Prescribing antibiotics for children with dengue infection in Taiwan: who are at risk and who are high prescribers?

Inappropriate antibiotic use contributes to antimicrobial resistance, a global public health threat. The non-specific manifestations of dengue, itself a growing public health threat, lead to avoidable empiric antibiotic prescription, particularly in children. In this national pooled population-based cross-sectional study, we evaluated child and physician characteristics associated with antibiotics prescription in confirmed dengue cases in Taiwan. Linking national health care insurance claims and reports of confirmed dengue cases from 2008 to 2015, there were 7086 children with confirmed dengue with 21 744 outpatient visits and 2520 inpatient admissions. We assessed the presence of antibiotic prescription in outpatient and inpatient settings separately a week before or after the confirmation date. Logistic regression models with generalized estimating equations were applied to identify patient, practitioner, and other factors associated with antibiotic prescription. A total of 29.4% of children <18 years old with dengue who did not have a concomitant bacterial infection were prescribed antibiotics during the 14-day assessment period. Antibiotics prescription was reduced from 13.5% to 6.3% and from 43.2% to 19.3% in outpatient and inpatient settings, respectively, after dengue was confirmed. Young children were more likely to receive antibiotics. Significant variations in antibiotic prescribing across physicians were observed only in outpatient settings: physicians ≥60 years old and physicians practicing at clinics and in non-urban facilities were more likely to prescribe antibiotics. Antibiotics were less likely to be prescribed during an exceptional 2-year epidemic than in other years. Antibiotic prescribing for dengue, an arboviral infection affecting half of the global population, was shown to occur in 29% of paediatric cases in Taiwan. That potentially avoidable antibiotic consumption could be reduced by improving antibiotic stewardship, informed by understanding the conditions under which antibiotics are prescribed and the availability of prevention strategies for viral diseases, including dengue. We identified a number of such factors in this national population-based study.

Advanced Age and Increased Risk for Severe Outcomes of Dengue Infection, Taiwan, 2014-2015.

Dengue, a mosquitoborne flavivirus infection, is increasingly a disease of older adults who are more likely to have chronic diseases that confer risk for severe outcomes of dengue infection. In a population-based study in Taiwan, adjusted risks for dengue-related hospitalization, intensive care unit admission, and death increased progressively with age.

Perception of transitional care quality associated with functional outcomes among patients with fractures and stroke in Taiwan.

This study aimed to examine the relationship between self-perceived quality of transitional care and functional outcome among patients with stroke and fractures. The Care Transition Measure (CTM-15) was used to survey patient's self-perceived transitional care quality before discharge. General estimating equations were used to investigate the influences of transitional care quality on patient's functional outcomes at before, 1 week after, and 1 or 3 months after discharge. Among stroke patients, higher CTM-15 scores were positively associated with greater outcome in Instrumental Activities of Daily Living (IADL) following discharge. Higher scores for "reader-friendly written care plan," "consideration of patient's preferences," and "understanding of health management" had significantly positive effects on functional recovery in IADL among both patient groups following discharge. These findings suggest that heterogeneity in transitional care needs between medical and surgical patients shall not be overlooked. A one-size-fits-all strategy may be insufficient for ensuring patient care continuity following discharge.

Association between sodium-glucose co-transporter 2 inhibitors and risk of psoriasis in patients with diabetes mellitus: a nationwide population-based cohort study.

