Relationship between practices of eye protection against solar ultraviolet radiation and cataract in a rural area

Background

Cataract is a public health concern worldwide that differentially affects rural residents of outlying islands where ultraviolet radiation (UVR) may have greater penetration because of less shading.

Objectives

To assess the relationships between attitudes and practices of eye protection and eye diseases for residents of an offshore island of Taiwan.

Methods

Questionnaire survey was administered to local residents (age > 50 years) regarding socio-demographic information, attitudes/practices of eye protection under sun exposure and eye diseases.

Results

A total of 816 participants (response rate 90.7%, 816/900) completed the questionnaires. Mean age was 63.7 (+ 10.8) years. Among these participants, 44.4%, 15.1% and 8.3% had cataract, dry eye and glaucoma, respectively. Although 86.3% and 88.2% of participants agreed that they should avoid outdoor activities and wear glasses/broad-brimmed hats in harsh daylight, 69.4% and 48.3% of participants never/rarely used glasses or hats/umbrellas in harsh daylight, respectively. Predictors of less practices of eye protection against solar UVR included residents who were male, with lower education level, with longer residence and lack of commercial health insurance. Multivariate logistic regression revealed that practices of eye protection under sun exposure were significantly associated with less cataract, but not glaucoma or dry eye. Participants who did not wear glasses, broad-brimmed hats/use umbrellas or both in harsh sunlight (almost) every time were respectively associated with a 57% (P = 0.028), 45% (P = 0.027) or 70% (P = 0.026) increase of cataract than those who did in harsh sunlight (almost) every time.

Conclusions

Practices of eye protection under sun exposure is associated with lower risk of cataract.

Estimating global burden of COVID-19 with disability-adjusted life years and value of statistical life metrics

BACKGROUND

Global burden of COVID-19 has not been well studied, disability-adjusted life years (DALYs) and value of statistical life (VSL) metrics were therefore proposed to quantify its impacts on health and economic loss globally.

METHODS

The life expectancy, cases, and death numbers of COVID-19 until 30th April 2021 were retrieved from open data to derive the epidemiological profiles and DALYs (including years of life lost (YLL) and years loss due to disability (YLD)) by four periods. The VSL estimates were estimated by using hedonic wage method (HWM) and contingent valuation method (CVM). The estimate of willingness to pay using CVM was based on the meta-regression mixed model. Machine learning method was used for classification.

RESULTS

Globally, DALYs (in thousands) due to COVID-19 was tallied as 31,930 from Period I to IV. YLL dominated over YLD. The estimates of VSL were US$591 billion and US$5135 billion based on HWM and CVM, respectively. The estimate of VSL increased from US$579 billion in Period I to US$2160 billion in Period IV using CVM. The higher the human development index (HDI), the higher the value of DALYs and VSL. However, there exits the disparity even at the same level of HDI. Machine learning analysis categorized eight patterns of global burden of COVID-19 with a large variation from US$0.001 billion to US$691.4 billion.

CONCLUSION

Global burden of COVID-19 pandemic resulted in substantial health and value of life loss particularly in developed economies. Classifications of such health and economic loss is informative to early preparation of adequate resource to reduce impacts.

The impact of different patterns of home- and community-based services on nursing home admission: National data from Taiwan

BACKGROUND

This study had two aims: (a) to identify the different patterns of use of home- and community-based services (HCBS) among older adults in Taiwan, and (b) to examine the effects of the different use patterns on HCBS recipients' use of institutional long-term care services.

METHODS

The study analyzed cohort data from Taiwan's first National 10-Year Long-Term Care Plan database and from National Health Insurance Claim Data. We extracted baseline information on older adults who were first evaluated for and prescribed HCBS from 2010 through 2013 (N = 71,260). We used latent class analysis to specify the underlying subgroups of recipients with similar patterns of HCBS use. We used hierarchical multinomial logistic regression to examine the effect of the different use patterns on the risk of institutional (e.g., nursing home) placement from 4 to 15 months after initial HCBS evaluation.

RESULTS

Four subgroups of HCBS recipients were identified, with patterns of home-based personal care (PC), home-based personal care and medical care (PC/MC), home-based medical care (MC), and community care services. Compared to the home-based PC/MC group, people in the home-based MC group had lower risk (OR = 0.54) and people in the community care group had higher risk (OR = 1.76) of admission to a nursing home.

CONCLUSIONS

Study findings may provide insights for policy makers regarding the usefulness of integrating medical care and other types of long-term care services into adult day care.

Barriers to bystanders defibrillation: A national survey on public awareness and willingness of bystanders defibrillation☆

BACKGROUND

After years of setting up public automated external defibrillators (AEDs), the rate of bystander AED use remains low all over the world. This study aimed to assess the public awareness and willingness of bystanders to use AEDs and to investigate the awareness on the Good Samaritan Law (GSL) and the factors associated with the low rate of bystander AED use.

METHODS

Using stratified random sampling, national telephone interviews were conducted using an author-designed structured questionnaire. The results were weighted to match the census data in Taiwan. The factors associated with public awareness and willingness of bystanders to use AEDs were analysed by logistic regression.

RESULTS

Of the 1073 respondents, only 15.2% had the confidence to recognise public AEDs, and 5.3% of them had the confidence to use the AED. Concerns on immature technique and legal issues remain the most common barriers to AED use by bystanders. Moreover, only 30.8% thought that the public should use AEDs at the scene. Few respondents (9.6%) ever heard of the GSL in Taiwan, and less than 3% understood the meaning of GSL. Positive awareness on AEDs was associated with high willingness of bystanders to use AEDs. Respondents who were less likely to use AEDs as bystanders were healthcare personnel and women.

CONCLUSION

The importance of active awareness and the barriers to the use of AEDs among bystanders seemed to have been underestimated in the past years. The relatively low willingness to use AEDs among bystander healthcare providers and women needs further investigation.

Empirical Investigation of Factors Influencing Consumer Intention to Use an Artificial Intelligence-Powered Mobile Application for Weight Loss and Health Management

Background: Research into interventions based on mobile health (m-Health) applications (apps) has attracted considerable attention among researchers; however, most previous studies have focused on research-led apps and their effectiveness when applied to overweight/obese adults. There remains a paucity of research on the attitudes of typical consumers toward the adoption of m-Health apps for weight management. This study adopted the tenets of the extended unified theory of acceptance and use of technology 2 (UTAUT2) as the theoretical foundation in developing a model that integrates personal innovativeness (PI) and network externality (NE) in seeking to identify the factors with the most pronounced effect on one's intention to use an artificial intelligence-powered weight loss and health management app. Materials and Methods: An online survey was conducted for Taiwanese participants aged ≥21 years from May 23 to June 30, 2018. Hypotheses were tested using structural equation modeling. Results: In the analysis of 458 responses, the proposed research model explained 75.5% of variance in behavioral intention (BI). Habit was the independent variable with the strongest performance in predicting user intention, followed by PI, NE, and performance expectancy (PE). Social influence weakly affects user intention through PE. In multi-group analysis, education was shown to exert a moderating influence on some of the relationships hypothesized in the model. Conclusions: The empirically validated model in this study provides insights into the primary determinants of user intention toward the adoption of m-Health app for weight loss and health management. The theoretical and practical implications are relevant to researchers seeking to extend the applicability of the UTAUT2 model to health apps as well as practitioners seeking to promote the adoption of m-Health apps. In the future, researchers could extend the model to assess the effects of BI on actual use behavior.

Early Do-Not-Resuscitate Directives Decrease Invasive Procedures and Health Care Expenses During the Final Hospitalization of Life of COPD Patients

CONTEXT

Nearly 70% of do-not-resuscitate (DNR) directives for chronic obstructive pulmonary disease (COPD) patients are established during their terminal hospitalization. Whether patient use of end-of-life resources differs between early and late establishment of a DNR is unknown.

OBJECTIVES

The objective of this study was to compare end-of-life resource use between patients according to DNR directive status: no DNR, early DNR (EDNR) (established before terminal hospitalization), and late DNR (LDNR) (established during terminal hospitalization).

