Factors associated with nonadherence to surveillance for hepatocellular carcinoma among patients with hepatic C virus cirrhosis, 2000-2015.

Hepatocellular carcinoma (HCC) surveillance can detect the early stage of tumors and lead to improved survival. Adherence to guideline-concordant HCC surveillance is crucial in at-risk populations, including patients with hepatic C virus (HCV) cirrhosis. This study was conducted to identify patient and provider factors associated with nonadherence to HCC surveillance in patients with HCV cirrhosis. Data were primarily obtained from the Taiwan National Health Insurance Research Database for the 2000 to 2015 period. Adult patients newly diagnosed as having HCV cirrhosis between 2003 and 2012 were enrolled. Each patient was followed up for 3 years and until the end of 2015. Annual HCC surveillance was defined as the uptake of an abdominal ultrasound and alpha-fetoprotein (AFP) test annually during the 3-years follow-up. Nonannual surveillance was defined as the lack of an annual abdominal ultrasound and AFP test during the same 3-years period. Multinomial logistic regression models were applied to determine factors influencing adherence or nonadherence to annual HCC surveillance. We included a total of 4641 patients with HCV cirrhosis for analysis. Of these patients, only 14% adhered to annual HCC surveillance. HCC surveillance improved in later years, compared with the earlier phases of the study period. Patients with HCV cirrhosis comorbid with coronary artery disease (CAD) or chronic obstructive pulmonary disease (COPD) or those with a relatively high number of comorbidities had a significantly higher likelihood of nonadherence. Patients who primarily received care from internists were significantly less likely to exhibit nonadherence to annual HCC surveillance compared with patients receiving care from physicians of other specialties. Patients who primarily received care from physicians practicing in larger hospitals were significantly less likely to exhibit nonadherence. HCC surveillance rates remain unacceptably low among high-risk patients, and our findings may be helpful in the development of effective interventions to increase HCC surveillance. The effective incorporation of HCC surveillance into routine visits for other chronic comorbidities, particularly for CAD or COPD, may be crucial for increasing HCC surveillance.

Late hepatitis C virus diagnosis among patients with newly diagnosed hepatocellular carcinoma: a case-control study.

BACKGROUND: New direct-acting antiviral therapies have revolutionized hepatitis C virus (HCV) infection therapy. Nonetheless, once liver cirrhosis is established, the risk of hepatocellular carcinoma (HCC) still exists despite virus eradication. Late HCV diagnosis hinders timely access to HCV treatment. Thus, we determined trends and risk factors associated with late HCV among patients with a diagnosis of HCC in Taiwan. METHODS: We conducted a population-based unmatched case-control study. 2008-2018 Claims data were derived from the Taiwan National Health Insurance Research Database. Individuals with an initial occurrence of liver cancer between 2012 and 2018 were included. The late HCV group were referred as individuals who were diagnosed with HCC within 3 years after HCV diagnosis. The control group were referred as individuals who were diagnosed more than 3 years after the index date. We used multivariable logistic models to explore individual- and provider-level risk factors associated with a late HCV diagnosis. RESULTS: A decreasing trend was observed in the prevalence of late HCV-related HCC diagnosis between 2012 and 2018 in Taiwan. On an individual level, male, elderly patients, patients with diabetes mellitus (DM), and patients with alcohol-related disease had significantly higher risks of late HCV-related HCC diagnosis. On a provider level, patients who were mainly cared for by male physicians, internists and family medicine physicians had a significantly lower risk of late diagnosis. CONCLUSIONS: Elderly and patients who have DM and alcohol related disease should receive early HCV screening. In addition to comorbidities, physician factors also matter. HCV screening strategies shall take these higher risk patients and physician factors into consideration to avoid missing opportunities for early intervention.

Therapeutic effect of cataract surgery with simultaneous intravitreal injection of aflibercept on diabetic macular edema: An observational study.

