Estimating global burden of COVID-19 with disability-adjusted life years and value of statistical life metrics.

BACKGROUND: Global burden of COVID-19 has not been well studied, disability-adjusted life years (DALYs) and value of statistical life (VSL) metrics were therefore proposed to quantify its impacts on health and economic loss globally. METHODS: The life expectancy, cases, and death numbers of COVID-19 until 30th April 2021 were retrieved from open data to derive the epidemiological profiles and DALYs (including years of life lost (YLL) and years loss due to disability (YLD)) by four periods. The VSL estimates were estimated by using hedonic wage method (HWM) and contingent valuation method (CVM). The estimate of willingness to pay using CVM was based on the meta-regression mixed model. Machine learning method was used for classification. RESULTS: Globally, DALYs (in thousands) due to COVID-19 was tallied as 31,930 from Period I to IV. YLL dominated over YLD. The estimates of VSL were US$591 billion and US$5135 billion based on HWM and CVM, respectively. The estimate of VSL increased from US$579 billion in Period I to US$2160 billion in Period IV using CVM. The higher the human development index (HDI), the higher the value of DALYs and VSL. However, there exits the disparity even at the same level of HDI. Machine learning analysis categorized eight patterns of global burden of COVID-19 with a large variation from US$0.001 billion to US$691.4 billion. CONCLUSION: Global burden of COVID-19 pandemic resulted in substantial health and value of life loss particularly in developed economies. Classifications of such health and economic loss is informative to early preparation of adequate resource to reduce impacts.

Barriers to bystanders defibrillation: A national survey on public awareness and willingness of bystanders defibrillation☆.

BACKGROUND: After years of setting up public automated external defibrillators (AEDs), the rate of bystander AED use remains low all over the world. This study aimed to assess the public awareness and willingness of bystanders to use AEDs and to investigate the awareness on the Good Samaritan Law (GSL) and the factors associated with the low rate of bystander AED use. METHODS: Using stratified random sampling, national telephone interviews were conducted using an author-designed structured questionnaire. The results were weighted to match the census data in Taiwan. The factors associated with public awareness and willingness of bystanders to use AEDs were analysed by logistic regression. RESULTS: Of the 1073 respondents, only 15.2% had the confidence to recognise public AEDs, and 5.3% of them had the confidence to use the AED. Concerns on immature technique and legal issues remain the most common barriers to AED use by bystanders. Moreover, only 30.8% thought that the public should use AEDs at the scene. Few respondents (9.6%) ever heard of the GSL in Taiwan, and less than 3% understood the meaning of GSL. Positive awareness on AEDs was associated with high willingness of bystanders to use AEDs. Respondents who were less likely to use AEDs as bystanders were healthcare personnel and women. CONCLUSION: The importance of active awareness and the barriers to the use of AEDs among bystanders seemed to have been underestimated in the past years. The relatively low willingness to use AEDs among bystander healthcare providers and women needs further investigation.

Empirical Investigation of Factors Influencing Consumer Intention to Use an Artificial Intelligence-Powered Mobile Application for Weight Loss and Health Management.

Background: Research into interventions based on mobile health (m-Health) applications (apps) has attracted considerable attention among researchers; however, most previous studies have focused on research-led apps and their effectiveness when applied to overweight/obese adults. There remains a paucity of research on the attitudes of typical consumers toward the adoption of m-Health apps for weight management. This study adopted the tenets of the extended unified theory of acceptance and use of technology 2 (UTAUT2) as the theoretical foundation in developing a model that integrates personal innovativeness (PI) and network externality (NE) in seeking to identify the factors with the most pronounced effect on one's intention to use an artificial intelligence-powered weight loss and health management app. Materials and Methods: An online survey was conducted for Taiwanese participants aged ≥21 years from May 23 to June 30, 2018. Hypotheses were tested using structural equation modeling. Results: In the analysis of 458 responses, the proposed research model explained 75.5% of variance in behavioral intention (BI). Habit was the independent variable with the strongest performance in predicting user intention, followed by PI, NE, and performance expectancy (PE). Social influence weakly affects user intention through PE. In multi-group analysis, education was shown to exert a moderating influence on some of the relationships hypothesized in the model. Conclusions: The empirically validated model in this study provides insights into the primary determinants of user intention toward the adoption of m-Health app for weight loss and health management. The theoretical and practical implications are relevant to researchers seeking to extend the applicability of the UTAUT2 model to health apps as well as practitioners seeking to promote the adoption of m-Health apps. In the future, researchers could extend the model to assess the effects of BI on actual use behavior.

