Lifetime risks, loss of life expectancy, and health care expenditures for 19 types of cancer in Taiwan

Impact of Healthy Lifestyle Factors on Life Expectancy and Lifetime Health Care Expenditure: Nationwide Cohort Study

BACKGROUND

The association between lifestyle risk factors and the risk of mortality and chronic diseases has been established, while limited research has explored the impact of healthy lifestyle factors on lifetime health care expenditure using longitudinal individual data.

OBJECTIVE

We aimed to determine the individual and combined effects of 5 healthy lifestyle factors on life expectancy and lifetime health care expenditure in Taiwan.

METHODS

Using data from the National Health Interview Survey cohort, 5 healthy lifestyle behaviors were defined and analyzed: nonsmoking, avoiding excessive alcohol consumption, engaging in sufficient physical activity, ensuring sufficient fruit and vegetable intake, and maintaining a normal weight. We used a rolling extrapolation algorithm that incorporated inverse probability of treatment weighting to estimate the life expectancy and lifetime health care expenditure of the study populations with and without healthy lifestyle factors.

RESULTS

A total of 19,893 participants aged ≥30 (mean age 48.8, SD 13.4) years were included, with 3815 deaths recorded during a median follow-up period of 15.6 years. The life expectancy and per capita estimated lifetime health care expenditures for the overall study population were 35.32 years and US $58,560, respectively. Multivariable-adjusted hazard ratios for all-cause mortality in participants adhering to all 5 healthy lifestyle factors, compared with those adhering to none, were 0.37 (95% CI 0.27-0.49). We found significant increases in life expectancy for nonsmokers (2.31 years; 95% CI 0.04-5.13; P=.03), those with sufficient physical activity (1.85 years; 95% CI 0.25-4.34; P=.02), and those with adequate fruit and vegetable intake (3.25 years; 95% CI 1.29-6.81; P=.01). In addition, nonsmokers experienced a significant reduction in annual health care expenditure (-9.78%; 95% CI -46.53% to -1.45%; P=.03), as did individuals maintaining optimal body weight (-18.36%; 95% CI -29.66% to -8.57%; P=.01). Overall, participants adhering to all 5 healthy lifestyle behaviors exhibited a life gain of 7.13 years (95% CI 1.33-11.11; P=.02) compared with those adhering to one or none, with a life expectancy of 29.19 years (95% CI 25.45-33.62). Furthermore, individuals adopting all 5 healthy lifestyle factors experienced an average annual health care expenditure reduction of 28.12% (95% CI 4.43%-57.61%; P=.02) compared with those adopting one or none.

CONCLUSIONS

Adopting a healthy lifestyle is associated with a longer life expectancy and a reduction of health care expenditure in Taiwanese adults. This contributes to a more comprehensive understanding of the impact of healthy lifestyle factors on the overall health and economic burden.

Estimating Taiwan's QALY league table for catastrophic illnesses: Providing real-world evidence to integrate prevention with treatment for resources allocation

BACKGROUND/PURPOSE

Curative technologies improve patient's survival and/or quality of life but increase financial burdens. Effective prevention benefits all three. We summarize estimation methods and provide examples of how much money is spent per quality-adjusted life year (QALY) or life year (LY) on treating a catastrophic illness under a lifetime horizon and how many QALYs/LYs and lifetime medical costs (LMC) could be potentially saved by prevention.

METHODS

We established cohorts by interlinkages of Taiwan's nation-wide databases including National Health Insurance. We developed methods to estimate lifetime survival functions, which were multiplied with the medical costs and/or quality of life and summed up to estimate LMC, quality-adjusted life expectancy (QALE) and lifetime average cost per QALY/LY for catastrophic illnesses. By comparing with the age-, sex-, and calendar year-matched referents simulated from vital statistics, we obtained the loss-of-QALE and loss-of-life expectancy (LE).

RESULTS

The lifetime cost-effectiveness ratios of ventilator-dependent comatose patients, dialysis, spinal cord injury, major trauma, and cancers were US$ 96,800, 16,200-20,000, 5500-5,900, 3400-3,600, and 2900-11,900 per QALY or LY, respectively. The successful prevention of lung, liver, oral, esophagus, stomach, nasopharynx, or ovary cancer would potentially save US$ 28,000-97,000 and > 10 QALYs; whereas those for end-stage kidney disease, stroke, spinal injury, or major trauma would be US$ 55,000-300,000 and 10-14 QALYs. Loss-of-QALE and loss-of-LE were less confounded indicators for comparing the lifetime health benefits of different technologies estimated from real-world data.

