Shou-Hsia Cheng

Atherogenicity and carcinogenicity of high-arsenic artesian well water. Multiple risk factors and related malignant neoplasms of blackfoot disease.

The objective of this study was to examine multiple risk factors and correlated malignant neoplasms of blackfoot disease (BFD), a unique peripheral vascular disease related to continuous exposure to high-arsenic artesian well water. A total of 241 BFD cases, Including 169 with spontaneous or surgical amputations of affected extremities, and 759 age-sex-resldence-matched healthy community controls were studied to explore the risk factors of BFD. Multiple logistic regression analysis showed that artesian well water consumption, arsenic poisoning, familial history of BFD, and undernourishment were significantly associated with the development of BFD. The life-table method used to analyze cancer mortality of 789 BFD patients followed for 15 years showed a significantly higher mortality from cardiovascular diseases, peripheral vascular diseases, and cancers of bladder, skin, lung, and liver among BFD patients as compared with the general population In Taiwan or residents In the BFD-endemic area. The results Imply the atherogenicity and carcinogenicity of the artesian well water In the BFD-endemic area.

Association of potentially inappropriate medication use with adverse outcomes in ambulatory elderly patients with chronic diseases: experience in a Taiwanese medical setting.

BackgroundPotentially inappropriate medication use among the elderly in an outpatient setting has been widely reported. However, the potential association between inappropriate medication use and adverse outcomes is seldom examined.ObjectivesTo identify the prevalence, risk factors for and adverse outcomes of potentially inappropriate medication use in ambulatory elderly patients with chronic diseases.MethodsData for this observational cohort study consisted of computerized claims from a tertiary medical centre in Taiwan to the Bureau of National Health Insurance. Consecutive ambulatory elderly patients aged ≥65 years who received long-term (3-month) prescriptions for treatment of a chronic disease were recruited from 1 to 31 March 2005. The cohort included 5741 elderly patients who received 7538 long-term prescriptions. Patients who required repeat prescriptions were able to be given the same prescription if their conditions were stable. The prevalence of potentially inappropriate medication use and the incidence of adverse outcomes, including emergency visits, hospitalizations and mortality, were documented for up to 6 months after the first day the patient was recruited. Beers’ 2002 criteria were used to determine the potential inappropriateness of prescribed medications. Associations between potentially inappropriate medications and adverse outcomes were examined by multivariate logistic regression analyses controlling for possible confounding factors.ResultsThe prevalence of potentially inappropriate medication use was 23.7% in the studied hospital. The most frequently prescribed potentially inappropriate medications of high severity (i.e. having a high likelihood of being associated with an adverse effect that was clinically significant) were amiodarone, chlorzoxazone, bisacodyl, nifedipine and amitriptyline. Logistic regression analysis revealed that female sex, advanced age, number of chronic diseases and number of medications taken all significantly increased the likelihood of receiving potentially inappropriate medications. The incidence of adverse outcomes in patients with potentially inappropriate medication use in the studied hospital was 25.1%. Multivariate logistic regression analysis revealed that potentially inappropriate medication use was significantly associated with hospitalization.ConclusionsPotentially inappropriate medication use is not a rare event in elderly patients and is associated with higher risk of hospitalization in this age group. In order to reduce the possibility of prescribing inappropriate medications, and therefore to reduce the consequent risk of hospitalization, more attention should be paid when prescribing drugs to, in particular, older female patients with multiple chronic illnesses that require treatment with multiple medications.

Evidence for improved control of hypertension in Taiwan: 1993-2002.

Objective This study reports the prevalence of hypertension, proportions of awareness, treatment, and control in the 2002 Taiwanese Survey on Hypertension, Hyperglycemia, and Hyperlipidemia (TwSHHH), and compared the changes of hypertension prevalence, awareness, treatment, and control in two recent nationwide surveys. Methods TwSHHH is the second nationwide survey designed to assess the prevalence, awareness, treatment, and control of hyperglycemia, hyperlipidemia, and hypertension. The TwSHHH survey applied a multistage, stratified, and random sampling during 2002 with a total of 7566 participants. Among them, 3088 male and 3391 female participants were 19 years old and over and were selected from households throughout Taiwan. The data of Nutrition and Health Survey in Taiwan (NAHSIT), the first nationwide survey to assess disease and nutrition status during 1993–1996, was also applied to compare changes of the prevalence, awareness, treatment, and control of hypertension between the two surveys. Results Compared with the NAHSIT, the prevalence of hypertension on TwSHHH decreased significantly in female adults, between 1993–1996 and 2002. In both males and females of all age groups, the awareness, treatment, and control of hypertension significantly and substantially improved between NAHSIT and TwSHHH. These results also correlated in time with the implementation of National Health Insurance since 1995. The favorable changes in education and availability of care may account for improved control of hypertension and, possibly, its prevention. Conclusions There was a significant improvement of hypertension awareness, treatment, and control in the TwSHHH survey compared with the NAHSIT survey in Taiwan.