Public knowledge, attitudes and willingness regarding bystander cardiopulmonary resuscitation: A nationwide survey in Taiwan.

BACKGROUND: A low bystander cardiopulmonary resuscitation (CPR) rate is one of the factors associated with low cardiac arrest survival. This study aimed to assess knowledge, attitudes, and willingness towards performing CPR and the barriers for implementation of bystander-initiated CPR. METHODS: Telephone interviews were conducted using an author-designed and validated structured questionnaire in Taiwan. After obtaining a stratified random sample from the census, the results were weighted to match population data. The factors affecting bystander-initiated CPR were analysed using logistic regression. RESULTS: Of the 1073 respondents, half of them stated that they knew how to perform CPR correctly, although 86.7% indicated a willingness to perform CPR on strangers. The barriers to CPR performance reported by the respondents included fear of legal consequences (44%) and concern about harming patients (36.5%). Most participants expressed a willingness to attend only an hour-long CPR course. Respondents who were less likely to indicate a willingness to perform CPR were female, healthcare providers, those who had no cohabiting family members older than 65 years, those who had a history of a stroke, and those who expressed a negative attitude toward CPR. CONCLUSION: The expressed willingness to perform bystander CPR was high if the respondents possessed the required skills. Attempts should be made to recruit potential bystanders for CPR courses or education, targeting those respondent subgroups less likely to express willingness to perform CPR. The reason for lower bystander CPR willingness among healthcare providers deserves further investigation.

Real-world cost-effectiveness of laparoscopy versus open colectomy for colon cancer: a nationwide population-based study.

BACKGROUND: Laparoscopic colectomy is increasingly being adopted for the treatment of colon cancer; however, the long-term effectiveness of this approach in a real-world clinical setting has yet to be verified. This study aims to compare the effectiveness and costs associated with laparoscopic and open colectomy from the perspective of the National Health Insurance (NHI) system in Taiwan. METHODS: A nationwide population-based colon cancer cohort was observed by linking the Taiwan Cancer Registry, claims data from NHI system, and the National Death Registry. Adult patients with Stage I to Stage III colon cancer who underwent primary cancer resection using either laparoscopy or open colectomy between 2009 and 2011 were included. A propensity score-matched cohort (1745 pairs) was applied to examine three clinical endpoints: overall survival, recurrence-free survival, and disease-free survival within 2 years after the operation. To comply with the perspective as well as the analytic horizon of the study, we limited the research to NHI claims from the study population for the corresponding time period. The health outcomes and net monetary benefits were verified by multivariate mixed-effect models. RESULTS: This analysis revealed that laparoscopy resulted in longer overall survival (adjusted difference 16.8 days, 95 % CI 7.3-26.2), recurrence-free survival (16.8 days, 5.0-28.6) and disease-free survival (26.4 days, 7.4-45.4), compared to open colectomy at 2 years post-op. Laparoscopy also led to a significantly shorter length of stay (3.2 days, 2.4-3.9) and lower index hospitalization costs (US$ 455, 181-729) than open colectomy; however, no differences in costs were observed over the long term. Overall, laparoscopy was more cost-effective than open colectomy under various willingness-to-pay thresholds in the setting of the Taiwan NHI. CONCLUSIONS: The continued adoption of laparoscopy in primary curable colon cancer resection is expected to reduce health care costs over the short term while providing considerable health benefits over the long term.

Accessibility of ophthalmic healthcare for residents of an offshore island-an example of integrated delivery system.