CONCLUSIONS

Integration of prevention with treatment for resources allocation seems feasible and would improve equity and efficiency.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HIGHLIGHTS

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

Lifetime risk, life expectancy, loss-of-life expectancy and lifetime healthcare expenditure for Stevens-Johnson syndrome/toxic epidermal necrolysis in Taiwan: follow-up of a nationwide cohort from 2008 to 2019

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) not only cause acute, devastating mucocutaneous reactions but also have long-lasting implications on survivors' lives.

OBJECTIVES

To quantify the lifetime burden of SJS/TEN.

METHODS

The cumulative incidence rate (CIR), life expectancy (LE), loss-of-life expectancy (LoLE) and lifetime healthcare expenditure (HE) for SJS/TEN were estimated over the period from 2008 to 2019 using data from the National Health Insurance Research Database of Taiwan and life tables of vital statistics.

RESULTS

In this nationwide cohort of 6552 incident SJS/TEN cases, a trend towards a decrease in the CIR was observed between 2008 and 2019. Compared with the general population, patients with SJS/TEN experience a tremendous loss of 9.43 (1.06) [mean (SEM)] years of LE after diagnosis of SJS/TEN. Male patients with SJS/TEN had higher LoLE [10.74 (1.22) vs. 7.69 (1.43) years] and annual HE than females. Younger age at diagnosis of SJS/TEN was associated with longer LE but greater LoLE and higher lifetime HE. Patients with intensive care unit admission on diagnosis, malignancy, diabetes mellitus, end-stage renal disease and SJS/TEN-associated sequelae experienced substantially greater LoLE and HE per life year.

CONCLUSIONS

Patients with SJS/TEN suffer substantial loss-of-LE and HE, particularly young patients, compared with the general population. These data provide a reference estimate of the lifetime burden of SJS/TEN to help health authorities evaluate the cost-effectiveness of future preventive and treatment strategies to minimize the burden of SJS/TEN.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Resilience among women with breast cancer surviving longer than five years: The relationship with illness perception and body image

PURPOSE

This study aimed to investigate the correlations and identify the relationships between the resilience, perception of illness and body image of women with breast cancer in the 5-year-or-above survivorship.

METHODS

We used convenient sampling to recruit from an outpatient department 106 women with breast cancer. The inclusion criteria were participants aged >20 years currently in a stable condition and were able to understand the Chinese language. Those women with mental health illness were excluded. All participants completed questionnaires on the following: demographic information, revision of illness perception (IPQ-R), body image scale (BIS), Eysenck personality questionnaire (EPQ), and resilience scale (RS). We conducted the structural equation modeling (SEM) to explore the factor structure.

RESULTS

SEM results showed a good fit to the data (comparative fit index = 0.97, Tucker-Lewis index = 0.94). Findings F indicated the existence of significant relationships between resilience and either illness perception or body image. Personality had a direct association with illness perception (β = 0.73, P < 0.05). Body image had an indirect effect on the relationship between resilience and illness perception (coefficient = -2.52; 95% bootstrapping CI = -31.36, -0.62).

CONCLUSIONS

Results indicated that illness perception is a crucial predictor for better resilience as mediated through body image. To provide adequate information to women with breast cancer can improve their perception of breast cancer more positively. Hence, their body image and their way of coping with survival life turn better.

Lifetime exposure to PM2.5 air pollution and disability-adjusted life years due to cardiopulmonary disease: A modeling study based on nationwide longitudinal data

BACKGROUND

As knowledge of the health risks of PM_2.5 has grown, the focus of PM_2.5-related health impact assessments has evolved from simple risk models to burden-of-disease estimates. We proposed an ecological approach to directly estimate the impacts of lifetime exposure to PM_2.5 on expected health losses due to cardiopulmonary diseases for older adult populations in Taiwan.

METHODS

We created study cohorts of 3.5 million older people living in 350 townships in Taiwan. We used a weighted regression model, with adjustments of area characteristic variables, to directly estimate the impacts of lifetime mean PM_2.5 exposure on health losses among the 350 cohorts. Potential avoidable disability-adjusted life years (DALYs) by assuming that ambient PM_2.5 met the air quality standard was estimated.

