Population-based assessment of factors influencing antibiotic prescribing for adults with dengue infection in Taiwan.

BACKGROUND: Antibiotic treatment for dengue is likely considerable and potentially avoidable but has not been well characterized. This study aimed to assess antibiotic prescribing for confirmed dengue cases in outpatient and inpatient settings and to identify associated patient, physician and contextual factors. METHODS: 57,301 adult dengue cases reported in Taiwan between 2008-2015 were analyzed. We assessed both outpatient and inpatient claims data of dengue patients from a week before to a week after their dengue infections were confirmed under Taiwan's National Health Insurance program. A multivariable logistic regression with generalized estimating equations was used to estimate the probability of antibiotic prescribing in dengue patients. RESULTS: Overall, 24.6% of dengue patients were prescribed an antibiotic during the 14 day-assessment period. Antibiotics were prescribed in 6.1% and 30.1% of outpatient visits and inpatient admissions, respectively. Antibiotic prescriptions were reduced by ~50% in epidemic years. Among inpatients, advanced age, females, and major comorbidities were risk factors for receipt of an antibiotic; antibiotics were used in 26.0% of inpatients after dengue was diagnosed. Significant differences in antibiotic prescribing practices were observed among physicians in outpatient settings but not in inpatient settings. CONCLUSIONS: In addition to patient and physician demographic characteristics, contextual factors such as care setting and during epidemics significantly influenced prescription of antibiotics. Characterization of prescribing patterns should help direct programs to curb antibiotic prescribing.

Long-Term Rehabilitation Utilization Pattern Among Stroke Patients Under the National Health Insurance Program.

OBJECTIVE: The aim of this study was to understand the frequency of patients receiving rehabilitation services at various periods after stroke and the possible medical barriers to receiving rehabilitation. DESIGN: A retrospective cohort study was conducted using a nationally representative sample in Taiwan. A total of 14,600 stroke patients between 2005 and 2011 were included. Utilization of physical therapy or occupational therapy at different periods after stroke onset was the outcome variable. Individual and geographic characteristics were investigated to determine their effect on patients' probability of receiving rehabilitation. RESULTS: More severe stroke or more comorbid diseases increased the odds of receiving physical therapy and occupational therapy; older age was associated with decreased odds. Notably, sex and stroke type influenced the odds of rehabilitation only in the early period. Copayment exemption lowered the odds of rehabilitation in the first 6 mos but increased the odds in later periods. Rural and suburban patients had significantly lower odds of receiving physical therapy and occupational therapy, as did patients living in areas with fewer rehabilitation therapists. CONCLUSIONS: Besides personal factors, geographic factors such as urban-rural gaps and number of therapists were significantly associated with the utilization of post-stroke rehabilitation care. Furthermore, the influence of certain factors, such as sex, stroke type, and copayment exemption type, changed over time.

A Population-Based Cohort Study on Chronic Comorbidity Risk Factors for Adverse Dengue Outcomes.

The global burden of dengue is increasing against a background of rising global prevalence of chronic noncommunicable diseases (NCDs) and an epidemiological shift of dengue toward older age groups. The contribution of NCDs toward risk for adverse clinical and healthcare utilization outcomes was assessed in a national linked-database study. About 51,433 adult dengue cases between 2014 and 2015 were assessed for outpatient and inpatient claims data in Taiwan's National Health Insurance Research Database for the 30 days after their dengue diagnosis. A multivariable logistic regression with generalized estimating equations was used to estimate the probability of adverse dengue outcomes in patients with NCDs compared with dengue patients without underlying diseases. Rheumatoid arthritis and related disease were associated with the highest risk of hospitalization after dengue diagnosis (odds ratio: 1.78; 95% CI: 1.37-2.30), followed by stroke, chronic kidney disease (CKD), liver cirrhosis, asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes, congestive heart failure, hypertension, and malignancy. Chronic kidney disease and diabetes were associated with higher risks of hospitalization, intensive care unit (ICU) use, and all-cause mortality. After adjusting for socioeconomic status and other variables, the number of coexisting chronic diseases was associated with increasing risk of adverse dengue outcomes. Specific NCDs were associated with longer hospitalizations, ICU admission, and higher healthcare costs. Quantifying the risks of adverse dengue outcomes and health expenditures among dengue patients with preexisting NCDs provides insights for improved clinical management and essential inputs for health economic analyses on the cost-benefit of risk-based routine or catch-up immunization programs.