BACKGROUND: To assess the utilization of and satisfaction with ophthalmic healthcare provided by integrated delivery system (IDS) since 2000 and vision-related quality of life (VRQoL) for residents of an offshore island of Taiwan. METHODS: Facilitators interviewed residents (age ≥ 50 years) with the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) for VRQoL and a questionnaire on clinical information, ophthalmic care utilization and satisfaction. RESULTS: A total of 841 participants (response rate 93.4 %, 841/900) completed the questionnaire survey. Mean age was 63.7 (±10. 7) years. The common eye diseases were cataract (44.7 %), dry eye (15.5 %), and glaucoma (8.7 %). Among the participants, 61.0 % sought ophthalmic care under the IDS in the past year and 17.6 % experienced unmet ophthalmic needs in the past 6 months. Satisfaction with ophthalmic care under the IDS was 88.1 %. Determinants of dissatisfaction under the IDS were distance to healthcare facility and VRQoL. Predictors of VRQoL included age, residential area, marital status, occupation, comorbid condition, commercial insurance, household income, cataracts and glaucoma. CONCLUSIONS: The implementation of IDS improves accessibility of ophthalmic care for residents of an offshore island. Geographic proximity to avail healthcare facility and VRQoL affect satisfaction with the IDS.

Comparing the effectiveness of capecitabine versus 5-fluorouracil/leucovorin therapy for elderly Taiwanese stage III colorectal cancer patients based on quality-of-life measures (QLQ-C30 and QLQ-CR38) and a new cost assessment tool.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer-related deaths in developed countries and its incidence increases with age. Intravenous administration of bolus 5-fluorouracil (5-FU) and leucovorin (LV) has been a standard treatment regime for stage III CRC. However, patients generally prefer oral therapy such as Capecitabine. Studies showed that combination of oxaliplatin and capecitabine demonstrated efficacy and safety on par with treatment involving various 5-FU/LV-based regimens in elderly patients as they are in younger ones. However, little is known regarding the cost of adjuvant therapy or the effect of therapy on HRQoL. Thus the aims of this study were to evaluate the influence of different adjuvant care for stage III CRC on the HRQoL of elderly patients and to compare the economic costs associated with capecitabine-based and 5-FU/LV-based adjuvant treatments from a societal perspective in Taiwan. METHODS: A prospective, open-label, observational, multicenter study involving 123 patients aged 70 and over from 11 different centers was conducted between July 2008 and July 2011 in Taiwan. The adjusted monthly costs per patient and HRQoL were evaluated from individual-level data. The HRQoL of patients was assessed before and after adjuvant treatment. Direct and indirect costs of adjuvant treatment were estimated from a number of sources, and QoL scores were compared between groups. RESULTS: After correcting for baseline characteristics of patients, no significant differences were observed in the global HRQoL scores between treatment groups during the study period. According to QLQ-CR38 results, capecitabine-based therapy appeared to alleviate problems related to defecation (4.54 vs. 8.5; P = 0.011); however, micturition problems increased (9.27 vs. 7.51; P = 0.04), compared with 5-FU/LV-based treatment. The adjusted monthly treatment cost per patient was NT$27,300 for capecitabine-based treatment and NT$53,671 for 5-FU/LV-based treatment. The total cost of 5-FU/LV-based treatment was 59 % greater than that of capecitabine-based treatment. CONCLUSIONS: Analyzing from the societal perspective in Taiwan, capecitabine-based therapy incurred lower treatment costs than 5-FU/LV-based therapy and did not jeopardize HRQoL. Therefore, capecitabine, with or without oxaliplatin, could be considered as an alternative treatment option for elderly patients with stage III CRC.

Health-related quality of life and cost comparison of adjuvant capecitabine versus 5-fluorouracil/leucovorin in stage III colorectal cancer patients.

