Impact of Atopic Dermatitis on Work and Activity Impairment in Taiwan

Atopic dermatitis has a substantial impact on work and activity impairment according to studies from Western communities. Prospective studies of work productivity and activity impairment in Asian patients with atopic dermatitis are lacking. The aims of this study were to investigate the impacts of atopic dermatitis on work productivity and activity impairment among Taiwanese patients, and to stratify the analyses by disease severity. One-third of employed participants reported missing work (absenteeism) in the preceding week due to atopic dermatitis, while 88.5% of the remaining two-thirds reported impaired work effectiveness (presenteeism). In addition, 92.5% of all participants reported impaired daily activities. Overall work impairment (aggregate productivity loss from absenteeism and presenteeism) was 1.8- and 2.6-fold greater in subjects with moderate and severe atopic dermatitis, respectively, compared with those with mild atopic dermatitis. Presenteeism, but not absenteeism, contributes to the majority of total work impairment in this cohort. Daily activity impairment was 1.5-fold greater in moderate atopic dermatitis, and 2.0-fold greater in severe atopic dermatitis, compared with mild atopic dermatitis. Both work and activity impairment showed significant positive correlations with atopic dermatitis severity scores (SCORing Atopic Dermatitis; SCORAD). In conclusion, work productivity and activity impairment is significantly correlated with disease severity in this Taiwanese atopic dermatitis cohort. In order to obtain a full picture of disease burden to patients and caregivers, patients with atopic dermatitis should be monitored for disease activity as well as corresponding impacts on quality of life.

Relationship between transfusion burden, healthcare resource utilization, and complications in patients with beta-thalassemia in Taiwan: A real-world analysis

Background

This study utilized a population‐based claims database to identify patients with beta‐thalassemia and evaluate associations between transfusion burden, healthcare resource utilization (HCRU), and complications.

Study design and methods

Taiwan's National Health Insurance Research Database was used to identify patients with beta‐thalassemia (ICD‐10 D56.1) in 2016. Patients with a beta‐thalassemia claim in 2016 were indexed into the study at their first claim on or after January 1, 2001 in the dataset through to December 31, 2016 and followed until the end of study. During the follow‐up period, red blood cell transfusion (RBCT) units, HCRU, iron chelation therapy use, and beta‐thalassemia‐related complications incidence were recorded. Patients were grouped into transfusion burden severity cohorts based on average number of RBCT units per 12 weeks during follow‐up: 0 RBCT units, >0 to <6 RBCT units (mild), ≥6 to <12 RBCT units (moderate), and ≥12 RBCT units (severe).

Results

A total of 2984 patients were included with mean follow‐up of 6.95 years. Of these, 1616 (54.2%) patients had no claims for RBCT units, 1112 (37.3%) had claims for >0 to <6 RBCT units, 112 (3.8%) for ≥6 to <12 RBCT units, and 144 (4.8%) for ≥12 RBCT units per 12 weeks. Transfused patients had significantly more all‐cause HCRU and iron chelation therapy compared with non‐transfused patients during follow‐up. Thalassemia‐related HCRU and risk of liver, endocrine, cardiac, and renal complications were significantly and positively correlated with increases of RBCT units.

Discussion

Clinical and healthcare resource burden of patients with beta‐thalassemia is closely related to transfusion burden.

[Epidemiological characteristics of adenovirus infection in hospitalized children with acute respiratory tract infection in Kunming during 2019]

