Hsiu-Yun Lai

Prevalence of the prescribing of potentially inappropriate medications at ambulatory care visits by elderly patients covered by the Taiwanese National Health Insurance program

BACKGROUND The use of potentially inappropriate medications can have profound medical consequences for elderly patients and place a substantial burden on the health care system. OBJECTIVES This study was conducted to determine the prevalence of potentially inappropriate medication prescribing at ambulatory care visits by patients aged > or =65 years covered by the Taiwanese National Health Insurance program, to examine the characteristics of and risk factors for such prescribing, and to investigate its influence on health care resource utilization. METHODS Ambulatory care visits by patients aged > or =65 years in 2001-2004 were identified from the National Health Insurance claims database. The 2003 Beers criteria for drugs to be avoided in the elderly were used to identify potentially inappropriate medications prescribed at these visits. Only drugs with the potential to lead to higher-severity adverse events were included. Multivariate logistic regression was used to determine predictors of the prescribing of potentially inappropriate medications at ambulatory care visits. Independent variables in the regression model included patient characteristics (eg, sex, age), physician characteristics (sex, age, and specialty), and visit characteristics (site and prescribed drug number). The dependent variable was visits that included a prescription for a potentially inappropriate medication. RESULTS Overall, 176,661,994 ambulatory care visits by patients aged > or =65 years were identified in 2001-2004. Of these, 19.1% involved a prescription for a potentially inappropriate medication. Although the frequency of potentially inappropriate medication prescribing declined over the study period, 62.5% of elderly patients were exposed to such medications in 2004. The only patient characteristic associated with an increased likelihood of the prescribing of potentially inappropriate medications was female sex (male sex: odds ratio [OR] = 0.982 [95% CI, 0.980-0.983], P < 0.001). Physician characteristics associated with a greater likelihood of the prescribing of potentially inappropriate medications was male sex (OR = 1.206 [95% CI, 1.202-1.210], P < 0.001); older age (43-50 years: OR = 1.021 [95% CI, 1.018-1.025], P < 0.001; >/=51 years: OR = 1.238 [95% CI, 1.235-1.242], P < 0.001); and family medicine/general practice (OR = 1.267 [95% CI, 1.265-1.269], P < 0.001). For visit characteristics, significant associations were found with visits to a primary care clinic (OR = 1.887 [95% CI, 1.881-1.892], P < 0.001) and the number of drugs prescribed (4-6 drugs: OR = 2.701 [95% CI, 2.696-2.706], P < 0.001; > or =7 drugs: OR = 4.528 [95% CI, 4.517-4.538], P < 0.001). The most commonly prescribed types of potentially inappropriate medications were antihistamines (4.8% of all prescriptions in 48.3% of elderly patients), muscle relaxants/antispasmodics (4.0% and 40.3%, respectively), and long-acting benzodiazepines (2.4% and 21.4%). In 2004, the mean number of ambulatory care visits per patient was significantly higher among those who received potentially inappropriate medications compared with those who did not (30.78 vs 16.57, respectively; P < 0.001). Patients who received potentially inappropriate medications also had significantly more emergency department visits (0.27 vs 0.15; P < 0.001) and hospital admissions (0.46 vs 0.27; P < 0.001). CONCLUSION There was a high prevalence of the prescribing of potentially inappropriate medications at ambulatory care visits by elderly patients in Taiwan in 2001-2004.

Potentially inappropriate medication for emergency department visits by elderly patients in Taiwan

The potential for adverse drug events caused by potentially inappropriate medication (PIM) use in elderly patients at emergency department (ED) visits is a growing concern. The objects of this study were to determine the prevalence, characteristics and risk factors of PIM use among elderly ED visits in Taiwan.

Predicting Mortality of Older Residents in Long-Term Care Facilities: Comorbidity or Care Problems?

OBJECTIVE Accurate prediction of life expectancy in long-term care facilities (LTCFs) is important, but previous studies emphasized demographic characteristics, disease diagnosis, or comorbidity. The purpose of this study was to evaluate the roles of geriatric care problems and comorbidity in predicting 12-month mortality in LTCFs. DESIGN Prospective, observational. SETTING Veterans Care Home. PARTICIPANTS Residents of Banciao Veterans Care Home. MEASUREMENTS A minimum data set (MDS) was implemented, and resident assessment protocol (RAP) triggers were collected as geriatric care problems. Comorbidity of the residents was evaluated using Charlsons comorbidity index (CCI). RESULTS A total of 559 residents (mean age = 80.9 ± 5.3 years, all males) were successfully followed, and 50 residents (7.9%) died during the study period. Compared with survivors, deceased subjects had a higher sum of RAP triggers (4.9 ± 2.0 versus 4.1 ± 2.0, P = .004) and CCI (1.2 ± 1.2 versus 0.7 ± 0.9, P = .014), and were more likely to be hospitalized (1.6 ± 1.9 versus 0.4 ± 0.9, P < .001) and visit the emergency department (0.9 ± 1.2 versus 0.5 ± 1.2, P = .012). Moreover, deceased subjects were more prone to have cognitive loss, urinary incontinence, and behavioral symptoms than survivors (P all < .05). A Cox proportional hazards model showed that both CCI (HR = 1.44, 95% CI: 1.13-1.82, P = .003) and the sum of RAP triggers (HR = 2.03, 95% CI: 1.08-3.82, P = .028) were significantly associated with 12-month mortality. CONCLUSION Independent of comorbidity, the sum of geriatric care problems is a significant predictor of 12-month mortality in a veterans care home. Further intervention studies are needed to evaluate whether elimination of these care problems can improve survival in the long-term care setting.

