Association of prostate cancer with human papillomavirus infections: a case-control study.

BACKGROUND: The highly oncogenic human papillomavirus (HPV) is associated with numerous cancer types. While the role of viruses in the development of certain cancers is well established, the association between HPV infections and prostate cancer remains a subject of ongoing debate. This study aimed to investigate a potential association of prostate cancer with HPV infections utilizing a case-control study. METHODS: We extracted data from the Taiwan Longitudinal Health Insurance Database 2010. We retrieved 5137 patients with prostate cancer as cases and a 3:1 ratio of propensity score-matched patients without prostate cancer (15,411 patients) as controls. Multiple logistic regression analyses were carried out to scrutinize the association of prostate cancer with HPV infections while taking into account age, monthly income category, geographic location and urbanization level of the patient's residence as well as hyperlipidemia, diabetes, hypertension and chronic prostatitis, tobacco use disorder, and alcohol abuse/alcohol dependence syndrome. RESULTS: The data indicate that out of all sampled patients, 1812 (8.8%) had a prior diagnosis of HPV infections before the index date. Among cases and matched controls, HPV infections were diagnosed in 743 (14.5%) and 1069 (6.9%) patients, respectively. The results from the chi-square test demonstrate that individuals with prostate cancer exhibited a significantly higher incidence rate of HPV infections than their control counterparts (p < 0.001). Furthermore, in comparison to controls, individuals with a history of HPV infections had an adjusted odds ratio of 2.321 (95% CI: 2.097~2.568) for developing prostate cancer. Notably, individuals diagnosed with chronic prostatitis were also more likely to be subsequently diagnosed with prostate cancer (adjusted odds ratio=1.586; 95% CI = 1.338~1.879), which aligns with expectations in this context. CONCLUSIONS: We found prostate cancer to be significantly associated with HPV infections, contributing to the mounting body of evidence indicating a plausible connection between the two.

Ten-year trends in the incidence of microtia: a nationwide population-based study from Taiwan.

PURPOSE: Few studies have explored population-based incidence rates of microtia using nationwide data. The aim of this study was to analyze the 10-year secular trends in the incidence of microtia and/or anotia in Taiwan from 2008 to 2017 using nationwide population-based data. METHODS: Patient data were retrieved from Taiwan's National Health Insurance Dataset, after identifying 1152 children aged ≤ 1 year with a first-time diagnosis of microtia or anotia between January 2008 and December 2017. The annual microtia-anotia incidence rate was the sum of new microtia-anotia cases in a year divided by total infant population in the year. Furthermore, we used the annual percent change (APC) to study the secular trend in microtia-anotia incidence rate. RESULTS: The annual incidence rate of microtia-anotia averaged across the 10-year period was 57.7 per 100,000 infants (standard deviation = 8.6). The annual incidence rates of microtia and anotia were 53.3 and 4.4 per 100,000 infants, respectively, during this period. Furthermore, female infants had a higher incidence than males (63.3 vs. 52.4 per 100,000). The incidence of microtia-anotia gradually decreased between 2008 and 2017 with an APC of - 5.64% (95% CI - 9.31 ~ - 1.18%, p = 0.004). Since 2011, females had a significantly higher annual incidence rate of microtia-anotia than males. CONCLUSIONS: The incidence of microtia-anotia was 57.7 per 100,000 infants in Taiwan, which declined during the study period 2008-2017. The female-to-male incidence ratio was 1.21:1.

Impact of Provider Competition under Global Budgeting on the Use of Cesarean Delivery.

OBJECTIVE: To examine the impact of provider competition under global budgeting on the use of cesarean delivery in Taiwan. DATA SOURCES/STUDY SETTING: (1) Quarterly inpatient claims data of all clinics and hospitals with birth-related expenses from 2000 to 2008; (2) file of health facilities' basic characteristics; and (3) regional quarterly point values (price conversion index) for clinics and hospitals, respectively, from the fourth quarter in 1999 to the third quarter in 2008, from the Statistics of the National Health Insurance Administration. STUDY DESIGN: Panel data of quarterly facility-level cesarean delivery rates with provider characteristics, birth volumes, and regional point values are analyzed with the fractional response model to examine the effect of external price changes on provider behavior in birth delivery services. PRINCIPAL FINDINGS: The decline in de facto prices of health services as a result of noncooperative competition under global budgeting is associated with an increase in cesarean delivery rates, with a high degree of response heterogeneity across different types of provider facilities. CONCLUSIONS: While global budgeting is an effective cost containment tool, intensified financial pressures may lead to unintended consequences of compromised quality due to a shift in provider practice in pursuit of financial rewards.

