Development of a long-term care service integration self-assessment tool.

The World Health Organization emphasizes the importance of providing integrated care for older people. Taiwan is the fastest aging country in the world. In 2016, Taiwan implemented the Long-Term Care Plan 2.0 (TLTCP 2.0), aimed at providing integrated long-term care (LTC) services in communities. However, LTC service agencies have not been able to evaluate the level of integrated care they provide due to the lack of an effective assessment tool. To address this need, this study sets out to develop an integration assessment tool, namely the Self-Assessment for Service Integration in Long-Term Care (SASI-LTC), which will allow LTC agencies to self-evaluate their current level of integration from multiple perspectives. The SASI-LTC was developed based on Evashwick's framework, underwent two rounds of Delphi panels with twenty-six experts, and a pilot test with 243 valid questionnaires from administrators of Tier A agencies who are responsible for integrating LTC. The Delphi experts assessed the content with high levels of agreement using medians, the scale content validity index (SCVI) and item content validity index (ICVI). The SASI-LTC included four domains (inter-entity organization and management, integrated care coordination, integrated resources, and integrated information systems) with thirty items. The SASI-LTC showed good reliability (Cronbach's α = 0.94) and good validity, and a confirmatory factor analysis showed a good model fit index [χ2/df = 1.38; RMSEA = 0.040; CFI = 0.963; SRMR = 0.049] in pilot testing. While the SASI-LTC is a useful and feasible tool for Taiwan's LTC service agencies to evaluate their level of integration in providing LTC services, it could also be used in other countries with minor adjustments to localization of items related to financial integration.

The Nudging Effect of a Reminder Letter to Reduce Duplicated Medications: A Randomized Controlled Trial.

BACKGROUND: The increasing trend of multiple chronic conditions across the world has worsened the problem of medication duplication in health care systems without gatekeeping or referral requirement. Thus, to overcome this problem, a reminder letter has been developed in Taiwan to nudge patients to engage in medication management. OBJECTIVE: To evaluate the effect of reminder letter on reducing duplicated medications. RESEARCH DESIGN: A 2-arm randomized controlled trial design. SUBJECTS: Patients with duplicated medications in the first quarter of 2019. MEASURES: The Taiwanese single-payer National Health Insurance Administration identified the eligible patients for this study. A postal reminder letter regarding medication duplication was mailed to the patients in the study group, and no information was provided to the comparison group. Generalized estimation equation models with a difference-in-differences analysis were used to estimate the effects of the reminder letters. RESULTS: Each group included 11,000 patients. Those who had received the reminder letter were less likely to receive duplicated medications in the subsequent 2 quarters (postintervention 1: odds ratio [OR]=0.95, 95% CI=0.87-1.03; postintervention_2: OR=0.99, 95% CI=0.90-1.08) and had fewer days of duplicated medications (postintervention 1: ß=-0.115, P =0.015; postintervention 2 (ß=-0.091, P =0.089) than those who had not received the reminder letter, showing marginal but significant differences. CONCLUSIONS: A one-off reminder letter nudge could mildly decrease the occurrence of duplicated medications. Multiple nudges or nudges incorporating behavioral science insights may be further considered to improve medication safety in health systems without gatekeeping.

Impact of a diabetes pay-for-performance program on nonincentivized mental disorders: a panel study based on claims database analysis.