This study aimed to investigate the therapeutic effect of cataract surgery along with simultaneous intravitreal injection (IVI) of aflibercept on diabetic macular edema (DME). This cohort study enrolled 106 patients aged >40 years with type 2 diabetes mellitus and DME who received cataract surgery from January 1, 2016, to October 31, 2020. The baseline and mean data of the following parameters were collected: age, sex, glycated hemoglobin level, diabetic retinopathy (DR) grading, previous DR treatments including IVI of anti-vascular endothelial growth factor and pan-retinal photocoagulation, intraocular pressure, use of intraocular pressure-lowering medication, central subfield thickness (CST), and log MAR visual acuity (VA). Patients were categorized into 2 groups based on whether they received aflibercept IVI or not during cataract surgery and were compared using the t test and Fisher exact test for continuous and discrete variables, respectively. Beta coefficient and standard error were calculated using multiple linear regression analysis to identify the explanatory variables predictive of the net change of CST and log MAR VA. There was no difference in the net change in CST (15.24 ± 45.07 µm vs 18.62 ± 33.84 µm, P = .772) and log MAR VA (-0.27 ± 0.29 vs -0.37 ± 0.31, P = .215). Gender, glycated hemoglobin level, aflibercept IVI during cataract surgery, and baseline CST did not interfere with the morphological and functional outcomes of DME in cataract surgery. Older age was significantly and independently associated with a greater net change in log MAR VA. Proliferative DR was significantly and independently associated with a greater net change in CST and log MAR VA. A greater baseline log MAR VA was significantly and independently associated with lower net change in log MAR VA. Simultaneous aflibercept IVI for treating DME may not interfere with the functional and tomographic parameters of cataract surgery relative to cataract surgery alone. Factors influencing the outcomes of patients with DME undergoing cataract surgery are as follows: age, baseline DR staging, and baseline VA. Identifying these factors of DME preoperatively may be an important consideration in preventing it from progressing and for improving the overall visual prognosis.

Factors associated with having home care physicians as an integrated source of medications for chronic conditions among homebound patients.

BACKGROUND: Inappropriate management of medications is a major threat to homebound patients with chronic conditions. Despite many efforts in improving medication reconciliation in ambulatory and inpatient settings, little research has focused on home care settings. In 2016, Taiwan initiated the Integrated Home Health Care programme, which was intended to reduce potentially inappropriate medication management and risks of uncontrolled polypharmacy through the integration of different medication sources for chronic conditions among homebound patients. This study investigated factors associated with having home care physicians as an integrated source of medications for chronic conditions among homebound patients. METHOD: This retrospective cohort study enrolled 3142 community-dwelling homebound patients from Taipei City Hospital. Homebound patients' adherence to using home care physicians as an integrated source of chronic condition medications was defined as having all prescriptions for their chronic conditions prescribed by a single home care physician for at least 6 months. Both patient and home care physician characteristics were analysed. Multivariable logistic regression was applied. RESULTS: Of the 3142 patients with chronic conditions, 1002 (31.9%) had consistently obtained all medications for their chronic illnesses from their home care physicians for 6 months and 2140 (68.1%) had not. The most common chronic diseases among homebound patients were hypertension, diabetes mellitus, dementia, cerebrovascular disease and constipation. Oldest-old patients with poor functional status, fewer daily medications, no co-payment exemption and no recent inpatient experience were more likely to adhere to this medication integration system. In addition, patients whose outpatient physicians were also their home care physicians were more likely to adhere to the system. CONCLUSIONS: The finding suggests that building trust and enhancing communication among homebound patients, caregivers and home care physicians are critical. Patient and provider variations highlight the need for further improvement and policy modification for medication reconciliation and management in home care settings. The improvement in medication management and care integration in home care settings may reduce misuse and polypharmacy and improve homebound patients' safety.

Comparison of intuitive assessment and palliative care screening tool in the early identification of patients needing palliative care.

