Nationwide analysis of medical utilization in people with severe mental illness receiving home care case management.

AIM: This nationwide study investigated the change in medical utilization of psychiatric home care case management (CM). METHODS: This nationwide study enrolled patients receiving CM (N = 10,274) from January 1, 1999 to December 31, 2010, from Taiwan's National Health Insurance Research Database. Through a 2-year mirror-image comparison weighted by the contributed person-time for each subject, we evaluated changes in medical utilization. Furthermore, a case-crossover analysis was used to verify the independent effect of CM in changing medical utilization by adjusting the time-variant variables between the pre-2-year (within 2 years before receiving CM) and post-2-year (within years after receiving CM) periods. The same methodology was applied for the subsequent 2-year comparison to assess the maintenance effect. RESULTS: Of the 10,274 patients receiving CM, 69.7% had schizophrenia. The results showed a chronological trend for the intervention of CM. The adjusted mirror-image analysis revealed a significant decrement of psychiatric and involuntary admissions after the intervention, and the utilization shifted toward psychiatric outpatient service. The case-crossover analysis with the adjustment of time-variant covariates confirmed the independent effect of CM on the changes of medical utilization. The comparable effect persisted after the next 2 years of intervention. However, CM showed no impact on lowering the admission rate for comorbid physical illnesses after the intervention. CONCLUSIONS: The CM model can effectively reduce psychiatric hospitalization and involuntary admission frequency but has no effect on comorbid physical illnesses. Care models aimed at ameliorating physical problems in such patients are needed.

Hospice Exposure Is Associated With Lower Health Care Expenditures in Taiwanese Cancer Decedents' Last Year of Life: A Population-Based Retrospective Cohort Study.

CONTEXT: Evidence for the association of hospice exposure with lower health care expenditures at end of life (EOL) remains inconclusive and neglects EOL care being concentrated in patients' last few months. OBJECTIVE: The association between hospice exposure and health care expenditures in cancer patients' last one, three, six, and 12 months was evaluated. METHODS: In this population-based, retrospective cohort study, Taiwanese cancer decedents in 2001-2010 (N = 195,228) were matched 1:1, with proportions of matched hospice users reaching 87.8%, by a hospice-utilization propensity score. For each matched pair, exposure to hospice (time from hospice enrollment to death) was matched to equivalent periods for hospice nonusers before death. Hospice-care associations with health care expenditures were evaluated by hospice use/exposure interactions with multilevel linear regression modeling using generalized estimating equations. RESULTS: The unadjusted main effect showed lower total mean health care expenditures for hospice users than for hospice nonusers only in the last one and three months (rate ratio [95% CI]: 0.86 [0.81, 0.90] and 0.93 [0.89, 0.96], respectively). However, after accounting for exposure time, hospice care was significantly associated with lower health care expenditures at exposures of ≤30, ≤60, and ≤180 days for health care expenditures measured in the last one and three months, six months, and 12 months, respectively. Savings for patients with lengthy hospice stays were neutralized or even disappeared. CONCLUSION: Hospice care was associated with lower health care expenditures when it could actively intervene in EOL care. Hospice philosophy should be applied not only shortly before death but also throughout the dying trajectory to achieve maximum cost savings.

Escalating Health Care Expenditures in Cancer Decedents' Last Year of Life: A Decade of Evidence from a Retrospective Population-Based Cohort Study in Taiwan.

