Comparing Survival Extrapolation within All-Cause and Relative Survival Frameworks by Standard Parametric Models and Flexible Parametric Spline Models Using the Swedish Cancer Registry

BACKGROUND

In health technology assessment, restricted mean survival time and life expectancy are commonly evaluated. Parametric models are typically used for extrapolation. Spline models using a relative survival framework have been shown to estimate life expectancy of cancer patients more reliably; however, more research is needed to assess spline models using an all-cause survival framework and standard parametric models using a relative survival framework.

AIM

To assess survival extrapolation using standard parametric models and spline models within relative survival and all-cause survival frameworks.

METHODS

From the Swedish Cancer Registry, we identified patients diagnosed with 5 types of cancer (colon, breast, melanoma, prostate, and chronic myeloid leukemia) between 1981 and 1990 with follow-up until 2020. Patients were categorized into 15 cancer cohorts by cancer and age group (18-59, 60-69, and 70-99 y). We right-censored the follow-up at 2, 3, 5, and 10 y and fitted the parametric models within an all-cause and a relative survival framework to extrapolate to 10 y and lifetime in comparison with the observed Kaplan-Meier survival estimates. All cohorts were modeled with 6 standard parametric models (exponential, Weibull, Gompertz, log-logistic, log-normal, and generalized gamma) and 3 spline models (on hazard, odds, and normal scales).

RESULTS

For predicting 10-y survival, spline models generally performed better than standard parametric models. However, using an all-cause or a relative survival framework did not show any distinct difference. For lifetime survival, extrapolating from a relative survival framework agreed better with the observed survival, particularly using spline models.

CONCLUSIONS

For extrapolation to 10 y, we recommend spline models. For extrapolation to lifetime, we suggest extrapolating in a relative survival framework, especially using spline models.

HIGHLIGHTS

For survival extrapolation to 10 y, spline models generally performed better than standard parametric models did. However, using an all-cause or a relative survival framework showed no distinct difference under the same parametric model.Survival extrapolation to lifetime within a relative survival framework agreed well with the observed data, especially using spline models.Extrapolating parametric models within an all-cause survival framework may overestimate survival proportions at lifetime; models for the relative survival approach may underestimate instead.

Possible overdiagnosis of early-stage lung adenocarcinoma among never-smokers in Taiwan

10-year survival for never-smokers with >1 cm but ≤3 cm AIS/BAC/MIA was not inferior to that of the matched referents, pointing to possible overdiagnosis. Clinicians might consider adhering to Lung-RADS and watchful waiting for these non-solid nodules. https://bit.ly/41U6kxs.

Chronic obstructive pulmonary disease trajectory: severe exacerbations and dynamic change in health-related quality of life

BACKGROUND

The life trajectory of chronic obstructive pulmonary disease (COPD) remains unknown.

PATIENTS AND METHODS

We collected data from two populations. In the first cohort, we recruited 375 patients with COPD from our hospital, and 1440 repeated assessments of quality of life (QoL) using the European Quality of Life-5 Dimensions questionnaire from 2006 to 2020. We analysed their dynamic changes using the kernel-smoothing method. The second cohort comprised 27 437 patients from the National Health Insurance (NHI) dataset with their first severe acute exacerbations (AEs) requiring hospitalisation from 2008 to 2017 were analysed for their long-term course of AEs. We employed a Cox hazard model to analyse the predictors for mortality or AEs.

RESULTS

Cohorts from our hospital and NHI were male predominant (93.6 and 83.5%, respectively). After the first severe AE, the course generally comprised three phases. The first was a 1-year period of elevated QoL, followed by a 2-year prolonged stable phase with a slowly declining QoL. After the second AE, the final phase was characterised by a rapid decline in QoL. For NHI cohort, 2712 died during the 11-year follow-up, the frequency of the first AE was approximately 5 per 10 000 per day. The median time from the first to the second AE was 3 years, which decreased to less than 6 and 3 months from 4th to 5th and 8th to 9th AE, respectively. The frequency of AE was increased 10-fold and 15-fold and risk of subsequent AE was increased 12-fold and 20-fold after the 6th and the 10th AE, relative to the first. Male gender, heart failure comorbidities were associated with the risk of subsequent AE and death.

CONCLUSIONS

The life trajectory of COPD includes the accelerated frailty phase, as well as elevated health and prolonged stable phase after the first AE.

Estimation of lifetime productivity loss from patients with chronic diseases: methods and empirical evidence of end-stage kidney disease from Taiwan

OBJECTIVE

Studies that examine the broad allocation of resources, regardless of who bears the costs, should ideally estimate costs from a societal perspective. We have successfully integrated survival rates, employment ratios, and earnings to address the significant challenge of evaluating societal value through productivity assessments of patients with end-stage kidney disease (ESKD) in Taiwan.

METHODS

Using a theoretical framework, we interconnected two nationwide databases: the Taiwan National Health Insurance (NHI) and the Taiwan Mortality Registry from 2000 to 2017. Due to the statutory retirement age of 65, we collected data on all patients (83,358) aged 25-64 years diagnosed with ESKD and undergoing maintenance dialysis. We estimated the lifetime survival function through a rolling extrapolation algorithm, which was then combined with the monthly employment ratio and wages to calculate the lifetime employment duration and productivity up to the legal retirement age of ESKD patients. These were compared with sex-, age-, and calendar year-matched referents to determine the loss of employment duration and productivity of ESKD patients.

RESULTS

ESKD patients experienced a loss of approximately 25-56% in lifetime employment duration and a larger loss of about 32-66% in lifetime productivity after adjustments for different age, sex, and calendar year. The annual productivity loss per male (female) ESKD patient relative to that of the age-and calendar year-matched referent ranges from 75.5% to 82.1% (82.3% to 90.3%). During the periods when they are able to work (over the on-the-job duration) male ESKD patients lose between 34 and 56% of their income, and female ESKD patients lose between 39 and 68% of their income, compared to the age-and calendar year-matched referents. The loss of lifetime productivity is a combination of reduced lifetime employment duration, functional disability, absenteeism, and presenteeism at the workplace. The loss related to presenteeism is implied by the reduced wages.

CONCLUSIONS

In addition to the loss of employment duration, we have empirically demonstrated the lifetime loss of productivity in patients with ESKD, also indicating the "presenteeism" resulted from inability to perform their job with full capacity over long-term periods.

Early HIV diagnosis enhances quality-adjusted life expectancy of men who have sex with men living with HIV: A population-based cohort study in Taiwan

BACKGROUND

Whether early HIV diagnosis is beneficial for HIV patients themselves remains uncertain, given the stigma and social discrimination associated with an HIV diagnosis. This study aimed to measure the impact of early HIV diagnosis on quality-adjusted life expectancy (QALE) in comparison with late HIV diagnosis, from real-world data in Taiwan under universal access to antiretroviral therapy (ART).

METHODS

This population-based cohort study included 14,570 men who have sex with men (MSM) in the national HIV registry and a quasi-random sample (n = 127) of MSM patients to measure quality of life using the EQ-5D health utility instrument. We integrated quality of life data into the extrapolated cohort survival curve to estimate the QALE in patients with early versus late HIV diagnosis (≤30 days before AIDS diagnosis). Loss-of-QALE were estimated by comparing the cohort with age-, sex-, and calendar-year-matched referents simulated from vital statistics. Difference-in-differences was estimated to quantify the effect of early HIV diagnosis.

RESULTS

Early HIV diagnosis is associated with a loss-of-life expectancy of 3.11 years, with an average health utility of 0.95, in contrast to those diagnosed late (loss-of-life expectancy 8.47 years, with an average health utility of 0.86). After integration of survival and life quality, early HIV diagnosis results in a reduction of loss-of-QALE by 8.28 quality-adjusted life years among MSM living with HIV.

CONCLUSIONS

Under universal access to ART, early HIV diagnosis is highly beneficial for people living with HIV themselves, with a net gain of 8.28 healthy life years compared with those diagnosed late.

Dynamic changes and lifetime effect of functional disability profiles for stroke patients: real-world evidence from South Korea

PURPOSE

This work aimed to investigate the long-term dynamic changes of functional disabilities and estimate lifetime outcomes of different functional disabilities after a stroke, using real-world data from a nationally representative South Korean cohort.

METHODS

Patients aged 18 and above with ischemic and hemorrhagic strokes were identified from the Korea Health Panel (KHP) data (2008-2018). Functional disabilities were repeatedly measured for patients aged 55 and over for the prevalence of disabilities associated with activities of daily living (ADL), and kernel smoothing means were estimated for each item. The lifetime survival function of stroke patients in Korea was adopted from another study utilizing the National Health Insurance Service of Korea's national sample cohort. By multiplying the disability-free proportion with the survival function throughout life, disability-free life expectancy (DFLE) for each ADL item was estimated. The loss-of-DFLE was calculated by subtracting the DFLE from age-, sex-, and calendar year-matched referents simulated from Korean life tables.

RESULTS

The KHP dataset included 466 stroke patients. The overall functional disability needs increased over time after stroke diagnosis. DFLE was lowest for bathing (10.1 years for ischemic stroke and 12.8 years for hemorrhagic stroke), followed by those for dressing and washing. Loss-of-DFLE was highest for bathing for ischemic and hemorrhagic strokes (7.2 and 10.7 years, respectively), indicating that this task required the most assistance for stroke patients compared with the other tasks. DFLEs were slightly lower than the quality-adjusted life expectancy of stroke patients.

