Urbanization and the utilization of outpatient services under National Health Insurance in Taiwan

Estimating expected years of life lost of psychiatric disorders in Taiwan: A Nationwide cohort study

OBJECTIVES

This study employed a national longitudinal cohort to assess expected years of life lost (EYLL) in newly diagnosed psychiatric patients.

METHODS

Data from Taiwan's National Death Registry and Health Insurance Research Database were scrutinized to identify patients with various psychiatric disorders. Disorders were ranked hierarchically, and age groups were categorized as young, middle-aged, and older adults. We utilized the semiparametric survival extrapolation method to estimate life expectancy (LE) and EYLL. Modifying effect of comorbid conditions and socioeconomic characteristics were also explored.

RESULTS

Among the 5,757,431 cases, young adults with dementia, alcohol use disorder, schizophrenia, and bipolar disorder experienced an excess of 15 years of EYLL. Middle-aged adults faced approximately 9 years or more of EYLL, while older adults had lower EYLL values. Comorbid conditions, low income levels, and living in rural areas were associated with higher EYLL.

CONCLUSIONS

This study underscores the substantial EYLL among young adults with psychiatric disorders and the significant impact of specific disorders on EYLL. Early intervention, tailored support, and healthcare system readiness are imperative for improved outcomes. Resource allocation and targeted interventions focusing on early detection and comprehensive treatment can alleviate the economic burden.

Increased NAFLD risk in newly diagnosed patients with RA during the first 4 years of follow-up: a nationwide, population-based cohort study

BACKGROUND

Although the non-alcoholic fatty liver disease (NAFLD) is prevalent in the general population, NAFLD risk in newly diagnosed rheumatoid arthritis (RA) has rarely been explored. In this population-based cohort, we examined NAFLD risk in patients with RA and identified the potential risk factors.

DESIGN

Retrospective study.

SETTING

Taiwan.

PARTICIPANTS

2281 newly diagnosed patients with RA and selected 91 240 individuals without RA to match with patients with RA (1:40) by age, gender, income status and urbanisation level of the residence.

OUTCOMES

In this retrospective study using the 2000-2018 claim data from two-million representative Taiwanese population, we identified and compared the incidence rates (IRs) of NAFLD and alcoholic fatty liver disease (AFLD) between RA and non-RA groups. Using multivariable regression analyses, we estimated adjusted HR (aHR) of NAFLD development in patients with RA compared with individuals without RA, with 95% CIs.

RESULTS

The incidences of NALFD and AFLD were not significantly different between individuals with RA and without RA during the 17-year follow-up period. However, patients with RA had significantly increased NAFLD risk during the first 4 years after RA diagnosis, with IR ratio of 1.66 fold (95% CI 1.18 to 2.33, p<0.005), but the risk was reduced after the first 4 years. Multivariable regression analyses revealed that aHR was 2.77-fold greater in patients not receiving disease-modifying anti-rheumatic drugs therapy than in non-RA subjects (p<0.05). Old age, women, low-income status and obesity could significantly predict NAFLD development.

CONCLUSIONS

We demonstrated elevated risk of NAFLD in patients with RA during the first 4 years after RA diagnosis, and old age, women, low-income status and obesity were significant predictors of NAFLD.

A flexible approach to measure care coordination based on patient-sharing networks

BACKGROUND

Effective care coordination may increase clinical efficiency, but its measurement remains difficult. The established metric "care density" (CD) measures care coordination based on patient-sharing among physicians, but it may be too rigid to generalize across disorders and countries. Therefore, we propose an extension called fragmented care density (FCD), which allows varying weights for connections between different types of providers. We compare both metrics in their ability to predict hospitalizations due to schizophrenia.

METHODS

We conducted a longitudinal cohort study based on German claims data from 2014 through 2017 to predict quarterly hospital admissions. 21,016 patients with schizophrenia from the federal state Baden-Württemberg were included. CD and FCD were calculated based on patient-sharing networks. The weights of FCD were optimized to predict hospital admissions during the first year of a 24-month follow-up. Subsequently, we employed likelihood ratio tests to assess whether adding either CD or FCD improved a baseline model with control variables for the second follow-up year.

RESULTS

The inclusion of FCD significantly improved the baseline model, Χ2(1) = 53.30, p < 0.001. We found that patients with lower percentiles in FCD had an up to 21% lower hospitalization risk than those with median or higher values, whereas CD did not affect the risk.

CONCLUSIONS

FCD is an adaptive metric that can weight provider relationships based on their relevance for predicting any outcome. We used it to better understand which medical specialties need to be involved to reduce hospitalization risk for patients with schizophrenia. As FCD can be modified for different health conditions and systems, it is broadly applicable and might help to identify barriers and promoting factors for effective collaboration.

Emergency department visits and associated factors among people with dementia residing in nursing homes in Taiwan: a one-year cohort study

BACKGROUND

Residing in a nursing home (NH) may increase emergency department (ED) utilization in patients with dementia; however, evidence regarding the status of and predictors for ED utilization of NH residents with dementia remains unclear, especially in Asia. This study aimed to assess the incidence density of ED visits and associated factors for the risk of ED utilization among NH residents with dementia.

METHODS

This one-year cohort study followed 6595 NH residents with dementia aged ≧ 40 years from Taiwan's National Health Insurance Research Database between 2012 and 2014. The Andersen-Gill extension of Cox regression analysis with death as a competing risk was applied to investigate the association of the risk of all causes and the most common causes of ED utilization with the predisposing, enabling, and need factors as defined by the Andersen model.

RESULTS

All participants encountered 9254 emergency visits in the 5371.49 person-years observed, representing incidence densities of ED visits of 1722.80 per 1000 person-years. Among them, respiratory disease was the most common cause of ED visits. The significant predictors for the risk of all-cause and respiratory-cause ED visits included: (1) predisposing factors (i.e., age and gender); (2) enabling factors (i.e., regional variables); and (3) need factors (i.e., prolonged ventilator dependence and comorbidity status).

CONCLUSIONS

Predisposing, enabling, and need factors could influence ED visits among studies patients. NH providers should consider these factors to develop strategies for reducing ED utilization.

Cost and effectiveness analyses of the anti-osteoporosis medication in patients with hip fracture in Taiwan: A population-based national claims database analysis

BACKGROUND

Real-world cost and effectiveness analyses of the anti-osteoporosis medications (AOM) using a nationwide database in Asia were limited. The aim of this study was to evaluate the cost and effectiveness of AOMs therapy under the reimbursement of National Health Insurance in Taiwan.

METHODS

Using Taiwan's National Health Insurance Research Database, patients who had hospitalization due to incident hip fractures with related operation between 2008 and 2017 were identified as our study population. Patients who initiated AOMs within 1 year post incident hip fracture were matched with those did not according to the propensity score. The direct medical cost and subsequent fracture within three years were estimated. Statistically significant differences of risk for subsequent fracture between the AOM and non-AOM groups were estimated using the COX proportional hazards model. All costs were presented as New Taiwan Dollars (NTD).

RESULTS

There were 27,357 new hip fracture patients who initiated AOMs, and 76% of them were women with a mean age of 77.7 years. Among patients ages ≥70 who encountered hip fractures, those who initiated AOMs experienced fewer non-vertebral fractures (HR = 1.07 (1.02-1.13), p = 0.0114 for those ages 70-79 years old; HR = 1.11 (1.06-1.17), p < 0.0001 for those ages ≥80 years) and mortality (HR = 1.18 (1.14-1.22), p < 0.0001 for those ages 70-79; HR = 1.20 (1.16-1.23), p < 0.0001) within 3 years post incident fracture; meanwhile, consuming fewer medical resources in the national insurance healthcare system. (Increment cost = -16011.2 NTD, p = 0.0248 for those ages 70-79; Increment cost = -17257.9 NTD, p = 0.0032 for those ages ≥80 years) CONCLUSION: Overall, under Taiwan's national health insurance, the use of AOMs is cost-saving, especially in the population aged ≥70 years. The finding of this research was valuable for policymakers in considering healthcare policy promotion and resource allocation in the future.

Constraining in reimbursement criteria and the adherence to anti-osteoporosis medications (AOMs) in Taiwan: Urbanization makes the difference

BACKGROUND

The Bureau of National Health Insurance in Taiwan implemented a new reimbursement scheme incorporating bone mineral density (BMD) criteria on Jan. 1, 2011. This study aimed to investigate a real-life 11-year secular trend of adherence in new AOMs users and evaluated the change of adherence to AOMs therapy in different urbanization areas after reimbursement criteria were restrained.

METHODS

We used Taiwan's National Health Insurance Research Database to identify new AOMs users as our study population. The AOMs in this study included denosumab, zoledronate, ibandronate, alendronate, raloxifene, and risedronate. The first prescription date of AOMs was defined as the cohort entry date. The adherence rates within one year after initiation were assessed.