The intuitive assessment of palliative care (PC) needs and Palliative Care Screening Tool (PCST) are the assessment tools used in the early detection of patients requiring PC. However, the comparison of their prognostic accuracies has not been extensively studied. This cohort study aimed to compare the validity of intuitive assessment and PCST in terms of recognizing patients nearing end-of-life (EOL) and those appropriate for PC. All adult patients admitted to Taipei City Hospital from 2016 through 2019 were included in this prospective study. We used both the intuitive assessment of PC and PCST to predict patients' 6-month mortality and identified those appropriate for PC. The c-statistic value was calculated to indicate the predictive accuracies of the intuition and PCST. Of 111,483 patients, 4.5% needed PC by the healthcare workers' intuitive assessment, and 6.7% had a PCST score ≥ 4. After controlling for other covariates, a positive response 'yes' to intuitive assessment of PC needs [adjusted odds ratio (AOR) = 9.89; 95% confidence interval (CI) 914-10.71] and a PCST score ≥ 4 (AOR = 6.59; 95%CI 6.17-7.00) were the independent predictors of 6-month mortality. Kappa statistics showed moderate concordance between intuitive assessment and PCST in predicting patients' 6-month mortality (k = 0.49). The c-statistic values of the PCST at recognizing patients' 6-month mortality was significantly higher than intuition (0.723 vs. 0.679; p < 0.001). As early identification of patients in need of PC could improve the quality of EOL care, our results suggest that it is imperative to screen patients' palliative needs by using a highly accurate screening tool of PCST.

Association of Visual Impairment with Psychological Distress in Older Adults: A Survey of 105,092 Older People in Taiwan.

This study aimed to evaluate the association between visual impairment (VI) and psychological distress (PD) among older adults in Taiwan. The present cohort study included participants aged >65 years who participated in a physical examination program. Participants were divided into two groups on the basis of whether they had PD at baseline. The association between PD and VI with other variables was compared using the two-sample t-test for continuous variables and chi-squared test for discrete variables. Cox regression analyses were used to calculate the hazard ratio (HR). Cumulative incidence of PD was analyzed using the Kaplan-Meier method, and differences among participants with different severities of VI were analyzed using the two-tailed log-rank test. Subgroup analyses were performed to calculate the HR for PD among participants with different severities of VI. The PD group showed a significantly high percentage of VI. In addition, participants with VI showed a significantly higher HR and seven-year cumulative incidence rate of PD than those without VI. VI was independently and significantly associated with a higher incidence of PD among older Asian people. Therefore, identifying and treating correctible VI is important to prevent PD and improve the overall quality of life.

Utilization of Palliative Care Screening Tool to Early Identify Patients with COVID-19 Needing Palliative Care: A Cohort Study.

There are very few programs that identify patients with coronavirus disease 2019 (COVID-19) who need palliative care. This cohort study presents a model to use a validated palliative care screening tool (PCST) to systematically identify hospitalized patients with COVID-19 in need of palliative care. In this prospective study, we consecutively recruited patients with COVID-19 admitted to Taipei City Hospital between 1 January and 30 July 2021. Patients' palliative care needs were determined by using the PCST. Advance care planning (ACP) and advance directives (AD) were systemically provided for all patients with a PCST score ≥ 4. Of 897 patients, 6.1% had a PCST score ≥ 4. During the follow-up period, 106 patients died: 75 (8.9%) with a PCST score < 4 and 31 (56.4%) with a PCST score ≥ 4. The incidence of mortality was 2.08 and 0.58/100 person-days in patients with PCST scores ≥ 4 and <4, respectively. After controlling for other covariates, a PCST score ≥ 4 was associated with a higher risk of mortality in patients with COVID-19 (adjusted HR = 2.08; 95% CI: 1.22-3.54; p < 0.001). During hospitalization, 55 patients completed an ACP discussion with their physicians, which led to 15 of them completing the AD. Since hospitalized patients with COVID-19 had a high mortality rate, it is imperative to implement a comprehensive palliative care program to early identify patients needing palliative care and promotion of AD and ACP.

