Cancer stages and mortality risk of breast cancer between women with and without disabilities: A national population-based cohort study in Taiwan

BACKGROUND

The second-most common cause of cancer-related death for women worldwide is breast cancer. However, there is little information about breast cancer among women with disabilities in Taiwan.

OBJECTIVES

This study investigated differences between women with and without disabilities regarding breast cancer stages and evaluated the probability of developing an advanced stage and the mortality risk of breast cancer.

METHODS

This study conducted a nationwide retrospective cohort study using the National Health Insurance Research Database and other nationwide databases. Our participants were newly diagnosed breast cancer patients, including women with and without disabilities, between 2004 and 2010. We matched both of them with propensity score matching methods (1:5), and all were followed up until the end of 2016.

RESULTS

This study included 50,683 participants with breast cancer. After matching, women with disabilities who did not receive breast cancer screening had a more significant proportion of advanced-stage breast cancer (19.95 %) than those without disabilities who did not receive breast cancer screening (16.87 %). After adjusting for related variables, women with disabilities were 1.27 times more likely to have advanced-stage breast cancer than those without disabilities. Additionally, after suffering from breast cancer, individuals with disabilities had a 1.23 times greater mortality risk compared to those without disabilities.

CONCLUSIONS

Although cancer stages were controlled, women with disabilities still had a higher mortality risk of breast cancer. Hence, policymakers should pay more attention to women with disabilities to treat them at an early stage, which can reduce the mortality risk attributable to advanced stages.

Stroke and suicide among people with severe mental illnesses

The associations between people with severe mental illnesses (SMI) and the risks of stroke, suicide, and death remain unclear. We examined healthcare service usage among adults with and without SMI and explored the risk of stroke, suicide, and death. We divided 18-80-year-old adults with SMI into catastrophic and non-catastrophic illness groups. These groups were subjected to a 1:5:5 propensity score matching with people without SMI. Data on demographic characteristics, economic factors, environmental factors, comorbid conditions, self-injury behavior, the number of outpatients and ED visits, and hospitalization were collected. The primary outcomes were risks of stroke, suicide, and death. We included 19,570 people with catastrophic SMI, 97,850 with non-catastrophic SMI, and 97,850 controls. Patients with SMI, especially those with catastrophic illnesses, had higher stroke risk, suicide, and death than those without SMI. People with SMI used health services more frequently than those without SMI. Patients with a history of hospitalization or ED access had a higher risk of stroke, suicide, and death. Our data indicate that special attention should be given to patients with SMI, particularly those with a history of healthcare service utilization, such as through more extended hospital stays with high-intensity interventions.

Effect of multidisciplinary team care on patient survival in chronic hepatitis B or C hepatocellular carcinoma

Introduction

Multidisciplinary team care coordinates with medical teams to improve the quality of cancer care. This study explored multidisciplinary team care in hepatitis B or hepatitis C virus-related hepatocellular carcinoma patients from the time of diagnosis to the first-time treatment interval and investigated treatment outcomes and prognosis.

Methods

This retrospective cohort study included data from a nationwide population from 2007 to 2016. Data were collected from the Taiwan Cancer Registry Database, linked to the Taiwan National Health Insurance Research Database. Propensity score matching was applied at a ratio of 1:2 to reduce the selection bias. A multiple regression model with generalized estimating equations was used to analyze whether multidisciplinary team care affected the diagnosis-to-treatment interval. The stratified Cox proportional hazards model examined whether involvement in multidisciplinary team care influenced survival status.

Results

A total of 10,928 and 21,856 patients with hepatocellular carcinoma received multidisciplinary and non-multidisciplinary care, respectively. Participants with multidisciplinary care had a longer diagnosis-to-treatment interval but a lower risk of cumulative cancer death (HR=0.88, 95% CI:0.84-0.92). In patients with intermediate- to advanced-stage hepatocellular carcinoma, multidisciplinary team care has obvious benefits for improving survival.

Conclusion

Patients with hepatocellular carcinoma who participated in multidisciplinary team care had a longer diagnosis-to-treatment interval but a lower risk of cancer death. Patients with intermediate- to advanced-stage hepatocellular carcinoma who received multidisciplinary team care significantly benefited from this outcome. Hospitals should provide HCC patients with multidisciplinary team care to improve cancer care.

The association between the workload of emergency physicians and the outcomes of acute myocardial infarction: a population-based study

Acute myocardial infarction (AMI) is the second leading cause of mortality in Taiwan. The correlation between the workload of emergency physicians and the outcome of AMI remains unknown. To determine the effects of the workload of emergency physicians on the outcomes of AMI. We included 17 661 patients (age > 18 years) with STEMI undergoing PCI, who visited the emergency department between 2012 and 2018. We used the logistic regression model with generalized estimating equations (GEEs) to analyze the risk of death within 30 days after emergency department visit, the risk of emergency department revisits within 3 days, and the risk of readmission within 14 days in all subgroups. After covariate adjustment, the risk of mortality within 30 days after visiting the emergency department was significantly higher in the subgroup whose visiting emergency physicians had the highest workload (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 1.12 to 1.72). Furthermore, the risk of revisiting the emergency department within 3 days after discharge from the hospital was significantly higher in the subgroup whose visiting emergency physicians' workload was within the second and third quartiles (OR 1.85; 95% CI 1.18 to 2.89). The workload of emergency physicians appears to be positively correlated with the mortality risk of patients with STEMI undergoing PCI.

Educational attainment affects the diagnostic time in type 2 diabetes mellitus and the mortality risk of those enrolled in the diabetes pay-for-performance program

Most patients are diagnosed as having diabetes only after experiencing diabetes complications. Educational attainment might have a positive relationship with diabetes prognosis. The diabetes pay-for-performance (P4P) program-providing comprehensive, continuous medical care-has improved diabetes prognosis in Taiwan. This retrospective cohort study investigated how educational attainment affects the presence of diabetes complications at diabetes diagnosis and mortality risk in patients with diabetes enrolled in the P4P program. From the National Health Insurance Research Database, we identified patients aged >45 years who had received a new diagnosis of type 2 diabetes during 2002-2015; they were followed up until the end of 2017. We next used logistic regression analysis to explore whether the patients with different educational attainments had varied diabetic complication risks at diabetes diagnosis. The Cox proportional hazard model was employed to examine the association of different educational attainments in people with diabetes with mortality risk after their enrollment in the P4P program. The results indicated that as educational attainment increased, the risk of diabetes complications at type 2 diabetes diagnosis decreased gradually. When type 2 diabetes with different educational attainments joined the P4P program, high school education had the highest effect on reducing mortality risk; however, those with ≤ 6th grade education had the lowest impact.

Diabetes Pay-for-Performance Program Participation and Dialysis Risk in Relation to Educational Attainment: A Retrospective Cohort Study

Pay-for-performance (P4P) programs for diabetes care enable the provision of comprehensive and continuous health care to diabetic patients. However, patient outcomes may be affected by the patient's educational attainment. The present retrospective cohort study aimed to examine the effects of the educational attainment of diabetic patients on participation in a P4P program in Taiwan and the risk of dialysis. The data were obtained from the National Health Insurance Research Database of Taiwan. Patients newly diagnosed with type 2 diabetes mellitus (T2DM) aged 45 years from 2002 to 2015 were enrolled and observed until the end of 2017. The effects of their educational attainment on their participation in a P4P program were examined using the Cox proportional hazards model, while the impact on their risk for dialysis was investigated using the Cox proportional hazards model. The probability of participation in the P4P program was significantly higher in subjects with a junior high school education or above than in those who were illiterate or had only attained an elementary school education. Subjects with higher educational attainment exhibited a lower risk for dialysis. Different educational levels had similar effects on reducing dialysis risk among diabetic participants in the P4P program.

Effectiveness of Palliative Care before Death in Reducing Emergency Care Utilization for Patients with Terminal Cancer and Trends in the Utilization of Palliative Care from 2005-2018

This retrospective cohort study aimed to examine the effect of palliative care for patients with terminal cancer on healthcare utilization. The National Health Insurance (NHI) Research Database and death certificates were utilized to identify patients who died of cancer between 2005 and 2018. The number of terminal cancer patients between 2005 and 2018 was 605,126. Propensity score matching and conditional logistic regression were performed. The odds ratios (ORs) for "emergency care utilization", "CPR", "endotracheal intubation", and "ICU admission" were significantly lower for enrolled patients regardless of enrollment time compared to unenrolled patients. Compared to unenrolled patients, the OR for "emergency care utilization" increased from 0.34 to 0.68, the OR for "CPR use" increased from 0.13 to 0.26, the OR for "intubation" increased from 0.15 to 0.26, and the OR for "ICU admission" increased from 0.27 to 0.40 in enrolled patients. Between 2005 and 2010, CPR utilization, intubation, and ICU admission in patients enrolled in palliative care declined each year. Since the inclusion of palliative care in NHI (from 2010 onward), its utilization has increased slightly each year. Patients with terminal cancer enrolled in palliative care consume fewer medical resources before death than unenrolled patients; however, the difference decreases with longer times before death.