PURPOSE: The purpose of this study was to compare health-related quality of life (HRQoL) and costs associated with 2 adjuvant chemotherapy regimens [capecitabine-based therapy versus 5-fluorouracil/leucovorin (5-FU/LV)-based therapy] in stage III colorectal cancer patients. METHODS: We conducted a prospective, open-label, observational, multicenter study from July 2008 to July 2011. The European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38 questionnaires was used to assess HRQoL before, during, and after treatment. The direct and indirect costs of adjuvant treatment were estimated from a specially prepared questionnaire, the National Health Insurance Research Database, and other published sources. We used propensity scoring to match samples between groups and performed multivariate analyses to adjust for differences in patient demographics and clinical characteristics. RESULTS: A total of 497 patients were enrolled, and 356 completed the surveys. Following propensity score matching, 239 patients were included in the analysis (122 in the capecitabine-based group, 117 in the 5-FU/LV-based group). Global HRQoL scores did not differ significantly between the two groups. However, compared to patients in the 5-FU/LV-based group, patients in the capecitabine-based group had less nausea and vomiting (mid-term, P = 0.024; final, P = 0.013), appetite loss (mid-term, P < 0.0001; final, P = 0.001), and fewer side effects from chemotherapy (mid-term, P = 0.017). In addition, the monthly cost of capecitabine-based therapy was lower than those of 5-FU/LV-based therapy [NT$31,895.46 (US$1063.18) vs. NT$79,159.24 (US$2638.64) per patient]. CONCLUSIONS: Capecitabine is a reasonable alternative and cost-effective treatment option under current conditions for patients with stage III colorectal cancer.

Shorter Door-to-Balloon Time in ST-Elevation Myocardial Infarction Saves Insurance Payments: A Single Hospital Experience in Taiwan.

BACKGROUND: The relationship between quality of care and cost of medical services is a popular topic. In this study, we examined whether a reduced door-to-balloon (D2B) time led to cost savings, benefitted insurance payers, and improved patient outcomes. METHODS: We retrospectively enrolled consecutive patients who presented with ST-segment elevation myocardial infarction (STEMI) and received primary percutaneous coronary intervention (PCI) between Feb. 1, 2007, and Jul. 31, 2009, at a tertiary hospital in Taiwan. The patient data were collected by chart review. We utilized claims data from the hospital financial system as the proxy for insurance payer costs. We only included the claims data, regardless of whether patients were inpatients or outpatients, associated with the first three cardiovascular related ICD-9 codes. Multivariable logistic regression was used to examine the relationships between the D2B time, in-hospital mortality and one-year cardiovascular readmission. We utilized a multivariable linear regression to test the relationships between the D2B time, hospitalization cost and one-year cardiovascular-related cost. RESULTS: The D2B time did not influence the in-hospital mortality rate, but a D2B time greater than 90 min increased the probability of one-year cardiovascular readmission (p = 0.018). The D2B time did not increase the index hospitalization cost, but patients with a D2B time above 90 min had 14.6% higher one-year cardiovascular- related costs. CONCLUSIONS: Our study shows that the D2B time in patients with STEMI could impact the one-year cardiovascular readmission and one-year cardiovascular-related health cost. These results suggest that the pursuit of high-quality care not only leads to better outcomes, but also reduces costs. KEY WORDS: Acute myocardial infarction; Cost; Door-to-balloon time; Insurance payer; Quality.

Is a diabetes pay-for-performance program cost-effective under the National Health Insurance in Taiwan?

PURPOSE: In October 2001, a pay-for-performance (P4P) program for diabetes was implemented by the National Health Insurance (NHI), a single-payer program, in Taiwan. However, only limited information is available regarding the influence of this program on the patient's health-related quality of life. The aim of this study was to estimate the costs and consequences of enrolling patients in the P4P program from a single-payer perspective. METHODS: A retrospective observational study of 529 diabetic patients was conducted between 2004 and 2005. The data used in the study were obtained from the National Health Interview Survey (NHIS) in Taiwan. Direct cost data were obtained from NHI claims data, which were linked to respondents in the NHIS using scrambled individual identification. The generic SF36 health instrument was employed to measure the quality-of-life-related health status and transformed into a utility index. Patients enrolled in the P4P program for at least 3 months were categorized as the P4P group. Following propensity score matching, 260 patients were included in the study. Outcomes included life-years, quality-adjusted life-years (QALYs), diabetes-related medical costs, overall medical costs, and incremental cost-effectiveness ratios (ICERs). A single-payer perspective was assumed, and costs were expressed in US dollars. Nonparametric bootstrapping was conducted to estimate confidence intervals for cost-effectiveness ratios. RESULTS: Following matching, no significant difference was noted between two groups with regard to the patients' age, gender, education, family income, smoking status, BMI, or whether insulin was used. The P4P group had an increase of 0.08 (95 % CI 0.077-0.080) in QALYs, and the additional diabetes-related medical cost was US$422.74 (95 % CI US$413.58-US$435.05), yielding an ICER of US$5413.93 (95 % CI US$5226.83-US$5562.97) per QALY gained. CONCLUSIONS: Our results provides decision makers with valuable information regarding the impact of the P4P program of diabetes care through a direct comparison of equivalent groups of patients receiving regular care. Under the single-payer NHI system, the use of financial incentives under the DM-P4P program may be an effective means to ensure the quality of follow-up treatment.