CONCLUSION

Our findings provide valuable insights for resource allocation and policy decisions in long-term stroke care, potentially enhancing the quality of life for stroke survivors and caregivers.

[Construction of a risk prediction model for diabetes after kidney transplantation based on genome-wide association study]

Objective: To explore the clinical risk factors and susceptibility genes of diabetes after kidney transplantation (PTDM) and construct a risk prediction model for PTDM. Methods: The data of kidney transplant recipients who underwent follow-up in the Affiliated Lihuili Hospital, Ningbo University and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine from January 2001 to December 2022 were retrospectively analyzed. The recipients were divided into PTDM group and Non-PTDM group according to whether they were complicated with PTDM. The differences in clinical indicators between the two groups were compared, the risk factors affecting the incidence of PTDM were determined, and susceptibility genes of PTDM were screened by genome-wide association study (GWAS). PTDM risk prediction models based only on clinical indicators (Model 1) and clinical indicators combined with susceptibility genes (Model 2) were established respectively, and the predictive performance of the two prediction models was compared. Finally, the Nomogram of the optimal model was drawn, and the discrimination, calibration and clinical applicability of the model were evaluated. Results: A total of 113 kidney transplant recipients (70 males and 43 females) were included, with an average age of (46.2±10.8) years. There were 51 cases in PTDM group and 62 cases in Non-PTDM group. The related factors screened by GWAS and logistic regression analysis included family history of diabetes (OR=88.912, 95%CI: 5.827-1 356.601, P=0.001), preoperative triglyceride (TG) (OR=1.888, 95 %CI: 1.150-3.098, P=0.012), uric acid (UA) (OR=1.011, 95%CI: 1.000-1.022, P=0.045) and rs802707 (OR=10.046, 95%CI: 1.462-69.042, P=0.019). The area under the curve (AUC) of the receiver operating characteristics analysis (ROC) predicted by Model 1 for PTDM was 0.891 (95%CI: 0.811-0.972), with the sensitivity of 0.889 and the specificity of 0.742. The AUC of ROC curve predicted by Model 2 for PTDM was 0.930 (95%CI: 0.864-0.995), with the sensitivity of 0.885 and the specificity of 0.900. Conclusions: Family history of diabetes, preoperative TG and UA, and rs802707 are significantly associated with the occurrence of PTDM. In addition, the combination of susceptibility genes could improve the predictive ability of clinical indicators for the risk of PTDM.

Fe3O4nanoparticles anchored on carbon nanotubes as high-performance anodes for asymmetric supercapacitors

Fe3O4/CNT composites are synthesized with ethylene glycol as solvent by a one-step solvothermal method and used as anode materials for asymmetric supercapacitors (ASC). An appropriate amount of water in ethylene glycol can accelerate the formation of Fe3O4and reduce the average size of Fe3O4to around 20 nm. However, spherical Fe3O4particles larger than 100 nm will form in pure ethylene glycol for long reaction time. The Fe3O4/CNT composite with small Fe3O4nanoparticles exhibits a high specific surface area, promoted electron transfer ability, as well as a high utilization rate of active materials. The optimized electrode shows a high specific capacity of 689 C g-1at 1 A g-1, and remains 443 C g-1at 10 A g-1. The inferior long-term cycling stability is due to the phase transition of Fe3O4and a reductive effect to form metallic Fe. An ASC using Fe3O4/CNT and NiCoO2/C composites as anode and cathode, respectively, delivers a high energy density of 58.1 Wh kg-1at a power density of 1007 W kg-1in a voltage window of 1.67 V and has a capacity retention of 63% after 5000 cycles. The self-discharge behavior of the ASC is also investigated.

Nerve excitability test and lead toxicity: a case-control study

BACKGROUND

Although conventional electrophysiological parameters have been proposed as clinical indicators for monitoring lead neuropathies, their correlations with blood lead level are weak. In this study, we investigated the applicability of nerve excitability tests (NETs) to evaluate lead intoxication.

METHODS

Fourteen workers who were exposed to lead with an elevated blood level ranging from 17.8 to 64.9 µg/dL and 20 healthy controls with similar ages and body heights were enrolled. Both workers and controls underwent nerve conduction studies (NCSs), motor evoked potentials (MEPs) with transcranial magnetic stimulation (TMS), and NETs.

RESULTS

NCSs showed prolonged distal latencies and decreased motor nerve conduction velocity of median nerves in the workers but without significant correlation to blood lead level (BLL). Significantly prolonged MEP latency was observed in the workers (+ 6 ms). NETs demonstrated hyperpolarized resting membrane potentials in stimulus-response curves and changes in the property of potassium channels under a hyperpolarized current in threshold electrotonus, implying that lead hyperpolarized nerves by interfering with potassium channels. NETs also showed a better correlation with BLL than conventional electrophysiological parameters.

CONCLUSIONS

Axonal hyperpolarization and central conduction delay are more apparently reflecting elevated BLL than NCS. NET may have the potential for early detection of lead neuropathy.

Estimation of disability free life expectancy in non small cell lung cancer based on real world data

To quantify the societal impact of disability in patients with non-small cell lung cancer (NSCLC), this study estimated the disability-free life expectancy (DFLE), loss-of-DFLE and explored their associations with quality-adjusted life expectancy (QALE) and loss-of-QALE. We interlinked national databases and applied a rolling-over algorithm to estimate the lifetime survival function for patients with NSCLC. Using the EuroQOL-5 Dimension (EQ-5D) and Barthel index (BI), we repeatedly measured the quality-of-life and disability functions of NSCLC patients who visited our hospital from 2011 to 2020. Age-, sex-matched referents were simulated from lifetables of the same calendar year of diagnosis. We categorized BI scores ≤ 70 as in need of long-term care and constructed linear mixed models to estimate the utility values and disability scores. We collected 960 cases and 3088 measurements. The proportions of measurements without disability at age 50-64 and in stage I-IIIa, 50-64 and stage IIIb-IV, 65-89 and stage I-IIIa and 65-89 and stage IIIb-IV were 97.3%, 89.3%, 94.8%,78.3%, corresponding to DFLEs of 15.3, 2.4, 6.8, 1.2 years and losses-of-DFLE of 8.1, 20.7, 4.0, 8.6 years, respectively, indicating that advanced stage had a stronger effect than old age. Survivors in advanced stages showed increased demands for assistance in almost all subitems. The DFLEs seemed to be approximate to the QALEs and the latter were shorter than the former due to discomfort and depression. From a societal perspective, future health technology assessment should consider the impact of lifetime duration of functional disability. Early diagnosis of NSCLC may decrease the burden of long-term care.

Losses of lifetime employment duration and productivity for patients with different subtypes and stages of lung cancer

BACKGROUND

How different subtypes and stages of lung cancer affect morbidity- and mortality-associated productivity have not been investigated. This study quantified the losses of lifetime employment duration and productivity among patients with various subtypes and stages of lung cancer.

METHODS

We identified nationwide lung cancer patients diagnosed at the ages of 50-64 between 2011 and 2019. Monthly survival probabilities were weighted by monthly employed-to-population ratios and working salaries to estimate lifetime employment duration and productivity. We compared lifetime employment duration and productivity of patients with those of the age-, sex-, calendar year-matched general population for losses of lifetime employment duration and productivity, which were multiplied by pathology and stage shifts based on the first-round screening of Taiwan Lung Cancer Screening in Never Smoker Trial (TALENT) to calculate the savings of lifetime employment duration and productivity.

RESULTS

Lung cancer patients had shorter survival and employment duration than the referents. Patients with lung cancers other than adenocarcinoma experienced greater losses of lifetime employment duration and productivity as compared to adenocarcinoma patients. Applying the estimations of never-smoking patients to 100 lung cancer patients with pathology and stage shifts based on the TALENT, the savings of lifetime employment duration and productivity were 132.2 (95% prediction interval: 116.2-147.4) years and 3353 (95% prediction interval: 2914-3802) thousand US dollars, respectively.

CONCLUSIONS

Early diagnosis of lung cancer would save the losses of employment duration and lifetime productivity. Future evaluation of the cost-effectiveness of lung cancer screening could consider incorporating these societal impacts.