Diabetes Mellitus, Glycemic Control, and Pneumonia in Long-Term Care Facilities: A 2-Year, Prospective Cohort Study

OBJECTIVE To determine the relationships among diabetes mellitus (DM), glycemic control, and long-term care facility (LTCF)-acquired pneumonia. DESIGN Prospective cohort study. SETTING Ten private LTCFs in Taiwan. PARTICIPANTS Participants were 233 LTCF residents. MEASUREMENTS Barthel index (BI), Charlson comorbidity index (CCI), hemoglobin A1c, episodes of LTCF-acquired pneumonia. INTERVENTION None. RESULTS A total of 233 residents (76.9 ± 10.6 years, 54.9% males, 27.9% diabetic) from 10 private LTCFs participated. There were 173 LTCF-acquired pneumonia episodes. The incidence of LTCF-acquired pneumonia between patients with and without diabetes, or between diabetic subjects with different status of glycemic control was similar. Adjusted for baseline BI, CCI, feeding tube placement, and baseline serum albumin, DM was not a significant risk factor for LTCF-acquired pneumonia. Poorer glycemic control (HbA1c >7%) was not a significant risk factor for LTCF-acquired pneumonia in diabetic subjects. CONCLUSIONS Tighter glycemic control did not protect diabetic LTCF residents from pneumonia. A prospective randomized controlled trial is needed to determine the optimal goal of glycemic control for LTCF residents.

Home healthcare services in Taiwan: a nationwide study among the older population

BackgroundHome healthcare services are important in aging societies worldwide. The present nationwide study of health insurance data examined the utilization and delivery patterns, including diagnostic indications, for home healthcare services used by seniors in Taiwan.MethodsPatients ≥65 years of age who received home healthcare services during 2004 under the Taiwanese National Health Insurance Program were identified and reimbursement claims were analyzed. Age, gender, disease diagnoses, distribution of facilities providing home healthcare services, and patterns of professional visits, including physician and skilled nursing visits, were also explored.ResultsAmong 2,104,978 beneficiaries ≥65 years of age, 19,483 (0.9%) patients received 127,753 home healthcare visits during 2004 with a mean number of 6.0 ± 4.8 visits per person. The highest prevalence of home healthcare services was in the 75-84 year age group in both sexes. Females received more home healthcare services than males in all age groups. Cerebrovascular disease was the most frequent diagnosis in these patients (50.7%). More than half of home healthcare visits and around half of the professional home visits were provided by community home nursing care institutions. The majority of the home skilled nursing services were tube replacements, including nasogastric tubes, Foley catheter, tracheostomy, nephrostomy or cystostomy tubes (95%).ConclusionsNine out of 1,000 older patients in Taiwan received home healthcare services during 2004, which was much lower than the rate of disabled older people in Taiwan. Females used home healthcare services more frequently than males and the majority of skilled nursing services were tube replacements. The rate of tube replacement of home healthcare patients in Taiwan deserves to be paid more attention.

CARE OF PATIENTS WITH DIABETES MELLITUS IN LONG-TERM CARE FACILITIES IN TAIWAN: DIAGNOSIS, GLYCEMIC CONTROL, HYPOGLYCEMIA, AND FUNCTIONAL STATUS

