Effects of an integrated ambulatory care program on healthcare utilization and costs in older patients with multimorbidity: a propensity score-matched cohort study.

BACKGROUND: Population aging has increased the prevalence of multimorbidity, jeopardizing the sustainability and efficiency of healthcare systems. This study aimed to evaluate the effects of an integrated ambulatory care program (IACP) on healthcare utilization and costs among older patients with multimorbidity while accounting for the confounding effects of frailty. METHODS: A retrospective cohort study using propensity matching including patients aged 65 or older with two or more chronic conditions attending the outpatient clinic at our hospital between June 1 and December 31, 2019, was conducted. Exposure was defined as receipt of IACP care. Patients not undergoing the IACP comprised the unexposed group and were matched at a ratio of 1:4 to patients undergoing the IACP group according to sex, age, Charlson Comorbidity Index score, multimorbidity frailty index score, and number of outpatient visits within 6 months before the index date. Outcomes were changes in healthcare utilization and related costs between 6 months before and after receiving IACP care. Multivariate regression analyses were used for data analysis and the Generalized Estimation Equation method was used to fit the regression models. RESULTS: A total of 166 (IACP) and 664 (non-exposed) patients were analyzed. The mean participant baseline ages were 77.15 ± 7.77 (IACP) and 77.28 ± 7.90 years (unexposed). In univariate analyses, the IACP group demonstrated greater reductions than the unexposed group in the frequency of outpatient visits (-3.16 vs. -1.36, p < 0.001), number of physicians visited (-0.99 vs. -0.17, p < 0.001), diagnostic fees (-1300 New Taiwan Dollar [NTD] vs. -520 NTD, p < 0.001), drug prescription fees (-250 NTD vs. -70 NTD, p < 0.001), and examination fees (-1620 NTD vs. -700 NTD, p = 0.014). Multivariate analyses demonstrated that patients in the IACP group experienced significant reduction in the frequency of outpatient visits (95% CI: -0.357 to -0.181, p < 0.001), number of physicians visited (95% CI: -0.334 to -0.199, p < 0.001), and overall outpatient costs (95% CI: -0.082 to -0.011, p = 0.01). However, emergency department utilization, hospitalization, and costs did not differ significantly. CONCLUSIONS: Expanding IACPs may help patients with multimorbidity reduce their use of outpatient clinics at the 6-month follow-up, reduce care fragmentation, and promote sustainability of the healthcare system.

Hepatitis C virus core antigen is cost-effective in community-based screening of active hepatitis C infection in Taiwan.

BACKGROUND AND PURPOSE: Hepatitis C virus (HCV) core antigen is highly sensitive and specific in viremic HCV diagnosis. This study evaluated the cost-effectiveness of HCV core antigen (HCVcAg) in community-based screening for active HCV infection. METHODS: Between 2017/07 and 2018/07, community-based screenings for active HCV infection with two-step (anti-HCV for screening and HCVRNA for diagnosis) and one-step processes (HCVcAg for screening and diagnosis) were conducted in two districts in Kaohsiung City. While HCVcAg test was positive at ≥3 fmol/L, the lowest level of HCV-RNA detection was 12 IU/mL. We analyzed the cost-effectiveness of two algorithms in identifying active HCV infection. RESULTS: There were two large-scale screenings using the two-step process with a total of 2452 residents enrolled; while six hundred and forty-four residents participated in continuous small-scale screening with the one-step process. The prevalence of anti-HCV and positive HCVcAg was 3.4% and 2.8%. The viremic rate was 1.4% and 2.8% for two- and one-step processes (p < 0.001). While all positive HCVcAg were viremic, 42.4% of positive anti-HCV patients had viremia. The positive predictive value was 42.2% and 100% for two- and one-step processes in detecting active HCV infection (p < 0.001). In identifying one active HCV infection, the cost was $755.3 and $711.1 dollars for two- and one-step processes respectively. CONCLUSION: Compared to the two-step process in community-based screening, continuous screening with the HCVcAg test as a one-step tool for active HCV infection was cost-effective in areas with low seroprevalence of HCV in Taiwan.