BACKGROUND: No population-based longitudinal studies on end-of-life (EOL) expenditures were found for cancer decedents. METHODS: This population-based, retrospective cohort study examined health care expenditures from 2001 to 2010 among 339,546 Taiwanese cancer decedents' last year of life. Individual patient-level data were linked from administrative datasets. Health care expenditures were converted from Taiwan dollars to U.S. dollars by health-specific purchasing power parity conversions to account for different health-purchasing powers. Associations of patient, physician, hospital, and regional factors with EOL care expenditures were evaluated by multilevel linear regression model by generalized estimating equation method. RESULTS: Mean annual EOL care expenditures for Taiwanese cancer decedents increased from 2000 to 2010 from U.S. $49,591 to U.S. $68,773, respectively, with one third of spending occurring in the patients' last month. Increased EOL care expenditures were associated with male gender, younger age, being married, diagnosed with hematological malignancies and cancers other than lung, gastric, and hepatic-pancreatic cancers, and dying within 7-24 months of diagnosis. Patients spent less at EOL when they had higher comorbidities and metastatic disease, died within 6 months of diagnosis, were under care of oncologists, gastroenterologists, and intensivists, and received care at a teaching hospital with more terminally ill cancer patients. Higher EOL care expenditures were associated with greater EOL care intensity at the primary hospital and regional levels. CONCLUSION: Taiwanese cancer decedents consumed considerable National Health Insurance disbursements at EOL, totaling more than was consumed in six developed non-U.S. countries surveyed in 2010. To slow increasing cost and improve EOL cancer care quality, interventions to ensure appropriate EOL care provision should target hospitals and clinicians less experienced in providing EOL care and those who tend to provide aggressive EOL care to high-risk patients. The Oncologist 2017;22:460-469Implications for Practice: Cancer-care costs are highest during the end-of-life (EOL) period for cancer decedents. This population-based study longitudinally examined EOL expenditures for cancer decedents. Mean annual EOL-care expenditures for Taiwanese cancer decedents increased from U.S. $49,591 to U.S. $68,773 from the year 2000 to 2010, with one third of spending in patients' last month and more than for six developed non-U.S. countries surveyed in 2010. To slow the increasing cost of EOL-cancer care, interventions should target hospitals/clinicians less experienced in providing EOL care, who tend to provide aggressive EOL care to high-risk patients, to avoid the physical suffering, emotional burden, and financial costs of aggressive EOL care.

Trend in and Correlates of Undergoing Radiotherapy in Taiwanese Cancer Patients' Last Month of Life.

CONTEXT: A significant proportion of cancer patients at end of life (EOL) undergo radiotherapy, but this evidence is not from nationwide population-based studies. OBJECTIVES: The aims of this population-based study were to investigate the trend in undergoing radiotherapy among Taiwanese cancer patients' last month of life (EOL radiotherapy) in 2001-2010 and to identify factors associated with EOL radiotherapy. METHODS: This was a population-based retrospective cohort study analyzing data from Taiwan's national death registry, cancer registry, and National Health Insurance claims for EOL radiotherapy using multilevel generalized linear mixed modeling. Participants were Taiwanese cancer patients (N = 339,546) who died in 2001-2010. RESULTS: Overall, 8.59% (7.97%-9.85%) of patients underwent EOL radiotherapy with a decreasing trend over time. Correlates of EOL radiotherapy included male gender, younger age, residing in less urbanized areas, diagnosis of lung cancer, metastatic disease, death within two years of diagnosis, and without comorbidities. Cancer patients were more likely to undergo EOL radiotherapy if they received primary care from medical oncologists and pediatricians, in a nonprofit, teaching hospital with a larger case volume of terminally ill cancer patients, and greater EOL care intensity. CONCLUSION: Approximately one-tenth of Taiwanese cancer patients underwent EOL radiotherapy with a decreasing trend over time. Undergoing EOL radiotherapy was associated with demographics, disease characteristics, physician specialty, and primary hospital's characteristics and EOL care practice patterns. Clinical and financial interventions should target hospitals/physicians that tend to aggressively treat at-risk cancer patients at EOL to carefully evaluate the appropriateness and effectiveness of using EOL radiotherapy.

Receipt of Life-Sustaining Treatments for Taiwanese Pediatric Patients Who Died of Cancer in 2001 to 2010: A Retrospective Cohort Study.

