Hospice utilization during the SARS outbreak in Taiwan

Hospice and Palliative Care during Disasters: A Systematic Review

Providing and maintaining hospice and palliative care during disasters poses significant challenges. To understand the impact of disasters on the provision of hospice and palliative care and the disaster preparedness initiatives in the field, a systematic review was undertaken. Eligibility criteria for the selection of studies were: peer-reviewed original research papers addressing HPC during disasters published between January 2001 and February 2023 in English. The databases CINAHL, MEDLINE, APA PsycInfo, APA PsycArticles, and SocINDEX were searched with textword and MeSh-terms between October 2022 and February 2023. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the studies. Content analysis was performed. The results are presented in the form of a narrative synthesis. Of 2581 studies identified, 57 met the inclusion criteria. Most studies were published recently on the impact of the COVID-19 pandemic. Four main themes were identified in the literature: disruption of the system, setting-specific differences, emotional challenges, and system adaptation. Overall, strategies to tackle hospice and palliative care needs have been poorly integrated in disaster preparedness planning. Our findings highlight the need to strengthen the resilience of hospice and palliative care providers to all types of disasters to maintain care standards.

End-of-life care in natural disasters including epidemics and pandemics: a systematic review

BACKGROUND

Natural disasters are becoming more frequent and severe, and place additional strains on end-of-life care services and users. Although end-of-life and palliative care are considered essential components of disaster planning and response, there are gaps in understandings about their real-life application, and how natural disasters impact end-of-life care.

OBJECTIVE

To synthesise existing evidence of the impacts of natural disasters (eg, bushfires, communicable pandemics, etc) on end-of-life care.

METHODS

A systematic review with a narrative synthesis was undertaken. The review was registered on PROSPERO (registration: CRD42020176319). PubMed, Scopus, PsycINFO, Science Direct and Web of Science were searched for studies published in English between 2003 and 2020, with findings explicitly mentioning end-of-life care impacts in relation to a natural disaster. Articles were appraised for quality using a JBI-QARI tool.

RESULTS

Thirty-six empirical studies met the inclusion criteria and quality assessment. Findings were synthesised into three key themes: impacts on service provision, impacts on service providers and impacts on service users. This review demonstrates that natural disasters impact profoundly on end-of-life care, representing a stark departure from a palliative care approach.

CONCLUSIONS

Clinical practitioners, policy makers and researchers must continue to collaborate for viable solutions to achieve universal access to compassionate and respectful end-of-life care, during natural disasters. Using models, policies and practices already developed in palliative care, involving those most impacted in disaster planning and anticipating barriers, such as resource shortages, enables development of end-of-life care policies and practices that can be rapidly implemented during natural disasters.

The Impact of COVID-19 on Pediatric Healthcare Utilization and Disease Dynamics: An Observational Study From Western Odisha

Introduction

Children were affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus during the first and second waves of the coronavirus disease 2019 (COVID-19 pandemic. Although the severity was less in children, the fear of contracting SARS-CoV-2 at the hospital might have led to a delayed health-seeking attitude. The objective of the study was tailored around emergency health care utilization affecting outcomes. The study was done to compare the trend concerning the utilization of pediatric healthcare and immunization services, changes in the profile of diseases, and the outcomes between the pre-COVID-19 period and the COVID-19 period in a tertiary care hospital.

Methods

This retrospective observational study was conducted in a tertiary care hospital in western Odisha. Data were collected retrospectively from different hospital registers (outpatient register, inpatient register, and immunization records) and analyzed between the pre-COVID-19 period (April 2019 to March 2020) and the COVID-19 period (April 2020 to March 2021) with appropriate statistical procedures.

Results

There was a 60%, 49.8%, 51.1%, and 25.5% reduction in outpatient attendance, indoor pediatric admissions, nutritional rehabilitation centre admissions, and newborn admissions, respectively in COVID-19 period as compared to the pre-COVID-19 period. The pediatric bed occupancy rate was reduced by 54.5%. Unfavourable outcomes (death, left against medical advice, and referral) were significantly high in hospitalized children (24% vs. 18.1%, p < 0.001). The reduction in hospitalization due to common conditions like acute respiratory tract infections, bronchiolitis and asthma, and acute gastroenteritis during COVID-19 was 76.5%, 86.2%, and 39.5%, respectively. A higher percentage of low birth weight and preterm (<34 weeks) babies were admitted to special neonatal care unit (SNCU) during the pandemic (61.8% vs. 58%, p < 0.05; 18.9% vs. 15.8%; p < 0.05 respectively).

