Yi-Wen Tsai

The impact of universal National Health Insurance on population health: the experience of Taiwan.

BackgroundTaiwan established a system of universal National Health Insurance (NHI) in March, 1995. Today, the NHI covers more than 98% of Taiwans population and enrollees enjoy almost free access to healthcare with small co-payment by most clinics and hospitals. Yet while this expansion of coverage will almost inevitably have improved access to health care, however, it cannot be assumed that it will necessarily have improved the health of the population. The aim of this study was to determine whether the introduction of National Health Insurance (NHI) in Taiwan in 1995 was associated with a change in deaths from causes amenable to health care.MethodsIdentification of discontinuities in trends in mortality considered amenable to health care and all other conditions (non-amenable mortality) using joinpoint regression analysis from 1981 to 2005.ResultsDeaths from amenable causes declined between 1981 and 1993 but slowed between 1993 and 1996. Once NHI was implemented, the decline accelerated significantly, falling at 5.83% per year between 1996 and 1999. In contrast, there was little change in non-amenable causes (0.64% per year between 1981 and 1999). The effect of NHI was highest among the young and old, and lowest among those of working age, consistent with changes in the pattern of coverage. NHI was associated with substantial reductions in deaths from circulatory disorders and, for men, infections, whilst an earlier upward trend in female cancer deaths was reversed.ConclusionsNHI was associated in a reduction in deaths considered amenable to health care; particularly among those age groups least likely to have been insured previously.

Health literacy, health status, and healthcare utilization of Taiwanese adults: results from a national survey

BackgroundLow health literacy is considered a worldwide health threat. The purpose of this study is to assess the prevalence and socio-demographic covariates of low health literacy in Taiwanese adults and to investigate the relationships between health literacy and health status and health care utilization.MethodsA national survey of 1493 adults was conducted in 2008. Health literacy was measured using the Mandarin Health Literacy Scale. Health status was measured based on self-rated physical and mental health. Health care utilization was measured based on self-reported outpatient clinic visits, emergency room visits, and hospitalizations.ResultsApproximately thirty percent of adults were found to have low (inadequate or marginal) health literacy. They tended to be older, have fewer years of schooling, lower household income, and reside in less populated areas. Inadequate health literacy was associated with poorer mental health (OR, 0.57; 95% CI, 0.35-0.91). No association was found between health literacy and health care utilization even after adjusting for other covariates.ConclusionsLow (inadequate and marginal) health literacy is prevalent in Taiwan. High prevalence of low health literacy is not necessarily indicative of the need for interventions. Systematic efforts to evaluate the impact of low health literacy on health outcomes in other countries would help to illuminate features of health care delivery and financing systems that may mitigate the adverse health effects of low health literacy.

Gender Differences in Smoking Behaviors in an Asian Population

BACKGROUND Gender-sensitive tobacco control policies are being challenged, and new directions are being sought because public health efforts have reduced cigarette consumption more substantially among men than among women. To better target women, it would help to identify the protective cultural factors that promote resiliency in women and discourage them from smoking. Whereas western cultures have generated a great deal of gender-specific research and programs on the prevention of smoking in women, Asian cultures have not. Taking a personal and sociocultural perspective, this study examines the effect of gender on smoking behaviors in Taiwan. METHODS In a 2004 cross-sectional random-sampled interview survey, 827 adult men and 90 adult women smokers in Taiwan were queried about the time they began smoking, maintenance of their habits, and their readiness to change. RESULTS The male/female smoking rate ratio was 9.5 (45.7% vs. 4.8%). Men smoked significantly more cigarettes per day than women (18 vs. 11). We found Taiwanese women started smoking around 20 years old, much later than their western counterparts. We also found that whereas the smoking behavior of the men was very sensitive to social environment and structural factors, that of women revolved around their desire to control their weight and handle their emotions. CONCLUSIONS Differences in the smoking behavior of men and women are a result of a different sociocultural environment and the life trajectories and social circumstances embedded within it. Comprehensive tobacco control policies need to be tailored to not just smoking behavior alone or one population alone but to the determinants of smoking behavior in specific groups, for example, women. Even when targeting women, some effort may be needed on targeting women of different ethnicities, for instance, Asian women in whom the prevalence is increasing at alarming rates.