RESULTS

High adherence (≥75%) in the first year increased markedly after the new reimbursement scheme in 2011, changing from 31.8% in 2008, and 41.7% in 2011 to 54.2% in 2018. On the other hand, low adherence (<25%) decreased from 38.8% in 2008 to 14.6% in 2018. In addition, the switchers increased from 5.9% in 2008 to 9.3% in 2018, indicating a more flexible choice of AOMs. The proportion of high adherence to AOMs was highest in high-urbanization areas, and the proportion increased about two times from 30% in 2008 to 60% in 2018.

CONCLUSION

The implementation of new reimbursement criteria in 2011 was associated with increased adherence to AOMs and the increase was most apparent in high-urbanization areas.

The association between abused adults and substance abuse in Taiwan, 2000-2015

OBJECTIVE

To investigate whether adults suffering from violence were at risk of substance abuse and provides insight into the relationship between male and female abusers and substance abuse from 2000 to 2015 in Taiwan.

METHODS

This study used data on outpatient, emergency, and inpatient visits for 2 million people enrolled in universal health insurance from 2000 to 2015. ICD-9 diagnosis codes 995.8 (abused adult) and E960-E969 (homicide and injury purposely inflicted by other persons) were defined in this case study, analyzing first-time violence in adults aged 18-64 (study group). Non-abused patients (control group) were matched in a 1:4 ratio, and the paired variables were gender, age (± 1 year), pre-exposure Charlson Comorbidity Index, and year of medical treatment. SAS 9.4 and Cox regression were used for data analysis.

RESULTS

A total of 8,726 people suffered violence (control group: 34,904 people) over 15 years. The prevalence of substance abuse among victims of violence was 78.3/10⁴, 61.9/10⁴, and 51.5/10⁴ for tobacco use disorder, alcoholism, and alcohol abuse, respectively. The risk (adults, overall) of drug abuse, drug dependence, and alcoholism after exposure to violence (average 9 years) was 7.47, 7.15, and 6.86 times (p < 0.01), respectively, compared with those without violence. The risk (adults, males) of drug abuse, drug dependence, and alcohol abuse after exposure to violence (average 9 years) was 6.85, 6.27, and 6.07 times, respectively, higher than those without violence (p < 0.01). Risks of drug dependence, alcohol abuse and alcoholism (adults, females) after exposure to violence (average 9 years) were 14.92, 12.26, and 11.55 times, respectively, higher than non-abused ones (p < 0.01).

CONCLUSION

The risks of substance abuse, after adult violence, are higher than in those who have not suffered violent injuries.

Relationship between periodontal disease and dizziness in Taiwanese adults: A nationwide population-based cohort study

Periodontal disease is often neglected and overlooking its initial symptoms can lead to tooth loss and systemic diseases. Patients with otitis media are at high risk of vestibular and balance dysfunction, consequently, and vertigo. Vertigo and dizziness are conditions with high reported incidences; they worsen with age and can burden health systems. The present study investigated whether periodontal disease causes dizziness. Research data covering 2008 through 2013 were retrieved from the National Health Insurance Research Database of Taiwan. Patients who were newly diagnosed as having periodontal disease or dizziness after at least 1 hospital admission or 3 outpatient visits were enrolled as participants. For our controls, we randomly selected individuals without periodontal disease who were sex- and age-matched with the investigated participants. In total, we enrolled 445 patients with periodontal disease and 1780 controls. The Kaplan-Meier curve indicated that the cumulative incidence of dizziness was significantly higher among the patients with periodontal disease relative to the controls. After adjustment for sex, age, income level, urbanization level, month of onset, and comorbidities, Cox proportional-hazards analysis revealed that patients with periodontal disease had an increased risk of dizziness (hazard ratio [HR]: 1.306, 95% confidence interval (CI): 1.155, 1.475). Compared with the controls, the risk of dizziness among patients with periodontal disease was higher for both female (HR: 1.439, 95%: 1.203, 1.720) and male patients (HR: 1.284, 95%: 1.123, 1.468); this risk was higher even when January (HR: 1.302, 95% CI: 1.145, 1.480), February (HR: 1.337, 95% CI: 1.178, 1.518), or March was excluded (HR: 1.308, 95% CI: 1.151, 1.487) and for patients without Ménière disease. Therefore, periodontal disease is not only a risk factor for dizziness but also an independent risk factor for dizziness. Future studies could clarify the mechanisms linking periodontal disease to dizziness.

Health-care utilization among dementia patients with or without comorbid depression in Taiwan: A nationwide population-based longitudinal study

BACKGROUND

Few studies have examined the association of comorbid depression with health-care utilization among dementia patients. This study compared health-care utilization between dementia patients with and without comorbid depression.

METHODS

Using Taiwan's National Health Insurance Research Database, we identified 10,710 patients with newly diagnosed dementia between 2005 and 2014: 1785 had comorbid depression (group 1) and 8925 did not (group 2). Patients were tracked for 1 year to evaluate outpatient, emergency, and inpatient service utilization and length of hospital stay (LOS). Multivariable regression was applied to examine the association between comorbid depression and health-care utilization and analyze factors associated with inpatient visits and LOS.

RESULTS

Group 1 had significantly fewer outpatient visits (β = -0.115; p < 0.001), more inpatient visits (β = 0.157; p = 0.005), and a longer LOS (β = 0.191; p < 0.001) than did group 2. The groups did not differ significantly in emergency visits (β = 0.030; p = 0.537). In group 1, age, gender, and specific comorbidities were predictors of inpatient visits; those factors and salary-based insurance premiums were predictors of LOS.

CONCLUSION

Group 1 utilized less outpatient care but more inpatient care, suggesting health-care service for these patients may be needed to improvement.

Adult abuse and poor prognosis in Taiwan, 2000-2015: a cohort study

BACKGROUND

To investigate the risk of poor prognosis regarding schizophrenic disorders, psychotic disorders, suicide, self-inflicted injury, and mortality after adult violence from 2000 to 2015 in Taiwan.

METHODS

This study used data from National Health Insurance Research Database (NHIRD) on outpatient, emergency, and inpatient visits for two million people enrolled in the National Health Insurance (NHI) from 2000 to 2015. The case study defined ICD-9 diagnosis code N code 995.8 (abused adult) or E code E960-E969 (homicide and intentional injury of another). It analyzed first-time violence in adults aged 18-64 years (study group). 1:4 ratio was matched with injury and non-violent patients (control group). The paired variables were sex, age (± 1 year), pre-exposure to the Charlson comorbidity index, and year of medical treatment. Statistical analysis was conducted using SAS 9.4 and Cox regression for data analysis.

RESULTS

In total, 8,726 individuals experienced violence (case group) while34,904 did not experienced violence (control group) over 15 years. The prevalence of poor prognosis among victims of violence was 25.4/10⁴, 31.3/10⁴, 10.5/10,⁴ and 104.6/10⁴ for schizophrenic disorders, psychotic disorders, suicide or self-inflicted injury and mortality, respectively. Among adults, the risks of suicide or self-inflicted injury, schizophrenic disorders, psychotic disorders, and mortality after exposure to violence (average 9 years) were 6.87-, 5.63-, 4.10-, and 2.50-times (p < 0.01), respectively, compared with those without violence. Among males, the risks were 5.66-, 3.85-, 3.59- and 2.51-times higher, respectively, than those without violence (p < 0.01), and they were 21.93-, 5.57-, 4.60- and 2.46-times higher than those without violence (p < 0.01) among females.

CONCLUSION

The risk of poor prognosis regarding schizophrenic disorders, psychotic disorders, suicide, or self-inflicted injury and mortality after adult violence was higher than in those who have not experienced a violent injury. Adults at the highest risk for violent suicide or self-inflicted injuries due to exposure to violent injuries -males were at risk for schizophrenia and females were at risk for suicide or self-inflicted injuries. Therefore, it is necessary for social workers and medical personnel to pay attention to the psychological status of victims of violence.

Medical use and costs for native fathers and children from transnational marriage families in Taiwan from 2004 to 2017

Objectives

This is the first study to examine health care utilization in terms of medical use and costs in native fathers and children from transnational families.

Methods

Taiwan National Health Insurance Research Database was used to compare the annual medical use and inflation-adjusted medical cost for ambulatory care from 2004 to 2017 between native fathers and children from transnational and native families.

Results

Native fathers from transnational families had lower annual medical use (-0.23 visits) but higher total medical costs (New Taiwan dollars, NT$, 966), especially in dialysis and psychiatry, compared with those from native families. Unlike fathers from transnational families, their children were observed to consistently have lower medical use (-1.35 visits) and costs (NT$ -636), compared with those from native families.

Conclusions

There was different medical use and costs in transnational marriage families, possibly as a result of features in transnational marriage families. These findings provide insight for future health care policies to address the different health care utilization by exploring the unmet needs and barriers relating to children and fathers from transnational families.