Objective: To investigate the epidemiology and clinical characteristics of adenovirus (ADV)-caused acute respiratory tract infection among hospitalized children in Kunming, China. Methods: Clinical and laboratory data were collected from 467 children with adenovirus infection who were hospitalized from January 1, 2019 to December 31, 2019 in 6 grade A class Ⅲ hospitals in Kunming area. The basic characteristics, epidemiology, mixed infection and adenovirus genotypes of the patients were retrospectively analyzed. The patients diagnosed with adenovirus pneumonia (AP) were divided into two groups, severe AP (SAP) group and general AP(GAP) group according to the severity of illness. Mann-Whitney U test or χ² test was used for comparison between groups, while multivariate regression was applied to analyze the risk factors of SAP. Results: Among 15 635 hospitalized children with respiratory tract infection, 467 cases were adenovirus positive, with a detection rate of 2.99%. Of the 467 patients with adenovirus infection, 284 were male and 183 female, the age was 2.4 (1.1,3.9) years, including 44 cases (9.4%) < 0.5 years, 59 cases (12.6%) of 0.5 to<1.0 years, 176 cases (37.7%) of 1.0 to <3.0 years, 150 cases (32.1%) of 3.0 to <7.0 years, and 38 cases (8.1%) of 7.0 to 14.0 years. Adenovirus infection was common in autumn and winter, and the high incidence months were October to December, which accounted for 51.6% (241/467) of the whole year cases. Co-infection was detected in 226 cases (48.4%) out of 467 patients, in which one pathogen co-infection was the most frequent form (172 cases, 76.1%). Of the 262 pathogen detected 108 (41.2%) were Mycoplasma pneumoniae. In 144 of ADV-positve cases (30.8%) were taken geno-typing was done by PCR amplification, the results showed that 74 cases (51.4%) were ADV 3, 7 subtypes and 65 cases (45.1%) of ADV 1, 2,6 subtypes. Of the 467 cases of ADV infection, 320 (68.5%) were diagnosed with pneumonia, 82 (17.6%) with upper respiratory tract infection and pharyngeal tonsillitis, and 65 (13.9%) with bronchitis, laryngeal bronchitis, and asthmatic bronchitis. Among the 320 patients with AP, 56 cases were severe and 264 cases were general. Two cases (3.6%) in severe group died. Compared with the GAP group, the age was young [17 (11,42) months vs. 24 (14,44) months, Z=2.222, P=0.026], the fever duration was long [8 (5,14) days vs. 6 (3,9) days, Z=3.380, P<0.01], and the proportions of preterm birth and having underlying diseases were high [respectively 19.6% (11/56) vs. 6.1% (16/264), 26.8% (15/56) vs. 10.2% (27/264), χ²=8.965,11.109, P<0.05] in SAP group. Referring to laboratory markers, white blood cell count, C-reactive protein, creatine kinase-MB and lactate dehydrogenase were significantly increased in SAP group as compared to GAP group(all P<0.05). Multivariate Logistic regression analysis showed that preterm birth (OR=3.284, 95%CI 1.079-9.993, P=0.036), underlying disease (OR=3.284, 95%CI 1.079-9.993, P=0.036), fever duration ≥10 d (OR=2.523,95%CI 1.195-5.328, P=0.015) and C-reactive protein ≥50 mg/L (OR=3.156, 95%CI 1.324-7.524, P=0.010) were positively correlated with the risk of SAP. Conclusions: The incidence of adenovirus infection among hospitalized children in Kunming was lower than the national level, and no outbreak occurred in 2019. Subtype 3 and 7 of ADV are the predominant strains for infection, which usually occurs in autumn and winter and mainly causes pneumonia. Premature birth, underlining diseases, long fever duration and markedly increased C-reactive protein are the risk factors for developing into severe pneumonia. This paper presents the prevalence and clinical characteristics of adenovirus infection in children at high altitude area.

Treatment patterns and survival in patients with small cell lung cancer in Taiwan

BACKGROUND

Small cell lung cancer (SCLC) is the most aggressive form of lung cancer. The chemotherapy regimens and their efficacy in practice are seldom reported. We aimed to investigate treatment patterns and survival outcomes of patients with SCLC in Taiwan.

METHODS

Patients newly diagnosed with SCLC from 2011 to 2015 were identified from the Cancer Registry database. Their clinical characteristics, treatment regimens, and survival status were obtained from National Health Insurance Research database. The Kaplan-Meier method and Cox-proportional hazard model were used to analyze the survival outcomes.

RESULTS

Among a total of 2707 patients enrolled, 439 were in the limited stage (LS, 16.22%) and 2268 were in the extensive stage of the disease (ES, 83.78%). The median age was 66 and the majority were male (90.36%). The first-line regimen used for the patients was etoposide/cisplatin-based treatment, followed by etoposide/carboplatin-based regimen, and etoposide only. The median overall survival (OS) was 16.92 months (95% confidence interval [CI] 15.31-18.92) and 8.71 months (95% CI 8.38-9.07) in LS and ES patients, respectively. Chemotherapy regimen, Eastern Cooperative Oncology Group performance status, and history of radiotherapy were significant factors associated with OS. On the other hand, the major second-line treatment was a topotecan-based regimen (68.3%). However, this showed inferior survival outcome compared to etoposide-based regimen (5.09 months [95% CI 4.76-5.62] versus 8.77 months [95% CI 6.31-11.89], p < 0.001).

CONCLUSION

Etoposide is the preferred and superior first-line chemotherapy regimen in combination with platinum, and an alternative choice of second-line regimen for Taiwanese patients with SCLC.

Switching and Discontinuation Pattern of Biologic Disease-Modifying Antirheumatic Drugs and Tofacitinib for Patients With Rheumatoid Arthritis in Taiwan

Rheumatoid arthritis (RA) is a chronic inflammatory systemic disease characterized by persistent joint synovial inflammation and swelling, leading to cartilage damage and bone erosion. This retrospective, longitudinal study is to evaluate the treatment patterns of biologic-naïve RA patients receiving index biologic disease-modifying antirheumatic drug (bDMARD) and tofacitinib by the data of Taiwan National Healthcare Insurance Claims and the Death Registry between 2012 and 2017. Drug survival and treatment patterns were determined by investigating the occurrence of switching and discontinuation from index treatment. At baseline, 70.0% of patients used tumor necrosis factor inhibitors (TNFi) bDMARD with the majority taking etanercept (27.0%) or adalimumab (26.2%). During the follow-up period, 40.0% (n = 3,464) of index users switched (n = 1,479) or discontinued (n = 1,985) the treatment with an average incidence rate of 0.18 per patient-year. Among the six index treatment groups, drug survival was the lowest for adalimumab and highest for tocilizumab. When compared with etanercept, only adalimumab had a higher cumulative probability of switching/discontinuation (adjusted HR = 1.17, 95% CI: 1.08-1.28), whereas golimumab, non-TNFi bDMARDs and tofacitinib were significantly less probable to switch or discontinue. For patients switching the index treatment, tocilizumab (31.2%) and tofacitinib (23.4%) were the main regimens being switched to. In addition, 48.2% of patients who discontinued the index treatment received further retreatment, and 63.8-77.0% of them were retreated with same agent. In conclusion, this population-based study found that TNFi were the preferred agents as the index treatments during 2012-2017. Non-TNFi and tofacitinib were more common second-line agents being switched to. Nearly half of discontinued patients received retreatment, with a majority receiving the same agent.

