2004 to 2017, and contrasted the results based on >0 defined daily dose (DDD) and ≥0.5 DDD. We identified 2,630,944 pregnancy events with live births; 89,897 (3.4%) of the associated pregnancy events had used some form of BZD during pregnancy. The prevalence of BZDs use, as defined by >0 DDD, decreased from 4.1% in 2004 to 2.9% in 2017, indicating a decrease in sporadic use and an increase in stable use within therapeutic doses. Meanwhile, BZDs use defined by ≥0.5 DDD increased from 0.1% in 2004 to 0.4% in 2017. Zolpidem was the most frequently prescribed BZDs, as defined by >0 DDD or ≥0.5 DDD. This national cohort study demonstrates the importance of average dosage in the definition of BZDs use in pregnancy events, and it found opposite trends in the prevalence of use between different dosages.

Global Research Trends in Gestational Diabetes Mellitus from 2000 to 2020: A Bibliometric Study

AIMS

This study analyzed major trends and topics in the field of gestational diabetes mellitus research between 2000 and 2020.

METHODS

Studies that investigated gestational diabetes mellitus published between 2000 and 2020 were retrieved from the Web of Science Core Collection database. Data from the identified studies were analyzed using CiteSpace software.

RESULTS

A total of 22,713 publications were retrieved, among which 21,722 publications were included in this scientometric analysis. Clustering analysis revealed 13 themes across all fields. Physical activity is an emerging trend. Co-word analysis showed that subject high-frequency keywords were: risk factor, obesity, insulin resistance, prevalence, and association. Centrality indices identified the most influential keywords to be: body mass index, risk factors, gestational weight gain, and obesity. Burst keywords revealed that there were six research frontier subtopics: i) prediction of adverse neonatal outcomes in gestational diabetes mellitus; ii) postpartum period research - blood glucose levels and insulin resistance; iii) meta-analysis - understanding the best evidence in pregnancy gestational diabetes mellitus; iv) gene expression profiles and DNA methylation in gestational diabetes mellitus; v) biomarkers for predicting higher birth and children weights; and vi) discussion on diagnostic criteria for gestational diabetes mellitus classification.

CONCLUSION

The number of studies on gestational diabetes mellitus is increasing. For two decades, the United States has been the global leader in the number of published studies. Studies on gestational diabetes mellitus are mainly from developed countries, with a few of them being from developing countries. An emerging field of research aims at elucidating the association between physical activity and gestational diabetes mellitus.

Validation of Stroke Risk Factors in Patients with Acute Ischemic Stroke, Transient Ischemic Attack, or Intracerebral Hemorrhage on Taiwan’s National Health Insurance Claims Data

Purpose

Taiwan has changed the coding system to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding since 2016. This study aimed to determine the optimal algorithms for identifying stroke risk factors in Taiwan’s National Health Insurance (NHI) claims data.

Patients and Methods

We retrospectively enrolled 4538 patients hospitalized for acute ischemic stroke (AIS), transient ischemic attack (TIA), or intracerebral hemorrhage (ICH) from two hospitals’ stroke registries, which were linked to NHI claims data. We developed several algorithms based on ICD-10-CM diagnosis codes and prescription claims data to identify hypertension, diabetes, hyperlipidemia, atrial fibrillation (AF), and ischemic heart disease (IHD) using registry data as the reference standard. The agreement of risk factor status between claims and registry data was quantified by calculating the kappa statistic.

Results

According to the registry data, the prevalence of hypertension, diabetes, hyperlipidemia, AF, and IHD among all patients was 77.5%, 41.5%, 47.9%, 12.1%, and 7.1%, respectively. In general, including diagnosis codes from prior inpatient or outpatient claims to those from the stroke hospitalization claims improved the agreement. Incorporating prescription data could improve the agreement for hypertension, diabetes, hyperlipidemia, and AF, but not for IHD. The kappa values of the optimal algorithms were 0.552 (95% confidence interval 0.524–0.580) for hypertension, 0.802 (0.784–0.820) for diabetes, 0.514 (0.490–0.539) for hyperlipidemia, 0.765 (0.734–0.795) for AF, and 0.518 (0.473–0.564) for IHD.

Conclusion

Algorithms using diagnosis codes alone are sufficient to identify hypertension, AF, and IHD whereas algorithms combining both diagnosis codes and prescription data are more suitable for identifying diabetes and hyperlipidemia. The study results may provide a reference for future studies using Taiwan’s NHI claims data.