Methodology and validation of health literacy scale development in Taiwan

This article reports a generic methodology for developing health literacy assessment tools, consisting of 5 steps: (a) semi-structured, in-depth interviews of health care consumers; (b) consultation with health care, education, and psychometrics experts; (c) generation of an item pool; (d) selection of items for inclusion in the Mandarin Health Literacy Scale; and (e) evaluation of readability. To illustrate, the authors applied the methodology in order to develop a health literacy scale for the Mandarin Chinese–speaking population. They field-tested the initial version of the scale with a random sample of 323 Taiwanese adults. In addition, the authors used item response theory and classical test theory to examine the psychometric properties of the scale. Results showed good validity and reliability.

Thiazolidinediones and cardiovascular events in patients with type 2 diabetes mellitus: a retrospective cohort study of over 473,000 patients using the National Health Insurance database in Taiwan.

AbstractBackground and objective: Concern has been expressed over the cardiovascular risks associated with rosiglitazone and pioglitazone. This study investigates the association between oral antihyperglycaemics (rosiglitazone, pioglitazone, sulfonylureas and metformin) with myocardial infarction, congestive heart failure, angina pectoris, stroke and transient ischaemic attack. Methods: We used Taiwan’s 2000–5 National Health Insurance database to conduct a population-based, retrospective cohort study of 473 483 newly diagnosed patients with type 2 diabetes mellitus. We classified study patients into five basic groups based on the agents they were prescribed during the study period: (i) rosiglitazone monotherapy; (ii) pioglitazone monotherapy; (iii) sulfonylurea-based therapy; (iv) metformin-based therapy; and (v) sulfonylurea and metformin-based therapy. Cox proportional hazards models were used to evaluate the association between the use of rosiglitazone or pioglitazone and the occurrence of cardiovascular events. Results: Patients receiving rosiglitazone monotherapy were at higher risk for any cardiovascular event (hazard ratio [HR] 1.89; 95% CI 1.57, 2.28), myocardial infarction (HR 2.09; 95% CI 1.36, 3.24), angina pectoris (HR 1.79; 95% CI 1.39, 2.30) and transient ischaemic attack (HR 2.57; 95% CI 1.33, 4.96) than those receiving metformin monotherapy. Overall, add-on rosiglitazone and pioglitazone were associated with comparable cardiovascular risk. Based on our point estimates, pioglitazone as an add-on therapy was found to have a favourable, but nonsignificant, effect on outcome. Conclusions: Our findings extend the evidence from current literature to a real-world setting and support data from clinical trials that the disadvantages or harm caused by thiazolidinediones, especially rosiglitazone, may outweigh their benefits in patients with type 2 diabetes.

Osteoporosis treatment and atrial fibrillation: alendronate versus raloxifene.

Objectives: Concerns have been raised about bisphosphonate use and risk of atrial fibrillation (AF) in women with osteoporosis. This study compares the risk of AF and of flutter or acute myocardial infarction (AMI) in women with osteoporosis taking alendronate or raloxifene. Methods: Using Taiwans National Health Insurance database to conduct a population-based retrospective cohort study, we reviewed the medical and prescription histories of 27,257 women with osteoporosis (21,037 receiving alendronate and 6,220 receiving raloxifene) between 2001 and 2007. Mean (SD) follow-up was 303.62 (422.87) days. For the main outcome measures, we calculated the adjusted relative risk of AF and AMI using the Cox proportional hazards model, adjusting for various confounders. Results: Incidence rates (per patient-year) of AF in the alendronate group (1.00%) and the raloxifene group (1.02%) were similar. Alendronate use was not associated with risk of AF (hazard ratio [HR], 1.06; 95% CI, 0.85-1.32) and AMI (HR, 1.02; 95% CI, 0.86-1.19) compared with raloxifene use. However, alendronate users who had previous cardiovascular events and had taken their medications for more than 1 year were at significantly greater risk of AMI than were the group taking raloxifene (HR, 2.24; 95% CI, 1.07-4.71). Users who received 70 mg of alendronate once a week were at significantly lower risk of AF than were those taking 10 mg daily (HR, 0.56; 95% CI, 0.47-0.68). Conclusions: Compared with raloxifene, alendronate did not increase the risk of AF and flutter in women with osteoporosis. Medical history contributed most to the development of AF or AMI in the women who received either raloxifene or alendronate. Long-term treatment with alendronate is not suggested for women with a history of cardiovascular events because they are at increased risk of AMI.