Aggressive life-sustaining treatments have the potential to be continued beyond benefit, but have seldom been systematically/nationally explored in pediatric cancer patients. Furthermore, factors predisposing children dying of cancer to receive life-sustaining treatments at end of life (EOL) have never been investigated in a population-based study. This population-based study explored determinants of receiving life-sustaining treatments in pediatric cancer patients' last month of life. For this retrospective cohort study, we used administrative data on 1603 Taiwanese pediatric cancer patients who died in 2001 to 2010. Individual patient-level data were linked with encrypted identification numbers from the National Register of Deaths Database, Cancer Registration System database, National Health Insurance claims datasets, and Database of Medical Care Institutions Status. Life-sustaining treatments included intensive care unit (ICU) care, cardiopulmonary resuscitation (CPR), and mechanical ventilation. Associations of patient, physician, hospital, and regional factors with receiving ICU care, CPR, and mechanical ventilation in the last month of life were evaluated by multilevel generalized linear mixed models. In their last month of life, 22.89%, 46.48%, and 61.45% of pediatric cancer patients received CPR, mechanical ventilation, and ICU care, respectively, with no significant decreasing trends from 2001 to 2010. Patients were more likely to receive all three identified life-sustaining treatments at EOL if they were diagnosed with a hematologic malignancy or a localized disease, died within 1 year of diagnosis, and received care from a pediatrician. Receipt of ICU care or mechanical ventilation increased with increasing EOL-care intensity of patients' primary hospital, whereas use of mechanical ventilation decreased with increasing quartile of hospice beds in the patients' primary hospital region. Taiwanese pediatric cancer patients received aggressive life-sustaining treatments in the month before death. Healthcare policies and interventions should aim to help pediatricians treating at-risk pediatric cancer patients and hospitals with a tendency to provide aggressive EOL treatments to avoid the expense of life-sustaining treatments when chance of recovery is remote and to devote resources to care that produces the greatest benefits for children, parents, and society.

Characteristics and Correlates of Increasing Use of Surgery in Taiwanese Cancer Patients' Last Month of Life, 2001-2010.

BACKGROUND/OBJECTIVES: Surgery offers the potential to relieve symptoms for patients with cancer at the end of life (EOL) but at significant physiological and economic costs. However, the characteristics and correlates of surgery in last month of life (EOL surgery) of patients with cancer have not been comprehensively explored. This population-based study characterized EOL surgery use and identified its correlates. METHODS: This retrospective cohort study examined administrative data among 339,546 Taiwanese cancer decedents, 2001 to 2010. We classified procedures according to their likely intent. RESULTS: Approximately 1 in 10 (11.44%, range: 11.08%-11.86%) patients underwent EOL surgery with an increasing utilization over time. The intention for EOL surgery was primarily palliative, followed by cancer-directed, nonmalignancy-directed, and diagnostic. EOL surgery for palliative intent increased whereas other intents decreased significantly over time. EOL surgery was more likely among those who were male, younger, and married; not diagnosed with hepatic-pancreatic or lung cancers; had no comorbidity or documented metastatic codes; and survived less than 1 year from diagnosis. The likelihood of EOL surgery use was higher for patients who received care in a teaching hospital with more acute care hospital beds and higher EOL care intensity. CONCLUSIONS: Rates of EOL surgery are lower in Taiwan than those reported in the United States. The increasing use of EOL surgery in Taiwan is primarily for palliative intent. Appropriateness of EOL surgery should be carefully evaluated to avoid underutilizing potentially beneficial, palliative-intent surgery and overutilizing cancer-directed and other surgical procedures, especially for physicians working in hospitals with abundant health care resources and a tendency to treat at-risk patients with cancer aggressively.

Increasing Receipt of High-Tech/High-Cost Imaging and Its Determinants in the Last Month of Taiwanese Patients With Metastatic Cancer, 2001-2010: A Retrospective Cohort Study.