METHODS

Electronic health records from all COPD decedents in a teaching hospital in Taiwan were analyzed retrospectively with respect to medical resource use during the last year of life and medical expenditures during the last hospitalization. Multivariate linear regression analysis was used to determine independent predictors of cost.

RESULTS

Of the 361 COPD patients enrolled, 318 (88.1%) died with a DNR directive, 31.4% of which were EDNR. COPD decedents with EDNR were less likely to be admitted to intensive care units (12.0%, 55.5%, and 60.5% for EDNR, LDNR, and no DNR, respectively), had lower total medical expenditures, and were less likely to undergo invasive mechanical ventilator support during their terminal hospitalization. The average total medical cost during the last hospitalization was nearly twofold greater for LDNR than for EDNR decedents. Multivariate linear regression analysis revealed that nearly 60% of medical expenses incurred were significantly attributable to no EDNR, younger age, longer length of hospital stay, and more comorbidities.

CONCLUSION

Although 88% of COPD decedents died with a DNR directive, 70% of these directives were established late. LDNR results in lower quality of care and greater intensive care resource use in end-of-life COPD patients.

Development and validation of nomograms for predicting survival probability of patients with advanced adenocarcinoma in different EGFR mutation status

INTRODUCTION

Molecular markers are important variables in the selection of treatment for cancer patients and highly associated with their survival. Therefore, a nomogram that can predict survival probability by incorporating epidermal growth factor receptor mutation status and treatments for patients with advanced adenocarcinoma would be highly valuable. The aim of the study is to develop and validate a novel nomogram, incorporating epidermal growth factor receptor mutation status and treatments, for predicting 1-year and 2-year survival probability of patients with advanced adenocarcinoma.

MATERIAL AND METHODS

Data on 13,043 patients between June 1, 2011, and December 31, 2014 were collected. Seventy percent of them were randomly assigned to the training cohort for nomogram development, and the remaining 30% assigned to the validation cohort. The most important factors for constructing the nomogram were identified using multivariable Cox regression analysis. The discriminative ability and calibration of the nomograms were tested using C-statistics, calibration plots, and Kaplan-Meier curves.

RESULTS

In the training cohort, 1-year and 2-year OS were 52.8% and 28.5% in EGFR(-) patients, and 73.9% and 44.1% in EGFR(+) patients, respectively. In EGFR(+) group, factors selected were age, gender, congestive heart failure, renal disease, number of lymph node examined, tumor stage, surgical intervention, radiotherapy, first-line chemotherapy, ECOG performance status, malignant pleural effusion, and smoking. In EGFR(-) group, factors selected were age, gender, myocardial infarction, cerebrovascular disease, chronic pulmonary disease, number of lymph node examined, tumor stage, surgical intervention, radiotherapy, ECOG performance status, malignant pleural effusion, and a history of smoking. Two nomograms show good accuracy in predicting OS, with a concordance index of 0.83 in EGFR(+) and of 0.88 in EGFR(-).

CONCLUSIONS

The survival prediction models can be used to make individualized predictions with different EGFR mutation status and a useful tool for selecting regimens for treating advanced adenocarcinoma.

Development of Alzheimer disease in old major depressive patients based upon their health status: A retrospective study in Taiwan

This study is conducted to investigate the association between major depressive disorder and the subsequent development of Alzheimer disease (AD) in elderly patients with different health statuses using Taiwan's National Health Insurance Research Database (NHIRD).A retrospective cohort study was performed on subjects over 65 years old from 2002 to 2006 using a random sampling from the 1 million beneficiaries enrolled in the NHI. Patients who were diagnosed with major depressive disorder were selected as the case group. Subjects in the control group were selected from elderly patients who did not have depression during the study period by matching age, sex, and index date of depression with subjects in the case group using a ratio of 1:4 (case:control). Both groups of patients were checked annually over a period of 7 years to observe whether they subsequently developed AD.A total of 1776 subjects were included in the case group while 7104 subjects were in the control group. After the follow-up period, 59 patients (3.3%) with depression developed AD while 96 patients (1.4%) without depression developed AD. The Kaplan-Meier curves showed that the incidence rate of AD in both groups varied significantly depending on different health statuses (log-rank P < .001). Results of the generalized estimating equation model found that patients with depression (hazard ratio [HR] = 1.898; 95% confidence interval [CI] = 1.451-2.438), very severe health status (HR = 1.630; 95% CI = 1.220-2.177), or artery diseases (HR = 1.692; 95% CI = 1.108-2.584) were at a higher risk of developing AD than other groups.The association between major depressive disorder and the later development of AD varied depending on the health statuses of elderly patients. Clinicians should exercise caution when diagnosing and treating underlying diseases in elderly depressed patients, and then attempt to improve their health status to reduce the incidence rate of subsequent AD development.

Effects of laparoscopic surgery on survival, quality of care and utilization in patients with colon cancer: a population-based study

OBJECTIVE

Laparoscopy is a safe and effective treatment for colon cancer. However, its effects on short- and long-term health outcomes and medical utilization are not fully elucidated. This study aimed to compare short- and long-term utilization and health outcomes of colon cancer patients who underwent either laparoscopic or open surgery in a population-based cohort.

METHODS

This study was conducted by linking data from Taiwan Cancer Registry, National Health Insurance claims and Death Registry. Patients aged 18 and older with colon cancer between 2009 and 2012 were included in the study. Propensity score matching was used to minimize selection bias between laparoscopic and open surgery groups. Cox proportional hazard regression and generalized linear mixed logistic regression were used to test hypotheses.

RESULTS

Among the 11,269 colon cancer patients who underwent colectomy, 3236 (28.72%) received laparoscopy and 8033 (71.28%) underwent open surgery. Patients who received laparoscopic surgery had better overall survival (HR = 0.82; 95% CI: 0.70-0.97). These patients also had lower 30 day mortality (0.44% vs. 0.91%), lower 1 year mortality (2.83% vs. 4.68%), lower overall occurrence of complications (6.16% vs. 8.77%), shorter mean length of stay (12.53 vs. 14.93 days) and lower cost for index hospitalization (US$4325.34 vs. US$4453.90). No significant differences were observed in medical utilization over a period of 365 days after the surgery.

CONCLUSIONS

Our results demonstrate that, in both the short- and long-term post-operation periods, laparoscopic surgery reduced the likelihood of postoperative complications, 30 day, and 1 year mortality while being no more expensive than open surgery for colon cancer.

Cost-effectiveness analysis of a fixed-dose combination of indacaterol and glycopyrronium as maintenance treatment for COPD

Objective

The aim of this study was to evaluate the cost-effectiveness of the long-acting beta-2 agonist (LABA)/long-acting muscarinic antagonist (LAMA) dual bronchodilator indacaterol/glycopyrronium (IND/GLY) as a maintenance treatment for COPD patients from the perspective of health care payer in Taiwan.

Patients and methods

We adopted a patient-level simulation model, which included a cohort of COPD patients aged ≥40 years. The intervention used in the study was the treatment using IND/GLY, and comparators were tiotropium or salmeterol/fluticasone combination (SFC). Data related to the efficacy of drugs, incidence of exacerbation, and utility were obtained from clinical studies. Direct costs were estimated from claims data based on the severity of COPD. The cycle length was 6 months (to match forced expiratory volume in 1 second [FEV₁] data), and the time horizons included 1, 3, 5, 10 years, and lifetime. Deterministic and probabilistic sensitivity analyses were conducted to test the robustness of the model results. Costs were expressed in US dollars with a discount rate of 3.0%.

Results

Compared to tiotropium and SFC, the incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) gained of patients treated with IND/GLY were US$5,987 and US$14,990, respectively. One-way sensitivity analysis revealed that the improvement in FEV₁ provided by IND/GLY, the distribution of patients with regard to the severity of COPD, and acute exacerbation rate ratio were the key drivers behind cost-effectiveness. Adopting a willingness to pay of US$60,000 per QALY gained as the threshold, there was a 98.7% probability that IND/GLY was cost-effective compared to tiotropium. Similarly, there was a 99.9% probability that IND/GLY was cost-effective compared to SFC.