Effects of the Time of Hospice and Palliative Care Enrollment before Death on Morphine, Length of Stay, and Healthcare Expense in Patients with Cancer in Taiwan

We aimed to investigate the effects of the time from hospice and palliative care enrollment to death on the quality of care and the effectiveness and trend of healthcare utilization in patients with terminal cancer. Data on the cancer-related mortality rates between 2005 and 2018 reported in the National Health Insurance Research Database in Taiwan were obtained. The effect of hospice and palliative care enrollment at different timepoints before death on healthcare utilization was explored. This retrospective cohort study included 605,126 patients diagnosed with terminal cancer between 2005 and 2018; the percentage of patients receiving hospice and palliative care before death increased annually. Terminal cancer patients who enrolled in hospice and palliative care at different timepoints before death received higher total morphine doses; the difference in the total morphine doses between the two groups decreased as the time to death shortened. The difference in the total morphine doses between the groups gradually decreased from 2005 to 2018. The enrolled patients had longer hospital stays; the length of hospital stays for both groups increased as the time to death lengthened, but the difference was not significant. The enrolled patients incurred lower total medical expenses, but the difference between the two groups increased as the time to death shortened.

Participation and Outcomes among Disabled and Non-Disabled People in the Diabetes Pay-for-Performance Program

OBJECTIVES

This study's objectives were to compare the participation rates of people with and without disabilities who had type 2 diabetes in a diabetes pay-for-performance (DM P4P) program, as well as their care outcomes after participation.

METHODS

This was a retrospective cohort study. The data came from the disability registry file, cause of death file, and national health insurance research database of Taiwan. The subjects included patients newly diagnosed with type 2 diabetes between 2001 and 2013 who were followed up with until 2014 and categorized as disabled and non-disabled patients. The propensity score matching method was used to match the disabled with the non-disabled patients at a 1:1 ratio. Conditional logistic regression analysis was used to determine the odds ratio between the disabled and non-disabled patients who joined the P4P program. The Cox hazard model was used to compare the risk of dialysis and death between the disabled and non-disabled patients participating in the P4P program.

RESULTS

There were 110,645 disabled and 110,645 non-disabled individuals after matching. After controlling for confounding factors, it was found that the disabled individuals were significantly less likely (odds ratio = 0.89) to be enrolled in the P4P program than the non-disabled individuals. The risk of dialysis was 1.08 times higher for people with disabilities than those without, regardless of their participation in the P4P program. After enrollment in the P4P program, the risk of death for people with disabilities decreased from 1.32 to 1.16 times that of persons without disabilities. Among the people with disabilities, the risk of death for those enrolled in the P4P program was 0.41 times higher than that of those not enrolled. The risk of death was reduced to a greater extent for people with disabilities than for those without disabilities upon enrollment in the DM P4P program.

CONCLUSION

People with disabilities are less likely to be enrolled in the P4P program in Taiwan and have unequal access to care. However, the P4P program was more effective at reducing mortality among people with disabilities than among those without.

Risk of rapid progression to dialysis in patients with type 2 diabetes mellitus with and without diabetes-related complications at diagnosis

Many adults with diabetes mellitus are unaware worldwide. The study objectives aimed to evaluate the risk of dialysis within 5 years of diagnosis between patients with newly diagnosed diabetes with and without diabetes-related complications. A retrospective longitudinal nationwide cohort study was conducted. Patients diagnosed with diabetes between 2005 and 2013 were followed up until 2018. They were categorized based on the presence or absence of complications, the number of complications, and the diabetes complications severity index (DCSI) scores. Dialysis outcomes were determined through the Registry of Catastrophic Illness from the National Health Insurance Research Database. Among the analyzed patients, 25.38% had complications at diagnosis. Patients with complications at diagnosis had a significantly higher risk of dialysis within 5 years (adjusted hazard ratio: 9.55, 95% confidence interval CI 9.02-10.11). Increasing DCSI scores and the number of complications were associated with higher dialysis risks. Patients with one complication had a 7.26-times higher risk (95% CI 6.83-7.71), while those with ≥ 3 complications had a 36.12-times higher risk (95% CI 32.28-40.41). In conclusion, newly diagnosed diabetes patients with complications face an increased risk of dialysis within 5 years. The severity and number of complications are directly linked to the risk of dialysis within this timeframe.

24-h PCI model does affect the outcome of STEMI patients: a population-based study

Acute myocardial infarction has been the second leading cause of death in Taiwan. It's a novel issue to evaluate the relationship between the 24-h PCI service model and the outcome of STEMI patients. The objective of this study was to determine the effect of 24-h PCI service model in STEMI patients to improving survival rate. This population-based cohort study included those STEMI patients, older than 18 year-old, who had ever called emergency department from 2012 to 2018. We had two groups of our study participant, one group for STEMI patients with 24-h PCI model and the other group for STEMI patients with non-24-h PCI model. We used the Logistic regression model to analyze the risk of death within 30 days, emergency department (ED) revisits within 3 days, and readmission within 14 days. After the relevant variables were controlled, the risk of death after an ED visit among the patients with STEMI who were sent to hospitals with 24-h PCI services was significantly lower than that among the patients with STEMI who were sent to hospitals without 24-h PCI services (OR 0.85; 95% CI 0.75-0.98). However, the model could not reduce the risk of ER revisits and readmission.

Survival and Its Correlates in Multiple Sclerosis Patients under a Universal Health Insurance Program in Taiwan: An 18-Year Nationwide Cohort Study

Despite the global decline in the standardized mortality rate of multiple sclerosis (MS), recent research on MS patient survival, especially in Taiwan, remains limited. This study aimed to investigate survival, mortality causes, and associated factors among MS patients in Taiwan. The Taiwan National Health Insurance Research Database was used as the primary data source, and a Cox proportional hazard model was employed to estimate and analyze factors related to survival. We analyzed data from 1444 MS patients diagnosed between 2000 and 2018. Age at diagnosis was positively correlated with the risk of death. Among the 190 patients who died, the leading causes of disease-related deaths were nervous system diseases (n = 83, 43.68%), followed by respiratory system diseases and certain infectious and parasitic diseases. The 8-, 13-, and 18-year survival rates for MS patients were 0.97, 0.91, and 0.81, respectively. This study highlights that the MS patient's socioeconomic status, environmental factors, comorbidity severity, and related medical variables were not significantly associated with survival.

Comparison of Cervical Cancer Screening Used between Individuals with Disabilities and Individuals without Disabilities

OBJECTIVE

Cervical cancer is the fourth most prevalent cancer in women worldwide. It is vital to achieve a high cervical cancer screening rate among women. We compared the Pap smear test (PST) used between individuals with disabilities and those without disabilities in Taiwan.

METHODS

Individuals registered in the Taiwan Disability Registration File and the National Health Insurance Research Database (NHIRD) were screened for this nationally representative retrospective cohort study. Women aged 30 and above in 2016 and who were still alive in 2016 were matched in a 1:1 ratio via propensity score matching (PSM); 186,717 individuals with disabilities and 186,717 individuals without disabilities were included. Controlling for relevant variables, the odds of receiving PST were compared using conditional logistic regression analysis.

RESULTS

A lower percentage of individuals with disabilities (16.93%) received PST than those without disabilities (21.82%). The odds of individuals with disabilities receiving PST were 0.74 times that of individuals without disabilities (OR = 0.74, 95% CI = 0.73-0.76). Compared to individuals without disabilities, individuals with intellectual and developmental disabilities had the lower odds of receiving PST (OR = 0.38, 95% CI = 0.36-0.40), followed by individuals with dementia (OR = 0.40, 95% CI = 0.33-0.48) or multiple disabilities (OR = 0.52, 95% CI = 0.49-0.54).

CONCLUSIONS

We highly recommend that healthcare practitioners recognize the unique needs of individuals with different types of disabilities, especially those with cognitive impairments.

Stable pulsed operation of Lissajous structured beams by Nd:YVO4/Cr4+:YAG laser in a concave-convex resonator

A Nd:YVO₄/Cr⁴⁺:YAG laser with a symmetric concave-convex cavity ensuring strong intracavity beam focusing on the absorber is designed for stable pulsed operation of Lissajous structured modes with transverse patterns as Lissajous figures. Setting the cavity length to fulfill the criterion for efficient passive Q switching (PQS), as well as to meet the accidental degenerate conditions, Lissajous pulsed beams with well-defined structures and good temporal stability are created under two-dimensional off-axis pumping. Although the multi-transverse-mode oscillation inevitably induces asynchronous pulsation and leads the short-term pulse profiles to reveal parasitic effects, the overall long-term behavior of Lissajous pulses can be kept regular with amplitude fluctuations ≤15% and pulse-to-pulse timing jitter ≤5%. With the maximum peak power exceeding 500 W at a pump power of 4.5 W, the PQS Lissajous modes are further transformed into trochoidal pulsed beams to realize high-order and high-peak power structured vortex fields.

Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single-payer health system

BACKGROUND

Enrollment in and adherence to a diabetes pay-for-performance (P4P) program can lead to desirable processes and outcomes of diabetes care. However, knowledge is limited on the potential exclusion of patients with individual or neighborhood social risks or interruption of services in the disease-specific P4P program without mandatory participation under a single-payer health system.

OBJECTIVE

To investigate the impact of individual and neighborhood social risks on exclusion from and adherence to the diabetes P4P program of patients with type 2 diabetes (T2D) in Taiwan.

METHODS

This study used data from Taiwan's 2009-2017 population-based National Health Insurance Research Database, 2010 Population and Housing Census, and 2010 Income Tax Statistics. A retrospective cohort study was conducted, and study populations were identified from 2012 to 2014. The first cohort comprised 183,806 patients with newly diagnosed T2D, who had undergone follow up for 1 year; the second cohort consisted of 78,602 P4P patients who had undergone follow up for 2 years after P4P enrollment. Binary logistic regression models were used to examine the associations of social risks with exclusion from and adherence to the diabetes P4P program.

RESULTS

T2D patients with higher individual social risks were more likely to be excluded from the P4P program, but those with higher neighborhood-level social risks were slightly less likely to be excluded. T2D patients with the higher individual- or neighborhood-level social risks showed less likelihood of adhering to the program, and the person-level coefficient was stronger in magnitude than the neighborhood-level one.