Correction: Routine Endoscopy for Esophageal Cancer Is Suggestive for Patients with Oral, Oropharyngeal and Hypopharyngeal Cancer.

[This corrects the article DOI: 10.1371/journal.pone.0072097.].

The effectiveness of preventive care at reducing curative care risk for the Taiwanese elderly under National Health Insurance.

Whether provision of free preventive care for the elderly under National Health Insurance has reduced the risk for curative care use raises much concern in Taiwan. This study analyzes the relationship by examining the impact of health examination utilization on the utilizations of outpatient care and inpatient care. Data come from the 2005 National Health Interview Survey and National Health Insurance Research Database. A two-stage method is used in the estimation. We found a negative relationship between the utilization of preventive care and hospitalization care in terms of length of stay and medical expenditures. On average, the elderly people who used preventive care tended to have 16 shorter hospitalization stays and NTD64,220 lower hospitalization expenditures than their counterparts. In order to improve the health of the elderly and reduce the escalation of medical expenditures due to aging, including preventive care in the health insurance is a very effective strategy.

Routine endoscopy for esophageal cancer is suggestive for patients with oral, oropharyngeal and hypopharyngeal cancer.

BACKGROUND: This study attempted to reveal the incidence and risk of synchronous and metachronous esophageal cancer in subjects with oral, oropharyngeal and hypopharyngeal cancer based on a population-wide database in Taiwan. METHODS: We retrieved data for this cross-sectional study from the Taiwanese Longitudinal Health Insurance Database 2000. The study group included 2,965 subjects who had received their first-time diagnosis of oral/oropharyngeal/hypopharyngeal cancer in 2002∼2009. We assigned the date of their first diagnosis of oral/oropharyngeal/hypopharyngeal cancer as the index date. We also randomly retrieved 29,650 comparison subjects matched with the study subjects in terms of gender and age group. We assigned their first medical utilization that occurred in the index year as the index date for the comparison group. We further performed a conditional logistic regression to investigate the association between esophageal cancer and oral cancer. RESULTS: Results showed that prevalences of esophageal cancer within 3 months before and after the index date were respectively 2.19% and 0.04% for the study and comparison groups. A conditional logistic regression revealed that the odds ratio (OR) of esophageal cancer for subjects with oral/oropharyngeal/hypopharyngeal cancer was 55.33 (95% confidence interval (CI): 29.86∼102.52) compared to comparison subjects. Furthermore, compared to comparison subjects, ORs for esophageal cancer were respectively 18.41 (95% CI: 8.50-39.85), 40.49 (95% CI: 15.11∼108.64), and 240.96 (95% CI: 125.49-462.69) for study subjects with a malignancy of the oral cavity, oropharynx, and hypopharynx. CONCLUSION: We concluded that there were relatively high chances for synchronous and metachronous esophageal cancers being detected through panendoscopy in patients with oral, oropharyngeal, and hypopharyngeal cancers. The routine use of panendoscopy in such patients should be encouraged with a higher priority.

The demand for preventive care services and its relationship with inpatient services.

OBJECTIVE: To examine not only the relationship between the utilization of preventive health care services and inpatient services, but to also investigate the factors affecting the utilization of such services by the middle-aged and elderly. METHOD: We use data obtained from the 2003 Survey of Health and Living Status of the Elderly in Taiwan (SHLSE), hypothesizing that preventive health care services can be regarded as an appropriate substitute for subsequent medical services such as inpatient services; a recursive simultaneous model is used to avoid the problems of endogeneity. RESULTS: The main results of this study indicate that the utilization of preventive health care services has the effect of reducing the probability of the utilization of inpatient services. CONCLUSION: The utilization of preventive care services can help to promote healthier lifestyles, provide early detection of illnesses, and reduce the need for subsequent inpatient care services amongst individuals. We suggest that effective outreach strategies to promote the utilization of preventive care services are essential.

Does high surgeon and hospital surgical volume raise the five-year survival rate for breast cancer? A population-based study.