Patient-sharing relationship between Chinese medicine doctors and other physicians: costs and outcomes of breast cancer survivorship care.

PURPOSE: Breast cancer survivors represent a unique group of patients who need complex and continuous care after their cancer treatment. These patients often see several providers in various specialties. This study aimed to analyze how traditional Chinese medicine (TCM) integration within care networks of patients with breast cancer might be related to health care costs and patient outcomes under the National Health Insurance program in Taiwan. METHODS: We enrolled all patients who underwent definitive mastectomy for newly diagnosed breast cancer between 2007 and 2015. We analyzed the presence of TCM physicians and the patient-sharing relationship between TCM physicians and other physicians during the first year after mastectomy. The outcomes included all-cause mortality, avoidable hospitalization, and medical expenditures. RESULTS: There were 68,987 patients with breast cancer, with a median age of 53 years. After propensity score matching, patients whose TCM doctors had the highest connectedness with other physicians had the lowest odds of avoidable hospitalization (adjusted odds ratio 0.86; 95% confidence interval [CI], 0.78-0.96) and lowest hazard of mortality (adjusted hazard ratio, 0.82; 95% CI, 0.72-0.93), followed by those with TCM doctors with medium connectedness, then low connectedness, and lastly those patients with no TCM doctor in their care network. CONCLUSIONS: A dose-response pattern was observed regarding the relationship between TCM doctor's connectedness with other physicians within a patient's care network and patient outcomes. IMPLICATIONS FOR CANCER SURVIVORS: The findings demonstrated that stronger connectedness between TCM and other physicians could help improve the health outcomes of breast cancer survivors.

Low acuity paediatric emergency visits under single-payer universal health insurance in Taiwan, 2000-2015: a population-based repeated cross-sectional design.

OBJECTIVES: Emergency services utilisation is a critical policy concern. The paediatric population is the main user of emergency department (ED) services, and the main contributor to low acuity (LA) ED visits. We aimed to describe the trends of ED and LA ED visits under a comprehensive, universal health insurance programme in Taiwan, and to explore factors associating with potentially unnecessary ED utilisation. DESIGN AND SETTING: We used a population-based, repeated cross-sectional design to analyse the full year of 2000, 2005, 2010 and 2015 National Health Insurance claims data individually for individuals aged 18 years and under. PARTICIPANTS: We identified 5 538 197, 4 818 213, 4 401 677 and 3 841 174 children in 2000, 2005, 2010 and 2015, respectively. PRIMARY AND SECONDARY OUTCOME MEASURES: We adopted a diagnosis grouping system and severity classification system to define LA paediatric ED (PED) visits. Generalised estimating equation was applied to identify factors associated with LA PED visits. RESULTS: The annual LA PED visits per 100 paediatric population decreased from 10.32 in 2000 to 9.04 in 2015 (12.40%). Infectious ears, nose and throat, dental and mouth diseases persistently ranked as the top reasons for LA visits (55.31% in 2000 vs 33.94% in 2015). Physical trauma-related LA PED visits increased most rapidly between 2000 and 2015 (0.91-2.56 visits per 100 population). The dose-response patterns were observed between the likelihood of incurring LA PED visit and either child's age (OR 1.06-1.35 as age groups increase, p<0.0001) or family socioeconomic status (OR 1.02-1.21 as family income levels decrease, p<0.05). CONCLUSION: Despite a comprehensive coverage of emergency care and low cost-sharing obligations under a single-payer universal health insurance programme in Taiwan, no significant increase in PED utilisation for LA conditions was observed between 2000 and 2015. Taiwan's experience may serve as an important reference for countries considering healthcare system reforms.

