Jui-fen Rachel Lu

The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups

The widespread use of standardized health surveys is predicated on the largely untested assumption that scales constructed from those surveys will satisfy minimum psychometric requirements across diverse population groups. Data from the Medical Outcomes Study (MOS) were used to evaluate data completeness and quality, test scaling assumptions, and estimate internal-consistency reliability for the eight scales constructed from the MOS SF-36 Health Survey. Analyses were conducted among 3,445 patients and were replicated across 24 subgroups differing in sociodemographic characteristics, diagnosis, and disease severity. For each scale, item-completion rates were high across all groups (88% to 95%), but tended to be somewhat lower among the elderly, those with less than a high school education, and those in poverty. On average, surveys were complete enough to compute scale scores for more than 96% of the sample. Across patient groups, all scales passed tests for item-internal consistency (97% passed) and item-discriminant validity (92% passed). Reliability coefficients ranged from a low of 0.65 to a high of 0.94 across scales (median=0.85) and varied somewhat across patient subgroups. Floor effects were negligible except for the two role disability scales. Noteworthy ceiling effects were observed for both role disability scales and the social functioning scale. These findings support the use of the SF-36 survey across the diverse populations studied and identify population groups in which use of standardized health status measures may or may not be problematic.

Who pays for health care in Asia

We estimate the distributional incidence of health care financing in 13 Asian territories that account for 55% of the Asian population. In all territories, higher-income households contribute more to the financing of health care. The better-off contribute more as a proportion of ability to pay in most low- and lower-middle-income territories. Health care financing is slightly regressive in three high-income economies with universal social insurance. Direct taxation is the most progressive source of finance and is most so in poorer economies. In universal systems, social insurance is proportional to regressive. In high-income economies, the out-of-pocket (OOP) payments are proportional or regressive while in low-income economies the better-off spend relatively more OOP. But in most low-/middle-income countries, the better-off not only pay more, they also get more health care.

The extended QUALIFLEX method for multiple criteria decision analysis based on interval type-2 fuzzy sets and applications to medical decision making

QUALIFLEX, a generalization of Jacquet-Lagreze’s permutation method, is a useful outranking method in decision analysis because of its flexibility with respect to cardinal and ordinal information. This paper develops an extended QUALIFLEX method for handling multiple criteria decision-making problems in the context of interval type-2 fuzzy sets. Interval type-2 fuzzy sets contain membership values that are crisp intervals, which are the most widely used of the higher order fuzzy sets because of their relative simplicity. Using the linguistic rating system converted into interval type-2 trapezoidal fuzzy numbers, the extended QUALIFLEX method investigates all possible permutations of the alternatives with respect to the level of concordance of the complete preference order. Based on a signed distance-based approach, this paper proposes the concordance/discordance index, the weighted concordance/discordance index, and the comprehensive concordance/discordance index as evaluative criteria of the chosen hypothesis for ranking the alternatives. The feasibility and applicability of the proposed methods are illustrated by a medical decision-making problem concerning acute inflammatory demyelinating disease, and a comparative analysis with another outranking approach is conducted to validate the effectiveness of the proposed methodology.

Cultural Issues in Using the SF-36 Health Survey in Asia: Results from Taiwan

BackgroundThe feasibility of using the SF-36 in non-Western cultures is important for researchers seeking to understand cultural influences upon health status perceptions. This paper reports on the performance of the Taiwan version of the SF-36, including the implications of cultural influences.MethodsA total of 1191 volunteered subjects from the general population answered the translated SF-36 Taiwan version, which was developed following IQOLA project protocols.ResultsResults from tests of scaling assumptions and reliability generally were satisfactory. Convergent validity, as assessed by comparing the SF-36 to a mental health oriented inventory, was acceptable. Results of principal components analysis were similar to US results for many scales. However, differences were seen for the Vitality scale which was a stronger measure of mental health than physical health in Taiwan. Results are compared to those from other Asian studies and the U.S.ConclusionThe results raise important questions regarding cultural influences in international studies of health status assessment. Further research into the conceptualization and components of mental health in Asian countries is warranted.