Chemotherapeutic Regimens and Chemotherapy-Free Intervals Influence the Survival of Patients with Recurrent Advanced Epithelial Ovarian Carcinoma: A Retrospective Population-Based Study

We aimed to evaluate factors influencing the outcomes of patients with platinum-sensitive recurrent epithelial ovarian carcinoma (EOC). Patients with advanced-stage EOC, who received debulking surgery and adjuvant chemotherapy for recurrence, were obtained from the National Health Insurance Research database of Taiwan between 2000 and 2013. A total of 1038 patients with recurrent advanced-stage EOC were recruited. The platinum + paclitaxel (PT) group had the best five-year overall survival (OS) compared with the other three groups (p < 0.001). The hazard ratios (HRs) of five-year OS for the platinum + liposomal doxorubicin (PD), topotecan (TOP), and pegylated liposomal doxorubicin (PLD) groups were 1.21 (p = 0.07), 1.35 (p = 0.016), and 1.80 (p < 0.001), respectively, compared with the PT group. The PT group also had lower hazard ratios of five-year OS for patients with platinum therapy-free interval (TFIp) between 6 and 12 months compared with the other three groups (p < 0.0001). However, the HRs of five-year OS did not differ between the PT and PD groups in patients with TFIp >12 months. Patients with TFIp >12 months had lower HRs of five-year OS compared with those with TFIp of 6–12 months, regardless of whether they were treated with platinum-based (p = 0.001) or non-platinum-based (p = 0.003) regimens. Chemotherapeutic regimens and TFIp influenced the outcomes of patients with recurrent EOC. For patients with TFIp of 6–12 months, the PT regimen is the first choice based on their best overall survival result. For patients with TFIp >12 months, either platinum-based or non-platinum regimens could be used because of their similar excellent overall survival.

The impact of atopic dermatitis on health-related quality of life in Taiwan

BACKGROUND/PURPOSE

Atopic dermatitis (AD) is a common skin disease. At present, there is little evidence regarding its impact on patients' health-related quality of life (HRQoL) in Taiwan. Therefore, this study investigated the relationship between AD severity and patients' HRQoL in Taiwan.

METHODS

Patients with AD were recruited from three hospitals in Taiwan from April 2018 to April 2019. AD severity was measured using the Scoring of AD (SCORAD) scale, and HRQoL was assessed using the Dermatology Life Quality Index (DLQI) and the five-level version of EuroQol five-dimension questionnaire (EQ-5D-5L).

RESULTS

A total of 200 patients (mean age: 34.4 years) were recruited, including 103 males and 97 females. They were further classified as 79 mild, 72 moderate, and 58 severe AD patients according to their SCORAD scores. There was a positive correlation between their SCORAD and DLQI scores (Spearman's r = 0.77, p < 0.001). Patients with severe AD had higher scores in all the DLQI questions, particularly the symptoms, feelings, and work/school. In addition, both the EQ-5D visual analogue scale (VAS) scores and utility index values were negatively correlated with the SCORAD scores (Spearman's r = -0.46 and -0.60, respectively, both p < 0.001). Patients with higher AD severity had more problems with mobility, usual activity, pain/discomfort, and anxiety/depression, while demographic characteristics did not significantly affect HRQoL.

CONCLUSION

Higher AD severity is associated with poorer HRQoL in Taiwanese AD patients, with AD's effects on symptoms, feelings, and work/school being the most troublesome. Meanwhile, demographic factors did not affect HRQoL significantly.

[Formaldehyde and xylene levels and protective effects in the pathology department of a hospital]

Objective: To investigate the status of exposure to xylene and Formaldehyde of medical and technical personnel in Pathology Department of a hospital, and to provide references for prevention of occupational hazards. Methods: From July to October in 2019, 52 medical workers and working places in Pathology Department of a third-class hospital in Jiangxi Province were selected as survey objects, the distribution of occupational hazards, protective measures and personal protective equipment were investigated, and the control wind speed of Formaldehyde, xylene and ventilation facilities were detected and analyzed statistically. Results: It showed that the detection rate of xylene and formaldehyde was 82.1% (23/28) , and the detection rate of xylene C(STEL) in the two sampling posts was 14.3% (2/14) , the local suction device on each side and the control wind speed of the fume hood do not meet the national standards. Conclusion: It is necessary to strengthen the prevention and control of the occupational hazards in the Department of Pathology to prevent the occurrence of occupational diseases.

Additive Effects of Arsenic and Aristolochic Acid in Chemical Carcinogenesis of Upper Urinary Tract Urothelium

BACKGROUND

Aristolochic acids (AA) and arsenic are chemical carcinogens associated with urothelial carcinogenesis. Here we investigate the combined effects of AA and arsenic toward the risk of developing upper tract urothelial carcinoma (UTUC).