[Evaluation of the efficacy and safety of Nocardia rubra cell wall skeleton immunotherapy for cervical high-risk HPV persistent infection]

Objective: To evaluate the efficacy and safety of Nocardia rubra cell wall skeleton (Nr-CWS) in the treatment of persistent cervical high-risk human papillomavirus (HR-HPV) infection. Methods: A randomized, double blind, multi-center trial was conducted. A total of 688 patients with clinically and pathologically confirmed HR-HPV infection of the cervix diagnosed in 13 hispital nationwide were recruited and divided into: (1) patients with simple HR-HPV infection lasting for 12 months or more; (2) patients with cervical intraepithelial neoplasia (CIN) Ⅰ and HR-HPV infection lasting for 12 months or more; (3) patients with the same HR-HPV subtype with no CINⅡ and more lesions after treatment with CINⅡ or CIN Ⅲ (CINⅡ/CIN Ⅲ). All participants were randomly divided into the test group and the control group at a ratio of 2∶1. The test group was locally treated with Nr-CWS freeze-dried powder and the control group was treated with freeze-dried powder without Nr-CWS. The efficacy and negative conversion rate of various subtypes of HR-HPV were evaluated at 1, 4, 8, and 12 months after treatment. The safety indicators of initial diagnosis and treatment were observed. Results: (1) This study included 555 patients with HR-HPV infection in the cervix (included 368 in the test group and 187 in the control group), with an age of (44.1±10.0) years. The baseline characteristics of the two groups of subjects, including age, proportion of Han people, weight, composition of HR-HPV subtypes, and proportion of each subgroup, were compared with no statistically significant differences (all P>0.05). (2) After 12 months of treatment, the effective rates of the test group and the control group were 91.0% (335/368) and 44.9% (84/187), respectively. The difference between the two groups was statistically significant (χ²=142.520, P<0.001). After 12 months of treatment, the negative conversion rates of HPV 16, 18, 52, and 58 infection in the test group were 79.2% (84/106), 73.3% (22/30), 83.1% (54/65), and 77.4% (48/62), respectively. The control group were 21.6% (11/51), 1/9, 35.1% (13/37), and 20.0% (8/40), respectively. The differences between the two groups were statistically significant (all P<0.001). (3) There were no statistically significant differences in vital signs (body weight, body temperature, respiration, pulse rate, systolic blood pressure, diastolic blood pressure, etc.) and laboratory routine indicators (blood cell analysis, urine routine examination) between the test group and the control group before treatment and at 1, 4, 8, and 12 months after treatment (all P>0.05); there was no statistically significant difference in the incidence of adverse reactions related to the investigational drug between the two groups of subjects [8.7% (32/368) vs 8.0% (15/187), respectively; χ²=0.073, P=0.787]. Conclusion: External use of Nr-CWS has good efficacy and safety in the treatment of high-risk HPV persistent infection in the cervix.

Elevated C-Reactive Protein Levels Modify the Effect of Magnesium on Depressive Symptoms: A Population-Based Study

Depression is a profound public health concern, yet its etiology remains unclear. A body's magnesium status and low-grade systemic inflammation are associated with depression. However, the interaction of magnesium status and inflammation on depression/depressive symptoms is unknown. We assessed the association between serum magnesium levels and depressive symptoms by analyzing data from the Nutrition and Health Survey in Taiwan 2005-2008. In total, 2196 participants aged ≥20 years were included. Depressive symptoms were assessed using the 5-item Brief-Symptom Rating Scale. We performed logistic regression and multiple linear regression analyses to examine the association. A dose-response analysis was performed using restricted cubic spline models, and stratification by chronic inflammation was also performed. We found that higher serum magnesium levels were associated with lower depression scores and a lower risk of depression. In the subgroup analysis, serum magnesium levels were inversely associated with depressive symptoms more prominently among people with higher CRP levels, with a threshold at 5 mg/L (≥5 vs. <5) showing a greater difference than at 3 mg/L (≥3 vs. <3). Conclusions: Serum magnesium levels were inversely associated with depressive symptoms. This inverse association was affected by inflammation level. A dose-response relationship was also observed.

The lifetime burden following stroke: Long term impact of stroke on survival and quality of life

Background The absolute burden of stroke in Korea is ever growing. Many studies have explored the outcomes of mortality, quality of life (QOL), and/or economic burden with limited periods of observation. Relatively few have addressed the lifetime outcomes that are estimated beyond the limited observation period of study samples.Aims By combining QOL and the survival functions over a lifetime horizon, our aims were to estimate the quality-adjusted life expectancy (QALE) and loss-of-QALE of patients with ischemic and hemorrhagic stroke in South Korea, and to compare them between genders.Methods The survival function of stroke patients (n=13,994) was estimated by the Kaplan-Meier's method from the National Health Insurance Service-National Sample Cohort of Korea (2002-2015), and then extrapolated to lifetime through a rolling-over algorithm. The QOL measurements, assessed by EuroQol 5-dimension (EQ-5D) questionnaire, of stroke patients (n=474) were extracted from the Korea Health Panel (KHP, 2008-2018) to estimate the QALE. All stroke patients were categorized by sex and two types of stroke: ischemic and hemorrhagic. Age-, sex-, and calendar year-matched referents were simulated from the Korean life tables to be integrated with the general population's QOL from the KHP to estimate the QALE of the referents. We calculated the loss-of-QALE by comparing the above two sets of QALE.Results The QALE and loss-of-QALE for ischemic stroke were 10.8 and 6.1 QALYs (quality-adjusted life years), respectively, and 14.0 and 9.0 QALYs for hemorrhagic stroke. The loss-of-QALE in men was 3.0 QALYs larger than that of women with hemorrhagic stroke (p < 0.05), while the difference for ischemic stroke was much smaller and statistically insignificant at 0.6 QALYs.Conclusions The lifetime impact of stroke in Korea is large, especially for males who survived hemorrhagic stroke. Future studies assessing the lifetime needs for long-term care of stroke patients are warranted to quantify the burden of stroke from the societal perspective.

Dynamic changes in quality of life, psychological status, and body image in women who underwent a mastectomy as compared with breast reconstruction: an 8-year follow up

BACKGROUND

Surgical decisions and methods of surgery highly influence long term QoL for breast cancer (BC) survivors. This study is aimed towards an exploration of the dynamic changes in quality of life (QoL), anxiety/depression status, and body image (BI) among women with BC who received a mastectomy compared with those receiving breast reconstruction (BR) within an 8-year follow-up period.

METHODS

Women with major BC surgeries were invited to complete the World Health Organization Quality of Life-Brief (WHOQOL-BREF), the European quality of life five dimensions questionnaire (EQ-5D), and a body image scale within 8 years of surgery. Kernel smoothing methods were applied to describe dynamic changes in QoL, anxiety/depression, and BI at different time points. Linear mixed effects models were constructed to identify the interaction between time, different types of surgery, and the determinants of QoL in these patients.

RESULTS

After 1:10 propensity score matching, a total of 741 women who had undergone a BR and mastectomy were included. The BR group exhibited a high WHOQOL QoL score one to five years after surgery with some fluctuations. The mastectomy group had comparatively stable QoL scores on WHOQOL items and were less depressed/anxious. The BR group generally showed fluctuating, higher BI scores two years after surgery, but they exhibited more anxiety/depression during follow up for 8 years. Medical comorbidities, the status of anxiety/depression, and BI were the major factors influencing all domains and items of the WHOQOL BREF among women with BC.

CONCLUSION

The mastectomy group showed a decreased trend toward depression in patients with BC. The BR group showed a significant improvement in QoL in the first 5 years with massive fluctuations. These findings should be considered and discussed in patient participatory decision-making and promotion of QoL for breast cancer survivors.

Plate-related complication and health-related quality of life after mandibular reconstruction by fibula flap with reconstruction plate or miniplate versus anterolateral thigh flap with reconstruction plate

BACKGROUND

Plate-related complications are major long-term complications in mandible reconstruction. There are controversies regarding the use of a reconstruction plate versus miniplates and a bone flap versus a soft tissue flap with a bridging plate. Direct comparisons of a fibula flap and an anterolateral thigh flap, the applicability between a reconstruction plate and miniplate, and the correlation between plate-related complications and quality of life remain unclarified. Therefore, this study aimed to the explore complications of different flaps and plates and how they impact the patients' quality of life.

METHODS

We retrospectively reviewed the medical records of a total of 205 patients aged >18 years who underwent segmental mandibulectomy and reconstruction using fibula flap with reconstruction plate (FR; n = 86), fibula flap with miniplate (FM; n = 61), and anterolateral thigh flap with reconstruction plate (AR; n = 58) due to cancer ablation, osteoradionecrosis, or benign tumor excision between August 2010 and December 2019. Data on characteristics, complications, and health-related quality of life were collected and analyzed.

RESULTS

The plate-related complication rate was the highest in the AR group (37.9%), then in the FR group (25.6%), and was the lowest in the FM group (13.1%; p = 0.0079). The plate exposure rate was the highest in the AR group (24.1%), then in the FR group (15.7%), and was the lowest in the FM group (4.9%; p = 0.0128). The plate fracture and dislodge rates for the AR group were both higher than those for the FR and FM groups (24.1% versus 9.3% versus 9.8%, respectively; p = 0.023). The AR group had worse complication-free survival (hazard ratio [HR]: 3.61, 95% CI: 1.99-6.56, and p < 0.0001) than the FR and FM groups. Osteoradionecrosis (HR: 6.19, 95% CI: 2.11-18.21, and p = 0.0009) and postoperative radiotherapy (HR: 2.87, 95% CI: 1.34-6.12, and p = 0.0402) were both independent adverse factors for complication-free survival, whereas patient treated primarily (HR: 0.35, 95% CI: 0.17-0.73, and p = 0.0048) was an independent protective factor. Plate-related complication negatively impacted the quality of life based on pain scores (β: -0.56, SE: 0.26, and p = 0.034).

CONCLUSIONS

Using a fibular flap fixed with miniplates and avoiding the use of a reconstruction plate may yield a reduced plate exposure rate and better health-related quality of life, particularly for patients with osteoradionecrosis or those who need postoperative radiotherapy.