Conclusion

The COVID-19 pandemic and the associated lockdown led to a significant decrease in pediatric and neonatal healthcare utilization. The impact of lower care-seeking and attendance resulting in poor patient-related outcomes (malnutrition, upsurge of vaccine-preventable diseases, disease-specific hospitalization, and mortality) post-pandemic is a real threat.

Complexity of the Diagnosis of COVID-19 in the Context of Pandemicity: Need for Excellence in Diagnostic Acumen

Coronavirus disease 2019 (COVID-19) is a highly infectious disease that has caused a pandemic devastating many countries worldwide. It is a complex and multifaceted disease with a unique coronavirus etiology, pathogenesis, zoonotic, and human-to-human transmission, causing acute respiratory distress syndrome with high mortality. Accurate and timely diagnosis is of utmost importance. In this study, we discussed the complexities of COVID-19 diagnostic elements in the context of pandemicity, drawing from our awareness, observations, and lessons learned from two previous coronavirus pandemics, namely SARS-CoV (severe acute respiratory syndrome coronavirus) in 2002 and MERS-CoV (Middle East respiratory syndrome-related coronavirus) in 2012, and how they applied to the diagnosis of COVID-19 today. Diagnosis of COVID-19 takes place without physician-patient personal contact due to isolation or quarantine or in the hospital setting, emergency units, and critical care units with the cumbersome barriers of personal protective equipment. Technical diagnosis is important, but we also emphasized the human impact of diagnosing COVID-19. Conveying the diagnosis of a critical disease to patients and families requires aspects of excellence in professionalism: ethics, empathy, and humility. Diagnostic skills in COVID-19 should extend to prognostication for patients suffering at the end of life, so that they will not be deprived of high-quality palliative care and comfort.

The Challenges of Caring for People Dying From COVID-19: A Multinational, Observational Study (CovPall)

CONTEXT

Systematic data on the care of people dying with COVID-19 are scarce.

OBJECTIVES

To understand the response of and challenges faced by palliative care services during the COVID-19 pandemic, and identify associated factors.

METHODS

We surveyed palliative care and hospice services, contacted via relevant organizations. Multivariable logistic regression identified associations with challenges. Content analysis explored free text responses.

RESULTS

A total of 458 services responded; 277 UK, 85 rest of Europe, 95 rest of the world; 81% cared for patients with suspected or confirmed COVID-19, 77% had staff with suspected or confirmed COVID-19; 48% reported shortages of Personal Protective Equipment (PPE), 40% staff shortages, 24% medicines shortages, 14% shortages of other equipment. Services provided direct care and education in symptom management and communication; 91% changed how they worked. Care often shifted to increased community and hospital care, with fewer admissions to inpatient palliative care units. Factors associated with increased odds of PPE shortages were: charity rather than public management (OR 3.07, 95% CI 1.81-5.20), inpatient palliative care unit rather than other settings (OR 2.34, 95% CI 1.46-3.75). Being outside the UK was associated with lower odds of staff shortages (OR 0.44, 95% CI 0.26-0.76). Staff described increased workload, concerns for their colleagues who were ill, whilst expending time struggling to get essential equipment and medicines, perceiving they were not a front-line service.

CONCLUSION

Palliative care services were often overwhelmed, yet felt ignored in the COVID-19 response. Palliative care needs better integration with health care systems when planning and responding to future epidemics/pandemics.

Palliative Care in Toronto During the COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19) first emerged in China in December 2019 and was declared a pandemic by the World Health Organization on March 11, 2020. Clinicians around the world looked to cities that first experienced major surges to inform their preparations to prevent and manage the impact the pandemic would bring to their patients and health care systems. Although this information provided insight into how COVID-19 could affect the Canadian palliative care system, it remained unclear what to expect. Toronto, the largest city in Canada, experienced its first known case of COVID-19 in January 2020, with the first peak in cases occurring in April and its second wave beginning this September. Despite warnings of increased clinical loads, as well as widespread shortages of staff, personal protection equipment, medications, and inpatient beds, the calls to action by international colleagues to support the palliative care needs of patients with COVID-19 were not realized in Toronto. This article explores the effects of the pandemic on Toronto's palliative care planning and reports of clinical load and capacity, beds, staffing and redeployment, and medication and PPE shortages. The Toronto palliative care experience illustrates the international need for strategies to ensure the integration of palliative care into COVID-19 management, and to optimize the use of palliative care systems during the pandemic.

