Fecal microbiota transplantation for treatment of refractory or recurrent Clostridioides difficile infection in Taiwan: a cost-effectiveness analysis.

Background: Compared to antibiotic treatment, fecal microbiota transplantation (FMT) is a more effective treatment for refractory or recurrent CDI (rCDI). Patients with inflammatory bowel disease (IBD) have a higher incidence of CDI and worse outcomes. There has been no study from Asia to evaluate the cost-effectiveness of FMT for overall rCDI patients and rCDI patients with IBD. Methods: We applied a Markov model with deterministic and probabilistic sensitivity analyses to evaluate the cost and effectiveness of different treatments for rCDI patients with a time horizon of 1 year from the payer's perspective. We compared the cost and clinical outcomes of FMT through colonoscopy to two antibiotics (vancomycin and fidaxomicin) using data from Chang Gung Memorial Hospital, Taoyuan, Taiwan. Results: Compared to vancomycin, FMT was cost-effective in overall rCDI patients as well as IBD patients with rCDI [USD 39356 (NT$1,101,971.98)/quality-adjusted life year (QALY) gained in overall patients; USD65490 (NT$1,833,719.14)/QALY gained in IBD patients]. Compared to fidaxomicin, FMT was only cost-effective in overall rCDI patients [USD20255 (NT$567,133.45)/QALY gained] but slightly increased QALY (0.0018 QALY gained) in IBD patients with rCDI. Conclusion: FMT is cost-effective, compared to vancomycin or fidaxomicin, for the treatment of rCDI in most scenarios from the payers' perspective in Taiwan.

Budget Impact Analysis of Comprehensive Genomic Profiling in Advanced Non-Small Cell Lung Cancer in Taiwan.

OBJECTIVES: The concept of precision oncology using genetic testing has become popular for cancer treatment in recent years. This research aimed to evaluate the financial impact of comprehensive genomic profiling (CGP) in patients with advanced non-small cell lung cancer before receiving any systemic treatments, compared with current practice using single-gene testing, in the hope that the findings can inform the National Health Insurance Administration the decision regarding CGP reimbursement. METHODS: A budget impact analysis model was developed comparing the sum of gene testing costs, the first-line and subsequent systemic treatment costs, and other medical costs between the current practice of traditional molecular testing and the new test strategy of CGP. The evaluation time horizon is 5 years from the perspective of the National Health Insurance Administration. Outcome endpoints were incremental budget impact and life-year gained. RESULTS: This research indicated CGP reimbursement would benefit 1072 to 1318 more patients receiving target therapies than the current practice and consequently had incremental 232 to 1844 life-years gained from 2022 to 2026. The new test strategy also led to higher gene testing cost and systemic treatment cost. Nevertheless, less medical resource utilization and better patient outcome were demonstrated. The incremental budget impact ranged from US dollar 19 to US dollar 27 million in the 5-year period. CONCLUSION: This research shows that CGP could pave the way for personalized healthcare with moderate increase of National Health Insurance budget.

Economic Burden of Cervical and Head and Neck Cancer in Taiwan from a Societal Perspective.

BACKGROUND: Head and neck cancers (HNC) are increasingly recognized as important human papillomavirus (HPV)-related malignancies in addition to cervical cancer (CC). However, data on the socioeconomic impact of HNC and CC in Taiwan are limited. METHODS: A retrospective cohort study was conducted to estimate the total direct medical cost and indirect productivity loss from CC and HNC between 2014 and 2015. Patient data from the Taiwan National Cancer Registry were analyzed, with matched non-cancer controls from the Taiwan National Healthcare Reimbursement Database. Indirect costs due to premature deaths were calculated using public data from Taiwanese government reports. RESULTS: In the direct cost analysis, 2083 patients with newly diagnosed CC and 11,078 with newly diagnosed HNC (10,036 males) were identified between 2014 and 2015 and followed up through the end of 2016 or until death. The total direct medical costs incurred in 2014 and 2015 due to HNC were 11.54 times higher in males than in females, and 4.55 times higher than CC. Indirect cost analysis showed the total annual productivity loss was New Taiwan Dollar (NTD) $12 billion in 2019, and 79.99% was attributed to male HNC. CONCLUSION: In Taiwan, the socioeconomic burden associated with male HNC is high and greater than that seen with CC. While not all HNCs are attributable to HPV infection, prevention of HNC through HPV vaccination should be considered for both sexes.