To the Editor: The principles of management of diabetes mellitus (DM) in frail older people in long-term care facilities (LTCFs) need extensive modifications. The prevalence of known DM in care homes has been found to be 7.2% to 17.5%, but this is an underestimate, because they were estimated using merely a questionnaire survey. It was reported that 26.7% of care home residents without DM eventually had DM according to a glucose tolerance test. Moreover, approximately 80% of DM in British care homes was undiagnosed after a pragmatic screening. Nevertheless, the model of care in Taiwanese LTCFs differs from that in Western countries, and so does DM care in this setting. In Taiwan, all LTCFs undergo periodic national accreditation for quality assurance, and the performance of annual health checks is included. Thus, underdiagnosis of DM in LTCFs may be less common, but the quality of care for patients with DM is of interest. In January 2007, LTCFs with bed capacity of 20 to 50 (most popular size in Taiwan) located in northern Taiwan were invited to participate in a study. A retrospective cohort was identified from participating LTCFs, and all of their records and medical records from the preceding year were reviewed. Functional status measured using the 100point Barthel Index had been documented in the LTCF chart records in January 2006. All study subjects underwent an annual health examination. Residents with abnormal test results were referred to medical consultations, and a second test was performed to confirm the diagnosis of DM. DM was diagnosed according to the American Diabetes Association criteria, and quality of care for DM was evaluated according to glycosylated hemoglobin A1c (HbA1c) testing and incidence of hypoglycemia in the past year. Hypoglycemia was as defined by the American Diabetes Association Workgroup on Hypoglycemia. Continuous variables were compared using Student t-test, and categorical variables using the chi-square test or Fisher exact test. Multiple logistic regression was used to determine the independent risk factors for hypoglycemia. For all tests, Po.05 was considered statistically significant. Ten LTCFs (282 residents) participated in the study, and 234 residents (aged 77.5 10.9, 52.6% male, mean Barthel Index 5 30.2 33.8 and 63.2% o30.0) were enrolled after excluding subjects whose informed consent was absent. The prevalence of known DM was 35.5% (83/234) according to the records, which became 30.8% (72/234) after plasma glucose testing, because 11 residents had non-diabetic fasting plasma glucose levels. Overall, the rate of undiagnosed DM was 3.8% (9/234), and 86.1% (62/72) of all subjects with DM were currently being treated with medication. Of all subjects being treated with medication, 66.1% (41/62) were managed using monotherapy, and 71.0% (44/62) had a HbA1c test during the preceding year (1.8 HbA1c tests/year, mean HbA1c level 5 7.1 1.6%). Metformin was the most popular agent for monotherapy, and sulphonyurea plus metformin was the most popular regimen for combination therapy. Of all subjects being treated with medication, 41.9% (26/62) had experienced hypoglycemia (median 2, range 1–10). From the perspective of drug therapy, insulin was more commonly associated with hypoglycemia (57.7% vs 19.4%, P 5.002), and metformin was less commonly associated with hypoglycemia (34.6% vs 66.7%, P 5.02) (Table 1). The independent risk factor for hypoglycemia was insulin therapy (odds ratio 5 4.0, 95% confidence interval 5 1.0–15.4, P 5.04). The low rate of undiagnosed DM in this study may be related to the national LTCF accreditation system that regularly evaluates the affiliation of LTCF and locality-based medical resources and whether residents receive an annual health examination. This system not only regulates the quality of care in LTCFs, but also assures that the study cohort is sufficiently representative of all Taiwanese LTCF residents. Like other countries, Taiwanese LTCF residents are old, disabled, and limited in communication, and have multiple comorbid medical conditions. The American Geriatrics Society has suggested that DM in frail elderly people or people with a short life expectancy should be controlled at the mean HbA1c of 8%. Although tight glycemic control provides better clinical outcomes, the risk of hypoglycemia probably outweighs the benefit of tight control in frail older people. To frail elderly LTCF residents, the realistic goal for control of DM is mainly to reduce the signs and symptoms of hyperglycemia rather than to attain euglycemia. Epidemiological evidence suggests that frail elderly patients with DM are at a higher risk of hypoglycemic coma because of impaired glucose counterregulations to hypoglycemia. In addition, cognitive impairment, limited ability to communicate, and blunted autonomic warning symptoms may also explain their risk of developing hypoglycemia. In conclusion, DM is a prevalent condition in Taiwanese LTCFs, but the undiagnosed rate is low. DM in Taiwanese LTCFs was tightly controlled, but 41.9% of pharmaceutically treated elderly diabetic patients experienced hypoglycemia. Further investigation is needed to

Risk factors of new onset diabetes mellitus among elderly Chinese in rural Taiwan

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Regular vitamin B12 supplementation among older Chinese men in a veterans care home in Taiwan