Continuity of care, medication adherence, and health care outcomes among patients with newly diagnosed type 2 diabetes: a longitudinal analysis.

Background:The effects of continuity of care (COC) on health care outcomes are well established. However, the mechanism of this association is not fully understood. Objective:The objective of this study was to examine the relationship between COC and medication adherence, as well as to investigate the mediating effect of medication adherence on the association between COC and health care outcomes, in patients with newly diagnosed type 2 diabetes. Research Design and Subjects:This study utilized a longitudinal design and included a 7-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. Patients aged 18 years or older who were first diagnosed with type 2 diabetes in 2002 were included in the study. Random intercept models were conducted to assess the temporal relationship between COC, medication adherence, and health care outcomes. Results:Patients with high or intermediate COC scores were more likely to be adherent to medications than those with low COC scores [odds ratio (OR), 3.37; 95% confidence interval (CI), 3.15–3.60 and OR, 1.84; 95% CI, 1.74–1.94, respectively]. In addition, the association between COC and health care outcomes was partly mediated by better medication adherence in patients with newly diagnosed type 2 diabetes. Conclusions:Improving the COC for patients with type 2 diabetes may result in higher medication adherence and better health care outcomes.

A longitudinal examination of a pay-for-performance program for diabetes care: evidence from a natural experiment.

Background:Numerous studies have examined the impacts of pay-for-performance programs, yet little is known about their long-term effects on health care expenses. Objectives:This study aimed to examine the long-term effects of a pay-for-performance program for diabetes care on health care utilization and expenses. Methods:This study represents a nationwide population-based natural experiment with a 4-year follow-up period under a compulsory universal health insurance program in Taiwan. The intervention groups consisted of 20,934 patients enrolled in the program in 2005, and 9694 patients continuously participated in the program for 4 years. Two comparison groups were selected by propensity score matching from patients seen by the same group of physicians. Generalized estimating equations were used to estimate differences-in-differences models to examine the effects of the pay-for-performance program. Results:Patients enrolled in the pay-for-performance program underwent significantly more diabetes specific examinations and tests after enrollment; the differences between the intervention and comparison groups declined gradually over time but remained significant. Patients in the intervention groups had a significantly higher number of diabetes-related physician visits in only the first year after enrollment and had fewer diabetes-related hospitalizations in the follow-up period. Concerning overall health care expenses, patients in the intervention groups spent more than the comparison group in the first year; however, the continual enrollees spent significantly less than their counterparts in the subsequent years. Conclusions:The program seemed to achieve its primary goal in improving health care and providing long-term cost benefits.

Physician performance information and consumer choice: a survey of subjects with the freedom to choose between doctors

Background: Increasing efforts have been made to provide information to help consumers to select a healthcare provider, but the public release of hospital performance data has had only a limited impact on consumer choice. Objectives: To understand the experience of consumers in searching for physician performance information and to investigate the potential impact on their propensity to change doctors if hypothetically provided with physician specific performance information. Design: A nationwide telephone interview survey using a structured questionnaire. Setting: The survey was conducted in Taiwan, a country with a universal health insurance programme where residents are free to choose between physicians for any medical consultation. Participants: 4015 adults aged over 20 years contacted by random digit dialling telephone calls. Main outcome measures: Subjects were asked (1) if they have ever compared the quality of care provided by physicians in their area; (2) if they would consult a performance report if it was available; and (3) if they would change doctors on the basis of information provided in the report. Results: Approximately half the subjects had made comparisons between doctors; 73% stated that they would consult a performance report if it was available, and 77% were prepared to change doctors if their doctor performed badly in the report. Conclusions: Providing physician specific performance reports to the public may be viewed favourably by consumers of health care and have a significant impact on physician selection and hence quality improvement.