Adults Suffering from Violence Are at Risk of Poor Prognosis in Taiwan, 2000-2015

Objective: To understand the risk of developing a poor prognosis in adulthood after violent injury in Taiwan. Methods: This study used the data of outpatients, from emergency departments, and from hospitalization of 2 million people under National Health Insurance from 2000 to 2015. The ICD-9 diagnostic code N-code was defined as the case of this study and was 995.8 (abused adult) or E-code was E960-E969 (homicide and intentional injury by others) The first violent injury of 18−64-year-old adults (the study group) was analyzed. Patients who had not suffered violent abuse were the control group. The groups were matched in a 1:4 ratio, and the paired variables were gender, age ±1 year, Charlson Comorbidity index (CCI) before exposure, and year of medical treatment. SAS 9.4 statistical software was used, and the Cox regression method was used for data analysis. Results: During the 15-year period, a total of 8726 people suffered from violence (34,904 controls). The incidences of common poor prognoses among the victims of violence were sleep disorder, anxiety, and depression, in 33.9%, 21.6%, and 13.2% of people, respectively. The risk (Adults, Overall) of developing Post-Traumatic Stress Disorder (PTSD), bipolar disorder, and manic disorder after being violently injured (average 9 years) was 34.86, 4.4, and 4.1 times higher than those who had not suffered violence (all p values < 0.01). The risk (Adults, Males) of developing PTSD, bipolar disorder, and manic disorder after being violently injured (average 9 years) was 30.0, 3.81, and 2.85 times higher, respectively, than those who had not suffered violence (all p values < 0.01). The risk (Adults, Females) of developing PTSD, manic disorder, and bipolar disorder after being violently injured (average 9 years) was 36.8, 6.71, and 5.65 times higher, respectively, than of those who had not suffered violence (all p values < 0.01). Conclusion: The risks of poor prognosis are higher in adults who have suffered violent abuse than in those who have not. Therefore, police, social workers, and medical personnel should pay attention to the mental state of victims of violence. They should aim to support prompt treatment, to avoid PTSD, bipolar disorder, manic disorder, etc.

Burden of mental disorders in children in the general population and in health facilities: discrepancies in years lived with disability based on national prevalence estimates between populations receiving care or not

Little is known about the discrepancies in the burden of child mental disorders based on differences in prevalence between populations with and without care. Identifying such discrepancies may help to elucidate the unmet needs related to child mental disorders. We compared the years lived with disability (YLD) between children with and without care for mental disorders using a representative national survey, Taiwan's National Epidemiological Study of Child Mental Disorders (TNESCMD), and a national health facility database, the Taiwan National Health Insurance Research Database (TNHIRD). The comorbidity-adjusted YLD rate ratio (RR) was reported to quantify the YLD discrepancy. The overall YLD rate for all mental disorders in the TNESCMD was 9.05 times higher than that in the TNHIRD with the lowest and highest YLD RRs for autism spectrum disorder (RR 3.51) and anxiety disorders (RR 360.00). Unlike the YLD proportion explained by attention-deficit/hyperactivity disorder and autism spectrum disorder, the proportions explained by anxiety disorders and conduct disorder/oppositional defiant disorder relative to the total YLD were relatively lower in the TNHIRD than in TNESCMD and the Global Burden of Disease 2016. The discrepancies in YLD between populations with and without care in child mental disorders ranged from ± 55% to 99% and had an overall value of ± 80.1%. High YLD discrepancies in child mental disorders between estimates based on the general population and those in health facilities suggest significant unmet needs for care in child mental disorders and that estimates of disease burden that rely heavily on a single source may result in unreliable results.

Exposure of Child Maltreatment Leads to a Risk of Mental Illness and Poor Prognosis in Taiwan: A Nationwide Cohort Study from 2000 to 2015

Objective: To investigate whether children with maltreatment exposure were associated with the risk of psychiatric disorders, suicide, and death. Methods: A retrospective cohort study was conducted, with 1592 child maltreatment cases and 6368 comparison cohort (1:4) matched for gender, age, and index year, from the Longitudinal Generation Tracking Database (LGTD2000) sampled from Taiwan National Health Insurance Research Database (NHIRD) in 2000, backtracking between 2000−2015 in Taiwan. The stratified Cox regression model was used to compare the risk of developing a mental illness and poor prognosis during the 15 years of follow-up. Results: There were 473 in the cohort with child maltreatment (675.10 cases per 100,000 person years) and 1289 in the comparison cohort (453.82 cases per 100,000 person years) that developed mental illness and poor prognosis. The stratified Cox regression model revealed that the adjusted hazard ratio (HR) was 1.91 to 11.76 (p < 0.05) after adjusting for monthly income level, occupation, and CCI after violence. Conclusion: Exposure to child maltreatment is associated with the risk of psychiatric disorders, but not suicide or death. This finding could be a reminder for clinicians about the mental health problems in patients with child maltreatment.

Impact of systemic lupus erythematosus on the 5-year survival of critically ill septic patients

Background

Infectious disease is an increasing threat to patients with systemic lupus erythematosus (SLE); however, the long-term outcome in critically ill septic patients with SLE remains unclear, and we aimed to address the impact of SLE on 5-year survival in critically ill septic patients.

Methods

We used the 2003–2017 nationwide data with 825,556 patients with sepsis in Taiwan. We identified lupus cases with sepsis that required admission to the intensive care unit and mechanical ventilation and selected controls matched (1:4) for age, sex, and index-year. Conditional logistic regression analysis was used to determine risk factors for mortality risk and shown as odds ratios (HRs) with 95% confidence intervals (CIs).

Results

A total of 513 SLE-sepsis patients and 2052 matched non-SLE septic individuals were enrolled. The mortality rate was higher in the SLE group (38.5 per 100,000 person-year) than that in the non-SLE group (13.7 per 100,000 person-year), with an IRR of 2.8 (95% CI, 2.5–3.2). We found that SLE was independently associated with a high mortality rate after adjusting relevant variables (HR 1.47, 95% CI 1.27–1.77). In addition to SLE, a higher age (HR 1.02, 95% CI 1.02–1.02), more comorbidities, and receiving prednisolone equivalent dose higher than 5 mg/day (HR 1.55, 95% CI 1.27–1.90), methotrexate (HR 2.19, 95% CI 1.61–2.99), and immunosuppressants (HR 1.45, 95% CI 1.22–1.74) were also independent risks for mortality.

Conclusions

We identified that SLE affects the long-term mortality in critically ill septic patients, and more studies are warranted for the underlying mechanism.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02649-x.

Air Pollutant Particles, PM2.5, Exposure and Glaucoma in Patients with Diabetes: A National Population-Based Nested Case-Control Study

The global prevalence of diabetes mellitus (DM) has reached 20%. Air pollutants with a particle size of less than 2.5 μm (PM_2.5) are a globally recognized risk factor for diabetes and glaucoma. We examined whether the risk of glaucoma would decrease or increase when patients with DM were exposed to different PM_2.5 concentrations. Data were obtained from the National Health Insurance Research Database (NHIRD) of Taiwan and the Air Quality Monitoring Network between 2008 and 2013. This nested case-control study involved 197 DM patients with glaucoma and 788 DM patients without glaucoma. Cases and controls were matched (1:4) by gender, age (±5 years), and index date (±6 months), and their data were entered in a logistic regression model adjusted for gender, age, urbanization level, income level, and comorbidities. The odds ratio (OR) of glaucoma at PM_2.5 exposure concentration in the fourth quartile (Q4) compared with in the first quartile (Q1) was 1.7 (95% CI: 1.084-2.764). For glaucoma risk, the OR was 1.013 (95% CI: 1.006-1.020) at a PM2.5 exposure concentration in Q1, 1.004 (95% CI: 1.001-1.007) in the third quartile (Q3), and 1.003 (95% CI: 1.001-1.004) in Q4. In the subgroup analysis of patients living in non-emerging towns and non-agricultural towns, the OR for glaucoma in Q4 compared with in Q1 was 2.1 (95% CI: 1.229-3.406) and 1.8 (95% CI: 1.091-2.803), respectively (p&nbsp;trend = 0.001 and 0.011). For patients without migraine, the OR for glaucoma was 1.7 (95% CI: 1.074-2.782; p = 0.006). These results demonstrate that, for patients with DM, PM_2.5 increased the risk of glaucoma and PM_2.5 was an independent risk factor for glaucoma in patients with DM.