BACKGROUND: Diabetes is one of the most prevalent chronic diseases with subsequent complications. The positive effects of diabetes pay-for-performance (P4P) programs on treatment outcomes have been reported. The program provides financial incentives based on physiological care indicators, but common mental disorder complications such as depression are not covered. METHODS: This study employed a natural experimental design to examine the spillover effects of diabetes P4P program on patients with nonincentivized depressive symptoms. The intervention group consisted of diabetes patients enrolled in the DM P4P program from 2010 to 2015. Unenrolled patients were selected by propensity score matching to form the comparison group. Difference-in-differences analyses were conducted to evaluate the effects of P4P programs. We employed generalized estimating equation (GEE) models, difference-in-differences analyses and difference-in-difference-in-differences analyses to evaluate the net effect of diabetes P4P programs. Changes in medical expenses (outpatient and total health care costs) over time were analysed for the treatment and comparison groups. RESULTS: The results showed that enrolled patients had a higher incidence of depressive symptoms than unenrolled patients. The outpatient and total care expenses of diabetes patients with depressive symptoms were lower in the intervention group than in the comparison group. Diabetes patients with depressive symptoms enrolled in the DM P4P program had lower expenses for depression-related care than those not enrolled in the program. CONCLUSIONS: The DM P4P program benefits diabetes patients by screening for depressive symptoms and lowering accompanying health care expenses. These positive spillover effects may be an important aspect of physical and mental health in patients with chronic disease enrolled in disease management programs while contributing to the control of health care expenses for chronic diseases.

The intention of utilization and experience toward traditional Chinese medicine among breast cancer patients in the early and late stages: a qualitative study.

BACKGROUND: In Taiwan, breast cancer patients usually take conventional medicine and traditional Chinese medicine simultaneously. The utilization of traditional Chinese medicine among breast cancer patients at various stages has not been examined. This study aims to compare the intention of utilization and experience toward traditional Chinese medicine among early- and late-stage breast cancer patients. METHOD: This qualitative research collected data from breast cancer patients through focus groups interview by convenience sampling. Conducted in 2 branches of Taipei City Hospital, a public hospital managed by the Taipei City government. Breast cancer patients > 20 years old and had used TCM for breast cancer therapy for at least 3 months were included in the interview. A semi-structured interview guide was adopted in each focus group interview. In the following data analysis, stages I and II were considered early-stage, and stages III and IV were late-stage. For analyzing the data and reporting the results, we used qualitative content analysis as the approach for data analysis, assisted by NVivo 12. Categories and subcategories were identified through content analysis. RESULTS: Twelve and seven early- and late-stage breast cancer patients were included in this study, respectively. The side effects were the main intention of utilizing traditional Chinese medicine. Improving side effects and constitution was the main benefit for patients in both stages. Additionally, early-stage breast cancer patients used traditional Chinese medicine to prevent recurrence or metastasis. Late-stage breast cancer patients responded more frequently to the use of traditional Chinese medicine due to the side effects of western medicine. However, some of their symptoms were not fully relieved. CONCLUSIONS: Breast cancer staging may influence the intention and utilization of traditional Chinese medicine. Health policymakers should consider the results of this research and the evidence-based illustrations to establish guidelines for integrating traditional Chinese medicine among various stages of breast cancer to improve the outcome and quality of care for cancer patients.

Determining the factors influencing the selection of post-acute care models by patients and their families: a qualitative content analysis.

BACKGROUND: This study conducted in-depth interviews to explore the factors that influence the choice of a post-acute care (PAC) model (inpatient rehabilitation hospital, skilled nursing facility, home health, and outpatient rehabilitation) among stroke patients and their families. METHODS: We conducted semi-structured, in-depth interviews of 21 stroke patients and their families at four hospitals in Taiwan. Content analysis was used in this qualitative study. RESULTS: Results revealed five main factors that influence respondents' choice of PAC: (1) medical professionals' suggestions, (2) health care accessibility, (3) continuity and coordination of care, (4) willingness and prior experience of patients and their relatives and friends, and (5) economic factors. CONCLUSIONS: This study identifies five main factors that affect the choice of PAC models among stroke patients and their families. We suggest that policymakers establish comprehensive health care resources based on the needs of patients and families. Health care providers shall provide professional recommendations and adequate information to support decision-making, which aligns with the preferences and values of patients and their families. From this research, we hope to improve the accessibility of PAC services in order to enhance the quality of care for stroke patients.

Efficacy of polyacrylate silver salt/polyvinylpyrrolidone-based liquid oral gel in management of concurrence chemoradiotherapy-induced oral mucositis.