BACKGROUND: Sodium-glucose co-transporter 2 inhibitor (SGLT2i) treatment may exert anti-inflammatory effects by modulating the NOD-like receptor family pyrin domain-containing 3 inflammasome and interleukin-17/23 inflammatory axis, which are both involved in the pathogenesis of psoriasis. However, the relationship between SGLT2i treatment and psoriasis remains unclear. AIM: To investigate the association between SGLT2i treatment and incident psoriasis. METHODS: Using the Taiwan National Health Insurance Database for the period 2007-2018, we matched 103 745 patients with Type 2 diabetes mellitus (T2DM) receiving SGLT2i with a control group of patients with T2DM who did not use SGLT2i, matching them in a 1 : 2 ratio by age, sex, diabetes duration, insulin use and comorbidities, and evaluating the psoriasis risk in both groups. RESULTS: The incident psoriasis risk did not significantly differ between the SGLT2i and control groups [hazard ratio (HR) = 1.24, 95% CI 0.95-1.64] after adjustment for potential confounders. Insulin use (HR = 1.65, 95% CI 1.24-2.19) and chronic liver disease and cirrhosis (HR = 1.34, 95% CI 1.01-1.77) were significantly associated with increased psoriasis risk. A slightly increased psoriasis risk was also detected in certain SGLT2i user subgroups, especially those with renal disease (HR = 2.73, 95% CI 1.45-5.13). CONCLUSION: SGLT2i-mediated protective effects in psoriasis could not be established. SGLT2i treatment increased psoriasis risk by 2.7-fold in patients with T2DM exhibiting renal diseases.

Gender differences in the risk of depressive disorders following the loss of a young child: a nationwide population-based longitudinal study.

BACKGROUND: Losing a child to death is one of the most stressful life events experienced in adulthood. The aim of the current study is to investigate parental risk of seeking treatment for major depression disorders (MDD) after a child's death and to explore whether such connection may operate differentially by parents' prior medical condition. METHODS: We studied a retrospective cohort of 7245 parents (2987 mothers and 4258 fathers) identified in the National Health Insurance Research Database of Taiwan (NHIRD) who had lost a child with age between 1 and 12 years. For comparison, the parents of 1:4 birth year- and gender-matched non-deceased children were retrieved (16,512 mothers and 17,753 fathers). Gender-specific Cox regression analyses were performed to estimate risk. RESULTS: Nearly 5.0% and 2.4% of bereaved mothers and fathers sought treatment for MDD within three years after a child's death, significantly higher than 0.8% and 0.5% in the non-bereaved parents. With covariate adjustment, the hazard ratio (HR) for maternal and paternal seeking treatment for MDD was estimated 4.71 (95% confidence interval [CI]: 3.35-6.64) and 1.93 (95% CI: 1.27-2.95), respectively. The increased risk of MDD varied by prior disease history; specifically, the increased risk of seeking treatment for MDD was especially prominent for those without chronic physical condition (CPC) (e.g., mothers with CPC: aHR = 2.38, 95% CI: 1.56-3.65 vs. no CPC: aHR = 9.55, 95% CI: 6.17-14.79). CONCLUSIONS: After the death of a child, parental elevated risk of MDD was especially prominent for the women and those without prior medical condition. Effective strategies addressing bereavement may require family-based, integrated physical and mental healthcare and even extended counseling service.

Longitudinal changes of frailty in 8 years: comparisons between physical frailty and frailty index.

BACKGROUND: Few studies have made longitudinal comparisons between frailty phenotype (FP) and frailty index (FI) changes. We aimed to investigate frailty status changes defined by FP and FI concurrently, and to compare the associated factors and incident disability among different combination of FI and FP trajectory groups. METHODS: Data on respondents aged over 50 who completed the 1999, 2003 and 2007 Taiwan Longitudinal Study on Aging (TLSA) surveys (n = 2807) were excerpted. Changes of FI, FP and major time-dependent variables were constructed by group-based trajectory modeling. Logistic regression was used to investigate the associated factors and relationships with incident disability among different frailty trajectories. RESULTS: We identified four FP trajectories - stably robust, worsened frailty, improved frailty, and stably frail and three FI trajectories - stable FI, moderate increase FI and rapid increase FI. Lower self-rated health, mobility impairment, and depressed mood were associated with unfavorable FP and FI changes (all p < 0.001). Regardless of FP trajectory groups, the moderate and rapid increase FI group had significantly more comorbidities than the stable FI group, and more visual, hearing, oral intake impairment, more difficulty in meeting living expenses, and poorer cognitive function in ≥65-year-olds (all p < 0.05). In addition, the worsened frailty, improved frailty, and stably frail groups had ORs for incident disability of 10.5, 3.0, and 13.4, respectively, compared with the stably robust group (all p < 0.01); the moderate and rapid increase FI groups had 8.4-fold and 77.5-fold higher risk than the stable FI group (both p < 0.001). When combining FI and FP trajectories, risk increased with FI trajectory steepness, independent of FP change (all p < 0.01 in rapid increase FI vs stable FI). CONCLUSIONS: Four FP trajectories (stably robust, worsened frailty, improved frailty, and stably frail) and three FI trajectories (stable FI, moderate increase FI and rapid increase FI) were identified. Lower self-rated health, mobility impairment, and depressed mood were associated with both unfavorable FP and FI trajectories. Nevertheless, even for individuals in stably robust or improved frailty FP groups, moderate or rapid increase in FI, either due to comorbidities, sensory impairment, cognitive deficits, or financial challenges, may still increase the risk of incident disability.