CONCLUSIONS

Our results indicate the importance of individual social risk adjustment and special financial incentives in disease-specific P4P programs. Strategies for improving program adherence should consider individual and neighborhood social risks.

Utility of monocyte distribution width in the differential diagnosis between simple and complicated diverticulitis: a retrospective cohort study

BACKGROUND

Colonic diverticulitis is a leading cause of abdominal pain. The monocyte distribution width (MDW) is a novel inflammatory biomarker with prognostic significance for coronavirus disease and pancreatitis; however, no study has assessed its correlation with the severity of colonic diverticulitis.

METHODS

This single-center retrospective cohort study included patients older than 18 years who presented to the emergency department between November 1, 2020, and May 31, 2021, and received a diagnosis of acute colonic diverticulitis after abdominal computed tomography. The characteristics and laboratory parameters of patients with simple versus complicated diverticulitis were compared. The significance of categorical data was assessed using the chi-square or Fisher's exact test. The Mann-Whitney U test was used for continuous variables. Multivariable regression analysis was performed to identify predictors of complicated colonic diverticulitis. Receiver operator characteristic (ROC) curves were used to test the efficacy of inflammatory biomarkers in distinguishing simple from complicated cases.

RESULTS

Of the 160 patients enrolled, 21 (13.125%) had complicated diverticulitis. Although right-sided was more prevalent than left-sided colonic diverticulitis (70% versus 30%), complicated diverticulitis was more common in those with left-sided colonic diverticulitis (61.905%, p = 0.001). Age, white blood cell (WBC) count, neutrophil count, C-reactive protein (CRP) level, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and MDW were significantly higher in the complicated diverticulitis group (p < 0.05). Logistic regression analysis indicated that the left-sided location and the MDW were significant and independent predictors of complicated diverticulitis. The area under the ROC curve (AUC) was as follows: MDW, 0.870 (95% confidence interval [CI], 0.784-0.956); CRP, 0.800 (95% CI, 0.707-0.892); NLR, 0.724 (95% CI, 0.616-0.832); PLR, 0.662 (95% CI, 0.525-0.798); and WBC, 0.679 (95% CI, 0.563-0.795). When the MDW cutoff was 20.38, the sensitivity and specificity were maximized to 90.5% and 80.6%, respectively.

CONCLUSIONS

A large MDW was a significant and independent predictor of complicated diverticulitis. The optimal cutoff value for MDW is 20.38 as it exhibits maximum sensitivity and specificity for distinguishing between simple and complicated diverticulitis The MDW may aid in planning antibiotic therapy for patients with colonic diverticulitis in the emergency department.

Comparison of the use of prenatal care services and the risk of preterm birth between pregnant women with disabilities and those without disabilities: A nationwide cohort study

Objective

The difficulties faced by pregnant women with disabilities in accessing health care may make them less likely to receive prenatal care. The aims of this study were to compare the number of prenatal services and the risk of preterm birth between pregnant women with and without disabilities.

Methods

A total of 2999 pregnant women aged ≥20 years with birth records in 2011-2014 in Taiwan were enrolled. Data were obtained from the Registration File for Physical and Mental Disabilities and the National Health Insurance Research Database. A 1:4 matching between pregnant women with disabilities and those without disabilities was performed. The logistic regression analysis with generalized estimating equations was used to analyze.

Results

The median of prenatal care services used by pregnant women with disabilities was 9.00 (interquartile range, IQR: 2.00). Pregnant women with disabilities used fewer services than those without disabilities (median, 10.00; IQR: 1.00). The disabled group (8.44%) had a significantly higher proportion of preterm births than did the non-disabled group (5.40%). The disabled group was at a 1.30 times higher risk of preterm births than was the non-disabled group.

Conclusions

Pregnant women with disabilities used significantly fewer prenatal care services and had a significantly higher risk of preterm birth than pregnant women without disabilities.

Comparison of Quality of Life Between Breast Cancer Patients Treated With and Without Adjunctive Traditional Chinese Medicine in Taiwan

In Taiwan, breast cancer has the highest incidence among all cancers. Although adjunctive traditional Chinese medicine treatment (TCM) have been used to ameliorate the side effects or discomfort caused by cancer treatments, no study has focused on the assessment of the quality of life of patients undergoing adjunctive TCM treatments. This study compared the quality of life between breast cancer patients treated with and without adjunctive TCM. Questionnaires were collected from 7 hospitals with a Chinese medicine clinic in 2018 to 2019. Breast cancer patients who had cancer stages I, II, or III and also underwent resection surgery were included in the study. They were divided into 2 groups: patients receiving cancer treatments with adjunctive traditional Chinese medicine (TCM group) and those receiving cancer treatments without adjunctive traditional Chinese medicine (non-TCM group). A 1:1 matching was used to obtain the study participants. The EQ-5D questionnaire was used to assess the quality of life. Statistical analysis was performed using the t-test and ANOVA to compare the differences between variables. The conditional multiple regression model was applied to explore the factors associated with quality of life in breast cancer patients. A total of 543 participants were surveyed, and 450 participants were included in the study. The EQ-5D score of the TCM group (81.60 ± 11.67) was significantly higher than that of the non-TCM group (78.80 ± 13.10; P < .05). The results of a conditional multiple regression model showed that the TCM group had a higher (3.45 points) quality of life than non-TCM group (P = .002) after adjusting for other related factors. After stratifying by cancer stage, patients with cancer stages II and III scored 5.58 and 4.35 points higher in the TCM group than did those in the non-TCM group (P < .05). Breast cancer patients undergoing cancer treatment with adjunctive traditional Chinese medicine have a higher quality of life than those treated without adjunctive traditional Chinese medicine.

Impact of chronic hepatitis on cardiovascular events among type 2 diabetes patients in Taiwan pay-for-performance program

To investigate the impact of chronic hepatitis on cardiovascular events in patients with type 2 diabetes mellitus (T2DM). This nationwide retrospective cohort study included 152,709 adult patients (> 20 years) with T2DM enrolled in the National Health Insurance Diabetes Pay-for-Performance Program from 2008 to 2010 and followed up until the end of 2017. Patients were categorized into groups with hepatitis B, hepatitis C, fatty liver disease, and patients without chronic hepatitis. The incidence of cardiovascular events in patients with T2DM and hepatitis C (79.9/1000 person-years) was higher than that in patients with diabetes combined with other chronic hepatitis, or without chronic hepatitis. After adjusting for confounding factors, T2DM with fatty liver (adjusted hazard ratio [HR]: 1.10; 95% confidence interval [CI]: 1.07–1.13) and hepatitis C (adjusted HR: 1.09; 95% CI: 1.03–1.12) demonstrated a significantly higher risk of cardiovascular events. The adjusted visit-to-visit coefficient of variation of HbA1c and fasting blood glucose were associated with a high risk of cardiovascular events (HRs of the highest quartile were 1.05 and 1.12, respectively). Chronic hepatitis affects cardiovascular events in adult patients with T2DM. Glucose variability could be an independent risk factor for cardiovascular events in such patients.

Stress on caregivers providing prolonged mechanical ventilation patient care in different facilities: A cross-sectional study

Purpose

Taiwan has implemented an integrated prospective payment program (IPP) for prolonged mechanical ventilation (PMV) patients that consists of four stages of care: intensive care unit (ICU), respiratory care center (RCC), respiratory care ward (RCW), and respiratory home care (RHC). We aimed to investigate the life impact on family caregivers of PMV patients opting for a payment program and compared different care units.

Method

A total of 610 questionnaires were recalled. Statistical analyses were conducted by using the chi-square test and multivariate logistic regression model.

Results

The results indicated no associations between caregivers’ stress levels and opting for a payment program. Participants in the non-IPP group spent less time with friends and family owing to caregiver responsibilities. The results of the family domain show that the RHC group (OR = 2.54) had worsened family relationships compared with the ICU group; however, there was less psychological stress in the RCC (OR = 0.54) and RCW (OR = 0.16) groups than in the ICU group. In the social domain, RHC interviewees experienced reduced friend and family interactivity (OR = 2.18) and community or religious activities (OR = 2.06) than the ICU group. The RCW group felt that leisure and work time had less effect (OR = 0.37 and 0.41) than the ICU group. Furthermore, RCW interviewees (OR = 0.43) were less influenced by the reduced family income than the ICU group in the economic domain.

Conclusions

RHC family caregivers had the highest level of stress, whereas family caregivers in the RCW group had the lowest level of stress.

Inequality in the Utilization of Breast Cancer Screening between Women with and without Disabilities in Taiwan: A Propensity-Score-Matched Nationwide Cohort Study

Because of the difficulties in accessing medical care, the likelihood of receiving breast cancer screening may be low for women with disabilities. We aimed to investigate differences in the utilization of breast cancer screening among women with and without disabilities. Participants included women with and without disabilities from 2004 to 2010, and it was observed whether the participants had received a breast cancer screening during 2011 and 2012. Propensity-score matching was employed to match disabled women with non-disabled women (1:1). Data sources included the National Health Insurance Research Database, the Cancer Screening Database, and the Disability Registration File. Conditional logistic regression was performed to examine the odds ratios (ORs) that both groups would undergo breast cancer screening. The proportion of women with disabilities who received breast cancer screening was 18.33%, which was significantly lower than that of women without disabilities (25.52%) (p < 0.001). Women with dementia had the lowest probability of receiving a mammography examination (OR = 0.34; 95% CI: 0.28−0.43), followed by those with multiple disabilities (OR = 0.43; 95% CI: 0.40−0.47) and intellectual disabilities (OR = 0.45; 95% CI: 0.41−0.50). In conclusion, compared to women without disabilities, those with disabilities were less likely to undergo breast cancer screening.