BACKGROUND/PURPOSE: Acute oral mucositis (OM) is a painful complication of concurrent chemoradiotherapy (CCRT). This severe adverse symptom may impact on patient's quality of life, lead to malnutrition. Thus, finding more effective methods in OM management is very important. The purpose of this study is to evaluate the efficacy of polyacrylate silver salt/Polyvinylpyrrolidone-based liquid oral gel (named as polyacrylate silver salt oral gel) in improving the symptomatic relief of CCRT-induced oral mucositis and oral dysfunction in neck and head cancer patients. METHODS: In this study, 24 oral cancer patients underwent CCRT and having OM grade 2 or higher were randomly assigned into the test group and the control group. Both groups followed Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO) clinical practice guidelines for the management of mucositis, but adding rinsing with 15 g oral gel right after oral hygiene treaded the test group. Clinical OM and oral function were assessed weekly for 4 consecutive weeks till 5-10 days after the completion of radiotherapy. For evaluation, Common Terminology Criteria for Adverse Events (CTCAE) v3.0 was used for collecting the data of OM grade. RESULTS: The results showed that polyacrylate silver salt oral gel had better effect for relieving the oral mucositis. There were statistically significant differences in OM grades (1.59 vs. 2.8, p < 0.0001) between the test group and the control group. CONCLUSION: Our clinical studies demonstrated that polyacrylate silver salt oral gel is an effective interventional option in terms of rapid mucositis healing.

Determinants associated with medical-related long-term care service use among community-dwelling older adults in Taiwan.

INTRODUCTION: Medical-related long-term care (LTC) service use among community-dwelling older adults in Taiwan is resource-intensive, and planning is essential to promote aging-in-place. METHODS: Administrative data from 4/1/2017 to 11/26/2019 among more than 14,000 residents were analyzed with generalized estimating equations (GEEs) to identify determinants of medical-related LTC service use. RESULTS: Older adults using medical-related LTC services tended to be younger (79.9 vs. 80.7; p<.0001), male (42.7% vs. 38.5%; p<.0001), multi-morbid (3.1 vs. 2.5; p<.0001), and higher mean activities of daily living (ADL) disability (8.2 vs. 4.2; p<.0001), instrumental ADL (IADL) disability (11.0 vs. 9.1; p<.0001), and hospitalizations (1.1 vs. 0.4; p<.0001). Significant determinants of medical-related LTC services include age, education, stroke, coronary heart disease, diabetes, vision impairment, ADL disability, and prior hospitalization. DISCUSSION: The success of LTC 2.0 will depend on ADL support and care coordination to manage chronic conditions such as diabetes, vision impairment, coronary heart disease, and stroke.

The relationships of health literacy, preferred involvement, and patient activation with perceived involvement in care among Mongolian patients with breast and cervical cancer.

OBJECTIVE: To explore the relationships of health literacy, preferred involvement, and patient activation with perceived involvement in care among patients with breast and cervical cancer. METHODS: A cross-sectional survey was conducted with patients aged 20 years or older, aware of their cancer diagnosis, and currently receiving care at the National Cancer Center, Mongolia. Descriptive statistics and multivariate regression analysis were used to identify the relationships among study variables. RESULTS: Two hundred twenty-five patients were included in the final analysis. Patients' perceived involvement was examined as two subdomains: patient information seeking (PIS) and patient decision-making (PDM). Patient health literacy was found to only significantly influence PIS, and patient preferred involvement demonstrated a significant influence only on PDM. However, patient activation predictor was found to significantly influence both PIS and PDM (PIS [ß = 0.22, p = 0.00] and PDM [ß = 0.14, p = 0.00]). CONCLUSION: Health literacy, preferred involvement, and patient activation each demonstrated distinct influences on patients' perceived involvement subdomains, with patient activation being the most important predictor. PRACTICE IMPLICATIONS: Comprehensive strategies at the healthcare organization, professional, and patient levels may help to facilitate and advance patient involvement in care, and ultimately improve the quality of healthcare services respective to domain of patient-centeredness.

