Integration and Assessment of ChatGPT in Medical Case Reporting: A Multifaceted Approach.

ChatGPT, a large language model, has gained significance in medical writing, particularly in case reports that document the course of an illness. This article explores the integration of ChatGPT and how ChatGPT shapes the process, product, and politics of medical writing in the real world. We conducted a bibliometric analysis on case reports utilizing ChatGPT and indexed in PubMed, encompassing publication information. Furthermore, an in-depth analysis was conducted to categorize the applications and limitations of ChatGPT and the publication trend of application categories. A total of 66 case reports utilizing ChatGPT were identified, with a predominant preference for the online version and English input by the authors. The prevalent application categories were information retrieval and content generation. Notably, this trend remained consistent across different months. Within the subset of 32 articles addressing ChatGPT limitations in case report writing, concerns related to inaccuracies and a lack of clinical context were prominently emphasized. This pointed out the important role of clinical thinking and professional expertise, representing the foundational tenets of medical education, while also accentuating the distinction between physicians and generative artificial intelligence.

Incidence and Nature of Short-Term Adverse Events following COVID-19 Second Boosters: Insights from Taiwan's Universal Vaccination Strategy.

This study evaluates the incidence and characteristics of adverse events (AEs) following the second COVID-19 booster dose, leveraging Taiwan's distinctive approach of extending booster vaccinations to all citizens, unlike the targeted high-risk group strategies in other countries. Utilizing data from Taipei Veterans General Hospital's Vaccine Adverse Event Reporting System (VAERS) from 27 October 2022 to 19 January 2023, this research examines AEs in 441 out of 1711 booster recipients, considering factors like age, vaccine brands, and booster combinations. The findings revealed incidence rates (IRs) of 25.6% (95% CI: 21.1-30.8) after the first booster and 24.9% (95% CI: 20.5-30.0) after the second, mostly non-serious, with those having AEs post-first booster being five times more likely to report them again (incidence rate ratio, 5.02, p < 0.001). Significantly, switching from the mRNA1273 vaccine to another brand reduced AE risk by 18%. This study underscores that AEs are more repetitive than cumulative with additional booster doses, advocating for personalized vaccination strategies based on individual medical histories and previous vaccine reactions. These insights are valuable for healthcare providers in discussing potential AEs with patients, thereby improving vaccine compliance and public trust, and for policymakers in planning future booster vaccination strategies.

Potentially inappropriate medication in long-term care wards of a veteran hospital in Taiwan: Investigation using a spreadsheet-based rapid assessment tool.

BACKGROUND: Multimorbidity and polypharmacy increase in the aging population and are accompanied by the use of potentially inappropriate medications (PIMs) and adverse drug events (ADEs). This study developed a rapid assessment tool to investigate PIM use among patients in long-term care wards. METHODS: We retrospectively collected the data of patients in long-term care wards of a veteran hospital in Taiwan between July 2019 and June 2020. The patients with chronic diseases and medications were selected. The data, including gender, age, diagnosis, and medications, were deidentified. Nonchronic disease diagnosis and short-term and topical use medications were excluded. We used Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA) and the 2019 version of the Beers Criteria to establish a rapid assessment tool. The correlations between the prevalence of PIM use and age, the number of diagnoses, and the number of medications were analyzed using SPSS version 23. RESULTS: A total of 176 patients were included in this study, of which 76.7% (n = 135) were male and 23.3% (n = 41) were female. The average age of men was 82.1 years and that of women was 83.4 years. The average number of diagnoses for men was 5.5, and that for women was 7.3. The average number of medications for men was 5.8, and that for women was 6.5. The prevalence of PIM use was 59.1% (n = 104). Logistic regression revealed that the prevalence of PIM use may be associated with the number of medications ( p < 0.001; odds ratio = 1.378). Decision tree analysis revealed that patients who simultaneously used more than four medications exhibited a higher risk of PIM. CONCLUSION: PIM use is a key factor causing ADEs among older adults. Therefore, comprehensive assessment of PIM use is necessary. This study designed a rapid assessment tool to simultaneously integrate and evaluate medications. Future studies may investigate the effectiveness of the proposed assessment tool.

Characteristics of Clinics without National Health Insurance Contracts: A Nationwide Survey in Taiwan.

