Lih-Wen Mau

Impact of the clinical conditions at dialysis initiation on mortality in incident haemodialysis patients: a national cohort study in Taiwan

BACKGROUND Glomerular filtration rate (GFR) and co-morbidity at dialysis initiation in relation to mortality in end-stage renal disease is still controversial. We studied factors potentially related to the mortality in incident haemodialysis (HD) patients. METHODS A national database included 23 551 incident HD patients from July 2001 to December 2004. Kaplan-Meier and Cox regression analyses were performed to assess the association between GFR estimated by the four-variable Modified Diet in Renal Disease equation and all-cause mortality. Analyses were performed from Day 91 after the start of dialysis. Patients were classified into five groups (quintiles) based on estimated glomerular filtration rate (eGFR) at the start of dialysis. RESULTS The median eGFR at dialysis initiation was low (4.7 mL/min/1.73 m(2)), as was the mortality in the first year of dialysis [13.2/100 patient-year, 95% confidence interval (95% CI) = 12.8-13.7]. There was an inverse association between lower eGFR and higher survival rate. The Cox regression model revealed an increase in mortality risk in Q5 (hazard ratio [HR] = 2.44, 95% CI = 2.11-2.81), Q4 (HR = 1.66, 95% CI = 1.43-1.93), Q3 (HR = 1.21, 95% CI = 1.04-1.41) and Q2 (HR = 1.18, 95% CI = 1.01-1.37) compared with the reference group of Q1 after adjusting for year of application, primary diseases (chronic glomerulonephritis, diabetic nephropathy, hypertension, chronic tubulointerstitial nephritis and others), demographics (age, sex), presence of co-morbidity (diabetes mellitus, hypertension, congestive heart failure, ischaemic heart diseases, cerebrovascular diseases, malignancies, liver cirrhosis, tuberculosis, other diseases and free of reported of co-morbidities) and haematocrit. Propensity score analysis also showed a higher eGFR to be associated with increased mortality risks. Adjustment for all covariates explained a high percentage of excess risk of mortality in the groups with low eGFR, but less risk in the groups with higher eGFR. CONCLUSIONS Lower eGFR at dialysis initiation is associated with lower mortality. Conditions at dialysis initiation explained excess 1-year mortality risk differently in patients who began dialysis at different levels of eGFR. Other factors likely contribute to the mortality of patients initiating dialysis at higher eGFR levels, and further study is needed.

Chronic kidney disease care program improves quality of pre‐end‐stage renal disease care and reduces medical costs

Aim:  Multidisciplinary care of patients with chronic kidney disease (CKD) provides better care outcomes. This study is to evaluate the effectiveness of a CKD care program on pre‐end‐stage renal disease (ESRD) care.

Increased risk of mortality in the elderly population with late-stage chronic kidney disease: a cohort study in Taiwan

BACKGROUND Taiwan has the worlds highest incidence and second highest prevalence of end-stage renal disease (ESRD), particularly in older age groups. However, the transition from chronic kidney disease (CKD) to death or ESRD remains unclear. This study aimed to investigate the impact of late-stage CKD on all-cause and cause-specific mortality by identifying the CKD population. METHODS This was an observational cohort study (n = 35 529), mean age 75.7 years (SD = 5.3), of participants in the Elderly Health Examination Program (EHEP) in Kaohsiung City, Taiwan, between 2002 and 2004. Estimated glomerular filtration rate (eGFR) was calculated by the simplified modified diet in renal disease equation. Proportional hazard ratios (HR) of mortality associated with late-stage CKD were assessed by Cox regression. RESULTS The crude prevalence rate of CKD stages 3-5 was 39.4%; 1840 participants (5.18%) died within 2-year follow-up, a mortality rate of 20.3 per 1000 person-years overall and 16.4 per 1000 person-years in the reference group. Higher HR for all-cause and cause-specific mortality were found in the groups with decreased eGFR. Compared with the reference group (eGFR > 60 mL/min/1.73 m(2)), adjusted HR for all-cause mortality were 1.5, 2.1 and 2.6 for groups with eGFR 30-44, 15-29 and < 15 mL/min/ 1.73 m(2), respectively (P < 0.001). Higher HR of mortality due to cardiovascular or renal diseases were also significantly associated with decreased eGFR (P < 0.05). CONCLUSION Late-stage CKD is a significant risk factor for mortality, especially due to cardiovascular and renal diseases, in elderly Taiwanese. Given the higher prevalence rate of late-stage CKD in the study area, CKD patient mortality was relatively lower, which might reflect underestimation of renal function for patients at early stages of CKD, or partly explain the high ESRD population.

Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty

PurposeComparing the responsiveness over time of the Harris Hip Score (HHS) and the SF-36 in patients who underwent total hip arthroplasty (THA) and assessing variation in the responsiveness of these measures by the number of co-morbidities.MethodsThis prospective study analyzed 335 THA patients treated at two southern Taiwan hospitals from 1997 to 2000. Magnitude of change in HRQoL was compared by generalized estimating equation. Bias-corrected and accelerated bootstrapping was used to measure magnitude of change in HHS and SF-36 subscale scores for five different time intervals spanning a 5-year period.ResultsThe analytical results indicated that the pain and physical function subscales of the HHS are more responsive than those of the SF-36 for short-term (within 1 year post-surgery) measurements but are less responsive for long-term measurements. At various follow-up intervals, the HHS and the SF-36 significantly differed in ES of changes in pain and physical function subscale scores for patients with one co-morbidity and for patients with two or more co-morbidities.ConclusionFor long-term evaluation of THA patients, clinicians and health researchers should weight both measures equally and should also consider co-morbidities.

HEALTH-RELATED QUALITY OF LIFE IN TAIWANESE DIALYSIS PATIENTS: EFFECTS OF DIALYSIS MODALITY

Taiwan has the highest incidence and prevalence of end‐stage renal disease worldwide. However, not many studies have focused on the influence of dialysis modality on health‐related quality of life (HRQoL) for dialysis patients in Taiwan. This study intended to compare the differences in HRQoL between peritoneal dialysis (PD) and hemodialysis (HD) and to evaluate the effects of dialysis modality on patient HRQoL. A cross‐sectional survey using the Taiwan‐version 36‐item short‐form health survey questionnaire (SF‐36) was completed by 244 dialysis patients (58 PD and 186 HD patients) at two hospital‐based dialysis units in southern Taiwan. Patient characteristics, diagnoses and laboratory data were individually extracted from the annual survey and matched with primary HRQoL data. Multiple linear regression analysis was performed to evaluate the effects of dialysis modality on HRQoL. Compared with HD patients, PD patients had higher scores in six of the eight SF‐36 subscales, including physical functioning, role limitations due to physical and emotional problems, bodily pain, vitality, and mental health. However, only role limitations due to emotional problems and bodily pain reached significant difference levels (p < 0.05). After controlling for patient characteristics, comorbid conditions and laboratory values, the bodily pain score was 7.88 points higher for PD patients compared with HD patients, while the social functioning score was 9.00 points higher for HD patients compared with PD patients (p < 0.05). The present study provides cross‐sectional confirmation for equivalent levels of HRQoL between PD and HD patients except for the subscales of bodily pain and social functioning. In addition to dialysis modality, HRQoL for dialysis patients may be more related to personal attributes, interactions with multiple diseases, social support and quality of care received. When informing patients about modality choices for dialysis, trade‐offs should be discussed and individual preferences for specific aspects of HRQoL should be considered.

Associations between socio-economic status measures and functional change among older people in Taiwan.

The major purpose of this study was to examine the effects of socio-economic status (SES) on changes in functional abilities, as measured by Activities of Daily Living (ADL) scales, among older people in Taiwan. A prospective longitudinal study design was used. A panel of 874 community-dwelling older people were followed over four years (1994 to 1998). Three SES indicators, education, having ‘extra’ money (more than required for basic necessities), and principal lifetime occupation were included in separate multiple logistic regression models of functional change in physical ADL (PADL) and in instrumental ADL (IADL). Over the four years, the study cohort experienced greater decreases in IADL functioning than in PADL functioning. Having ‘extra’ money was significantly and negatively associated with PADL decline, while level of education had a strong positive relationship with IADL functioning. In addition to SES, age was significantly associated with PADL and IADL functioning change. The paper also reports a comparison of similar findings from several eastern and western countries. This has established that among the available SES indicators, the level of education has most consistently been shown in both eastern and western population studies to be related to health and health change, and that self-perceived economic resource is also related to older peoples health in Asian populations.

Cost-Effectiveness of Diabetes Pay-for-Performance Incentive Designs

Background:Taiwan’s National Health Insurance (NHI) Program implemented a diabetes pay-for-performance program (P4P) based on process-of-care measures in 2001. In late 2006, that P4P program was revised to also include achievement of intermediate health outcomes. Objectives:This study examined to what extent these 2 P4P incentive designs have been cost-effective and what the difference in effect may have been. Research Design and Method:Analyzing data using 3 population-based longitudinal databases (NHI’s P4P dataset, NHI’s claims database, and Taiwan’s death registry), we compared costs and effectiveness between P4P and non-P4P diabetes patient groups in each phase. Propensity score matching was used to match comparable control groups for intervention groups. Outcomes included life-years, quality-adjusted life-years (QALYs), program intervention costs, cost-savings, and incremental cost-effectiveness ratios. Results:QALYs for P4P patients and non-P4P patients were 2.08 and 1.99 in phase 1 and 2.08 and 2.02 in phase 2. The average incremental intervention costs per QALYs was TWD

Chronic medical conditions as predictors of functional disability in an older population in Taiwan

335,546 in phase 1 and TWD

Planned Creation of Vascular Access Saves Medical Expenses for Incident Dialysis Patients

298,606 in phase 2. The average incremental all-cause medical costs saved by the P4P program per QALYs were TWD

Impact of late-stage CKD and aging on medical utilization in the elderly population: a closed-cohort study in Taiwan

602,167 in phase 1 and TWD