The Clinical and Economic Impact of a Nonavalent Versus Bivalent Human Papillomavirus National Vaccination Program in Taiwan.

OBJECTIVES: This study aimed to estimate the epidemiologic and economic impact of a nonavalent human papillomavirus (HPV) vaccination program for 13- to 14-year-old females compared with that of the bivalent vaccine in Taiwan. METHODS: A previously developed dynamic transmission model for the nonavalent HPV vaccine was adapted to the Taiwan setting. The natural history of cervical cancer and genital warts was simulated by the HPV model assuming an 80% vaccination coverage rate in girls aged 13 to 14 years of age with a 2-dose schedule for the nonavalent and bivalent HPV vaccines. A lifetime duration of vaccine protection was assumed for the HPV vaccine types. RESULTS: The model estimated that the nonavalent HPV vaccine would prevent an additional 15 951 cervical cancer cases, 6600 cervical cancer-related deaths, 176 702 grade 2 or grade 3 cervical intraepithelial neoplasia cases, 103 959 grade 1 cervical intraepithelial neoplasia cases, and 1 115 317 genital warts cases compared with the bivalent HPV vaccine. The nonavalent HPV vaccination program was projected to cost an additional New Taiwan dollars (NTD) 675.21 per person and to produce an additional 0.00271 quality-adjusted life-year per person over 100 years compared with the bivalent HPV vaccine. Thus, the incremental cost-effectiveness ratio of the nonavalent HPV vaccine versus the bivalent HPV vaccine was NTD 249 462/quality-adjusted life-year. CONCLUSIONS: A nonavalent HPV vaccination program for 13- to 14-year-old girls would have additional public health and economic impacts and would be highly cost-effective compared with the bivalent HPV vaccine, relative to per capita gross domestic product, which is estimated at NTD 746 526 for Taiwan.

Survival, treatment regimens and medical costs of women newly diagnosed with metastatic triple-negative breast cancer.

Individuals diagnosed with metastatic triple-negative breast cancer (mTNBC) suffer worse survival rates than their metastatic non-TNBC counterparts. There is little information on survival, treatment patterns, and medical costs of mTNBC patients in Asia. Therefore, this study aimed to examine 5-year survival, regimens of first-line systemic therapy, and healthcare costs of mTNBC patients in Taiwan. Adult females newly diagnosed with TNBC and non-TNBC as well as their survival data, treatment regimens and costs of health services were identified and retrieved from the Cancer Registry database, Death Registry database, and National Health Insurance (NHI) claims database. A total of 9691 (19.27%) women were identified as TNBC among overall BC. The 5-year overall survival rate of TNBC and non-TNBC was 81.28% and 86.50%, respectively, and that of mTNBC and metastatic non-TNBC was 10.81% and 33.46%, respectively. The majority of mTNBC patients received combination therapy as their first-line treatment (78.14%). The 5-year total cost in patients with metastatic non-TNBC and with mTNBC was NTD1,808,693 and NTD803,445, respectively. Higher CCI scores were associated with an increased risk of death and lower probability of receiving combination chemotherapy. Older age was associated with lower 5-year medical costs. In sum, mTNBC patients suffered from poorer survival and incurred lower medical costs than their metastatic non-TNBC counterparts. Future research will be needed when there are more treatment options available for mTNBC patients.

Outcome and cost analysis of primary total knee arthroplasty in end-stage renal disease patients: A nationwide population-based study.