Hospital response to a global budget program under universal health insurance in Taiwan

OBJECTIVES Global budget programs are utilized in many countries to control soaring healthcare expenditures. The present study was designed to evaluate the responses of Taiwanese hospitals to a new global budget program implemented in 2002. METHODS Using data obtained from the Bureau of National Health Insurance (NHI) and two nationwide surveys conducted before and after the global budget program, changes in the length of stay, treatment intensity, insurance claims, and out-of-pocket fees were compared in 2002 and 2004. The analysis was conducted using the Generalized Estimating Equations (GEEs) method. RESULTS Regression models revealed that implementation of the global budget was followed by a 7% increase in length of stay and a 15% increase in the number of prescribed procedures and medications per admission. The claim expenses increased by 14%, and out-of-pocket fees per admission increased by 6%. Among the hospitals, no coalition action was found during the study period. CONCLUSIONS In the present study, it appears that hospitals attempted to increase per-case expense claims to protect their reimbursement from possible discounts under a global budget cap. How Taiwanese hospitals respond to this challenge in the future deserves continued, long-term observation.

Does continuity of care matter in a health care system that lacks referral arrangements

INTRODUCTION Numerous studies have suggested that better continuity of care (COC) can lead to fewer emergency department (ED) visits and fewer hospital admissions. However, these studies were conducted in countries where patients have their own family physician or in countries with referral systems. This study aimed to determine whether the association between lower COC and increased health care utilization may be apparent in a health care system that lacks a family physician or a referral system. METHODS The study population included a total of 134 422 subjects who made four or more visits to physicians in 2005. Negative binominal regressions were performed to examine the effects of three different COC indices on the numbers of hospital admissions and ED visits in 2005 and in the subsequent year (2006). RESULTS The data suggest that lower COC was associated with increased hospital admissions and ED visits in our study population. Compared with the high COC group, subjects in the low and medium COC groups had 42-82% and 39-46% more hospital admissions, respectively, as well as 75-102% and 41-45% more ED visits, respectively, in 2005. Weaker protective effects of COC were also observed in the subsequent year. CONCLUSIONS This study indicates that lower COC is associated with increased hospital admissions and ED visits, even in a health care system that lacks a referral arrangement framework. This suggests that improving the COC is beneficial both for patients and for the health care system.

The impacts of DRG-based payments on health care provider behaviors under a universal coverage system: a population-based study.

OBJECTIVE To examine the impacts of diagnosis-related group (DRG) payments on health care providers behavior under a universal coverage system in Taiwan. METHODS This study employed a population-based natural experiment study design. Patients who underwent coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty, which were incorporated in the Taiwan version of DRG payments in 2010, were defined as the intervention group. The comparison group consisted of patients who underwent cardiovascular procedures which were paid for by fee-for-services schemes and were selected by propensity score matching from patients treated by the same group of surgeons. The generalized estimating equations model and difference-in-difference analysis was used in this study. RESULTS The introduction of DRG payment resulted in a 10% decrease (p<0.001) in patients length of stay in the intervention group in relation to the comparison group. The intensity of care slightly declined with p<0.001. No significant changes were found concerning health care outcomes measured by emergency department visits, readmissions, and mortality after discharge. CONCLUSION The DRG-based payment resulted in reduced intensity of care and shortened length of stay. The findings might be valuable to other countries that are developing or reforming their payment system under a universal coverage system.

Continuity of care, potentially inappropriate medication, and health care outcomes among the elderly: evidence from a longitudinal analysis in Taiwan.

Background:Better continuity of care (COC) is associated with improved health care outcomes, such as decreased hospitalization and emergency department visit. However, little is known about the effect of COC on potentially inappropriate medication. Objectives:This study aimed to investigate the association between COC and the likelihood of receiving inappropriate medication, and to examine the existence of a mediating effect of inappropriate medication on the relationship between COC and health care outcomes and expenses. Methods:A longitudinal analysis was conducted using claim data from 2004 to 2009 under universal health insurance in Taiwan. Participants aged 65 years and older were categorized into 3 equal tertiles by the distribution of COC scores. This study used a propensity score matching approach to assign subjects to 1 of 3 COC groups to increase the comparability among groups. Generalized estimating equations were used to examine the association between COC, potentially inappropriate medication, and health care outcomes and expenses. Results:The results revealed that patients with the best COC were less likely to receive drugs that should be avoided [odd ratios (OR), 0.44; 95% confidence interval (CI), 0.43–0.45) or duplicated medication (OR, 0.22; 95% CI, 0.22–0.23) than those with the worst COC. The findings also indicated that potentially inappropriate medication was a partial mediator in the association between COC and health care outcomes and expenses. Conclusion:Better COC is associated with fewer negative health care outcomes and lower expenses, partially through the reduction of potentially inappropriate medication. Improving COC deserves more attention in future health care reforms.