Based on the 1978 Alma-Ata Declaration, the key to achieving health for all is primary health care, and many countries have established various comprehensive health care systems. Because of the financial toll of a public health care system, government-sponsored public health insurance is not universally accepted. This study used Taiwan as the backdrop to understand why many health clinics have chosen not to accept the National Health Insurance (NHI), despite it covering 99.93% of the country's population. The clinics' operational details were garnered from the datasets of Taiwan's open government data platforms and checked against the list of contracting clinics within the NHI. Of 10,907 Western medicine primary care clinics in 2016, as many as 9846 (90.3%) clinics had signed contracts with the NHI. The remaining 1061 noncontracting clinics were distributed in urban (94.5%, n = 1003), suburban (4.9%, n = 52), and rural/remote areas (0.6%, n = 6). The NHI did not have contracts with 183 plastic surgery, 88 internal medicine, and 85 surgery clinics. In conclusion, nearly one-tenth of clinics practiced independently of the NHI in Taiwan. Their reasons for declining the contract and practices for delivering their services deserve further studies.

Endovascular aortic repair is a cost-effective option for in-hospital patients with abdominal aortic aneurysm.

BACKGROUND: To investigate the cost-effectiveness of endovascular aortic repair (EVAR) versus open aortic repair (OAR) for abdominal aortic aneurysm (AAA) using incremental costs per decreased in-hospital mortality rate gained through our patients' cohort. METHODS: Medical records and healthcare costs of patients with AAA hospitalized between 2010 and 2015 were extracted from the National Health Insurance Research Database (NHIRD) of Taiwan. Multiple regression analysis was applied to adjust for confounding factors and to compare the differences in postoperative clinical outcomes between patients who received EVAR and OAR. The incremental cost-effectiveness ratio (ICER) of EVAR was determined based on the healthcare cost obtained from the analyzed data. RESULTS: A total of 2803 AAA patients were identified (n = 559 with ruptured AAA and n = 2244 unruptured AAA). Patients with ruptured AAA who underwent EVAR compared with OAR patients had shorter hospital and intensive care unit (ICU) stays (all p < 0.05). For patients with unruptured AAA, those who received EVAR compared with OAR, the adjusted odds ratio (aOR) of postoperative complications and in-hospital mortality were 0.371 and 0.447 (all p < 0.05). The total direct surgical costs and medical expenses during hospitalization in all AAA patients were higher for the EVAR group; however, ICER was <1 per capita gross domestic product. Stratification by age groups further suggested that ICER for patients with unruptured AAA who received EVAR, compared with OAR, decreased with age. CONCLUSION: Total direct medical costs were higher for AAA patients receiving EVAR regardless of rupture status; however, the cost is offset by lower odds of postoperative complications and in-hospital mortality. The observed decrease in ICER with age and EVAR use warrants further analysis. Our findings further validate the use of EVAR over OAR. These results provides supporting evidence for physicians and patients with AAA to inform shared decision making regarding endovascular or OAR options.

LACE Score-Based Risk Management Tool for Long-Term Home Care Patients: A Proof-of-Concept Study in Taiwan.

BACKGROUND: Effectively predicting and reducing readmission in long-term home care (LTHC) is challenging. We proposed, validated, and evaluated a risk management tool that stratifies LTHC patients by LACE predictive score for readmission risk, which can further help home care providers intervene with individualized preventive plans. METHOD: A before-and-after study was conducted by a LTHC unit in Taiwan. Patients with acute hospitalization within 30 days after discharge in the unit were enrolled as two cohorts (Pre-Implement cohort in 2017 and Post-Implement cohort in 2019). LACE score performance was evaluated by calibration and discrimination (AUC, area under receiver operator characteristic (ROC) curve). The clinical utility was evaluated by negative predictive value (NPV). RESULTS: There were 48 patients with 87 acute hospitalizations in Pre-Implement cohort, and 132 patients with 179 hospitalizations in Post-Implement cohort. These LTHC patients were of older age, mostly intubated, and had more comorbidities. There was a significant reduction in readmission rate by 44.7% (readmission rate 25.3% vs. 14.0% in both cohorts). Although LACE score predictive model still has room for improvement (AUC = 0.598), it showed the potential as a useful screening tool (NPV, 87.9%; 95% C.I., 74.2-94.8). The reduction effect is more pronounced in infection-related readmission. CONCLUSION: As real-world evidence, LACE score-based risk management tool significantly reduced readmission by 44.7% in this LTHC unit. Larger scale studies involving multiple homecare units are needed to assess the generalizability of this study.