Diabetes Shared Care Program (DSCP) and risk of infection mortality: a nationwide cohort study using administrative claims data in Taiwan.

OBJECTIVE: The Diabetes Shared Care Program (DSCP) is an integrated care model in Taiwan that has been proven to improve the care quality of patients with diabetes. We aimed to evaluate the efficacy of DSCP in decreasing the hospital mortality of infectious diseases. METHODS: From 1 662 929 patients with type 2 diabetes newly diagnosed between 1999 and 2013, we retrieved a total of 919 patients who participated in the DSCP with the first hospitalisation for an infectious disease as the study cohort and 9190 propensity score-matched patients with type 2 diabetes who did not participate as the comparison.The efficacy of DSCP was evaluated via the following comparisons between the DSCP and non-DSCP cohorts: hospital mortality, 1-year medical cost prior to and during the hospitalisation, and complications, such as receiving mechanical ventilation and intensive care unit admission. The ratio (OR) for hospital mortality of the DSCP participants was calculated by logistical regression. Further stratification analyses were conducted to examine which group of patients with type 2 diabetes benefited the most from the DSCP during hospitalisation for infectious diseases. RESULTS: The DSCP cohort had a lower hospital mortality rate than the non-DSCP participants (2.18% vs 4.82%, p<0.001). The total medical cost during the hospitalisation was lower in the DSCP cohort than in the non-DSCP cohort (NT$72 454±30 429 vs NT$86 385±29 350) (p=0.006). In the logistical regression model, the DSCP participants exhibited a significantly decreased adjusted OR for hospital mortality (adjusted OR=0.42, 95% CI 0.26 to 0.66, p=0.0002). The efficacy of the DSCP was much more prominent in male patients with type 2 diabetes and in patients with lower incomes. CONCLUSION: Participation in the DSCP was associated with a lower risk of hospital mortality for infectious diseases.

Optimizing mass casualty burns intensive care organization and treatment using evidence-based outcome predictors.

BACKGROUND: Majority of current research focuses on pre-hospital care in mass casualty incidents (MCI) whereas this study is the first to examine multifactorial aspects of intensive care unit (ICU) resource management during a surge in massive burn injury (MBI) patients whilst identifying key outcome predictors that resulted in successful disaster managements. METHODS: Both critical care, surgical parameters and cost-effectiveness are investigated in patients admitted with severe burns resulting from the explosion. A fully integrated trauma response and expansion of critical care resources in Linkou Chang Gung Memorial Hospital (CGMH) in this incident is analyzed. RESULTS: 52 burn patients were treated in CGMH and 27 patients (51.9%) had TBSA greater than 45% with the mean TBSA of 44.6±20.3%. ICU based management of MBI including early debridement and resource strategizing. The overall mortality rate was 2/52 (3.85%). Patients had an average of 14.8days on mechanical ventilation and 43days as an inpatient in total. Operative treatment wise, 44.2% of patients received escharotomies and each patient received an average of 2 skin grafting procedures. The initial TBSA was a significant predictor for burn wound infection (OR 1.107, 95% CI 1.023-1.298; p=0.011). Each patient cost an average of USD 1035 per TBSA% with an average total cost of USD 50415. CONCLUSION: With ever increasing chances of terrorist activity in urban areas, hospitals can hopefully increase their preparedness using outcome-predictors presented in this study.

Socioeconomic Inequality in One-Year Mortality of Elderly People with Hip Fracture in Taiwan.

Hip fracture commonly results in considerable consequences in terms of disability, mortality, long-term institutional care and cost. Taiwan launched its universal health insurance coverage in 1995, which largely removes financial barriers to health care. This study aims to investigate whether socioeconomic inequality in one-year mortality exists among Taiwanese elderly people. This population-based cohort study included 193,158 elderly patients (≥65 years) admitted for hip fracture between 2000 and 2012. With over a one-year follow-up, 10.52% of the participants died from all causes. The mortality rate was low in the northern part of Taiwan and in urban and high-family-income areas. Multiple Poisson regression models further suggested that the level of >Q1-Q3 and >Q3-Max showed significantly reduced odds ratio of one-year mortality at 0.90 (95% confidence interval (CI), 0.87-0.93) and 0.77 (95% CI, 0.74-0.81), respectively, compared with that of the lowest family income level (i.e., Min.-Q1). Despite a monotonic decline in overall one-year mortality during the study period, socioeconomic inequality in one-year mortality rate remained evident. The annual percentage change in one-year mortality was higher (-2.86) in elderly people from families with high income (>Q3-Max.) than that for elderly patients from family with low income (Min.-Q1, -1.94). Accessibility, rather than affordability, to health care for hip fracture is probably responsible for the observed socioeconomic inequality.