Evolution of Taiwan’s health care system

This study aims to present an overview of the evolutionary policy process in reforming the health care system in Taiwan, through dissecting the forces of knowledge, social-cultural context, economic resources and political system. We further identify factors, which had a significant impact on health care reform policies in Taiwan through illustrative policy examples. One of the most illuminating examples highlighted is the design and implementation of a single-payer National Health Insurance (NHI) program in 1995, after nearly five years of planning efforts (1988-1993) and a two-year legislative marathon. The NHI is one of the most popular social programs ever undertaken in the history of Taiwan, which greatly enhances financial protection against unexpected medical expenses and assures access to health services. Nonetheless, health care reform still has an unfinished agenda. Despite high satisfaction ratings, Taiwans health care system today is encountering mounting pressure for new reforms as a result of its rapidly aging population, economic stagnation, and imbalanced NHI checkbook. Although there may exist some heterogeneous system characteristics and challenges among different health care systems around the world, Taiwans experiences in reforming its health care system for the past few decades may provide valuable lessons for countries going through rapid economic and political transition.

Joint predictability of health related quality of life and leisure time physical activity on mortality risk in people with diabetes

BackgroundReduced health related quality of life (HRQOL) has been associated with increased mortality in individuals with diabetes. In contrast, increased leisure time physical activity (LTPA) has been associated with reduced mortality. The aim of this study was to investigate the combined relationship of HRQOL and LTPA on mortality and whether high levels of LTPA are associated with reduced risk of mortality in adults with diabetes and inferior HRQOL.MethodsWe analyzed data from a national sample of adults (18 years or older) with self-reported physician-diagnosed diabetes, who participated in the 2001 National Health Interview Survey in Taiwan (N = 797). A total of 701 participants had complete Short Form 36 (SF-36) and LTPA data and were followed from 2002 to 2008. Participants were divided into 3 groups based on their LTPA: (1) a regularly active group who reported 150 or more min/week of moderate-intensity activity; (2) an intermediately active group who reported engaging in LTPA but did not meet the criterion for the “regular” category; and (3) an inactive group who reported no LTPA. The physical component summary (PCS) and mental component summary (MCS) scores were dichotomised at the median (high vs. low) (PCS = 45.11; MCS = 47.91). Cox proportional-hazards models were used to investigate associations between baseline characteristics and mortality.ResultsAfter 4,570 person-years of follow-up, 121 deaths were recorded and the crude mortality rate was 26.5 per 1,000 person-years. Both PCS scores and LTPA were significant predictors of mortality, whereas no significant relationship was observed between MCS and mortality. After adjustment for other factors, participants with low PCS who reported no LTPA had a hazard ratio (HR) for mortality of 4.49 (95% CI = [2.15-9.36]). However, participants with low PCS who were active (including intermediate and regular LTPA) had a HR for mortality of 1.36 (95% CI = [0.64-2.92]).ConclusionsOur results show a significantly increased mortality risk of diabetes associated with reduced HRQOL in individuals who report no LTPA. Engaging in LTPA may be associated with improved survival in participants with diabetes with poor self-rated physical health status.