One strategy for controlling the skyrocketing costs of cancer care may be to target high-tech/high-cost imaging at the end of life (EOL). This population-based study investigated receipt of high-tech/high-cost imaging and its determinants for Taiwanese patients with metastatic cancer in their last month of life.Individual patient-level data were linked with encrypted identification numbers from computerized administrative data in Taiwan, that is, the National Register of Deaths Database, Cancer Registration System database, and National Health Insurance claims datasets, Database of Medical Care Institutions Status, and national census statistics (population/household income). We identified receipt of computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and radionuclide bone scans (BSs) for 236,911 Taiwanese cancer decedents with metastatic disease, 2001 to 2010. Associations of patient, physician, hospital, and regional factors with receiving CT, MRI, and bone scan in the last month of life were evaluated by multilevel generalized linear-mixed models.Over one-third (average [range]: 36.11% [33.07%-37.31%]) of patients with metastatic cancer received at least 1 high-tech/high-cost imaging modality in their last month (usage rates for CT, MRI, PET, and BS were 31.05%, 5.81%, 0.25%, and 8.15%, respectively). In 2001 to 2010, trends of receipt increased for CT (27.96-32.22%), MRI (4.34-6.70%), and PET (0.00-0.62%), but decreased for BS (9.47-6.57%). Facilitative determinants with consistent trends for at least 2 high-tech/high-cost imaging modalities were male gender, younger age, married, rural residence, lung cancer diagnosis, dying within 1 to 2 years of diagnosis, not under medical oncology care, and receiving care at a teaching hospital with a larger volume of terminally ill cancer patients and greater EOL care intensity. Undergoing high-tech/high-cost imaging at EOL generally was not associated with regional characteristics, healthcare resources, and EOL care intensity.To more effectively use high-tech/high-cost imaging at EOL, clinical and financial interventions should target nonmedical oncologists/hematologists affiliated with teaching hospitals that tend to aggressively treat high volumes of terminally ill cancer patients, thereby avoiding unnecessary EOL care spending and transforming healthcare systems into affordable high-quality cancer care delivery systems.

Determinants of Hospital Death for Taiwanese Pediatric Cancer Decedents, 2001-2010.

CONTEXT: Factors influencing pediatric cancer patients' place of death may have evolved with advances in medical and hospice care since earlier studies were done. OBJECTIVES: To comprehensively analyze factors associated with hospital death in an unbiased population of pediatric cancer patients in Taiwan. METHODS: This was a retrospective cohort study using administrative data for 1603 Taiwanese pediatric cancer patients who died in 2001-2010. Place of death was hypothesized to be associated with 1) patient sociodemographics and disease characteristics, 2) primary physician's specialty, 3) characteristics and health care resources at both the hospital and regional levels, and 4) historical trends. RESULTS: Most Taiwanese pediatric cancer patients (87.4%) died in an acute care hospital. The probability of dying in hospital increased slightly over time, reaching significance only in 2009 (adjusted odds ratio [AOR], 95% CI: 2.84 [1.32-6.11]). Children were more likely to die in an acute care hospital if they resided in the most urbanized area, were diagnosed with leukemia or lymphoma (2.32 [1.39-3.87]), and received care from a pediatrician (1.58 [1.01-2.47]) in a nonprofit proprietary hospital (1.50 [1.01-2.24]) or large hospital, reaching significance for the third quartile (2.57 [1.28-5.18]) of acute care hospital beds. CONCLUSION: Taiwanese pediatric cancer patients predominantly died in an acute care hospital with a slightly increasing trend of shifting place of death from home to hospital. Propensity for hospital death was determined by residential urbanization level, diagnosis, primary physician's specialty, and the primary hospital's characteristics and health care resources. Clinical interventions and health policies should ensure that resources are allocated to allow pediatric cancer patients to die in the place they and their parents prefer to achieve a good death and promote their parents' bereavement adjustment.

Cancer incidence in people with affective disorder: nationwide cohort study in Taiwan, 1997-2010.

BACKGROUND: Cancer is a serious public health problem worldwide, and its relationship with affective disorders is not clear. Aims To investigate alcohol- and tobacco-related cancer risk among patients with affective disorders in a large Taiwanese cohort. METHOD: Records of newly admitted patients with affective disorders from January 1997 through December 2002 were retrieved from the Psychiatric Inpatient Medical Claims database in Taiwan. Cancers were stratified by site and grouped into tobacco- or alcohol-related cancers. Standardised incidence ratios (SIRs) were calculated to compare the risk of cancer between those with affective disorders and the general population. RESULTS: Some 10 207 patients with bipolar disorder and 9826 with major depression were included. The risk of cancer was higher in patients with major depression (SIR = 2.01, 95% CI 1.85-2.19) than in those with bipolar disorder (SIR 1.39, 95% CI 1.26-1.53). The elevated cancer risk among individuals ever admitted to hospital for affective disorders was more pronounced in tobacco- and/or alcohol-related cancers. CONCLUSIONS: Elevated cancer risk was found in patients who had received in-patient care for affective disorders. They require holistic approaches to lifestyle behaviours and associated cancer risks.