Statin Therapy for Hyperlipidemic Patients With Chronic Kidney Disease and End-Stage Renal Disease: A Retrospective Cohort Study Based on 925,418 Adults in Taiwan

Background: For non-dialysis patients with hyperlipidemia, statins may provide clinical benefits in reducing mortality risk; however, the optimal treatment for dialysis patients with hyperlipidemia remains debatable. We evaluated the mortality risks for hyperlipidemic patients with renal disorders associated with statin therapy (ST), using the insurance claims data of Taiwan.

Methods: From hyperlipidemic patients diagnosed in 2000–2011, we identified 555,153 patients receiving statin treatment for at least 90 days continuously and 1,141,901 non-statin users, and then randomly selected, from both groups, the propensity score-matched subcohorts of statin users and nonusers in a 1:1 pair by renal function: 415,453 pairs with normal renal function , 43,632 pairs with chronic kidney disease (CKD), and 3,624 pairs with end-stage renal disease (ESRD). We compared the mortalities, by the end of 2016, from all causes, cancer, heart disease, and septicemia between statin users and non-users and between hydrophilic-statin users and lipophilic-statin users. The Cox method estimated ST users to non-user hazard ratios. The time-dependent model was also conducted as sensitivity analysis.

Results: The mean ages were 58.7 ± 10.7, 64.2 ± 10.7, and 62.2 ± 10.8 years in normal renal function, CKD, and ESRD groups, respectively. Compared with non-users, statin users had reduced mortality risks from all causes for 32%–38%, from cancer for 37%–46%, from heart disease for 6%–24%, and from septicemia for 17%–21% in all three renal groups. The hydrophilic statin therapy was superior than the lipophilic statin therapy, particularly for reducing deaths from all-causes and cancer. The results under the time-dependent model were similar.

Conclusion: Statin therapy is associated with reduced all-causes and non-cardiovascular mortality in ESRD patients.

Explainable deep neural network for echocardiography view classification

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Science and Technology, Taiwan

Background

Deep neural network may assist echocardiography interpretation in several tasks; however, the lack of expandability hindered its broader application since physicians couldn’t realize the rationale of interpretation clearly and comfortably.

Method

Retrospectively, we manually annotated 26,465 transthoracic echocardiography images into 29 classes for model development in 4:1 ratio as training and validation datasets. We added an autoencoder component into our model, adapted from capsule net, for view-classifying to deconvolute the feature maps of last layer as decoder for human interpretation. The performance of view classification was measured in accuracy and confusion matrix, and the interpretability of model were assessed by cardiologist.

Result

After appropriate model training, the accuracy of our model achieved averaged 98.2% for echocardiography view classification, ranged from lowest 80.0% in suprasternal view to 100% of several more common view in validation dataset. The successful deconvolution of feature map to reconstruct images showed essential independent components of echocardiography view and could be interpretated by cardiologist and clinical physicians.

Conclusion

With the use of autoencoder in model for echocardiography view classification showed maintainable good performance in accuracy and facilitated clinical interpretation to enhance its reliability. Abstract Figure. Model architecture and performance  Abstract Figure. Example of explaniable deconvolution

Epidemiological investigation of multiple sclerosis and related medical utilisation in Taiwan

BACKGROUND

The increasing trend in the prevalence of multiple sclerosis (MS) cannot be neglected. Long-term epidemiological investigations of MS patients who have been registered in Taiwan are very scarce.

OBJECTIVE

The aim of this study was to investigate the epidemiology of MS and medical utilisation among MS patients in Taiwan.

METHODS

The National Health Insurance Research Database was used as the source of the research population; the time period investigated was 2001-2015. A descriptive statistical analysis of the number of MS patients was conducted. For newly diagnosed MS patients, the frequencies of emergency visits and hospitalisations and changes in their temporal distributions were calculated.

RESULTS

The standardised incidence of MS peaked at 0.50/100,000 in 2003, and the highest standardised prevalence was 7.14/100,000 in 2015. The highest standardised mortality was 0.11/100,000 in 2015, with an overall mortality rate of 13.34/1000 person-years. The number of annual emergency visits for MS patients peaked at 0.9 ± 3.5 in 2011, and the longest annual length of hospital stays was 19.2 ± 40.1 days in 2001, which decreased to 5.6 ± 23.5 days in 2015.

CONCLUSION

The standardised prevalence of MS steadily increased, and its incidence slightly decreased from 2001 to 2015.

Influence of Admission Time on Health Care Quality and Utilization in Patients with Stroke: Analysis for a Possible July Effect and Weekend Effect

(1) Purpose: Undesirable health care outcomes could conceivably increase as a result of the entry of new, less experienced health care personnel into patient care during the month of July (the July effect) or as a result of the less balanced allocation of health care resources on weekends (the weekend effect). Whether these two effects were present in Taiwan’s National Health Insurance (NHI) system was investigated. (2) Methods: The current study data were acquired from the NHI Research Database. The research sample comprised ≥18-year-old patients diagnosed as having a stroke for the first time from 1 January 2006 to 30 September 2012. The mortality rate within 30 days after hospitalization and readmission rate within 14 days after hospital discharge were used as health care quality indicators, whereas health care utilization indicators were the total length and cost of initial hospitalization. (3) Results: The results revealed no sample-wide July effect with regard to the four indicators among patients with stroke. However, an unexpected July effect was present among in-patients in regional and public hospitals, in which the total lengths and costs of initial hospitalization for non-July admissions were higher than those for July admissions. Furthermore, the total hospitalization length for weekend admissions was 1.06–1.07 times higher than that for non-weekend admissions; the total hospitalization length for weekend admissions was also higher than that for weekday admissions during non-July months. Thus, weekend admission did not affect the health care quality of patients with stroke but extended their total hospitalization length. (4) Conclusions: Consistent with the NHI’s general effectiveness in ensuring fair, universally accessible, and high-quality health care services in Taiwan, the health care quality of patients examined in this study did not vary significantly overall between July and non-July months. However, a longer hospitalization length was observed for weekend admissions, possibly due to limitations in personnel and resource allocations during weekends. These results highlight the health care efficiency of hospitals during weekends as an area for further improvement.

Effect of introducing biologics to patients with rheumatoid arthritis on the risk of venous thromboembolism: a nationwide cohort study

In the United States, 100,000-300,000 patients die from venous thromboembolism (VTE) each year, with more than 500,000 people related hospitalizations. While in Europe, 500,000 people die from VTE each year. Patients with rheumatoid arthritis are at increased risk of VTE. The use of biologics in patients with rheumatoid arthritis may be associated with an increased risk of VTE. We identified all patients who had been newly approved for Catastrophic Illness Card of rheumatoid arthritis extracted the claims data from the National Health Insurance research database and Registry for Catastrophic Illness Patient Database from 2003 to 2016. VTE was defined as the presence of inpatient VTE diagnostic codes (including DVT or PE) according to the discharge diagnosis protocol. An analysis of VTE variables indicated that the incidence of VTE in the biologic group (14.33/10,000 person-years) was higher than that in the conventional drug group (12.61/10,000 person-years). As assessed by the Cox proportional hazards model, the relative HR for VTE in the biologic group (HR: 1.11; 95% CI 0.79-1.55) versus that in the conventional drug group did not reach a significant difference. In conclusion, this study found no significant differences in risk were observed between the use of conventional DMARDs and biologics.

Effects and Relative Factors of Adjunctive Chinese Medicine Therapy on Survival of Hepatocellular Carcinoma Patients: A Retrospective Cohort Study in Taiwan

Some patients with cancer use adjunctive Chinese medicine, which might improve the quality of life. This study aims to investigate the effects and relative factors of adjunctive Chinese medicine on survival of hepatocellular carcinoma patients at different stages. The study population was 23 581 newly diagnosed hepatocellular carcinoma patients and received surgery from 2004 to 2010 in Taiwan. After propensity score matching with a ratio of 1:10, this study included 1339 hepatocellular carcinoma patients who used adjunctive Chinese medicine and 13 390 hepatocellular carcinoma patients who used only Western medicine treatment. All patients were observed until the end of 2012. Kaplan-Meier method and Cox proportional hazards model was applied to find the relative risk of death between these 2 groups. The study results show that the relative risk of death was lower for patients with adjunctive Chinese medicine treatment than patients with only Western medicine treatment (hazard ratio = 0.68; 95% confidence interval = 0.62-0.74). The survival rates of patients with adjunctive Chinese medicine or Western medicine treatment were as follows: 1-year survival rate: 83% versus 72%; 3-year survival rate: 53% versus 44%; and 5-year survival rate: 40% versus 31%. The factors associated with survival of hepatocellular carcinoma patients included treatment, demographic characteristics, cancer stage, health status, physician characteristics, and characteristics of primary medical institution. Moreover, stage I and stage II hepatocellular carcinoma patients had better survival outcome than stage III patients by using adjunctive Chinese medicine therapy. The effect of adjunctive Chinese medicine was better on early-stage disease.

Incidence, risk, and associated risk factors of stroke among people with different disability types and severities: A national population-based cohort study in Taiwan

BACKGROUND

The number of people with disabilities is increasing. People with disabilities are more likely to be physically inactive, which can lead to chronic diseases, including stroke. Stroke is a leading cause of illness and death worldwide, but little is known regarding stroke among people with disabilities.

OBJECTIVE

To evaluate the incidence density rate, relative risk, and associated risk factors of stroke and measure the risk of death due to stroke among people with disabilities in Taiwan.