BACKGROUND: A number of patients with end-stage renal disease (ESRD) undergo total knee arthroplasty (TKA) due to advanced knee joint osteoarthritis. There are few studies describing the incidence, morbidities, mortality rate, and cost analysis regarding ESRD patients receiving TKA. METHODS: We retrospectively retrieved patient data from National Health Insurance Research Database in Taiwan during 2005-2011, and evaluated the outcomes of TKA in patients with (ESRD group) and without ESRD (non-ESRD group). Patients' demographic data, comorbidities, mortality, and in-hospital cost were recorded. RESULTS: A total of 578 TKAs and 110,895 TKAs were identified in the ESRD and non-ESRD group, respectively. The incidence of patients receiving TKA was higher in the ESRD than in non-ESRD group by at least 2 folds. The ESRD group showed significantly more medical complications (pneumonia, peptic ulcer disease, and acute myocardial infarction) after surgery. In prosthesis-related complications, the ESRD group also had more periprosthetic joint infections, and prosthetic loosenings by one year. The one-year mortality rate was more than 6 times higher in the ESRD than in the non-ESRD group. The ESRD group had higher in-hospital medical expense than the non-ESRD group, especially when there were complications, even when the dialysis-related costs were exempted. CONCLUSION: The complication rate, mortality rate, and cost were higher in the ESRD patients receiving TKA. When considering TKA in ESRD patients, it is crucial to weigh the risks against benefits of TKA, and have a thorough discussion with the patients.

National trends in incidence, mortality, hospitalizations, and expenditures for pemphigus in Taiwan.

BACKGROUND: Data on trends in epidemiological characteristics and economic burden of pemphigus are scarce. OBJECTIVE: To describe national trends in pemphigus' incidence, mortality, hospitalizations, and expenditures between 2003 and 2015 in Taiwan. METHODS: This nationwide study used the Taiwan National Health Insurance Research Database to identify pemphigus patients from 2003 to 2015. Annual incidence, prevalence, healthcare utilization, and expenditure trends were calculated and analyzed. RESULTS: Pemphigus' incidence increased significantly from 3.19 to 4.70 per million person-years in 2003-2010 but fluctuated in 2011-2015. Pemphigus patients had higher mortality and care costs. Medical utilization and expenditure declined for pemphigus inpatients and outpatients. Systemic corticosteroid use decreased, but mortality remained stable. CONCLUSION: The health expense reduction for pemphigus was mainly attributed to decreased utilization, length of stay, and inpatient costs. The persistently elevated mortality rate highlights an unmet need in pemphigus therapy.

Prevalence and related drug cost of comorbidities in HIV-infected patients receiving highly active antiretroviral therapy in Taiwan: A cross-sectional study.

BACKGROUND: To determine the prevalence of chronic comorbidities and associated medication costs in Taiwanese HIV patients in order to increase awareness of the disease burden among healthcare providers and patients. METHODS: HIV-diagnosed patients receiving highly active antiretroviral therapy (HAART; 2010-2013) were identified from the Taiwan National Health Insurance Research Database with the corresponding International Classification of Diseases, ninth revision (ICD-9) code. Comorbidities (type II diabetes mellitus, hypertension, dyslipidemia, major depressive disorder, acute coronary syndrome, and cholelithiasis/nephrolithiasis) were identified according to ICD-9 or relevant medication use. Comorbidity medication and associated costs were identified using the drug classification code from the Anatomical Therapeutic Chemical classification system code series and series outpatient prescriptions. RESULTS: Of 20,726 HIV-diagnosed Taiwanese patients (2010-2013), 13,142 receiving HAART were analyzed. Prevalence of all chronic comorbidities was significantly greater (p < 0.0001) in patients aged ≥40 years versus <40 years (diabetes mellitus, 14.95% vs. 3.30%; hypertension, 46.73% vs. 26.83%; dyslipidemia, 34.93% vs. 18.37%; depression, 23.75% vs. 19.88%; acute coronary syndrome, 1.16% vs. 0.21%; nephrolithiasis/cholelithiasis, 7.26% vs. 4.56%; >2 comorbidities, 24.80% vs. 7.21%). An increase in comorbidity medication spending (2010 vs. 2013 medication costs) was observed (antidyslipidemia, $88,878 vs. $168,180; antihyperglycemia, $32,372 vs. $73,518; antidepressants, $78,220 vs. $125,971; sedatives, $60,009 vs. $85,055; antihypertension, $47,115 vs. $95,134), contributing to overall treatment costs increasing almost two-fold from 2010 to 2013. CONCLUSIONS: Among HIV-infected Taiwanese patients receiving HAART, significant increases in comorbidity prevalence with age, along with rising comorbidity medication costs, suggest the need for preventative as well as chronic care.