Prior beta-blocker treatment improves outcomes in out-of-hospital cardiac arrest patients with non-shockable rhythms

The prognosis of out of cardiac arrest is poor and most cardiac arrest patients suffered from the non-shockable rhythm especially in patients without pre-existing cardiovascular diseases and medication prescription. Beta-blocker (ß-blocker) therapy has been shown to improve outcomes in cardiovascular diseases such as heart failure, ischemia related cardiac, and brain injuries. Therefore, we investigated whether prior ß-blockers use was associated with reduced mortality in patients with cardiac arrest and non-shockable rhythm. We conducted a population-based retrospective cohort study using multivariate propensity score-based regression to control for differences among patients with cardiac arrest. A total of 104,568 adult patients suffering a non-traumatic and non-shockable rhythm cardiac arrest between 2005 and 2011 were identified. ß-blocker prescription at least 30 days prior to the cardiac arrest event was defines as the ß-blockers group. We chose 12.5 mg carvedilol as the cut-off value and defined greater or equal to carvedilol 12.5 mg per day and its equivalent dose as high-dose group. After multivariate propensity score-based logistic regression analysis, patients with prior ß-blockers use were associated with better 1-year survival [adjusted odds ratio (OR), 1.15, 95% confidence interval (CI) 1.01-1.30; P = 0.031]. Compared to non-ß-blocker use group and prior low-dose ß-blockers use group, prior high-dose ß-blockers use group was associated with higher mechanical ventilator wean success rate (adjusted OR 1.19, 95% CI 1.01-1.41, P = 0.042). In conclusion, prior high dose ß-blockers use was associated with a better 1-year survival and higher weaning rate in patients with non-shockable cardiac arrest.

The Impact of Pharmaceutical Home Care on Medical Utilization for Frequent Users of Outpatient Services in Taiwan

Due to the high-accessibility and low-copayment of healthcare system in Taiwan, the clinical visit frequency of people is relatively high, which often leads to an excessively high healthcare expenditure. The aim of this research was to explore the effectiveness of pharmaceutical home care for frequent users of outpatient service and to analyze the impact of pharmaceutical home care on medical utilization. The study was based on the Taiwan National Health Insurance Research Database. Patients with over 100 clinical visits during 2010 to 2012 were selected as subjects. Whether these patients participate the experimental plan of pharmaceutical home care in the following year and the medical utilization of the research subjects were analyzed to compare the difference between participating group and non-participating group in this plan. The generalized estimating equation was employed to examine the difference of medical utilization. A total of 3943 subjects were included in this study, including 591 patients (14.99%) participating in the experimental plan. The average number of physician visits during the following year of the participating group was higher than that of the non-participating group by 0.12 visits, and the outpatient medical expense was lower than the non-participating group by 18,302 points (1 point = 0.03 US dollars). After participating in the plan, the average number of clinical visits of frequent users of outpatient services was significantly reduced by 6.63 visits, and the outpatient expense was significantly decreased by 9871 points. After joining the experimental plan of pharmaceutical home care, the average number of outpatient visits decreased significantly and the medical expense was lower when compared with those who did not participate in the plan.

Association of the Risk of Primary Sjögren's Syndrome With Fibrocystic Breast Disease: A Nationwide, Population-Based Study

Objective: Primary Sjögren's syndrome (pSS) is characterized by exocrine glandular inflammation; however, the association between preceding mammary-gland-inflammation-related diseases and newly diagnosed pSS remains unexplored.

Methods: We used the 2003–2013 data retrieved from Taiwan's National Health Insurance Research Database (NHIRD) to conduct the present population-based study. We identified newly diagnosed pSS female patients during the 2001–2013 period, as well as age-matched (1:20) and propensity-score-matched (1:2) non-SS individuals (as controls). We explored the associations between pSS and a history of mastitis and fibrocystic breast disease by determining adjusted odds ratios (aORs) with 95% confidence intervals (CIs) using a conditional logistical regression analysis after controlling for potential confounders.

Results: We identified 9,665 patients with pSS and 193,300 age-matched non-SS controls, as well as 9,155 SS cases and 18,310 propensity-score-matched non-SS controls. We found that fibrocystic breast disease (aOR, 1.75; 95% CI, 1.63–1.88) were independently associated with incident SS, whereas mastitis and childbirth-associated breast infections were not associated with incident SS. We also found positive associations between SS and previously reported SS-associated diseases, including cardiovascular diseases, thyroid diseases, pancreatitis, bronchiectasis, infectious diseases, osteoporosis, and ankylosing spondylitis. In the propensity-score-matched populations, the associations between pSS and fibrocystic breast disease (aOR, 1.74; 95% CI, 1.58–1.91) remained consistent.

Conclusion: The present population-based study revealed a previously unexplored association between pSS and history of fibrocystic breast disease, and the finding highlights the need to survey pSS in patients with mammary-gland-inflammation-associated diseases.

Low socio-economic status associated with increased risk of dengue haemorrhagic fever in Taiwanese patients with dengue fever: a population-based cohort study

BACKGROUND

Evidence indicates that socio-economic status (SES) may affect health outcomes in patients with chronic diseases. However, little is known about the impact of SES on the prognosis of acute dengue. This nationwide cohort study determined the risk of dengue haemorrhagic fever (DHF) in Taiwanese dengue fever patients from 2000 to 2014.

METHODS

From 1 January 2000, we identified adult dengue cases reported in the Taiwan Centers for Disease Control Notifiable Diseases Surveillance System Database. Dengue cases were defined as positive virus isolation, nucleic acid amplification tests or serological tests. Associations between SES and incident DHF were estimated using a Cox proportional hazards model.

RESULTS

Of 27 750 dengue patients, 985 (3.5%) had incident DHF during the follow-up period, including 442 (4.8%) and 543 (2.9%) with low and high SES, respectively. After adjusting for age, sex, history of dengue fever and comorbidities, low SES was significantly associated with an increased risk of incident DHF (adjusted hazard ratio [AHR] 1.61 [95% confidence interval {CI} 1.42 to 1.83]). Rural-dwelling dengue patients had a higher likelihood of DHF complication than their urban counterparts (AHR 2.18 [95% CI 1.90 to 2.51]).

CONCLUSIONS

This study suggests low SES is an independent risk factor for DHF. Future dengue control programs should particularly target dengue patients with low SES for improved outcomes.

An Exploratory Study of the Association between Housing Price Trends and Antidepressant Use in Taiwan: A 10-Year Population-Based Study

This study examined the relationship between various economic indexes and incidences of antidepressant prescriptions during 2001-2011 using the National Health Insurance Research Database (NHIRD). As of 2007, approximately 98.4% of Taiwanese people were enrolled in the NHIRD. In total, 531,281 records identified as antidepressant prescriptions were collected. Furthermore, 2556 quarterly observations from the Taiwan Housing Index (THI) and Executive Yuan were retrieved. We examined the association between the housing index and antidepressant prescription incidence. During the 10-year follow-up period, a higher incidence of antidepressant prescriptions was associated with the local maximum housing index. The relative risk of being prescribed antidepressant increased by 13.3% (95% confidence interval (CI): 1.01~1.27) when the THI reached a peak. For the low-income subgroup, the relative risk of being prescribed antidepressants increased by 28% during the high season of the THI. We also stratified the study sample on the basis of their sex, age, and urbanization levels. Both sexes followed similar patterns. During 2001-2011, although rising economic indexes may have increased incomes and stimulated the housing market, the compromise of public mental health could be a cost people have to pay additional attention to.

Association Between PM2.5 Exposure Level and Primary Open-Angle Glaucoma in Taiwanese Adults: A Nested Case-Control Study

Primary open-angle glaucoma (POAG) is the most common type of glaucoma. However, little is known about POAG in adults and exposure to air pollution. The current study aims to investigate whether exposure to particulate matter with a mass median aerodynamic diameter of ≤2.5 μm (PM_2.5) is associated with POAG diagnosis. Patient data were obtained from the Longitudinal Health Insurance Database 2010 (LHID2010) of Taiwan for the 2008–2013 period. PM_2.5 concentration data, collected from the Ambient Air Quality Monitoring Network established by the Environmental Protection Administration of Taiwan, were categorized into four groups according to World Health Organization (WHO) exposure standards for PM_2.5. We estimated the odds ratios (ORs) and 95% CIs for risk factors for POAG with logistic regression. The OR of per WHO standard level increase was 1.193 (95% CI 1.050–1.356). Compared with the normal level, the OR of WHO 2.0 level was 1.668 (95% CI 1.045–2.663, P < 0.05). After excluding confounding risk factors for POAG in this study, we determined that increased PM_2.5 exposure is related to POAG risk (ORs > 1, P < 0.05). In this study, PM_2.5 was an independent factor associated with open-angle glaucoma. Further research is required to better understand the mechanisms connecting PM_2.5 and open-angle glaucoma.

Effects of physical and social environments on the risk of dementia among Taiwanese older adults: a population-based case-control study

Background

Physical and social environments may influence cognition health in older adults. However, evidence regarding physical and social environments linked to dementia is lacking, especially in Asia. This study aims to explore the influence of physical and social environments on the incidence of dementia through a population-based case-control design in Taiwan.

Methods

We identified 26,206 incident cases with dementia aged≧65 years in 2010, with the same no. of controls from National Health Insurance claims. Environmental measures were collected from government statistics including three physical environments and three social environments. Multilevel logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CI) of the association between dementia incidence and the environmental measures at the township level.