Losses of Life Expectancy and Productivity Associated with COVID-19 Pandemic in Canada: Policy Implication for Future Communicable Disease Control

This research examines whether the Coronavirus disease 2019 (COVID-19) did harm to the population's health through comparing the changes in the life expectancy of Canadians with those of Australians over the period from March 2019 to February 2021 by using a difference-in-differences (DID) estimation method. We found that the pandemic did cause differences in life expectancies between Canada and Australia, probably because of different initial control policies for COVID-19. This study uses the indicator of disability-adjusted life years (DALYs) to measure the societal health burden, which was corroborated by estimating temporal productivity loss (TPL) and permanent productivity loss (PPL) based on the human capital approach (HCA) using data from Health Canada. The societal health burden in Canada amounted to 6.493 DALYs per 1000 male persons and 5.316 DALYs per 1000 female persons. The economy's permanent productivity loss was around USD 5.3 billion, while the temporary productivity loss was around USD 3 billion from February 2020 to April 2022. The sum of the above two losses amounted to 0.477% of the GDP in 2019. Swift and decisive decisions at the very early stage of a pandemic can nip contagions in the bud before numbers get out of hand and would be less damaging to people's health and the economy, as seen in Australia, in contrast to what happened in Canada. We thus recommend that such policies plus telecommunication systems in healthcare services be implemented early on to cope with the future outbreak of any emerging infectious diseases such as COVID-19.

[Research progress on the treatment of presbyopia]

Presbyopia is a physiological aging situation that the plasticity and elasticity of the lens and the function of the ciliary muscle become weaker, resulting in a decreased accommodation and inability to focus on near objects. Nowadays, there are many clinical strategies to correct presbyopia, each of which has its own advantages and disadvantages, however, there is no true sense of way to restore accommodation function. This article reviews both worldwide and domestic research on presbyopia, and analyzes and summaries the status quo as well as research progress of presbyopia correction modalities, surgical approaches, and drug therapies, hoping to provide a reference for clinical works.

PM2.5 exposure and risk of lung adenocarcinoma in women of Taiwan: A case-control study with density sampling

BACKGROUND AND OBJECTIVE

The prevalence of smoking among women in Taiwan is <5%, but the incidence of lung cancer remains high. This study determined the association between PM_2.5 (fine particulate matter with an aerodynamic diameter of ≤2.5 μm) exposure and lung cancer among women in Taiwan.

METHODS

In total, 21,301 female lung cancer cases nationwide were newly diagnosed between 2012 and 2017. Each case was age-, sex- and calendar year-matched with four controls randomly selected from the general population. Allowing a latent period of 5 years, we estimated the PM_2.5 and nitrogen dioxide (NO₂ ) exposures for each individual according to the residential changes from 2000. We adopted self-reported smoking statuses for the cases, while those of controls were estimated using annual surveys in each residential county. We performed multiple logistic regression analyses to examine the associations between PM_2.5 and NO₂ exposures and incident lung cancer cases.

RESULTS

The ORs of lung adenocarcinoma for the third (30.5-35.1 μg/m³ ), fourth (35.1-39.3 μg/m³ ) and fifth PM_2.5 exposure quintiles (39.3-48.1 μg/m³ ) relative to the first quintile were 1.10 (95% CI: 1.04-1.16), 1.12 (95% CI: 1.06-1.19) and 1.10 (95% CI: 1.04-1.16), respectively, after adjusting for smoking, residence and comorbidities. A dose-response relationship (p = 0.004) was found. The associations persisted with a 10-year latency and were not detected for small-cell and squamous cell carcinoma after control for smoking. We did not observe a similar effect for NO₂ exposure.

CONCLUSION

Residential PM_2.5 exposure higher than 30 μg/m³ was associated with an increased risk of lung adenocarcinoma in women of Taiwan.

Dynamic changes of quality of life in muscle-invasive bladder cancer survivors

Background

To explore the dynamic changes and effects of radical cystectomy on quality of life in muscle-invasive bladder cancer survivors.

Methods

Patients with muscle-invasive bladder cancer were randomly recruited in this study. We used the World Health Organization Quality of Life-Brief questionnaire to assess consecutive patients’ quality of life. We applied kernel smoothing to illustrate the dynamic changes of the domain and item scores after treatment. Mixed-effects models were constructed to determine the effects of radical cystectomy on the scores of each item and domain of the World Health Organization Quality of Life-Brief questionnaire after controlling demographic and clinical factors.

Results

We collected 397 repeated measurements of the World Health Organization Quality of Life-Brief questionnaire from 109 muscle-invasive bladder cancer patients. Forty-two of them received radical cystectomy. Patients with radical cystectomy exhibited higher levels of education, less co-morbidities (i.e., diabetes and heart diseases), but were associated with more malignancies. Construction of mixed-effects models showed patients with radical cystectomy and those with bladder sparing had similar scores in the three main domains and their items, except that of certain items of physical domain. By applying kernel smoothing method, we found that stage III–IV patients consistently showed higher scores on sleep and rest after radical cystectomy for more than 5 years. In contrast, stage II patients receiving radical cystectomy did not show a higher score on the “sleep and rest” item compared with those with bladder sparing operation.

Conclusions

Radical cystectomy may result in sound sleep and rest, especially in those with stage III–IV bladder cancer.

[Clinical validation of the 2020 diagnostic approach for pediatric autoimmune encephalitis in a single center]

Objective: To evaluate the value of the 2020 diagnostic criteria (Cellucci criteria) for pediatric autoimmune encephalitis (AE) in children with suspected AE in a single center. Methods: The clinical data of 121 children hospitalized at the First Affiliated Hospital of Zhengzhou University from October 2019 to October 2021, with a diagnosis of suspected AE, were retrospectively collected and analyzed. The children were divided into definite antibody-positive AE (dAPAE), probable antibody-negative AE (prANAE), possible AE (pAE) and non-AE groups according to the Chinese expert consensus and the Graus criteria. A new diagnosis was made according to the Cellucci criteria which was compared with the clinical diagnosis to evaluate the diagnostic value of the Cellucci criteria. The Mann-Whitney U test, Kruskal-Wallis test, and χ² test were used to compare the differences among groups. The sensitivity and specificity were used to evaluate efficacy of the Cellucci criteria. Results: Among the 121 children, 72 were males and 49 were females, with an age of 10.3 (6.5, 14.0) years at disease onset. There were 99 cases diagnosed as AE according the clinical diagnosis (58 males and 41 females), of which 43 cases were diagnosed as dAPAE, 14 cases as prANAE and 42 cases as pAE, and the other 22 cases were not AE (14 males and 8 females). The top 2 initial symptoms in the 99 children with AE were seizures (53 cases, 53.5%) and abnormal mental behaviors (35 cases, 35.4%). And the most common symptoms during the course of the disease were abnormal mental behaviors (77 cases, 77.8%) and seizures (64 cases, 64.6%). There were statistically differences in the incidence of consciousness disorders, autonomic dysfunctions during the course of the disease and the length of hospitalization among the 4 groups (χ²=21.63, 13.74, H=22.60, all P<0.05). Ninety-six of the 121 children were tested for AE-related antibodies, of which 45 cases (46.9%) were antibody-positive. According to the Cellucci criteria, 42 cases were diagnosed as dAPAE, 34 cases as prANAE and 14 cases as pAE. Compared with the clinical diagnosis, the sensitivity of the Cellucci criteria for the diagnosis of the 3 types of AE were 93.02%, 92.86% and 87.88%, and the specificity were 96.23%, 74.39% and 86.36%, respectively. Conclusions: The Cellucci criteria has a high sensitivity and specificity for the diagnosis of pAE and dAPAE in the clinical management of children with suspected AE, while a high sensitivity but low specificity for the diagnosis of prANAE. Therefore, it is recommended to apply the Cellucci criteria selectively in clinical practice according to the actual situation, especially in the diagnosis of prANAE.

Pay-for-performance and continuity of care synergistically reduced amputation of lower extremity in patients with diabetes: a population-based cohort study

Background

Diabetic foot is a common and costly complication of diabetes. No existing study has looked at the effect of continuity of care on amputations of diabetes (DM) patients while considering pay-for-performance (P4P) participation. We investigated the impact of the P4P program and the continuity of care index (COCI) on the incidence of lower extremity amputations (LEA) among diabetics in Taiwan.

Methods

This was a population-based cohort study using insurance claims data from 1997 to 2013. We selected 15,650 DM patients in the P4P program along with age- and sex-matched non-P4P participants at a 1:4 ratio. Time-weighted average (TWA) of the COCI was calculated and included in the time-dependent Cox proportional hazard models to examine the impact of P4P and COCI on the risk of LEA, while controlling for individual and area level characteristics.

Results

During four-year follow-up, 1816 subjects experienced LEA. The cumulative LEA hazard rate of the P4P group (n = 153) was significantly lower than that of the non-P4P group (n = 1663) (hazard ratio = 0.37, 95% CI = 0.31–0.43, p < 0.0001, by log-rank test). In the time-dependent Cox proportional hazard model, the adjusted hazard ratios (aHR) for the P4P group was 0.35, (p < 0.0001). With the low COCI (< 0.360) group as the reference, the aHR of LEA was 0.49 (p < 0.0001) for the middle COCI group, (p < 0.0001), and the aHR of LEA for the high COCI (≥0.643) group was 0.23 (p < 0.0001).