METHODS

This retrospective cohort study used nationwide data from the National Health Insurance Research Database, National Disability Registry Database, and Cause of Death File. Incidence density rates of stroke were estimated as new cases per 1000 person-years. Cox proportional hazard models were used to estimate the relative risk of stroke, adjusted survival curves, and adjusted cumulative incidence curves.

RESULTS

A total of 670,630 people with disabilities were included in our analyses. The average person-years of observation was 9.43 ± 5.31, with a yearly rate of 16.72 new cases of stroke per 1000 person-years. The highest risk of stroke was found among people with balance disorder (hazard ratio [HR] = 2.27, 95% confidence interval [CI] = 2.00-2.57) and intractable epilepsy (HR = 1.85, 95% CI = 1.56-2.19). The highest risk of death due to stroke was found among people with dementia and multiple disabilities.

CONCLUSIONS

Stroke rates were higher among people with disabilities than among the general population, and certain disabilities were associated with a higher stroke risk and death rate.

Effect of multidisciplinary team care on survival of oesophageal cancer patients: a retrospective nationwide cohort study

Oesophageal cancer is the sixth leading cause of cancer death worldwide. This nationwide study analyses the survival results of oesophageal cancer under multidisciplinary team (MDT) care. We enrolled oesophageal cancer patients diagnosed between 2010 and 2015 with follow-up for at least 1 year. This study performed propensity score matching with a ratio of 1:1 between MDT participants and non-MDT participants. We performed conditional Cox proportional hazards model to research relative risk of survival and associated factors of survival. The adjusted survival curves were plotted. 8184 newly diagnosed oesophageal cancer patients were included. The favourable survival factors include participant status of MDT, gender, monthly salary, urbanization level, other catastrophic illness, stage of cancer, treatment methods, and service volume of physicians (P < 0.05). MDT participants showed lower risk of death (HR = 0.73; 95% CI 0.67–0.79). Further stratification analysis revealed that the incorporation of an MDT reduced the death risk of patients with stages 2, 3, and 4 cancer, with the greatest reduction observed in patients with stage 3 cancer (HR = 0.72; 95% CI 0.67–0.79). The risk of death was lower for oesophageal cancer patients who enrolled in MDT care.

Comparison of colorectal cancer screening between people with and without disability: a nationwide matched cohort study

Background

The World Health Organization has recognized that people with disability are among the most marginalized in the world. This study’s objective was to investigate the differences in the probability of colorectal cancer (CRC) screening with faecal immunochemical testing (FIT) between people with disability and without disability in Taiwan.

Methods

The study participants included people with and without disability from the Disability Registration Database (2012) and the National Health Insurance Research Database (2009–2012). The study included 50- to 69-year-olds with and without disability who were screened from 2011 to 2012 and were alive in 2012. There were 16 categories of disability. After propensity score matching (PSM) between the two groups, conditional logistic regression analysis with control variables was used to investigate the odds ratio (OR) that people with or without disability would undergo CRC screening.

Results

The percentage of people with disability receiving CRC screening was 21.84%, and the highest rate of those receiving CRC screening (38.72%) was found in people with intractable epilepsy, whose OR was 1.47 times that of people with moving functional limitation (95% confidence interval (CI) = 1.17–1.85). The results showed that the probability of CRC screening in people with disability was lower than that in people without disability (OR = 0.88, 95%CI = 0.87–0.89). The probability of receiving CRC screening differed between people with different categories of disability.

Conclusions

Although the probability of CRC screening in the four categories of disability was higher than that in the general population, overall, people with disability were less likely than people without disability to undergo CRC screening. Health inequalities still exist under National Health Insurance in Taiwan.

Effects of Body Mass Index and Pay-for-Performance Program on Risk of Death in Patients with Type 2 Diabetes: A Nationwide Cohort Study

Background: The diabetes patients enrolled in the pay-for-performance (P4P) program demonstrate reduced risk of death. Body mass index (BMI) is a risk factor of all-cause death. This study investigates the effects of BMI and P4P on the risk of death in type 2 diabetes patients. Methods: This is a retrospective cohort study. The study population includes the 3-wave National Health Interview Survey in Taiwan. A total of 6354 patients with diabetes aged ≥ 20 years were enrolled and followed up until the end of 2014. Results: The highest mortality rate per 1000 person-years was 61.05 in the underweight patients with diabetes. A lower crude death rate was observed in the P4P participants than non-P4P participants. The risk of death was 1.86 times higher in the underweight patients with diabetes than that in the normal weight group (95% CI: 1.37–2.53) and was lower in the P4P participants, as compared to the non-participants (HR: 0.55, 95% CI: 0.44–0.69). The most significant effect of joining the P4P program in reducing death risk was found in the underweight patients with diabetes (HR: 0.11, 95% CI: 0.04–0.38), followed by the obesity group (HR: 0.30, 95% CI: 0.17–0.52). Conclusions: Different effects of joining the P4P program on reducing death risk were observed in the underweight and obesity groups. We strongly recommend that patients with diabetes and without healthy BMIs participate in the P4P program.

The Cancer Risk among Physicians in Taiwan, a Population-Based Propensity Score Matched Cohort Study

Background

The field of physician health is gaining increasing attention; however, most research and interventions have concentrated on factors such as job stress, mental health, and substance abuse. The risks of major cancers in physicians remain unclear. We used a propensity score-matched analysis to investigate the risk of cancer in physicians relative to the general population who had no healthcare-related professional background.

Methods

Data were obtained from the National Health Insurance system in Taiwan. The physician cohort contained 29,713 physicians, and each physician was propensity score-matched with a person from the general population.

Results

The physicians demonstrated a 0.90-fold lower risk of all-cancers (95% confidence interval [CI] = 0.83 - 0.96) when compared with the general population. Female physicians had a higher risk of cancer than male physicians (adjusted hazard ratio [HR] = 1.59; 95% CI = 1.28 - 1.96). Physicians had higher risks of prostate (HR = 1.26; 95% CI = 1.00 - 1.59) and thyroid cancers (HR = 3.16; 95% CI = 1.69 - 5.90) when compared with the general population.

Conclusion

Physicians have lower rates of overall cancer risk than the general population. Female physicians have higher cancer risks than male physicians. Male physicians have higher risks of thyroid and prostate cancer relative to the general population.

Different effects on right ventricular function in different etiology of secondary tricuspid regurgitation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Science and Technology, Excutive Yuan, Taiwan

Background

Tricuspid regurgitation (TR) is traditionally classified as primary or secondary TR. The effects of TR on right ventricular (RV) function were not consistent. We hypothesized that secondary TR is not a unique group, sophisticated sub-grouping can be useful for studying effects of TR on RV function.

Methods

207 consecutive patients identified as significant TR (moderate and severe) by echocardiography were recruited. Standard measurements for right heart were done according to guideline. Lateral tricuspid annulus systolic tissue velocity (S’) and RV fractional area change (FAC) were used for RV function. We classified these patients into primary TR and 6 subgroups of secondary TR according to a new systemic approach.

Results

Mean age of subjects was 71.2 ± 14.7 years, and there were 84 (40.6%) male. There were 29 (14%) primary TR. Secondary TR was further classified into 6 groups included 18 (8.7%) pacemaker related, 81 (39.1 %) left heart diseases, 6 (2.9%) congenital heart diseases, 3 (1.4%) RV myopathy, 27 (13.0%) pulmonary hypertension, and 43 (20.8%) idiopathic TR. Among 4 major groups (congenital heart disease and RV myopathy were not included in analysis due to low numbers) of secondary TR, S’ was significant higher in idiopathic TR and RV FAC were higher in pacemaker related and idiopathic TR. RV dysfunction was defined as FAC &lt; 35%. RV dysfunction presented mostly in pulmonary hypertension related TR and leastly in idiopathic TR (59.3% vs. 14%, p &lt;0.001). Multivariate analysis using idiopathic TR as reference and controlled TR maximal velocity, RV end-diastolic area, right atrial area, and severity of TR, left heart disease related TR had higher risk of RV dysfunction (OR 4.178, 95% CI 1.490-11.703, p = 0.007).

Conclusions

Effects of TR on RV function were different among different subgroups of secondary TR. Left heart disease related TR had highest risk for RV dysfunction. Secondary TR should not be regarded as a single disease.

Characteristics of idiopathic tricuspid regurgitation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Science and Technology, Executive Yuan, Taiwan

Background

Tricuspid regurgitation (TR) were traditionally classified as primary and secondary TR. Recently a new category of TR was developed and named as idiopathic TR. However, diagnosis and characteristics of idiopathic TR were not consisted. We tried to identify idiopathic TR by a new systemic approach and studied its characteristics.

Methods

207 consecutive patients (mean age 71.2 ± 14.7 years, 40.6% male) identified as significant TR (moderate and severe) by echocardiography were recruited. We classified TR by a new systemic approach. The classification process started from identified primary TR, then pacemaker related TR, left heart disease related TR, congenital heart related TR, right ventricular (RV) myopathy, pulmonary hypertension and, finally idiopathic TR step by step.