Assess the Performance and Cost-Effectiveness of LACE and HOSPITAL Re-Admission Prediction Models as a Risk Management Tool for Home Care Patients: An Evaluation Study of a Medical Center Affiliated Home Care Unit in Taiwan.

The LACE index and HOSPITAL score models are the two most commonly used prediction models identifying patients at high risk of readmission with limited information for home care patients. This study compares the effectiveness of these two models in predicting 30-day readmission following acute hospitalization of such patients in Taiwan. A cohort of 57 home care patients were enrolled and followed-up for one year. We compared calibration, discrimination (area under the receiver operating curve, AUC), and net reclassification improvement (NRI) to identify patients at risk of 30-day readmission for both models. Moreover, the cost-effectiveness of the models was evaluated using microsimulation analysis. A total of 22 readmissions occurred after 87 acute hospitalizations during the study period (readmission rate = 25.2%). While the LACE score had poor discrimination (AUC = 0.598, 95% confidence interval (CI) = 0.488-0.702), the HOSPITAL score achieved helpful discrimination (AUC = 0.691, 95% CI = 0.582-0.785). Moreover, the HOSPITAL score had improved the risk prediction in 38.3% of the patients, compared with the LACE index (NRI = 0.383, 95% CI = 0.068-0.697, p = 0.017). Both prediction models effectively reduced readmission rates compared to an attending physician's model (readmission rate reduction: LACE, 39.2%; HOSPITAL, 43.4%; physician, 10.1%; p < 0.001). The HOSPITAL score provides a better prediction of readmission and has potential as a risk management tool for home care patients.

Risk of Parkinson's disease among patients with herpes zoster: a nationwide longitudinal study.

OBJECTIVE: Several studies suggested a potential role of viral infection in the pathophysiology of Parkinson's disease (PD). However, the association between herpes zoster and PD was not investigated well till now. METHODS: Using the Taiwan National Health Insurance Research Database, 13 083 patients aged ≥45 years with herpes zoster and 52 332 (1:4) age-/sex-matched controls were enrolled between 1998 and 2008 and followed to the end of 2011. Those who developed PD during the follow-up period were identified. RESULTS: The Cox regression analysis with adjustment of demographic characteristics, health system utilization, and comorbidities demonstrated that patients with herpes zoster had an increased risk (hazard ratio [HR]: 1.80, 95% confidence interval [CI]: 1.43-2.28) of developing PD in later life compared to the control group. Sensitivity tests after excluding the first year (HR: 1.50, 95% CI: 1.16-1.93) and first 2-year (HR: 1.44, 95% CI: 1.10-1.88) observation periods showed consistent results. CONCLUSIONS: Patients with herpes zoster were more likely to develop PD in later life compared to the controls. Additional studies are necessary for validating our results and to clarify the underlying pathophysiology between herpes zoster and PD.

Lots of little ones: Analysis of charitable donations to a hospice and palliative care unit in Taiwan.

BACKGROUND: Charitable donations play a major role in the provision of hospice and palliative care (HPC) services, most of which are not reimbursed by health insurance programs. A good understanding of the constitution and use of donations is thus conducive to maintaining a high-quality HPC unit. METHODS: The data sources were the publicly available balance sheet, work report, and donor lists of a foundation exclusively supporting one of the best HPC units in Taiwan in the fiscal year of 2017. The analysis included the donation amounts and frequencies by donor type (individual, corporate, and group) and the categories of expenses. RESULTS: The foundation received 3033 donations worth a total of 7.8 million New Taiwan dollars (NTD) (approximately 258 thousand US dollars) in 2017. Two-thirds of the donations were allocated to the provision of direct care services. Of the 3033 donations, only 11 (0.4%) were worth 100 000 NTD or more, while 108 (3.6%) were valued between 10 000 and 99 999 NTD, 1268 (41.8%) were valued between 1000 and 9999 NTD, and 1646 (54.2%) were worth less than 1000 NTD. Of 1051 donors, 974 (92.7%) were individuals, 378 (36.0%) donated more than once, and 106 (10.1%) donated 12 or more times in one year. CONCLUSION: HPC services in Taiwan are sponsored by lots of individuals and small donations. For sustainability of standards-based and quality HPC services, the benevolence of the public should be thus cherished and adequately responded to.