This study sets out to examine the relationship between both surgeon and hospital volume and five-year survival rates for breast cancer patients. We performed Cox proportional hazard regressions on a pooled population-based database linking the Taiwan National Health Insurance Research Database with the 'cause of death' data file, covering the three-year period from January 1997 to December 1999. Of the 13,360 breast cancer resection patients in our study sample, the five-year survival rates, by surgeon volume, were 77.3% in the high-volume group (>201 cases), 76.9% in the medium-volume group (45-200), and 69.5% in the low-volume group (585 cases), 74.5% for medium-volume hospitals (259-585) and 72.1% for low-volume hospitals (

Taiwan's high rate of cesarean births: impacts of national health insurance and fetal gender preference.

BACKGROUND: Taiwan has a high rate of cesarean section, approximately 33 percent in the past decade. This study investigates and discusses 2 possible factors that may encourage the practice, one of which is fetal gender difference and the other is Taiwan's recently implemented National Health Insurance (NHI). METHODS: A logistic regression model was used with the 1989 and 1996 National Maternal and Infant Health Survey and with the 2001 to 2003 NHI Research Databases. RESULTS: Using survey data, we found a statistically significant 0.3 percent gender difference in parental choice for cesarean section. However, no statistically significant difference was found in the rate of cesarean section before and after NHI implementation. CONCLUSIONS: Taiwan's high cesarean section rate is not directly related to financial incentives under NHI, indicating that adjusting policy to lower financial incentives from NHI would have only limited effect. Likewise, focusing effort on the small gender difference is unlikely to have much impact. Effective campaigns by health authorities might be conducted to educate the general population about risks associated with cesarean section and the benefits of vaginal birth to the child, mother, and society.

The effect of Taiwan's National Health Insurance on infants' preventive care use and inpatient care use.

OBJECTIVE: To test whether utilization of infant preventive care services has reduced utilization of inpatient care and to determine whether implementation of Taiwan's National Health Insurance (NHI) has brought about any differences in the utilization of infant health care services. DATA SOURCES: Data were taken from the 1989 and 1996 National Maternal and Infant Health Surveys (NMIHSs). In total, 1662 and 3623 effective samples were used in the study from the 2 years. STUDY DESIGN: We constructed a simultaneous recursive model to obtain efficient estimates by treating preventive care (neonatal care and well-baby care) and inpatient care (hospitalization admissions) as dependent variables. PRINCIPAL FINDINGS: Utilization of neonatal care had strongly negative significant coefficients for the likelihood of being admitted to the hospital. The impact of the NHI was found to be significant. CONCLUSIONS: The hypothesis that the NHI interferes with the effectiveness of preventive care at reducing inpatient care use was not reinforced. Since support from the NHI depends on a balance of push and pull between access to inpatient care and the benefits of preventive care, it can further improve infant health by promoting the benefits of preventive care while making both types of care more accessible.

Impact of hospital and physician characteristics on medical expenditures for acute myocardial infarction hospitalization.

This study aims to examine the impact of length of stay, hospital characteristics, physician characteristics and other factors on the expenditures of hospitalization for acute myocardial infarction (AMI) under Taiwan's National Health Insurance program. This study uses data collected from the Taiwan's National Health Research Institute's 2001-2003 National Health Insurance Research Database. We estimated contributors to increased expenditures of hospitalization using three-stage least square regression model. The hospital expenditures for the treatment of AMI averaged NT$126,366 (US$3829, US$1=NT$33) per discharge, with the largest proportion (27%) spent on room expenditures. They were strongly impacted by length of stay, increasing around 4.8% per day. We conclude that hospital expenditures for the treatment of AMI patients may vary widely depending on the characteristics of the hospital and physicians that provide them care.

Physician and hospital characteristics related to length of stay for acute myocardial infarction patients: a 3-year population-based analysis.

BACKGROUND: The lack of studies on the simultaneous contributions of hospital and physician to the length of stay (LOS) for acute myocardial infarction (AMI) has hampered the development of hospital- and physician-level strategies by clinicians and policymakers. This study used 3 years of population-based data to examine the relationships of physician and hospital characteristics with LOS for AMI patients in Taiwan. METHODS AND RESULTS: Multiple regression analysis was carried out to explore the relationships, using the 2001-2003 National Health Insurance Research Database of the National Health Research Institute, Taiwan. The study samples were identified by a principal diagnosis of AMI (ICD-9-CM code 410), with a total of 19,907 eligible admissions. The mean LOS was 9.1 days. The results revealed that compared with district hospitals, the LOS was significantly longer in both medical centers and regional hospitals (both p<0.001). The LOS among patients attended by cardiologists was 28.0% shorter than those attended by physicians specializing in surgery, family medicine, or emergency medicine. CONCLUSIONS: The results of this study demonstrate that there are wide variations among the different types of physician and levels of hospital in the LOS for AMI patients, which highlights the importance of developing national treatment protocols for AMI in order to reduce variations in hospital and physician behaviors.