Results

We observed a significant reduction of 12% in the odds ratios of dementia in areas with higher availability of playgrounds and sport venues (OR 0.88, 95% CI 0.81–0.95), after controlling for individual and other environmental characteristics. Community center availability was also significantly associated with an 8% decreased odds for dementia (OR 0.92, 95% CI 0.87–0.99), but the association was not significant after further consideration of individual-level characteristics. Although higher odds of dementia were found in areas with high median annual family income (OR 1.14, 95% CI 1.04–1.25), such a significant relationship did not appear in the full model.

Conclusions

Our study suggests that specific physical and social environmental features have different influences on the risk of dementia. Public health interventions may consider these environmental aspects for preventing dementia incidence.

Factors associated with sepsis risk in immune-mediated inflammatory diseases receiving tumor necrosis factor inhibitors: a nationwide study

Background:

Risk factors for sepsis have not been assessed in patients receiving tumor necrosis factor-alpha inhibitors (TNFi) for immune-mediated inflammatory diseases (IMIDs) who are vulnerable to serious/hospitalized infections.

Methods:

Data from 2003–2017 were obtained from Taiwan’s National Health Insurance Research Database to identify patients receiving TNFi, including etanercept, adalimumab, and golimumab, for IMIDs including rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriasis (PsO), psoriatic arthritis (PsA), Crohn’s disease (CD), and ulcerative colitis (UC). To investigate risk factors for sepsis, we used the Sepsis-3 definition and calculated hazard ratios (HRs) with 95% confidence intervals (CIs) using Cox regression analysis.

Results:

There were 17,764 patients (mean age 49.3 ± 14.3 years; females, 57.6%) receiving TNFi for IMIDs, including RA (58.6%), AS (19.1%), PsO (15.1%), PsA (2.5%), CD (3.0%), and UC (1.7%). The overall incidence rate of sepsis was 1088 per 100,000 person-years. After adjustment for potential confounders, recent sepsis within 3 months before TNFi initiation (HR, 2.35; 95% CI, 1.73–3.20), CD (HR, 3.36; 95% CI 2.11–5.34; reference group: AS) and glucocorticoid use (prednisolone-equivalent dose, mg/day HR, 1.05; 95% CI, 1.05–1.06) were associated with the risk of sepsis. Intriguingly, golimumab users appeared to have a lower risk of sepsis compared with etanercept users (HR, 0.56; 95% CI, 0.38–0.83). In addition, socioeconomic status, including urbanization level and insured amount, was associated with sepsis in a dose-response manner.

Conclusions:

Recent sepsis, CD, concomitant glucocorticoid use, and low socioeconomic status, which were associated with an increased risk of sepsis, are crucial for individualized risk management plans.

Tinnitus Among Patients With Anxiety Disorder: A Nationwide Longitudinal Study

OBJECTIVES

The association between tinnitus and anxiety disorder remains debated. We used a retrospective cohort study to investigate the relationship between anxiety disorder and tinnitus, aiming to decipher possible risk factors for tinnitus in patients with anxiety disorder.

METHOD

Data on a total of 7,525 patients with anxiety disorder and 15,050 patients without (comparison cohort) were extracted from the Longitudinal Health Insurance Database 2005 in Taiwan. The Kaplan-Meier estimator with the log rank test and the Cox proportional-hazard regression model were used to compare the incidence of tinnitus in both groups and to identify risk factors that predicted tinnitus.

RESULTS

After adjusting for related covariates, the hazard ratio for the development of tinnitus during the follow-up period was 3.54 (95% confidence interval: 3.11-4.02, P < .001) for anxiety disorder cohort relative to comparison cohort. Age ≧ 60 years, female sex, hypertension, and hyperlipidemia were statistically significant predictive risk factors of tinnitus in patients with anxiety disorder.

CONCLUSION

A significant increase in the lifetime incidence of tinnitus was exhibited in patients with anxiety disorder. Elderly subjects, female sex, hypertension, and hyperlipidemia were risk factors. Clinicians should be alert to the possibility of tinnitus in subjects with anxiety disorder.

Investigating the causal effect of socioeconomic status on quality of care under a universal health insurance system - a marginal structural model approach

Background

Social disparities in healthcare persist in the US despite the expansion of Medicaid under the Affordable Care Act. We investigated the causal impact of socioeconomic status on the quality of care in a setting with minimal confounding bias from race, insurance type, and access to care.

Methods

We designed a retrospective population-based study with a random 25% sample of adult Taiwan population enrolled in Taiwan’s National Health Insurance system from 2000 to 2016. Patient’s income levels were categorized into low-income group (<25th percentile) and high-income group (≥25th percentile). We used marginal structural modeling analysis to calculate the odds of hospital admissions for 11 ambulatory care sensitive conditions identified by the Agency for Healthcare Research and Quality and the odds of having an Elixhauser comorbidity index greater than zero for low-income patients.

Results

Among 2,844,334 patients, those in lower-income group had 1.28 greater odds (95% CI 1.24–1.33) of experiencing preventable hospitalizations, and 1.04 greater odds (95% CI 1.03–1.05) of having a comorbid condition in comparison to high-income group.

Conclusions

Income was shown to be a causal factor in a patient’s health and a determinant of the quality of care received even with equitable access to care under a universal health insurance system. Policies focusing on addressing income as an important upstream causal determinant of health to provide support to patients in lower socioeconomic status will be effective in improving health outcomes for this vulnerable social stratum.

Trends in the utilization of acupuncture among children in Taiwan from 2002 to 2011: a nationwide population-based study

BACKGROUND

In recent years, acupuncture has been increasingly integrated into pediatric care worldwide. However, recent epidemiological studies about pediatric users of acupuncture are lacking. The current study aimed to fill the gap and carry out the large-scale investigation on the basis of the pediatric population in Taiwan.

METHODS

We conducted a nationwide population-based study to investigate the utilization of acupuncture in Taiwan. We analyzed data from the Longitudinal Health Insurance Database 2000 (LHID 2000). The datasets contained all original claims data for 1 million beneficiaries who were randomly sampled from the registry of all beneficiaries enrolled in the Taiwan's National Health Insurance Program from January 1, 2000 to December 31, 2011. Children younger than 18 years old were enrolled into our study for analysis. The demographic data, treatment modalities and distributions by disease categories of the pediatric acupuncture users were analyzed by descriptive statistics. Logistic regression analysis was used to investigate the trends in acupuncture use over time.

RESULTS

The one-year prevalence of pediatric acupuncture users increased from 1.78% in 2002 to 5.34% in 2011. Acupuncture use significantly increased each year (p-value< 0.0001). Patients who were male, of greater age, resided in highly urbanized areas and suffered from injury or disorders of the musculoskeletal system were more likely to accept acupuncture treatment. Infantile cerebral palsy and psychoses were the top two health issues among those receiving complex acupuncture treatment. Older (> 9 years old) children tended to receive acupuncture treatment due to injury and musculoskeletal system disorders more than younger (≤9 years old) children.

CONCLUSIONS

Our study revealed that the utilization of acupuncture in pediatrics became increasingly popular year by year in Taiwan from 2002 to 2011. The results of this study may provide some valuable information for further clinical practice and acupuncture research, as well as to the government and societies concerning pediatric health care.

Incidence of Cellulitis Following Acupuncture Treatments in Taiwan

Background: Cellulitis is a complication of acupuncture, but the risk factors and annualized incidence remain unclear. Objective: This study analyzed the incidence and risk factors of cellulitis related to acupuncture in a cohort of one million participants derived from Taiwan’s Longitudinal Health Insurance Database. Methods: We tracked this cohort between 1997 and 2012 and recorded all outpatient medical information including diagnosis and treatment. Patients were categorized according to age, gender, comorbidities, residential area, and number of acupuncture treatments. We compared the incidence and risk of cellulitis between different demographics and comorbidities by logistic regression analysis and adjusted odds ratio (aOR) with a 95% confidence interval (95% CI). Results: We included 407,802 patients and 6,207,378 acupuncture treatments. The incidence of cellulitis after acupuncture was 64.4 per 100,000 courses of acupuncture treatment. The most common sites of cellulitis after acupuncture were the legs, feet, and face. Comorbidity was associated with post-acupuncture cellulitis; a multivariate logistic regression analysis showed that chronic kidney disease (aOR, 1.71; 95% CI, 1.55–1.88), rheumatoid arthritis (aOR, 1.86; 95% CI, 1.21–3.60), liver cirrhosis (aOR, 1.23; 95% CI, 1.15–1.32), diabetes mellitus (aOR, 1.69; 95% CI, 1.57–1.82), stroke (aOR, 1.44; 95% CI, 1.31–1.58), varicose veins (aOR, 2.38; 95% CI, 2.17–2.84), or heart failure (aOR, 1.81; 95% CI, 1.65–1.98) significantly increased cellulitis. Repeated exposure to acupuncture treatment was associated with an increased risk of cellulitis. Conclusions: A variety of chronic diseases may increase the risk of cellulitis after acupuncture. Physicians asked about past medical history before acupuncture might help to reduce cellulitis.