Factors Associated with Access of Marital Migrants and Migrant Workers to Healthcare in Taiwan: A Questionnaire Survey with Quantitative Analysis.

In Taiwan, migrants come mostly for marriage and work. Several researchers have conducted health-related studies of marital migrants and migrant workers, but the access of the two groups to healthcare has not been studied. Therefore, our study investigated the factors associated with migrants' access to healthcare, with the main foci being marital migrants and migrant workers in Taiwan. A structured and cross-sectional questionnaire was anonymously self-administered by migrants recruited to participate in this survey on a voluntary basis from 11 medical centers and 11 migrant-helping associations in Taiwan between May 1st and September 21st, 2018. A total of 753 questionnaires were analyzed. The majority of marital migrants (n = 243) and migrant workers (n = 449) surveyed were enrolled in Taiwan's National Health Insurance system (92.7 vs. 93.5%, p = 0.68). More of the migrant workers (n = 205) than the marital migrants (n = 42) encountered language barriers while seeking medical services (48.0 vs. 17.1%, p < 0.001). A professional interpreter at the point of care was considered important by more of the migrant workers (n = 316) than the marital migrants (n = 89) (70.2 vs. 39.6%, p < 0.001). Although more than 90% of the surveyed migrants were enrolled in the health insurance system in Taiwan, many, especially among the migrant workers, still faced language barriers while seeking medical services.

Age threshold for the use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with atrial fibrillation: insights into the optimal assessment of age and incident comorbidities.

AIMS: The stroke risk of patients with atrial fibrillation (AF) is not static, since AF patients get older and accumulate more comorbidities after AF is diagnosed. Therefore, the stroke risk of AF patients given certain comorbidities in different age strata should ideally be analysed using an assessment which considers incident comorbidities and the actual age when ischaemic stroke occurred. The goal of the present study is to report the age treatment thresholds for the use of non-vitamin K antagonist oral anticoagulants (NOACs) for AF patients without or with only one comorbidity of the CHA2DS2-VASc score, based on an 'ideal method' of stroke risk assessments. METHODS AND RESULTS: The study cohort included 31 039 and 39 020 AF patients who did not have any or had only one risk factor comorbidity of the CHA2DS2-VASc score except for age and sex. The risks of ischaemic stroke in each age strata for each comorbidities were analysed in three ways, as follows: (i) the conventional way (based on baseline risk factors and age), (ii) dynamic method (patients were censored when new comorbidities occurred), and (iii) an ideal method (patients were censored when new comorbidities occurred and the stroke risk was related to the actual age when stroke happened). The tipping point for the use of NOACs was set at a stroke risk of 0.9%/year. The overall risk of ischaemic stroke using the conventional way was overestimated compared to the dynamic or ideal assessment with the incidence rate ratio of 1.24 for patients with hypertension, 1.20 for heart failure, 1.37 for diabetes mellitus, and 1.38 for vascular diseases; all P-values <0.01. The risk of ischaemic stroke for each age strata was generally higher with the conventional or dynamic methods compared with the ideal assessment. With heart failure, the tipping point (age 35 years) of NOACs was similar, irrespective of methods used for stroke risk assessment. According to the results of ideal assessment, the age thresholds for the use of NOACs for patients with hypertension, diabetes mellitus, and vascular diseases were 50 years, 50 years, and 55 years, respectively. CONCLUSION: Ischaemic stroke risk in AF is heterogeneous, depending on different risk factors with age being as an important driver of stroke risk. Age thresholds for the use of NOACs were different for AF patients having different single risk factors beyond sex despite the same CHA2DS2-VASc score point (1 for males and 2 for females); that is, 35 years for heart failure, 50 years for hypertension or diabetes, and 55 years for vascular diseases.

Rural-urban disparities in family physician practice patterns: A nationwide survey in Taiwan.

INTRODUCTION: In a world with increasing urbanization, rural-urban disparities in health care utilization have been a long-term concern. However, the details regarding the practice patterns of family physicians in Taiwan have not received sufficient attention thus far. METHODS: The National Health Insurance Research Database of Taiwan offered 0.2% of the total ambulatory visit records for Taiwan in 2013. Records from community clinics of family medicine were collected, with the clinics categorized as rural, suburban, or urban area clinics according to their locations. RESULTS: Among 100 334 visits to family medicine clinics, the median patient age was 50 years for urban clinics, 51 for suburban clinics, and 58 for rural clinics. The distributions of patient ages differed in the three areas (P < 0.001). Four types of chronic diseases (cardiovascular diseases, diabetes, chronic respiratory diseases, and cancers) accounted for 10.8%, 11.3%, and 13.6%, of the visits to urban, suburban, and rural clinics, respectively. The most common procedure was wound treatment, and the pattern of the top 10 procedures was similar in the three areas. CONCLUSION: Although rural patients in Taiwan were older and had more chronic diseases than urban and suburban patients, the pattern of procedures undertaken by rural family physicians did not differ from those of urban and suburban family physicians.