The Gaps of Healthcare Service Quality in Nurse Practitioner Practice and Its Associated Factors From the Patients' Perspective.

PURPOSE: This study investigates the expectations, perceptions, and gaps of the healthcare service quality (HSQ) from the patients' perspective, and explores the significant demographic and clinical factors associated with the HSQ in nurse practitioner practice (NPP). DESIGN: A cross-sectional design was carried out, with convenience sampling performed under the NPP in Taiwan, from June to November 2016. METHODS: The Nurse Practitioner Healthcare Service Quality Scale was used to assess the expectations, perceptions, and gaps of the HSQ. The demographics, clinical characteristics, and symptom severity of patients were collected, and the Importance-Performance Analysis was applied to identify the priority of ranking items for the improvement of nurse practitioners (NPs). The Generalized Estimating Equation was used to explore the factors associated with the HSQ in NPP. FINDINGS: A total of 200 patients completed the questionnaires. The results revealed that the patients had overall high expectations (M = 6.35, SD = 0.46), moderate perceptions (M = 4.21, SD = 0.95), and a mild HSQ gap (M = -2.14, SD = 0.69), with statistically significant differences (p < .001). In NPP, the largest gap in the HSQ dimensions was reliable responsiveness, followed by empathy, assurance, and tangibility. Patients with greater symptom severity and a longer in-hospital stay were associated with larger HSQ gaps; however, patients who were transferred from the emergency department had smaller gaps than those in the outpatient department. CONCLUSIONS: The patients' expectations were not fully satisfied in the NPP, especially for the dimensions of reliable responsiveness and empathy. The patients' symptom severity was a significant factor related to the gaps in the HSQ. The awareness of unmet needs, from the patients' perspective, could guide the convergence of a rational policy to promote healthcare delivery in the NPP. CLINICAL RELEVANCE: The managers of NPP need to pay attention to increasing NPs' reliable responsiveness and empathy, by setting the appropriate scope of practice, regulating the NP-to-patient ratio, applying for certification programs in prescribing training, and cultivating patient-centered care with shared decision making. In addition, building up the knowledge and competency of symptom management is also suggested for NP training.

Association of intrinsic and extrinsic motivating factors with physician burnout and job satisfaction: a nationwide cross-sectional survey in Taiwan.

OBJECTIVE: The aim of this study was to systematically and simultaneously examine the association of intrinsic and extrinsic motivating factors with physician burnout and job dissatisfaction. DESIGN: A nationally representative survey was fielded from September to November 2017. SETTING: Hospitals and clinics throughout Taiwan. PARTICIPANTS: A total of 6674 physicians. MAIN EXPOSURE MEASURE: The main exposure measures were intrinsic motivators (sense of calling, personally rewarding hours per day and meaningful, long-term relationships with patients) and extrinsic motivators (income, work hours, autonomy, and pay-for-performance (P4P) and bundled payment initiatives). MAIN OUTCOME MEASURES: The main outcome measures were physician burnout and job dissatisfaction. RESULTS: A total of 1152 physicians returned the surveys. More sense of calling and personally rewarding hours per day were associated with less physician burnout (OR 0.16, 95% CI 0.10 to 0.26 and OR 0.25, 95% CI 0.13 to 0.47, respectively) and job dissatisfaction (OR 0.35, 95% CI 0.21 to 0.57 and OR 0.46, 95% CI 0.26 to 0.83, respectively). Longer work hours were associated with more physician burnout (OR 2.67, 95% CI 1.54 to 4.63) and job dissatisfaction (OR 1.71, 95% CI 1.05 to 2.79). Not receiving P4P bonuses from their organisations was associated with more physician burnout (OR 1.56, 95% CI 1.02 to 2.38). Not sharing the losses from caring for patients included in the bundled payment system was associated with less physician burnout (OR 0.59, 95% CI 0.36 to 0.97). CONCLUSIONS: Fostering a healthcare work environment that supports intrinsic motivation and improves work hours may reduce physician burnout and job dissatisfaction. Rewarding physicians fairly and equitably may prevent them from feeling burned out. Value-based care delivery and payment model innovations, such as bundled payments, may encourage healthcare professionals to coordinate care through the standardisation of care to decrease burnout.