Conclusions

Participating in the P4P program and increasing COCI might reduce the risk of amputation for DM patients, independently and synergistically.

Cost Utility Analysis of Multidisciplinary Postacute Care for Stroke: A Prospective Six-Hospital Cohort Study

Background

Few studies have compared the optimal duration and intensity of organized multidisciplinary neurological/rehabilitative care delivered in a regional/district hospital with the standard rehabilitative care delivered in the general neurology/rehabilitation ward of a medical center. This study measured functional outcomes and conducted cost-utility analysis of an organized multidisciplinary postacute care (PAC) project in secondary care compared with standard rehabilitative care delivered in tertiary care.

Methods

This prospective cohort study enrolled 1,476 patients who had a stroke between March 2014 and March 2018 and had a modified Rankin scale score of 2–4. After exact matching for age ± 1 year, sex, year of stroke diagnosis, nasogastric tube, and Foley catheter and propensity score matching for the other covariates, we obtained 120 patients receiving PAC (the PAC group) from four regional/district hospitals and 120 patients not receiving PAC (the non-PAC group) from two medical centers.

Results

At baseline, the non-PAC group showed significantly better functional outcomes than the PAC group, including EuroQol-5 dimensions (EQ-5D), Mini-Mental State Examination (MMSE) and Barthel index (BI). During weeks 7–12 of rehabilitation, improvements in all functional outcomes were significantly larger in the PAC group (P < 0.001) except for Functional Oral Intake Scale (FOIS). Cost-utility analysis revealed that the PAC group had a significantly lower mean (± standard deviation) of direct medical costs (US$3,480 ± $1,758 vs. US$3,785 ± $3,840, P < 0.001) and a significantly higher average gain of quality-adjusted life years (0.1993 vs. 0.1233, P < 0.001). The PAC project was an economically “dominant” strategy.

Conclusions

The PAC project saved costs and significantly improved the functional outcomes of patients with stroke with slight to moderately severe disabilities. Randomized control trials are required to corroborate these results.

Combined quality of life and survival for estimation of long-term health outcome of patients with stroke

Background

Advanced medical technologies can prolong life of stroke survivors. Dynamic change of health outcomes provides essential information to manage stroke. Mathematical models, to extrapolate health status over a lifetime from cross-sectional data, can be used to investigate long term health outcomes among stroke survivors. This study aimed to estimate the health outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) at each survival time point.

Methods

The cohort of 5391 patients with IS and ICH stroke, registered at Ramathibodi Hospital from 2005 to 2013, were followed up regarding survival status until 2016 with the National Mortality Registry. Survival functions were extrapolated over 50 years to age- and sex-matched referents simulated from the national data of the Thailand National Health Statistic Office. From July to December 2016, the EuroQoL 5-dimension questionnaire was used to measure quality of life (QoL) among 400 consecutive, cross-sectional subsamples. The survival functions were then adjusted by the utility values of QoL for the stroke cohort to estimate quality adjusted life expectancy (QALE).

Results

The average health utility values were lower in the initial months, then slowly increased to stable levels. However, male stroke survivors presented higher health utility than females. Throughout lifetime estimation, patients with IS stroke exhibit better health outcomes than those with ICH [10.2 vs. 7.5 quality-adjusted life years (QALYs)]. Patients with ICH presented a significantly decreased QoL than patients with IS (16.3 and 8.5 QALYs).

Conclusion

Preventing stroke can save people from reduced years and QoL, which can be quantified by loss-of-QALE in QALY units to compare health benefits from prevention, clinical diagnosis and direct treatment.

Intubation difficulty scale contributors and time delay in clinical practice

The intubation difficulty scale (IDS) includes 7 contributors that provide a comprehensive assessment of difficult intubation. However, the effect of each contributor is unclear, and the scale has not been revalidated recently and has not been validated in orient. This study determined the duration of successful intubation (DSI) for each of these 7 contributors.The patients were intubated by attending anesthesiologists. The duration and other data were recorded by 2 research assistants. Anaesthesiologists reported the IDS and their perceptions. A linear mixed-effects model with a DSI was constructed using IDS factors.In total, 1095 patients were enrolled. The average DSI was 23.9 ± 21.8 seconds (37.1% IDS = 0). All 7 factors were independently associated with duration, with the exception of vocal cord adduction. The best model was as follows: DSI (in seconds) = 15.2 + 31.1 (number of additional attempts) + 26.2 (number of additional operators) + 11.4 (number of alternative techniques) + 7.9 (increased lift force) + 4.9 (external laryngeal pressure) + 3.5 (Cormack grade 1). The mixed models were similar except for the regression coefficient for the number of alternative techniques that decreased from 11.4 to 6.9 seconds.We confirmed that each IDS contributor affects the DSI and validated a prediction model with 6 IDS contributors. This prediction model may facilitate the development of strategic plans for critical airway management. Furthermore, it could improve simulations and monitor learning progress and help provide valuable feedback.

Estimating US Earnings Loss Associated with COVID-19 Based on Human Capital Calculation

Infection with COVID-19 could result in lockdown, quarantine of contacts, absenteeism from work, and temporary productivity loss. This research aims to calculate (1) how the pandemic affects on-the-job probability and earnings for the working population, and (2) how much productivity loss is associated with self or a family member sick with COVID-19. Based on data collected from the U.S Research and Development Survey (RANDS), this research projects the relationship between on-the-job possibility and age of the index group and calculates the employment possibilities of the index group relative to the healthy group, namely the employment ratio. The weekly loss of productivity, presented by earnings, associated with COVID-19 for groups aged 18-44 years and 45-64 years was calculated, since the 18- to 64-year-old population is an economy's active workforce. Analytical results indicate that the older the age group, the lower the on-the-job possibility, and the higher the weekly productivity loss due to self or a family member being sick from COVID-19. For the group aged 45-64 years, the employment ratio of the index group relative to the healthy group dropped from 0.863 to 0.39, corresponding to a weekly productivity loss of 136-590 US dollars. The overall impact would be about a 9% loss in GDP. Infected or quarantined people would be confined to working in relatively isolated offices or places to allow for social distancing. Proactive health promotion in the workplace plus reactive work through telecommunication systems would reduce such losses. Such preparedness needs to be implemented early for more vulnerable workers who are of middle or old age and/or those comorbid with diabetes.

Cost-Effectiveness of Nivolumab Plus Ipilimumab With and Without Chemotherapy for Advanced Non-Small Cell Lung Cancer

Background

First-line treatment with nivolumab plus ipilimumab (N+I) or nivolumab plus ipilimumab with two cycles of chemotherapy (N+I+chemotherapy) improve overall survival and progression-free survival for patients with metastatic non-small cell lung cancer (NSCLC), yet researchers have not concomitantly compared the cost-effectiveness of N+I and N+I+chemotherapy with chemotherapy alone.

Materials and methods

Using outcomes data from the CheckMate 227 and CheckMate 9LA phase 3 randomized trials, we developed a Markov model with lifetime horizon to compare the costs and effectiveness of N+I and N+I+chemotherapy versus chemotherapy from the U.S. health care sector perspective. Subgroup analysis by programmed death-ligand 1 (PD-L1) expression levels (≥1% and <1%) and probabilistic analysis were performed.

Results

The incremental cost-effectiveness ratio (ICER) of N+I versus chemotherapy was $239,072 per QALY, and $838,198 per QALY for N+I+chemotherapy versus N+I. The ICER of N+I versus chemotherapy was $246,584 per QALY for patients with PD-L1 ≥ 1% and $185,620 per QALY for those with PD-L1 < 1%. In probabilistic analysis, N+I had a 2.6% probability of being cost-effective at a willingness-to-pay threshold of $150,000 per QALY. The probability was 0.4% for patients with PD-L1 ≥ 1% and 10.6% for patients with PD-L1 < 1%.

Conclusion

First-line N+I or N+I+chemotherapy for metastatic NSCLC was not cost-effective regardless of PD-L1 expression levels from the U.S. health care sector perspective.

Determinants and Dynamic Changes of Generic Quality of Life in Human Bladder Cancer Patients

We measured and determined the factors associated with long-term generic quality-of-life (QOL) changes in human bladder cancer patients. We utilized the World Health Organization QOL-Brief questionnaire to assess consecutive patients’ QOL at outpatient clinics of our hospital. A mixed-effects model was constructed to investigate the determinants of QOL changes according to each domain and individual item after controlling for demographic and clinical factors, as well as the effect of radical cystectomy. We also applied a kernel smoothing method to describe the long-term dynamic changes after the first definite treatment. In total, 1185 repeated measurements were collected from 343 bladder cancer patients. The mixed-effects models demonstrated that marital status, monthly income, and comorbidity with heart disease and diabetes were significant determinants among all the study participants. Regardless of the urinary diversion type, radical cystectomy contributed to lower scores for all four domains, mainly from 4–5 years after cystectomy, which declined significantly in patients who were older than 60 years. As for non-muscle-invasive bladder cancer (NMIBC) patients with preserved bladders, tumor recurrence was a major predictor for lower scores for sexual activity in the social domain. In summary, generic QOL can be independently influenced by many factors, not only cystectomy and tumor recurrence, which should be discussed with patients before treatment.