METHODS

Hospital-based (n = 89) and population-based (2,921 cases and 11,684 controls) Taiwanese UTUC cohorts were used to investigate the association between exposure to AA and/or arsenic and the risk of developing UTUC. In the hospital cohort, AA exposure was evaluated by measuring aristolactam-DNA adducts in the renal cortex and by identifying A>T TP53 mutations in tumors. In the population cohort, AA exposure was determined from prescription health insurance records. Arsenic levels were graded from 0 to 3 based on concentrations in well water and the presence of arseniasis-related diseases.

RESULTS

In the hospital cohort, 43, 26, and 20 patients resided in grade 0, 1+2, and 3 arseniasis-endemic areas, respectively. Aristolactam-DNA adducts were present in >90% of these patients, indicating widespread AA exposure. A>T mutations in TP53 were detected in 28%, 44%, and 22% of patients residing in grade 0, 1+2, and 3 arseniasis-endemic areas, respectively. Population studies revealed that individuals who consumed more AA-containing herbs had a higher risk of developing UTUC in both arseniasis-endemic and nonendemic areas. Logistic regression showed an additive effect of AA and arsenic exposure on the risk of developing UTUC.

CONCLUSIONS

Exposure to both AA and arsenic acts additively to increase the UTUC risk in Taiwan.

IMPACT

This is the first study to investigate the combined effect of AA and arsenic exposure on UTUC.

Is the risk of second primary malignancy increased in multiple myeloma in the novel therapy era? A population-based, retrospective cohort study in Taiwan

Longer survival in patients with multiple myeloma (MM) after treatment with novel agents (NA) such as thalidomide, bortezomib, and lenalidomide may be associated with increased risks of developing second primary malignancies (SPM). Few data describe the risk of SPM in patients with MM in Asia. This population-based retrospective cohort study assessed the risk of SPM in MM using the Taiwan National Cancer Registry and National Health Insurance Research databases from 2000 to 2014. Among 4,327 patients with newly diagnosed MM initiated with either novel agents alone (NA), chemotherapy combined with novel agents (CCNA), or chemotherapy alone (CA), the cumulative incidence of SPM overall was 1.33% at year 3. The SPM incidence per 100 person-years (95% confidence interval [CI]) was 0.914 (0.745–1.123) overall, 0.762 (0.609–1.766) for solid tumours, and 0.149 (0.090–0.247) for haematological malignancies. We compared risks of SPM using a cause-specific Cox regression model considering death as a competing risk for developing SPM. After controlling for age, gender, Charlson Co-morbidity Index, and time-period, the risk of developing any SPM or any haematological malignancy was significantly reduced in patients initiated on NA (2010–2014 period) compared to chemotherapy alone (adjusted hazard ratio 0.24, 95% CI 0.07–0.85, and 0.10, 95% CI 0.02–0.62, respectively). Contemporary treatment regiments using NA (mainly bortezomib) were associated with a lower risk for a SPM in comparison with CA.

Prevalence of baseline comorbidities in patients with atopic dermatitis: A population-based cohort study in Taiwan

BACKGROUND

Atopic dermatitis has been linked to increased risk of many comorbidities. However, the risks of certain comorbidities are still debated.

OBJECTIVE

To better characterize the basic demographics, treatment patterns, and associations between atopic dermatitis and comorbidities and to further investigate the influence of severity on comorbidities.

METHODS

We used a sample cohort of 999,992 people from the National Health Insurance Research Database of Taiwan to evaluate atopic dermatitis in the general population.

RESULTS

A total of 12,780 patients with atopic dermatitis in 2010 were identified. The prevalence was 1.28%. The proportions of severe and moderate cases were 7.43% and 19.26%, respectively. The most commonly used systemic treatment was corticosteroids. Compared with the general population, atopic dermatitis patients showed increased risks of all 9 groups of comorbidities, including autoimmune disorders, atopic disorders, chronic urticaria, ocular disorders, metabolic disorders, hypertensive disorders, ischemic heart disorders, cerebrovascular disorders, and psychiatric disorders. The severity and persistence of atopic dermatitis were correlated with the development of certain comorbidities.

LIMITATIONS

Miscoding and misclassification might have occurred, and only patients with active disease were enrolled.

CONCLUSION

Patients with atopic dermatitis have higher risks of various comorbidities. Comprehensive monitoring and treatment plans are needed to better manage these patients.