Outpatient Dental Treatment Expenditure for Patients with Oromaxillofacial Cancer: A Cohort Study in Taiwan

The information on the outpatient expenditure of patients with oromaxillofacial cancer is minimal. This study aimed to compare the average annual expenditure on dental treatment for these patients 5 years before and 5 years after oromaxillofacial cancer diagnosis. In this study, 7731 patients who received oromaxillofacial cancer diagnosis in 2005 were selected from the Registry of Catastrophic Illness Database as the case-cohort. In the control cohort, 38,655 people without cancer were selected from the National Health Insurance Research Database, with the case–control ratio being 1:5. All participants were observed for 5 years before diagnosis and 5 years after diagnosis. The conditional logistic regression model was used to determine the odds ratios of annual expenditures incurred by participants in the case-cohort. The measurement results indicated that in the oromaxillofacial cancer cohort, the average annual dental expenditure levels at 1, 2, 3, 4, and 5 years after diagnosis were US $97.34, US $77.23, US $109.65, US $128.43, and US $128.03 and those at these years before diagnosis were US $37.52, US $32.10, US $31.86, US $29.14, and US $29.35, respectively. In conclusion, the average annual expenditure on the dental treatment of oromaxillofacial cancer patients after five years of diagnosis was increased compared to five years before diagnosis.

Positive Predictive Value of ICD-10 Codes for Cerebral Venous Sinus Thrombosis in Taiwan's National Health Insurance Claims Database

Objective

This study aims to determine the positive predictive value (PPV) of case definitions for cerebral venous sinus thrombosis (CVST) in Taiwan’s National Health Insurance claims database based on the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnostic codes.

Study Design and Setting

Inpatient records with ICD-10-CM codes of G08, I629, I636, or I676 were retrieved from the claims data of all hospital branches of Chang Gung Medical Foundation. Manual review of the medical records and images was performed in order to ascertain the diagnosis. The PPV of various case definitions for CVST was estimated.

Results

Of the 380 hospitalizations, 166 and 214 were determined to be true-positive and false-positive episodes of acute CVST, respectively. The PPV of the ICD-10-CM codes of G08, I629, I636, and I676 was 88.2%, 2.0%, 100.0%, and 91.3%, respectively. The PPV generally increased when acute CVST was defined as a primary diagnosis or as ICD-10-CM codes plus anticoagulant use. Miscoding in other conditions, tentative diagnosis, and remote episode of CVST were determined as the main reasons for false-positive diagnosis of acute CVST.

Conclusion

This study determined the PPV of ICD-10-CM codes for identifying CVST, which may offer a reference for future claims-based research.

Exploring the COVID-19 Pandemic as a Catalyst for PHR App User Behavior Change in Taiwan: A Development and Usability Study

Background

During the COVID-19 pandemic, personal health records (PHRs) have enabled patients to monitor and manage their medical data without visiting hospitals and, consequently, minimize their infection risk. Taiwan’s National Health Insurance Administration (NHIA) launched the My Health Bank (MHB) service, a national PHR system through which insured individuals to access their cross-hospital medical data. Furthermore, in 2019, the NHIA released the MHB software development kit (SDK), which enables development of mobile apps with which insured individuals can retrieve their MHB data. However, the NHIA MHB service has its limitations, and the participation rate among insured individuals is low.

Objective

We aimed to integrate the MHB SDK with our developed blockchain-enabled PHR mobile app, which enables patients to access, store, and manage their cross-hospital PHR data. We also collected and analyzed the app’s log data to examine patients’ MHB use during the COVID-19 pandemic.

Methods

We integrated our existing blockchain-enabled mobile app with the MHB SDK to enable NHIA MHB data retrieval. The app utilizes blockchain technology to encrypt the downloaded NHIA MHB data. Existing and new indexes can be synchronized between the app and blockchain nodes, and high security can be achieved for PHR management. Finally, we analyzed the app’s access logs to compare patients’ activities during high and low COVID-19 infection periods.

Results

We successfully integrated the MHB SDK into our mobile app, thereby enabling patients to retrieve their cross-hospital medical data, particularly those related to COVID-19 rapid and polymerase chain reaction testing and vaccination information and progress. We retrospectively collected the app’s log data for the period of July 2019 to June 2021. From January 2020, the preliminary results revealed a steady increase in the number of people who applied to create a blockchain account for access to their medical data and the number of app subscribers among patients who visited the outpatient department (OPD) and emergency department (ED). Notably, for patients who visited the OPD and ED, the peak proportions with respect to the use of the app for OPD and ED notes and laboratory test results also increased year by year. The highest proportions were 52.40% for ED notes in June 2021, 88.10% for ED laboratory test reports in May 2021, 34.61% for OPD notes in June 2021, and 41.87% for OPD laboratory test reports in June 2021. These peaks coincided with Taiwan’s local COVID-19 outbreak lasting from May to June 2021.