Early palliative care: the surprise question and the palliative care screening tool-better together.

OBJECTIVE: The 'surprise question' (SQ) and the palliative care screening tool (PCST) are the common assessment tools in the early identification of patients requiring palliative care. However, the comparison of their prognostic accuracies has not been extensively studied. This study aimed to compare the prognostic accuracy of SQ and PCST in terms of recognising patients nearing end of life (EOL) and those appropriate for palliative care. METHODS: This prospective study used both the SQ and PCST to predict patients' 12-month mortality and identified those appropriate for palliative care. All adult patients admitted to Taipei City Hospital in 2015 were included in this cohort study. The c-statistic value was calculated to indicate the predictive accuracies of the SQ and PCST. RESULTS: Out of 21 109 patients, with a mean age of 62.8 years, 12.4% and 11.1% had a SQ response of 'no' and a PCST score of ≥4, respectively. After controlling for other covariates, an SQ response of 'no' and a PCST score of ≥4 were the independent predictors of 12-month mortality. The c-statistic values of the SQ and PCST at recognising patients in their last year of life were 0.680 and 0.689, respectively. When using a combination of both SQ and PCST in predicting patients' 12-month mortality risk, the predictive value of the c-statistic increased to 0.739 and was significantly higher than either one in isolation (p<0.001). CONCLUSION: A combination of the SQ with PCST has better prognostic accuracy than either one in isolation.

Association of visual impairment with cognitive decline among older adults in Taiwan.

This study investigated the association between visual impairment and cognitive decline among the elderly in Taiwan. The data were obtained from a government-sponsored, annual physical examination program for elderly citizens ≥ 65 years in Taipei City during 2005-2012. Distance presenting visual acuity was measured using the Snellen chart. Visual impairment was classified into low vision and blindness. The Short Portable Mental Status Questionnaire (SPMSQ) was selected to measure cognitive decline. The confounding factors including age, sex, sociodemographic factors: living status, marital status, education level, health behaviors: smoking, alcohol consumption, betel nut chewing, and physical comorbidities: BMI, hypertension, diabetes, cholesterol and triglyceride were collected for analysis. We recruited 105,208 participants and 4542 (4.3%) have abnormal SPMSQ. The abnormal SPMSQ had significantly higher prevalence of low vision (44.52% vs 18.79%) and blindness (8.89% vs 0.93%) compared with normal SPMSQ. The hazard ratios of abnormal SPMSQ in low vision and blindness were 2.34 (95% CI 2.17-2.52), and 5.13 (95% CI 4.50-5.85), after adjustment for confounders. In conclusion, visual impairment was independently and significantly associated with greater incident cognitive decline among elderly Asian people. Prevention of visual impairment may help to reduce the incidence of cognitive decline in the aged Asian population.

Association between obesity and education level among the elderly in Taipei, Taiwan between 2013 and 2015: a cross-sectional study.

The inverse association between obesity and education level has been demonstrated in many developed countries; however, few studies have investigated obesity in geriatric populations. This cross-sectional analysis explored the association between geriatric obesity and education level, along with other demographic characteristics in Taipei, Taiwan between 2013 and 2015. Taipei citizens ≥ 65 years (aborigines ≥ 55 years) were recruited to participate in the elderly health examination programme. Logistic regression was applied to analyse the relationship between obesity (defined as body mass index ≥ 27 kg/m2 in Taiwan) and education level among men and women after controlling for age, race, income status, and smoking status. A total of 28,092 men and 31,835 women were included in the final analysis. Compared to those with education years ≥ 16, older men and women with education years ≤ 12 had higher odds of being obese. The odds ratios increase as years of education decrease, and the trend is more pronounced among women. Aborigines had much higher chances of being obese among men and women, while there were no differences by income status. The results clarified the factors related to obesity in the elderly, and will be useful for authorities working to improve health outcomes among this population.