Urban-rural disparities in office-based dermatological services in Taiwan - a nationwide survey.

INTRODUCTION: Shortages and maldistribution of dermatology services have negative impacts on the quality of care for patients with skin problems. Only a limited amount of literature is available regarding the current state of dermatologic services in Taiwan. The aim of this study was to examine the urban-rural distribution of dermatologists and office-based dermatology services in Taiwan. METHODS: Data regarding dermatology workforce and their geographic distribution were collected from the Taiwan Medical Association, Taiwan Dermatological Association, and Department of Household Registration, Ministry of the Interior, while data on the locations and opening hours of dermatologic clinics were sourced from the National Health Insurance Administration. The locations and opening times of dermatologic clinics were stratified by urbanisation levels. RESULTS: There were 4.27 dermatologists per 100 000 persons in Taiwan. Taipei City was the most dermatologist-dense area (9.61 dermatologists per 100 000 people), while Lienchiang County had no dermatologists at all. Among the 444 office-based dermatologic clinics in Taiwan, the overwhelming majority were located in urban (77.5%) and suburban (20.9%) areas, with two-thirds of towns in Taiwan (67.1%, n=247) having no dermatologic clinics at all. On average, the clinics provided 14.9 service sessions per week (standard deviation 3.04). Altogether, only 57.1% of the rural clinics were open during any of Saturday evening, Sunday daytime and Sunday evening, while the corresponding percentage was 75.9% for urban areas. Statistical analysis shows that the open ratios in suburban areas were significantly lower than those in urban areas on Saturday evening, Sunday daytime and Sunday evening (p<0.001), while urban and rural areas had no significant difference in open ratios on these three sections. CONCLUSIONS: In Taiwan, dermatologists are unevenly geographically distributed, with most practising in urban areas. Also, there are remarkable urban-rural disparities in the availability of services on Saturday evening, Sunday daytime and Sunday evening.

A Doctor's Name as a Brand: A Nationwide Survey on Registered Clinic Names in Taiwan.

In countries where the private clinics of physicians can be freely named, registering a clinic with a physician's name is one way to make patients familiar with the physician. No previous study had investigated how clinics make use of this method of personal branding. Therefore, the current study analyzed 10,847 private physician Western medicine clinics in Taiwan. Of those clinics, 31.0% (n = 3363) were named with a physician's full name, 8.9% (n = 960) with a surname, and 8.1% (n = 884) with a given name. The proportion of clinics registered with a physician's name was lower in rural areas (37.3%) than in urban (48.5%) and suburban areas (49.2%), respectively. Among clinics with only one kind of specialist, a physician's name was used most frequently in clinics of obstetrics and gynecology (64.9%), otorhinolaryngology (64.1%), and dermatology (63.4%). In Taiwan, fewer than half of clinics used a physician's name as a brand. The sociocultural or strategic factors and real benefits of doing so could be further studied in the future for a better understanding of healthcare services management.

Temporal availability of obstetrics and gynecology clinics in Taiwan: A nationwide survey.

OBJECTIVE: Obstetrician-gynecologists are the main providers of women's healthcare. However, workforce shortages and excessive workloads among these providers have been encountered in many countries. While most past studies on this subject have investigated the spatial distribution of obstetrics-gynecology clinics, few have focused on their temporal availability, especially on the national level. MATERIALS AND METHODS: The weekly opening time schedules (divided into morning, afternoon, and evening sessions) of all obstetrics-gynecology clinics in Taiwan were extracted from the web site of Taiwan's National Health Insurance Administration in July 2015. The numbers of open sessions were then analyzed and stratified by urbanization level and practice type. RESULTS: Among 742 obstetrics-gynecology clinics in Taiwan, 521 were located in urban areas, 194 in suburban areas, and 27 in rural areas. The numbers of open sessions per week in suburban areas were higher than those in urban and rural areas (16.7 ± 2.6 vs. 15.9 ± 3.1 and 15.9 ± 2.7). Group practices had more open sessions per week than solo practices (16.8 ± 2.8 vs. 15.8 ± 3.0). With respect to after-hours services in rural areas, only two rural obstetrics-gynecology clinics remained open on Sunday mornings, while none remained open on Sunday afternoons and evenings. CONCLUSION: Obstetrics-gynecology clinics in Taiwan offered great temporal availability. In addition to the remarkable urban-rural disparity in the distribution of obstetrics-gynecology clinics, the availability of services on Sundays in rural areas demands special attention.