Influence of PM2.5 Exposure Level on the Association between Alzheimer's Disease and Allergic Rhinitis: A National Population-Based Cohort Study

Alzheimer's disease (AD) is an irreversible neurodegenerative disease that leads to dementia, health impairment, and high economic cost. Allergic rhinitis (AR) is a chronic inflammatory and allergic disease of the respiratory system that leads to health problems and has major effects on the daily lives of patients and their caregivers. Particulate matter (PM) refers to air pollutants 2.5 μm or less in diameter that are a source of concern because of their role in numerous diseases, including AR and other neurodegenerative diseases. To date, no study has demonstrated how PM_2.5 exacerbates AR and results in AD. We conducted a national population-based cohort study by obtaining patient data from the National Health Insurance Research Database of Taiwan for the 2008-2013 period. PM_2.5 concentration data were obtained from the ambient air quality monitoring network established by the Environmental Protection Administration of Taiwan. Monthly PM_2.5 exposure levels were categorized into quartiles from Q1-Q4. The Cox proportional hazards analysis, after adjusting for age, sex, low income, and urbanization level, revealed that patients with AR had an elevated risk of developing AD (hazard ratio (HR): 2.008). In addition, the cumulative incidence of AD in the AR group was significantly higher than in the comparison group. The PM_2.5 levels at Q2-Q4 (crude HR: 1.663-8.315; adjusted HR: 1.812-8.981) were stratified on the basis of the PM_2.5 exposure group and revealed that AR patients exposed to PM_2.5 are significantly prone to develop AD. In addition, the logistic regression analyses, after adjustment, demonstrated that an increase in the PM_2.5 exposure level at Q2-Q4 (adjusted odds ratio (OR): 2.656-5.604) increased the risk of AR in AD patients. In conclusion, an increased PM_2.5 exposure level could be correlated with AR, which could in turn cause AD. AR increased the risk of AD, in which exposure to PM_2.5 increases the higher probability of AD.

Shared prenatal impacts among childhood asthma, allergic rhinitis and atopic dermatitis: a population-based study

Background

Increasing prevalence of childhood allergic diseases including asthma is a global health concern, and we aimed to investigate prenatal risk factors for childhood asthma and to address the potential shared prenatal impacts among childhood asthma, allergic rhinitis (AR) and atopic dermatitis (AD).

Methods

We used two claim databases, including Taiwan Birth Cohort Study (TBCS) and National Health Insurance Research Database (NHIRD), to identify independent paired mother–child data (mother–child dyads) between 2006 and 2009. The association between prenatal factors and asthma was determined by calculating adjusted odds ratio (aOR) with 95% confidence interval (CI) using conditional logistic regression analysis.

Results

A total of 628,878 mother–child dyads were included, and 43,915 (6.98%) of children developed asthma prior to age 6. We found that male gender (aOR 1.50, 95% CI 1.47–1.53), maternal asthma (aOR 1.80, 95% CI 1.71–1.89), maternal AR (aOR 1.33, 95% CI 1.30–1.37), preterm birth (aOR 1.32, 95% CI 1.27–1.37), low birth weight (aOR 1.14, 95% CI 1.10–1.19) and cesarean section (aOR 1.10, 95% CI 1.08–1.13) were independent predictors for childhood asthma. A high urbanization level and a low number of older siblings were associated with asthma in a dose–response manner. Notably, we identified that the association between maternal asthma and childhood asthma (aOR 1.80, 95% CI 1.71–1.89) was stronger compared with those between maternal asthma and childhood AR (aOR 1.67, 95% CI 1.50–1.87) as well as childhood AD (aOR 1.31, 95% CI 1.22–1.40). Similarly, the association between maternal AR and childhood AR (aOR 1.62, 95% CI 1.53–1.72) was higher than those between maternal AR and childhood asthma (aOR 1.33, 95% CI 1.30–1.37) as well as childhood AD (aOR 1.35, 95% CI 1.31–1.40). Furthermore, the number of maternal allergic diseases was associated with the three childhood allergic diseases in a dose–response manner.

Conclusions

In conclusion, this population-based study provided evidence of prenatal impacts on childhood asthma and demonstrated the shared maternal impacts among childhood asthma, AR, and AD. These findings highlight the shared prenatal impacts among allergic diseases, and studies are warranted to address the pivotal pathway in allergic diseases.

Association of Environmental Features and the Risk of Alzheimer's Dementia in Older Adults: A Nationwide Longitudinal Case-Control Study

Little is known about the association between environmental features and the risk of Alzheimer’s dementia (AD). This study aims to investigate the association of physical and social environments with the incidence of AD. We identified 12,401 newly diagnosed AD cases aged ≥65 years in 2010, with the same no. of matched controls from National Health Insurance claims in Taiwan. Environmental data were collected from government statistics including three physical environments and three social environments. Multilevel logistic regression was conducted to calculate the odds ratios (OR) of AD in association with environmental features at the township level. Results showed that living in the areas with higher availability of playgrounds and sport venues was associated with a 3% decreased odds of AD (95% CI = 0.96–0.99), while higher density of elderly living alone was associated with a 5% increased odds of AD (95% CI = 1.01–1.11), after controlling for individual and other environmental factors. In further examination by urbanization level, the above relationships were found only in rural areas but not in urban areas. This study provides evidence that specific physical and social environmental features have different impacts on the risk of AD.

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.

Factors associated with healthcare utilization among community-dwelling elderly in Shanghai, China

OBJECTIVE

The objective of this study was to evaluate the factors associated with the health status of older Chinese people living in the community, in order to inform strategies to expand access to healthcare.

METHODS

Two-phase stratified cluster sampling was applied; 2000 older people participated in this study. Face-to-face interviews were conducted in Shanghai between June and August, 2011. Descriptive analysis was used to examine the respondents' characteristics. Based on Andersen's healthcare utilization model, a chi-squared test and multiple logistic regression were performed to examine the influences of predisposing, enabling, need, and contextual factors on healthcare utilization.

RESULTS

We found that 44.5% of the older people in the sample had good self-reported health status, while 12.8% were poor, 14.5% had visited hospitals or clinics as outpatients in the previous two weeks, and 16.5% had been hospitalized in the previous year. Logistic regression analysis revealed that outpatient health services were more likely to be used by women and those whose income was from friends or social relief, who had poor to good self-reported health status, who were experiencing declining health, who engaged in volunteer activities, and who had chronic diseases. Meanwhile, hospitalization was more likely among those in the older age groups, those with pension income, living in outer suburbs, with poor self-reported health status, experiencing difficulty with activities of daily living and outdoor activities, or having a chronic disease.

CONCLUSIONS

The results showed the impact of economic status, health status, demographic and social characteristics, and other factors on the health service utilization of elderly people living in the community in Shanghai. Need variables were the strongest predictors of health service use, although contextual factors also contributed.

Utilization of Chinese medicine for respiratory discomforts by patients with a medical history of tuberculosis in Taiwan

Background

Tuberculosis (TB) is one of the world’s major communicable infectious diseases, and it still imposes a great health burden in developing countries. The development of drug-resistant TB during the treatment increases the treatment complexity, and the long-term pulmonary complications after completing treatment raise the epidemic health burden. This study intended to investigate the utilization of Chinese medicine (CM) for respiratory symptoms by patients with a medical history of TB in Taiwan.

Methods

We analyzed a cohort of one million individuals who were randomly selected from the National Health Insurance Research Database in Taiwan. The inclusion criteria of patients (n = 7905) with history of TB (ICD-9-CM codes 010–018 and A02) were: (1) TB diagnosed between January 1, 1997 and December 31, 2010 (2) 18 years old or over (3) Clinical records for at least 2 months with complete demographic information (4) Record of treatment with first-line TB medication prescriptions. CM users for conditions other than respiratory discomforts (n = 3980) were excluded. Finally, a total of 3925 TB patients were categorized as: CM users for respiratory discomforts (n = 2051) and non-CM users (n = 1874).

Results

Among the 3925 subjects, 2051 (52.25%) were CM users, and 1874 (44.753%) were non-CM users. Female patients and those who were younger (18–39 y/o) and who lived in urbanized areas relatively tended to be CM users (p < .0001). Most of the CM users (1944, 94.78%) received Chinese medicines. The most commonly prescribed herbal formulas and single herbs were Xiao-Qing-Long-Tang and Radix Platycodonis (Jie-Geng), respectively. The core pattern of Chinese medicines for TB patients consisted of Ma-Xing-Gan-Shi-Tang, Bulbus Fritillariae Thunbergii (Bei-Mu), Radix Platycodonis (Jie-Geng) and Semen Armeniacae (Xing-Ren).

Conclusions

The use of CM is popular among patients with a medical history of TB complicated with long-term respiratory discomforts in Taiwan. Further pharmacological investigations and clinical trials are required.

Sleep disorders associated with risk of rheumatoid arthritis

BACKGROUND

Immune disorders impair sleep quality and sleep disorders (SDs) may derange immune function.