Obesity, but Not Metabolic Diseases, Is Associated with Risk of Psoriasis: A Population-Based Cohort Study in Taiwan.

BACKGROUND: Obesity and metabolic diseases including diabetes, hyperlipidemia, and hypertension are reportedly associated with an increased risk of psoriasis. However, few prospective studies have investigated the association of obesity and metabolic diseases with the risk of psoriasis. OBJECTIVE: To examine whether obesity or metabolic diseases increase the risk of psoriasis. METHODS: Participants were collected from 4 rounds (2001, 2005, 2009, and 2013) of the Taiwan National Health Interview Survey. Incident cases of psoriasis were identified from the National Health Insurance database. Participants were followed from the time of the National Health Interview Survey interview until December 31, 2017, or until a diagnosis of psoriasis was made or the participant died. The Cox regression model was used for the analyses. RESULTS: Of 60,136 participants, 406 developed psoriasis during 649,506 person-years of follow-up. Compared to participants with a BMI of 18.5-22.9, the adjusted hazard ratios (aHR) of psoriasis were 1.34 (95% CI 1.05-1.71) for a BMI of 25.0-29.9 and 2.70 (95% CI 1.95-3.72) for a BMI ≥30. Neither individual nor multiple metabolic diseases were associated with incident psoriasis. Participants with a BMI ≥30 were at significantly higher risk of both psoriasis without arthritis (aHR 2.60; 95% CI 1.85-3.67) and psoriatic arthritis (aHR 3.96; 95% CI 1.45-10.82). CONCLUSION: Obesity, but not metabolic diseases, significantly increased the risk of psoriasis.

Do patients bypass primary care for common health problems under a free-access system? Experience of Taiwan.

BACKGROUND: A common challenge for free-access systems is that people may bypass primary care and seek secondary care through self-referral. Taiwan's government has undertaken various initiatives to mitigate bypass; however, little is known about whether the bypass trend has decreased over time. This study examined the extent to which patients bypass primary care for treatment of common diseases and factors associated with bypass under Taiwan's free-access system. METHODS: This repeated cross-sectional study analyzed data from Taiwan's National Health Insurance Research Database. A random sample of 1 million enrollees was drawn repeatedly from the insured population during 2000-2017. To capture visits beyond the community level, the bypass rate was defined as the proportion of self-referred visits to the top two levels of providers, namely academic medical centers and regional hospitals, among all visits to all providers. Subgroup analyses were conducted for visits with a single diagnosis. Logistic regressions were used to investigate factors associated with bypass. RESULTS: The standardized bypass rate for all diseases analyzed exhibited a decreasing trend. In 2017, it was low for common cold (0.7-1.3%), moderate for hypertension (14.0-29.5%), but still high for diabetes (32.0-47.0%). Moreover, the likelihood of bypass was higher for male, patients with higher salaries or comorbidities, and in areas with more physicians practicing in large hospitals or less physicians working in primary care facilities. CONCLUSIONS: Although the bypass trend has decreased over time, continuing efforts may be required to reduce bypass associated with chronic diseases. Both patient sociodemographic and market characteristics were associated with the likelihood of bypass. These results may help policymakers to develop strategies to mitigate bypass.