Incidence of stroke among patients with polycystic kidney disease in Taiwan: a retrospective population-based cohort study using National Health Insurance Database

BACKGROUND

Few studies documented incidence rates of different types of stroke among patients with polycystic kidney disease (PKD).

MATERIALS AND METHODS

We conducted a retrospective cohort study based on the National Health Insurance (NHI) Database of Taiwan. The PKD cohort comprised patients aged≥20 years diagnosed with PKD using inpatient claims from 1998 to 2011, excluding prior stroke. The reference cohort was established by inpatients without PKD using 1:4 frequency-matched with age, gender, and baseline comorbidities. The two cohorts were followed-up until stroke hospitalization, death, withdrawal from the NHI program, or the end of 2012. To account for competing risks of death, we used multivariable competing risks regression models to estimate sub-distribution hazard ratio (SHR) adjusted for age, gender, baseline comorbidities and end stage renal disease.

RESULTS

7837 PKD patients and 31211 reference subjects were followed up through 2012. A total of 955 cases of stroke were identified in the PKD cohort, including 441 ischemic stroke (IS), 289 intracranial hemorrhage (ICH), 73 subarachnoid hemorrhage (SAH) and 232 other stroke. The incidence rates of overall stroke, IS, ICH, and SAH were 21.3, 10.2, 6.8, and 1.7 per 1000 person-years, respectively. The SHR for overall stroke was 1.39 [95% confidence interval (CI) 1.28-1.50]. SAH had the highest SHR, 4.55 [95% CI 3.26-6.37], followed by ICH (1.84), other stroke (1.24), and IS (1.22).

CONCLUSIONS

This study illustrated the incidence rates of stroke among inpatient of PKD. The PKD patients had a significantly increased risk of all kinds of stroke after adjusting baseline comorbidities.

Integrating domain knowledge with machine learning to detect obstructive sleep apnea: Snore as a significant bio-feature

Our study's main purpose is to emphasise the significance of medical knowledge of pathophysiology before machine learning. We investigated whether combining domain knowledge with machine learning results might increase accuracy and minimise the number of bio-features used to detect obstructive sleep apnea (OSA). The present study analysed data on 36 self-reported symptoms and 24 clinical features obtained from 3,495 patients receiving polysomnography at a regional hospital and a medical centre. The area under the receiver operating characteristic (AUC) curve was used to evaluate patients with and without moderate or severe OSA using three prediction models on the basis of various estimation methods: the multiple logistic regression (MLR), support vector machine (SVM), and neural network (NN) methods. Odds ratios stratified by gender and age were also measured to account for clinicians' common sense. We discovered that adding the self-reported snoring item improved the AUC by 0.01-0.10 and helped us to rapidly achieve the optimum level. The performance of four items (gender, age, body mass index [BMI], and snoring) was comparable with that of adding two or more items (neck and waist circumference) for predicting moderate to severe OSA (Apnea-Hypopnea Index ≥15 events/hr) in all three prediction models, demonstrating the medical knowledge value of pathophysiology. The four-item test sample AUCs were 0.83, 0.84, and 0.83 for MLR, SVM, and NN, respectively. Participants with regular snoring and a BMI of ≥25 kg/m² had a greater chance of moderate to severe OSA according to the stratified adjusted odds ratios. Combining domain knowledge into machine learning could increase efficiency and enable primary care physicians to refer for an OSA diagnosis earlier.

Functional and Cognitive Impairments Increased Risks of Outcomes of Healthcare Utilization in Patients With Stroke Receiving Home and Community-Based Care in Taiwan

Aim: Stroke is a leading cause of disability; however, little is known about the outcomes of the utilization of long-term care (LTC) recipients in Taiwan. This study aimed to quantify the burdens of disease of stroke survivors receiving LTC by evaluating the outcomes of their utilization including mortality, readmissions, and re-emergency within 1 year after diagnoses of strokes. Methods: By interlinkages among the national mortality registry, LTC dataset (LTC-CM), and the National Health Insurance Research Dataset (NHIRD), the outcomes and the factors associated with receiving LTC up to 1 year were explored. Patients were aged 50 years and over with an inpatient claim of the first diagnosis of stroke of intracerebral hemorrhage (ICH) and ischemic stroke during 2011-2016. Outcomes of the healthcare utilization include rehospitalization and re-emergency. Results: There were 15,662 patients with stroke who utilized the LTC services in the dataset among the stroke population in NHIRD. Stroke survivors receiving LTC showed no difference in clinical characteristics and their expected years of life loss (EYLL = 7.4 years) among those encountered in NHIRD. The LTC recipients showed high possibilities to be rehospitalized and resent to emergency service within 1 year after diagnosis. Apart from the comorbidity and stroke severity, both the physical and mental functional disabilities and caregiving resources predicted the outcomes of the utilization. Conclusions: For stroke survivors, both severe functional impairments and cognitive impairments were found as important factors for healthcare utilizations. These results regarding reserving functional abilities deserve our consideration in making the decision on the ongoing LTC policy reform in the aged society of Taiwan.

Residential green space structures are associated with a lower risk of bipolar disorder: A nationwide population-based study in Taiwan

Although many researchers have identified the potential psychological benefits offered by greenness, the association between green space structures and mental disorders is not well understood. The purpose of this study was to identify associations between green space structures and the incidence of bipolar disorder. To this end, we investigated 1,907,776 individuals collected from Taiwan's National Health Insurance Research Database. After a follow-up investigation from 2005 to 2016, among those with no history of bipolar disorder, 20,548 individuals were further found to be diagnosed with bipolar disorder. A geographic information system and landscape index were used to quantify three indices of green space structures: mean patch area (area and edge), mean fractal dimension index (shape), and mean proximity index (proximity). Additionally, greenness indices, the normalized difference vegetation index, and the enhanced vegetation index were used to confirm the association between greenness and incidence of bipolar disorder. These five indices were used to represent the individual's exposure according to the township of the hospital that they most frequently visited with symptoms of the common cold. Spearman's correlation analysis was performed to select variables by considering their collinearity. Subsequently, the frailty model for each index was used to examine the specific associations between those respective indices and the incidence of bipolar disorder by adjusting for related risk factors, such as socioeconomic status, metabolic syndrome, and air pollution. A negative association was identified between the mean patch area and the mean proximity index, and the incidence of bipolar disorder. In contrast, a positive association was found between the mean fractal dimension index and the incidence of bipolar disorder. We observed similar results in sensitivity testing and subgroup analysis. Exposure to green spaces with a larger area, greater proximity, lower complexity, and greener area may reduce the risk of bipolar disorder.

Increased Risk of Gastric Cancer in Asbestos-Exposed Workers: A Retrospective Cohort Study Based on Taiwan Cancer Registry 1980-2015

Asbestos has been recognized as a human carcinogen associated with malignant mesothelioma, cancers of lung, larynx, and ovary. However, a putative association between gastric cancer and asbestos exposure remains controversial. In this study, we aimed to explore gastric cancer risk of workers potentially exposed to asbestos in Taiwan. The asbestos occupational cohort was established from 1950 to 2015 based on the Taiwan Labor Insurance Database, and Taiwan Environmental Protection Agency regulatory datasets, followed by the Taiwan Cancer Registry for the period 1980–2015. Standardized incidence ratios (SIRs) for cancer were computed for the whole cohort using reference rates of the general population, and also reference labor population. Compared with the general population, SIR of the asbestos occupational cohort for the gastric cancer increased both in males (1.05, 95% confidence interval (CI): 1.02–1.09) and females (1.10, 95% CI: 1.01–1.18). A total of 123 worksites were identified to have cases of malignant mesothelioma, where increased risk for gastric cancer was found with a relative risk of 1.76 (95% CI: 1.63–1.90). This 35-year retrospective cohort study of asbestos-exposed workers in Taiwan may provide support for an association between occupational exposure to asbestos and gastric cancer.

Maintaining Quality of Care among Dialysis Patients in Affected Areas after Typhoon Morakot

Natural disasters have negative health impacts on patients who need dialysis in affected areas. Severely affected areas are usually rural, with limited basic infrastructure and a population without optimal dialysis-specific care after a disaster. A population-based longitudinal case–cohort study enrolled 715,244 adults from the National Health Insurance Registry who lived in areas affected by a major natural disaster, Typhoon Morakot, in 2009. The observation period was from 2008 to 2011. A total of 13,268 patients (1.85%) had a history of end-stage renal disease (ESRD). Of the ESRD patients, 1264 patients (9.5%) received regular dialysis. Only eight patients missed dialysis sessions in the first month after the disaster. Compared to the moderately affected areas, the incidences of acute cerebrovascular and cardiovascular diseases were higher in patients in severely affected areas. Male dialysis patients aged 45–75 years had a higher mortality rate than that of the general population. Among the affected adults receiving regular dialysis, patients with diabetes (adjusted hazard ratio (aHR): 1.58, 95% confidence interval (CI): 1.20–2.08) or a history of cerebrovascular disease (aHR: 1.58, 95% CI: 1.12–2.21), chronic obstructive pulmonary disease (COPD) or asthma (aHR: 1.99, 95% CI: 1.24–3.17) in moderately affected areas had significantly elevated mortality rates. Additionally, among dialysis patients living in severely affected areas, those with a history of cerebrovascular disease (aHR: 4.52 95% CI: 2.28–8.79) had an elevated mortality rate. Early evacuation plans and high-quality, accessible care for cardiovascular and cerebrovascular diseases are essential to support affected populations before and after disasters to improve dialysis patients’ health outcomes.