Depression and subjective economy among elderly people in Asian communities: Japan, Taiwan, and Korea.

The objective of this study is to investigate the cross-cultural relationship between depressive state and subjective economic status, as well as subjective quality of life (QOL) and activities of daily living (ADL) among elderly people in communities in Japan, Taiwan, and Korea. We studied 595 subjects aged 65 years or older in three Asian communities (261 subjects in T town in Japan, 164 in D town in Taiwan, and 170 in H town in Korea). The Geriatric Depression Scale-15, a self-rating questionnaire assessing ADL, subjective QOL, social situations, and past and current medical status, was used. Depression of the elderly was associated with dependence in basic ADL, subjective QOL, and subjective sense of low economic status. After adjusting for the effects of age, sex, and basic ADL, subjective sense of low economic status was closely associated with depression in community-living elderly people in all three communities in Asia. In conclusion, absolute and objective economic status is an important contributing factor to depressive state or psychosocial deterioration, however, we should pay more attention to the roles of perception of low economic status in determining depressive state in community-dwelling elderly people.

The impact of depression on self-care activities and health care utilization among people with diabetes in Taiwan.

Using cross-sectional analyses of a nationally representative community sample (n=1260), we found that in people with diabetes, depression was associated with lower rates of reducing or quitting smoking and alcohol, less exercise, less regular lifestyle, but more health care utilization and a higher rate of foot care.

Adherence patterns with first- versus second-generation antipsychotics for newly diagnosed schizophrenia in Taiwan.

OBJECTIVE: The aim of this study was to compare the early adherence patterns for first-generation antipsychotics and second-generation antipsychotics during the first month of treatment for patients newly diagnosed as having schizophrenia. METHODS: With a random sample from the Taiwan national health insurance database, persons with a schizophrenia diagnosis (ICD-9-CM code 295.X) and a concurrent initial antipsychotic prescription from 1998 to 2006 were defined as being newly treated for schizophrenia. Adherence patterns within one month of diagnosis were categorized into four independent groups: refill, switch, admission, and discontinuation. RESULTS: Treatment initiated with first-generation or second-generation antipsychotics resulted in similar rates of refill (57% versus 59%). However, patients who started with first-generation antipsychotics were significantly less likely to switch (9% versus 14%) but more likely to discontinue (34% versus 26%) medications than those whose treatment was initiated with second-generation antipsychotics. CONCLUSIONS: The data substantiated previous observations of the magnitude of adherence problems in Asian populations and highlight the importance of developing new strategies for intervention.

One-year follow-up of relapse to risky behaviors and incidence of syphilis among patients enrolled in the HIV case management program.

A longitudinal prospective study was conducted at an AIDS designated hospital in Taiwan. The study aimed to determine the incidence of syphilis and to identify risk factors predicting new onset syphilis and relapse into risky behaviors among 117 patients enrolled in the HIV case management program for 1 year. Having a new episode of syphilis was defined as patients had a fourfold increase of serum rapid plasma reagin titers from baseline to 12-month follow-up. After enrollment, 17% relapsed in unprotected sexual intercourse. New onset syphilis was noted in ten (10.4%) participants, and all were men having sex with men. The incidence of syphilis was 5.8 per 100 person-years. Predictors of a new episode of syphilis were higher CD4 cell counts [hazard ratio (HR), 1.003; 95% confidence interval (CI), 1.00-1.006], and recreational drug use (HR, 18.89; 95% CI, 2.78-128.15). Regular screening for syphilis among patients retaining in HIV care remains necessary.

Changes in high-density lipoprotein and homeostasis model assessment of insulin resistance in medicated schizophrenic patients and healthy controls.