Conclusion

As a maintenance treatment for COPD, we consider the dual bronchodilator IND/GLY as a cost-effective strategy when compared to either tiotropium or SFC.

Implementation of a seven-day hospitalist program to improve the outcomes of the weekend admission: A retrospective before-after study in Taiwan

Objective

Patients admitted during weekends may have worse outcomes than those during weekdays. Adjusting the practice of senior physicians over weekends may reduce the weekend effect.

Design

A controlled before-after study, with propensity score matching (PSM) for potential confounding variables, to compare outcomes between weekday and weekend admissions.

Setting

A 2000-bed medical centre in Taiwan

Participants

Hospitalised general medicine patients cared for by traditional internal medicine teams (pre-intervention cohort) and those cared for by hospitalists after introducing a seven-day hospitalist program in the first six-month (post-intervention cohort) and following three-year periods.

Main outcome measures

Proportion of intensive care unit (ICU) admissions, cardiopulmonary resuscitation (CPR) events, and in-hospital mortality.

Results

The pre-intervention cohort included 982 patients. Significantly higher mortality rates (11.3% vs. 6.2%, p = 0.032) were recorded in the case of weekend admissions, with similar proportions of ICU admission and CPR events. The post-intervention cohort included 601 patients. No significant difference was recorded in any of the main outcomes between weekday and weekend admissions. PSM for pre-intervention and post-intervention cohort showed shorter LOS after intervention, with no difference in ICU admission, CPR, and morality for the weekday and weekend admissions, respectively. The three-year cohort that followed, consisting of 3315 patients, showed no difference of outcomes between weekday and weekend admissions. After PSM, there were no significant differences in ICU admission rates (1.0% vs. 1.8%), CPR (0.3% vs. 0.2%) events and hospital mortality rates (8.1% vs. 8.5%), when weekday and weekend admissions were compared.

Conclusions

The seven-day hospitalist program shows potential in providing equally safe care for both weekday and weekend general medicine admissions with sustainable development.

Epidemiology, treatment pattern and health care utilization of myopic choroidal neovascularization: a population based study

PURPOSE

To investigate the prevalence and incidence of myopic choroidal neovascularization (CNV) in Taiwan, including the health care utilization and treatment-associated costs.

METHODS

A retrospective cohort study using existing data from the Taiwanese National Health Insurance claims database to identify patients who had a diagnosis of myopic CNV recorded from 1 January 2009 to 31 December 2011. The prevalence of myopic CNV was monitored during this period, and the frequency and cost of both treatment visits and monitoring visits were analyzed for 2 years following diagnosis.

RESULTS

The prevalence of myopic CNV was 0.017%. In total, 9068 patients with myopic CNV were identified, 12.3% (n = 1111) of whom were treated. Of those treated, 72.0% (n = 800) received intravitreal anti-vascular endothelial growth factor injections (IVI); the remainder received either photodynamic therapy with verteporfin (vPDT), laser photocoagulation, or a combination of therapies. IVI was associated with the largest number of treatment visits as well as a higher administrative (non-drug) cost per treatment visit (a mean of USD 57.18). vPDT alone was associated with a higher overall cost per treatment visit and more monitoring visits than IVI or laser photocoagulation. Costs for monitoring visits were highest for IVI.

CONCLUSIONS

The prevalence of myopic CNV was lower than that reported in previous studies, possibly because of differences in age distribution in the populations studied. The frequencies of treatment administered were similar to those reported in previous studies; however, a cost-effectiveness comparison could not be made owing to lack of data in previous studies.

Cost-effectiveness analysis of quadrivalent versus trivalent influenza vaccine in Taiwan: A lifetime multi-cohort model

A government-funded trivalent influenza vaccine (TIV) program to prevent seasonal influenza was implemented in Taiwan since 1998. However, mismatch between the vaccine and circulating strains may occur. Alternatively, a quadrivalent influenza vaccine (QIV) includes all 4 influenza lineages could minimize the risk of mismatches. Therefore, QIV could be considered as an alternative strategy to enhance protection against seasonal influenza. The objective of the study was to analyze, from a governmental perspective, the cost-effectiveness of using QIV vs. TIV as a vaccination strategy in Taiwan. A lifetime multi-cohort, static Markov model was constructed with 9 age groups to assess the costs and effectiveness of QIV vs. TIV. Direct costs were obtained from a database released by the Ministry of Health and Welfare. Outcomes included life-years gained, quality-adjusted life years (QALYs) gained, influenza cases avoided and incremental cost-effectiveness ratios (ICERs). The discount rate of costs and effectiveness was set at 3.5% and the time horizon used in the model was 100 y. Results show that a vaccination strategy utilizing QIV instead of TIV would bring an additional 10,557 QALYs at an extra cost of US$39.4 million, yielding an ICER of US$3,015.07 per QALY gained. When setting the willingness-to-pay threshold at US$10,000, compared to TIV, the probability that QIV would be cost-effective was 98%. Sensitivity analyses show that ICER was sensitive to the changes of circulation of influenza virus subtypes and vaccine mismatch. From a governmental perspective, the QIV vaccination could be considered as a cost-effective strategy within the context of public health in Taiwan.

Real-world cost-effectiveness of laparoscopy versus open colectomy for colon cancer: a nationwide population-based study

BACKGROUND

Laparoscopic colectomy is increasingly being adopted for the treatment of colon cancer; however, the long-term effectiveness of this approach in a real-world clinical setting has yet to be verified. This study aims to compare the effectiveness and costs associated with laparoscopic and open colectomy from the perspective of the National Health Insurance (NHI) system in Taiwan.

METHODS

A nationwide population-based colon cancer cohort was observed by linking the Taiwan Cancer Registry, claims data from NHI system, and the National Death Registry. Adult patients with Stage I to Stage III colon cancer who underwent primary cancer resection using either laparoscopy or open colectomy between 2009 and 2011 were included. A propensity score-matched cohort (1745 pairs) was applied to examine three clinical endpoints: overall survival, recurrence-free survival, and disease-free survival within 2 years after the operation. To comply with the perspective as well as the analytic horizon of the study, we limited the research to NHI claims from the study population for the corresponding time period. The health outcomes and net monetary benefits were verified by multivariate mixed-effect models.

RESULTS

This analysis revealed that laparoscopy resulted in longer overall survival (adjusted difference 16.8 days, 95 % CI 7.3-26.2), recurrence-free survival (16.8 days, 5.0-28.6) and disease-free survival (26.4 days, 7.4-45.4), compared to open colectomy at 2 years post-op. Laparoscopy also led to a significantly shorter length of stay (3.2 days, 2.4-3.9) and lower index hospitalization costs (US$ 455, 181-729) than open colectomy; however, no differences in costs were observed over the long term. Overall, laparoscopy was more cost-effective than open colectomy under various willingness-to-pay thresholds in the setting of the Taiwan NHI.

CONCLUSIONS

The continued adoption of laparoscopy in primary curable colon cancer resection is expected to reduce health care costs over the short term while providing considerable health benefits over the long term.

Influence of patient and provider factors on the workload of on-call physicians: A general internal medicine cohort observational study

Factors associated with the physician workload are scarcely reported. The study aims to investigate the associated factors of on-call physician workload based on a published conceptual framework.The study was conducted in a general internal medicine unit of National Taiwan University Hospital. On-call physician workloads were recorded on a shift basis from 1198 hospitalized patients between May 2010 and April 2011. The proxy of on-call workloads included night calls, bedside evaluation/management (E/M), and performing clinical procedures in a shift. Multivariable logistic and negative binomial regression models were used to determine the factors associated with the workloads of on-call physicians.During the study period, 378 (31.6%) of patients had night calls with related workloads. Multivariate analysis showed that the number of patients with unstable conditions in a shift (odds ratio [OR] 1.89 and 1.66, respectively) and the intensive care unit (ICU) training of the nurse leader (OR 2.87 and 3.08, respectively) resulted in higher likelihood of night calls to and bedside E/M visits by the on-call physician. However, ICU training of nurses (OR = 0.37, 95% confidence interval: 0.16-0.86) decreased the demand of performing clinical procedures by the on-call physician. Moreover, number of patients with unstable conditions (risk ratio [RR] 1.52 and 1.55, respectively) had significantly increased the number of night calls and bedside E/M by on-call physicians by around 50%. Nurses with N1 level (RR 2.16 and 2.71, respectively) were more likely to place night calls and facilitate bedside E/M by the on-call physician compared to nurses with N0 level. In addition, the nurse leaders with ICU training (RR 1.72 and 3.07, respectively) had significant increases in night calls and bedside E/M by the on-call physician compared to those without ICU training.On-call physician workload is associated with patient factors and the training of nurses. Number of unstable patients in a shift may be considered in predicting workload. The training of nurses may improve patient safety and decrease demand for clinical procedure.