Can we treat bladder cancer with intravesical Bacillus Calmette-Guerin in patients with prior tuberculosis infection? A population-based cohort study.

BACKGROUND: Intravesical bacillus Calmette-Guerin (BCG) therapy is the treatment of choice for patients with T1 or high-grade superficial bladder cancer or those with carcinoma in situ after transurethral resection. A personal history of tuberculosis infection has been viewed as a relative contraindication for BCG therapy, because it may increase the risk of complications or decrease the treatment effectiveness. We determined the safety and efficacy of intravesical BCG treatment for patients with prior tuberculosis infection by analyzing the data obtained from the National Health Insurance Research Database in Taiwan. METHODS: We included patients who were newly diagnosed with bladder cancer from 2000 to 2009 and who received adjuvant intravesical BCG therapy within 3 months after the surgery. We excluded those who developed upper urinary tract cancer during the study period. Disease recurrence, disease progression, and major adverse effects were compared between patients with and without a prior diagnosis of tuberculosis infection until December 31, 2011. RESULTS: Among the 3915 patients included, 187 (4.8%) had been previously diagnosed with tuberculosis infection. The proportion of men (84.0% versus 76.9%) and older patients was higher in the group with a prior tuberculosis infection than in those without a prior tuberculosis infection. Significant differences in disease recurrence (20.3% versus 22.8%; hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.63-1.21, p = 0.404) or disease progression (10.2% versus 12.8%, HR, 0.74; 95% CI, 0.46-1.17, p = 0.191) were not observed between the two groups. None of the patients with a prior tuberculosis infection had severe urinary tract infections, whereas four (0.1%) patients without such an infection developed severe urinary tract infections. CONCLUSION: A prior tuberculosis infection did not affect the treatment efficacy or safety of intravesical BCG treatment. The efficacy and safety of intravesical BCG therapy are comparable between bladder cancer patients with and without prior tuberculosis infections.

Neurological Cancer is a Risk Factor for Bullous Pemphigoid: 11-Year Population-Based Cohort Study.

BACKGROUND: There is evidence suggesting an association between bullous pemphigoid (BP) and a range of neurological diseases. Whether neurological cancer is a risk factor for BP remains unknown. OBJECTIVE: The aim of the study was to investigate the risk of subsequent BP among patients with neurological cancer. METHODS: This nationwide population-based cohort study was based on data obtained from the Taiwan National Health Insurance Research Database between 2000 and 2012. A total of 8313 patients with neurological cancer and 33,252 age-, sex-, and index-date-matched controls were recruited. The hazard ratio (HR) for subsequent BP in patients with neurological cancer was analyzed using a Cox model and Fine-Gray competing risk model, with mortality as the competing event. RESULTS: The incidence rates of BP per 100,000 person-years were 37.2 for patients with neurological cancer and 6.8 for controls. The crude incidence rate ratio was 5.49 (95% confidence interval [CI] 2.18-13.30). The mean time to occurrence of BP was 4.48 ± 3.40 years for patients with neurological cancer. Neurological cancer (HR 9.65, 95% CI 3.76-24.77 for the Cox model; HR 2.41, 95% CI 1.14-5.14 for the competing risk model), age per year (HR 1.10, 95% CI 1.05-1.15 for the Cox model; HR 1.06, 95% CI 1.02-1.09 for the competing risk model), and dementia (HR 6.31, 95% CI 2.49-15.99 for the Cox model; HR 7.50, 95% CI 2.84-19.85 for the competing risk model) significantly increased the risk of BP. CONCLUSIONS: Neurological cancer increased the risk for subsequent BP by 2.4-fold, with a relatively short gap of 4.5 years.

An Interventional Study for the Early Identification of Patients With Palliative Care Needs and the Promotion of Advance Care Planning and Advance Directives.