Vitamin B(12) deficiency is common in older adults, and may be associated with cognitive impairment and depression. The main purpose of this study is to explore clinical effectiveness of regular vitamin B(12) supplementation on cognitive function and depressive symptoms among oldest old men living in a Taiwanese veterans care home. All residents of Banchiao Veterans Care Home were invited for study. Status of regular vitamin B(12) supplementation was determined. Cognitive function and depressive symptoms were evaluated by mini-mental state examination (MMSE) and geriatric depression scale (GDS). Subjects with renal insufficiency or established diagnosis of vitamin B(12) deficiency were excluded. Comparisons of demographic data, MMSE, GDS, and serum vitamin B(12) between subjects with and without regular supplementation were done. In total, 419 residents (mean age=80.8+/-5.5 years, all males) were enrolled. The mean serum level of vitamin B(12) was 1294.1+/-189.1 pg/ml (range: 50-30,000 pg/ml). Forty-five subjects (10.7%) reported regular vitamin B(12) supplementation, and their mean serum levels of vitamin B(12) were significantly higher than the non-supplementation subjects (8057.4+/-1408.3 pg/ml vs. 480.4+/-14.5 pg/ml, p<0.001). The mean MMSE (26.7+/-4.6 vs. 26.7+/-3.7, p=0.965), GDS (1.8+/-1.7 vs. 1.9+/-2.3, p=0.595), prevalence of cognitive impairment (13.6% vs. 19.3%, p=0.420) and depressive symptoms (4.5% vs. 8.4%, p=0.375) were similar between subjects with and without regular vitamin B(12) supplementation. In conclusion, regular vitamin B(12) supplementation and high serum level of vitamin B(12) are not associated with better cognitive function or depressive symptoms among asymptomatic oldest old men in a Taiwanese veterans care home.

Pain and health-care utilization among older men in a veterans care home

Pain is a common health-care issue, and the prevalence increases with advancing age. Although it is often assumed that people with chronic pain are associated with a higher consumption of health care, evidence supporting this assertion is insufficient. Data from the Longitudinal Older VEterans (LOVE) study were stratified to explore the prevalence of pain and its relationship with health-care utilization. In total, data from 574 residents (mean age: 80.9+/-5.4 years, all male) were obtained. Among them, 92.8% were physically independent and 20.2% of them had mild to moderate cognitive impairment. Overall, 153 (26.3%) subjects reported pain; 114 (74.5%) subjects with mild pain and the remaining 39 (25.5%) subjects with moderate pain. The most commonly reported pain was lower back pain (40.5%, 62/153), which was followed by joint pain (29.4%, 45/153). Subjects with pain were more likely to have higher scores on the Geriatric Depression Scale (2.4+/-2.4 vs. 1.8+/-2.2, p = 0.023) and care-complexity problems (4.7+/-2.0 vs. 3.9+/-1.9, p < 0.001), despite being similar in age (81.3+/-5.0 vs. 80.8+/-5.5, p = 0.271), cognitive status and physical independence. Compared with pain-free subjects, subjects with pain were more likely to be hospitalized in the 12-month study period (0.71+/-1.20 vs. 0.46+/-1.00, p = 0.010), but the utilization of emergency department treatment (1.74+/-1.23 vs. 1.88+/-1.63, p = 0.560) was not statistically significant. In conclusion, the prevalence of pain among residents in a Taiwanese veterans care home was 26.3%; subjects with pain having more depressive symptoms, higher clinical-care complexity, and more likely to be hospitalized during the 12-month follow-up.

Intra-articular hyaluronic acid for treatment of osteoarthritis: a nationwide study among the older population of Taiwan

BackgroundAlthough intra-articular treatment with hyaluronic acid (HA) for symptomatic osteoarthritis has become widely accepted in recent decades, the pattern of its use has seldom been reported. We have explored the epidemiology of intra-articular HA treatment in Taiwan by using the rich data source from nationwide insurance claims.MethodsTaiwans National Health Insurance (NHI), which covers 97% of inhabitants, offers extensive hospitalisation and ambulatory care. We identified the beneficiaries aged 60 years and older who received intra-articular HA within the NHI during 2004. The number of visits in which HA was administered were analysed by patients age and gender and by the physicians specialty and practice site.ResultsAmong the 73,410,777 ambulatory visits by 2,909,219 beneficiaries aged 60 years and older in 2004, 35,782 (1.2%) patients received intra-articular HA treatment in 205,012 (0.3%) visits. The highest prevalence of HA use was in the 70–79 year age group in both sexes. Women received intra-articular HA treatment more frequently than men in all age groups, especially in the 60–69 and 70–79 year groups (1.6% vs. 0.5%, 2.2% vs. 1.0%, respectively). Most intra-articular HA procedures were performed by orthopaedic surgeons (75.1%) and physical medicine and rehabilitation physicians (15.2%), and at metropolitan hospitals (34.5%) and local community hospitals (38.2%).ConclusionOne out of 100 older patients in Taiwan received intra-articular HA treatment for osteoarthritis of the knee during the course of the year. There were age-gender differences in use of HA treatment. The completion rate of this treatment in our study was high, and thus intra-articular HA might be a good alternative for patients for whom conventional treatment fails. Further research is needed to examine the age-gender differences in use of intra-articular HA in Taiwan.