Accessibility of ophthalmic healthcare for residents of an offshore island-an example of integrated delivery system

Background

To assess the utilization of and satisfaction with ophthalmic healthcare provided by integrated delivery system (IDS) since 2000 and vision-related quality of life (VRQoL) for residents of an offshore island of Taiwan.

Methods

Facilitators interviewed residents (age ≥ 50 years) with the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) for VRQoL and a questionnaire on clinical information, ophthalmic care utilization and satisfaction.

Results

A total of 841 participants (response rate 93.4 %, 841/900) completed the questionnaire survey. Mean age was 63.7 (±10. 7) years. The common eye diseases were cataract (44.7 %), dry eye (15.5 %), and glaucoma (8.7 %). Among the participants, 61.0 % sought ophthalmic care under the IDS in the past year and 17.6 % experienced unmet ophthalmic needs in the past 6 months. Satisfaction with ophthalmic care under the IDS was 88.1 %. Determinants of dissatisfaction under the IDS were distance to healthcare facility and VRQoL. Predictors of VRQoL included age, residential area, marital status, occupation, comorbid condition, commercial insurance, household income, cataracts and glaucoma.

Conclusions

The implementation of IDS improves accessibility of ophthalmic care for residents of an offshore island. Geographic proximity to avail healthcare facility and VRQoL affect satisfaction with the IDS.

Shorter Door-to-Balloon Time in ST-Elevation Myocardial Infarction Saves Insurance Payments: A Single Hospital Experience in Taiwan

BACKGROUND

The relationship between quality of care and cost of medical services is a popular topic. In this study, we examined whether a reduced door-to-balloon (D2B) time led to cost savings, benefitted insurance payers, and improved patient outcomes.

METHODS

We retrospectively enrolled consecutive patients who presented with ST-segment elevation myocardial infarction (STEMI) and received primary percutaneous coronary intervention (PCI) between Feb. 1, 2007, and Jul. 31, 2009, at a tertiary hospital in Taiwan. The patient data were collected by chart review. We utilized claims data from the hospital financial system as the proxy for insurance payer costs. We only included the claims data, regardless of whether patients were inpatients or outpatients, associated with the first three cardiovascular related ICD-9 codes. Multivariable logistic regression was used to examine the relationships between the D2B time, in-hospital mortality and one-year cardiovascular readmission. We utilized a multivariable linear regression to test the relationships between the D2B time, hospitalization cost and one-year cardiovascular-related cost.

RESULTS

The D2B time did not influence the in-hospital mortality rate, but a D2B time greater than 90 min increased the probability of one-year cardiovascular readmission (p = 0.018). The D2B time did not increase the index hospitalization cost, but patients with a D2B time above 90 min had 14.6% higher one-year cardiovascular- related costs.

CONCLUSIONS

Our study shows that the D2B time in patients with STEMI could impact the one-year cardiovascular readmission and one-year cardiovascular-related health cost. These results suggest that the pursuit of high-quality care not only leads to better outcomes, but also reduces costs.

KEY WORDS

Acute myocardial infarction; Cost; Door-to-balloon time; Insurance payer; Quality.

Disease burden of enterovirus infection in Taiwan: Implications for vaccination policy

OBJECTIVES

This study aimed to assess the disease burden and economic impacts of human nonpolio enteroviruses (NPEV) and enterovirus A71 (EV-A71) infection in Taiwan.

MATERIALS AND METHODS

We included children under five years old (n=983,127-1,118,649) with ICD-9-CM codes 0740 (herpangina) or 0743 (hand-foot-and-mouth disease) from the 2006 to 2010 National Health Insurance Database. Severity of enterovirus infection was assessed from outpatient/emergency visits, hospitalization (with/without intensive care unit [ICU] admission), infection with severe complications, and death. We estimated medical costs and indirect costs from the societal perspective.

RESULTS

The annual rates of NPEV events for children under five years old ranged from 13.9% to 38.4%, of which 5.1-8.8% were hospitalized. EV-A71 accounted for 7.8% of all NPEV medical costs, but 79.1% of NPEV ICU costs. Travel costs and productivity loss of caregivers were $37.1 (range: $24.5-$64.7) million per year. These costs were not higher in the EV-A71 dominant year ($34.4 million) compared with those in the other years. Productivity losses resulting from premature mortality by NPEV infection were $0.8 (range: $0.0-$2.9) million per year, of which 96.3% were caused by EV-A71.

CONCLUSIONS

Diseases associated with NPEV other than EV-A71 were responsible for most of the medical expenses. In addition, caregiver productivity loss by high rates of NPEV infection impacted the society much more than medical costs. A multi-valent vaccine that includes EV-A71 and other serotypes, for example coxsackievirus A16, may be beneficial to the health of children in Taiwan.

Therapeutic inertia and intensified treatment in diabetes mellitus prescription patterns: A nationwide population-based study in Taiwan

Objective

To measure therapeutic inertia by characterizing prescription patterns using secondary data obtained from the nationwide diabetes mellitus pay-for-performance (DM-P4P) programme in Taiwan.

Methods

Using reimbursement claims from Taiwan’s National Health Insurance Research Database, a nationwide retrospective cohort study was undertaken of patients with diabetes mellitus who participated in the DM-P4P programme from 2006–2008. Glycosylated haemoglobin results were used to evaluate modifications in therapy in response to poor diabetes control. Prescription patterns were used to assign patients to either a therapeutic inertia group or an intensified treatment group. Therapeutic inertia was defined as the failure to act on a known problem.

Results

The research sample comprised of 168 876 patients with diabetes mellitus who had undergone 899 135 tests. Of these, 37.4% (336 615 visits) of prescriptions were for a combination of two types of drug and 27.7% (248 788 visits) were for a combination of three types of drug. The proportion of patients in the intensified therapy group who were prescribed more than two types of drug was considerably higher than that in the therapeutic inertia group.

Conclusion

In many cases in the therapeutic inertia group only a single type of hypoglycaemic drug was prescribed or the dosage remained unchanged.

Comparing the effectiveness of capecitabine versus 5-fluorouracil/leucovorin therapy for elderly Taiwanese stage III colorectal cancer patients based on quality-of-life measures (QLQ-C30 and QLQ-CR38) and a new cost assessment tool

Background

Colorectal cancer (CRC) is a leading cause of cancer-related deaths in developed countries and its incidence increases with age. Intravenous administration of bolus 5-fluorouracil (5-FU) and leucovorin (LV) has been a standard treatment regime for stage III CRC. However, patients generally prefer oral therapy such as Capecitabine. Studies showed that combination of oxaliplatin and capecitabine demonstrated efficacy and safety on par with treatment involving various 5-FU/LV-based regimens in elderly patients as they are in younger ones. However, little is known regarding the cost of adjuvant therapy or the effect of therapy on HRQoL. Thus the aims of this study were to evaluate the influence of different adjuvant care for stage III CRC on the HRQoL of elderly patients and to compare the economic costs associated with capecitabine-based and 5-FU/LV-based adjuvant treatments from a societal perspective in Taiwan.

Methods

A prospective, open-label, observational, multicenter study involving 123 patients aged 70 and over from 11 different centers was conducted between July 2008 and July 2011 in Taiwan. The adjusted monthly costs per patient and HRQoL were evaluated from individual-level data. The HRQoL of patients was assessed before and after adjuvant treatment. Direct and indirect costs of adjuvant treatment were estimated from a number of sources, and QoL scores were compared between groups.