The Cost of Hypoglycemia Associated With Type 2 Diabetes Mellitus in Taiwan.

OBJECTIVES: To quantify the incremental burden of patients with type 2 diabetes mellitus (T2DM) and a hypoglycemic event in Taiwan using the National Health Insurance Research Database. METHODS: Data from 2000 through 2013 with an index period of 2001 through 2012 from the National Health Insurance Research Database's 2-million-patient sample were used. Using a nested case-control study design, patients were indexed if they reported a diagnosis of T2DM during the index period. Patients with T2DM with a hypoglycemic event (defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes) during the index period were identified. Patients with T2DM without a hypoglycemic event were included to form a 4:1 (controls to cases) matched cohort on the basis of age, sex, the Charlson Comorbidity Index, and the T2DM diagnosis date. Both cohorts were followed up for 1 year after the hypoglycemic event and had their treatment utilization, resource utilization, and healthcare costs measured. RESULTS: A total of 144 213 patients with T2DM were identified, with 3 651 (2.5%) recording a hypoglycemic event. Before matching, patients with T2DM with a hypoglycemic event were, on average, older (64.2 vs 56.6) and had higher mean CCI scores (2.4 vs 1.9) than did patients with T2DM without a hypoglycemic event. After matching, patients with T2DM and a hypoglycemic event incurred an additional $1353 in average direct healthcare costs during the 1 year of follow-up compared with the matched cohort. Patients with T2DM with hypoglycemia also spent an additional 5.9 days in the hospital during the follow-up period compared with the matched cohort. CONCLUSIONS: Patients with hypoglycemic events, on average, experienced a substantially higher economic burden than did their counterparts without a hypoglycemic event during the same period.

Assessment of CHA2DS2-VASc score for predicting cardiovascular and cerebrovascular outcomes in acute myocardial infarction patients.

Although established guidelines currently recommend the use of the CHA2DS2-VASc score for evaluating embolic risk in AF patients, few studies have evaluated the use of the CHA2DS2-VASc score for predicting cardiovascular outcomes in patients with acute myocardial infarction (AMI). The aim of this study was to determine whether CHA2DS2-VASc score is a predictor of a major adverse cardiocerebral vascular event (MACCE) in AMI patients.This study analyzed data in the Taiwan National Health Insurance Research Database from January 2008 to December 2012. Cardiovascular outcomes were analyzed according to the baseline characteristics, presence of AF, and CHA2DS2-VASc score.Twenty nine thousand four hundred fifty-two patients with non-fatal AMI, 1171 patients (8.3%) were with AF. The Cox regress model showed with the exception of women sex and peripheral artery disease, all the baseline characteristics considered risks in CHA2DS2-VASc scores were independently associated with the increased incidence of MACCE within 1 year after AMI. A CHA2DS2-VASc score of <5 had negative predictive values of 93.37% for recurrent MI, 98.45% for stroke, 94.86% for HF admission, 98.83% for mortality, and 87.80% for MACCE. Regardless of the presence of AF, the CHA2DS2-VASc score was correlated with 1-year MACCE.The CHA2DS2-VASc score was correlated with 1-year MACCE in AMI patients who were discharge alive. The CHA2DS2-VASc score is useful predictor for 1 year MACCE in patients with AMI.

No Difference in Morbidity and Mortality After Total Joint Arthroplasty in Liver Transplant Recipients: A Propensity Score-Matched Analysis of a Nationwide, Population-Based Study Using Universal Healthcare Data.