Cost-effectiveness evaluation of mammography screening program in Taiwan: Adjusting different distributions of age and calendar year for real world data

BACKGROUND/PURPOSE

We estimated loss-of-life expectancy (LE) and lifetime medical expenditures (LME) stratified by stages to evaluate the cost-effectiveness of breast cancer (BC) screening in Taiwan.

METHODS

We interlinked four national databases- Cancer Registry, Mortality Registry, National Health Insurance Claim, and Mammography Screening. A cohort of 123,221 BC was identified during 2002-2015 and followed until December 31, 2017. We estimated LE and loss-of-LE by rolling extrapolation algorithm using age-, sex-, and calendar-year-matched referents simulated from vital statistics. LME was estimated by multiplying monthly cost with survival probability and adjusted for annual discount rate. We calculated incremental cost-effectiveness ratio (ICER) by comparing the loss-of-LE of those detected by screening versus non-screening after accounting for administration fees and radiation-related excess BC.

RESULTS

The LEs of stages I, II, III, and IV were 31.4, 27.2, 20.0, and 5.2 years, respectively, while the loss-of-LEs were 1.2, 4.9, 11.7, and 25.0 years with corresponding LMEs of US$ 73,791, 79,496, 89,962, and 66,981, respectively. The difference in LE between stages I and IV was 26.2 years while that of loss-of-LE was 23.8 years, which implies that a potential lead time bias may exist if diagnosis at younger ages for earlier stages were not adjusted for. The ICER of mammography seemed cost-saving after the coverage exceeded half a million.

CONCLUSION

Mammography could detect BC early and be cost-saving after adjustment for different distributions of age and calendar year of diagnosis. Future studies exploring healthcare expenditure and impaired quality of life for false-positive cases are warranted.

Investing preventive care and economic development in ageing societies: empirical evidences from OECD countries

BACKGROUND

The proportion of the elderly aged 65 years old or above will reach 16% in 2050 worldwide. Early investment in effective prevention would generally reduce the morbidity, complication, functional disability, and mortality of most chronic illnesses and save resources in both healthcare and social services. This research aims to investigate how the optimal allocation of medical resources between prevention and treatment adds value to the population's health as well as examine the interaction between ageing, health, and economic performance.

METHODS

This research undertakes ageing-health analyses by developing an economic growth model. Based on the Organization for Economic Co-Operation and Development (OECD) countries' experiences over the period from 2000 to 2017, this research further examines the hypothesis that an ageing society could increase demand for preventive and curative healthcare.

RESULTS

Theoretical analysis found that the prevention share for maximizing growth is the same as that for minimizing ill health and maximizing welfare; this share increases with treatment share and ageing ratios. Estimation results from OECD countries' experiences indicate that when treatment share increases by 1%, the prevention demand increases by 0.036%. A one-percent increase in the ageing ratio yields a change in prevention share of 0.0368%. The optimal share of prevention health expenditure to GDP would be 1.175% when the prevalence rate of ill health isat 6.13%; a higher or lower share of prevention would be accompanied with a higher prevalence of ill health. For example, a zero and 1.358% preventive health expenditure would be associated with an 18.01% prevalence of ill health, while the current share of prevention of 0.237% is associated with a 10.26% prevalence of ill health.

CONCLUSION

This study shows that appropriate prevention is associated with decreases in the prevalence rates of ill health, which in turn attains sustainable growth in productivity. Too much prevention, however, could lead to higher detection of new chronic diseases with mild severity, which would result in longer illness duration, and higher prevalence rates of ill health. With suitable allocation of medical resources, the economic growth rate will help to cancel out increases in healthcare spending for the elderly and for expenses needed for the improvement of the population's health as a whole.

Optimal Intervals of Ultrasonography Screening for Early Diagnosis of Hepatocellular Carcinoma in Taiwan

IMPORTANCE

There are different clinical practices regarding ultrasonography screening intervals for hepatocellular carcinoma (HCC) despite recommendations from international guidelines.

OBJECTIVE

To evaluate whether ultrasonography screening using intervals suggested by international guidelines is associated with cancer stage shifting, reductions in mortality, and improved quality of life (QoL) for patients with HCC.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide comparative effectiveness research study estimated lifetime survival functions using interlinkages of 3 databases from Taiwan-the Taiwan National Health Insurance, Taiwan National Cancer Registry, and National Mortality Registry-combined with QoL measurements obtained from National Cheng Kung University Hospital. In total, 114 022 patients listed as having newly diagnosed HCC from 2002 through 2015 in the Taiwan National Cancer Registry were followed up until 2017. The QoL values of 1059 patients with HCC who visited National Cheng Kung University Hospital were prospectively measured with the European QoL-5 dimensions questionnaire from 2011 through 2019. Patients were categorized based on the time between their last ultrasonography screening and the index date (90 days prior to HCC diagnosis) as 1 of 5 subcohorts: 6 months (0-6 months), 12 months (7-12 months), 24 months (13-24 months), 36 months (25-36 months), and longer than 36 months (no screening in the previous 3 years). Data were analyzed from April 2020 to April 2021.

MAIN OUTCOMES AND MEASURES

Life expectancy, quality-adjusted life expectancy, and loss of life expectancy or loss of quality-adjusted life expectancy compared with age-, sex-, and calendar year-matched cohorts.

RESULTS

There were 59 194 patients with Barcelona Clinic Liver Cancer staging information, including 42 081 men (mean [SD] age, 62.2 [12.6] years) and 17 113 women (mean [SD] age, 69.0 [11.2] years). There was a consistent trend showing that the longer the interval between ultrasonography examinations, the higher the loss of life expectancy and loss of quality-adjusted life expectancy for both sexes. Loss of quality-adjusted life expectancy values for male subcohorts were 10.0 (95% CI, 9.1-10.9) quality-adjusted life-years (QALYs) for ultrasonography screening intervals of 6 months, 11.1 (95% CI, 10.4-11.8) QALYs for 12 months, 12.1 (95% CI, 11.5-12.7) QALYs for 24 months, 13.1 (95% CI, 12.6-13.6) QALYs for 36 months, and 14.6 (95% CI, 14.2-15.0) QALYs for longer than 36 months. Loss of quality-adjusted life expectancy values for female subcohorts were 9.0 (95% CI, 8.3-9.6) QALYs for 6 months, 9.7 (95% CI, 9.2-10.2) QALYs for 12 months, 10.3 (95% CI, 9.8-10.7) QALYs for 24 months, 10.7 (95% CI, 10.2-11.1) QALYs for 36 months, and 11.4 (95% CI, 11.0-11.8) QALYs for longer than 36 months. Patients with underlying hepatitis B virus infection or cirrhosis had the greatest improvement in life expectancy with shorter screening intervals.

CONCLUSIONS AND RELEVANCE

Regular ultrasonography screening with intervals less than 6 to 12 months may be associated with early detection of HCC, save lives, and improve the quality of life for patients with HCC from a lifetime perspective.

QALYs and medical costs saved from prevention of a cancer: Analysis of nation-wide real-world data of Taiwan with lifetime horizon

BACKGROUND/PURPOSE

To quantify savings of loss-of-QALE (quality-adjusted life expectancy) and lifetime medical costs from prevention of different cancers.

METHODS

We collected nation-wide data on 808,700 new cancer cases of 14 different organ systems and followed them from 1998 to 2014 in Taiwan. We also collected 13,005 cancer patients from a medical center and 47,320 repeated measurements of quality of life (QoL) of EQ-5D to obtain utility values and multiplied them with the corresponding survival rates to calculate QALE. With Kaplan-Meier estimation to survival function to the end of follow-up, we extrapolated to lifetime through a rolling over algorithm on the logit transform of the survival ratio between the index cohort and age-, sex, and calendar year matched referents simulated from vital statistics. Lifetime costs for each cancer were estimated by multiplying survival with average monthly costs after adjustment with annual discount rate. The loss-of-QALE was estimated by the difference in QALE between the index cancer cohort and corresponding referents.

RESULTS

The dynamic changes and weighted averages of the QoL utility values of 14 different cancers ranged from 0.82 to 0.95. Successful prevention of liver, lung, esophagus, or nasopharynx cancer would save more than 10 quality-adjusted life years and more than 21,000 USD per case for both genders. Since the saving of loss-of-QALE was adjusted for different age, sex, and calendar-year distributions, it could be used in cost effectiveness evaluation.

CONCLUSION

Savings of loss-of-QALE and lifetime costs could be used for comparison of prevention, diagnosis, treatment and rehabilitation from a lifetime horizon.

Estimated Loss of Lifetime Employment Duration for Patients Undergoing Maintenance Dialysis in Taiwan

BACKGROUND AND OBJECTIVES

An accurate estimate of the loss of lifetime employment duration resulting from kidney failure can facilitate comprehensive evaluation of societal financial burdens.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

All patients undergoing incident dialysis in Taiwan during 2000-2017 were identified using the National Health Insurance Research Database. The corresponding age-, sex-, and calendar year-matched general population served as the referents. The survival functions and the employment states of the index cohort (patients on dialysis) and their referents for each age strata were first calculated, and then extrapolated until age 65 years, where the sum of the product of the survival function and the employment states was the lifetime employment duration. The difference in lifetime employment duration between the index and referent cohort was the loss of lifetime employment duration. Extrapolation of survival function and relative employment-to-population ratios were estimated by the restricted cubic spline models and the quadratic/linear models, respectively.