Conclusions

This study developed a blockchain-enabled mobile app, which can periodically retrieve and integrate PHRs from the NHIA MHB's cross-hospital data and the investigated hospital's self-pay medical data. Analysis of users’ access logs revealed that the COVID-19 pandemic substantially increased individuals’ use of PHRs and their health awareness with respect to COVID-19 prevention.

Nonsteroidal Anti-Inflammatory Drugs Reduce Second Cancer Risk in Patients With Breast Cancer: A Nationwide Population-Based Propensity Score-Matched Cohort Study in Taiwan

Nonsteroidal anti-inflammatory drugs (NSAIDs) reduce mortality in patients with cancer, especially breast cancer, but their influence on second cancer risk is uncertain. This study aimed to examine whether NSAID use is associated with second cancer risk in patients with breast cancer. This population-based propensity score-matched cohort study using Taiwan’s National Health Insurance Research Database enrolled patients with newly diagnosed breast cancer (n = 7356) with and without (n = 1839) NSAID therapy from 2000 to 2009. They were followed up until the diagnosis of second cancer, death, or end of 2011. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR). The NSAID cohort had a lower incidence rate of second cancer than the non-NSAID cohort (5.57 vs. 9.19 per 1,000 person-years), with an aHR of 0.63 (95% confidence interval (CI) 0.46–0.87). When compared with the non-NSAID cohort, the second cancer incidence was lower in patients taking non-cyclooxygenase 2 inhibitors (aHR 0.67, 95% CI 0.47–0.94) and in those receiving multiple NSAIDs during follow-up (aHR 0.55, 95% CI 0.37–0.84). A dose–response relationship existed in NSAID cumulative days. The findings demonstrate that NSAID use reduces second cancer risk in a dose-dependent manner in patients with primary breast cancer.

Risk of chronic spontaneous urticaria in reproductive-aged women with abnormal uterine bleeding: A population-based cohort study

Women with abnormal uterine bleeding (AUB) have been reported to develop chronic spontaneous urticaria (CSU). Nevertheless, whether or not AUB women have an increased risk of CSU has not been examined in large-scale epidemiologic studies. This study aimed to investigate the risk of CSU among reproductive-aged women with AUB. A total of 79 595 patients and 79 107 propensity-score matched controls were recruited from Taiwan's National Health Insurance Research Database to conduct a nationwide cohort study. The Cox proportional-hazard regression model was applied to examine the adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for CSU in relation to AUB. We found that women with AUB had a higher risk for CSU (aHR = 1.83; 95% CI, 1.76-1.90) than women without AUB. Subgroup analyses revealed that AUB with an abnormal bleeding frequency (aHR = 1.70; 95% CI, 1.60-1.79), irregular bleeding (aHR = 1.80; 95% CI, 1.71-1.89), and intermenstrual bleeding (aHR = 1.65; 95% CI, 1.49-1.83) were associated with an increased risk of CSU compared with those without abnormalities. The Kaplan-Meier analysis revealed that the cumulative incidence of developing CSU was consistently higher in the AUB cohort than in the non-AUB cohort during the entire follow-up period (log-rank test, p < 0.001). In conclusion, reproductive-aged women with AUB were found to have a higher risk of developing CSU. This study emphasizes the importance of enquiring CSU patients about menstrual problems in clinical practice. Further consultation with obstetrician-gynecologists may be beneficial.

Validation of ICD-10-CM Diagnosis Codes for Identification of Patients with Acute Hemorrhagic Stroke in a National Health Insurance Claims Database

Purpose

The performance of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for identifying acute hemorrhagic stroke in Taiwan’s National Health Insurance claims database has not been assessed. This study aimed to construct and validate the case definitions for acute hemorrhagic stroke based on ICD-10-CM diagnostic codes.