CONTEXT: Programs identifying patients needing palliative care and promoting advance care planning (ACP) are rare in Asia. OBJECTIVES: This interventional cohort study aimed to identify hospitalized patients with palliative care needs using a validated palliative care screening tool (PCST), examine the ability of the PCST to predict mortality, and explore effects of a pragmatic ACP program targeted by PCST on the utilization of life-sustaining treatment during the last three months of life. METHODS: In this prospective study, we used PCST to evaluate patients' palliative care needs between 2015 and 2016 and followed patients for three months. ACP with advance directives (ADs) was systematically offered to all patients with PCST score ≥4. RESULTS: Of 47,153 hospitalized patients, 10.4% had PCST score ≥4. During follow-up, 2121 individuals died within three months of palliative care screening: 1225 (25.0%) with PCST score ≥4 and 896 (2.1%) with PCST score <4. After controlling for covariates, PCST score ≥4 was significantly associated with a higher mortality within three months of screening (adjusted odds ratio [AOR] 6.86; 95% CI 6.16-7.63). Moreover, ACP consultation (AOR 0.78; 95% CI 0.66-0.92) and AD completion (AOR 0.49; 95% CI 0.36-0.65) were associated with a lower likelihood of receiving life-sustaining treatments during the last three months of life. CONCLUSION: We demonstrated the feasibility of implementing a comprehensive palliative care program to identify patients with palliative care needs and promote ACP and AD in Eastern Asia. ACP consultation and AD completion were associated with reduced utilization of life-sustaining treatments during the last three months of life.

Patient and provider factors associated with enrolment in the pre-end-stage renal disease pay-for-performance programme in Taiwan: a cross-sectional study.

OBJECTIVE: The incidence and prevalence of end-stage renal disease (ESRD) in Taiwan have been ranked the highest worldwide. Therefore, the National Health Insurance Administration has implemented the pre-ESRD pay-for-performance (P4P) programme since November 2006, which had significantly reduced the incidence of dialysis and all-cause mortality. This study aimed to identify the factors associated with the enrolment in the pre-ESRD P4P programme. DESIGN: Cross-sectional study. SETTING: The National Health Insurance research database 2007-2012 in Taiwan. PARTICIPANTS: Patients with prevalent pre-ESRD aged more than 18 years between January 2007 and December 2012 were enrolled. Patient demographics and hospital characteristics between P4P and non-P4P groups were compared. A logistic regression model was used to analyse the factors associated with P4P enrolment, and a generalised estimating equation was used to verify the results. PRIMARY OUTCOME MEASURE: Enrolment in the pre-ESRD P4P programme. RESULTS: In total, 82 991 patients were enrolled in the programme, with a 45.6% participation rate. Patients who were males (adjusted OR (AOR)=0.89, 95% CI=0.86 to 0.91) and employed (AOR=0.95, 95% CI=0.92 to 0.97) had a significantly lower probability to be enrolled in the programme. Older patients (66-75 years old, AOR=1.23, 95% CI=1.14 to 1.33) and those with higher Charlson Comorbidities Index (CCI 5+, AOR=4.01, 95% CI=3.55 to 4.53) tended to be enrolled in the programme, while those in the 76+ years age group were not (AOR=1.03, 95% CI=0.95 to 1.13). Hospitals located in the central (AOR=1.48, 95% CI=1.05 to 2.08) and Kao-Ping regions (AOR=1.62, 95% CI=1.18 to 2.22) also tended to enrol patients in the pre-ESRD P4P programme. Enrolment rates increased over time. CONCLUSION: Pre-ESRD patients of the female gender, greater age and more comorbidities were more likely to be enrolled in the pre-ESRD P4P programme. Healthcare providers and health authorities should focus attention on patients who are male, younger and with less comorbidities to improve the healthcare quality and equality for all pre-ESRD patients.

Factors associated with post-partum smoking relapse in Taiwan: A trial of Smoker's helpline.