BACKGROUND: Controversy remains regarding the outcomes after total joint arthroplasty (TJA) among patients with or without liver transplantation (LT). This study aimed at investigating the prevalence of TJA in patients after LT and comparing the morbidity and mortality with the non-LT group. METHODS: We conducted a nationwide, population-based study, with data extracted from a universal health insurance database, based on the International Classification of Disease, Ninth Revision, Clinical Modification. Patients who underwent TJAs between January 2001 and December 2014 were included. Patients who had bilateral TJAs or a TJA before LT were excluded. A total of 43 patients with LT and 350,337 patients without LT were included. The analysis was implemented using data from all patients and those matched by 1-to-10 propensity score matching. Multivariable logistic regression was used to control confounding variables. RESULTS: The prevalence of patients undergoing TJA after LT was 1.3% (43/3276). After propensity score matching, patients with LT were not associated with 30-day complications (adjusted odds ratio [aOR], 0.98; 95% confidence interval [CI], 0.93-1.03; P = .35), 30-day readmission rates (aOR, 0.93; 95% CI, 0.92-1.08; P = .87), 90-day complication rates (aOR, 0.95; 95% CI, 0.88-1.02; P = .16), 1-year infection rates (aOR, 1.04; 95% CI, 0.96-1.12; P = .35), reoperation rates (aOR, 1.06; 95% CI, 0.92-1.23; P = .41), or mortality (aOR, 0.91; 95% CI, 0.80-1.04; P = .18). CONCLUSION: The morbidity and mortality seem to be comparable whether TJA is performed in patients with or without LT. Methods for risk assessment would be feasible in liver transplant recipients.

One-year survival rate and healthcare costs after cardiac arrest in Taiwan, 2006-2012.

OBJECTIVES: The annual increase in costs and the quality of life of survivors of cardiac arrest are major concerns. This study used National Health Insurance Research Database (NHIRD) of Taiwan to evaluate the 1-year survival rate and the annual healthcare costs of survivors after cardiac arrest. METHODS: This retrospective, fixed-cohort study conducted from 2006 to 2012, involved 2 million individuals randomly selected from the NHIRD of Taiwan. Adult patients at least 18 years old who were diagnosed with cardiac arrest were enrolled. Survival was followed up for 1 year. RESULTS: In total, 2,256 patients were enrolled. The survivor cohort accounted for 4% (89/2256) of the study population. There were no significant differences in the demographic characteristics of the survival and non-survival cohorts, with the exceptions of gender (male: survival vs. non-survival, 50.6% vs. 64.5%, p = 0.007), diabetes mellitus (49.4% vs. 35.8%, p = 0.009), and acute coronary syndrome (44.9% vs. 31.9%, p = 0.010). Only 38 (1.7%) patients survived for > 1 year. The mean re-admission to hospital during the 1-year follow up was 73.5 (SD: 110.2) days. The mean healthcare cost during the 1-year follow up was $12,953. Factors associated with total healthcare costs during the 1-year follow up were as follows: city or county of residence, being widowed, and Chronic Obstructive Pulmonary Disease (city or county of residence, ß: -23,604, p < 0.001; being widowed, ß: 25,588, p = 0.049; COPD, ß: 14,438, p = 0.024). CONCLUSIONS: There was a great burden of the annual healthcare costs of survivors of cardiac arrest. Socioeconomic status and comorbidity were major confounders of costs. The outcome measures of cardiac arrest should extend beyond the death, and encompass destitution. These findings add to our knowledge of the health economics and indicate future research about healthcare of cardiac arrest survivors.

New Drug Reimbursement and Pricing Policy in Taiwan.

BACKGROUND: Taiwan has implemented a national health insurance system for more than 20 years now. The benefits of pharmaceutical products and new drug reimbursement scheme are determined by the Expert Advisory Meeting and the Pharmaceutical Benefit and Reimbursement Scheme (PBRS) Joint Committee in Taiwan. OBJECTIVES: To depict the pharmaceutical benefits and reimbursement scheme for new drugs and the role of health technology assessment (HTA) in drug policy in Taiwan. METHODS: All data were collected from the Expert Advisory Meeting and the PBRS meeting minutes; new drug applications with HTA reports were derived from the National Health Insurance Administration Web site. Descriptive statistics were used to analyze the timeline of a new drug from application submission to reimbursement effective, the distribution of approved price, and the approval rate for a new drug with/without local pharmacoeconomic study. RESULTS: After the second-generation national health insurance system, the timeline for a new drug from submission to reimbursement effective averages at 436 days, and that for an oncology drug reaches an average of 742 days. New drug approval rate is 67% and the effective rate (through the approval of the PBRS Joint Committee and the acceptance of the manufacturer) is 53%. The final approved price is 53.6% of the international median price and 70% of the proposed price by the manufacturer. Out of 95 HTA reports released during the period January 2011 to February 2017, 28 applications (30%) conducted an HTA with a local pharmacoeconomic study, and all (100%) received reimbursement approval. For the remaining 67 applications (70%) for which HTA was conducted without a local pharmacoeconomic analysis, 54 cases (81%) were reimbursed. CONCLUSIONS: New drug applications with local pharmacoeconomic studies are more likely to get reimbursement.