Results

After correcting for baseline characteristics of patients, no significant differences were observed in the global HRQoL scores between treatment groups during the study period. According to QLQ-CR38 results, capecitabine-based therapy appeared to alleviate problems related to defecation (4.54 vs. 8.5; P = 0.011); however, micturition problems increased (9.27 vs. 7.51; P = 0.04), compared with 5-FU/LV-based treatment. The adjusted monthly treatment cost per patient was NT$27,300 for capecitabine-based treatment and NT$53,671 for 5-FU/LV-based treatment. The total cost of 5-FU/LV-based treatment was 59 % greater than that of capecitabine-based treatment.

Conclusions

Analyzing from the societal perspective in Taiwan, capecitabine-based therapy incurred lower treatment costs than 5-FU/LV-based therapy and did not jeopardize HRQoL. Therefore, capecitabine, with or without oxaliplatin, could be considered as an alternative treatment option for elderly patients with stage III CRC.

Web-based and telephone surveys to assess public perception toward the national health insurance in taiwan: a comparison of cost and results

Background

Numerous studies have examined the impact of global budget payment systems of health insurance on patient access to medical care. In order to monitor the population’s accessibility to health services, a series of survey are often used to understand public perceptions of the health care provider. Taiwan implemented the single-payer National Health Insurance in 1995 and has been conducting a series of surveys to monitor public perception of the NHI after adopting a global budget payment system in 2002. Although telephone surveys are commonly used in obtaining public opinions on various public health issues, limitations such as higher cost and influence of interviewers do raise some concerns. Web-based surveys, one of the alternative methods, may be free from these problems.

Objective

Our aim was to examine the difference of sociodemographic characteristics, satisfaction of NHI and NHI-contracted health care providers, attitude toward NHI-related issues, behavior in seeking medical advice and self-reported health status between those who completed Web-based surveys and those reached by telephone.

Methods

This study compared the demographic factors of participants who took either a Web-based survey (1313 participants) or random digit dialing telephone survey (2411 participants) that contained identical questions.

Results

Compared to telephone survey respondents, Web-based respondents tended to be younger (P<.001), unmarried (P<.001), non-smokers (P<.001), with a higher education (P<.001), and a higher monthly household income (P<.001) and worse self-reported health status (P=.008); however, they were less likely to report suffering from a chronic disease (P<.001). Despite these differences in background characteristics, no significant differences were observed in their answers related to the seeking of medical care or NHI-related issues. Telephone survey respondents reported greater satisfaction with NHI services. Web-based surveys were also shown to provide a lower average cost per sample (US$0.71) compared to telephone surveys (US$3.98).

Conclusions

Web-based surveys provide a low-cost alternative method for the polling of public attitudes toward NHI-related issues. Despite general similarities between the two polling methods with regard to responses, respondents to telephone surveys reported a stronger agreement with regard to satisfaction with NHI services and a more positive self-reported health status.

Patient severity matters for night-shift workload for internal medicine residents in Taiwan

Background

Although work hour is an important factors for resident workload, other contributing factors, such as patient severity, with regards to resident workload have been scarcely studied.

Methods

A prospective observational cohort study was conducted in a general medicine unit in an academic medical center in Taiwan. Every event for which the nurses needed to call the on-call residents was recorded. To quantify the workload, the responses of on-duty residents to calls were analyzed. To allow comparisons of patient factors to be made, we classified all patients by assigning them stable, unstable, or do-not-resuscitate (DNR) codes. The reasons for the calls were categorized to facilitate the comparisons across these three groups.

Results

From October 2009 to September 2011, a total of 2,518 patients were admitted to the general medicine unit. The nurses recorded a total of 847 calls from 730 call nights, ranging from 0 to 7 per night. Two peaks of calls, at 0-2 am and 6-7 am, were noted. Calls from stable, unstable, and DNR patients were 442 (52.2%), 95 (11.2%), and 298 (35.2%), respectively. For both unstable and DNR patients, the leading reason was abnormal vital signs (62.1% and 67.1%, respectively), while only 36.2% for stable patients. Both unstable and DNR patients required more bedside evaluation and management compared to stable patients.

Conclusion

Beyond work hours and patient census, patients with different clinical severity and palliative goal produce different workload for on-call residents.

A randomized controlled trial of clinic-based and home-based interventions in comparison with usual care for preterm infants: effects and mediators

This study examined the effects and mediators of a clinic-based intervention program (CBIP) and a home-based intervention program (HBIP) compared with usual care in very-low-birth-weight (VLBW) preterm infants on developmental and behavioral outcomes at 24 months of age (corrected for prematurity). In this randomized controlled trial, VLBW preterm infants received either CBIP (n=57), HBIP (n=63), or usual care (n=58) from hospitalization to 12 months. At 12 months, infant emotional regulation was assessed using the toy-behind-barrier procedure and dyadic interaction was observed during free play. At 24 months, infant developmental and behavioral outcomes were assessed using the Bayley Scales of Infant and Toddler Development- 3rd edition and the Child Behavior Checklist for Ages 1.5-5, respectively. Compared with infants under usual care, the CBIP-group infants showed higher cognitive composite scores (difference, 95% confidence interval (CI)=4.4, 0.8-7.9) and a lower rate of motor delay (odds ratio (OR), 95% CI=0.29, 0.08-0.99); the HBIP-group infants had lower sleep problem scores (difference, 95% CI=-1.4, -2.5 to -0.3) and a lower rate of internalizing problems at 24 months (OR, 95% CI=0.51, 0.28-0.93) (all p<.05). The CBIP's effect on cognitive outcome was attenuated when maternal or dyadic interactive behavior was considered; whereas the HBIP's effect on sleep and internalizing behavior was attenuated when duration of orientation to a toy or object was considered. In conclusions, interventions enhanced the cognitive, motor, and behavioral outcomes of VLBW preterm infants. The effects on cognitive and behavioral outcomes might be mediated by early-improved mother-infant interaction and infant emotional regulation, respectively.

Cost-effectiveness comparison between monofocal and multifocal intraocular lens implantation for cataract patients in Taiwan

PURPOSE

Our aim was to conduct a cost-effectiveness analysis (CEA) of monofocal and multifocal intraocular lenses (IOLs) for cataract patients in Taiwan.

METHODS

This prospective nonrandomized study was designed to evaluate the effectiveness of monofocal and multifocal IOLs by means of visual performance, visual quality, vision-related quality of life, and spectacle-independence rates. The direct costs were calculated using the payment points of the fee schedule for medical services multiplied by the treatment items. The concept of incremental cost effectiveness ratios was used to evaluate the costs of different types of IOLs in cataract surgery and postoperative outcomes in patients.

FINDINGS

A total of 61 patients from the monofocal IOL group (n = 21), multifocal IOL group 1 (n = 22), and multifocal IOL group 2 (n = 18) who completed the study were included in the analysis. No significant differences were observed in mean ages or patient to eye ratio. Significant differences in effectiveness after the implantations of monofocal and multifocal IOLs were observed for spectacle-free rate and monocular contrast sensitivity under glare conditions only. The incremental cost-effectiveness ratios of monofocal versus multifocal IOLs indicated that it cost an additional $57 to $58 (US dollars) to increase each 1% of the spectacle-independence rate.

IMPLICATIONS

This study's results indicated that multifocal IOLs provided better effectiveness on vision-related indicators like the incremental cost effectiveness ratios of postoperative spectacle-independence rate and binocular best-corrected visual acuity measurements at near vision. Our findings suggest that multifocal IOLs can be highly cost effective for patients who prefer to be spectacle free, so it is important to ensure that patients have realistic expectations when making choices between monofocal and multifocal IOLs.

Patient empowerment in a hand hygiene program: differing points of view between patients/family members and health care workers in Asian culture

BACKGROUND

"Patient empowerment" is an important component of World Health Organization hand hygiene program, but little is known about the intentions and attitude of patients/families and health care workers (HCWs) regarding this.