Repeated filling of elastomeric infuser pumps for home-based subcutaneous medications: a case series

BACKGROUND

Several medical devices have been developed for continuous subcutaneous drug infusion for home palliative care (HPC), such as elastomeric infuser pumps (EIP). There is no evidence on the repeated filling of EIP for continuous subcutaneous delivery for HPC.

AIM

A clinical case series report of terminally-ill patients cared for in HPC, with repeated filling of EIPs for home-based subcutaneous medications.

METHODS

A retrospective analysis of each patient's EIP-related entries in an anonymised database regarding: 1) EIP general functioning aspects; 2) clinical aspects: symptom control and local skin complications. Overall and per-patient cost-saving was also calculated.

FINDINGS

A total of 10 cases were analysed (four 50-hour EIP and six 30-hour EIP). All EIPs had a mean number of refillings (standard deviation (SD), mode) of 1.6 ((0.5), 2); with 3.2 drugs on average used in each EIP ((1.4), 4). Approximate total mean (SD) usage time for both types of EIP was 87 (29) hours; and all EIP were used, on average (SD), 49 (23) hours more than its labelled duration. All EIPs showed a complete reservoir deflation between refilling. Only one patient had a minor skin complication and no symptom aggravation was observed, except for two cases with mild anxiety and agitation. Cost-saving analysis for the complete case series showed that EIP refillings saved, on average, €24 per-patient and a total of nearly €240, for both types of infuser pumps.

CONCLUSION

This preliminary study suggests that refilling is safe and reduces cost. Future research on EIP refilling using controlled and systematic methodologies are warranted.

Effect of the COVID-19 lockdown on disease recognition and utilisation of healthcare services in the older population in Germany: a cross-sectional study

BACKGROUND

There is little evidence about the utilisation of healthcare services and disease recognition in the older population, which was urged to self-isolate during the COVID-19 lockdown.

OBJECTIVES

We aimed to describe the utilisation of physician consultations, specialist referrals, hospital admissions and the recognition of incident diseases in Germany for this age group during the COVID-19 lockdown.

DESIGN

Cross-sectional observational study.

SETTING

1,095 general practitioners (GPs) and 960 specialist practices in Germany.

SUBJECTS

2.45 million older patients aged 65 or older.

METHODS

The number of documented physician consultations, specialist referrals, hospital admissions and incident diagnoses during the imposed lockdown in 2020 was descriptively analysed and compared to 2019.

RESULTS

Physician consultations decrease slightly in February (-2%), increase before the imposed lockdown in March (+9%) and decline in April (-18%) and May (-14%) 2020 compared to the same periods in 2019. Volumes of hospital admissions decrease earlier and more intensely than physician consultations (-39 versus -6%, respectively). Overall, 15, 16 and 18% fewer incident diagnoses were documented by GPs, neurologists and diabetologists, respectively, in 2020. Diabetes, dementia, depression, cancer and stroke were diagnosed less frequently during the lockdown (-17 to -26%), meaning that the decrease in the recognition of diseases was greater than the decrease in physician consultations.

CONCLUSION

The data suggest that organisational changes were adopted quickly by practice management but also raise concerns about the maintenance of routine care. Prospective studies should evaluate the long-term effects of lockdowns on patient-related outcomes.

Caring Advanced Cancer Patients at Home During COVID-19 Outbreak: Burnout and Psychological Morbidity Among Palliative Care Professionals in Italy

CONTEXT

Providing palliative care (PC) at home for patients with advanced cancer has become essential during the COVID-19 emergency. Nevertheless, the home PC professionals (PCPs) faced a challenging situation because of increased number of discharged patients, reduced availability of health-care facilities, and physical/relational barriers between them and patients.

OBJECTIVES

This study aimed to investigate the impact of COVID-19 pandemic on burnout and psychological morbidity among home PCPs in Italy.