Psychometric testing of the SF‐36 Taiwan version on older stroke patients

AIM AND OBJECTIVE To assess the psychometric properties of the SF-36 Taiwan version on a sample of older stroke patients in Taiwan. BACKGROUND The Medical Outcomes Study Short Form-36 (SF-36) has proven to be a valid and reliable instrument in evaluating outcomes among stroke patients in western countries; however, less is known regarding its value for Asian stroke patients. DESIGN A descriptive correlational study design was used to explore the reliability and validity of the SF-36 Taiwan version. METHOD Older stroke patients (n = 87) from a medical centre in northern Taiwan were interviewed at the end of the first and sixth months after hospital discharge. RESULTS Items on each subscale of the SF-36 Taiwan version had similar standard deviations, supporting the scaling assumption of equal-item variance in measuring the same concept. Correlations between items and their subscale were generally >or=0.70 with a few being 0.50 or 0.60. Cronbachs alpha coefficients were >0.70 for almost all subscales, supporting internal consistency. At both the first and sixth months after discharge, participants had lower scores, especially on the physical- and social function-related scales, than the norm for older people. At both times, patients with physical dependence had lower scores across subscales than those without physical dependence, supporting construct validity. CONCLUSIONS The SF-36 Taiwan version demonstrated good reliability and validity when applied to stroke patients at either a transitional or stable time point after hospital discharge. However, the SF-36 Taiwan version has a potential to underestimate changes in certain domains due to floor or ceiling effects. RELEVANCE TO CLINICAL PRACTICE Health care providers who deal with Taiwanese/Chinese stroke patients can use the SF-36 Taiwan version to assess health outcomes at either a transitional or a stable time point after hospital discharge.

Health‐related quality of life predicts hospital admission within 1 year in people with diabetes: a nationwide study from Taiwan

Aims  To investigate whether health‐related quality of life (HRQOL) predicts hospital admission in a nationally representative sample of adults with diabetes.

The spillover effect of National Health Insurance on household consumption patterns: evidence from a natural experiment in Taiwan.

While providing financial risk protection was one of the major aims of introducing a National Health Insurance (NHI) program in Taiwan in 1995, one may also wonder how the households may exploit resources freed up and available to them as a result of reduced exposure to risk due to health insurance. This paper aims at studying and evaluating the impact of social insurance on these differing household consumption patterns. A differences-in-differences estimation model was applied to a sample of 17,899 households from the 1993-2000 Taiwan Survey of Family Income and Expenditure to assess the NHIs impact. This effect was evaluated by the changes in the proportion of the consumption expenditure devoted to medical items and non-medical items in the post-NHI period (1996-2000) compared to the pre-NHI period (1993-1994). Our study found that spending related to the improvement of housing conditions (rental and water bills) had the most significant increase, 1.87% (in the share). Furthermore, examining the NHI impact across socioeconomic status (SES) strata (in terms of income and education levels), our study found that households with the lowest SES experienced the largest increase in spending share (2.16%) for rental and water bills, and the least drop (0.64%) on education items. Recognizing how households can exploit the potential benefits associated with NHI provision could enable the government to devise specific policy tools to facilitate better targeting of investment decisions with limited resources available for less well-off households.

Building a Hospital Alliance — Taiwan Landseed Medical Alliance

Following the launch of the National Health Insurance (NHI) program in 1995, universal coverage was achieved in Taiwan. In the period immediately following the introduction of the program, private hospitals did well and many opportunists entered Taiwans rapidly expanding, prosperous healthcare market. However, the boom did not last long, ending with Bureau of NHIs hospital global budget system in 2002. The new NHI policies, stricter regulations, and higher public expectations of healthcare services intensified competition in the healthcare market and many private hospitals were forced to close.The Taiwan Landseed Medical Alliance (TLMA) was formed in 1993 by eight hospitals. It was the first successful hospital alliance in Taiwan. Although most of the alliance members were private district hospitals, through collaboration and integrated networks TLMA offered a unique model that combined the strength of each of these small-scale hospitals. The alliance thus enhanced the ability of its members to survive despite fierce competition, and increased their capacity to provide first-rate health care. By fully implementing the operations and development strategies inherent in a collaborative hospital group, TLMA members worked through difficulties together and are already on course to meet many other alliance goals including the upgrading of hospital management practices and service quality, improvement of the medical environment, and promotion of good hospital practice.The case aims to evoke discussion on the important role of alliances in competitive markets and ways to form strategic alliances. Supportive actions and alliance structures should also be considered.