Comorbidities and risk of mortality in patients with sleep apnea.

BACKGROUND: A variety of disorders, most notably cardiovascular diseases, was linked to sleep apnea (SA), but their impact on mortality of SA patients had not been systematically investigated. We aimed to develop a composite index based on the comorbidity burden to predict mortality risk. METHODS: Using Taiwan National Health Insurance Research Database, 9853 adult SA patients were enrolled and their comorbidity profile at baseline was recorded. The subjects were followed from 1995 till death or the end of 2011. A Cox regression model was used for multivariable adjustment to identify independent predictors for mortality. RESULTS: During an average follow-up period of 5.3 ± 3.1 years, 311 (3.2%) subjects died. SA patients with any comorbidity had a higher risk for death compared to those without comorbidity (HR: 11.01, 95% CI 4.00-30.33, p < 0.001). Age and 10 comorbidities related to increased overall mortality were identified, from which the CoSA (Comorbidities of Sleep Apnea) index was devised. The corresponding hazard ratios for patients with CoSA index scores of 0, 1-3, 4-6, and >6 were 1 (reference), 3.29 (95% CI, 2.04-5.28, p < 0.001), 13.56 (95% CI, 8.63-21.33, p < 0.001), and 38.47 (95% CI, 24.92-59.38, p < 0.001), respectively. CONCLUSIONS: Based on the comorbidity burden, we developed an easy-to-use tool to evaluate mortality risk in SA. Key messages: Sleep apnea (SA) is linked to a variety of disorders, particularly cardiovascular diseases. SA patients with any comorbidity may experience a higher risk of death in comparison to those without comorbidity. Comorbidities related to increased mortality are identified and converted into a simple risk indicator, the CoSA (Comorbidities of Sleep Apnea) index scores, which may help to stratify risk of death in daily practice.

Branding Palliative Care Units by Avoiding the Terms "Palliative" and "Hospice".

The term "palliative care" has a negative connotation and may act as a barrier to early patient referrals. Rebranding has thus been proposed as a strategy to reduce the negative perceptions associated with palliative care. For example, using the term "supportive care" instead of "palliative care" in naming palliative care units has been proposed in several studies. In Taiwan, terms other than "palliative" and "hospice" are already widely used in the names of palliative care units. With this in mind, this study investigated the characteristics of palliative care unit names in order to better understand the role of naming in palliative care. Relevant data were collected from the Taiwan Academy of Hospice Palliative Medicine, the National Health Insurance Administration of the Ministry of Health and Welfare, and the open database maintained by the government of Taiwan. We found a clear phenomenon of avoiding use of the terms "palliative" and "hospice" in the naming of palliative care units, a phenomenon that reflects the stigma attached to the terms "palliative" and "hospice" in Taiwan. At the time of the study (September, 2016), there were 55 palliative care units in Taiwan. Only 20.0% (n = 11) of the palliative care unit names included the term "palliative," while 25.2% (n = 14) included the term "hospice." Religiously affiliated hospitals were less likely to use the terms "palliative" and "hospice" (χ2 = 11.461, P = .001). There was also a lower prevalence of use of the terms "palliative" and "hospice" for naming palliative care units in private hospitals than in public hospitals (χ2 = 4.61, P = .032). This finding highlights the strong stigma attached to the terms "palliative" and "hospice" in Taiwan. It is hypothesized that sociocultural and religious factors may partially account for this phenomenon.

Urban-Rural Disparity in Geographical and Temporal Availability of Pediatric Clinics: A Nationwide Survey in Taiwan.