RESULTS

Each 10 μg/m³ increase in lifetime mean exposure to PM_2.5 for an individual corresponded to an increment of 0.25 (95 % confidence interval (CI): 0.18-0.32) DALYs due to cardiopulmonary diseases, after adjusting for a wide range of ecological covariates. We estimated that 611.8 (95 % CI: 440.4-783.2) DALYs per 1000 older adult population could potentially be avoided by achieving air quality standards of WHO in Taiwan.

CONCLUSIONS

Reducing PM_2.5 pollution in Taiwan associated with significant health co-benefits, providing important implications for public health and environmental management.

Lin H, Hwang JS. Mortality risk and years of life lost for people with reduced renal function detected from regular health checkup: A matched cohort study

With the increasing threat of metabolic syndromes, a focus on maintaining kidney health from early- to mid-adulthood is necessary. This study elucidates mortality risk and years of life lost (YLLs) due to abnormal renal function. This was a retrospective, matched cohort study from health checkup data from 2000 to 2015. We identified 12,774 participants with abnormal renal function (eGFR < 60 mL/min/1.73 m²) and used propensity score matching to identify 25,548 participants with normal renal function (eGFR ≥ 60). YLLs were estimated using the life expectancy differences between the abnormal and matched normal cohorts. Cox models were used to estimate the adjusted mortality risk. The estimated life expectancy of participants with proteinuria and eGFR < 60 was 26.24 years, with a 95 % confidence interval of (23.96, 29.36), 17.62 (16.37, 18.78), and 11.70 (11.02, 12.46) for age groups of 30 - 54, 55 - 64, and 65 - 79 years, respectively. The estimated YLLs of participants with proteinuria and eGFR < 60, as compared with the matched normal cohort, were 17.86 (13.41, 20.36), 12.55 (11.41, 13.78), and 8.31 (7.47, 9.13) years for the three age groups, respectively. The Cox model estimates of mortality hazard ratios of participants having proteinuria and eGFR < 60 against matched referents were 5.29 (3.97, 7.05), 3.99 (3.34, 4.75), and 3.05 (2.62, 3.55) for the three age groups, respectively. Abnormal renal function shortens life expectancy, particularly in patients with proteinuria and in younger adults. Active health management of renal function can reduce the disease burden.

How aging of the global population is changing oncology

Population aging is causing a demographic redistribution with implications for the future of healthcare. How will this affect oncology? First, there will be an overall rise in cancer affecting older adults, even though age-specific cancer incidences continue to fall due to better prevention. Second, there will be a wider spectrum of health functionality in this expanding cohort of older adults, with differences between “physiologically older” and “physiologically younger” patients becoming more important for optimal treatment selection. Third, greater teamwork with supportive care, geriatric, mental health and rehabilitation experts will come to enrich oncologic decision-making by making it less formulaic than it is at present. Success in this transition to a more nuanced professional mindset will depend in part on the development of user-friendly computational tools that can integrate a complex mix of quantitative and qualitative inputs from evidence-based medicine, functional and cognitive assessments, and the personal priorities of older adults.

Survival-Weighted Health Profiles in Patients Treated for Advanced Oral Cavity Squamous Cell Carcinoma

Objectives

For patients with oral cavity squamous cell carcinoma (OSCC), particularly for those with advanced disease, quality of life (QoL) is a key outcome measure. Therefore, we estimated survival-weighted psychometric scores (SWPS), life expectancy (LE), and quality-adjusted LE (QALE) in patients with advanced OSCC.

Methods and Materials

For estimation of survival function, we enrolled 2313 patients with advanced OSCC diagnosed between January 1, 2007, and December 31, 2013. The patients were followed until death or December 31, 2014. To acquire the QoL data, data from 194 patients were collected by employing the Taiwan Chinese versions of the Quality of Life Questionnaire Core 30 and Quality of Life Questionnaire Head and Neck 35 developed by the European Organisation for Research and Treatment of Cancer and the EQ-5D-3L between October 1, 2013, and December 31, 2017. The LE of the patients with OSCC were estimated through linear extrapolation of a logit-transformed curve. SWPS and QALE were determined by integrating the LE and corresponding QoL outcomes.

