Chin Shyan Chen

An analysis of private health insurance purchasing decisions with national health insurance in Taiwan

The Taiwanese health insurance industry is just over 30 years old. Originally private and domestic, the industry underwent substantial institutional changes when it opened to foreign competition between 1987 and 1994 and when the Taiwanese government established national health insurance (NHI) coverage in 1995. Congruent with these changes, rapid growth occurred in the Taiwanese demand for private health insurance. In order to better understand the recent performance of the Taiwanese health insurance industry, the structure of the NHI system is described and then household decisions to purchase private health insurance are analyzed using a two-part (hurdle) model on 1998 Survey of Family Income and Expenditure data. Logistic and OLS regressions are used to examine the factors influencing the probability and amount of private health insurance purchased. Generally, factors affecting the probability of having insurance also influence the amount of insurance coverage purchased. Higher income and education levels are associated with increased probabilities and larger quantities of private insurance purchases. Married females, the employed, and household heads working in state-run enterprises are more likely to purchase private insurance than their counterparts. The probability of private insurance purchases varies by region, with northern Taiwanese households having higher odds of owning private insurance than non-northern households. Compared to those in rural villages, households in cities and towns are more likely to have private insurance. The likelihood of private insurance purchase also tends to rise with advancing age and larger family sizes. In addition, one important implication in the private health insurance market is highlighted. There is no complementarity between the public and private systems.

Urbanization and stroke prevalence in Taiwan: analysis of a nationwide survey.

This study aims to explore the prevalence of strokes among individuals and the association with urbanization levels. A total sample of 9,794 individuals was obtained from a nationwide survey on Taiwan for subsequent analysis in this study. After adjusting for gender, age, other risk factors for stroke and individual socioeconomic status, a multivariate logistic regression model was employed to investigate the relationships existing between the prevalence of strokes and the level of urbanization. This study finds that those living in areas at the highest level of urbanization (level 1) had the highest prevalence of strokes (2.49%). With decreasing urbanization level, there was a general decline in stroke prevalence. After adjusting for other factors, the multivariate logistic regression analyses showed that compared to participants living in the highest urbanization level, the respective odds ratios of suffering a stroke for those living in areas at the lowest levels of urbanization (levels 7 and 8), were 0.43 and 0.30. We conclude that after adjusting for other stroke risk factors, the level of urbanization is an important contributory factor to the overall prevalence of strokes in Taiwan.

Seasonality and Climatic Associations with Violent and Nonviolent Suicide: A Population-Based Study

Background: Using 7-year population-based data on Taiwan, we examined seasonal variation in violent versus nonviolent suicide, and its association with meteorological factors: ambient temperature, relative humidity, atmospheric pressure, rainfall and daily sunshine hours. Methods: We used Taiwan’s nationwide mortality data from 1997 to 2003, categorizing the sample decedents into two groups, violent (ICD-9-CM codes E953–E958) and nonviolent (E950–E952) suicide, based on the suicide method used. Seasonal autoregressive integrated moving average (SARIMA) modeling was used to detect seasonality of suicide, and the association of climate variables with violent versus nonviolent suicide. Results: The SARIMA test of seasonality was significant for both genders and the pooled sample (all p < 0.001) in violent suicide deaths, but not nonviolent suicides. Seasonal trends show a significant peak in March–May (early to late spring) for violent suicides. Increasing ambient temperature predicted increasing violent suicide rates. Conclusions: We conclude that seasonality exists in violent but not nonviolent suicide rates. Our findings suggest that suicide is a heterogeneous phenomenon and violent suicide may be more influenced by biochemical and chronobiological mechanisms.

The association between readmission rates and length of stay for schizophrenia: A 3-year population-based study

OBJECTIVE A nationwide population-based dataset was used to explore the association between length of stay (LOS) and 30-day readmission rates for hospitalized patients with schizophrenia in Taiwan. METHODS The National Health Insurance Research Database was used for the years 2001-2003 and included a total of 29,373 patients with schizophrenia divided equally into four groups according to LOS of index hospitalization. After adjusting for hospital, physician and patient characteristics, a multivariate regression analysis was used to determine the relationship between LOS and 30-day readmission rates. RESULTS After discharge from their index hospitalization, 12,468 (42.5%) patients with schizophrenia were readmitted within 30 days. The adjusted odds ratio for 30-day readmission rates was increased for shorter LOS. CONCLUSIONS Healthcare providers should exert caution while trying to reduce LOS within the current cost-conscious environment and balance it with creating a minimal status necessary for discharge.