BACKGROUND: This study intended to simultaneously investigate the relationships between high-density lipoprotein (HDL) and homeostasis model assessment of insulin resistance (HOMA-IR) in medicated schizophrenic patients vs healthy controls. METHODS: During a 1-year period, we recruited 37 medicated schizophrenic patients and 30 healthy controls. Metabolic syndrome-related biomarkers including insulin and lipid profiles were enzymatically determined. RESULTS: An analysis of covariance (ANCOVA) with BMI adjustment revealed that the patients had significantly lower HDL levels than the healthy controls (p = 0.017). ANCOVA with age adjustment revealed that the patients had significantly higher fasting insulin levels than the healthy controls (p = 0.034). In addition, in comparison with the healthy controls, the patients had higher mean serum levels of triglycerides, low-density lipoprotein, and total cholesterol as well as higher HOMA-IR values. However, there were no significant differences in any marker in the ANCOVA analysis after adjustment for age or BMI. CONCLUSION: We found lower HDL and higher insulin levels in medicated schizophrenic patients than in healthy controls.

Predictors of the incidence and discontinuation of long-term use of benzodiazepines: a population-based study.

Long-term use of benzodiazepines (BZDs) has been linked with an array of negative health consequences and increased medical costs and social burden. In this study, we sought to investigate the factors accounting for differential risks in the process from incident BZD use to long-term use and discontinuation in the general population. On the basis of a random sample of 187,413 people enrolled in Taiwan's National Health Insurance program on January 1, 2000, data of 2000-2002 healthcare and pharmacological services utilization were retrieved. Long-term use (LTU) was defined by having received BZD prescriptions for 180 or more days within any given calendar year. Multivariate logistic regression analyses were carried out to assess the strength of associations while adjusting for the effects of individual sociodemographics, service providers, and pharmacological agents simultaneously. Results indicated that males, elderly, and those with physical or mental disorders were more likely to become long-term users of BZDs. Having received BZD prescriptions in multiple pharmacological agents, short-acting or mixed-type agents, and hypnotic indication were associated with a roughly 2- to 5-fold increased risk of BZD LTU soon after prescription initiation. With respect to discontinuation, the effects of pharmacological characteristics seem more salient as compared to those of individual and service-provider factors. Future strategies targeting individual factors and modifying service-provider prescription behaviors may be considered to reduce possible negative consequences of BZD LTU.

Clinical and economic impact of multidrug resistance in nosocomial Acinetobacter baumannii bacteremia.

OBJECTIVE: To investigate the impact of antimicrobial resistance on clinical and economic outcomes among hospitalized patients with multidrug-resistant (MDR) Acinetobacter baumannii bacteremia. DESIGN: A retrospective, matched-cohort study. SETTING: A tertiary care university teaching hospital. METHODS: A matched case-control (1 : 1) study was conducted to compare the differences in clinical and economic outcomes of patients with MDR A. baumannii bacteremia and patients with non-MDR A. baumannii bacteremia. Case patients were matched to control patients on the basis of sex, age, severity of underlying and acute illness, and length of hospital stay before onset of bacteremia. RESULTS: Forty-six (95.8%) of 48 cases with MDR A. baumannii bacteremia were eligible for the study and matched with appropriate controls. The sepsis-related mortality rate was 34.8% among cases and 13.0% among controls, for an attributable mortality rate of 21.8% (adjusted odds ratio, 4.1 [95% confidence interval, 1.1-15.7]; P=.036). After the onset of bacteremia, cases and controls had a significantly different length of hospital stay (54.2 vs 34.1 days; P=.006), hospitalization cost (US$9,349 vs US$4,865; P=.001), and antibiotic therapy cost (US$2,257 vs US$1,610; P=.014). Thus, bacteremia due to MDR A. baumannii resulted in 13.4 days of additional hospitalization and US$3,758 of additional costs, compared with bacteremia due to non-MDR A. baumannii. CONCLUSIONS: Patients with MDR A. baumannii bacteremia had a higher mortality rate and incurred greater medical costs than patients with non-MDR A. baumannii bacteremia.