METHODS

A cross-sectional survey using questionnaires was conducted in a tertiary teaching hospital in Taiwan to assess hand hygiene knowledge and the attitudes and intentions regarding patient empowerment among patients/families and HCWs.

RESULTS

Among patients/families, 95.4% (329/345) had positive attitudes regarding patient empowerment; however, only 67.2% (232/345) had the positive intention to remind HCWs about hand hygiene (P < .001). Risk factors for negative intention were being female (odds ratio [OR], 1.82; 95% confidence interval [CI]: 1.08-3.03), illiteracy (OR, 3.18; 95% CI: 0.86-11.7), and being patients/families in the pediatric department (OR, 1.86; 95% CI: 0.93-3.64). Among HCWs, the difference between positive attitude (81.1%; 714/880) and positive intention regarding being reminded about hand hygiene (62.8%; 553/880) was significant (P < .001). Risk factors for negative intention were age > 25 years (OR, 3.20; 95% CI: 1.51-6.81) and a negative attitude toward patient empowerment (OR, 10.00; 95% CI: 5.88-16.67).

CONCLUSION

There were significant gaps between attitude and intention regarding patient empowerment both among patients/families and HCWs. Special strategies targeting women, the pediatric population, or illiterate people may help improve patient/family participation. Additionally, hand hygiene education should be incorporated into early-stage medical/nursing education to create a facilitating environment. Patients/families and HCWs cooperation is needed to promote the hand hygiene program further.

Demand and predictors for post-discharge medical counseling in home care patients: a prospective cohort study

Rationale

Post-discharge care is challenging due to the high rate of adverse events after discharge. However, details regarding post-discharge care requirements remain unclear. Post-discharge medical counseling (PDMC) by telephone service was set-up to investigate its demand and predictors.

Methods

This prospective study was conducted from April 2011 to March 2012 in a tertiary referral center in northern Taiwan. Patients discharged for home care were recruited and educated via telephone hotline counseling when needed. The patient’s characteristics and call-in details were recorded, and predictors of PDMC use and worsening by red-flag sign were analyzed.

Results

During the study period, 224 patients were enrolled. The PDMC was used 121 times by 65 patients in an average of 8.6 days after discharge. The red-flag sign was noted in 17 PDMC from 16 patients. Of the PDMC used, 50% (n = 60) were for symptom change and the rest were for post-discharge care problems and issues regarding other administrative services. Predictors of PDMC were underlying malignancy and lower Barthel index (BI). On the other hand, lower BI, higher adjusted Charlson co-morbidity index (CCI), and longer length of hospital stay were associated with PDMC and red-flag sign.

Conclusions

Demand for PDMC may be as high as 29% in home care patients within 30 days after discharge. PDMC is needed more by patients with malignancy and lower BI. More focus should also be given to those with lower BI, higher CCI, and longer length of hospital stay, as they more frequently have red flag signs.

Can cancer patients seeking a second opinion get better care?

OBJECTIVES

To investigate whether cancer patients who sought a second opinion received better medical care.

STUDY DESIGN

A total of 1358 newly diagnosed colorectal cancer patients undergoing resection were identified from Taiwan's National Health Insurance Research Database between 2004 and 2008. The frequency of doctor shopping and hospital shopping in the 6 months before resection was used to define "seeking a second opinion."

METHODS

A generalized hierarchical linear model was used to determine the influence of doctor shopping and hospital shopping on in-hospital complications and prolonged hospitalization after colorectal resection.

RESULTS

The risk of in-hospital complications for heavy doctor shoppers was significantly higher than that for patients who were not doctor shoppers (odds ratio [OR] = 1.675, P = .037). However, the risk was significantly lower for heavy hospital shoppers compared with those who were not hospital shoppers (OR = 0.272, P = .007). The frequency of doctor shopping and hospital shopping was not significantly associated with prolonged hospitalization.

CONCLUSIONS

For colorectal resection patients, the selection of a proper hospital for surgery resulted in better surgical care. The quality of surgical care was worse with heavy doctor shopping. We suggest that healthcare authorities disclose data about the quality of a hospital's cancer treatment to increase patient access to such information. This may help patients find quality healthcare providers more quickly and reduce the waste of medical resources resulting from the long process of seeking medical care.

Evaluation of clinically significant adverse events in patients discharged from a tertiary-care emergency department in Taiwan

OBJECTIVE

To investigate the reasons for the occurrence of clinically significant adverse events (CSAEs) in emergency department-discharged patients through emergency physicians' (EPs) subjective reasoning and senior EPs' objective evaluation.

DESIGN

This was a combined prospective follow-up and retrospective review of cases of consecutive adult non-traumatic patients who presented to a tertiary-care emergency department in Taiwan between 1 September 2005 and 31 July 2006. Data were extracted from 'on-duty EPs' subjective reasoning for discharging patients with CSAEs (study group) and without CSAEs (control group)' and 'objective evaluation of CSAEs by senior EPs, using clinical evidences such as recording history, physical examinations, laboratory/radiological examinations and observation of inadequacies in the basic management process (such as recording history, physical examinations, laboratory/radiological examinations and observation) as the guide'. Subjective reasons for discharging patients' improvement of symptoms, and the certainty of safety of the discharge were compared in the two groups using χ(2) statistics or t test.

RESULTS

Of the 20,512 discharged cases, there were 1370 return visits (6.7%, 95% CI 6.3% to 7%) and 165 CSAEs due to physicians' factors (0.82%, 95% CI 0.75% to 0.95%). In comparisons between the study group and the control group, only some components of discharge reasoning showed a significant difference (p<0.001). Inadequacies in the basic management process were the main cause of CSAEs (164/165).

CONCLUSION

The authors recommended that EP follow-up of the basic management processes (including history record, physical examination, laboratory and radiological examinations, clinical symptoms/signs and treatment) using clinical evidence as a guideline should be made mandatory.

Association of treatment and outcomes of doctor-shopping behavior in patients with hepatocellular carcinoma

BACKGROUND

A variety of unfulfilled needs may trigger doctor-shopping behavior (DSB) in patients. In oncology, treatment results usually cause patients the most concern. This study investigated the association of DSB with active treatments received by patients with hepatocellular carcinoma (HCC) and outcomes.

METHODS

With approval from the institutional review board, all patients registered in the cancer database of a teaching hospital and diagnosed as having HCC by self-referral from outside hospitals or by in-house diagnosis were retrospectively identified. Patient data were then reviewed and analyzed via electronic medical records.

RESULTS

Hepatitis B carriers were significantly more likely than noncarriers to show first-time DSB. Recurrent disease was less likely to result in DSB than predicted. Patients from outside hospitals not receiving upfront first treatment after diagnosis were significantly more likely to show more frequent DSB than those receiving it. Male patients eligible for salvage treatment were less likely to have frequent occurrences of DSB than their female counterparts. Receiving first salvage treatment was not associated with more frequent DSB. Treatment recommendations offered in the study hospital did not influence patients' decisions to leave or stay. Only elderly patients (>70 years) were less likely to show DSB.

CONCLUSION

DSB can occur throughout the entire course of treatment for HCC for a variety of reasons. Active treatments, disease status, and patient characteristics all exerted an influence on DSB.

Why do general medical patients have a lengthy wait in the emergency department before admission?

BACKGROUND/PURPOSE

Emergency department (ED) overcrowding is a universal problem, especially with the shortage of hospital beds. We studied the characteristics and outcomes of patients with prolonged ED stays, which has rarely been studied before.

METHODS

We conducted a retrospective study at a tertiary medical center in Taiwan. Prolonged stay in the ED was defined as a stay of more than 72 hours in the ED before admission. The medical records were reviewed for data analysis.