BACKGROUND: The shortage and maldistribution of pediatricians affected after-hours pediatric services, especially in rural areas. Our study aimed to examine the urban-rural disparity in geographical and temporal availability of the pediatrician workforce in Taiwan by analyzing opening time schedules of all pediatric clinics throughout the country. METHODS: The opening time schedules of nonhospital pediatric clinics were downloaded from the website of the National Health Insurance Administration in Taiwan for analysis. The geographical and temporal availability of pediatric clinics was calculated and stratified by urbanization level and opening time, which was divided into daytime and evening sessions over 1 week. Each of 368 towns in Taiwan was also regarded as a unit of measurement to estimate the local availability of at least one pediatric clinic open in after-hours sessions. RESULTS: Among 1483 nonhospital pediatric clinics in Taiwan, the overwhelming majority were situated in urban (65.8%) and suburban (30.6%) areas. On average, a pediatric clinic provided 16.3 (standard deviation=3.04) sessions of services per week. One-third (34.7%, n=50) of 144 suburban towns and over three-fourths (77.4%, n=120) of 155 rural towns had no pediatric clinic. Most pediatric clinics remained open on weekday evenings (91.1%) and during Saturday daytime (91.8%). The percentage of open clinics gradually decreased over the weekend: Saturday evening (58.1%), Sunday daytime (33.4%), and Sunday evening (19.4%). Rural pediatric clinics remained closed mostly on weekends. On Sunday evenings, pediatric clinics were open only in 5.2% of rural towns, with a decline of 77.1%, whereas they were open in 78.3% of urban towns, with a decline of 18.2%. CONCLUSION: Pediatric clinics in Taiwan were unevenly distributed between urban and rural areas. The disparity of pediatric services became more obvious at weekends. The consequences of undersupplied rural pediatric care deserve further investigation.

Medical care utilization and costs on end-of-life cancer patients: The role of hospice care.

Although there are 3 hospice care programs for terminal cancer patients in Taiwan, the medical utilization and expenses for these patients by programs have not been well-explored. The aim of this study was to examine the medical utilization and expenses of terminal cancer patients under different programs of hospice care in the last 90, 30, and 14 days of life.This was a retrospective observational study by secondary data analysis. By using the National Health Insurance claim database and Hospice Shared Care Databases. We identified cancer descents from these databases and classified them into nonhospice care and hospice care groups based on different combination of hospice care received. We then analyzed medical utilization including inpatient care, outpatient care, emergency room visits, and medical expenses by patient groups in the last 90, 30, and 14 days of life.Among 118,376 cancer descents, 46.9% ever received hospice care. Patients had ever received hospice care had significantly lower average medical utilization and expenses in their last 90, 30, and 14 days of life (all P < 0.001) compared to nonhospice care group. Each hospice care group had significantly less medical utilization and expenses in the last 90, 30, and 14 days of life (all P < 0.01).Different kinds of hospice care program have different effects on medical care utilization reduction and cost-saving at different stage of the end of life of terminal cancer patients.

Impact on Outcomes of Changing Treatment Guideline Recommendations for Stroke Prevention in Atrial Fibrillation: A Nationwide Cohort Study.

OBJECTIVE: To investigate the impact on outcomes of changing treatment guideline recommendations by comparing the proportion of patients with atrial fibrillation (AF) recommended oral anticoagulants (OACs) under the 2011 and 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. PATIENTS AND METHODS: We used the "National Health Insurance Research Database" in Taiwan, which included 354,649 patients with AF from January 1, 1996 through December 31, 2011. Patients with a CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score of 2 or more and a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex category) score of 2 or more were considered to have a definitive indication for receiving OACs according to the 2011 and 2014 ACC/AHA guidelines, respectively. RESULTS: The percentages of patients with AF recommended OACs increased from 69.3% (n=245,598) under the 2011 guideline to 86.7% (n=307,640) under the new 2014 guidelines, an increment of 17.5% (95% CI, 17.4-17.6). Most women with AF (94.1%) and patients older than 65 years (97.2%) would receive OACs on the basis of the 2014 guidelines. Among patients previously not being recommended OACs in older guidelines, OAC use under the new guidelines was associated with a lower risk of adverse outcomes (ischemic stroke or intracranial hemorrhage or bleeding requiring blood transfusion or mortality) with an adjusted hazard ratio of 0.89 (95% CI, 0.85-0.94). CONCLUSION: In this nationwide cohort study, use of the 2014 guidelines led more patients with AF to receive OACs for stroke prevention, and this increased OAC use was associated with better outcomes. Better efforts to implement guidelines would lead to improved outcomes for patients with AF.