Reducing low value services in surgical inpatients in Taiwan: Does diagnosis-related group payment work?

Reducing low-value care is a top priority in health care. However, how prospective payment methods such as diagnosis-related group (DRG) payment scheme reduce the use of low-value services is unclear. This study aimed to assess frequency of low-value preoperative testing services among surgical inpatients over time and to investigate whether the 2010 Tw-DRG policy has reduced utilization of these services under the National Health Insurance program in Taiwan. The nationwide National Health Insurance claims data in Taiwan from 2008 to 2013 were used. The difference-in-differences (DID) method was adopted. Utilization of three low-value preoperative testing services (chest x-ray, echocardiogram, and stress testing) were assessed. The prevalence of the three preoperative tests ranged from 0.13 per 100 admissions (preoperative stress testing) to 78.12 per 100 admissions (preoperative chest x-ray). Following the implementation of the Tw-DRG policy, the predicted probability of low-value care use was significantly reduced from 67.91% to 64.93% in the DRG group but remained relatively stable in the comparison group (from 69.44% to 68.43%) in 2010. The use of three selected preoperative tests had only a minor temporary reduction in 2010, but later increased over time. The 2010 Tw-DRG policy did not significantly moderate the growth of low-value preoperative use. Hospital financial incentives alone may be insufficient for reducing the provision of low-value care.

Variation in the 11-year trajectories of medical care seeking behaviors in diabetes patients under a single payer system: persisting gaps to be filled.

BACKGROUND: Care-seeking behavior is widely acknowledged to have strong influences on health outcomes among individuals with chronic conditions including diabetes. Despite its dynamic nature, care seeking behavior are often considered as time invariant in most studies. The likelihood of patients changing their regularity and source of chronic care over time is often neglected. This study aimed to determine the long-term trajectories of care-seeking patterns of both care-seeking regularity and health provider choices; and their associated factors among patients with type 2 diabetes under the National Health Insurance (NHI) program in Taiwan. METHODS: We utilized population-based data from the National Health Insurance Research Database (NHIRD) in Taiwan. Three thousand, nine hundred and eighty-seven adult patients with newly diagnosed type 2 diabetes in 1999 were enrolled in the cohort. We assessed their trajectories of regular care visits and sources of diabetes care from 2000 to 2010. A group-based trajectory model was applied. RESULTS: Seven distinct groups of long-term care-seeking patterns were identified. Only 51.44% of patients with newly diagnosed diabetes had regularly visited their providers over time. Among them, 56.41 and 16.09% had persistently sought care from generalized and specialized providers, respectively. 27.50% had sought care from different levels of providers. Patients who were male, elderly, low-income, and had a higher baseline diabetes severity were significantly more likely to either continue with their irregular care-seeking behavior or fail to maintain their regular care seeking behavior over time. Those who were younger, had a higher socioeconomic status, and lived in an urban area were significantly more likely to persistently seek care from specialized care settings. CONCLUSIONS: This study is the first population-based assessment of long-term care-seeking behaviors of type 2 diabetes patients under a single-payer system with a comprehensive benefit coverage. The most alarming finding was that, despite the existence of the comprehensive universal health insurance coverage in Taiwan, almost 50% of patients did not seek or maintain regular visits to providers over time as recommended. Understanding variations in the long-term trajectories of care adherence and sources of care may help to identify gaps in diabetes care management.

Effects of National Health Insurance on household out-of-pocket expenditure structure.