Patients and Methods

From January 2018 to December 2019, all inpatient records with ICD-10-CM code of I60 or I61 in any field of the discharge diagnoses were retrieved from the hospitalization claims data and all hospitalizations with a final diagnosis of subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) were identified from the stroke registry databases. The clinical diagnosis in the stroke registry was treated as the reference standard. For hospitalizations not recorded in the stroke registry, manual review of the medical records and images was done to ascertain the diagnosis. The positive predictive value (PPV) and sensitivity of various case definitions for acute hemorrhagic stroke were estimated.

Results

Among the 983 hospitalizations, 860, 111, and 12 were determined to be true-positive, false-positive, and false-negative episodes of acute hemorrhagic stroke, respectively. The PPV and sensitivity of the ICD-10-CM codes of I60 or I61 for identifying acute hemorrhagic stroke were 88.6% and 98.6%, respectively. The PPV increased to 98.2%, whereas the sensitivity decreased to 93.1% when acute hemorrhagic stroke was defined as hospitalizations in which the primary diagnosis field contained I60 or I61. Hemorrhagic transformation of ischemic stroke and concomitant cerebrovascular diseases other than SAH or ICH were the main reasons for a false-positive and false-negative diagnosis of acute hemorrhagic stroke, respectively.

Conclusion

This study demonstrated the performance of ICD-10-CM codes for identifying acute hemorrhagic stroke and may offer a reference for future claims-based stroke studies.

Risk of Psychiatric Disorders in Multiple Sclerosis: A Nationwide Cohort Study in an Asian Population

BACKGROUND

Multiple sclerosis (MS) is a demyelinating disease that can damage neurons in the brain and spinal cord and is associated with several psychiatric disorders. However, few studies have evaluated the risk of psychiatric disorders in patients with MS by using a nationwide database. This study investigated the association between MS and the risk of psychiatric disorders.

METHODS

Using data from the Taiwan National Health Insurance Research Database from 2000 to 2015, we identified 1066 patients with MS. After adjustment for confounding factors, Fine and Gray's competing risk model was used to compare the risk of psychiatric disorders during 15 years of follow-up.

RESULTS

Of the patients with MS, 531 (4622.86 per 10⁵ person years) developed psychiatric disorders; by contrast, 891 of the 3198 controls (2485.31 per 10⁵ person years) developed psychiatric disorders. Fine and Gray's competing risk model revealed an adjusted hazard ratio (HR) of 5.044 (95% confidence interval = 4.448-5.870, p < 0.001) after adjustment for all the covariates. MS was associated with depression, anxiety, bipolar disorder, sleep disorders, schizophrenia, schizophreniform disorder, and other psychotic disorders (adjusted HR: 12.464, 4.650, 6.987, 9.103, 2.552, 2.600, 2.441, and 2.574, respectively; all p < 0.001). Some disease-modifying drugs were associated with a lower risk of anxiety or depression.

CONCLUSION

Patients with MS were determined to have a higher risk of developing a wide range of psychiatric disorders.

Performance of ICD-10-CM Diagnosis Codes for Identifying Acute Ischemic Stroke in a National Health Insurance Claims Database

Purpose

The validity of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding for the identification of acute ischemic stroke (AIS) in Taiwan’s National Health Insurance claims database has not been investigated. This study aimed to construct and validate the case definition algorithms for AIS based on ICD-10-CM diagnostic codes.

Patients and Methods

This study identified all hospitalizations with ICD-10-CM code of I63* in any position of the discharge diagnoses from the inpatient claims database and all patients with a final diagnosis of AIS from the stroke registry between Jan 2018 and Dec 2019. Hospitalizations in the claims data that could be successfully linked to those in the registry data were regarded as true episodes of AIS. Otherwise, their electronic medical records and images were manually reviewed to ascertain whether they were true episodes of AIS. Using the true episodes of AIS as the reference standard, the positive predictive value (PPV) and sensitivity of various case definition algorithms for AIS were calculated.

Results

A total of 1227 hospitalizations were successfully linked. Among the 155 hospitalizations that could not be linked, 54 were determined to be true episodes of AIS. Using ICD-10-CM code of I63* in any position of the discharge diagnoses to identify AIS yielded a PPV and sensitivity of 92.7% and 99.4%, respectively. The PPV increased to 99.8% with >12% decrease in the sensitivity when AIS was restricted to those with I63* as the primary diagnosis. When AIS was defined to be I63* as the primary, first secondary, or second secondary diagnosis, both PPV and sensitivity were greater than 97%.

Conclusion

This study demonstrated the validity of various case definition algorithms for AIS based on ICD-10-CM coding and can provide a reference for future claims-based stroke research.