Treatment evolution and improved survival in multiple myeloma in Taiwan

The incidence of multiple myeloma (MM) is increasing worldwide, but the rate of increase is greatest in Asia. Few data describe the epidemiology and treatment of MM in Asia. Building on a cohort study from 2007 to 2012 using the Taiwan National Healthcare Insurance Research database, we extended our analysis to estimate the disease burden and treatment patterns of patients with MM in Taiwan through 2015. A further 1664 patients with newly diagnosed MM from 2013 to 2015 (total 4387 patients from 2007 to 2015) were enrolled and followed up until death or end of the observation period (December 31, 2016), whichever occurred first. The age distribution of the 2013–2015 cohort was similar to that for previous years, but there were fewer men (52.1% versus 58.0%), and more patients had renal impairment at diagnosis (19.7% versus 16.4%). From 2007 to 2015, crude annual incidences per 100,000 population of newly diagnosed MM increased from 1.74 to 2.48 and age-adjusted incidences from 1.41 to 1.65. Crude all-cause mortality rates increased over time. Case fatality decreased from 25.5 to 18.3% and median survival increased from 2.10 to 3.12 years. From 2007 to 2015, the percentage of patients receiving first-line therapy with novel agents increased from 0.4 to 89.4%, autologous stem cell transplantation doubled, and chemotherapy use decreased by 81%. Comprehensive national data covering 9 years of follow-up demonstrate continuing change in the disease burden, treatment, and survival of MM in Taiwan. Despite increased use of new treatments, MM remains largely incurable.

Increased Risk of Cutaneous Squamous Cell Carcinoma in Organ Transplant Recipients and Patients on Chronic Dialysis: A Cancer Registry-based Study in Taiwan

This study investigated the predominant skin cancer subtype among organ transplant recipients, patients on chronic dialysis, and patients with chronic kidney disease in Asian subjects. Among 23,644 patients with skin cancer, identified from Taiwan Cancer Registry Database, 53 were organ transplant recipients, 255 were on chronic dialysis, 1,792 had chronic kidney disease, and 21,544 were in the control group. The proportions of squamous cell carcinoma were 52.8%, 47.8%, 40.1%, and 33.5%, respectively. Compared with the control group, organ transplant recipients (1.99-fold) and patients on chronic dialysis (1.25-fold) were at higher risk of developing squamous cell carcinoma than other skin cancers after adjustment for potential confounders. Subgroups or covariates associated with increased squamous cell carcinoma compared with other skin cancer risk included patients with chronic kidney disease aged < 70 years (vs. control group; 1.3-fold), old age (vs. young age; 2.8-fold), male sex (vs. female sex; 1.1-fold), and south Taiwan residency (vs. north Taiwan residency; 1.1-fold). Organ transplant recipients and patients on chronic dialysis had immune dysregulation, resulting in a higher risk of squamous cell carcinomas.

Comparison of Healthcare Utilization and Costs Between RA Patients Receiving Biological and Conventional Synthetic DMARDs: A Nationwide Population-Based Cohort Study in Taiwan

Background: The therapy with biological disease-modifying anti-rheumatic drugs (bDMARDs) has proven to rapidly reduce articular symptoms/signs, decrease morbidities, and improve health outcome in patients with rheumatoid arthritis (RA) and be cost-effective in Western countries. However, the difference in healthcare utilization and costs between conventional synthetic DMARDs (csDMARDs) and bDMARDs in the treatment of RA patients in Taiwan remains largely unexplored.

Methods: Two cohorts of RA patients and their matched controls were identified from the National Health Insurance Research database (NHIRD). The csDMARD cohort comprised of patients who submitted claims during 1997–2003 for cyclosporine≥50 mg/day with concomitant use of ≥2 csDMARDs for ≥28 days (n=1,569), whilst the bDMARD cohort comprised of patients who had ≥1 claim during 2003–2011 for bDMARD (n = 1,530). The per-patient per-year healthcare utilization and costs were estimated by bootstrapping method, with a comparison being undertaken between csDMARD and bDMARD.

Results: The incremental number of hospitalization days was reduced from 2.3 days for csDMARD to 0.58 day for bDMARD. When compared to csDMARD-treated patients, the incremental total costs and RA-related medication costs were significantly higher in bDMARD-treated patients (US$9,081 vs. US$2,481; US$8,992 vs. US$1,883). However, the combined incremental healthcare utilization costs and non-RA medication costs were significantly lower in bDMARDs-treated patients compared to csDMARD-treated patients (US$374.7 vs. US$1,156.2).

Conclusion: Although total costs increased as a result of introducing biologics in RA treatment, biologics have undoubtedly given rise to the benefits of reduced healthcare utilization. The increase in medication costs from biologics was offset by the lower costs of healthcare utilization. Our findings suggest that the medication costs of biologics may be alleviated by an improvement in clinical outcomes.

Patients with chronic urticaria have a higher risk of psychiatric disorders: a population-based study

BACKGROUND

The prevalence of psychiatric comorbidities in patients with chronic urticaria (CU) in a national population is largely unknown.

OBJECTIVES

To investigate the prevalence of psychiatric disorders and psychiatric medication use in patients with CU in Taiwan.

METHODS

Data were sourced from Taiwan's National Health Insurance Research Database for 2011. Patients who had a primary/secondary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 708·1, 708·8 or 708·9 during 2011 with at least two outpatient visits and an antihistamine prescription were identified as CU cases. Patients with CU were classified into three disease severity groups according to their medication types. Psychiatric disorders were identified by patients having three outpatient visits with a primary or secondary diagnosis of a given psychiatric disease. Psychiatric medication use was defined by having at least four outpatient visits with prescriptions for anxiolytics, antidepressants or sleeping pills in 2010 or 2011.