Results

There were 29 (14%) primary TR, 18 (8.7%) pacemaker related, 81 (39.1 %) left heart diseases, 6 (2.9%) congenital heart diseases, 3 (1.4%) RV myopathy, 27 (13%) pulmonary hypertension, and 43 (20.8%) idiopathic TR. Mean age of idiopathic TR was 72.9 ± 11.4 years and 39.5% was male which were not different from other groups. Atrial fibrillation was presented highest in patients with pacemaker related TR (77.8%) and left heart disease (55.6%), lowest in primary TR (24.1%) and pulmonary HT (25.9%), and modest in idiopathic TR (44.2%). Among the echocardiographic characteristics of right heart measurements, idiopathic TR had lowest TR maximal velocity (3.0 ± 0.3 m/s), pulmonary (41.2 ± 8.7 mmHg) and right atrium pressure (5.3 ± 0.3 mmHg; all p &lt;0.001). Idiopathic TR had smallest RV wall thickness (4.5 ± 1.4 mm; p = 0.008), tricuspid annulus diameter (3.2 ± 0.7 cm; p = 0.001), and right atrial area (18.9 ± 8.4 cm2; p &lt;0.001). RV function represented as tricuspid annulus velocity S’ (12.8 ± 3.3 cm/s; p = 0.011) and RV fractional area change FAC (42.6 ± 16.0 %; p &lt;0.001) were best in idiopathic TR. RV dysfunction (FAC &lt; 35%) was lowest (14%) in idiopathic TR.

Conclusions

Idiopathic TR had better RV function then other types of TR. Idiopathic TR can be regarded as a unique disease category in studying TR.

Characteristics and related factors of emergency department visits, readmission, and hospital transfers of inpatients under a DRG-based payment system: A nationwide cohort study

Objectives

Taiwan has implemented the Diagnosis Related Groups (DRGs) since 2010, and the quality of care under the DRG-Based Payment System is concerned. This study aimed to examine the characteristics, related factors, and time distribution of emergency department (ED) visits, readmission, and hospital transfers of inpatients under the DRG-Based Payment System for each Major Diagnostic Category (MDC).

Methods

We conducted a retrospective cohort study using data from the National Health Insurance Research Database (NHIRD) from 2012 to 2013 in Taiwan. Multilevel logistic regression analysis was used to examine the factors related to ED visits, readmissions, and hospital transfers of patients under the DRG-Based Payment System.

Results

In this study, 103,779 inpatients were under the DRG-Based Payment System. Among these inpatients, 4.66% visited the ED within 14 days after their discharge. The factors associated with the increased risk of ED visits within 14 days included age, lower monthly salary, urbanization of residence area, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, Diseases and Disorders of the Kidney and Urinary Tract (MDC11) conferred the highest risk of ED visits within 14 days (OR = 4.95, 95% CI: 2.69–9.10). Of the inpatients, 6.97% were readmitted within 30 days. The factors associated with the increased risk of readmission included gender, age, lower monthly salary, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, the inpatients with Pregnancy, Childbirth and the Puerperium (MDC14) had the highest risk of readmission within 30 days (OR = 20.43, 95% CI: 13.32–31.34). Among the inpatients readmitted within 30 days, 75.05% of them were readmitted within 14 days. Only 0.16% of the inpatients were transferred to other hospitals.

Conclusion

The study shows a significant correlation between Major Diagnostic Categories in surgery and ED visits, readmission, and hospital transfers. The results suggested that the main reasons for the high risk may need further investigation for MDCs in ED visits, readmissions, and hospital transfers.

Impact of Liver Cirrhosis on Incidence of Dialysis Among Patients with Type 2 Diabetes

INTRODUCTION

Renal injury is a common complication of liver cirrhosis and type 2 diabetes mellitus (T2DM). The aim of this study was to analyze the association between cirrhosis and dialysis in patients with T2DM.

METHODS

This was a retrospective study of specific patient populations using data collected from the National Health Insurance Research Database, National Health Research Institutes, Taiwan on patients treated between 1999 and 2007. The study population comprised 1271,759 patients with T2DM without cirrhosis, 38,860 patients with cirrhosis without T2DM, 11,487 patients with T2DM and cirrhosis, and 579,173 patients without T2DM and cirrhosis (non-cirrhotic control group).

RESULTS

The average incidence of dialysis in patients with T2DM and liver cirrhosis (2.466%) was 10.6-, 2.3-, and 102.7-fold higher than that in patients with T2DM without cirrhosis (0.232%), with cirrhosis without T2DM (1.071%), and patients without both T2DM and cirrhosis (0.024%), respectively. Adjusted odds ratio (OR) for dialysis risk was 3.19 in patients with T2DM and cirrhosis, 2.16 in patients with T2DM without cirrhosis, and 1.98 in patients with cirrhosis without T2DM, compared to that in patients without T2DM and cirrhosis. Male sex (adjusted hazard ratio [HR] 1.15), age (45-49 vs. 20-34 years [reference]; adjusted HR 1.34), low-income households (adjusted HR 1.46), cirrhosis (adjusted HR 3.42), and diabetic complications severity index (adjusted HR 1.71) were predictors of dialysis in T2DM patients. In addition, those with T2DM participating in the pay-for-performance (P4P) program had a significantly lower relative risk for requiring dialysis (HR 0.64).

CONCLUSION

Liver cirrhosis is an independent risk factor for dialysis in patients with T2DM. Participating in the P4P program for diabetes care may reduce the risk of requiring dialysis in patients with T2DM.

Effect of multidisciplinary team care on the risk of recurrence in breast cancer patients: A national matched cohort study

BACKGROUND

Cancer has been the leading cause of death in the past decade in Taiwan, with breast cancer being the most common type of cancer in females. Very few studies looked at the risk of recurrence in patients who received multidisciplinary team (MDT) care. We analyzed the influence of MDT on the risk of recurrence and death in breast cancer patients.

METHOD

In this retrospective study, we included newly diagnosed patients from 2004 to 2010. The study included 9,266 breast cancer patients who were enrolled in MDT care and 9,266 patients who were not. The study used log-rank test to analyze patients' characteristics, hospital characteristics, cancer staging, and treatment methods to compare the recurrence rates in MDT care and non-MDT care participants. We used Cox proportional hazards model to examine the effect of MDT and associated factors on the risk of recurrence and mortality of breast cancer patients.

RESULTS

Relative risk of recurrence was lower for patients who received MDT care than for patients who did not (HR, 0.84; 95%CI: 0.70-0.99) after matching. The mortality risk for breast cancer patients with relapse was 8.48 times (95%CI: 7.53-9.54) than that for patients without relapse.

CONCLUSIONS

The relative risk of recurrence and death was significantly lower for breast cancer patients who received MDT care than for those who did not. We suggest that MDT care be implanted in the National Health Policy settings of breast cancer patients.

Recurrence, death risk, and related factors in patients with stage 0 colorectal cancer: A nationwide population-based study

In this study, the National Health Insurance Research Database of Taiwan was used to examine the recurrence and death risk for stage 0 colorectal cancer patients. We examined stage 0 colorectal cancer patients to identify factors causing recurrence and death.This is a retrospective study, and stage 0 colorectal cancer patients that are registered in the Taiwan Cancer Registry of the Health Promotion Administration in 2007 to 2012 were included. The database was linked to the National Health Insurance Research Database, and subjects were followed up until the end of 2016. The mean follow-up period was 69 months. Bivariate analysis methods (log-rank test) and Cox proportional hazards model were used to evaluate the risk of recurrence and death and demographic characteristics, economic factors, environmental factors, health factors, treatment and hospitals, and absence/presence of postoperative tests were used to examine related risk factors.Our study showed that the 5-year recurrence rate and 5-year mortality rate for stage 0 colorectal cancer are 1.68% and 0.6%, respectively. For stage 0 colorectal cancer, age (61-74 years) is the only factor affecting recurrence in patients (hazard ratio (HR) = 2.44; 95% CI: 1.41-4.22), while age >75 years (HR = 4.35; 95% CI: 1.14-16.68) and Charlson Comorbidity Index >4 points (HR = 7.20, 95% CI: 2.60-19.94) can increase the risk of death. In contrast, patients who underwent one (HR = 0.27, 95% CI: 0.10-0.71) and two or more colonoscopies (HR = 0.26, 95% CI: 0.10-0.70) within 2 years after surgery can reduce the risk of death from stage 0 colorectal cancer. In addition, the risk of recurrence is higher in patients who underwent colonoscopic polypectomy (HR = 2.07, 95% CI: 0.98-4.33) and patients with rectal cancer (HR = 2.74, 95% CI: 0.96-7.83), but these differences are not statistically significant (P > .05).From this study, we can see that age and comorbidity index increase the risk of recurrence and death for stage 0 colorectal cancer, while postoperative colonoscopy can decrease the risk of death.

Alendronate medication possession ratio and the risk of second hip fracture: an 11-year population-based cohort study in Taiwan

Alendronate is effective in preventing second hip fracture in osteoporotic patients. However, no consensus exists on the duration that is effective in preventing a second hip fracture. Our study demonstrated that risk can be reduced when the prescription is ≥ 6 months for the year following the index hip fracture.

INTRODUCTION

Alendronate is effective in preventing second hip fracture in osteoporotic patients. However, no consensus exists on the accurate medication possession ratio (MPR) that is effective in preventing a second hip fracture. Our objective was to compare the risk of second hip fracture in patients treated with different MPR of alendronate.

METHODS

In this population-based cohort study, data from National Health Insurance Research Database of Taiwan were analyzed. Patients 50 years and older who had an index hip fracture and were not receiving any osteoporotic medications before their fracture during 2000-2010 were included. The cohort consisted of 88,320 patients who were new alendronate users (n = 9278) and non-users (n = 79,042). Those without alendronate were matched 4:1 as the control group. Patients were subdivided into those with no medication, MPR < 25%, MPR 25-50%, MPR 50-75%, and MPR 75-100%. Cox proportional hazard models were used to calculate the adjusted hazard ratios for different MPRs of alendronate.