[Development and Psychometric Testing of the Nurse Practitioner Healthcare Service Quality Scale].

BACKGROUND: Many hospitals in Taiwan currently use the nurse practitioner (NP) care model to ameliorate the chronic shortage of resident physicians. However, no healthcare service quality scale is presently available that allows the evaluation of the healthcare quality provided by NPs from the perspective of patients. A scale of this type is necessary in order to effectively monitor and improve care outcomes. PURPOSE: This project was designed to develop the Nurse Practitioner Healthcare Service Quality Scale (NPHSQS) and then to test its validity and reliability. METHODS: A cross-sectional design combined with Parasuraman, Zeithaml, and Berry's Service Quality Model was adopted to construct the NPHSQS. After expert evaluation and confirmation of the model's content validity, 200 valid questionnaires were collected from a convenience sample of patients from medical center wards in northern Taiwan that regularly used the NP care model. The data were analyzed by group using item analysis, construct validity, internal consistency, and discriminant validity. RESULTS: The 25-item NPHSQS developed in this study earned a CVI (content validity index) of .91 and a good CR (critical ratio). Exploratory factor analysis revealed that four factors extracted in the expectation level, including reliable responsiveness, assurance, empathy, and tangibility, explained 62.47% of the total variance. Furthermore, three factors extracted in the perception level, including reliable responsiveness, trust, and tangibility, explained 67.71% of the total variance. The NPHSQS has a good overall internal consistency coefficient and may also significantly distinguish differences in patient satisfaction between good and bad healthcare service quality groups (p < .001). CONCLUSIONS: The developed NPHSQS has good reliability and validity and is a reliable instrument for assessing the quality of NP-provided healthcare services from the perspective of healthcare recipients.

Continuity of Care, Follow-Up Care, and Outcomes among Breast Cancer Survivors.

This retrospective cohort study examined the effects of care continuity on the utilization of follow-up services and outcome of breast cancer patients (stages I-III) in the post-treatment phase of care. Propensity score matching and generalized estimation equations were used in the analysis of data obtained from national longitudinal databases. The continuity of care index (COCI) was calculated separately for primary care physicians (PCP) and oncologists. Our results revealed that breast cancer survivors with a higher oncology COCI were more likely than those with a lower oncology COCI to use mammography or breast ultrasound during the follow-up period (OR = 1.26, 95% CI: 1.19-1.32; OR = 1.12, 95% CI: 1.06-1.18; respectively). In terms of health outcomes, a higher oncology COCI was associated with a lower likelihood of hospitalization (OR = 0.78, 95% CI: 0.71-0.85) and emergency department use (OR = 0.88, 95% CI: 0.82-0.95). A higher PCP COCI was also associated with a lower likelihood of hospitalization (OR = 0.77, 95% CI: 0.70-0.85) and emergency department use (OR = 0.75, 95% CI: 0.68-0.82). Overall, this study determined that ambulatory care continuity is positively associated with the likelihood of using recommended follow-up care services and negatively associated with adverse health events among breast cancer survivors.

Can Elderly Patients with Severe Mitral Regurgitation Benefit from Trans-catheter Mitral Valve Repair?

