The impact of physician subspeciality on the quality of diabetes care for people living with HIV.

BACKGROUND: Management of comorbidities of people living with HIV (PLHIV) involves different care models, including providing diabetes care and HIV care by the same infectious diseases physician (IDP) ("consolidated care") or providing diabetes care by the physicians other than IDP ("shared care"). The impact of diabetes care model on PLHIV with diabetes mellitus (DM) has not been well-evaluated. METHODS: A nationwide cross-sectional sample in the Taiwan National Health Insurance Research Database was used to compare the performance rates of seven guideline-recommended tests provided by the different subspecialists. RESULTS: Of 523 PLHIV with DM, there were 54.88% (n = 287) in the consolidated care group and 45.12% (n = 236) in the shared care group. More patients in the consolidated care group received the tests of lipid profile (92.33% vs. 79.24%), creatinine (Cr) (93.73% vs. 78.39%), and alanine transaminase (ALT) (91.99% vs. 75.42%), but fewer received urine protein test (35.54% vs. 51.69%) and fundoscopic examination (8.01% vs. 33.90%). The two groups did not differ in the performance rates of serum fasting glucose and HbA1c. After controlling for demographic factors and diabetic severity, the consolidated group was less likely to miss the serum tests of lipid profile (odds ratio [OR]: 0.30), Cr (OR: 0.19), and ALT (OR: 0.23), but more often missed urine protein test (OR: 1.56) and fundoscopic examination (OR: 4.97). CONCLUSION: These findings suggest the need to focus on different process indicators of diabetes cares in different care models to enhance the diabetes care for PLHIV.

The moderator effect of retention in care on late presentation in HIV-infected patients.

The moderator effect of retention in care on late presenters in HIV patients has not been well evaluated. A nationwide cohort study focusing on HIV-infected patients with new engagement in care was conducted by using the Taiwan National Health Insurance Research Database. Retention in care was defined based on the healthcare utilization in the first year after engaging in HIV care. Then, the impact of late presentation, retention in care, and their interaction on the risk of subsequent hospitalizations due to opportunistic infections (OIs-hospitalizations) in the second year were examined. More than half (59.38%) of the total patients (n = 9112) were retained in care in the first year, 8.63% were late presenters, and 110 (1.21%) patients had subsequent hospitalization in the second year. Late presentation and non-retention were independent predictors of OIs-hospitalizations in the second year (OR: 2.58 and OR: 3.27, respectively) and the interaction between them was statistically significant (non-retention in care × late presentation, OR: 3.82). This study showed that retention in care in the first year is a moderator providing a stronger protective effect for late presenters than early presenters. Our findings call for policymakers to develop different strategies for early or late presenters.

Physician code creep after the initiation of outpatient volume control program and implications for appropriate ICD-10-CM coding.

BACKGROUND: Most studies on the physician code creep (i.e., changes in case mix record-keeping practices to improve reimbursement) have focused on episodes (inpatient hospitalizations or outpatient procedures). Little is known regarding changes in diagnostic coding practices for better reimbursement among a fixed cohort of patients with chronic diseases. METHODS: To examine whether physicians in tertiary medical centers changed their coding practices after the initiation of the Outpatient Volume Control Program (OVCP) in Taiwan, we conducted a retrospective observational study of four patient cohorts (two interventions and two controls) from January 2016 to September 2017 in Taiwan. The main outcomes were the number of outpatient visits with four coding practices: 1) OVCP monitoring code recorded as primary diagnosis; 2) OVCP monitoring code recorded as secondary diagnosis; 3) non-OVCP monitoring code recorded as primary diagnosis; 4) non-OVCP monitoring code recorded as secondary diagnosis. RESULTS: The percentage change of the number of visits with coding practice 1 between 2016Q1 and 2017Q3 was - 74% for patients with hypertension and - 73% with diabetes in tertiary medical centers and - 23% and - 17% in clinics, respectively. By contrast, the percentage changes of coding practice 3 were + 73% for patients with hypertension and + 46% for patients with diabetes in tertiary medical centers and - 19% and - 2% in clinics, respectively. CONCLUSIONS: Physician code creep occurred after the initiation of the OVCP. Education regarding appropriate outpatient coding for physicians will be relatively effective when proper coding is related to reimbursement.

Changes in drowning mortality rates and quality of reporting from 2004-2005 to 2014-2015: a comparative study of 61 countries.