Patient severity matters for night-shift workload for internal medicine residents in Taiwan.

BACKGROUND: Although work hour is an important factors for resident workload, other contributing factors, such as patient severity, with regards to resident workload have been scarcely studied. METHODS: A prospective observational cohort study was conducted in a general medicine unit in an academic medical center in Taiwan. Every event for which the nurses needed to call the on-call residents was recorded. To quantify the workload, the responses of on-duty residents to calls were analyzed. To allow comparisons of patient factors to be made, we classified all patients by assigning them stable, unstable, or do-not-resuscitate (DNR) codes. The reasons for the calls were categorized to facilitate the comparisons across these three groups. RESULTS: From October 2009 to September 2011, a total of 2,518 patients were admitted to the general medicine unit. The nurses recorded a total of 847 calls from 730 call nights, ranging from 0 to 7 per night. Two peaks of calls, at 0-2 am and 6-7 am, were noted. Calls from stable, unstable, and DNR patients were 442 (52.2%), 95 (11.2%), and 298 (35.2%), respectively. For both unstable and DNR patients, the leading reason was abnormal vital signs (62.1% and 67.1%, respectively), while only 36.2% for stable patients. Both unstable and DNR patients required more bedside evaluation and management compared to stable patients. CONCLUSION: Beyond work hours and patient census, patients with different clinical severity and palliative goal produce different workload for on-call residents.

Why do general medical patients have a lengthy wait in the emergency department before admission?

BACKGROUND/PURPOSE: Emergency department (ED) overcrowding is a universal problem, especially with the shortage of hospital beds. We studied the characteristics and outcomes of patients with prolonged ED stays, which has rarely been studied before. METHODS: We conducted a retrospective study at a tertiary medical center in Taiwan. Prolonged stay in the ED was defined as a stay of more than 72 hours in the ED before admission. The medical records were reviewed for data analysis. RESULTS: From November 1, 2009 to January 31, 2010, a total of 1364 general medical patients were enrolled. The mean age was 66.4 ± 17.8 years, with 53.4% male. The mean Charlson Comorbidity Index (CCI) was 3.0 ± 3.1. The mean length of ED stay was 43.9 ± 41.0 hours. The CCI (4.1 ± 3.5 vs. 2.8 ± 3.0, p < 0.001) and do-not-resuscitate (DNR) rates (18.8% vs. 10.3%, p = 0.001) of the patients with prolonged ED stays were higher than those of the patients with shorter stays. For patients with high CCI (≥3) and DNR consent, the odds ratio of prolonged ED stay was 1.73 and 1.60, respectively. Patients with prolonged ED stays also had a lower Barthel index (60.3 ± 34.8 vs. 66.4, p = 0.011) and higher in-hospital mortality (11.6% vs. 6.0%, p = 0.006). CONCLUSION: Complex comorbidities and terminal conditions with DNR consent were associated with the prolonged ED stay for general medical patients. The hospital manager should pay attention to general medical patients with multiple comorbidities as well as those who require palliative care.

Progression of stages 3b-5 chronic kidney disease--preliminary results of Taiwan national pre-ESRD disease management program in Southern Taiwan.