BACKGROUND AND OBJECTIVES: Age is a traditional risk factor for open-heart surgery. The efficacy and safety of transcatheter edge-to-edge mitral valve repair, using MitraClip (Abbott Vascular), has been demonstrated in patients with severe mitral regurgitation (MR). Since octogenarians or older patients are usually deferred to receive open-heart surgery, the main interest of this study is to elucidate the procedural safety and long-term clinical impact of MitraClip in elderly patients. METHODS: Patients with symptomatic severe MR were evaluated by the heart team. For those with high or prohibitive surgical risks, transcatheter mitral valve repair was performed in hybrid operation room. Transthoracic echocardiography (TTE), blood tests, and six-minute walk test (6MWT) were performed before, 1-month, 6-months, and 1 year after index procedure. RESULTS: A total of 46 consecutive patients receiving MitraClip procedure were enrolled. Nineteen patients (84.2±4.0 years) were over 80-year-old and 27 (73.4±11.1 years) were younger than 80. Compare to baseline, the significant reduction in MR severity was achieved after the procedure and sustained. All the patients benefited from significant improvement in New York Heart Association functional class. The 6-minute walk test (6MWT) increased from 259±114 to 319±92 meters (p=0.03) at 1 year. The overall 1-year survival rate was 80% in the elderly and 88% in those <80 years, p=0.590. Baseline 6MWT was a predictor for all-cause mortality (odds ratio, 0.99; 95% confidence interval, 0.982-0.999; p=0.026) after the MitraClip procedure. CONCLUSIONS: Trans-catheter edge-to-edge mitral valve repairs are safe and have positive clinical impact in subjects with severe MR, even in advanced age.

Differences in the outcomes of adjuvant chemotherapy for colon cancer prescribed by physicians in different disciplines: a population-based study in Taiwan.

OBJECTIVES: One feature unique to the Taiwanese healthcare system is the ability of physicians other than oncologists to prescribe systemic chemotherapy. This study investigated whether the care paths implemented by oncologists and non-oncologists differ with regard to patient outcomes. SETTING: Data from the Taiwan Cancer Registry and National Health Insurance Database were linked to identify patients with colon cancer who underwent colectomy as first treatment within 3 months of diagnosis and adjuvant chemotherapy between 2005 and 2009. PARTICIPANTS AND METHODS: Postoperative patients who underwent adjuvant chemotherapy were included in this study. The exclusion criteria included patients with stage IV disease, a positive surgical margin and early disease recurrence. Among the patients presenting with multiple primary cancers, we also excluded patients who were diagnosed with colon cancer but for whom this was not the first primary cancer. The variables included sex, age, comorbidities, disease stage, chemotherapy cycle and changes in treatment regimen as well as the specialty of treatment providers and their case volume. Cox regression models and Kaplan-Meier analysis were used to examine differences in outcomes in the matched cohorts. RESULTS: We examined 3534 patients who were prescribed adjuvant chemotherapy by physicians from different disciplines. In terms of 5-year disease-free survival, no significant difference was observed between the groups of oncologists or surgeons among patients with stage II (90.02%vs88.99%) or stage III (77.64%vs79.99%) diseases. Patients who were subjected to changes in their chemotherapy regimens presented recurrence rates higher than those who were not. CONCLUSIONS: The discipline of practitioners is seldom taken into account in most series. This is the first study to provide empirical evidence demonstrating that the outcomes of patients with colon cancer do not depend on the treatment path, as long as the selection criteria for adjuvant chemotherapy is appropriate. Further study will be required before making any further conclusions.

Insight into Patients' Experiences of Cancer Care in Taiwan: An Instrument Translation and Cross-Cultural Adaptation Study.