Pediatric end-of-life care for Taiwanese children who died as a result of cancer from 2001 through 2006.

PURPOSE: Patterns of aggressive end-of-life (EOL) care have not been extensively explored in a pediatric cancer population, especially outside Western countries. The purpose of this population-based study was to examine trends in aggressive pediatric EOL cancer care in Taiwan. METHODS: Retrospective cohort study that used administrative data among 1,208 pediatric cancer decedents from 2001 through 2006. RESULTS: Taiwanese pediatric cancer patients who died in 2001 through 2006 received aggressive EOL care. The majority of these patients in their last month of life continued to receive chemotherapy (52.5%), used intensive care (57.0%), underwent intubation (40.9%), underwent mechanical ventilation (48.2%), or spent greater than 14 days (69.5%) in hospital, and they died in an acute care hospital (78.8%). Of these pediatric cancer patients, one in four received cardiopulmonary resuscitation in the month before they died, and only 7.2% received hospice care. Among those who received hospice care, 21.8% started such care within the last 3 days of life. This pattern of aggressive EOL care did not change over the study period except for significantly decreased intubation in the last month of life. CONCLUSION: Continued chemotherapy and heavy use of life-sustaining treatments in the last month of life coupled with lack of hospice care to support Taiwanese pediatric cancer patients dying at home may lead to multiple unplanned health care encounters, prolonged hospitalization at EOL, and eventual death in an acute care hospital for the majority of these patients. Future research should design interventions that enable Taiwanese pediatric cancer patients to receive EOL care that best meets the individual or the parental needs and preferences.

Propensity for home death among Taiwanese cancer decedents in 2001-2006, determined by services received at end of life.

CONTEXT: The discrepancy between patients' preferred and actual place of death highlights the dilemma inherent in achieving their preferences for home death. Research on determinants of home death has been limited largely by focusing on individual-level factors and somewhat on health care resources at the primary hospital and regional levels. OBJECTIVES: To investigate factors associated with home death, specifically, services received by cancer patients at the end of life (EOL). METHODS: This was a retrospective cohort study using administrative data from 201,201 Taiwanese cancer decedents in the period 2001-2006. RESULTS: Rates of home death decreased significantly over time (from 35.67% to 32.39%). Dying at home was associated with patient demographics (gender, age, and marital status) and disease characteristics (cancer type, metastatic status, postdiagnosis survival time, and comorbidity level). Taiwanese cancer patients were less likely to die at home if they received care from a medical oncologist and in hospitals or regions with abundant health care resources. Furthermore, Taiwanese cancer patients were less likely to die at home if they used life-sustaining treatments (intensive care unit care, cardiopulmonary resuscitation, intubation, and mechanical ventilation) in the last month of life. However, multiple emergency room visits in the last month of life and receiving hospice care increased Taiwanese cancer patients' propensity to die at home. CONCLUSION: Despite the causal ambiguity in interpreting our research findings, they indicate that using life-sustaining treatments at EOL not only exacts a substantial toll from patients, family members, and society, but also decreases the likelihood of dying at home.

Balloon angioplasty versus surgical revision for thrombosed dialysis graft outlet stenosis after graft thrombectomy.