Asian Dust Storm Events are Associated With an Acute Increase in Pneumonia Hospitalization

PURPOSE This study aims to examine the association of Asian dust storm (ADS) events with the daily number of pneumonia admissions using 10-year population-based data in the Taipei metropolitan region. METHODS We identified 1,933,247 admissions with a principal discharge diagnosis of pneumonia between 2000 and 2009. The auto-regressive integrated moving average (ARIMA) method was used to examine the associations between ADS episodes and the logarithm of the daily number of pneumonia hospitalizations. RESULTS There was a significant difference in the mean number of daily pneumonia admissions between ADS event days, post-ADS event days, and non-ADS event days (P < .001); the mean number of daily admissions for ADS event days, post-ADS event days, and non-ADS event days were 292.5, 305.7, and 279.0, respectively. After adjusting for the time-trend effect, ambient temperature, and SO(2), CO, and O(3), the ARIMA showed that compared with non-ADS event days, ADS event days and post-ADS event days 1 through 4 had a significantly higher mean number of pneumonia admissions for the total group. CONCLUSIONS Our results suggest that ADS event days and post-ADS days 1 through 4 had significantly higher mean numbers of pneumonia admissions than non-ADS days.

National health insurance and the antenatal care use: a case in Taiwan

Many studies have found evidence for the importance of antenatal care on pregnancy outcomes. This paper focuses on the determinants of antenatal care use in Taiwan and provides a comparison of access to care before and after National Health Insurance (NHI) was implemented in 1995. A negative binomial model is applied to data from the 1989 and 1996 Taiwan Maternal and Infant Health Surveys to analyze antenatal care use. The results show that women in some situations had more antenatal care visits than average regardless of NHI implementation. These situations include: having a highly educated husband; gaining more weight than average during pregnancy; experiencing a first pregnancy; carrying twins or triplets; having care provided by a doctor rather than other caregivers; and switching to another health care facility during pregnancy. Regarding societal change, the trend toward delaying pregnancy is causing a change in care use. Additionally, three changes in care patterns after NHI are noteworthy. First, antenatal care visits at maternity clinics increased more than visits at hospitals. Second, before NHIs implementation, women who did blue-collar work or farm work sought care more frequently than housewives, but after NHI began government employees and businesswomen sought care more frequently. Third, antenatal care visits of mothers living in Taiwans central area increased more than visits of those in the northern area. The expansion of medical care in aboriginal areas and outlying islands may prove to be one of NHIs best achievements.

SEASONALITY OF PNEUMONIA ADMISSIONS AND ITS ASSOCIATION WITH CLIMATE: AN EIGHT-YEAR NATIONWIDE POPULATION-BASED STUDY

The aim of the study was to examine seasonal variability in monthly admissions for community-acquired pneumonia (CAP) in Taiwan. Our study sample comprised 477,541 pneumonia patients in Taiwan between 1998 and 2005, inclusive. Results showed a fairly consistent seasonal pattern of pneumonia admissions, regardless of sex and age, and for the groups combined. Seasonal trends showed a peak in hospitalizations from January through April, followed by a sharp decrease in May and a trough from August through October. The auto-regressive integrated moving average (ARIMA) test found significant seasonality for all age and sex groups and for the whole sample (all p < 0.001). After adjusting for seasonality, month, and trends, the ARIMA regression models revealed that the monthly pneumonia admissions rate was significantly associated with ambient temperature, for the total sample, for female groups, and for the 65–74 and ≥75 age groups (all p < 0.01). A 1°C decrease in ambient temperature was associated with roughly a 0.03 increase in monthly pneumonia admissions rate (per 10,000 people) for the entire sample. We conclude the monthly pneumonia admissions rate was significantly associated with seasonality, and was higher in periods with low ambient temperatures. (Author correspondence: henry11111@tmu.edu.tw)