RESULTS

Of the 167 132 patients with CU, 82·5% had mild CU, 17·0% had moderate CU and 0·4% had severe CU. Patients with CU had a higher prevalence of psychiatric disorders and psychiatric medication prescription than control groups. The relative risk (RR) of psychiatric disorders was 1·43 for patients with mild, 1·50 for patients with moderate and 2·32 for patients with severe CU vs. the controls (P < 0·001). For psychiatric medication prescription, the RRs were 1·95, 2·70 and 2·09, respectively, vs. controls (P < 0·001).

CONCLUSIONS

Patients with CU had a higher prevalence and risk of psychiatric disorders and psychiatric medication prescription than control groups. What's already known about this topic? Previous studies have shown a high prevalence of psychiatric comorbidities in patients with chronic urticaria (CU), with rates ranging from 35% to 60%. Anxiety, depression and somatoform disorders have been reported as the most prevalent mental disorders in patients with CU. What does this study add? Patients with CU had a higher prevalence of psychiatric disorders and psychiatric medication use than control groups in the general population. The relative risk (RR) of psychiatric disorders was 1·43 for those with mild CU, 1·50 for those with moderate CU and 2·32 for those with severe CU vs. controls. The RR for psychiatric medication use was 1·95 for those with mild CU, 2·70 for those with moderate CU and 2·09 for those with severe CU vs. controls. Mental health evaluations and management are important elements in CU management.

Tofacitinib in the treatment of moderate-to-severe rheumatoid arthritis: a cost-effectiveness analysis compared with adalimumab in Taiwan

Aims: Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). This analysis investigated the cost-effectiveness of the second-line treatment with tofacitinib, compared with adalimumab, both plus methotrexate (MTX), in patients with moderate-to-severe RA and an inadequate response to the first-line MTX, from a Taiwan National Health Insurance Administration perspective. Materials and methods: A patient-level simulation model was used to project lifetime costs and quality-adjusted life-years (QALYs). Base-case analysis compared second-line treatment with tofacitinib 5 mg twice daily plus MTX vs adalimumab 40 mg every 2 weeks plus MTX. Patients switched or discontinued treatment due to a lack or loss of effectiveness or a serious adverse event. Efficacy was measured by change in Health Assessment Questionnaire-Disability Index (HAQ-DI) score. HAQ-DI scores were used to predict mortality and resource utilization, and were mapped onto utility values to estimate QALYs. Efficacy and safety data were derived from clinical trials and other secondary sources. Uncertainty in model parameters was explored using one-way deterministic and probabilistic sensitivity analyses. Results: Patients gained 0.09 more QALYs with second-line tofacitinib plus MTX compared with adalimumab plus MTX (5.13 vs 5.04, respectively) at an additional cost of New Taiwan Dollars (NT$) 12,881. The incremental cost-effectiveness ratio was NT$143,122/QALY. One-way sensitivity analysis confirmed the base-case result was robust. Limitations: The lack of available clinical data, particularly for HAQ-DI scores, may introduce some bias in the analysis. No patients were in an early stage of RA, which may limit the generalizability of these results. Base-case results from our study are not necessarily generalizable to countries with healthcare systems that differ considerably from Taiwan. Conclusions: From a payer perspective, second-line treatment with tofacitinib plus MTX is a cost-effective treatment strategy, compared with adalimumab plus MTX, in patients with moderate-to-severe RA in Taiwan.

Healthcare utilization, medical costs and mortality associated with malnutrition in patients with chronic obstructive pulmonary disease: a matched cohort study

Objective: Although disease-related malnutrition has prognostic implications for patients with chronic obstructive pulmonary disease (COPD), its health-economic impact and clinical burdens are uncertain. We conducted a population-level study to investigate these questions. Methods: We excerpted data relevant to malnutrition, prolonged mechanical ventilation and medications from claims by 1,197,098 patients which were consistent with COPD and registered by the Taiwan National Health Insurance Administration between 2009 and 2013. These patients were separated into cohorts with or without respiratory failure requiring long-term mechanical ventilation, and each cohort was divided to compare cases who developed malnutrition after their first diagnosis consistent with COPD, versus non-malnourished propensity-score matched controls. Results: The prevalence of malnutrition was 3.8% overall (10,259/287,000 non-ventilator-dependent; 1198/15,829 ventilator-dependent). Propensity-score matched non-ventilator-dependent patients who became malnourished (N = 10,242) had comparatively more hospitalizations, emergency room and outpatient visits, longer hospitalization (all p < .01), and higher mortality (HR = 2.26, 95% CI 2.18-2.34) than non-malnourished controls (N = 40,968). Malnourished ventilator-dependent patients (N = 1197) had higher rates of hospitalization, emergency room and outpatient visits, but shorter hospitalization (all p < .001) and lower mortality (HR = 0.85, 95% CI 0.80-0.93) than matched non-malnourished controls (N = 4788). Total medical expenditure on malnourished non-ventilator-dependent COPD patients was 75% higher than controls (p < .001), whereas malnourished ventilator-dependent patients had total costs 7% lower than controls (p < .001). Conclusions: Malnourishment among COPD patients who were not dependent on mechanical ventilation was associated with greater healthcare resource utilization and higher aggregate medical costs.