Results

For the patients with advanced OSCC, the estimated LE and QALE were 8.7 years and 7.7 quality-adjusted life years (QALYs), respectively. The loss of LE and QALE was 19.0 years and 20.0 QALYs, respectively. The estimated lifetime impairments of swallowing, speech, cognitive functioning, physical functioning, social functioning, and emotional functioning were 8.3, 6.5, 6.5, 6.1, 5.7, and 5.4 years, respectively. The estimated lifetime problems regarding mouth opening, teeth, social eating, and social contact were 6.6, 6.1, 7.5, and 6.1 years, respectively. The duration of feeding tube dependency was estimated to be 1.6 years.

Conclusions

Patients with advanced OSCC had an estimated LE of 8.7 years and QALE of 7.7 QALYs. SWPS provided useful information regarding how advanced OSCC affects the subjective assessment of QoL. Our study results may serve as a reference for the allocation of cancer treatment resources.

Associations between LncRNA MALAT1 Polymorphisms and Lymph Node Metastasis in Prostate Cancer

Current evidence elucidates that long noncoding RNA metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) could regulate genetic expression and play a crucial role in both the diagnosis and prognosis of prostate cancer. Single-nucleotide polymorphisms (SNPs) of MALAT1 could alter the oncogenesis in various cancers. However, the associations between MALAT1 SNPs and prostate cancer have barely been investigated to date. This study included 579 patients with prostate cancer who received robotic-assisted radical prostatectomy at Taichung Veterans General Hospital from 2012 to 2017. Three SNPs of MALAT1 were analyzed to identify the impacts of SNPs on the clinicopathologic features in Taiwanese prostate cancer. Our results show that patients with a polymorphic G allele at rs619586 had a significantly higher risk of being in an advanced Gleason grade group (AOR: 1.764; 95% CI: 1.011–3.077; p = 0.046). Moreover, individuals with at least one polymorphic A allele at MALAT1 rs1194338 in the PSA >10 ng/mL group were positively associated with node-positive prostate cancer. In conclusion, MALAT1 SNPs are significantly associated with the susceptibility to both advanced Gleason grade and nodal metastasis in prostate cancer. The presence of MALAT1 SNPs rs619586 and rs1194338 seems to enhance oncogenesis in prostate cancer.

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

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

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

BACKGROUND/PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND/PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Complications of Outpatient and Inpatient Renal Biopsy: A Systematic Review and Meta-Analysis

Background: The evidence indicates that the optimal observation period following renal biopsy ranges between 6 and 8 h. This systematic review and meta-analysis explored whether differences exist in the complication rates of renal biopsies performed in outpatient and inpatient settings. Methods: We searched the MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from 1985 to February 2020. Two reviewers independently selected studies evaluating the bleeding risk from renal biopsies performed in outpatient and inpatient settings and reviewed their full texts. The primary and secondary outcomes were risks of bleeding and major events (including mortality) following the procedure, respectively. Subgroup analysis was conducted according to the original study design (i.e., prospective or retrospective). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random effect meta-analysis. Heterogeneity was assessed using the I² test. Results: Data from all 10 eligible studies, which included a total of 1801 patients and 203 bleeding events, were included for analysis. Renal biopsies in outpatient settings were not associated with a higher bleeding risk than those in inpatient settings (OR = 0.81; 95% CI, 0.59–1.11; I² = 0%). The risk of major events was also comparable across both groups (OR = 0.45; 95% CI, 0.16–1.29; I² = 4%). Conclusions: Similar rates of bleeding and major events following renal biopsy in outpatient and inpatient settings were observed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Lifetime Risks, Life Expectancy, and Health Care Expenditures for Rheumatoid Arthritis: A Nationwide Cohort Followed Up From 2003 to 2016

Objective

This study was undertaken to estimate the cumulative incidence rate of rheumatoid arthritis (RA) in the Taiwanese population ages 16–84 years, and life expectancy, loss of life expectancy, and lifetime health care expenditures for incident RA in Taiwan after 2003, when biologics began to be prescribed.

Methods

We obtained all claims data for the period 1999 to 2016 from the National Health Insurance program of Taiwan, and validated the data against the Catastrophic Illness Registry to establish the study cohort. We estimated the survival function for RA and extrapolated to lifetime using a rolling‐over algorithm. For every RA case, we simulated sex‐, age‐, and calendar year–matched referents from vital statistics and estimated their life expectancy. The difference between the life expectancy of the referent and the life expectancy of the RA patient was the loss of life expectancy for the RA patient. Average monthly health care expenditures were multiplied by the corresponding survival rates and summed up throughout the lifetime to calculate the lifetime health care expenditures.