Association of High-Volume Surgeons Working in High-Volume Hospitals with Cost of Free Flap Surgeries.

BACKGROUND: We examined the associations of surgeon and hospital volume with total cost, length of stay (LOS), and cost per day for free tissue transfer (FTT) surgeries. Evidence demonstrates a higher likelihood of success for FTT in higher volume hospitals. Little, however, is known about volume-outcome associations for surgical costs and LOS. We hypothesized that higher provider volume is associated with lower cost and shorter LOS. METHODS: Using Taiwan's national data (2001-2012), we conducted a retrospective cohort study of all adults 18-64 years of age who underwent FTT during the study period. We used hierarchical regression modeling for our analyses. Our 3 outcome variables were total cost of FTT surgery, LOS in hospital, and cost per day. RESULTS: Except for functional muscle flap, in which LOS was 12 days shorter in high-volume compared with low-volume hospitals (P = 0.017), no association between hospital volume and LOS was found. Contrary to our hypothesis, our results for all FTT cases demonstrate positive associations of medium-volume hospitals (OR = 1.31; CI, 1.11-1.55) and high-volume surgeons (OR = 1.16; CI,1.03-1.32) with total cost and cost per day, respectively. The interactions of hospital volume and surgeon volume show that in medium- and high-volume hospitals, surgeons with the highest volume had the lowest predicted cost per day among hospitals in that category; but all differences in cost were small. CONCLUSIONS: There were no substantial variations based on different hospital or surgeon volume in LOS, total cost, or cost per day for FTT operations performed in Taiwan.

Decreased antimicrobial resistance and defined daily doses after implementation of a clinical culture-guided antimicrobial stewardship program in a local hospital.

BACKGROUND: We aimed to report the implementation of an antimicrobial stewardship program (ASP) guided by clinically significant cultures in a hospital to assess its pharmaceutical, microbiological, financial, and outcome effects. METHODS: A 3-year cohort study of an antimicrobial restriction policy implementation was performed. The ASP with culture-guided de-escalation of antibiotics was instituted in a local hospital since January 1, 2012. The cost of antimicrobials, defined daily dose (DDD), susceptibility to antimicrobials, and outcome of all admitted patients were calculated and evaluated before and after the ASP implementation. RESULTS: Average monthly length of stay of admitted patients decreased from 7.8 ± 0.5 days in 2011 to 6.9 ± 0.3 days in 2013 (p < 0.001). The average monthly cost of antimicrobials decreased 46.9% from US$30,146.8 in 2011 to US$16,021.3 in 2013 (p < 0.001). Total intravenous antimicrobial DDDs per 100 bed-days of the inpatients were 66.9, 54.1 and 48.4 in 2011, 2012 and 2013, respectively. A total of 18.6 DDDs per 100 bed-days of inpatients (27.7%) decreased from 2011 to 2013. By comparing data in 2013 to those in 2011, the ASP reduced antimicrobial resistance of Gram-positive bacteria (p = 0.013), Gram-negative bacteria (p < 0.001), and predominant species (all p < 0.05). The yearly mortality also decreased from 1.3% in 2011 to 1.1% in 2012 and 1.0% in 2013. CONCLUSIONS: The ASP with a culture-guided de-escalation of antibiotics successfully reduced length of stay, mortality, the cost of antimicrobials, DDDs, and antimicrobial resistance rate, and that is highly recommended for local hospitals.