BACKGROUND: It is important to correct underlying graft outlet stenosis after thrombectomy of dialysis grafts. This study retrospectively reviewed patients who received dialysis graft thrombectomy at this institution to compare the effectiveness of 2 different methods. METHODS AND RESULTS: A total of 289 dialysis graft thrombectomy procedures performed during 2001-2003 were retrospectively reviewed. The results of 163 cases in balloon angioplasty group were compared with those of 129 patients who underwent outlet revision. Patient characteristics between the 2 groups were similar with regard to demographic characteristics and comorbidities (P > .05). The mean primary patency of balloon and revision groups are 7.23 +/- 7.38 and 8.35 +/- 9.53 (months), respectively. Survival curves for each group were calculated by Kaplan-Meier method. There was no difference between 2 groups regarding graft patency. CONCLUSIONS: The result of dialysis graft outlet balloon angioplasty was comparable to that of surgical revision. Considering the invasiveness, balloon angioplasty should be considered when treating thrombosed dialysis grafts.

Determinants of ICU care in the last month of life for Taiwanese cancer decedents, 2001 to 2006.

BACKGROUND: Use of the hospital ICU is rising rapidly for end-of-life care. The purpose of this population-based study was to determine the prevalence of ICU care in the last month of life of patients with cancer and the associations between ICU care and patient demographics, disease characteristics, physician specialty, hospital characteristics, and availability of health-care resources at the hospital and regional levels in Taiwan. METHODS: This retrospective cohort study used administrative data for 204,850 cancer decedents from 2001 to 2006. RESULTS: Rates of hospital ICU care in the last month of life did not change significantly from 2001 to 2006 (11.27%-12.71%). ICU use in the last month of life was more likely for single male patients aged < 65 years who had hematologic malignancies or esophageal cancer and more comorbidities or a nononcologist as primary-care physician. Patients with cancer were one-third less likely to use ICU care in their last month of life if they received care in a private hospital than if they were cared for in a public hospital. Patient propensity to receive ICU care in the last month of life was positively associated with increasing quartile of total hospital beds in their primary hospital's region. CONCLUSIONS: Slightly more than one-tenth of Taiwanese patients with cancer received ICU care in their last month of life. ICU use was strongly influenced by receiving care in hospitals and regions with abundant health-care resources. Resources should be devoted to ensure that ICU care at the end of life best meets patients' individual needs and interests.

Quality of end-of-life care between medical oncologists and other physician specialists for Taiwanese cancer decedents, 2001-2006.

BACKGROUND: Oncologists play a significant role in cancer care throughout the cancer trajectory and have traditionally emphasized underuse of procedures/treatments with well-established effectiveness as the source of poor care quality with little attention to overusing end-of-life (EOL) care. The purpose of this population-based study was to compare the quality of EOL care between medical oncologists and other physician specialists. METHODS: This retrospective cohort study compared indicators of poor quality EOL care by examining administrative data for 204,850 Taiwanese cancer decedents in 2001-2006. RESULTS: Taiwanese cancer patients whose primary physician was a medical oncologist were significantly more likely than patients of other physician specialists to receive chemotherapy and to spend >14 days in a hospital in the last month of life. However, they were significantly less likely than patients of other physician specialists to visit the emergency room (ER) more than once and to use intensive care unit (ICU) care, cardiopulmonary resuscitation (CPR), intubation, and mechanical ventilation in the last month of life. CONCLUSION: The quality of EOL cancer care in Taiwan varied significantly by physician specialty. Cancer decedents cared for by medical oncologists were more likely to receive chemotherapy and prolonged hospitalization but less likely to have multiple ER visits, ICU care, or undergo CPR, intubation, or mechanical ventilation in the last month of life than patients of other physician specialists.

A population-based study on the prevalence and determinants of cardiopulmonary resuscitation in the last month of life for Taiwanese cancer decedents, 2001-2006.