METHODS

One hundred and ninety-eight PC physicians and nurses working in home assistance in Italy were invited to participate. The results obtained by the investigation conducted during the COVID-19 emergency (COVID2020) were compared with data collected in 2016 in the same setting (BURNOUT2016). The questionnaires (socio-demographics, Maslach Burnout Inventory and General Health Questionnaire-12) were the same for both the surveys. The PCPs participating in COVID2020 survey (n = 145) were mostly the same (70%) who participated in the BURNOUT2016 study (n = 179).

RESULTS

One hundred and forty-five PCPs participated in the study (response rate 73.2%). During the COVID-19 emergency, home PCPs presented a lower burnout frequency (P < .001) and higher level of personal accomplishment than in 2016 (P = .047). Conversely, the risk for psychological morbidity was significantly higher during the pandemic (P < .001).

CONCLUSIONS

In the age of COVID-19, the awareness of being at the forefront of containing the pandemic along with the sense of responsibility toward their high-risk patients may arouse PCPs' psychological distress, but, on the other hand, this condition may improve their sense of professional satisfaction and personal accomplishment.

Were Clinical Routines for Good End-of-Life Care Maintained in Hospitals and Nursing Homes During the First Three Months of the Outbreak of COVID-19? A National Register Study

CONTEXT

Although the coronavirus disease 2019 (COVID-19) pandemic might affect important clinical routines, few studies have focused on the maintenance of good quality in end-of-life care.

OBJECTIVES

The objective was to examine whether adherence to clinical routines for good end-of-life care differed for deaths because of COVID-19 compared with a reference cohort from 2019 and whether they differed between nursing homes and hospitals.

METHODS

Data about five items reflecting clinical routines for persons who died an expected death from COVID-19 during the first three months of the pandemic (March-May 2020) were collected from the Swedish Register of Palliative Care. The items were compared between the COVID-19 group and the reference cohort and between the nursing home and hospital COVID-19 deaths.

RESULTS

About 1316 expected deaths were identified in nursing homes and 685 in hospitals. Four of the five items differed for total COVID-19 group compared with the reference cohort: fewer were examined by a physician during the last days before death, pain and oral health were less likely to be assessed, and fewer had a specialized palliative care team consultation (P < 0.0001, respectively). Assessment of symptoms other than pain did not differ significantly. The five items differed between the nursing homes and hospitals in the COVID-19 group, most notably regarding the proportion of persons examined by a physician during the last days (nursing homes: 18%; hospitals: 100%).

CONCLUSION

This national register study shows that several clinical routines for end-of-life care did not meet the usual standards during the first three months of the COVID-19 pandemic in Sweden. Higher preparedness for and monitoring of end-of-life care quality should be integrated into future pandemic plans.

Learning a palliative care approach during the COVID-19 pandemic: A case study in an Infectious Diseases Unit

BACKGROUND

Hospital palliative care is an essential part of the COVID-19 response, but relevant data are lacking. The recent literature underscores the need to implement protocols for symptom control and the training of non-specialists by palliative care teams.

AIM

The aim of the study was to describe a palliative care unit's consultation and assistance intervention at the request of an Infectious Diseases Unit during the COVID-19 pandemic, determining what changes needed to be made in delivering palliative care.

DESIGN

This is a single holistic case study design using data triangulation, for example, audio recordings of team meetings and field notes.

SETTING/PARTICIPANTS

This study was conducted in the Palliative Care Unit of the AUSL-IRCCS hospital of Reggio Emilia, which has no designated beds, consulting with the Infectious Diseases Unit of the same hospital.

RESULTS

A total of 9 physicians and 22 nurses of the Infectious Diseases Unit and two physicians of the Palliative Care Unit participated in the study.Our Palliative Care Unit developed a feasible 18-day multicomponent consultation intervention. Three macro themes were identified: (1) new answers to new needs, (2) symptom relief and decision-making process, and (3) educational and training issues.

CONCLUSION

From the perspective of palliative care, some changes in usual care needed to be made. These included breaking bad news, patients' use of communication devices, the limited time available for the delivery of care, managing death necessarily only inside the hospital, and relationships with families.

Changing patterns of mortality during the COVID-19 pandemic: Population-based modelling to understand palliative care implications

BACKGROUND

COVID-19 has directly and indirectly caused high mortality worldwide.