Smoking, but not alcohol, is associated with risk of psoriasis in a Taiwanese population-based cohort study.

BACKGROUND: Alcohol consumption and smoking have long been suspected of increasing the risk of developing psoriasis. Most evidence to date has derived from cross-sectional or case-control studies. OBJECTIVE: We sought to investigate the effects of alcohol and smoking on incident psoriasis. METHODS: Alcohol consumption, smoking status, and other covariates were collected from four rounds (2001, 2005, 2009, and 2013) of the Taiwan National Health Interview Survey. Incident psoriasis was identified from the National Health Insurance database. Cox regression model was used for the analysis. RESULTS: Of 60,136 subjects, 242 (0.40%) developed psoriasis. After controlling for demographics and comorbidities, alcohol consumption was not significantly associated with psoriasis risk. Conversely, psoriasis risk was higher for current smokers than never smokers (adjusted hazard ratio 1.47 [95% confidence interval 1.04-2.07]). The risks were higher among subjects who smoked >25 cigarettes per day and for >20 pack-years. In subgroup analysis, current smoking was significantly associated with risk of psoriasis without psoriatic arthritis but not psoriatic arthritis alone. LIMITATIONS: Alcohol consumption was not assessed based on the number of drinks consumed. CONCLUSION: Current smoking increased the risk of psoriasis, particularly augmented for individuals who smoked >25 cigarettes per day and for >20 pack-years, while alcohol consumption was not significantly associated with psoriasis development.

Facility size and mortality in hospital-based and freestanding haemodialysis units: A nationwide retrospective cohort study.

AIM: Existing studies on the association between haemodialysis facility size/volume and patient survival are mostly limited to freestanding dialysis units in the United States. This study in Taiwan explored the facility size - mortality association in both hospital-based and freestanding haemodialysis (HD) units. METHODS: In this nationwide population-based retrospective cohort study, we used the Taiwan National Health Insurance Research Database to include patients who began maintenance (HD) between 2008 and 2012. Facility size was categorized according to the number of stations in the HD unit. The 5 years mortality rate was analyzed using a frailty model for Cox regression. The patients in hospital-based and freestanding HD units were examined separately. RESULTS: Among the 39 506 patients, 24 597 (62.3%) and 14 909 (37.7%) patients received HD in hospital-based and freestanding facilities, respectively. After the 4th month of dialysis initiation, the 5 years survival rates of patients in hospital-based and freestanding HD units were 50.7% and 52.3%, respectively. When patient and other facility characteristics were adjusted, patients in the smallest facility category (1-15 stations) showed the highest mortality risk (hazard ratio, 1.36; 95% confidence interval, 1.11-1.67) among all the patients treated in hospital-based units. The patients treated in freestanding units with 1-15, 16-30 and 31-45 stations showed 31%, 33% and 36%, respectively, higher mortality risks than those of patients treated in units with more than 45 stations. CONCLUSION: A small facility size was associated with an increased mortality risk in HD patients, and the threshold size was higher in freestanding units.

Variation in the 11-year trajectories of medical care seeking behaviors in diabetes patients under a single payer system: persisting gaps to be filled.

BACKGROUND: Care-seeking behavior is widely acknowledged to have strong influences on health outcomes among individuals with chronic conditions including diabetes. Despite its dynamic nature, care seeking behavior are often considered as time invariant in most studies. The likelihood of patients changing their regularity and source of chronic care over time is often neglected. This study aimed to determine the long-term trajectories of care-seeking patterns of both care-seeking regularity and health provider choices; and their associated factors among patients with type 2 diabetes under the National Health Insurance (NHI) program in Taiwan. METHODS: We utilized population-based data from the National Health Insurance Research Database (NHIRD) in Taiwan. Three thousand, nine hundred and eighty-seven adult patients with newly diagnosed type 2 diabetes in 1999 were enrolled in the cohort. We assessed their trajectories of regular care visits and sources of diabetes care from 2000 to 2010. A group-based trajectory model was applied. RESULTS: Seven distinct groups of long-term care-seeking patterns were identified. Only 51.44% of patients with newly diagnosed diabetes had regularly visited their providers over time. Among them, 56.41 and 16.09% had persistently sought care from generalized and specialized providers, respectively. 27.50% had sought care from different levels of providers. Patients who were male, elderly, low-income, and had a higher baseline diabetes severity were significantly more likely to either continue with their irregular care-seeking behavior or fail to maintain their regular care seeking behavior over time. Those who were younger, had a higher socioeconomic status, and lived in an urban area were significantly more likely to persistently seek care from specialized care settings. CONCLUSIONS: This study is the first population-based assessment of long-term care-seeking behaviors of type 2 diabetes patients under a single-payer system with a comprehensive benefit coverage. The most alarming finding was that, despite the existence of the comprehensive universal health insurance coverage in Taiwan, almost 50% of patients did not seek or maintain regular visits to providers over time as recommended. Understanding variations in the long-term trajectories of care adherence and sources of care may help to identify gaps in diabetes care management.