Household out-of-pocket medical expenditures and National Health Insurance in Taiwan: income and regional inequality.

BACKGROUND: Unequal geographical distribution of medical care resources and insufficient healthcare coverage have been two long-standing problems with Taiwan's public health system. The implementation of National Health Insurance (NHI) attempted to mitigate the inequality in health care use. This study examines the degree to which Taiwan's National Health Insurance (NHI) has reduced out-of-pocket medical expenditures in households in different regions and varying levels of income. METHODS: Data used in this study were drawn from the 1994 and 1996 Surveys of Family Income and Expenditure. We pooled the data from 1994 and 1996 and included a year dummy variable (NHI), equal to 1 if the household data came from 1996 in order to assess the impact of NHI on household out-of-pocket medical care expenditures shortly after its implementation in 1995. RESULTS: An individual who was older, female, married, unemployed, better educated, richer, head of a larger family household, or living in the central and eastern areas was more likely to have greater household out-of-pocket medical expenditures. NHI was found to have effectively reduced household out-of-pocket medical expenditures by 23.08%, particularly for more affluent households. With the implementation of NHI, lower and middle income quintiles had smaller decreases in out-of-pocket medical expenditure. NHI was also found to have reduced household out-of-pocket medical expenditures more for households in eastern Taiwan. CONCLUSION: Although NHI was established to create free medical care for all, further effort is needed to reduce the medical costs for certain disadvantaged groups, particularly the poor and aborigines, if equality is to be achieved.

The effect of Taiwan's tax-induced increases in cigarette prices on brand-switching and the consumption of cigarettes.

The effect of raising cigarette taxes to reduce smoking has been the subject of several studies, which often treat the price of cigarettes as an exogenous factor given to smokers who respond to it by adjusting their smoking behavior. However, cigarette prices vary with brand and quality, and smokers can and do switch to lower-priced brands to reduce the impact of the tax on the cost of cigarettes as they try to consume the same number of cigarettes as they had before a tax hike. Using data from a two-year follow-up interview survey conducted before and after a new cigarette tax scheme was imposed in Taiwan in 2002, this study examines three behavioral changes smokers may make to respond to tax-induced cigarette price increase: brand-switching, amount consumed, and amount spent on smoking. These changes were studied in relation to smoker income, before-tax cigarette price, level of addiction, exposure to advertizing, and consumer loyalty. We found that smokers, depending upon exposure to advertizing, level of consumer loyalty and initial price of cigarettes, switched brands to maintain current smoking habits and control costs. We also found that the initial amount smoked and level of addiction, not price, at least not at the current levels in Taiwan, determined whether a smoker reduced the number of cigarettes he consumed.

The Taiwan National Health Insurance program and full infant immunization coverage.

OBJECTIVES: We compared hospital-born infants and well-baby care use associated with complete immunizations in Taiwan before and after institution of National Health Insurance (NHI). METHODS: We used logistic regression to analyze data from 1989 and 1996 National Maternal and Infant Health Surveys of 1398 and 3185 1-year-old infants, respectively. RESULTS: Infants born in hospitals were found to receive fewer immunizations than those born elsewhere before NHI but significantly more after NHI. Use of well-baby care correlates strongly and positively with the probability that a child will receive a full course of immunization after NHI. CONCLUSIONS: The NHI policy of including hospitals as immunization providers facilitates access to immunization services for children born in those facilities. Through NHI provision of free well-baby care, health planners have stimulated the demand for immunization.

The role of Taiwan's National Health Insurance program in influencing adequate prenatal care.

This paper reviews achievements in the utilization of prenatal care by pregnant women in Taiwan by analysing the 1989 and 1996 National Maternal and Infant Health Survey data. More precisely, it identifies and examines the programmatic and non-programmatic factors that influence prenatal care utilization, thus determining the areas that require further attention from the programe. Logistic regression results show that the adequacy of prenatal care use was significantly associated with the implementation of the National Health Insurance (NHI). A higher likelihood of adequate care utilization was found among women who were married or employed, had a higher level of education, had more experience with regard to pregnancy and were at higher risk in terms of obstetrics. The effect of facility choice showed variations after the implementation of the NHI programme. Prior to NHI, no differences were noted between the use of clinics and hospitals. After the implementation of NHI, on the other hand, women who received most of their care from clinics had a higher likelihood of receiving more adequate prenatal care than those who received care from hospitals. Regional differences in seeking adequate prenatal care were also evident. Mothers who were living in southern areas were less likely to receive adequate prenatal care despite the implementation of NHI. The Bureau of NHI, therefore, still needs to work on mechanisms to ensure that more attention is given to the distribution of its medical resources and that additional health care accessibility is provided to pregnant women in these areas.