OBJECTIVE: Many women quit smoking during pregnancy resume in postpartum period and difficult to prevent. No studies had focused on their psychosocial response in Taiwan. We analyzed data from a trial of Taiwan Smoker's Helpline (TSH) to determine factors associated with smoking relapse after delivery. MATERIALS AND METHODS: A prospective cohort was conducted at Taipei City Hospital during Sep. 2014 and Nov. 2015 period. We collected data by self-developed questionnaire combining theory of planned behavior (TPB), Fagerstrom test for nicotine dependence (FTND) and Edinburgh Postnatal Depression Scale (EPDS) from 68 women immediately after delivery, 2 months later and followed up until 6 months. Multivariable logistic models for relapse of smoking at the end of 3rd month and 6th month were created. RESULTS: At 6th month, 42.6% participants relapsed with odds lower among first parity (OR = 0.04, 95% CI = <0.01-0.54, p = 0.015), having quitting experience in past (OR = 0.09, 95% CI = 0.01-0.84, p = 0.019) and higher perceived behavior control (PBC) (OR = 0.99, 95% CI = 0.98-1.00, p = 0.035), but greater for those with longer smoking duration in past (OR = 1.29, 95% CI = 1.04-1.58, p = 0.018). CONCLUSION: Protective and precipitating factors to post-partum's smoking relapse were identified in our study.

The Risk of Mortality among Psoriatic Patients with Varying Severity: A Nationwide Population-Based Cohort Study in Taiwan.

Background: Previous studies showed conflicting results regarding the mortality risk in psoriasis patients with respect to disease severity and presence of psoriatic arthritis. This study aimed to determine the mortality risk in patients with mild and severe psoriasis and patients with psoriatic arthritis (PsA). Methods: A nationwide population-based cohort study was conducted based on data from the Taiwan National Health Insurance Research Database between 2002 and 2012. Incident psoriasis subjects were classified into two groups: psoriasis without arthritis and psoriasis with arthritis. Patients who had received systemic therapy and/or phototherapy were classified as having severe psoriasis; otherwise, patients were classified as having mild psoriasis. Control subjects without psoriasis were selected to match each psoriasis patient from the database within the same observational period. Cox proportional hazards analysis was used to compare the hazard ratio (HR) of time to death. Results: A total of 106,701 patients with psoriasis were included in this study. After controlling for demographics and comorbidities, psoriasis patients had a higher mortality risk compared with the control group (HR 1.41; 95% confidence interval (CI) 1.36 to 1.46). Compared with psoriasis alone, the mortality risk was not increased for PsA (HR = 1.01; 95% CI 0.93 to 1.10). Besides, severe psoriasis did not increase mortality risk compared with mild psoriasis (HR = 1.0; 95% CI 0.95 to 1.06). Conclusions: Patients with psoriasis had a higher mortality risk compared with control subjects, whereas psoriasis severity and presence of PsA had no impact on mortality risk in psoriasis patients.

Factors associated with advance directives completion among patients with advance care planning communication in Taipei, Taiwan.

BACKGROUND: Although advance directives (AD) have been implemented for years in western countries, the concept of AD is not promoted extensively in eastern countries. In this study we evaluate a program to systematically conduct advance care planning (ACP) communication for hospitalized patients in Taiwan and identify the factors associated with AD completion. METHODS: In this retrospective evaluation of a clinical ACP program, we identified adult patients with chronic life-limiting illness admitted to Taipei City Hospital between April 2015 and January 2016. Trained healthcare providers held an ACP meeting to discuss patients' preference regarding end-of-life care and AD completion. A multiple logistic regression was performed to determine the factors associated with the AD completion. RESULTS: A total of 2878 patients were determined to be eligible for ACP during the study, among which 1798 (62.5%) completed ACP and data was available for 1411 patients (49.1%). Of the 1411 patients who received ACP communication with complete data, the rate of AD completion was 82.6%. The overall mean (SD) age was 78.2 (14.4) years. Adjusting for other variables, AD completion was associated with patients aged ≥ 85 years [adjusted odds ratio (AOR) = 1.80, 95% CI 1.21-2.67], critical illness (AOR = 1.17, 95% CI 1.06-1.30), and social workers participating in ACP meetings (AOR = 1.74, 95% CI 1.24-2.45). CONCLUSION: The majority of inpatients with chronic life-limiting illness had ACP communication as part of this ACP program and over 80% completed an AD. Our study demonstrates the feasibility of implementing ACP discussion in East Asia and suggests that social workers may be an important component of ACP communication with patients.