RESULTS

A total of 83,358 patients with kidney failure were identified. Men had a higher rate of employment than women in each age strata. The expected loss of lifetime employment duration for men with kidney failure was 11.8, 7.6, 5.7, 3.8, 2.3, 1.0, and 0.2 years for those aged 25-34, 35-40, 41-45, 46-50, 51-55, 56-60, and 61-64 years, respectively; and the corresponding data for women was 10.5, 10.1, 7.9, 5.6, 3.3, 1.5, and 0.3 years, respectively. The values for loss of lifetime employment duration divided by loss of life expectancy were all >70% for women and >88% for men across the different age strata. The sensitivity analyses indicated that the results were robust.

CONCLUSIONS

The loss of lifetime employment duration in patients undergoing dialysis mainly originates from loss of life expectancy.

Downstream Complications and Healthcare Expenditure after Invasive Procedures for Lung Lesions in Taiwan

This study aimed to estimate the downstream complications and healthcare expenditure after invasive procedures for lung lesions, which in turn could be used for future cost-effectiveness analyses of lung cancer screening in Taiwan. We interlinked the Taiwan National Beneficiary Registry with the National Health Insurance Reimbursement databases to identify non-lung cancer individuals aged 50–80 years who underwent invasive lung procedures within one month after non-contrast chest computed tomography between 2014 and 2016. We directly matched one individual with 10 controls by age, gender, calendar year, residence area, comorbidities, and the past one-year healthcare expenditure to calculate incremental one-month complication rates and attributable costs. A total of 5805 individuals who underwent invasive lung procedures were identified and matched with 58,050 controls. The incremental one-month complication rates were 13.4% (95% CI: 10.9% to 15.8%), 10.7% (95% CI: 9.2% to 12.1%), and 4.4% (95% CI: 2.0% to 6.7%) for thoracic surgery, bronchoscopy, and needle biopsy, respectively. The incremental one-month healthcare expenditure for minor, intermediate, and major complications were NT$1493 (95% CI: NT$-3107 to NT$6092), NT$18,422 (95% CI: NT$13,755 to NT$23,089), and NT$58,021 (95% CI: NT$46,114 to NT$69,929), respectively. Individuals aged 60–64 years incurred the highest incremental costs. Downstream complications and the healthcare expenditure after invasive procedures for lung lesions would be substantial for non-lung cancer individuals 50–80 years of age. These estimates could be used in modeling the cost-effectiveness of the national lung screening program in Taiwan.

The association between economic indicators and the incidence of tetraplegia from traumatic spinal cord injury in Taiwan

Background

Economic performance may affect public health parameters. This study aimed to determine the time trend of incidence of traumatic spinal cord injury (SCI) and its association with income, presented by GDP (gross domestic product) per capita.

Methods

This study was a retrospective observational study in Taiwan. Newly diagnosed SCI patients with moderate to severe disability from 2002 to 2015 were identified from the reimbursement database of the National Health Insurance (NHI) system (1998–2015). CIR_16–99 (cumulative incidence rate, aged 16–99 years, per 10³ person-years) and CIR_16–59 (aged 16–59 years) of SCI from 2002 to 2015 were measured.

Results

There were 5048 newly diagnosed SCI patients during the study period. After controlling the factors of sex, urbanization level, literacy, income inequality, and global financial crisis (mixed effects models), the CIR_16–99 of SCI, traumatic SCI, motor vehicle (MV)-related SCI, fall-related SCI, tetraplegia, traumatic tetraplegia, MV-related tetraplegia, and fall-related tetraplegia were inversely associated with GDP per capita; the β coefficients ranged from − 4.85 (95% confidence interval − 7.09 to − 2.6) for total SCI to − 0.8 (− 1.3 to − 0.29) for fall-related tetraplegia. We restricted our comparison to Taipei City and the 4 lowest densely populated counties, which also corroborated with the above results. The income elasticity analysis revealed when GDP per capita increased by 1%, the total SCI decreased by 1.39‰; which was also associated with a decrease of 1.34‰, 1.55‰, 1.36‰, 1.46‰, 1.54‰, 1.54‰, and 1.62‰ for traumatic SCI, MV-related SCI, fall-related SCI, tetraplegia, traumatic tetraplegia, MV-related tetraplegia, and fall-related tetraplegia respectively. The β coefficients show that the compared areas of urbanization level were also inversely correlated with CIR_16–59 in the SCI population.

Conclusions

We conclude that the incidence of tetraplegia of traumatic SCI in Taiwan decreases with good economic performance, which may be resulted from the provision of public goods and services, possibly through improvements in the infrastructure of transportation and construction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02141-8.

Cost-effectiveness of percutaneous coronary intervention versus medical therapy in patients with acute myocardial infarction: real-world and lifetime-horizon data from Taiwan

Although some studies have assessed the cost-effectiveness of percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI), there has been a lack of nationwide real-world studies estimating life expectancy (LE), loss-of-LE, life-years saved, and lifetime medical costs. We evaluated the cost-effectiveness of PCI versus non-PCI therapy by integrating a survival function and mean-cost function over a lifelong horizon to obtain the estimations for AMI patients without major comorbidities. We constructed a longitudinal AMI cohort based on the claim database of Taiwan's National Health Insurance during 1999–2015. Taiwan's National Mortality Registry Database was linked to derive a survival function to estimate LE, loss-of-LE, life-years saved, and lifetime medical costs in both therapies. This study enrolled a total of 38,441 AMI patients; AMI patients receiving PCI showed a fewer loss-of-LE (3.6 versus 5.2 years), and more lifetime medical costs (US$ 49,112 versus US$ 43,532). The incremental cost-effectiveness ratio (ICER) was US$ 3488 per life-year saved. After stratification by age, the AMI patients aged 50–59 years receiving PCI was shown to be cost-saving. From the perspective of Taiwan's National Health Insurance, PCI is cost-effective in AMI patients without major comorbidities. Notably, for patients aged 50–59 years, PCI is cost-saving.

Increasing burden of major trauma in elderly adults during 2003-2015: Analysis of real-world data from Taiwan

BACKGROUND

Major trauma has been one of the leading causes of morbidity, mortality, and functional disability, resulting in substantial societal burden. The aim of this study was to estimate the trends in burden of adult major trauma in Taiwan during 2003-2015.

METHODS

Adult patients with initial encounter of major trauma (injury severity score ≥ 16) were abstracted from the claim data of National Health Insurance (NHI) in Taiwan from January 2003 to December 2015. We explored the trends of incidence and mortality rates over time stratified by age and sex, as well as life expectancy (LE), loss-of-LE, lifetime healthcare expenditure and total loss-of-LE compared with age, sex and calendar-year matched referents simulated from the vital statistics of Taiwan.

RESULTS

A total of 71,731 cases of adult major trauma, and an estimated loss of 979,676 life-years were found with an increasing trend in cumulative incidence rate (CIR_18-84) during 2003-2015. The incidence rates were significantly higher in men than women. For both sexes, the incidence rates for those aged 65 and above were about 2-3 times higher than those of all other age groups. The one-year case fatality rates among the elderly were about 31-61%, higher than all other ages. The lifetime healthcare expenditures per person were 47,616 USD in men and 43,416 USD in women.

CONCLUSION

There is a consistently increasing trend in incidence and mortality of major trauma in Taiwan, especially among elderly people. For Taiwan, an aged society beginning since 2018, the challenge should be tackled more effectively in the coming decades.

Savings of loss-of-life expectancy and lifetime medical costs from prevention of spinal cord injuries: analysis of nationwide data followed for 17 years

BACKGROUND

The objectives of this research were to determine the savings of loss-of-life expectancy (LE) and lifetime medical costs (LMC) from prevention of spinal cord injuries (SCI) in Taiwan.

METHODS

From the claims database of Taiwan National Health Insurance, we identified 6164 adult patients with newly diagnosed SCI with permanent functional disability from 2000 to 2015 and followed them until the end of 2016. We estimated survival function through the Kaplan-Meier method and extrapolated it to lifetime.

RESULTS

For the SCI cohort, the LE and loss-of-LE were 17.6 and 13.3 years, respectively, while those for SCI with coding of external causes (E-code) were 18.1 and 13.0 years, respectively. For the SCI cohort with E-code, the loss-of-LE of motor vehicle (MV)-related SCI was significantly higher than that of fall-related SCI. In young and middle-aged patients with SCI with E-code, the loss-of-LE of MV-related paraplegia was significantly higher than that of MV-related quadriplegia and fall-related SCI. With a 3% discount rate, the LMC for patients with SCI after diagnosis were US$82 772, while those for patients with SCI with E-code were US$81 473. The LMC and the cost per year for those living with quadriplegia were significantly higher than those for paraplegia in all age groups, possibly related to the higher frequencies of stroke, chronic lung disease and dementia.

CONCLUSIONS

We conclude that quadriplegia has a higher impact on medical costs than paraplegia, and MV-related SCI has a higher impact on loss-of-LE than fall-related SCI. We recommend comprehensive SCI prevention be established, including infrastructures of construction and transportation.