BACKGROUND: This study assessed international variations in changes in drowning mortality rates and the quality of reporting specific information in death certificates over the past decade. METHODS: Drowning mortality data of 61 countries were extracted from the World Health Organization Mortality Database. We calculated the percentage change (PC) in age-standardized drowning mortality rates and percentage of drowning deaths reported with unspecified codes between 2004 and 2005 and 2014-2015. RESULTS: Of the 61 countries studied, 50 exhibited a reduction in drowning mortality rates from 2004 to 2005 to 2014-2015. Additionally, five countries-Lithuania, Moldova, Kyrgyzstan, Romania, and El Salvador-with a high mortality rate in 2004-2005 (> 40 deaths per 100,000) showed improvement (PC < - 32%). By contrast, four countries-South Africa, Guyana, Morocco, and Guatemala-exhibited a more than twofold increase in mortality rates. Regarding the quality of reporting, 34 countries exhibited a decrease in the percentage of unspecified codes. Additionally, three countries-Paraguay, Serbia, and Croatia-with moderate and high percentages of unspecified codes (> 40%) exhibited a marked reduction (PC < - 60%), whereas three countries-Malaysia, Belgium, and Nicaragua-exhibited a notable increase. CONCLUSIONS: Large international variations in the extent of changes in drowning mortality rates and the quality of reporting specific information on the death certificate were observed during the study period.

Using cluster analysis to identify phenotypes and validation of mortality in men with COPD.

PURPOSE: Cluster analysis has been proposed to examine phenotypic heterogeneity in chronic obstructive pulmonary disease (COPD). The aim of this study was to use cluster analysis to define COPD phenotypes and validate them by assessing their relationship with mortality. METHODS: Male subjects with COPD were recruited to identify and validate COPD phenotypes. Seven variables were assessed for their relevance to COPD, age, FEV(1) % predicted, BMI, history of severe exacerbations, mMRC, SpO(2), and Charlson index. COPD groups were identified by cluster analysis and validated prospectively against mortality during a 4-year follow-up. RESULTS: Analysis of 332 COPD subjects identified five clusters from cluster A to cluster E. Assessment of the predictive validity of these clusters of COPD showed that cluster E patients had higher all cause mortality (HR 18.3, p < 0.0001), and respiratory cause mortality (HR 21.5, p < 0.0001) than those in the other four groups. Cluster E patients also had higher all cause mortality (HR 14.3, p = 0.0002) and respiratory cause mortality (HR 10.1, p = 0.0013) than patients in cluster D alone. CONCLUSION: COPD patient with severe airflow limitation, many symptoms, and a history of frequent severe exacerbations was a novel and distinct clinical phenotype predicting mortality in men with COPD.

Antioxidant and antiaging effect of traditional Thai rejuvenation medicines in Caenorhabditis elegans.

OBJECTIVE: This study explored the rejuvenation mechanisms of Thai polyherbal medicines using different approaches, including in vitro methods, as well as a well-defined nematode model, Caenorhabditis elegans. METHODS: THP-R-SR012 decoction was selected from 23 polyherbal medicines, based on metal-chelating and chain-breaking antioxidant capacities. The influences of this extract on the survival and some stress biomarkers of C. elegans under paraquat-induced oxidative stress were evaluated. Furthermore, lifespan analysis and levels of lipofuscin accumulation were examined in senescent nematodes. The phytochemical profile of THP-R-SR012 was analyzed. RESULTS: Supplementation with THP-R-SR012 decoction significantly increased the mean lifespan and reduced the oxidative damage to C. elegans under oxidative stress conditions. Further, THP-R-SR012 supplementation slightly influenced the lifespan and the level of lipofuscin accumulation during adulthood. Antioxidant-related phytochemical constituents of THP-R-SR012 decoction were rutin, naringenin, 3,4-dihydroxybenzoic acid, gallic acid, glycyrrhizic acid, demethoxycurcumin and 18α-glycyrrhetinic acid. CONCLUSION: The antioxidant potential of THP-R-SR012 was due to its scavenging properties, its enhancement of antioxidant-related enzyme activities, and the presence of the antioxidant-related compound. These results support the traditional use of THP-R-SR012 decoction as a tonic for nourishing and strengthening the whole body.

An easy-to-implement approach for analyzing case-control and case-only studies assuming gene-environment independence and Hardy-Weinberg equilibrium.

The case-control study is a simple and an useful method to characterize the effect of a gene, the effect of an exposure, as well as the interaction between the two. The control-free case-only study is yet an even simpler design, if interest is centered on gene-environment interaction only. It requires the sometimes plausible assumption that the gene under study is independent of exposures among the non-diseased in the study populations. The Hardy-Weinberg equilibrium is also sometimes reasonable to assume. This paper presents an easy-to-implement approach for analyzing case-control and case-only studies under the above dual assumptions. The proposed approach, the 'conditional logistic regression with counterfactuals', offers the flexibility for complex modeling yet remains well within the reach to the practicing epidemiologists. When the dual assumptions are met, the conditional logistic regression with counterfactuals is unbiased and has the correct type I error rates. It also results in smaller variances and achieves higher powers as compared with using the conventional analysis (unconditional logistic regression).