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.

Sexual inequality in incident tuberculosis: a cohort study in Taiwan.

OBJECTIVE: Animal studies showed that male subjects had lower activity of immune response to infections than female subjects, which may increase the risk of the development of tuberculosis in male population. This study intended to investigate the risk of incident tuberculosis in male and female adults in Taiwan. DESIGN: This is a retrospective cohort study. SETTING: The present analyses used data of Taiwan National Health Interview Survey 2001, 2005 and 2009, National Register of Deaths Dataset, and National Health Insurance Research Database from 2000 to 2013. PARTICIPANTS: A total of 43 424 subjects with a mean age of 43.04 years were analysed. PRIMARY OUTCOME MEASURES: Incidence of tuberculosis. RESULTS: During 381 561 person-years of follow-up period, incident tuberculosis was recognised in 268 individuals. The incidence rates of tuberculosis were 97.56 and 43.24 per 100 000 person-years among male and female participants, respectively. Kaplan-Meier curves comparing male and female subjects showed statistical significance (log-rank test, P value<0.01). After adjusting for subjects' demographics and comorbidities, men showed increased risks of incident tuberculosis (adjusted HR, 1.68; 95% CI 1.21 to 2.34; P value<0.01) compared with women. On subgroup analysis, after stratifying by age, smoking and alcohol use, men had a higher risk of incident tuberculosis than women in all patient subgroups, except those who were current smokers. CONCLUSIONS: This study suggests that men had a higher risk of incident tuberculosis than women. Future tuberculosis control programmes should particularly target the male population.

Heavy alcohol consumption increases the risk of active tuberculosis in Taiwanese adults: a nation-wide population-based cohort study.

AIMS: To investigate the impact of alcohol exposure on tuberculosis (TB) development in Taiwanese adults. DESIGN: Participants from the Taiwan National Health Interview Survey. Alcohol consumption and other covariates were collected by in-person interviews at baseline. Incident cases of active TB were identified from the National Health Insurance database. A multivariable Cox regression model was used to estimate the association between alcohol consumption and active TB, with adjustment for age, sex, smoking, socio-economic status and other covariates. SETTING: Taiwan National Health Interview Survey. PARTICIPANTS: A total of 46 196 adult participants aged ≥ 18 years from three rounds (2001, 2005, 2009) of the Taiwan National Health Interview Survey. MEASUREMENTS: Alcohol consumption was classified into never, social, regular or heavy alcohol use. Heavy alcohol consumption was defined as intoxication at least once/week. FINDINGS: Of the 46 196 study subjects, 61.8, 24.2, 13.5 and 0.5% were classified as never, social, regular and heavy alcohol users, respectively. During the 398 443 person-years of follow-up, 279 (0.60%) subjects developed new-onset active TB. After adjusting for the subject demographics and comorbidities, heavy [hazard ratio (HR) = 5.27; 95% confidence interval (CI) = 2.51-11.09] and regular alcohol users (HR = 1.80; 95% CI = 1.32-2.45) had increased risks of incident TB compared to never users. Moreover, a positive trend between increasing levels of alcohol consumption and the risk of active TB was noted (P < 0.001). CONCLUSIONS: In Taiwan, heavy and regular alcohol consumption are associated with higher risks of active tuberculosis.