National Health Insurance and the antenatal care use: a case in Taiwan.

Many studies have found evidence for the importance of antenatal care on pregnancy outcomes. This paper focuses on the determinants of antenatal care use in Taiwan and provides a comparison of access to care before and after National Health Insurance (NHI) was implemented in 1995. A negative binomial model is applied to data from the 1989 and 1996 Taiwan Maternal and Infant Health Surveys to analyze antenatal care use. The results show that women in some situations had more antenatal care visits than average regardless of NHI implementation. These situations include: having a highly educated husband; gaining more weight than average during pregnancy; experiencing a first pregnancy; carrying twins or triplets; having care provided by a doctor rather than other caregivers; and switching to another health care facility during pregnancy. Regarding societal change, the trend toward delaying pregnancy is causing a change in care use. Additionally, three changes in care patterns after NHI are noteworthy. First, antenatal care visits at maternity clinics increased more than visits at hospitals. Second, before NHI's implementation, women who did blue-collar work or farm work sought care more frequently than housewives, but after NHI began government employees and businesswomen sought care more frequently. Third, antenatal care visits of mothers living in Taiwan's central area increased more than visits of those in the northern area. The expansion of medical care in aboriginal areas and outlying islands may prove to be one of NHI's best achievements.

The impact of National Health Insurance on neonatal care use and childhood vaccination in Taiwan.

The objective of this study was to assess the impact of National Health Insurance (NHI) on the utilization of neonatal care and childhood vaccination in Taiwan. Data are selected from two nationwide maternal and infant surveys undertaken in 1989 and 1996, which were funded by the Department of Health. The questionnaire was administered in all 23 administrative districts, including two metropolitan areas - the cities of Taipei and Kaohsiung. The first and second cohort consisted of 1641 and 3499 infants, respectively. This study used a bivariate probit estimation procedure to examine the factors that determine the probability of neonatal care use and vaccination by pooling the 2 years. Generally, the mothers who are older, more educated and more satisfied with birth delivery services were found to be more likely to use neonatal preventive care. The likelihood of receiving such care also tends to rise with advancing gestational age and higher probability of neonatal complication (icterus neonatorum) and being born in a hospital. The likelihood of care was also found to vary regionally with northern neonates having higher odds of receiving preventive care than non-northern neonates. In spite of having an insignificant impact on the use of care, NHI does lessen the inequality in use of these two services in various regions. However, regional variations in neonatal care use still exist. Residents of the southern area remain less likely to receive neonatal care than those of the northern area after NHI. This finding deserves serious consideration when attempting to design effective policies, such as expanding medical institutions in the aboriginal southern areas so as to increase the accessibility of such health care.

An analysis of private health insurance purchasing decisions with national health insurance in Taiwan.

The Taiwanese health insurance industry is just over 30 years old. Originally private and domestic, the industry underwent substantial institutional changes when it opened to foreign competition between 1987 and 1994 and when the Taiwanese government established national health insurance (NHI) coverage in 1995. Congruent with these changes, rapid growth occurred in the Taiwanese demand for private health insurance. In order to better understand the recent performance of the Taiwanese health insurance industry, the structure of the NHI system is described and then household decisions to purchase private health insurance are analyzed using a two-part (hurdle) model on 1998 Survey of Family Income and Expenditure data. Logistic and OLS regressions are used to examine the factors influencing the probability and amount of private health insurance purchased. Generally, factors affecting the probability of having insurance also influence the amount of insurance coverage purchased. Higher income and education levels are associated with increased probabilities and larger quantities of private insurance purchases. Married females, the employed, and household heads working in state-run enterprises are more likely to purchase private insurance than their counterparts. The probability of private insurance purchases varies by region, with northern Taiwanese households having higher odds of owning private insurance than non-northern households. Compared to those in rural villages, households in cities and towns are more likely to have private insurance. The likelihood of private insurance purchase also tends to rise with advancing age and larger family sizes. In addition, one important implication in the private health insurance market is highlighted. There is no complementarity between the public and private systems.