AIM

To explore patterns of mortality during the COVID-19 pandemic and implications for palliative care, service planning and research.

DESIGN

Descriptive analysis and population-based modelling of routine data.

PARTICIPANTS AND SETTING

All deaths registered in England and Wales between 7 March and 15 May 2020. We described the following mortality categories by age, gender and place of death: (1) baseline deaths (deaths that would typically occur in a given period); (2) COVID-19 deaths and (3) additional deaths not directly attributed to COVID-19. We estimated the proportion of people who died from COVID-19 who might have been in their last year of life in the absence of the pandemic using simple modelling with explicit assumptions.

RESULTS

During the first 10 weeks of the pandemic, there were 101,614 baseline deaths, 41,105 COVID-19 deaths and 14,520 additional deaths. Deaths in care homes increased by 220%, while home and hospital deaths increased by 77% and 90%, respectively. Hospice deaths fell by 20%. Additional deaths were among older people (86% aged ⩾ 75 years), and most occurred in care homes (56%) and at home (43%). We estimate that 22% (13%-31%) of COVID-19 deaths occurred among people who might have been in their last year of life in the absence of the pandemic.

CONCLUSION

The COVID-19 pandemic has led to a surge in palliative care needs. Health and social care systems must ensure availability of palliative care to support people with severe COVID-19, particularly in care homes.

Impact of the COVID-19 Pandemic on the Utilization of Hospice Care Services: A Cohort Study in Taiwan

CONTEXT

Hospice care focuses on improving the quality of end-of-life care and respecting patients' preferences regarding end-of-life treatment. The impact of coronavirus disease 2019 (COVID-19) on the utilization of hospice services is unknown.

OBJECTIVES

To investigate the utilization of hospice care services before and during the COVID-19 pandemic.

METHODS

All patients (n = 19,900) cared for at Taipei City Hospital from January 2019 to April 2020 were divided into three time points: January-April 2019 (before COVID-19), May-December 2019 (interim), and January-April 2020 (during COVID-19). This cohort study compared the monthly utilization of hospice services before and during the COVID-19 pandemic.

RESULTS

There was no significant difference in hospice home visits (194 vs. 184; P = 0.686) and new enrollments (15 vs. 14; P = 0.743) to hospice home care before and during the pandemic. However, the bed occupancy rate in hospice units in the hospital was significantly reduced from 66.2% before the pandemic to 37.4% during the pandemic (P = 0.029), whereas that in nonhospice units had a nonsignificant decrease from 81.6% before the pandemic to 71.8% during the pandemic (P = 0.086). During the pandemic, the number of inpatient days was affected more severely in hospice units than in nonhospice units (-42.4% vs. -10.9%; P = 0.029).

CONCLUSIONS

This study suggests that hospice home care services were maintained during the COVID-19 pandemic, while the utilization of hospice inpatient care services reduced. Home care for hospice patients is an essential component of palliative care during a pandemic.

Palliative Care Utilization Among Patients With COVID-19 in an Underserved Population: A Single-Center Retrospective Study

BACKGROUND

As health-care institutions mobilize resources to address the coronavirus disease 2019 (COVID-19) pandemic, palliative care may potentially be underutilized. It is important to assess the use of palliative care in response to the COVID-19 pandemic.

METHODS

This is a retrospective single-center study of patients with COVID-19 diagnosed via reverse transcriptase-polymerase chain reaction assay admitted between March 1, 2020, and April 24, 2020. An analysis of the utilization of palliative care in accordance with patient comorbidities and other characteristics was performed while considering clinical outcomes. Chi-square test was used to determine associations between categorical variables while t-tests were used to compare continuous variables.

RESULTS

The overall mortality rate was 21.5% (n = 52), and in 48% (n = 25) of these patients, palliative care was not involved. Fifty-nine percent (n = 24) of those who had palliative consults eventually elected for comfort measures and transitioned to hospice care. Among those classified as having severe COVID-19, only 40% (n = 31) had palliative care involvement. Of these patients with severe COVID-19, 68% (n = 52) died. Patients who got palliative care consults were of older age, had higher rates of intubation, a need for vasopressors, and were dead.