A comparison of aspirin and clopidogrel with or without proton pump inhibitors for the secondary prevention of cardiovascular events in patients at high risk for gastrointestinal bleeding

OBJECTIVE This study was conducted to compare the risk of recurrent hospitalization for major gastrointestinal (GI) complications (peptic ulcer, bleeding, and perforation) in patients at high GI risk who require ongoing antiplatelet therapy (aspirin [acetylsalicylic acid] or clopidogrel) with or without proton pump inhibitors (PPIs). METHODS This population-based, retrospective cohort study employed data from the Taiwanese National Health Insurance database (January 2001 through December 2006) for patients who had a history of hospitalization for GI complications before the initiation of antiplatelet therapy with aspirin or clopidogrel. Recurrent hospitalizations for major GI complications were analyzed using a Cox proportional hazards model, with adjustment for age, sex, ulcer-related medical history, ulcer-related risk factors, and use of ulcer-related medications during follow-up. The propensity score method was applied to adjust for selection bias. RESULTS The analysis included data from 14,627 patients (12,001 receiving aspirin, 2626 receiving clopidogrel). The incidence of recurrent hospitalization for major GI complications was 0.125 per person-year in aspirin users, 0.103 per person-year in users of aspirin plus a PPI, 0.128 per person-year in clopidogrel users, and 0.152 per person-year in users of clopidogrel plus a PPI. Among aspirin users, those taking PPIs had a significantly lower adjusted risk of hospitalization for major GI complications than did non-PPI users (hazard ratio [HR] = 0.76; 95% CI, 0.64-0.91). Use of a PPI was not associated with a significant risk reduction among clopidogrel users (HR = 1.08; 95% CI, 0.89-1.33). An adjusted survival curve for the risk of recurrent hospitalization for major GI complications indicated that the risk increased numerically faster in clopidogrel users compared with those using aspirin plus a PPI, although the mean drug cost per person-year was 5.08 times higher in clopidogrel users than in users of aspirin plus a PPI. CONCLUSIONS In this analysis in patients at high GI risk who were receiving antiplatelet therapy for the secondary prevention of cardiovascular events, aspirin plus a PPI was associated with a reduced risk of recurrent hospitalization for major GI complications. This was not the case for clopidogrel plus a PPI.

Hip and Subtrochanteric or Diaphyseal Femoral Fractures in Alendronate Users: A 10-Year, Nationwide Retrospective Cohort Study in Taiwanese Women

BACKGROUND A link between the use of alendronate and atypical diaphyseal femoral fracture has been suggested. OBJECTIVE The goal of this study was to evaluate the benefits of alendronate in preventing rehospitalization due to hip fractures and whether its use increases risk of hospitalization for atypical diaphyseal femoral fractures in Taiwan. METHODS Using Taiwans National Health Insurance database, we identified women with osteoporosis with a first-ever hospitalization for vertebral or hip fractures between 2001 and 2007, which consisted of all patients receiving alendronate, raloxifene, calcitonin salmon, or teriparatide after the index fracture hospitalization. Data of untreated women were obtained as the untreated cohort. Study outcomes were defined as a rehospitalization due to hip fracture or a new hospitalization for subtrochanteric or diaphyseal femoral fracture. RESULTS Among 11,278 women identified (mean age, 77 years), 2425 (21.5%) received alendronate, 2694 (23.9%) received other antiosteoporosis drugs, and 6159 (54.6%) were untreated. Patients in each group were comparable in fracture history and major comorbidities; untreated patients were more likely to have stroke (11.2%; P = 0.01) and those treated with alendronate were more likely to have a history of hyperlipidemia (16.2%; P = 0.03). Compared with the untreated patient cohort, our analysis suggested that patients prescribed alendronate were associated with decreased risk of rehospitalization due to hip fracture (hazard ratio = 0.67 [95% CI, 0.54-0.82]). Neither patients prescribed alendronate, nor those prescribed other antiosteoporosis drugs, differed significantly from the untreated patient cohort in terms of risk of hospitalization for atypical femoral fracture (adjusted hazard ratios = 0.77 and 0.49 [95% CI, 0.40-1.47 and 0.22-1.12], respectively). Consistent with these data, short- or long-term alendronate use was not found to be significantly associated with higher risk of atypical femoral fractures. CONCLUSIONS This study in Taiwanese patients suggests that alendronate use was associated with a reduction in risk of rehospitalization due to hip fracture. We did not find a significant association between alendronate use and risk of hospitalization for atypical femoral fracture.

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.

Relationship between cardiovascular outcomes and proton pump inhibitor use in patients receiving dual antiplatelet therapy after acute coronary syndrome

There is conflicting evidence regarding the potential interaction between clopidogrel and proton pump inhibitors (PPIs), with observational studies suggesting an increased risk of adverse cardiovascular (CV) outcomes and clinical trials suggesting there is no such risk.