Background: Since Taiwan launched the Cancer Prevention Act in 2003, several prevention strategies and early detection programs have been implemented to reduce the incidence, morbidity and mortality rates of cancer. However, most of the programs have concentrated on healthcare providers. Evaluations from the patient's perspective have been lacking. Thus, in this study a cancer patient experience questionnaire was developed in the Taiwanese context and a preliminary nationwide investigation was conducted on the status of cancer care from the patient's perspective. Methods: An extensive literature review was first conducted to collect information on the existing instruments used to measure the cancer patient's experience. Thereafter, a multidisciplinary expert panel was convened to select an optimal instrument based on the IOM's six domains for evaluating patient-centered care. The European Organisation for Research and Treatment of Cancer (EORTC) translation procedure was applied to the questionnaire for cross-cultural adaptation. A nationwide field test was then implemented at certificated cancer care hospitals. Results: Fifteen questionnaires were collected for the literature review. The expert panel selected the National Cancer Patient Experience Survey based on the IOM's recommendations. After cross-cultural translation of the questionnaire, a total of 4000 questionnaires were administered in 19 certificated cancer care hospitals and two major cancer patient associations, with 1010 being returned (25.25% response rate). Most of the respondents were middle-aged, and 70% were female. The respondents reported they had a good experience with cancer care, except for "Home care and support" and "Finding out what was wrong with you". Stratified analysis was conducted, with the results showing that the cancer patients' experiences varied depending on their sociodemographic and cancer-related characteristics. Conclusions: A Taiwanese version of the cancer patient experience survey questionnaire was developed. Its results showed that the cancer patient's experiences varied, depending on the patient's age, cancer type, and cancer history. This study can be used as a basis to establish a patient-centered care model for cancer care in Taiwan.

Impact of Targeted Therapy on the Quality of End-of-Life Care for Patients With Non-Small-Cell Lung Cancer: A Population-Based Study in Taiwan.

CONTEXT: Targeted therapies with epidermal growth factor receptor tyrosine kinase inhibitors have been widely used in the treatment of advanced non-small-cell lung cancer (NSCLC). However, little research has focused on the use of targeted therapies at the end of life (EOL). OBJECTIVES: This study investigated the determinants of receiving targeted therapy during the last month of life and how targeted therapies affect the quality of EOL care. METHODS: We conducted a retrospective population-based study using a cancer registry and National Health Insurance claims data among 42,678 Taiwanese NSCLC decedents in 2005-2012. Propensity score matching and generalized linear mixed models were used to estimate associations. RESULTS: We identified 3439 (21.3%) NSCLC patients who received targeted therapy within 30 days of death. Younger age, adenocarcinoma histology, postdiagnosis survival exceeding six months, and later year of death were associated with receiving targeted agents at EOL. The odds increased when patients were treated by pulmonologists or oncologists or in district hospitals or facilities with a higher case volume. Patients who were prescribed targeted therapy near death were significantly more likely to undergo aggressive EOL care (odds ratio = 2.35, 95% CI = 1.83-3.02) including multiple emergency department visits, hospitalization exceeding 14 days, admission to intensive care units, use of intubation and mechanical ventilation, cardiopulmonary resuscitation, and late hospice referrals. CONCLUSIONS: Targeted therapy at EOL should be considered a quality-of-care indicator. Guidance in the cessation of targeted therapy and the ongoing monitoring of practice initiatives are warranted. The decision-making processes associated with EOL care also require further investigation.

Quality of life of breast cancer survivors following breast-conserving therapy versus mastectomy: a multicenter study in Taiwan.

BACKGROUND: Breast cancer is the most common female malignancy worldwide. The aim of this study was to investigate the influence of surgical procedures and quality-of-care (QoC) on quality-of-life (QoL) among breast cancer survivors who underwent breast-conserving therapy (BCT) or mastectomy, and to identify provider- and patient-related factors pertaining to QoL. METHOD: In this cross-sectional study, structured-questionnaires were distributed among breast cancer survivors in 19 hospitals. QoL was evaluated using the European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30) and the breast cancer specific module (EORTC QLQ-BR23). QoC is indicated by adherence to the core measures stipulated for the treatment of breast cancer. Multiple regression and hierarchical linear modeling were used for multivariate analysis. RESULTS: A total of 544 female survivors of Stage 0-III breast cancer were included, among whom 217 (39.9%) underwent BCT and 327 (60.1%) underwent mastectomy. Surgical modality does not appear to have a notable impact on any QoL domains except body image; i.e. patients who underwent BCT reported better body image (diff = 11.20, P < 0.001), particularly at 1-5 years after the initial treatment. Independent factors including age, education, employment, marital status, income, chemotherapy, duration since treatment, recurrence status, primary hospital accreditation level and location all appear to be correlated to QoL. CONCLUSION: Patients with breast cancer should be informed of differences in QoL when discussing treatment options. Furthermore, physicians should recognize that the impact of surgical treatment modality on QoL may vary according to patients' sociodemographic and clinical characteristics.