RESULTS

From November 1, 2009 to January 31, 2010, a total of 1364 general medical patients were enrolled. The mean age was 66.4 ± 17.8 years, with 53.4% male. The mean Charlson Comorbidity Index (CCI) was 3.0 ± 3.1. The mean length of ED stay was 43.9 ± 41.0 hours. The CCI (4.1 ± 3.5 vs. 2.8 ± 3.0, p < 0.001) and do-not-resuscitate (DNR) rates (18.8% vs. 10.3%, p = 0.001) of the patients with prolonged ED stays were higher than those of the patients with shorter stays. For patients with high CCI (≥3) and DNR consent, the odds ratio of prolonged ED stay was 1.73 and 1.60, respectively. Patients with prolonged ED stays also had a lower Barthel index (60.3 ± 34.8 vs. 66.4, p = 0.011) and higher in-hospital mortality (11.6% vs. 6.0%, p = 0.006).

CONCLUSION

Complex comorbidities and terminal conditions with DNR consent were associated with the prolonged ED stay for general medical patients. The hospital manager should pay attention to general medical patients with multiple comorbidities as well as those who require palliative care.

Noncancer Palliative Care

Little is known about the picture of patients receiving palliative care in the acute care setting. The study was conducted in a medical center in Taiwan. Cancer palliative care (CPC) was performed for terminal do-not-resuscitate (DNR) patients with advanced cancers. Noncancer palliative care (NCPC) was performed for DNR patients who did not fulfill the criteria of CPC. Of the 1379 consecutive admissions, 258 patients were identified, with 193 (74.8%) requiring NCPC and 65 (25.2%) requiring CPC. The NCPC patients were older and had lower Charlson comorbidity index (2.6 vs 8.6, P < .001) than CPC patients and had poorer consciousness and more organ failure than CPC patients when recognized. Many noncancer patients without access to specialist palliative care services were treated in the acute care setting with delayed recognition.

A multilevel analysis of regional and individual effects on methadone maintenance treatment in Taiwan

OBJECTIVE

This study evaluated the direct and interactive effects of regional-level and individual-level characteristics on methadone maintenance treatment (MMT), after considering the individual characteristics in Taiwan.

METHODS

This study utilized a survey research method. Opioid-dependent patients who participated in the outpatient MMT program in 2009 and met the eligibility criteria were recruited from five hospitals. The impact of MMT on self-perceived health was assessed by using questionnaires. This study assessed the participants' quality of life and treatment outcomes during 3-month follow-up visits, before evaluating the direct effects of regional and individual characteristics. Multilevel linear models were used to estimate whether regional levels influenced individual behavior and treatment outcomes.

RESULTS

Three hundred thirty-four opioid-dependent patients agreed to participate in this study. After the follow-up period, 127 participants completed the study (completion rate = 38%). Participants receiving MMT demonstrated significant improvements in psychological state, HIV risk-taking behavior, social functioning, and health. Regional characteristics, such as the lower than junior high school rate, low-income family rate, and related crime rates, of the study regions were negatively associated with improvements in drug abuse behavior.

CONCLUSIONS

This study shows that MMT can significantly improve the HIV risk-taking behavior and health of the study participants. Disadvantaged regions, however, exhibit poor treatment outcomes. This study suggests actions to minimize the treatment variations between regions.

A model to personalize scheduling of complex prescriptions

Medication adherence tends to affect the recovery of patients. Patients having poor medication adherence show a worsening of their condition and/or increased complications. Unfortunately, between 20% and 50% of chronic patients are unable to manage their medications. This study proposes a model to improve the patients' medication compliance by reducing medication frequency. Published studies have shown that, based on the patients' lifestyle, simplification of the medication frequency and remodeling of the medication schedule is able to help improve medication adherence. Therefore, this study tried to simplify medication frequency by combining therapies. Moreover, by adjusting according to lifestyle, the study also tries to remodel medication timing in relation to mealtimes to create personal medication schedules. In this study, we used 19,393,452 outpatient prescriptions from the National Health Insurance Research Database to verify our system (algorithm optimized). At the same time, we examined the differences between the frequency summarized by general public and experts' advice medication behavior. Compared with the experts' advice method, this system has reduced the medication frequency in about 49% of prescriptions. Using combined medication to simplify medication frequency is able to reduce the medication frequency significantly and improve medication adherence. Furthermore, this should also improve patient recovery, reduce drug hazards and result in less drug wastage.

Pharmacoeconomic analysis of capecitabine versus 5-fluorouracil/leucovorin as adjuvant therapy for stage III colon cancer in Taiwan

OBJECTIVES

To assess the cost-effectiveness of oral capecitabine compared with intravenous bolus 5-fluorouracil/leucovorin (5-FU/LV) in the adjuvant treatment of stage III colon cancer in Taiwan from payer (Bureau of National Health Insurance [BNHI]) perspectives.

METHODS

A health state-transition model was developed to estimate the incremental costs and effectiveness of capecitabine versus 5-FU/LV. The time horizons studied were: treatment duration (24 weeks) plus 36 months, 48 months, 60 months, 120 months, and lifetime. Costs were expressed in Taiwanese new dollars (NT$). Clinical outcomes, medical resource use, and utilities were extracted from published sources. Unit costs were estimated from BNHI fee schedules, published sources, and local expert opinion. Outcomes and future costs were discounted at 3%. Cost-effectiveness was expressed as cost per quality-adjusted life-month (QALM). The effects of uncertainty were explored through a one-way sensitivity analysis.

RESULTS

For the 24-week time period, drug acquisition costs were higher for capecitabine than 5-FU/LV (NT$114,405 vs. NT$4,904 per patient); however, these were offset by the higher administration costs of 5-FU/LV (NT$2,573 vs. NT$204,201 per patient). Overall direct costs for the 24-week treatment period were less with capecitabine than 5-FU/LV (NT$129,327 vs. NT$233,873 per patient). Cost savings with capecitabine were also evident when longer time horizons were considered. Over a lifetime, the projected survival benefit for capecitabine was 7 QALMs.

CONCLUSIONS

From the perspectives of the BNHI and society in Taiwan, capecitabine not only saves costs but also improves health outcomes compared with 5-FU/LV in the adjuvant treatment of stage III colon cancer.

Application of data mining on the development of a disease distribution map of screened community residents of Taipei county in Taiwan

This study used data mining techniques to investigate disease forms in various administrative areas and to analyze the differences among various administrative areas in order to further draw up a disease distribution map. It is hoped that may help formulate future public health strategies and to allocate medical resources more appropriately. The major disease forms for residents under the age of 60 were hypertension, hyperglycemia and hyperlipidemia. In regard to the neighboring areas, three neighboring areas, A1, A3, and B9, shared the same disease problems with A4, A5, and B3, while two mountain-area cities, B7 and C10, experienced higher instances of liver function impairment. In terms of the clustering phenomenon among municipally graded administrative areas, the major health problems in Grade A cities were hypertension, hyperglycemia, and hyperlipidemia. The health problems such as liver function impairment and renal dysfunction were more frequently observed in Grade B and Grade C cities.

The use of statistical process control (risk-adjusted CUSUM, risk-adjusted RSPRT and CRAM with prediction limits) for monitoring the outcomes of out-of-hospital cardiac arrest patients rescued by the EMS system

OBJECTIVE

Based on previous experience from surgical surveillance, risk-adjusted cumulative sum (CUSUM)-type charts were applied to monitor out-of-hospital cardiac arrest (OHCA) patient mortality.

MATERIALS AND METHODS

Data from 2356 OHCA patients were collected by the Taipei County Fire Bureau from June 2006 to November 2007. Logistic regression analysis was applied to create a risk-adjusted model. Next, a risk-adjusted CUSUM chart, a risk-adjusted resetting sequential probability ratio test chart and a cumulative risk-adjusted mortality with prediction limits chart were used to detect excess deaths of the OHCA patients rescued by the emergency medical service (EMS) system.

RESULTS

The overall mortality rate, defined as having no return of spontaneous circulation, was 79.3%. These three charts signalled an increase in the death rate at similar sites, and also suggested a small process shift.

CONCLUSION

A visual approach to EMS systems monitoring that combines the risk-adjusted cumulative sum, Risk-adjusted resetting sequential probability ratio test and cumulative risk-adjusted mortality with prediction limits charts was established. It was found that this approach can be effectively used by the EMS community to monitor OHCA outcomes in real time.