BACKGROUND/PURPOSE: The outcomes and their predictors, and rates of estimated glomerular filtration rate (eGFR) changes among Taiwanese, an ethnic Chinese population, with chronic kidney disease (CKD) stages 3b-5, enrolled in a nationwide pre-end-stage renal disease (pre-ESRD) management program that have not been previously reported. METHODS: This study focused on a cohort of patients enrolled in the Taiwan's pre-ESRD disease management program from Southern Taiwan, including 4061 CKD 3b-5 patients who received more than 12 weeks of follow-up from 2007 to 2010. The decline rates of eGFR, outcomes, and the predictors of initiating dialysis were analyzed. RESULTS: The study participants consisted of patients who were 70.1 ± 12.3 years old, of whom 56.4% were male, 46.3% were diabetic, and 72.1% were hypertensive. The mean annual eGFR changes were 0.47 ± 0.42 mL/min/1.73 m(2)/year, -1.27 ± 0.32 mL/min/1.73 m(2)/year, and -2.69 ± 0.39 mL/min/1.73 m(2)/year for stages 3b, 4, and 5, respectively; however, more rapid declines were noted in diabetic patients. The Kaplan-Meier analyses revealed that the probabilities of patients remaining alive and free of dialysis treatment for CKD stage 3b, 4, and 5 without or with diabetes were 89.46% versus 84.65%, 79.88% versus 55.68%, and 34.42% versus 9.64%, respectively, during 42 months of follow-up. Male gender, diabetes, lower baseline eGFR, higher systolic blood pressure, lower hematocrit, and albumin levels were the significant risk factors for initiating dialysis. CONCLUSION: Even though we cannot conclude with certainty that the Taiwan pre-ESRD disease management program is beneficial in slowing the progression of CKD stages 3b-5, our preliminary results seem to suggest this trend. Furthermore, the program may be improved by integrating it with other programs, such as those on diabetes and hypertension, thus making it a more patient-centered, multidisciplinary program.

Evaluation of clinically significant adverse events in patients discharged from a tertiary-care emergency department in Taiwan.

OBJECTIVE: To investigate the reasons for the occurrence of clinically significant adverse events (CSAEs) in emergency department-discharged patients through emergency physicians' (EPs) subjective reasoning and senior EPs' objective evaluation. DESIGN: This was a combined prospective follow-up and retrospective review of cases of consecutive adult non-traumatic patients who presented to a tertiary-care emergency department in Taiwan between 1 September 2005 and 31 July 2006. Data were extracted from 'on-duty EPs' subjective reasoning for discharging patients with CSAEs (study group) and without CSAEs (control group)' and 'objective evaluation of CSAEs by senior EPs, using clinical evidences such as recording history, physical examinations, laboratory/radiological examinations and observation of inadequacies in the basic management process (such as recording history, physical examinations, laboratory/radiological examinations and observation) as the guide'. Subjective reasons for discharging patients' improvement of symptoms, and the certainty of safety of the discharge were compared in the two groups using χ(2) statistics or t test. RESULTS: Of the 20,512 discharged cases, there were 1370 return visits (6.7%, 95% CI 6.3% to 7%) and 165 CSAEs due to physicians' factors (0.82%, 95% CI 0.75% to 0.95%). In comparisons between the study group and the control group, only some components of discharge reasoning showed a significant difference (p<0.001). Inadequacies in the basic management process were the main cause of CSAEs (164/165). CONCLUSION: The authors recommended that EP follow-up of the basic management processes (including history record, physical examination, laboratory and radiological examinations, clinical symptoms/signs and treatment) using clinical evidence as a guideline should be made mandatory.

A multilevel analysis of regional and individual effects on methadone maintenance treatment in Taiwan.

OBJECTIVE: This study evaluated the direct and interactive effects of regional-level and individual-level characteristics on methadone maintenance treatment (MMT), after considering the individual characteristics in Taiwan. METHODS: This study utilized a survey research method. Opioid-dependent patients who participated in the outpatient MMT program in 2009 and met the eligibility criteria were recruited from five hospitals. The impact of MMT on self-perceived health was assessed by using questionnaires. This study assessed the participants' quality of life and treatment outcomes during 3-month follow-up visits, before evaluating the direct effects of regional and individual characteristics. Multilevel linear models were used to estimate whether regional levels influenced individual behavior and treatment outcomes. RESULTS: Three hundred thirty-four opioid-dependent patients agreed to participate in this study. After the follow-up period, 127 participants completed the study (completion rate = 38%). Participants receiving MMT demonstrated significant improvements in psychological state, HIV risk-taking behavior, social functioning, and health. Regional characteristics, such as the lower than junior high school rate, low-income family rate, and related crime rates, of the study regions were negatively associated with improvements in drug abuse behavior. CONCLUSIONS: This study shows that MMT can significantly improve the HIV risk-taking behavior and health of the study participants. Disadvantaged regions, however, exhibit poor treatment outcomes. This study suggests actions to minimize the treatment variations between regions.