COPD in Taiwan: a National Epidemiology Survey.

OBJECTIVES: To determine the prevalence of COPD in Taiwan and to document the disease characteristics and associated risk factors. METHODS: We conducted a random cross-sectional national survey of adults older than 40 years in Taiwan. Respiratory health screening questions identified subjects with diagnosed COPD or whose reported symptoms also fulfilled an epidemiological case definition; these were eligible to complete the survey, which also included indices of symptom severity and disability and questions on comorbidities, medical treatments, smoking habits, and occupations potentially harmful to respiratory health. Subjects with diagnosed COPD were subdivided by smoking status. Subjects who fulfilled the case definition of COPD and smoked were designated as "possible COPD". Participants who did not fit the case definition of COPD were asked only about their personal circumstances and smoking habits. Data from these groups were analyzed and compared. RESULTS: Of the 6,600 participants who completed the survey, 404 (6.1%) fulfilled the epidemiological case definition of COPD: 137 with diagnosed COPD and 267 possible COPD. The most common comorbidities of COPD were hypertension or cardiovascular diseases (36.1%). Subjects with definite COPD had significantly higher COPD Assessment Test scores than the possible COPD group (14.6±8.32 vs 12.6±6.49, P=0.01) and significantly more comorbid illnesses (P=0.01). The main risk factors contributing to health care utilization in each COPD cohort were higher COPD Assessment Test scores (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.04-1.26), higher modified Medical Research Council Breathlessness Scale scores (OR 1.97, 95% CI 1.11-3.51), and having more than one comorbidity (OR 5.19, 95% CI 1.05-25.61). CONCLUSION: With estimated prevalence of 6.1% in the general population, COPD in Taiwan has been underdiagnosed. Symptoms and comorbidities were independent risk factors for health care utilization in subjects with definite or possible COPD. There is an urgent need to raise awareness of the importance of early evaluation and prompt treatment for subjects with chronic airway symptoms.

Fixed-Dose Combinations of Renin-Angiotensin System Inhibitors and Calcium Channel Blockers in the Treatment of Hypertension: A Comparison of Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors.

Fixed-dose combinations (FDCs) of different regimens are recommended in guidelines for the treatment of hypertension. However, clinical studies comparing FDCs of angiotensin receptor blocker (ARB)/calcium channel blocker (CCB) and angiotensin-converting enzyme inhibitor (ACE inhibitor)/CCB in hypertensive patients are lacking.Using a propensity score matching of 4:1 ratio, this retrospective claims database study compared 2 FDC regimens, ARB/CCB and ACE inhibitor/CCB, in treating hypertensive patients with no known atherosclerotic cardiovascular disease. All patients were followed for at least 3 years or until the development of major adverse cardiovascular events (MACEs) during the study period. In addition, the effect of medication adherence on clinical outcomes was evaluated in subgroup analysis based on different portions of days covered.There was no significant difference in MACE-free survival (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 0.98-1.50; P = 0.08) and survival free from hospitalization for heart failure (HR: 1.15; 95% CI: 082-1.61; P = 0.431), new diagnosis of chronic kidney disease (HR: 0.98; 95% CI: 071-1.36; P = 0.906), and initiation of dialysis (HR: 0.99; 95% CI: 050-1.92; P = 0.965) between the 2 study groups. The results remained the same within each subgroup of patients with different adherence statuses.ARBs in FDC regimens with CCBs in the present study were shown to be as effective as ACE inhibitors at reducing the risks of MACEs, hospitalization for heart failure, new diagnosis of chronic kidney disease, and new initiation of dialysis in hypertensive patients, regardless of the medication adherence status.

Newly diagnosed atrial fibrillation is an independent factor for future major adverse cardiovascular events.