BACKGROUND: The success rate of cardiopulmonary resuscitation (CPR) for cancer patients following in-hospital cardiac arrest has remained poor over the last 3 decades, but little is known about determinants of undergoing CPR for these patients at the end of life. OBJECTIVE: To determine the prevalence of CPR for Taiwanese cancer patients in the last month of life and the association between their undergoing CPR and patient demographics, disease characteristics, physician specialty, hospital characteristics, and availability of healthcare resources at the hospital and regional levels. METHODS: This retrospective cohort study examined administrative data for a cohort of 204,850 cancer decedents in 2001-2006. RESULTS: Rates of CPR decreased substantially over the study period, from 13.18% to 8.63%, and the adjusted odds ratio of undergoing CPR decreased significantly by a factor of 0.93 for each successive year. Taiwanese cancer patients were predisposed to undergo CPR in their last month of life if they were male, young, and unmarried (except for widowhood); had high comorbidity; had certain cancers (hematological malignancies, head and neck, esophageal, and prostate cancers); had a localized or newly diagnosed (within 1-2 months of death) cancer; had a non-oncologist as their primary physician; and received care at a non-teaching hospital. CONCLUSION: One-tenth of Taiwanese cancer patients underwent CPR in the last month of life, and the rates of CPR decreased substantially from 2001 to 2006. The propensity for CPR was influenced by patient demographics, disease characteristics, physician specialty, and teaching status of the patient's primary hospital.

Determinants of aggressive end-of-life care for Taiwanese cancer decedents, 2001 to 2006.

PURPOSE: To assess the association between aggressiveness of end-of-life (EOL) care and patient demographics, disease characteristics, primary physician's specialty, hospital characteristics, and availability of health care resources at the hospital and regional levels in Taiwan for a cohort of 210,976 cancer decedents in 2001 to 2006. METHODS: This retrospective cohort study examined administrative data. Aggressiveness of EOL care was examined by a composite measure adapted from Earle et al. Scores range from 0 to 6, with higher scores indicating more aggressive EOL care. RESULTS: The mean composite score for aggressiveness of EOL care was 2.04 (mean) +/- 1.26 (standard deviation), increasing from 1.96 +/- 1.26 in 2001 to 2.10 +/- 1.26 in 2006. Each successive year of death significantly increased the composite score. Cancer decedents received more aggressive EOL care if they were male, younger, single, had a higher level of comorbidity, had more malignant and extensive diseases or hematologic malignancies, were cared for by oncologists, and received care in a hospital with a greater density of beds. CONCLUSION: Controlling for patient demographics and cormorbidity burden, EOL care in Taiwan was more aggressive for patients with cancer with highly malignant and extensive diseases, for patients with oncologists as primary care providers, or in hospitals with abundant health care resources. Health policies should aim to ensure that all patients receive treatments that best meet their individual needs and interests and that resources are devoted to care that produces the greatest health benefits.

Patency rates of cuffed and noncuffed extended polytetrafluoroethylene grafts in dialysis access: a prospective, randomized study.

BACKGROUND: Although autogenous arteriovenous fistulae are the optimal route for dialysis access, extended polytetrafluoroethylene (ePTFE) grafts continue to be the preferred access for patients without suitable superficial veins. Among the common complications related to dialysis grafts, thrombosis due to graft outlet stenosis is the most frequently encountered clinical problem. A cuffed graft was designed to eliminate the outflow turbulence to reduce outlet stenosis and to enhance the clinical patency of ePTFE grafts. We conducted a prospective, randomized study to compare the clinical outcomes of cuffed ePTFE grafts and noncuffed grafts in dialysis access. METHODS: Between November 2004 and October 2005, 89 ePTFE grafts were implanted for hemodialysis access in the upper extremities of end-stage renal patients. Graft selection was randomized, with patients receiving a cuffed graft (Venaflo) or a regular noncuffed graft (Stretch Gore-Tex). All patients were monitored for signs of thrombosis or other complications. Primary and secondary graft patency was analyzed by using a life-table analysis, and the log-rank test was applied to compare graft patencies. RESULTS: Demographic data for both groups were similar without statistical difference. The primary patency rates and secondary patency rates at 12 months after implantation were 56% and 91% for cuffed grafts, and 41% and 78% for noncuffed grafts, respectively. The cuffed group outperforms the noncuffed group regarding primary and secondary patencies statistically. However, the incidence of other complications that required further surgery was similar in both groups. CONCLUSIONS: This investigation revealed that the cuffed ePTFE graft, which was designed to decrease graft outlet stenosis, may enhance the clinical patency rates of dialysis grafts.