Achieving universal health insurance coverage is a major objective for many countries. Taiwan implemented its National Health Insurance (NHI) program with universal coverage in 1995. This study investigates whether the NHI program affects the level and structures of out-of-pocket (OOP) health expenditures. We used data from the Taiwan Survey of Family Income and Expenditure released by the Directorate-General of Budget, Accounting and Statistics. We identified a case and a control group and then employed coarsened exact matching to match the two groups using several available variables. We then conducted a difference-in-difference analysis and determined that there was a statistically significant negative effect on OOP expenditure that was attributable to NHI (a reduction of 2.11 percentage points in total household expenditure). The largest reductions were found in health care services (-1.63%) and pharmaceuticals (-0.45%). We found a statistically significant positive effect on purchases of private insurance related to health care, which was attributable to NHI (an increase of 0.96 percentage points in household budget share). In addition, we discovered that the NHI program had a greater impact on households of a lower socioeconomic status compared with higher socioeconomic status households. The structure of OOP payments in the post-NHI period remained similar to that of the pre-NHI period in the full sample but varied slightly depending on the educational level of the head of the household.

Public Trust in Physicians-Health Care Commodification as a Possible Deteriorating Factor: Cross-sectional Analysis of 23 Countries.

Trust in physicians has declined, and surveys of public opinion show a poor level of public trust in physicians. Commodification of health care has been speculated as a plausible driving force. We used cross-national data of 23 countries from the International Social Survey Programme 2011 to quantify health care commodification and study its role in the trust that patients generally place in physicians. A modified health care index was used to quantify health care commodification. There were 34 968 respondents. A question about the level of general trust in physicians and a 4-item "general trust in physicians" scale were used as our major and minor outcomes. The results were that compared with those in the reference countries, the respondents in the health care-commodified countries were approximately half as likely to trust physicians (odds ratio: 0.47, 95% confidence interval [CI]: 0.31-0.72) and scored 1.13 (95% CI: 1.89-0.37) less on the general trust scale. However, trust in physicians in the health care-decommodified countries did not differ from that in the reference countries. In conclusion, health care commodification may play a meaningful role in the deterioration of public trust in physicians.

Effect of Continuity of Care on Drug-Drug Interactions.

BACKGROUND: Drug-drug interaction (DDI) is a critical concern in health care systems because it is directly associated with patient outcomes and is generally preventable. However, few studies have been conducted on whether poor continuity of care (COC) is a determinant of DDIs and whether this effect varies by level of comorbidity. Patients with higher comorbidity normally require more complex treatment regimens than other patients, and hence their COC is more critical for ensuring the accuracy of their medication information. OBJECTIVE: This study investigated the association between COC and DDI, with COC being measured as physician and site COC. The effect of comorbidities on DDI events was also analyzed. METHODS: The Taiwan National Health Insurance claims data of ∼1,000,000 randomly selected insurance beneficiaries were used. Each person was longitudinally followed from 2005 to 2013. Negative nominal regressions were estimated to determine the effect of COC on DDI. RESULTS: Higher COC was found to decrease the risk of DDI, and this risk reduction was even greater with physician COC and a higher Charlson comorbidity index. In the 1-year observation interval, patients exhibited a 3% reduction in DDIs for every 0.1 increment in their COC index. The ability of COC to reduce DDIs increased with the level of comorbidity. Similar results were observed when the observation interval was increased. CONCLUSIONS: Improving COC is critical for reducing DDIs. The effect of high-quality COC on the reduction of DDI is more significant for patients with higher levels of comorbidity; thus, they should be targeted to improve COC.

Changes in caregiver burden among informal caregivers of stroke patients in Mongolia.