Total pharyngolaryngectomy and voice reconstruction with ileocolon free flap: functional outcome and quality of life

Total pharyngolaryngectomy (PL) reconstruction with an ileocolon free flap not only restores swallowing but also provides potential for speech. We report our surgical technique, functional outcome and quality of life (QoL) of 17 (15 males and two females) patients who underwent total PL/voice reconstruction with an ileocolon free flap between 2004 and 2009. The patients were retrospectively reviewed and swallowing, speech and QoL evaluated. Speech intelligibility was assessed using Hirose and Chen scoring systems, in addition to sound spectrogram analysis. QoL was evaluated using the European Organisation for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30) in conjunction with the disease-specific Head & Neck Cancer Module (QLQ-H&N35). The mean age of patients was 49 (range 35-69) years and the mean follow-up period was 22 (range 6-72) months. There was one partial flap failure and another flap was successfully salvaged. Swallowing function was achieved by 16 (94%) patients at 4 weeks, whilst 12 (71%) demonstrated moderate-to-excellent speech intelligibility. There were no cases of aspiration pneumonia. QLQ-C30 global QoL and functional subscales indicated patients had average-to-good functioning. Comparison of QLQ-H&N35 scores with EORTC reference values indicated our patients had greater difficulty with social contact, mouth opening and weight gain. Total PL/voice reconstruction with the ileocolon free flap is a viable option in selected patients, who desire autologous voice reconstruction. A low complication rate and reasonable QoL support this reconstructive method.

Psychological profile of Taiwanese female cosmetic surgery candidates: understanding their motivation for cosmetic surgery

BACKGROUND

Psychological processes consisting of body image and self-esteem are considered key to the motivation for cosmetic surgery (CS). The current study aimed to investigate such processes as well as social support, perception of other people's opinion, and sex life satisfaction of Taiwanese female CS candidates. Further analyses were conducted to identify which processes predicted motivation for CS.

METHOD

Questionnaires comprising subscales of the Multidimensional Body-Self Relations Questionnaire, the Rosenberg Self-Esteem Scale, the Perception of Other Peoples' Opinion Scale, and social support and sex life questions were completed by Taiwanese female CS candidates (n = 85) preoperatively. The results were compared with those for a sex-matched nonsurgical control group (n = 105) as well as previously published data and reference norms. Correlation and multiple regression analysis also was conducted to identify any relationship between variables as well as which variable best predicted the likelihood of a patient having surgery.

RESULTS

A total of 29 CS candidates (34.1%) reported before their surgical consultation that they would "very likely" or "likely" have CS, and 54 (63.5%) received support from all three social groups, namely, family, friends, and partner. The body image (appearance evaluation, orientation, and body area satisfaction) of the CS candidates was not significantly different from that of the control group. The former had significantly higher self-esteem and perception of other people's opinion scores. Self-esteem was positively correlated with appearance evaluation (r = 0.484; p < 0.01) and body area satisfaction (r = 0.494; p < 0.01). Body area satisfaction had a fair degree of negative correlation with the likelihood of having CS (r = -0.413; p < 0.01). Regression analysis indicated that only body area dissatisfaction predicted the likelihood of having CS, accounting for 29.4% of the total variance.

CONCLUSIONS

The results of this study indicate that the Taiwanese female CS candidates did not have higher body image dissatisfaction or greater body image investment than the control group. However, body area dissatisfaction was the only significant predictor for the likelihood of having CS, a feature not previously recognized in Asian CS candidates. The higher self-esteem of the CS candidates opposes the view that low self-esteem is a principal motivating factor for CS.

Correlation of visual function with health-related quality of life in glaucoma patients

OBJECTIVES

The purpose of this study was to assess visual impairment and quality of life (QOL), the relationship between visual function and health-related and vision-related QOL, and to identify factors significantly impacting QOL for glaucoma patients.

METHODS

One-on-one interviews of 280 glaucoma patients at a regional hospital in Taiwan from 1 April 2005 to 30 September 2005. Data collected included demographics, clinical examinations and treatment status. QOL data collected utilized the Chinese (Taiwanese) version of the Medical Outcomes Study Short-Form 36 Health Survey (SF-36) and the National Eye Institute Visual Function-25 (NEIVFQ-25).

RESULTS

The majority of study participants had open-angle glaucoma (54.3%) and were classified as moderate stage (33.6%). The higher the health-related QOL scores for both questionnaires, the fewer difficulties experienced by the patients. Moderate correlation was found between the SF-36 and NEIVFQ-25 subscales and visual function. Significant predicting factors for the SF-36 were gender, age, employment status, presence of systemic disease, better-eye visual acuity and better-eye mean defect. For the NEIVFQ-25, these were general vision, near and distance activities, colour vision and peripheral vision scores.

CONCLUSIONS

A combination of demographic data, clinical examination and QOL questionnaires may help clinicians better ascertain the impact of disease severity on glaucoma patients' QOL. This information may help in patient education, treatment compliance and selection of treatment options.

Continuity of diabetes care is associated with avoidable hospitalizations: evidence from Taiwan's National Health Insurance scheme

OBJECTIVE

Taiwan's health-care system allows patients to utilize specialty services without referrals by primary care providers. This discontinuity of care may lead to increases in future hospitalizations. This study aims to determine whether the discontinuity of care is associated with the risk of hospitalization.

DESIGN

A secondary data analysis based on a claim data of a nationally representative random sample of diabetic patients in Taiwan. A usual provider continuity (UPC) index was developed-a ratio of the visits to the physician that subjects most usually see relevant to diabetes care to the total physician visits relevant to diabetes care-to investigate its association with the risk of hospitalization.

SETTING

Taiwan's National Health Insurance scheme from 1997 through 2002.

PARTICIPANTS

Totally 6476 diabetic patients. INTERVENTION(s) None. MAIN OUTCOME MEASURE(s) Diabetes-related short-term and long-term ambulatory care sensitive condition (ACSC) admissions.

RESULTS

Patients with ACSC admissions had significantly lower UPC scores compared with those without ACSC admissions. Using a Cox regression model that controlling for age, sex, severity of diabetes and the number of total visits, patients with low to medium continuity of care (UPC <0.75) were found to be significantly associated with increased risk of hospitalization as compared with patients with high continuity of care, especially for long-term ACSC admissions (relative risk: 1.336 [1.019-1.751]).

CONCLUSIONS

Higher continuity of care with usual providers for diabetic care is significantly associated with lower risk of future hospitalization for long-term diabetic complication admissions. To avoid future hospitalization, health policy stakeholders are encouraged to improve the continuity of care through strengthening the provider-patient relationships.

Evidence-based decision-making in Asia-Pacific with rapidly changing health-care systems: Thailand, South Korea, and Taiwan

OBJECTIVE

To review the use of evidence in the market approval process, reimbursement, and price control mechanisms for medicines and medical devices in Thailand, South Korea, and Taiwan.

METHODS

Documentary reviews supplemented by interviews with senior policymakers of relevant public health authorities.

RESULTS

Drug regulatory authorities play a vital role in the market authorization process by considering evidence on safety, efficacy and quality for new medicines, and bio-equivalence for new generic products of previously patented medicines. For the formulation of the reimbursement list, all three cases applied evidence on cost-effectiveness, to various degrees, with clear institutional structure, capacity, and functions. Only Thailand has specified an explicit benchmark on cost-effectiveness for inclusion in the reimbursement list. For price control, all have established mechanisms and processes for price negotiation. These mechanisms apply evidence on cost structure and relative prices in other countries to ensure affordable prices, especially with the patented drug industry. Thailand's universal insurance schemes use a capitation payment model which proves effective in implicit price control. To increase access to essential medicines that have patents on and high price, Thailand applied Trade-Related Aspects of Intellectual Property flexibilities; "government use of patent," for public noncommercial purposes to seven essential drugs in 2006 to 2008.

CONCLUSION

Rapidly increasing health expenditure and universal health insurance systems have created greater requirement for proof of "value for money" in the approval and funding of new medical technologies. All settings have established clear mechanisms to apply appropriate evidence in the processes of market approval, reimbursement, and pricing control.