Psychometric testing of the short version of the world health organization quality of life (WHOQOL-BREF) questionnaire among pulmonary tuberculosis patients in Taiwan.

BACKGROUND: Studies on the effects of tuberculosis on a patient's quality of life (QOL) are scant. The objective of this study was to evaluate the psychometric properties of the Taiwan short version of the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire using patients with tuberculosis in Taiwan and healthy referents. METHODS: The Taiwanese short version of the WHOQOL-BREF was administered to patients with tuberculosis undergoing treatment and healthy referents from March 2007 to July 2007. Patients with tuberculosis (n = 140) and healthy referents (n = 130), matched by age, sex, and ethnicity, agreed to an interview. All participants lived in eastern Taiwan. Reliability assessments included internal consistency, whereas validity assessments included construct validity, convergent validity, and discriminant validity. RESULTS: More than half of these patients and referents were men (70.7% and 66.2%, respectively), and their average ages were 50.1 and 47.9 years, respectively. Approximately 60% of patients and referents were aboriginal Taiwanese (60.7% and 61.1%, respectively). The proportion with low socioeconomic status was greater for these patients. The internal consistency reliability coefficients were .92 and .93 for the patients and healthy referents, respectively. Exploratory factor analysis on the healthy referents displayed a 4-domain model, which was compatible with the original WHOQOL-BREF 4-domain model. However, for the TB patient group, after deleting 3 items, both exploratory and confirmatory factor analysis revealed a 6-domain model. CONCLUSION: Psychometric evaluation of the Taiwan short version of the WHOQOL-BREF indicates that it has adequate reliability for use in research with TB patients in Taiwan. However, the factor structure generated from this TB patient sample differed from the WHO's original 4-factor model, which raised a validity concern to apply the Taiwan short version of the WHOQOL-BREF to Taiwanese TB patients. Future research recruiting another sample to revisit this validity issue must be conducted to determine the validity of the WHOQOL-BREF TW in patients with TB.

Pharmacoeconomic analysis of capecitabine versus 5-fluorouracil/leucovorin as adjuvant therapy for stage III colon cancer in Taiwan.

OBJECTIVES: To assess the cost-effectiveness of oral capecitabine compared with intravenous bolus 5-fluorouracil/leucovorin (5-FU/LV) in the adjuvant treatment of stage III colon cancer in Taiwan from payer (Bureau of National Health Insurance [BNHI]) perspectives. METHODS: A health state-transition model was developed to estimate the incremental costs and effectiveness of capecitabine versus 5-FU/LV. The time horizons studied were: treatment duration (24 weeks) plus 36 months, 48 months, 60 months, 120 months, and lifetime. Costs were expressed in Taiwanese new dollars (NT$). Clinical outcomes, medical resource use, and utilities were extracted from published sources. Unit costs were estimated from BNHI fee schedules, published sources, and local expert opinion. Outcomes and future costs were discounted at 3%. Cost-effectiveness was expressed as cost per quality-adjusted life-month (QALM). The effects of uncertainty were explored through a one-way sensitivity analysis. RESULTS: For the 24-week time period, drug acquisition costs were higher for capecitabine than 5-FU/LV (NT$114,405 vs. NT$4,904 per patient); however, these were offset by the higher administration costs of 5-FU/LV (NT$2,573 vs. NT$204,201 per patient). Overall direct costs for the 24-week treatment period were less with capecitabine than 5-FU/LV (NT$129,327 vs. NT$233,873 per patient). Cost savings with capecitabine were also evident when longer time horizons were considered. Over a lifetime, the projected survival benefit for capecitabine was 7 QALMs. CONCLUSIONS: From the perspectives of the BNHI and society in Taiwan, capecitabine not only saves costs but also improves health outcomes compared with 5-FU/LV in the adjuvant treatment of stage III colon cancer.