CONCLUSION

There was a low utilization rate of palliative care in patients with COVID-19. Conscious utilization of palliative care is needed at the time of COVID-19.

The Role and Response of Palliative Care and Hospice Services in Epidemics and Pandemics: A Rapid Review to Inform Practice During the COVID-19 Pandemic

Cases of coronavirus disease 2019 (COVID-19) are escalating rapidly across the globe, with the mortality risk being especially high among those with existing illness and multimorbidity. This study aimed to synthesize evidence for the role and response of palliative care and hospice teams to viral epidemics/pandemics and inform the COVID-19 pandemic response. We conducted a rapid systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in five databases. Of 3094 articles identified, 10 were included in this narrative synthesis. Included studies were from West Africa, Taiwan, Hong Kong, Singapore, the U.S., and Italy. All had an observational design. Findings were synthesized using a previously proposed framework according to systems (policies, training and protocols, communication and coordination, and data), staff (deployment, skill mix, and resilience), space (community provision and use of technology), and stuff (medicines and equipment as well as personal protective equipment). We conclude that hospice and palliative services have an essential role in the response to COVID-19 by responding rapidly and flexibly; ensuring protocols for symptom management are available, and training nonspecialists in their use; being involved in triage; considering shifting resources into the community; considering redeploying volunteers to provide psychosocial and bereavement care; facilitating camaraderie among staff and adopting measures to deal with stress; using technology to communicate with patients and carers; and adopting standardized data collection systems to inform operational changes and improve care.

Response and role of palliative care during the COVID-19 pandemic: A national telephone survey of hospices in Italy

BACKGROUND

Palliative care is an important component of health care in pandemics, contributing to symptom control, psychological support, and supporting triage and complex decision making.

AIM

To examine preparedness for, and impact of, the COVID-19 pandemic on hospices in Italy to inform the response in other countries.

DESIGN

Cross-sectional telephone survey, in March 2020.

SETTING

Italian hospices, purposively sampled according to COVID-19 regional prevalence categorised as high (>25), medium (15-25) and low prevalence (<15) COVID-19 cases per 100,000 inhabitants. A brief questionnaire was developed to guide the interviews. Analysis was descriptive.

RESULTS

Seven high, five medium and four low prevalence hospices provided data. Two high prevalence hospices had experienced COVID-19 cases among both patients and staff. All hospices had implemented policy changes, and several had rapidly implemented changes in practice including transfer of staff from inpatient to community settings, change in admission criteria and daily telephone support for families. Concerns included scarcity of personal protective equipment, a lack of hospice-specific guidance on COVID-19, anxiety about needing to care for children and other relatives, and poor integration of palliative care in the acute planning response.

CONCLUSION

The hospice sector is capable of responding flexibly and rapidly to the COVID-19 pandemic. Governments must urgently recognise the essential contribution of hospice and palliative care to the COVID-19 pandemic and ensure these services are integrated into the health care system response. Availability of personal protective equipment and setting-specific guidance is essential. Hospices may also need to be proactive in connecting with the acute pandemic response.

Palliative care in the context of a pandemic: similar but different

Palliative care is an important component of the medical response to pandemics and other health emergencies. The principles of palliative care do not change, but the practice of palliative care has to change as a result of factors such as greater demand and infection control measures. This article makes suggestions for palliative care provision during a pandemic (in developed countries), based on a limited review of the literature and personal experience of the ongoing pandemic (COVID-19 infection).

Health care utilization and health outcomes: a population study of Taiwan

Facing escalating health care expenditures, the governments of countries with national health insurance programs are trying to control or even to reduce health care utilization. Little research has examined the effects of decreased health care utilization on health outcomes. Applying a natural experiment design to the Taiwan population between 2000 and 2004, which includes the 2003 SARS epidemic when an average 20% decline in health care utilization occurred, this study examines the association between a decline in health care utilization and health outcomes measured by cause-specific mortality rates. We analyse the monthly mortality rates caused by infectious diseases, cancer, diabetes mellitus, nervous system diseases, cerebrovascular diseases, heart and other vascular diseases, respiratory system diseases, digestive system diseases, genitourinary system diseases and accidents. Models control for age, sex, month and year effects. Results show the heterogeneous effect of reduced health care utilization on health outcomes. Patients with diabetes mellitus or cerebrovascular diseases are vulnerable to short-term reductions in health care; compared with the non-SARS period, mortality caused by diabetes mellitus and cerebrovascular diseases significantly increased during the SARS epidemic by 8.4% and 6.2%, respectively. No significant change in mortality rates caused by the other diseases or accidents is found. This study suggests that governments of countries where health care utilization and spending are similar to or inferior to those in Taiwan should carefully evaluate the impact of policies that attempt to reduce health care utilization. Furthermore, when an area encounters an epidemic, governments should be aware of the negative consequences of voluntary restraints on access to health care that accompany decreases in utilization.