Is vegetarian diet associated with a lower risk of breast cancer in Taiwanese women?

BACKGROUND: Studies on the relationship between vegetarian diet and breast cancer in Asian populations are limited. This study aimed to investigate the relationship between vegetarian diet, dietary patterns, and breast cancer in Taiwanese women. METHODS: This case-control study compared the dietary patterns of 233 breast cancer patients and 236 age-matched controls. A questionnaire about vegetarian diets and 28 frequently-consumed food items was administered to these 469 patients in the surgical department of Taipei Tzu Chi Hospital. Serum biochemical status was also examined. RESULTS: There were no significant differences between the two groups for age, education, family history, oral contraceptive usage, or regular exercise. However, the cancer group presented with both a higher body mass index and an older age of primiparity (P < 0.05). Two food items (shellfish and seafood) were highly correlated (correlation coefficient = 0.77), so shellfish was excluded to avoid multicollinearity. A factor analysis of 27 food items produced five dietary patterns: meat, processed meat, fruit/vegetable/soybean, dessert/sugar, and fermented food. Multivariate logistic regression showed that meat/fat and processed meat dietary patterns were associated with breast cancer risk (odds ratio (OR): 2.22, 95% CI 1.67-2.94, P < 0.001; OR: 1.49, 95% CI 1.09-2.04, P = 0.013, respectively). Vegetarian diet, high isoflavone intake, and high albumin levels were inversely associated with breast cancer risk (P < 0.05). Vegetarians had a higher daily soy isoflavone intake than non-vegetarians (25.9 ± 25.6 mg vs. 18.1 ± 15.6 mg, P < 0.001). CONCLUSIONS: Vegetarian diets show as protective role against breast cancer risk, while meat and processed meat dietary patterns are associated with a higher breast cancer risk.

The laparoscopic right gastroepiploic lymph node flap transfer for upper and lower limb lymphedema: Technique and outcomes.

BACKGROUND: Lymph node flap transfer popularity for treatment of extremity lymphedema is increasing quickly. Multiple flap donor sites were described in search of the optimal one. We describe the technique and outcomes of a laparoscopically harvested right gastroepiploic lymph node flap for treatment of extremity lymphedema. METHODS: From January 2012 to January 2013, 10 consecutive female patients, average age 54.8 years, with International Society of Lymphology stage II-III extremity lymphedema refractory to conservative management were included. Five patients had upper limb breast cancer-related lymphedema and five patients had lower limb pelvic cancer-related lymphedema. All patients underwent laparoscopic harvest of the right gastroepiploic lymph node flap, transferred to the wrist and ankle as recipient sites. Flaps were covered with a small skin graft taken from the thigh. Perioperative assessment included physical exam, photography, circumference measurements, CT scans, lymphoscintigraphy, and Lymphedema Quality of Life (LYMQOL) questionnaire. Clinical and CT evaluation of donor-site morbidity were performed. RESULTS: The flap survival rate was 100%, with a mean harvest time of 32 minutes and total operating time of 164 minutes. One case required regrafting for skin graft loss. The mean limb reduction rate was 39.5% at a mean follow-up of 14.7 months. Perioperative lymphoscintigraphy demonstrated transferred lymph node viability and lymphatic transport improvement. LYMQOL showed a 2.6-fold quality-of-life improvement (P < 0.01). No donor-site morbidity was encountered. CONCLUSIONS: The use of the laparoscopically harvested right gastroepiploic lymph node flap may be a safe technique that improves limb measurements and quality of life in extremity lymphedema patients. © 2015 Wiley Periodicals, Inc. Microsurgery 37:197-205, 2017.