Potential benefits of biologics on stroke and mortality in patients with rheumatoid arthritis: A nationwide population-based cohort study in Taiwan

AIM

To examine the changes in the risks of death and cardiovascular diseases (CVD) in rheumatoid arthritis (RA) patients treated with conventional synthetic or biologic disease-modifying antirheumatic drugs (csDMARD or bDMARD) during 1997-2013.

METHODS

Two cohorts of RA patients and their matched controls were identified from the National Health Insurance Research database. There were 1569 patients in the csDMARD cohort who received cyclosporine ≥50 mg/d with concomitant usage of ≥2 csDMARDs during 1997-2003. There were 1530 patients in the bDMARD cohort if patients had ≥1 claim for bDMARD during 2003-2011. Adjusted hazard ratios (aHRs) for the risk of death, myocardial infarction, and stroke, were assessed using the Kaplan-Meier survival curves and the Cox proportional hazards models.

RESULTS

Compared with matched cohorts, the incidence of death was higher with csDMARD with a more than 6-fold increase (csDMARD vs controls: 33% vs 5%); while it only increased with a much smaller magnitude with bDMARD (bDMARD vs controls: 15% vs 11%). In addition, an increase in the reduction of incidence rate of stroke with bDMARD (bDMARD vs controls: 2% vs 5%) than that with csDMARD (csDMARD vs controls: 3% vs 4%) was found. Results from multivariate analysis showed that RA patients receiving bDMARD had a significantly lower increase in the risk of deaths (aHR 1.05; 95% CI 0.84-1.33) compared with those receiving csDMARD (aHR 8.75; 95% CI 7.43-10.31). In addition, bDMARD was associated with a higher reduction in the risk of stroke compared with csDMARD (bDMARD: aHR 0.37; 95% CI 0.22-0.62; csDMARD: aHR 0.73; 95% CI 0.51-1.05).

CONCLUSION

Biologics used in RA patients have been shown to have a beneficial impact on improving clinical outcomes, including decreased risks of death and stroke. The economic burden from costs of biologics may be alleviated by improving outcomes.

Cost-Effectiveness Analysis of Human Papillomavirus Vaccination in Adolescent Girls in Taiwan

Objective:

Three vaccines are available to Taiwanese young girls for cervical cancer (CC) prevention. Here we evaluate the cost-effectiveness of the two-dose (2D) AS04-adjuvanted HPV-16/18 vaccine (2D-AS04-HPV-16/18v)+screening compared with a screening programme alone, with 2D human papillomavirus 6/11/16/18 vaccine (2D-4vHPVv)+screening, and with 2D/three-dose (3D) human papillomavirus 6/11/16/18/31/33/45/52/58 vaccine (9vHPVv)+screening, for Taiwan universal mass vaccination.

Methods:

A static Markov cohort model simulated the natural history of human papillomavirus (HPV) infection and CC screening for a 12-year-old cohort of Taiwanese girls (N=120,000). The model ran in 1-year cycles over the cohort’s lifetime. Vaccine efficacy irrespective of HPV type was considered in the analysis for each vaccine. Input data were obtained from published literature, local databases, government reports and websites, and expert opinion. The analysis incorporated direct medical costs only, with an annual discount rate of 3.0%. The threshold was determined as 1 Gross Domestic Product per capita (New Taiwan dollar [NT$] 727,818; year 2016).

Results:

The 2D-AS04-HPV-16/18v+screening yielded 0.0365 quality-adjusted life year (QALY) gained at an additional cost of NT$ 5,770 per person compared with the screening programme alone. This resulted in an incremental cost-effectiveness ratio well below the threshold. Compared with 2D-4vHPVv+screening and 2D/3D-9vHPVv+screening, discounted results demonstrated additional QALYs gained at lower cost for 2D-AS04-HPV-16/18v+screening, making it dominant over both 2D-4vHPVv+screening and 2D/3D-9vHPVv+screening.

Conclusions:

Vaccinating Taiwanese girls with 2D-AS04-HPV-16/18v in addition to screening to prevent CC is cost-effective compared with using a screening programme alone and the dominant option compared with 2D-4vHPVv+screening and 2D/3D-9vHPVv+screening.

Assessing the relationship between healthcare market competition and medical care quality under Taiwan's National Health Insurance programme

Background

There is still significant uncertainty as to whether market competition raises or lowers clinical quality in publicly funded healthcare systems. We attempted to assess the effects of market competition on inpatient care quality of stroke patients in a retrospective study of the universal single-payer health insurance system in Taiwan.

Methods

In this 11-year population-based study, we conducted a pooled time-series cross-sectional analysis with a fixed-effects model and the Hausman test approach by utilizing two nationwide datasets: the National Health Insurance Research Database and the National Hospital and Services Survey in Taiwan. Patients who were admitted to a hospital for ischemic or hemorrhagic stroke were enrolled. After excluding patients with a previous history of stroke and those with different types of stroke, 247 379 ischemic and 79 741 hemorrhagic stroke patients were included in our analysis. Four outcome indicators were applied: the in-hospital mortality rate, 30-day post-operative complication rate, 14-day re-admission rate and 30-day re-admission rate.

Results

Market competition exerted a negative or negligible effect on the medical care quality of stroke patients. Compared to hospitals located in a highly competitive market, in-hospital mortality rates for hemorrhagic stroke patients were significantly lower in moderately (β = -0.05, P < 0.01) and less competitive markets (β = -0.05, P < 0.01). Conversely, the impact of market competition on the quality of care of ischemic stroke patients was insignificant.