Optimizing outcome of charles procedure for chronic lower extremity lymphoedema.

BACKGROUND: The Charles procedure for late-stage lower limb lymphoedema (LLL) is often criticized for its unpredictable and poor results. We have adopted a systematic approach to optimize outcome of patients treated with this excisional surgery. METHODS: From June 2004 to March 2009 we performed the Charles procedure on 1 lower limb of 19 women and 8 men with late-stage LLL. Mean age and follow-up was 48 (range, 16.5-77.8) years and 21.6 (range, 1.5-48) months, respectively. RESULTS: Average inpatient stay was 27 (range, 11-54) days. After discharge, 16 (59.3%) patients underwent further minor surgery. The most frequent complication was a single, short episode of cellulitis, affecting 5 (18.5%) patients. Self-reported mobility was either the same or improved at 6 months, and appearance of their limbs satisfactory. CONCLUSIONS: The Charles procedure is an effective treatment for selected patients and by applying our systematic approach, a positive outcome can be achieved.

Predictors for readmission of acute ischemic stroke in Taiwan.

BACKGROUND/PURPOSE: Hospital readmission rates are usually higher for stroke than for other chronic conditions. To prevent readmission, effective clinical services and accurate estimates of the absolute readmission rates are required. This study examined the patterns of care received by patients with ischemic stroke, estimated stroke readmission rates, and identified predictors related to readmission in Taiwan. METHODS: A retrospective analysis of the claims database of the Bureau of National Health Insurance in 2004-2007 was performed. This study included ischemic stroke patients who survived hospitalization and whose initial admission occurred in 2006. Time-dependent Cox regression models were developed separately to identify predictors of readmission within 1 month, 6 months, and 1 year after index discharge. RESULTS: We identified 1194 patients from the data set. At the initial stroke, the care provided was almost fully concordant with evidence-based practice guidelines, and the prevalence of antiplatelet therapy was 87.8%. The percentage of patients regularly taking antiplatelet agents within 1 month, 6 months, and 1 year after the index discharge was 65.0%, 18.8%, and 8.0%, respectively. The stroke readmission rates for survivors at 1 month, 6 months, and 1 year after the index discharge were 9.9%, 23.0%, and 30.7%, respectively. Older age, diabetes, longer length of stay for the index admission, and continuous use of antiplatelet agents less than 9 months after the index discharge were all predictors of readmission for acute ischemic stroke. CONCLUSION: Stroke readmissions are not related to receipt of less than optimum or below standard health care during index admission in Taiwan. Additional stroke readmissions in Taiwan might be avoided if more patients used antiplatelet agents for a longer period.

Factors Influencing the Use of Health Information Exchange by Physicians-Using the National Health Insurance PharmaCloud System in Taiwan.

This study aimed to investigate the factors influencing physicians use of the PharmaCloud system in Taiwan through Technology Continuance Theory (TCT) and to construct a TCT-based structured questionnaire to demonstrate the attitude and behavior of physicians in the Taiwanese medical system. It focused on investigating "confirmation", "perceived usefulness", "perceived ease of use", "attitude", "satisfaction", and "continuance intention" towards the preload-based comparison and manual search in PharmaCloud by attending physicians during their outpatient clinics. Path analysis was used to analyze the cause and effect relationship between variables. This study collected 528 valid questionnaires and the results of path analysis found that factors affecting physicians' continued use of preload-based comparison in PharmaCloud included "perceived usefulness", "satisfaction", and "attitude" (all p < 0.001); however, factors that influenced physicians' continued use of manual search in PharmaCloud were only "satisfaction" and "attitude" (all p < 0.001). Additionally, the effects of "perceived usefulness" and "perceived ease of use" on "satisfaction" could only be seen in preload-based comparison in PharmaCloud. In conclusion, when physicians' actual use of PharmaCloud met their expectations, physicians had higher levels of confirmation and better perceived usefulness, which naturally increased their satisfaction and attitude towards PharmaCloud and positively prompted them to continue using it.