Results

A total of 29,352 new RA cases were identified during 2003–2016. There was a decreasing trend in cumulative incidence rate in those ages 16–84 for both sexes. Mean life expectancy after diagnosis of RA was 26.3 years, and mean lifetime cost was $72,953. RA patients had a mean loss of life expectancy of 4.97 years. Women with RA survived 1–2 years longer than men with RA of the same age, which resulted in higher lifetime expenditures for the former. Since the life expectancy for women in Taiwan was 6–7 years higher than that for men, the loss of life expectancy for women with RA was higher than that for men with RA. Annual health care expenditures were similar for both sexes.

Conclusion

Our findings indicate that since biologics became available, RA patients have lived longer and had higher lifetime expenditures, which should be monitored and evaluated for cost‐effectiveness.

Increased risk of dementia in patients with nasopharyngeal cancer treated with radiation therapy: A nationwide population-based cohort study

PURPOSE

We evaluated the risk of dementia in patients with nasopharyngeal cancer (NPC) after undergoing radiation therapy (RT).

METHODS

Between January 1, 2000, and December 31, 2015, 594 patients newly diagnosed with NPC and treated with RT (NPC cohort) were identified from the Longitudinal Health Insurance Database (LHID) for this nationwide population-based matched cohort study. LHID is a subset of the National Health Insurance Research Database of Taiwan. We selected 2376 controls (non-NPC comparison cohort) using a four-fold propensity score-matched by sex, age, comorbidities, education level, tobacco abuse, and index date (the date when the patient received first RT). After adjusting for confounding factors, Fine and Gray's competing risk analysis compared dementia development between the NPC study cohort and non-NPC comparison cohort over the observation period from 2000 to 2015.

RESULTS

Dementia development was 6.57% (39 of 594) and 4.42% (105 of 2376) in the NPC study cohort and non-NPC comparison cohort, respectively. Patients with NPC receiving RT were more likely to develop dementia than the comparison cohort, with a crude hazard ratio (HR) of 1.63 [95% confidence interval (CI) = 1.25-2.13, P < 0.001]. After adjusting for age, sex, education level, tobacco abuse, comorbidity, geographic area, urbanization level of the residence, and care level, the adjusted HR was 1.91 (95% CI = 1.42-2.51, P < 0.001).

CONCLUSIONS

Patients with NPC receiving RT had a 1.91-fold higher risk of dementia than the non-NPC comparison controls.

Estrogen-related receptor-α promotes gallbladder cancer development by enhancing the transcription of Nectin-4

Estrogen-related receptor-α (ERRα) is a nuclear receptor of transcription factor that binds to estrogen responsive elements and estrogen-related responsive elements. Estrogen-related receptor-α is involved in metabolic processes and implicated in the progression and growth of several human malignancies. However, the biologic role and clinical significance of ERRα in gallbladder cancer (GBC) remains to be clarified. Here, we reported that ERRα protein expression was notably higher in GBC tissues than in cholecystitis tissues, and that the aberrantly higher ERRα expression was positively correlated with advanced TNM stage and indicated dismal prognosis of GBC (P < .01). In GBC cell lines NOZ and OCUG, the targeted depletion of ERRα retarded the growth and suppressed the migration and invasive capabilities of GBC cells, and inhibited epithelial-mesenchymal transition by decreasing the expression of mesenchymal markers and elevating the expression of epithelial markers. Moreover, ERRα knockdown inhibited tumor growth in nude mice and led to decreased expression levels of Nectin-4, p-PI3K p85α, and p-AKT. Overexpression of ERRα in the GBC-SD cell line showed exactly the opposite effect. The targeted inhibition of Nectin-4 antagonized GBC cell proliferation and invasion, which were induced by ERRα upregulation. Moreover, Nectin-4 depletion inhibited the ERRα-induced activation of the PI3K/AKT pathway. Chromatin immunoprecipitation analysis and dual-luciferase reporter gene assays showed that ERRα enhanced the transcription of Nectin-4 by binding to the promoter of Nectin-4. In conclusion, our data indicated that ERRα could be a potential target for the genetic treatment of GBC.