Resident burnout in Taiwan Hospitals-and its relation to physician felt trust from patients.

BACKGROUND/PURPOSE: This study hypothesized that low 'felt trust' from patients may induce resident burnout. The authors developed and validated a scale to measure physician felt trust from patients and surveyed residents in Taiwan to estimate the prevalence of burnout, and to verify the association between felt trust and burnout. METHODS: Residents in Taiwan were surveyed between November 2015 and May 2016. The Chinese version occupational burnout inventory and the four-item 'physician-felt-trust-from-patient' (PFTFP) scale were used to measure burnout and physician felt trust. Generalized linear model with generalized estimating equation with burnout as the dependent variable was employed to estimate the association between physician felt trust and burnout while adjusting other potential confounders. RESULTS: There were 1016 questionnaires returned (response rate 67.8%). The prevalence of personal burnout and client-related burnout were 44.0% and 14.8%. The PFTFP scale demonstrated adequate internal consistency (Chrobach's α 0.68) and favorable construct validity. Residents feeling less trusted from patients had significantly more burnout, especially client-related burnout, which showed a strong dose-response pattern. Residents having longer work hours or consecutive work hours and higher psychological job demands experienced more burnout, especially personal burnout. Residents with self-reported medical errors in recent 3 months had more client-related but not personal burnout. CONCLUSION: The prevalence of burnout among residents in Taiwan was high, especially personal burnout. The validity of the PFTFP scale is satisfactory. Strategies in improving wellbeing of residents shall not overlook the importance of positive social capital such as resident's feeling of patient trust.

Albumin levels and cause-specific mortality in community-dwelling older adults.

To investigate the association between serum albumin levels and cause-specific mortality among community-dwelling older adults. This cohort study was based on data obtained from the government-sponsored Annual Geriatric Health Examination Program for the older adults in Taipei City between 2006 and 2010. The study sample consisted of 77,531 community-dwelling Taipei citizens (≥65 years old). Mortality was determined by matching the participants' medical records with national death files. Serum albumin levels were categorized into <3.6, 3.6-3.7, 3.8-3.9, 4.0-4.1, 4.2-4.3, and ≥4.4 g/dL. Cox proportional hazards regression models were used to evaluate the association between albumin levels and cause-specific mortality. Spline regression was used to calculate the risk of mortality associated with albumin levels, modeled as continuous variables. Community-dwelling older adults had a mean albumin level of 4.3 g/dL, which significantly reduced by age. Compared to albumin levels ≥4.4 g/dL, mildly low albumin levels (4.2-4.3 g/dL) were associated with an increased mortality risk (hazard ratio [HR]: 1.16, 95% confidence interval [CI]: 1.05-1.28 for all-cause mortality), and albumin levels <4.2 g/dL were associated with significantly higher rates of all-cause, cancer, cardiovascular, and respiratory mortalities. In the spline regression, the curve of mortality risk was relatively flat at an albumin level ≥4.4 g/dL, and the mortality risk gradually increased as the albumin level declined. Albumin levels ≥4.4 g/dL were associated with better survival among community-dwelling older adults, and mortality risk increased as the albumin level decreased.