PURPOSE

The study evaluated the incidence and risk of rheumatoid arthritis (RA) in patients with SDs using a nationwide cohort.

METHODS

We recognized the patients with SDs from 1998 to 2002 by using the Taiwan National Health Insurance Research Database. One control patient for each SD patient was randomly selected and matched based on the proportion of age, sex, and index year. We calculated the person years of follow-up for each participant from the index date to RA diagnosis, censoring, or until December 31, 2011. The risk of RA was estimated by using Cox models incorporating demographics and comorbidities.

RESULTS

We enrolled 65,754 patients with SDs and 65,753 controls and followed for 637,906 and 662,514 person-years, respectively. The patients with SDs exhibited a 1.49-fold greater risk of RA development compared with the comparison cohort when we adjusted for covariates. The patients with sleep apnea (SA) showed the greatest incidence density rate of RA, followed by those with non-apnea SDs and the non-SD cohort (4.11, 3.29, and 2.15 per 10,000 person-years, respectively). The SA cohort had a 2.56-fold adjusted hazard ratio (aHR) of RA (95% confidence interval [CI] = 1.11-5.91) and the non-apnea SD cohort had a 1.47-fold aHR of RA (95% CI = 1.18-1.84) compared with the non-SD cohort. Women with SDs presented a considerable risk of developing RA.

CONCLUSIONS

This nationwide cohort study indicates that SDs are associated with the risk of RA development.

Association between socioeconomic status and cerebral palsy

Background

The present study investigated the annual prevalence of cerebral palsy (CP) among children aged <7 years in Taiwan and the association between socioeconomic status and CP prevalence.

Methods

Data from the Taiwan National Health Insurance Research Database for the 2002−2008 period were used in this population-based study. Severe and total CP were defined according to catastrophic illness certificate and medical claim records, respectively. The annual CP prevalence was calculated as the number of children with CP among all children aged <7 years.

Results

From 2002 to 2008, the annual prevalence of total and severe CP ranged from 1.9 to 2.8 and from 1.1 to 1.4 per 1000 children, respectively. Boys were 30% more likely to have CP than girls [adjusted relative risk (RR) and 95% confidence interval (CI) ranged from 1.3 (1.2−1.4) to 1.4 (1.2−1.5)]. Low family income was associated with a higher CP prevalence [adjusted RR (95% CI) ranged from 5.1 (4.2−6.2) to 6.4 (5.4−7.6)]. The prevalence of CP in rural area was higher than that in urban or suburban areas. The mortality rate of severe CP ranged from 12.2−22.7 per 1000 children within the 7 years study period.

Conclusions

The prevalence of CP in Taiwan is similar to that in Western countries. A higher prevalence of CP is associated with male sex, low income, and rural residential location. Our findings provide insights into CP epidemiology among the Chinese population.

The association between methylphenidate treatment and the risk for fracture among young ADHD patients: A nationwide population-based study in Taiwan

Attention-deficit hyperactivity disorder (ADHD) is associated with higher risk for fracture. Whether the medical treatment for ADHD would mitigate the risk remains unclear. In this study, we sought to investigate the effect of methylphenidate treatment on risk for fracture, as well the moderational role of treatment duration on the risk of fracture, in a large national sample. Cases less than 18 years old were identified from Taiwan's National Health Insurance Research Database with a new primary diagnosis of ADHD (ICD-9:314) between 1996 and 2013. A total of 6201 cases with ADHD were included as the study cohort. The cases were divided into 3 groups according to the duration of methylphenidate treatment (0, 1-180, and more than 180 days). All groups were followed until the end of 2013 for first diagnoses of fracture (ICD-9 codes 800 to 829). Cox proportional hazards models were applied. Compared to the group without methylphenidate treatment, the risk for fracture was lower among the group treated for more than 180 days. The adjusted hazard ratio was 0.77 (95% Confidence interval: 0.63-0.94). The groups treated for 180 days or fewer had no significant difference in the risk for fracture. In conclusion, methylphenidate treatment was associated with lower risk for fracture among ADHD patients. The association was evident only in the cohort treated for more than 180 days.

Acute hospital administration of amiodarone and/or lidocaine in shockable patients presenting with out-of-hospital cardiac arrest: A nationwide cohort study

BACKGROUND

Terminating ventricular fibrillation (VF) or pulseless ventricular tachyarrhythmia (VT) is critical for successful resuscitation of patients with shockable cardiac arrest. In the event of shock-refractory VF, applicable guidelines suggest use of anti-arrhythmic agents. However, subsequent long-term outcomes remain unclear. A nationwide cohort study was therefore launched, examining 1-year survival rates in patients given amiodarone and/or lidocaine for cardiac arrest.

METHODS

Medical records accruing between years 2004 and 2011 were retrieved from the Taiwan National Health Insurance Research Database (NHIRD) for review. This repository houses all insurance claims data for nearly the entire populace (>99%). Candidates for study included all non-traumatized adults receiving DC shock and cardiopulmonary resuscitation immediately or within 6h of emergency room arrival. Analysis was based on data from emergency rooms and hospitalization.

RESULTS

One-year survival rates by treatment group were 8.27% (534/6459) for amiodarone, 7.15% (77/1077) for lidocaine, 11.10% (165/1487) for combined amiodarone/lidocaine use, and 3.26% (602/18,440) for use of neither amiodarone nor lidocaine (all, p<0.0001). Relative to those given neither medication, odds ratios for 1-year survival via multiple regression analysis were 1.84 (95% CI: 1.58-2.13; p<0.0001) for amiodarone, 1.88 (95% CI: 1.40-2.53; p<0.0001) for lidocaine, and 2.18 (95% CI: 1.71-2.77; p<0.0001) for dual agent use.

CONCLUSIONS

In patients with shockable cardiac arrest, 1-year survival rates were improved with association of using amiodarone and/or lidocaine, as opposed to non-treatment. However, outcomes of patients given one or both medications did not differ significantly in intergroup comparisons.

The Utilization of Rehabilitation in Patients with Hemophilia A in Taiwan: A Nationwide Population-Based Study

INTRODUCTION

Rehabilitation plays an important role in the physical health of patients with hemophilia. However, comprehensive information regarding the utilization of rehabilitation for such patients remains scarce.

AIM

This population-based study aimed to examine the characteristics, trends, and most important factors affecting rehabilitation usage in patients with hemophilia A using a nationwide database in Taiwan.

METHODS

Data from 777 patients with hemophilia A who were registered in the National Health Insurance Research Database between 1998 and 2008 were analyzed using SAS 9.0.

RESULTS

Musculoskeletal or nervous system-related surgical procedures and clotting factor VIII concentrate costs were identified as factors affecting rehabilitation usage; musculoskeletal or nervous system-related surgical procedures (odds ratio = 3.788; P < 0.001) were the most important predictor of whether a patient with hemophilia A would use rehabilitation services. Joint disorders, arthropathies, bone and cartilage disorders, intracranial hemorrhage, and brain trauma were common diagnoses during rehabilitation use. The costs of physical therapy (physiotherapy) comprised the majority (71.2%) of rehabilitation therapy categories. Increasingly, rehabilitation therapy was performed at physician clinics. The total rehabilitation costs were <0.1% of the total annual medical costs.

CONCLUSION

Musculoskeletal or nervous system-related surgical procedures and increased use of clotting factor VIII concentrate affect the rehabilitation utilization of patients with hemophilia A the most. The findings in this study could help clinicians comprehensively understand the rehabilitation utilization of patients with hemophilia A.

The Risk of Nephrolithiasis Among Patients With Ankylosing Spondylitis: a Population-Based Cohort Study

Objectives

This study aims to investigate the correlation of ankylosing spondylitis (AS) with nephrolithiasis by performing a nationwide population- based cohort study.

Patients and methods

The data used in this retrospective cohort study were collected from the Taiwan National Health Insurance Research database. The study included a total of 3,334 AS patients (1,914 males, 1,420 females; mean age 44.51±16.83 years; range 22 to 79 years) and 13,336 non-AS patients (7,656 males, 5,680 females; mean age 44.27±17.01 years; range 21 to 78 years) who had been followed-up on an average of 6.78 years and 6.75 years, respectively, between January 2000 and December 2008.

Results

The percentage of newly diagnosed nephrolithiasis was 4.8% in all study subjects. However, the percentages of newly diagnosed nephrolithiasis were 5.76% and 4.58% in the AS and non-AS cohorts, respectively. After adjusting the patients' sex, age, urbanization level, and comorbidities, the hazard ratio obtained from our multivariable Cox model was 1.19.

Conclusion

Our study findings indicate that patients with AS are more likely to develop nephrolithiasis than non-AS patients.

First Fall-Related Injuries Requiring Hospitalization Increase the Risk of Recurrent Injurious Falls: A Nationwide Cohort Study in Taiwan

Objectives

Recurrent falls not only have risk factors different from those of single falls but also have less favorable outcomes. The aim of our study was to determine the association between the injury characteristics of a first fall and the likelihood of recurrent injurious falls in a cohort of hospitalized patients.