Endovascular treatment of iatrogenic iliac artery disruption in lumbar disc surgery.

Major vessel (aorta or iliac vessels) injury is a rare yet catastrophic complication of spinal surgery. Prompt diagnosis is vital for effectively treating these injuries. A 56-year-old female with iliac artery iatrogenic injury during lumbar discectomy was successfully treated by percutaneous placement of a self-expanding stent graft in an emergent setting in an angiography suite. Postprocedural angiogram demonstrated complete exclusion of the pseudoaneurysm without contrast agent leakage. Endovascular treatment is suggested as an excellent alternative to open surgery for iatrogenic great vessel injuries, particularly in critical conditions.

Surgical thrombectomy for thrombosed dialysis grafts: comparison of adjunctive treatments.

BACKGROUND: Vascular surgeons often encounter dialysis graft failure in hemodialysis patients during their daily practice. Despite advances in percutaneous treatment, there remains a role for surgical thrombectomy of thrombosed dialysis grafts. This study was designed to investigate the long-term outcome of dialysis graft thrombectomy and to examine the indications for and effectiveness of therapies adjuvant to Fogarty thrombectomy. METHODS: Surgical outcomes of 590 consecutive dialysis graft thrombectomies performed between 2001 and 2003 were retrospectively reviewed. The 590 cases were classified into four groups based on the procedure performed adjuvant to Fogarty thrombectomy: group A, surgical thrombectomy by Fogarty thrombectomy catheter alone; group B, thrombectomy plus intraoperative angioplasty of graft outlet; group C, thrombectomy plus sequential balloon angioplasty in subsequent intervention; group D, thrombectomy plus graft outlet surgical revision. Age, gender, co-morbidity, and primary patency of grafts were reviewed and analyzed. RESULT: The four groups exhibited similar demographic features and comorbidities (p>0.05). Mean primary patency in the four groups was 1.99+/-4.02, 7.21+/-7.61, 8.35+/-9.53, and 7.26+/-6.99 (months), respectively. Survival curves for each group were determined by Kaplan-Meier methods. Primary patency in group A was statistically inferior to all of the other three groups, whereas groups B, C, and D did not significantly differ with regard to graft patency. CONCLUSIONS: Surgical thrombectomy alone is inadequate for treating a thrombosed dialysis graft. The underlying graft outlet stricture requires direct surgical revision or balloon angioplasty during surgery or intervention in the angiography suite to ensure long-term patency of the graft.

Impact of cuffed, expanded polytetrafluoroethylene dialysis grafts on graft outlet stenosis.

BACKGROUND: The objective of this study was to determine prospectively the difference between the graft outlet strictures of a polytetrafluoroethylene (ePTFE) graft with a cuff at the graft-vein anastomosis (Venaflo; Bard industries, Tempe, Ariz.) and that of the regular ePTFE graft (Stretch Gore-Tex; Gore, Flagstaff, Ariz.) placed for hemodialysis access. METHODS: Between January and April 2005, 36 consecutive patients (average age: 63.3 years) underwent ePTFE graft implantation (36 implantations) for hemodialysis at the Vascular Surgery Section of Chang Gung Memorial Hospital. The patients of the study cohort were randomly assigned to two groups based on the graft used: cuffed graft group (Venaflo graft) and non-cuffed standard graft group (Gore-Tex graft). Each patient underwent antegrade venography at the 3-month follow-up to demonstrate the graft outlet stricture. Results of the graft outlet angiography analysis were examined, and all medical records were reviewed at end of the study. The degree of the graft outlet stenosis was compared between the two groups. RESULTS: Average stenosis of the cuffed graft group and non-cuffed (standard) graft group were 22.76 +/- 26.37%% and 44.95 +/- 27.48%%, respectively; the difference between the two groups was statistically significant (P < 0.05). CONCLUSIONS: The graft outlet stricture of cuffed ePTFE grafts for hemodialysis 3 months after implantation was less severe than that for the standard ePTFE graft. The correlation between the stricture level and dialysis graft patency requires further clarification.