Public Trust in Physicians-Health Care Commodification as a Possible Deteriorating Factor: Cross-sectional Analysis of 23 Countries.

Trust in physicians has declined, and surveys of public opinion show a poor level of public trust in physicians. Commodification of health care has been speculated as a plausible driving force. We used cross-national data of 23 countries from the International Social Survey Programme 2011 to quantify health care commodification and study its role in the trust that patients generally place in physicians. A modified health care index was used to quantify health care commodification. There were 34 968 respondents. A question about the level of general trust in physicians and a 4-item "general trust in physicians" scale were used as our major and minor outcomes. The results were that compared with those in the reference countries, the respondents in the health care-commodified countries were approximately half as likely to trust physicians (odds ratio: 0.47, 95% confidence interval [CI]: 0.31-0.72) and scored 1.13 (95% CI: 1.89-0.37) less on the general trust scale. However, trust in physicians in the health care-decommodified countries did not differ from that in the reference countries. In conclusion, health care commodification may play a meaningful role in the deterioration of public trust in physicians.

Effect of Continuity of Care on Drug-Drug Interactions.

BACKGROUND: Drug-drug interaction (DDI) is a critical concern in health care systems because it is directly associated with patient outcomes and is generally preventable. However, few studies have been conducted on whether poor continuity of care (COC) is a determinant of DDIs and whether this effect varies by level of comorbidity. Patients with higher comorbidity normally require more complex treatment regimens than other patients, and hence their COC is more critical for ensuring the accuracy of their medication information. OBJECTIVE: This study investigated the association between COC and DDI, with COC being measured as physician and site COC. The effect of comorbidities on DDI events was also analyzed. METHODS: The Taiwan National Health Insurance claims data of ∼1,000,000 randomly selected insurance beneficiaries were used. Each person was longitudinally followed from 2005 to 2013. Negative nominal regressions were estimated to determine the effect of COC on DDI. RESULTS: Higher COC was found to decrease the risk of DDI, and this risk reduction was even greater with physician COC and a higher Charlson comorbidity index. In the 1-year observation interval, patients exhibited a 3% reduction in DDIs for every 0.1 increment in their COC index. The ability of COC to reduce DDIs increased with the level of comorbidity. Similar results were observed when the observation interval was increased. CONCLUSIONS: Improving COC is critical for reducing DDIs. The effect of high-quality COC on the reduction of DDI is more significant for patients with higher levels of comorbidity; thus, they should be targeted to improve COC.

Short- and long-term use of medication for psychological distress after the diagnosis of cancer.

PURPOSE: This study investigated the short- and long-term use of medication for psychological distress after the diagnosis of cancer. METHODS: Longitudinal data from the Taiwan National Health Insurance database were used to follow 35,137 cancer patients for 2.5 years after being diagnosed in 2006 and 2007. RESULTS: Among those patients who survived for at least 180 days, 20.9 % had used psychotropic medications; sedatives were the most frequently prescribed (14.3 %), followed by antidepressants (5.5 %), anxiolytics (3.6 %), and antipsychotics (2.7 %). Lung cancer, prostate cancer, and oral cancer showed a significant association with the regular use of medication in the first 180 days. Among patients who survived for at least 2.5 years, 4.8 % still used psychotropic medication on a regular basis. Lung cancer and prostate cancer were associated with such prolonged use. CONCLUSIONS: This longitudinal study found that the type of cancer was significantly associated with the use of psychotropic drugs after the diagnosis was made. It provided information about the trajectory of that use and found that a small number of patients were still using those medications after 2.5 years.

Older Age, Low Socioeconomic Status, and Multiple Comorbidities Lower the Probability of Receiving Inpatient Rehabilitation Half a Year After Stroke.