Uniformed service nurses' experiences with the severe acute respiratory syndrome outbreak and response in Taiwan

Severe Acute Respiratory Syndrome (SARS) had an enormous effect on Taiwan's public health and the nation's economy. To prevent the spread of the epidemic, the government implemented strategies and measures for the control of the epidemic. The Ministry of National Defense also fully supported epidemic prevention by mobilizing all necessary human and material resources. Under the plan executed by the Ministry of National Defense, the SongShan Armed Forces Hospital became Taiwan's first hospital dedicated exclusively for the treatment of patients with SARS. Uniformed Service Nurses' devoted to caring for patients with SARS during the outbreak made significant contributions to the prevention and control of SARS.

Palliating a pandemic: "all patients must be cared for"

In the event of an overwhelming influenza pandemic, many health care systems will implement a triage system that would potentially deny critical care treatment to some seriously ill patients. Although all triage systems have guaranteed palliative care for those who are denied critical care, no jurisdiction has yet developed a plan to accommodate the anticipated "surge" in demand for palliative care. The authors present a mathematical and ethical justification for a palliative care surge plan and outline some of the key elements that should be included in such a plan.

Hospitalization for ambulatory-care-sensitive conditions in Taiwan following the SARS outbreak: a population-based interrupted time series study

BACKGROUND/PURPOSE

In 2003, the severe acute respiratory syndrome (SARS) outbreak resulted in 8096 probable cases and 774 deaths in 26 countries. The purpose of this study was to explore the effect of the SARS outbreak on hospitalization for chronic ambulatory-care-sensitive conditions (ACSCs) in Taiwan.

METHODS

We applied a population-based interrupted time series study design and used the time series auto-regressive integrated moving-average model to compare the actual and predicted admission rates of seven selected chronic ACSCs. The analyses were based on National Health Insurance hospital inpatient claims data from 1997 to 2003.

RESULTS

The impact of SARS on ACSCs after the outbreak varied among seven selected chronic conditions. Hospitalization for respiratory conditions was significantly lower than the predicted values, whereas hospitalization for diabetes was significantly higher than the predicted values after the outbreak.

CONCLUSION

Admission rates for most ACSCs, except for diabetes, did not change in the post-SARS period. The reductions in outpatient utilization during the SARS outbreak did not appear to affect adversely admissions for most ACSCs.

Impact of SARS on healthcare utilization by disease categories: implications for delivery of healthcare services

Objective

To assess the impact of the SARS epidemics in Taiwan on ambulatory care and inpatient utilization by disease categories and accreditation levels of hospital.

Methods

The National Health Insurance claims data of Taipei were analyzed. We calculated the changes in utilization between June 2002 and June 2003 to estimate the impact that SARS had on utilization.

Results

The top three disease categories with the most significant drop in utilization were gastroenteritis (−53%), acute bronchitis (−45%), and tonsillitis (−40%) in ambulatory care and acute bronchitis (−82%), gastroenteritis (−72%), and pneumonia (−64%) in inpatient care. On the other hand, the disease categories with the smallest reduction were allergic reactions (−4%), skin infections (−6%), and anxiety (−10%) in ambulatory care and respiratory failure (+40%), delivery (−2%), and fractures of lower limbs (−5%) in inpatient care.

Conclusions

Disease categories could be classified into three groups according to the extent of change in utilization during the SARS outbreaks. Diseases with a prominent reduction were respiratory diseases, minor problems, and elective procedures. Diseases with a moderate reduction were mainly chronic diseases. Diseases with a limited reduction were acute conditions, difficult mental disorders, or procedures that could not be postponed. The utilization of some diseases shifted significantly from medical centers to district hospitals or clinics.