RESULTS

After matching, 38,675 patients were included in this study; 20,363 (52.7%) were women, and 30,940 (80%) patients were without medication of alendronate. During follow-up on December 31, 2012, 2392 patients had a second hip fracture, for an incidence of 1449/100,000 person-years. Patients with alendronate MPR 50-75% had a lower risk of a second hip fracture compared to non-users (hazard ratio 0.66). When the MPR increased to 75-100%, the hazard ratio decreased to 0.61.

CONCLUSIONS

In this population-based cohort study, risk of a second hip fracture can be reduced when the alendronate MPR is ≥ 50% for the year following the index hip fracture. As the MPR increases, the risk of a second hip fracture decreases.

Impact of family physician integrated care program on decreasing utilization of emergency department visit and hospital admission: a population-based retrospective cohort study

BACKGROUND

Hospital admission and emergency department(ED) visits are a massive burden in medical expenditures. In 2003, the Taiwanese government developed Family Physician Integrated Care Program (FPIC) to increase the quality of primary care and decrease medical expenditures. This study's goals were to determine whether FPIC decreased hospital admissions and ED visits and identify the factors influencing the outcomes.

METHODS

This nationwide retrospective cohort study was conducted for the period between 2006 and 2013 by using data obtained from the Taiwan National Health Insurance Research Database. A total of 68,218 individuals were divided into those who joined FPIC and those who did not. We used propensity score matching at a ratio of 1:1 and logistic regression with the generalized estimating equation (GEE) model having a difference-in-difference design to investigate the effects of the FPIC policy on hospital admissions and ED visits in 7 years.

RESULTS

Using logistic regression with the GEE model with the difference-in-difference design, we found no reduction in ED visits and hospital admissions between the two groups. The participants' risk of hospital admissions increased in the first year after joining FPIC (OR: 1.11, 95% CI: 1.03-1.20, P < .05). However, participants who joined FPIC showed an 8% lower risk of hospital admissions in the sixth and seventh years after joining FPIC, compared with those who did not join FPIC (OR: 0.92, 95% CI: 0.85-1.00, P < .05).

CONCLUSIONS

FPIC in Taiwan could not decrease medical utilization initially but might reduce hospital admissions in the long term.

Demographics and medical disorders associated with smoking: a population-based study

Background

Few studies have investigated factors associated with smoking behaviors. In this population-based study, we investigated demographics and medical comorbid diseases to establish a prediction model for smoking behaviors by using the National Health Interview Survey (NHIS) and National Health Insurance Research Database (NHIRD).

Methods

We enrolled individuals aged ≥40 years who had participated in the NHIS in 2001, 2005, and 2009. We identified the smoking behaviors of the study participants in the NHIS. Smoking behaviors were divided into ever smokers (current smokers and ex-smokers) and nonsmokers (never smokers).We defined medical comorbid disorders of the study participants by using medical claim data from the NHIRD. We used multivariable logistic regression models to calculate the adjusted odds ratio and 95% confidence interval for variables associated with smoking. The significant variables in the multivariable model were included in the receiver operating characteristic curves (ROC) to predict the sensitivity and specificity of the model.

Results

In total, 26,375 participants (12,779 men and 13,596 women) were included in the analysis. The prevalence of smoking was 39.29%. The mean ages of the 16,012 nonsmokers were higher than those of the 10,363 smokers (57.86 ± 12.92 years vs. 53.59 ± 10.82 years). Men outnumbered women among smokers (68.18% vs. 31.82%). Male sex, young age and middle age, being insured categories, residence in suburban areas, and chronic obstructive pulmonary disease (COPD) were independent factors associated with smoking. The area under the ROC curve of these significant factors to predict smoking behaviors was 71.63%.

Conclusion

Sex, age, insured categories, residence in suburban areas, and COPD were associated with smoking in people.

Effect of time interval from diagnosis to treatment for non-small cell lung cancer on survival: a national cohort study in Taiwan

OBJECTIVES

This study aimed to determine if treatment delay after non-small cell lung cancer (NSCLC) diagnosis impacts patient survival rate.

STUDY DESIGN

This study is a natural experiment in Taiwan. A retrospective cohort investigation was conducted from 2004 to 2010, which included 42 962 patients with newly diagnosed NSCLC.

METHODS

We identified 42 962 patients with newly diagnosed NSCLC in the Taiwan Cancer Registry from 2004 to 2010. We calculated the time interval between diagnosis and treatment initiation. All patients were followed from the index date to death or the end of 2012. Cox proportional hazard models were used to examine the relationship between mortality and time interval.

RESULTS

We included 42 962 patients (15 799 men and 27 163 women) with newly diagnosed NSCLC. The mortality rate exhibited a significantly positive correlation to time interval from cancer diagnosis to treatment initiation. The adjusted HRs ranged from 1.04 to 1.08 in all subgroups time interval more than 7 days compared with the counterpart subgroup of the interval from cancer diagnosis to treatment ≤7 days. The trend was also noted regardless of the patients with lung cancer in stage I, stage II and stage III.

CONCLUSIONS

There is a major association between time to treat and mortality of patients with NSCLC, especially in stages I and II. We suggest that efforts should be made to minimise the interval from diagnosis to treatment while further study is ongoing to determine causation.

The effect of pay for performance on risk incidence of hip fracture in type 2 diabetic patients: a nationwide population-based cohort study

OBJECTIVES

Diabetes mellitus (DM) increases the risk of hip fracture. The literature rarely discusses the importance of pay-for-performance (P4P) programs for the incidence of hip fractures in patients with type 2 DM (T2DM). This study aimed to examine the impact of the P4P program on hip fracture risk in patients with T2DM.

METHODS

This retrospective cohort study focused on data from T2DM patients aged 45 and older between 2001 and 2012. We continued to track these data until 2013. The data were collected from the National Health Insurance Research Database in Taiwan. To minimize selection bias, T2DM patients were divided into P4P enrollees and non-enrollees. Propensity score matching by greedy matching technique (1:1 ratio) was used to include 252,266 participants. A Cox proportional hazard model was performed to examine the impact of the P4P program on hip fracture risk. We used the bootstrap method to perform sensitivity analysis by random sampling with replacement.

RESULTS

Our results showed that the risk of hip fracture in P4P enrollees was 0.92 times that of non-enrollees. (hazards ratio [HR] = 0.92; 95% confidence interval [CI]: 0.85-0.99). P4P enrollees who received regular treatment had lower risk in the first 4 years (HR = 0.90; 95%CI: 0.84-0.96) but no statistically significant difference after 4-year enrollment (HR = 0.99; 95%CI: 0.93-1.06). There was no statistically significant difference in the effect of hip fractures between P4P non-enrollees and P4P enrollees with irregular treatment (HR = 0.94, 95%CI: 0.87-1.03). Through sensitivity analysis, the results also showed P4P enrollees had a lower risk of hip fracture compared to P4P non-enrollees (mean HR = 0.919; 95% CI: 0.912-0.926). Stratified analysis showed that patients without DM complications (DCSI = 0) who enrolled in P4P had lower risks of hip fractures than the non-enrollees (HR = 0.90; 95% CI: 0.82-0.98).

CONCLUSION

T2DM patients enrolled in P4P program can reduce the risks of hip fracture incidence. Early inclusion of patients without DM complications in the P4P program can effectively reduce hip fractures.

Cost-benefit analysis, cost-effectiveness analysis, and impact of antiepileptic drugs on the risk of fracture in patients with epilepsy: A nationwide cohort study

PURPOSE

Although nonenzyme-inducing antiepileptic drugs (nEIAEDs) are accepted for the treatment of epilepsy, few studies have examined the costs, benefits, and cost-effectiveness of nEIAEDs in relation to the incidence of fracture among patients with epilepsy. In the present study, we performed cost-benefit and cost-effectiveness analyses comparing the influence of enzyme-inducing AEDs (EIAEDs) and nEIAEDs on the risk of fracture in this population.

METHODS

A total of 4864 patients with epilepsy were classified into EIAED and nEIAED groups. Propensity score matching was applied to reduce the influence of selection bias. Clinical outcomes were measured in relation to AED fee, medical expenses associated with epilepsy and fracture, and the total number of fractures. Cost-benefit and cost-effectiveness analyses were performed for all patients.

RESULTS

Patients in the unmatched EIAED cohort (n = 3686) were older and had more comorbidities. After matching, the cohorts exhibited similar features (n = 2432 each). Fracture risk was lower in the nEIAED group than in the EIAED group (HR = 0.70). The additional medical expense of nEIAEDs in fractures and epilepsy for 2 years per person was 107,731 New Taiwan dollars (NT$). The additional cost for nEIAEDs to reduce one event of fracture was $14,789,421 NT$.

CONCLUSIONS

Patients with epilepsy using nEIAEDs had a lower risk of fracture than those using EIAEDs. However, the cost-benefit ratio and cost-effectiveness of such treatment were lower in the nEIAED group than in the EIAED group.

Assessment of the Risk of Oral Cancer Incidence in A High-Risk Population and Establishment of A Predictive Model for Oral Cancer Incidence Using A Population-Based Cohort in Taiwan

We aimed to assess the risk of oral cancer incidence in a high-risk population, establish a predictive model for oral cancer among these high-risk individuals, and assess the predictive ability of the constructed model. Individuals aged ≥30 years who had a habit of smoking or betel nut chewing and had undergone oral cancer screening in 2010 or 2011 were selected as study subjects. The incidence of oral cancer among the subjects at the end of 2014 was determined. The annual oral cancer incidence among individuals with a positive screening result was 624 per 100,000 persons, which was 6.5 times that of the annual oral cancer incidence among all individuals screened. Male sex, aged 45-64 years, divorce, low educational level, presence of diabetes, presence of other cancers, high comorbidity severity, a habit of smoking or betel nut chewing, and low monthly salary were high-risk factors for oral cancer incidence (p < 0.05). The area under the curve of the predictive model for oral cancer incidence was 0.73, which indicated a good predictive ability. Therefore, the oral cancer screening policy for the high-risk population with a habit of smoking and/or betel nut chewing is beneficial for the early diagnosis of oral cancer.