BACKGROUND: Modern therapeutics and health care improvements prolong stroke patients' survival; however, the degree of disability remains high. Stroke survivors often require caregivers, particularly in the first year after the onset of the stroke. Longitudinal assessment of and factors associated with caregiver burden (CGB) among caregivers of stroke patients has been scarcely discussed. This study aimed to define the changes in CGB in the first year of caregiving among the caregivers of stroke patients and to identify associated factors. METHODS: A prospective, multi-centered observational study was conducted in nine public hospitals in Mongolia. We used the Montgomery CGB Scale for assessing CGB, and repeated the assessment after 1 year. Stroke patient characteristics were included in the analyses. Multinomial logistic regressions were conducted to analyze changes in CGB. RESULTS: A paired t-test analysis revealed that demand burden increased (from 12.61 to 11.50, p = 0.034), whereas stress burden decreased (from 10.69 to 11.60, p = 0.016). Although objective burden decreased, the difference was not significant. Factors associated with these changes in CGB were the caregiver's marital status, the caregiver's relationship with the patient, financial difficulties, and the patient's sex and dependency. DISCUSSION: The information on factors predicting changes in CGB in the first year of caregiving provided in this study suggests that social or financial support can assist in reducing CGB among the caregivers of post-stroke patients.

Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study.

BACKGROUND: Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD. METHODS: We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients. RESULTS: During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care. CONCLUSIONS: Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.

Relationship between women's characteristics and continuum of care for maternal health in Kenya: Complex survey analysis using structural equation modeling.

The objective of this study was to understand and estimate the complex relationships in the continuum of care for maternal health to provide information to improve maternal and newborn health outcomes. Women (n = 4,082) aged 15-49 years in the 2008/2009 Kenya Demographic and Health Survey data were used to explore the complex relationships in the continuum of care for maternal health (i.e., before, during, and after delivery) using structural equation modeling. Results showed that the use of antenatal care was significantly positively related to the use of delivery care (ß = 0.06; adjusted odds ratio [AOR] = 1.06; 95% confidence interval [CI]: 1.02-1.10) but not postnatal care, while delivery care was associated with postnatal care (ß = 0.68; AOR = 1.97; 95% CI: 1.75-2.22). Socioeconomic status was significantly related to all elements in the continuum of care for maternal health; barriers to delivery of care and personal characteristics were only associated with the use of delivery care (ß = 0.34; AOR = 1.40; 95% CI: 1.30-1.52) and postnatal care (ß = 0.03; AOR = 1.03; 95% CI: 1.01-1.05), respectively. The three periods of maternal health care were related to each other. Developing a referral system of continuity of care is critical in the Sustainable Development Goals era.

Older Age, Low Socioeconomic Status, and Multiple Comorbidities Lower the Probability of Receiving Inpatient Rehabilitation Half a Year After Stroke.

OBJECTIVE: To determine the predictors of receiving inpatient rehabilitation during 7 to 12 months after stroke. DESIGN: Retrospective cohort study. SETTING: A nationally representative sample of 1 million National Health Insurance enrollees. PARTICIPANTS: Patients with new-onset stroke (N=13,828) were included. Studied participants were patients who received inpatient rehabilitation during 4 to 6 months after stroke. Patients who died within 1 year of the stroke event were excluded (n=488). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The outcome variable of interest was the probability of receiving inpatient rehabilitation during 7 to 12 months after stroke. The characteristics of both patients and medical care providers were investigated to determine their effect on patients receiving inpatient rehabilitation. RESULTS: Older patients, patients of low socioeconomic status, patients with Charlson Comorbidity Index ≥5, and patients who received outpatient rehabilitation during 4 to 6 months after stroke have a lower rate of receiving inpatient rehabilitation than do their counterparts. In addition, receiving inpatient rehabilitation during 7 to 9 months after stroke is a strong positive predictor of receiving inpatient rehabilitation during 10 to 12 months after stroke (odds ratio, 38.556; P<.0001). CONCLUSIONS: This study revealed that older age, lower socioeconomic status, and multiple comorbidities are negative predictive factors with a cumulative predictive power for the probability of receiving inpatient rehabilitation during 7 to 12 months after stroke.

Does Pay-For-Performance Program Increase Providers Adherence to Guidelines for Managing Hepatitis B and Hepatitis C Virus Infection in Taiwan?