Insulin and Metformin Control Cell Proliferation by Regulating TDG-Mediated DNA Demethylation in Liver and Breast Cancer Cells.

Type 2 diabetes mellitus (T2DM) is a frequent comorbidity of cancer. Hyperinsulinemia secondary to T2DM promotes cancer progression, whereas antidiabetic agents, such as metformin, have anticancer effects. However, the detailed mechanism for insulin and metformin-regulated cancer cell proliferation remains unclear. This study identified a mechanism by which insulin upregulated the expression of c-Myc, sterol regulatory element-binding protein 1 (SREBP1), and acetyl-coenzyme A (CoA) carboxylase 1 (ACC1), which are important regulators of lipogenesis and cell proliferation. Thymine DNA glycosylase (TDG), a DNA demethylase, was transactivated by c-Myc upon insulin treatment, thereby decreasing 5-carboxylcytosine (5caC) abundance in the SREBP1 promoter. On the other hand, metformin-activated AMP-activated protein kinase (AMPK) increased DNA methyltransferase 3A (DNMT3A) activity to increase 5-methylcytosine (5mC) abundance in the TDG promoter. This resulted in decreased TDG expression and enhanced 5caC abundance in the SREBP1 promoter. These findings demonstrate that c-Myc activates, whereas AMPK inhibits, TDG-mediated DNA demethylation of the SREBP1 promoter in insulin-promoted and metformin-suppressed cancer progression, respectively. This study indicates that TDG is an epigenetic-based therapeutic target for cancers associated with T2DM.

Health care utilization pattern prior to maltreatment among children under five years of age in Taiwan.

BACKGROUND: Several studies have hypothesized that the pattern of health care utilization among maltreated children differ from others without the experience. However, the conclusions have not been consistent. OBJECTIVE: The study aims to examine whether the pattern of health care utilization among children 0-5 years old with maltreatment different from their counterparts without maltreatment in Taiwan. SUBJECTS AND SETTING: All children born in 2007 in Taiwan. METHOD: This is a population-based and case-controlled study. Cases are children under five years of ago with maltreatment-related diagnosis in the claims data of the National Health Insurance in Taiwan during the 2007-2013 period. For each case, there were 10 birth date-matched controls. Exposure variables include the number of injury or non-injury-related outpatients, emergency department (ED) visits, and hospitalization. Multivariate models were employed, with adjustment for sex, urbanization level, and comorbidities of children. RESULTS: Of children born in 2007, 382 had maltreatment-related diagnosis during the age of 0-5. The adjusted odds ratio (aOR) for having two or more ED visits with or without injury-related diagnosis is 3.52 (95% CI 1.75-7.07) and 2.0-0 (95% CI 1.47-2.72), respectively. Children with maltreatment also had significantly higher number of hospitalization without injury-related diagnosis and aOR for those having two more hospitalizations stands at 2.47 (95% CI 1.59-3.83). CONCLUSIONS: Children with maltreatment when 0-5 years old had higher number of ED visits with injury-related diagnosis, as well as hospitalization without injury-related diagnosis. Recognition of the health care utilization is conducive to early identification of children with risk for maltreatment.

Changes in the number and causes of maternal deaths after the introduction of pregnancy checkbox on the death certificate in Taiwan.

OBJECTIVE: To examine changes in the number and causes of maternal deaths after the introduction of pregnancy checkbox on the death certificate in January 2014 in Taiwan. MATERIALS AND METHODS: We first used the cause-of-death (COD) mortality data for years 2010 through 2017 to examine the number of deaths by item of pregnancy checkbox. We then compared the distribution of the causes of maternal deaths before and after the introduction of pregnancy checkbox. RESULTS: Between 2014 and 2017, 111 women died, for whom the certifiers indicated the following in the pregnancy checkbox items: 2 (pregnant at the time of death; n = 10), 3 (died within 42 days after the termination of pregnancy; n = 64), and 4 (died between 43 days and 1 year after the termination of pregnancy; n = 37). However, in only 61 of the 111 deaths, the certifiers reported pregnancy or delivery-related diagnosis in the COD section of the death certificate-5 each for items 2 and 4 and 51 for item 3. The number of maternal deaths was 55 in 2010-2013; this number increased to 82 in 2014-2017. A decline in the percentage of maternal deaths from obstetric hemorrhage was noted from 38% (21/55) in 2010-2013 to 21% (17/82) in 2014-2017. CONCLUSION: The number of maternal deaths increased, and the distribution of causes of maternal deaths changed after the introduction of pregnancy checkbox. Additional studies are required to examine the possible misclassification of pregnancy-associated deaths indicated in the pregnancy checkbox.