Methods

We designed a nationwide retrospective cohort study and selected hospitalized patients who had injurious falls between 2001 and 2010. Cox proportional hazards models were used to estimate the hazard ratios (HRs) of recurrent injurious falls requiring hospitalization in the following year on the basis of the patients’ demographic characteristics, comorbidities, and the characteristics of injuries from the first injurious fall requiring hospitalization.

Results

Among the 504 512 patients hospitalized for injurious falls, 19 442 experienced recurrent injurious falls requiring hospitalization. The 1-year incidence of recurrent injurious falls requiring hospitalization was 3.85%. The incidence density was the highest within the 3-month period after the first injurious fall. The risk of recurrent injurious falls among patients aged 40 to 64, 65 to 74, and ≥ 75 years increased progressively (HR: 2.11, 95% confidence interval [CI]: 1.90–2.34; HR: 2.80, 95% CI: 2.51–3.11; and HR: 3.80, 95% CI: 3.42–4.23, respectively). The length of hospitalization (LOH) ≥ 15 or ≥ 31 days (HR: 1.39, 95% CI: 1.30–1.48; and HR: 1.59, 95% CI: 1.43–1.77, respectively) and injury to the head (HR: 1.59, 95% CI: 1.53–1.65) or spine (HR: 1.66, 95% CI: 1.59–1.74) were also found to be major risk factors.

Conclusions

Our findings show that the LOH and head and spine injuries are associated with an increased risk of recurrent injurious falls leading to hospitalization. The risk of recurrent injurious falls requiring hospitalization increased significantly among adults older than 40 years. We suggest further research on the effects of injury characteristics associated with the first injurious fall requiring hospitalization and resultant anatomical damages on the risk of recurrent injurious falls requiring hospitalization. High-risk patients should receive tailored rehabilitation addressing their respective injuries within 3 months after hospital discharge.

The benefit of early rehabilitation following tendon repair of the hand: A population-based claims database analysis

STUDY DESIGN

A retrospective cohort.

INTRODUCTION

The benefits of early rehabilitation after hand tendon repair have not been analyzed using population-based datasets.

PURPOSE OF THE STUDY

to analyze whether early rehabilitation reduces the resurgery risk and the use of rehabilitation resources.

METHODS

Patients (n = 1219) who underwent hand tendon repairs followed by rehabilitation were identified from a nationwide claims database and divided into 3 groups: early (<1 wk after tendon repair), intermediate (1-6 wk), or late (>6 wk) rehabilitation. The resurgery rate and the use of rehabilitation resources after tendon repair were calculated. Cox proportional hazards models were used to evaluate the relevant predictors of resurgery.

RESULTS

The early rehabilitation group exhibited the lowest resurgery rate and used the fewest rehabilitation resources. Compared with late rehabilitation, early or intermediate rehabilitation conferred protective effects against resurgery in patients without a concomitant upper-limb fracture.

CONCLUSION

Our findings suggest the benefit of early rehabilitation after hand tendon repair.

LEVEL OF EVIDENCE

4.

Increasing trend in emergency department visits for hypoglycemia from patients with type 2 diabetes mellitus in Taiwan

AIMS

We analyze the time trends of hypoglycemia-related emergency department visits in Taiwan between 2000 and 2010, focusing on type 2 diabetic patients receiving antidiabetic agents.

METHODS

From a national dataset containing longitudinal medical claims of one million persons, we ascertained 4479 hypoglycemia-related emergency department visits from 3184 type 2 diabetic patients for analysis. We used negative binomial regression to calculate the incidence rate ratios (IRRs) for comparing event rates of hypoglycemia-related emergency department visits in different study periods.

RESULTS

Rates of hypoglycemia-related emergency department visits increased 4.8 folds from year 2000 to 2010 (adjusted IRR 4.88, 95% CI 3.94-6.05, P<0.001). Severe hypoglycemia requiring emergency department visits prevailed among women, older patients (≥ 65 years), and those not lived in the urban areas.

CONCLUSIONS

Within a 10-year period, there was a substantial increase in the rates of hypoglycemia-related emergency department visits from type 2 diabetic patients in Taiwan. Appropriate risk management plans should be developed to prevent the occurrence of severe hypoglycemia in patients with type 2 diabetes in Taiwan.

Association of systemic lupus erythematosus and sleep disorders: a nationwide population-based cohort study

Objective

Using a population-based cohort study, we investigated whether sleep disorders (SDs) increase the risk of systemic lupus erythematosus (SLE).

Patients and methods

We identified patients with SDs and a control cohort from 1998–2001 by using the Taiwan Longitudinal Health Insurance Database 2000. Two controls for each patient with an SD were selected and randomly frequency-matched according to age, gender, and index year. The follow-up person–years were estimated for the patients from the index date to SLE diagnosis, loss to follow-up, or the end of 31 December 2011. We used the Cox proportional hazards models to evaluate how SDs influence the risk of SLE after adjustments for demographic factors and comorbidities.

Results

A total of 144,396 subjects (48,132 SD cases and 96,264 controls) were followed for 1,477,055 person–years. The patients with SDs displayed higher incidence density rate of developing SLE than did the controls (1.03 vs 0.46 per 10,000 person–years). After adjustment for covariates, the patients with SDs exhibited a 2.20-fold higher adjusted hazard ratio (aHR) of developing SLE than the controls (95% confidence interval (CI) = 1.44–3.36). Women exhibited a greater prevalence of SDs and SLE compared to men. Patients with SDs aged 49 years and younger exhibited a significantly increased risk of SLE compared to the controls (aHR=2.30, 95% CI = 1.33–3.98). Patients with SDs living in urban areas exhibited a significantly increased risk of SLE.

Conclusion

This large population-based cohort study revealed that SDs increase the risk of SLE development.

Increased risk of dementia in patients exposed to nitrogen dioxide and carbon monoxide: a population-based retrospective cohort study

Background

The air pollution caused by vehicular emissions is associated with cognitive decline. However, the associations between the levels of nitrogen dioxide (NO₂) and carbon monoxide (CO) exposure and dementia remain poorly defined and have been addressed in only a few previous studies.

Materials and Methods

In this study, we obtained data on 29547 people from the National Health Insurance Research Database (NHIRD) of Taiwan, including data on 1720 patients diagnosed with dementia between 2000 and 2010, and we evaluated the risk of dementia among four levels of air pollutant. Detailed data on daily air pollution were available from January 1, 1998 to December 31, 2010. Yearly average concentrations of pollutants were calculated from the baseline to the date of dementia occurrence, withdrawal of patients, or the end of the study, and these data were categorized into quartiles, with Q1 being the lowest level and Q4 being the highest.

Results

In the case of NO₂, the adjusted hazard ratios (HRs) of dementia for all participants in Q2, Q3, and Q4 compared to Q1 were 1.10 (95% confidence interval (CI), 0.96–1.26), 1.01 (95% CI, 0.87–1.17), and 1.54 (95% CI, 1.34–1.77), and in the case of CO, the adjusted HRs were 1.07 (95% CI, 0.92–1.25), 1.37 (95% CI, 1.19–1.58), and 1.61 (95% CI, 1.39–1.85).

Conclusion

The results of this large retrospective, population-based study indicate that exposure to NO₂ and CO is associated with an increased risk of dementia in the Taiwanese population.

Effects of changes in health insurance reimbursement level on outpatient service utilization of rural diabetics: evidence from Jiangsu Province, China

Background

Outpatient reimbursement levels of the New Rural Cooperative Medical Scheme have changed in recent years in China, and those changes may have a greater impact on patients with chronic diseases due to their higher outpatient expenses. This study represents the first attempt to identify the effects of reimbursement level on outpatient service utilization for chronic patients in rural China and it also gives strong estimation results by conducting a tracer illness study in order to control for possible biases associated with studying several diseases together.

Methods

This study used difference-in-differences models to examine how changes in yearly maximum reimbursement amount and outpatient reimbursement rates affected rural residents with type 2 diabetes in three counties in Jiangsu Province, China. Other factors, such as sex, age and severity of illness, were also included in the model estimations. To make sure the treated group and control group are comparable, Propensity Score Match (PSM) was used to analysis the gender, age and severity of illness of the two groups.

Results

The results indicate that an increase in yearly maximum reimbursement amount for outpatient visits could cause an increase in yearly total outpatient expenses for patients with type 2 diabetes mellitus. However, changes in outpatient reimbursement rates between 2010 and 2011 did not significantly affect the utilization of different types of health institution.

Conclusions

The reimbursement rates of village clinics should be substantially increased from the existing basis and the gap of reimbursement rates among different institutions should be further widened. It is also important for village clinics to improve their services. Moreover, measures to improve the quality of care and scope of services at lower-level healthcare institutions, and promote the health service utilization of rural women should be considered.