Later-Life Exposure to Moderate PM2.5 Air Pollution and Life Loss of Older Adults in Taiwan

Background: Few studies have directly estimated expected life loss attributable to lifetime exposure to fine particulate matter (PM_2.5). Methods: We used claims data from Taiwan’s National Health Insurance to create 63 study cohorts of 1.91 million residents aged 60–79 years old residing in small areas where air quality monitoring stations are situated. The survival status of each person was followed from 2001 to 2016. We applied an extrapolation algorithm to estimate the lifetime survival function so that we could directly estimate life expectancy (LE) and the lifetime exposure to PM_2.5 of each cohort. We estimated the association between LE and lifetime exposure to PM_2.5 among the 63 cohorts. We also fit a Cox proportional hazards model to all the data combined to estimate the relative risk of mortality. Results: Older adults who lived in an area with a higher lifetime weighted average PM_2.5 of 10 μg/m3 had a shortened LE by 0.34 (95% CI: 0.22–0.46) years. The hazard ratio of mortality was 1.0245 (1.0242–1.0248) per one μg/m3 increase in lifetime average PM_2.5. Conclusion: This study provides strong evidence that later-life exposure to moderate PM_2.5 air pollution had a substantial impact on the life loss of older adults.

Lifetime risks, expected years of life lost, and cost-per-life year of esophageal cancer in Taiwan

Besides lifetime risks, we estimated life expectancy (LE), expected years of life lost (EYLL), lifetime costs, and cost-per-LY (life-year) stratified by different stages of esophageal cancer (EC). From the Taiwan Cancer Registry, we collected 14,420 EC to estimate the incidence rates during 2008–2014. They were followed to 2015 to obtain the survival function, which was extrapolated to lifetime by a semiparametric method. We abstracted the monthly healthcare expenditures from the reimbursement database of National Health Insurance, which were multiplied with the corresponding survival probabilities to quantify lifetime cost and cost-per-LY after adjustments. About 93.7% of patients were male; 90.8% had squamous cell carcinoma. Most patients were diagnosed at advanced stages, with 44.6% and 28.3% at stages III and IV. The lifetime risk of EC in males increased in Taiwan with a cumulative incidence rate (CIR_30–84) of 0.0146% (2008~2010) to 0.0165% (2013–2014). The EYLL for stages I-IV were 15.8, 17.5, 20.5, and 22.5, while the average of cost-per-LY for stages I-IV were US$ 6,987, $8,776, $12,153, and $22,426. EC in Taiwan appears to have shifted into younger ages groups and incidence is still increasing. Strategies for prevention, early diagnosis and treatment are warranted to improve the cost-effectiveness and control of this cancer.

Superiority of NBI endoscopy to PET/CT scan in detecting esophageal cancer among head and neck cancer patients: a retrospective cohort analysis

Background

Second primary cancer of the esophagus is frequent in head and neck patients, especially in high-risk populations, and has a great impact on the prognosis. Although Positron emission tomography (PET)/computed tomography (CT) scan is commonly conducted in head and neck patients, its ability to detect early esophageal cancer is limited. Narrow-band imaging endoscopy is an accurate and convenient technique for esophageal examination. We aimed to compare PET/CT scan and narrow-band imaging endoscopy for the detection of esophageal cancer in head and neck cancer patients.

Methods

From November 2015 to November 2018, all head and neck cancer patients who underwent both PET/CT scan and narrow-band imaging endoscopy at Changhua Christian Hospital were retrospectively enrolled. Descriptive statistics, receiver operating characteristic curve analysis, logistic regression analysis, independent Student’s t-test, and Kaplan–Meier survival analysis were conducted with MedCalc Statistical Software.

Results

A total of 147 subjects were included in the analysis; suspicious esophageal lesions were identified by PET/CT scan in 8 (5.44%) and by narrow-band imaging in 35 (23.81%). The final pathologic diagnoses were esophageal squamous cell carcinoma in 10 and high-grade dysplasia in 5. The respective sensitivity, specificity, and area under the curve for detecting suspicious esophageal lesions were 33.33, 97.73%, and 0.655 for PET/CT scan, and 100.0, 84.85%, and 0.924 for narrow-band imaging endoscopy. Hypopharyngeal or laryngeal location of the primary head and neck cancer was the only risk factor for developing second primary esophageal cancer.

Conclusions

PET/CT scan was inferior to narrow-band imaging endoscopy in detecting second primary esophageal cancer in head and neck cancer patients. In addition to PET/CT scan, narrow-band imaging endoscopy should be considered in head and neck patients at high risk for developing second primary esophageal cancer.