A comparison of quality of life between patients treated with different dialysis modalities in Taiwan

Purpose

This study compared the quality of life (QOL) of hemodialysis (HD) and peritoneal dialysis (PD) patients in Taiwan.

Methods

This cross-sectional study recruited end-stage renal disease patients from 34 Taiwanese hospitals or clinics. Patient characteristics, diagnoses, and laboratory data were extracted from charts. The Chinese version of the Quality of Life Index–Dialysis version (QLI-D) was used. Multiple linear regression analysis showed the effects of dialysis modality on QOL. P<0.05 indicated statistical significance.

Results

In total, 600 HD and 387 PD patients were included. The mean health and functioning, social and economic, psychological/spiritual, and family subscale scores and total QOL scores were significantly lower in HD patients than PD patients. After adjusting for region, hospital level, age, education level, marital status, and Karnofsky Performance Scale, the total QOL was 2.81 points higher for PD patients than for HD patients visiting medical centers (p<0.001). The total QOL was 2.53 points lower in PD patients than in HD patients for those visiting clinics.

Conclusion

Compared to HD patients, PD patients had better QOL in Taiwanese medical centers. The current survey improves our understanding of the QOL of patients undergoing different dialysis modalities in Taiwan.

P1771 Gender differences of the blood pressure effects on early changes of left ventricle mechanics in untreated hypertension

Background

Left ventricular (LV) diastolic dyssynchrony and global and layer-specific strain can be used for evaluation of early myocardial changes in hypertension. We tried to investigate the gender differences in these early changes in untreated uncomplicated hypertension.

Methods

This study included 43 consecutive patients (mean age 51.3 ±12.5 years, 56% men) with newly diagnosed hypertension from an out-patient clinic. All subjects were free of complications including renal dysfunction, LV hypertrophy, and diabetes. Comprehensive transthoracic echocardiography (E9, GE, USA) was conducted before treatment of hypertension. Diastolic and systolic parameters were measured by two-dimension (2D), Doppler, tissue Doppler imaging and 2D speckle tracking echocardiography (STE). The time-to-peak early diastolic myocardial annulus velocity (Te) at 6 LV segments from apical-4-chamber, apical-2-chamber and apical-3-chamber views were measured with reference to the QRS complex. The time to peak early diastolic strain rate (TDSr), global longitudinal strain (GLS), layer-specific longitudinal strain included sub-epicardial strain (EpiLS) and sub-endocardial strain (EndLS) were measured from 18 LV segments by STE. Diastolic dyssynchrony parameters were defined as the standard deviation (SD) of Te of all LV segments (Te-SD), SD of TDSr of 18 LV segments (TDSr-SD), and the maximal difference between any two TDSr of the 18 LV segments (MaxD-TDSr).

Results

There were no differences between men (56%) and women (44%) regarding age, initial blood pressure, hypertension duration, LV mass index, LV ejection fraction, and early mitral velocity to average early annulus velocity ratio. Regarding diastolic dyssynchrony parameters, men were significantly higher than women including Te-SD (22.3 ± 13.8 vs. 14.7 ± 4.2 ms; p = 0.016), TDSrSD (46.0 ± 13.3 vs. 35.3 ± 11.4 ±ms; p = 0.008), and MaxD-TDSr (162.0 ± 40.3 vs. 128.1 ± 50.7 ms; p = 0.019). Men also had worse GLS (-17.6 ± 1.9 vs. -19.5 ± 2.5 %; p = 0.007), EpiLS (-15.1 ± 1.7 vs. -17.0 ± 2.3, p = 0.003), and EndLS (-20.5 ± 2.2 vs. -22.4 ± 2.8 %; p = 0.018) than women. After multivariate analysis controlling age, systolic blood pressure, and LV mass index, TeSD (p = 0.039), TDSrSD (p = 0.018), MaxD-TDSr (p = 0.035) were still significantly higher than women. GLS (p = 0.046), and EpiLS (p = 0.025) were still worse in men.

Conclusion

In the same age, blood pressure, hypertension duration and LV mass index, men have more diastolic dyssynchrony and worse myocardial strain in untreated hypertension.

Posterior cruciate ligament reconstruction implemented by the Ligament Advanced Reinforcement System over a minimum follow-up of 10 years

PURPOSE

This study evaluated the long-term clinical follow-up results of patients who underwent double-bundle posterior cruciate ligament (PCL) reconstruction using the Ligament Advanced Reinforcement System (LARS).

METHODS

Patients were assessed using clinical scores that included the Tegner activity level scale, the Lysholm score, and the International Knee Documentation Committee (IKDC) score. KT-1000 was adopted to assess stability. Radiographs and magnetic resonance imaging (MRI) were used to evaluate osteoarthritis and LARS condition.

RESULTS

This study examined 38 patients, of which follow-up procedures were completed for 33 patients, resulting in a follow-up rate of 86.8%. The average follow-up period was 11.9 ± 1.2 years (range: 10.3-14.2 years). The median scores of the clinical scales were as follows: Tegner activity score, 6 (range: five to seven); Lysholm score, 90 (range: 67-100); and IKDC score, 89.7 (range: 46-100). The median of the side-to-side difference (SSD) was four millimeters (range: 0-10 mm). In radiographs, the moderate OA rate was 6.9%. MRI results revealed that 26 patients exhibited ingrowth and 11 patients exhibited partial rupture of the LARS. With SSD ≤ 3 mm set as the standard for successful knee stabilization, the optimal cutoff point of LARS midsubstance thickness in the receiver operating characteristic (ROC) curve analysis was 14.3 mm.

CONCLUSIONS

Long-term follow-up of the studied patients demonstrated the durability of LARS. However, clinical outcomes showed no enhancement using LARS, so it is not recommended for routine use in PCL reconstruction.

LEVEL OF EVIDENCE

IV.

Effect of the Integrated Prospective Payment Program on Family Members' Knowledge and Acceptance of Hospice Care of Patients on Prolonged Mechanical Ventilation

BACKGROUND

We sought to evaluate the effect of an integrated prospective payment program (IPP) on knowledge of hospice care and willingness to participate in hospice care among family members of patients on prolonged mechanical ventilation (PMV).

METHODS

Between November 2013 and April 2014, we used paper-based survey questionnaires from 64 institutions to evaluate knowledge, willingness, and related factors among the main caregivers of patients on PMV regarding hospice care and to determine whether their decisions for the patients were affected by the IPP.

RESULTS

The average ages of the respondents and patients on PMV were 51.9 y and 70.8 y respectively; 70.6% of the respondents knew about the Hospice Palliative Care Act (HPCA), and 42.3% of the medical staff had introduced hospice care-related information to patients and caregivers in Taiwan. Among the caregiver respondents, 67.6% agreed to write a letter of intent regarding the choice of hospice care or limited life-sustaining treatment. In total, 66.2% (16.1 + 50.1%) of the respondents agreed to hospice care for their family members (ie, the patients on PMV) when the condition was terminal. The factors of greater HPCA knowledge among the patients on PMV were IPP participation, female sex, and coma status. Factors leading to higher levels of HPCA knowledge included age ≥ 65 y being married, higher income, awareness of the law, and being introduced to hospice care by medical staff.

CONCLUSIONS

High levels of hospice care knowledge were unrelated to willingness to participate. HPCA knowledge was greater in the IPP group than in the non-IPP group; however, there was no significant difference in the willingness to agree to hospice care. It is recommended that individuals be encouraged to express their medical decisions.

Pay-for-performance programmes reduce stroke risks in patients with type 2 diabetes: a national cohort study

OBJECTIVES

A pay-for-performance (P4P) programme is a management strategy that encourages healthcare providers to deliver high quality of care. In Taiwan, the P4P programme has been implemented for diabetes, and certified diabetes physicians voluntarily enrol patients with diabetes into the P4P programme. The objectives of this study were to compare the risk of stroke and its related factors in patients with type 2 diabetes who were enrolled in a P4P programme compared with those who were not.

STUDY DESIGN

This study is a natural experiment in Taiwan. A retrospective cohort investigation was conducted from 2002 to 2013, which included 459 726 patients with type 2 diabetes, who were grouped according to P4P enrolment status following a propensity score matching process.

METHODS

We reviewed patients ≥45 years of age newly diagnosed with type 2 diabetes mellitus (DM) from the National Health Insurance Research Database in Taiwan. A Cox proportional hazards model was used to compare the relative risk of stroke between patients with type 2 DM enrolled in the P4P programme and those who were not enrolled.

RESULTS

Compared with the patients not enrolled, there was a significantly lower stroke risk in P4P participants (HR=0.97, 95% CI 0.95 to 0.99). Although a significantly lower risk of haemorrhagic stroke was observed (HR=0.87, 95% CI 0.82 to 0.93) in P4P participants, no statistically significant difference for the risk of ischaemic stroke between P4P and non-P4P patients (HR=0.99, 95% CI 0.97 to 1.02) was found. Following stratification analysis, a significantly reduced stroke risk was observed in male patients with type 2 diabetes, but not in women.

CONCLUSIONS

Participants in Taiwan's Diabetes P4P programme displayed a significantly reduced stroke risk, especially haemorrhagic stroke. We recommend the continual promotion of this programme to the general public and to physicians.