Seasonal variation in ischemic stroke incidence and association with climate: A six-year population-based study

Questions about the seasonality of stroke remain controversial. Using a nationwide population‐based dataset, this study presents a time series analysis of seasonal patterns in ischemic stroke occurrence, along with their association with climate in Taiwan. Using data from the Taiwan National Health Insurance Research Database, a total of 168,977 visits to emergency departments between 1998 and 2003 for ischemic stroke were identified for patients ranging between 20 and 84 yrs of age. Monthly stroke incidences were calculated for 72 months, by sex and stroke subtype, and for the age groups 20–54, 55–64, 65–74, and ≥75 yrs per 100,000 of the population. We performed auto‐regressive integrated moving average (ARIMA) analysis to investigate the presence of seasonality and any association with climate for acute ischemic stroke events. We found no significant seasonal variation in the incidence of ischemic stroke for any age or sex groups. Furthermore, after adjusting for seasonality, month, and trend, the ARIMA regression model revealed only associations between ischemic stroke incidence and atmospheric pressure. We conclude that seasonality of ischemic stroke does not exist in Taiwan. Ischemic stroke incidence is, however, significantly related to atmospheric pressure.

Household out-of-pocket medical expenditures and national health insurance in Taiwan: income and regional inequality

BackgroundUnequal geographical distribution of medical care resources and insufficient healthcare coverage have been two long-standing problems with Taiwans public health system. The implementation of National Health Insurance (NHI) attempted to mitigate the inequality in health care use. This study examines the degree to which Taiwans National Health Insurance (NHI) has reduced out-of-pocket medical expenditures in households in different regions and varying levels of income.MethodsData used in this study were drawn from the 1994 and 1996 Surveys of Family Income and Expenditure. We pooled the data from 1994 and 1996 and included a year dummy variable (NHI), equal to 1 if the household data came from 1996 in order to assess the impact of NHI on household out-of-pocket medical care expenditures shortly after its implementation in 1995.ResultsAn individual who was older, female, married, unemployed, better educated, richer, head of a larger family household, or living in the central and eastern areas was more likely to have greater household out-of-pocket medical expenditures. NHI was found to have effectively reduced household out-of-pocket medical expenditures by 23.08%, particularly for more affluent households. With the implementation of NHI, lower and middle income quintiles had smaller decreases in out-of-pocket medical expenditure. NHI was also found to have reduced household out-of-pocket medical expenditures more for households in eastern Taiwan.ConclusionAlthough NHI was established to create free medical care for all, further effort is needed to reduce the medical costs for certain disadvantaged groups, particularly the poor and aborigines, if equality is to be achieved.

Monthly variation in acute appendicitis incidence: A 10-year nationwide population-based study

BACKGROUND The present study investigated the monthly variation of acute appendicitis and its association with climatic factors (ambient temperature, relative humidity, atmospheric pressure, rainfall, and hours of sunshine) using a nationwide population-based data set in Taiwan. METHODS We identified 237,760 first-time hospitalizations for acute appendicitis from 2000 to 2009. We used the auto-regressive integrated moving average method to examine the monthly variation in the acute appendicitis incidence rates after adjusting for the time-trend effect and seasonality. RESULTS Throughout the 10-year study period, we found that the monthly incidence rate of acute appendicitis demonstrated a fairly similar monthly pattern for each gender independently and for the pooled data. May through July had the greatest rates, decreasing in August to a trough in February. We used the autoregressive integrated moving average test for seasonality and found a significant difference in the monthly incidence rate for the pooled genders and for the male- and female-only groups (all P < 0.001). Furthermore, the auto-regressive integrated moving average regression models for the male, female, and combined groups all suggested that a significant positive association exists between the monthly incidence rates of acute appendicitis per 100,000 population and the ambient temperature after adjusting for time trends and month. CONCLUSIONS The results of our study have revealed a significant difference in the monthly incidence rate of acute appendicitis.