BACKGROUND: Many people are concerned about that the quality of preventive care for patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is suboptimal. Taiwan, a hyperendemic area of chronic HBV and HCV infection, implemented a nationwide pay-for-performance (P4P) program in 2010, which aimed to improve the preventive care provided to HBV and HCV patients by increasing physicians' adherence to guidelines through financial incentives. The objective of this study was to evaluate the early effects of the P4P program on utilization of preventive services by HBV and HCV patients. METHODS: Using a quasi-experimental design with propensity score matching method, we matched the HBV and HCV patients enrolled in the P4P program with non-enrollees in 2010, resulting in 21,643 patients in each group. Generalized estimating equations was applied to examine the difference-in-difference effects of P4P program enrollment on the utilization of three guideline-recommended preventive services (regular outpatient follow-up visits, abdominal ultrasonography (US) examinations, and aspartate aminotransferase and alanine aminotransferase (AST/ALT) tests by HBV and HCV patients. RESULTS: The P4P program enrollees were significantly more likely to attend twice-annual follow-up visits, to receive recommended US examinations and AST/ALT tests, than non-enrollees. CONCLUSIONS: The results of our preliminary assessment indicate that financial incentives offered by the P4P program was associated with a modest improvement in adherence to guidelines for better chronic HBV and HBC management.

Disease-specific Pay-for-Performance Programs: Do the P4P Effects Differ Between Diabetic Patients With and Without Multiple Chronic Conditions?

BACKGROUND: Several studies have investigated the effects of pay-for-performance (P4P) initiatives. However, little is known about whether patients with multiple chronic conditions (MCC) would benefit from P4P initiatives similarly to patients without MCC. OBJECTIVES: The objective of this study was to compare the effects of the diabetes mellitus pay-for-performance (DM-P4P) program on the quality of diabetic care between type 2 diabetic patients with and without MCC. METHODS: This study used data from Taiwan's Longitudinal Health Insurance Database 2005. Of this cohort, 52,276 diabetic patients were identified. To address potential selection bias between the intervention and comparison groups, the propensity score matching method was used. Generalized estimating equations were applied to analyze the difference-in-difference model to examine the effect of the intervention, the DM-P4P program. RESULTS: The disease-specific DM-P4P program had positive impacts on process and outcome indicators of health care quality regardless of patients' MCC status. Diabetic patients with MCC experienced a significantly larger decrease in the admission rate of diabetes-related ambulatory care sensitive conditions after the P4P enrollment over time compared with patients without MCC. CONCLUSIONS: The positive impacts on use of diabetes-related services were comparable between diabetic patients with and without MCC. Most importantly, for MCC patients, the disease-specific DM-P4P program had a stronger positive impact on health outcomes. Hence, the commonly observed phenomenon of "cherry picking" in implementing P4P strategies may lead to disparities in the quality of diabetic care between diabetic patients with and without MCC.

Associations in the continuum of care for maternal, newborn and child health: a population-based study of 12 sub-Saharan Africa countries.