Long Term Survival of Pathological Thoracolumbar Fractures Treated with Vertebroplasty: Analysis Using a Nationwide Insurance Claim Database

Background: There are still debates on the long-term outcome of treating pathological thoracolumbar fractures, including osteoporosis and oncologic problems, using vertebroplasty. Methods: We collected 8625 patients with pathological thoracolumbar fractures (ICD-9-CM codes 733.13 combined with 805.2 or 805.4) between the years of 2003 to 2013, from the two million random samples from the National Health Insurance Research Database in Taiwan. Survival analysis was conducted to estimate the mortality risks of different treatments, including vertebroplasty (n = 1389), conventional open surgery (n = 1219), or conservative treatment (n = 6017). A multivariable Cox proportional hazard model was constructed for adjustment of age, gender, comorbidities and complications. Results: Crude incidence rate of patients with pathological thoracolumbar fractures in Taiwan gradually increased year by year. Compared with conservative treatment, conventional open surgery and vertebroplasty seemed to improve long-term survival with adjusted hazard ratios (aHR) of 0.80 (95% confidence interval (CI) 0.70–0.93), and 0.87 (95% CI 0.77–0.99), respectively. The survival advantage of vertebroplasty appeared more evident for those aged over 75. However, we were unable to rule out confounding by indication. Conclusion: Although conventional open surgery would usually be the best choice for the treatment of patients with pathological thoracolumbar fractures, database information from current real-world practice appears to support vertebroplasty as a viable choice for elderly people over 75 years of age.

Dynamic Changes Of Body Image And Quality Of Life In Breast Cancer Patients

Purpose

Dynamic changes of body image and quality of life (QoL) in breast cancer patients were not commonly investigated. We aimed to compare the dynamic changes in QoL and body image of breast cancer survivors receiving breast-conserving surgery or total mastectomy within 5–10 years after surgery.

Methods

Patients with non-metastatic breast cancer who received surgery were invited to complete the World Health Organization Quality of Life–Brief (WHOQOL-BREF) questionnaire and the Body Image Scale (BIS) within 10 years after surgery. We applied kernel smoothing methods to capture the dynamic changes of the patients’ QoL and body image within 5 years after surgery. We also constructed multiple linear regression models to identify predictive factors for QoL and body image.

Results

A total of 581 patients were collected, and 211 of them received breast-conserving surgery. There were no statistically significant differences in QoL and body image for breast-conserving surgery versus total mastectomy, but the former showed fluctuating trends. BIS was a predictor of every item and domain in the WHOQOL-BREF in the multiple linear regression model, and explanatory of the trends of dynamic change over time. Patients without lymph node dissection seemed to have less positive feelings but were more satisfied with sexual activities.

Conclusion

Body image is predictive of the QoL of breast cancer patients. Dynamic changes of body image and QoL would be useful for shared decision-making regarding surgery in breast cancer patients.

Estimating Life Expectancy and Lifetime Healthcare Costs for Alzheimer's Disease in Taiwan: Does the Age of Disease Onset Matter?

BACKGROUND

People with early onset Alzheimer's disease (EOAD) seem to suffer greater impact. But there is a lack of population-based studies on loss of life expectancy (LE) and lifetime healthcare costs.

OBJECTIVES

We conducted this study to estimate LE, expected years of life lost (EYLL), and lifetime healthcare costs for Alzheimer's disease (AD) in Taiwan stratified by onset age and gender, using a method which integrates the product of the survival function and the mean cost function over a lifetime horizon.

METHODS

We linked the National Health Insurance datasets with the National Mortality Registry and extrapolated the survival to lifetime to estimate the mean cumulative costs since the date of the first AD diagnosis using medical claims between 2001 and 2012.

RESULTS

A total of 21,615 mild to moderate AD patients (including 20,358 late-onset (LOAD) and 1,257 EOAD) were recruited. The average onset age for EOAD was 61 years old, while that of LOAD was 78. Although the LE of EOAD was 4.8 years longer than that of LOAD due to younger age, the EYLL for the former was 8.7 years versus 1.7 years for the latter. EOAD also had higher lifetime healthcare costs than the LOAD group (USD$37,957±2,403 versus 33,809±786).