Conclusions

Simply fostering market competition might not achieve the objective of improving the quality of health care. Other health policy actions need to be contemplated.

Relationship Between Statin Use and Outcomes in Patients Having Cardiac Arrest (from a Nationwide Cohort Study in Taiwan)

Pretreatment with statins is associated with improved outcomes in severe sepsis, acute coronary syndrome, and stroke. Patients with cardiac arrest experience sepsis-like syndrome and ischemia reperfusion injuries in the heart and brain. The objective of this study was to investigate the effects of statin use before cardiac arrest on outcomes in cardiac arrest patients. Medical records of 142,131 adult patients who experienced nontraumatic cardiac arrest and were resuscitated between 2004 and 2011 were analyzed. Patients were grouped into 2 groups: the "statin group" comprised patients who had received statin treatment for at least 30 days before the cardiac arrest event; the "never statin group" comprised patients who had no statin use within 30 days before the event. Patients with previous statin treatment had better chance of survival to hospital discharge (6.1% vs 4.3%, p <0.0001) and 1-year survival (4.8% vs 3.2%, p <0.0001) after propensity score matching. Previous statin use was an independent predictor for 1-year survival (adjusted odds ratio 1.41, 95% confidence interval 1.16 to 1.71; p = 0.001). A favorable outcome effect of statin on 1-year survival was observed in the presence of diabetes mellitus, chronic kidney disease, and Charlson Comorbidity Index score greater than 5 in the subgroup analysis. In conclusion, statin use before cardiac arrest is associated with 1-year survival in a propensity score-matched nationwide cohort study.

Comparisons of the risk of medication noncompliance and suicidal behavior among patients with depressive disorders using different monotherapy antidepressants in Taiwan: A nationwide population-based retrospective cohort study

BACKGROUND

The aim of this study was to assess the association between various classes of antidepressants and the risk of medication noncompliance as well as suicidal behavior among depressed patients.

METHODS

A retrospective cohort study was conducted utilizing two nationwide population-based datasets in Taiwan from 2010 to 2016. The outcome measures included the risk of medication noncompliance, attempted suicide, and completed suicide. Cox proportional hazards models with stratification of the propensity score deciles were performed.

RESULTS

A total of 447,411 new antidepressant users were identified. Compared to SSRIs, patients who received SARIs [adjusted hazard ratio (aHR) = 1.124, 95% confidence interval (CI) = 1.108-1.142], SNRIs (aHR = 1.049, 95% CI = 1.033-1.065), and other classes of antidepressants (aHR = 1.037, 95% CI = 1.024-1.051) were more likely to exhibit poor medication noncompliance. Patients who received SNRIs had a higher risk of attempted suicide (aHR = 1.294, 95% CI = 1.114-1.513), compared to SSRIs. However, patents in the TCAs group revealed the opposite result (aHR = 0.543, 95% CI = 0.387-0.762). Concerning the risk of completed suicide, this analysis detected no statistical significance across different types of antidepressants.

LIMITATIONS

Although the universal coverage of Taiwan's national health insurance program tends to minimize the risk of selection and recall bias, it is difficult to rule out medical surveillance bias by using claim data.

CONCLUSIONS

This study demonstrated that classes of antidepressants exert different degrees of impact on the risk of medication noncompliance and attempted suicide, but not completed suicide, among depressed patients.

Out-of-pocket costs and productivity losses in haemodialysis and peritoneal dialysis from a patient interview survey in Taiwan

OBJECTIVES

The total medical (economic) costs of haemodialysis (HD) and peritoneal dialysis (PD), including direct medical costs, out-of-pocket (OOP) costs and productivity losses, have become an important issue. This study aims to compare the direct non-medical costs and indirect medical costs of both modalities in Taiwan.

DESIGN AND SETTING

This multicentre study included cross-sectional interviews of patients over 20 years old and articulate, who had been continuously receiving long-term HD or PD for more than 3 months between April 2015 and March 2016. Mann-Whitney U test, Wilcoxon rank-sum test and 1000 bootstrap procedures with replacement were used for analysis.

OUTCOME MEASURES

Differences in OOP costs and productivity losses.

RESULTS

There were 308 HD and 246 PD patients available for analysis. HD patients had significantly higher monthly OOP costs than PD patients after bootstrap procedures (NTD 5912 vs NTD 5225, p<0.001; NTD, new Taiwan dollars; 1 US dollar=30 NTD). Compared with PD patients, HD patients had higher monthly productivity losses after bootstrap procedures (NTD 14 150 vs NTD 11 611, p<0.001), resulting from more time spent seeking outpatient care (HD, 70.4 hours vs PD, 4.4 hours, p<0.001) and time spent by family caregivers for outpatient care (HD, 66.1 hours vs PD, 6.1 hours, p<0.001). The total costs per patient-month of HD and PD modalities, including OOP costs and productivity losses, were NTD 20 062 and NTD 16 836, respectively.

CONCLUSIONS

The HD modality has higher OOP costs and productivity losses than the PD modality in Taiwan.