OBJECTIVES: This study aims to investigate the impact of newly diagnosed atrial fibrillation (AF) on future major adverse cardiac events (MACE). AF is the most common form of cardiac arrhythmia and is associated with several other cardiovascular (CV) events. Little is known about whether newly diagnosed AF is an independent factor for future MACE, especially in patients without such a history. METHODS AND RESULTS: We evaluated data from the National Health Insurance Research Database, which represented a retrospective cohort of 713,288 adults in Taiwan from 2006 to 2010. Individuals with previous MACE were excluded. Newly diagnosed AF patients were identified by assigning International Classification of Diseases codes. Propensity score matching adjusted for gender, age, hypertension, diabetes mellitus and dyslipidemia. Cox proportional hazard models estimated future MACE ratios. We compared a total of 3,737 patients with newly diagnosed AF and 704,225 patients without. After matching, there was no difference in baseline demographic characteristics in patients across newly diagnosed AF and non-AF groups. The result showed that newly diagnosed AF in multivariate analysis were associated with increased incidents of MACE (hazard ratio: 3.11-3.51 in different models) and mortality. Newly diagnosed AF without other CV risk factors had 8.45 times the risk of developing future MACE than healthy adults. The more associated CV risk factors in addition to AF, the increased rate of future CV events. CONCLUSIONS: Newly diagnosed AF is an independent factor that leads to future CV events after gender, age, hypertension, diabetes mellitus and dyslipidemia matching. AF is associated with a higher mortality rate.

Using Dynamic Transmission Modeling to Determine Vaccination Coverage Rate Based on 5-Year Economic Burden of Infectious Disease: An Example of Pneumococcal Vaccine.

BACKGROUND: Vaccination can reduce the incidence and mortality of an infectious disease and thus increase the years of life and productivity for the entire society. But when determining the vaccination coverage rate, its economic burden is usually not taken into account. OBJECTIVE: This article aimed to use a dynamic transmission modeling (DTM), which is based on a susceptible-infectious-recovered model and is a system of differential equations, to find the optimal vaccination coverage rate based on the economic burden of an infectious disease. METHODS: Vaccination for pneumococcal diseases was used as an example to demonstrate the main purpose. 23-Valent pneumococcal polysaccharide vaccines (PPV23) and 13-valent pneumococcal conjugate vaccines (PCV13) have shown their cost-effectiveness in elderly and children, respectively. Scenarios analysis of PPV23 to elderly aged 65+ years and of PCV13 to children aged 0 to 4 years was applied to assess the optimal vaccination coverage rate based on the 5-year economic burden. Model parameters were derived from Taiwan's National Health Insurance Research Database, government data, and published literature. Various vaccination coverage rates, the vaccine efficacy, and all epidemiologic parameters were substituted into DTM, and all differential equations were solved in R Statistical Software. RESULTS: If the coverage rate of PPV23 for the elderly and of PCV13 for the children both reach 50%, the economic burden due to pneumococcal disease will be acceptable. CONCLUSIONS: This article provided an alternative perspective from the economic burden of diseases to obtain a vaccination coverage rate using the DTM. This will provide valuable information for vaccination policy decision makers.

Clinical outcomes and healthcare costs in hypertensive patients treated with a fixed-dose combination of amlodipine/valsartan.

This retrospective claims database analysis compared two strategies of hypertension treatment in outpatient, emergency, and inpatient departments: a fixed-dose combination (FDC) of amlodipine/valsartan vs free combinations of angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) (ARB+CCB group). After a mean follow-up of 15.2 months, the FDC group had significantly lower total healthcare costs (US $1844 vs US $2158; P<.001) and hospitalization rates (14.57% vs 18.43%; P<.001), a higher proportion of days covered (80.35% vs 72.57%; P<.001), and better persistence (266 vs 225 days; P<.001) compared with the ARB+CCB group. The FDC group also had a better major adverse cardiovascular event (MACE)-free survival (hazard ratio, 0.83; 95% confidence interval, 0.73-0.94; P=.003) and decreased rates of heart failure (2.12% vs 3.26%; P<.001), malignant dysrhythmia (0.18% vs 0.42%; P=.021), and percutaneous coronary intervention (0.76% vs 1.26%; P=.015). Compared with free combinations of ARB+CCB, an FDC of amlodipine/valsartan improved MACE-free survival and medication compliance and decreased total healthcare costs and hospitalization rates in hypertensive patients.