CONCLUSIONS

Since EOAD patients had both higher EYLL and lifetime healthcare costs than LOAD, future studies should pay more attention to the needs of EOAD patients.

Estimation of Quality-Adjusted Life Expectancy of Patients With Oral Cancer: Integration of Lifetime Survival With Repeated Quality-of-Life Measurements

BACKGROUND

Quality-adjusted life year is widely applied nowadays, which consider both survival and quality of life (QoL). When most diseases are becoming chronic, it is imperative to quantify the overall health impact of a disease in lifetime perspective.

OBJECTIVE

The purpose of this study is to introduce methods for estimating quality-adjusted life expectancy (QALE) and loss of QALE in patients with a disease or specific conditions.

METHODS

The QALE of an index cohort can be represented as the integration of the product of lifetime survival function and mean QoL function. We introduce a robust extrapolation approach for estimating lifetime survival function and propose an approach for estimating lifetime mean QoL function for studies with limited follow-up. The best part of the proposed method is that the survival data and QoL data can be collected separately. A cohort of patients with a specific condition can be identified by databases that regularly collect data for the control of diseases, and their survival status is verified by linking to a mortality registry. Although nationwide QoL data are not available, researchers can implement a relative short-term follow-up interview on a random sample of patients to collect QoL data. For demonstration, we applied the proposed methods to estimate QALE and loss of QALE of oral cancer patients.

RESULTS

The estimates (95% confidence interval) of QALE for oral cancer patients were 11.0 (10.5-11.6) and 14.2 (12.7-15.5) quality-adjusted life years (QALYs) for men and women, respectively. The estimates of loss of QALE for the male and female patients with oral cancer were 14.4 (13.8-14.9) and 7.5 (6.2-9.0) QALYs, respectively.

CONCLUSIONS

The methods for estimating QALE and loss of QALE can be applied to economic evaluation of cancer control, including screening.

Age-standardized expected years of life lost: quantification of cancer severity

Background

The critical implications of the expected years of life lost (EYLL) index of cancer for health policy assessments have been largely overlooked. We advocate to standardize life lost indices.

Methods

Using the Taiwan Cancer Registry database as an example, we calculated the EYLL and the age-standardized EYLL to facilitate comparisons among cancer types (a total of 903,935 patients from the database). The International Cancer Survival Standard was used for calculating age-standardized EYLL.

Results

Pancreatic cancer is the most severe cancer in Taiwan, with the greatest age-standardized EYLL for the men (15.6 years) and women (18.0 years) as well as for the men and women combined (16.6 years). Negative correlations were observed between unstandardized EYLL of cancer and mean age at diagnosis.

Conclusions

The unstandardized EYLL represents an overall assessment of disease burden, whereas the age-standardized EYLL is a suitable measure of disease severity. We suggest that both measures be incorporated into routine annual reports of cancer statistics alongside the usual incidence and mortality rates and their age-standardized counterparts.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6843-9) contains supplementary material, which is available to authorized users.

Psychometric evaluation of the WHOQOL-BREF, Taiwan version, across five kinds of Taiwanese cancer survivors: Rasch analysis and confirmatory factor analysis

BACKGROUND

Quality of life (QoL) is important for clinicians to evaluate how cancer survivors judge their sense of well-being, and WHOQOL-BREF may be a good tool for clinical use. However, at least three issues remain unresolved: (1) the psychometric properties of the WHOQOL-BREF for cancer patients are insufficient; (2) the scoring method used for WHOQOL-BREF needs to be clarify; (3) whether different types of cancer patients interpret the WHOQOL-BREF similarly.

METHODS

We recruited 1000 outpatients with head/neck cancer, 1000 with colorectal cancer, 965 with liver cancer, 1438 with lung cancer and 1299 with gynecologic cancers in a medical center. Data analyses included Rasch models, confirmatory factor analysis (CFA), and Pearson correlations.

RESULTS

The mean WHOQOL-BREF domain scores were between 13.34 and 14.77 among all participants. CFA supported construct validity; Rasch models revealed that almost all items were embedded in their expected domains and were interpreted similarly across five types of cancer patients; all correlation coefficients between Rasch scores and original domain scores were above 0.9.

CONCLUSION

The linear relationship between Rasch scores and domain scores suggested that the current calculations for domain scores were applicable and without serious bias. Clinical practitioners may regularly collect and record the WHOQOL-BREF domain scores into electronic health records.