OBJECTIVE: To determine the predictors of receiving inpatient rehabilitation during 7 to 12 months after stroke. DESIGN: Retrospective cohort study. SETTING: A nationally representative sample of 1 million National Health Insurance enrollees. PARTICIPANTS: Patients with new-onset stroke (N=13,828) were included. Studied participants were patients who received inpatient rehabilitation during 4 to 6 months after stroke. Patients who died within 1 year of the stroke event were excluded (n=488). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The outcome variable of interest was the probability of receiving inpatient rehabilitation during 7 to 12 months after stroke. The characteristics of both patients and medical care providers were investigated to determine their effect on patients receiving inpatient rehabilitation. RESULTS: Older patients, patients of low socioeconomic status, patients with Charlson Comorbidity Index ≥5, and patients who received outpatient rehabilitation during 4 to 6 months after stroke have a lower rate of receiving inpatient rehabilitation than do their counterparts. In addition, receiving inpatient rehabilitation during 7 to 9 months after stroke is a strong positive predictor of receiving inpatient rehabilitation during 10 to 12 months after stroke (odds ratio, 38.556; P<.0001). CONCLUSIONS: This study revealed that older age, lower socioeconomic status, and multiple comorbidities are negative predictive factors with a cumulative predictive power for the probability of receiving inpatient rehabilitation during 7 to 12 months after stroke.

Understanding the relationship between cesarean birth and stress, anxiety, and depression after childbirth: A nationwide cohort study.

BACKGROUND: Women who undergo cesarean birth might have an increased risk for poor mental health after childbirth, possibly because of maternal and neonatal physical problems, low parental confidence, and decreased levels of oxytocin. However, this relationship remains controversial and requires further examination. The study aimed to examine the effect of cesarean birth on postpartum stress, anxiety, and depression. METHODS: This nationwide population-based cohort study was conducted using the Taiwan National Health Insurance Database. A total of 12 619 women who underwent cesarean birth and 12 619 control women who underwent vaginal birth were matched by propensity score based on age, socioeconomic status, residential urbanicity, antepartum comorbidity, and index year of delivery. We compared the incidence of stress, anxiety, and depression during the first postpartum year between cesarean and comparison groups by calculating incidence rate ratios (IRRs). RESULTS: The cesarean group showed a significantly higher risk for stress symptoms (IRR 1.4 [95% confidence interval {CI} 1.02-1.92]), but not anxiety (IRR 1.14 [95% CI 0.95-1.38]) or depression (IRR 1.32 [95% CI 0.94-1.87]), although the IRRs were also greater than one. The cesarean group had a significantly higher risk of any of the above-listed three disorders than the comparison group (incidence 27.6 vs 23.4 per 1000 person-years; IRR 1.18 [95% CI 1.01-1.38]). CONCLUSIONS: Cesarean birth was associated with an increased risk of postpartum stress symptoms. Health professionals should avoid unnecessary cesarean birth, pay attention to women who deliver by cesarean, and intervene appropriately in an attempt to improve mental health among postpartum women.

Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study.

BACKGROUND: Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD. METHODS: We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients. RESULTS: During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care. CONCLUSIONS: Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.

Relationship between women's characteristics and continuum of care for maternal health in Kenya: Complex survey analysis using structural equation modeling.

The objective of this study was to understand and estimate the complex relationships in the continuum of care for maternal health to provide information to improve maternal and newborn health outcomes. Women (n = 4,082) aged 15-49 years in the 2008/2009 Kenya Demographic and Health Survey data were used to explore the complex relationships in the continuum of care for maternal health (i.e., before, during, and after delivery) using structural equation modeling. Results showed that the use of antenatal care was significantly positively related to the use of delivery care (ß = 0.06; adjusted odds ratio [AOR] = 1.06; 95% confidence interval [CI]: 1.02-1.10) but not postnatal care, while delivery care was associated with postnatal care (ß = 0.68; AOR = 1.97; 95% CI: 1.75-2.22). Socioeconomic status was significantly related to all elements in the continuum of care for maternal health; barriers to delivery of care and personal characteristics were only associated with the use of delivery care (ß = 0.34; AOR = 1.40; 95% CI: 1.30-1.52) and postnatal care (ß = 0.03; AOR = 1.03; 95% CI: 1.01-1.05), respectively. The three periods of maternal health care were related to each other. Developing a referral system of continuity of care is critical in the Sustainable Development Goals era.