BACKGROUND: Despite the progress in the Millennium Development Goals (MDGs) 4 and 5, inequity in the utilization of maternal, newborn and child health (MNCH) care services still remain high in sub-Saharan Africa (SSA). The continuum of care for MNCH that recognizes a tight inter-relationship between maternal, newborn and child health at different time periods and location is key towards reducing inequity in health. In this study, we explored the distributions in the utilization MNCH services in 12 SSA countries and further investigated the associations in the continuum of care for MNCH. METHODS: Using Demographic and Health Surveys data of 12 countries in SSA, structural equation modeling approach was employed to analyze the complex relationships in continuum of care for MNCH model. The Full Information Maximum Likelihood estimation procedure which account for the Missing at Random (MAR) and Missing Completely at Random (MCAR) assumptions was adopted in LISREL 8.80. The distribution of MNCH care utilization was presented before the estimated association in the continuum of care for MNCH model. RESULTS: Some countries have a consistently low (Mali, Nigeria, DR Congo and Rwanda) or high (Namibia, Senegal, Gambia and Liberia) utilization in at least two levels of MNCH care. The path relationships in the continuum of care for MNCH from 'adequate antenatal care' to 'adequate delivery care' (0.32) and to 'adequate child's immunization' (0.36); from 'adequate delivery care' to 'adequate postnatal care' (0.78) and to 'adequate child's immunization' (0.15) were positively associated and statistically significant at p < 0.001. Only the path relationship from 'adequate postnatal care' to 'adequate child's immunization' (-0.02) was negatively associated and significant at p < 0.001. CONCLUSIONS: In conclusion, utilization of each level of MNCH care is related to the next level of care, that is - antenatal care is associated with delivery care which is then associated with postnatal and subsequently with child's immunization program. At the national level, identification of communities which are greatly contributing to overall disparity in health and a well laid out follow-up mechanism from pregnancy through to child's immunization program could serve towards improving maternal and infant health outcomes and equity.

Family Structure Types and Adequate Utilization of Antenatal Care in Kenya.

Features of the health care delivery system may not be the only expounding factors of adequate utilization of antenatal care among women. Other social factors such as the family structure and its environment contribute toward pregnant women's utilization of antenatal care. An understanding of how women in different family structure types and social groups use basic maternal health services is important toward developing and implementing maternal health care policy in the post-Millennium Development Goal era, especially in the sub-Saharan Africa where maternal mortality still remains high.

The Effect of Continuity of Care on Emergency Room Use for Diabetic Patients Varies by Disease Severity.

BACKGROUND: Although many studies have reported that high-quality continuity of care (COC) is associated with improved patient outcomes for patients with diabetes, few studies have investigated whether this positive effect of COC depends on the level of diabetes severity. METHODS: A total of 3781 newly diagnosed diabetic patients selected from the 2005 National Health Insurance database were evaluated for the period 2005-2011. Generalized estimating equations combined with negative binomial estimation were used to determine the influence of COC on the overall emergency room (ER) use and diabetes mellitus (DM)-specific ER use. Analyses were stratified according to diabetes severity (measured using the Diabetes Complications Severity Index [DCSI]), comorbidities (measured using the Charlson comorbidity score), and age. RESULTS: COC effects varied according to diabetes severity. Stratified analysis showed that the positive effect of COC on DM-specific ER use was the highest for a DCSI of 0 (least severe), with an incidence rate ratio (IRR) of 0.49 (95% CI, 0.41-0.59) in the high-COC group (reference group: low-COC group). Compared with the low-COC group, high-quality COC had a significant beneficial effect on overall ER use in younger patients (IRR 0.51; 95% CI, 0.39-0.66 for the youngest [18-40 years] group, and IRR 0.67; 95% CI, 0.59-0.76 for the oldest [>65 years] group) and those with a high number of comorbidities. CONCLUSIONS: The positive effects of high-quality COC on the treatment outcomes of patient with diabetes, based on the overall and DM-specific ER use, depends on the level of disease severity. Therefore, providing health education to enhance high-quality COC when the disease severity is low may be critical for ensuring optimal positive effects during diabetes disease progression.

Decreasing trend of hysterectomy in Taiwan: A population-based study, 1997-2010.

OBJECTIVE: Gynecologists in Taiwan are lacking a comprehensive picture of the changes in clinical practice and indications of hysterectomy over a long period of time. The aims of this study were to examine the national trends in the utilization of hysterectomy and to explore changes in its utilization rate over a 14-year period from 1997 to 2010. MATERIALS AND METHODS: We conducted a population-based trend analysis using the claims data from the Taiwan's National Health Insurance program. RESULTS: We identified a total of 341,993 women aged 20 years or older who underwent hysterectomy between 1997 and 2010. The total number of hysterectomies increased from 22,961 in 1997 to 27,757 cases in 1999, followed by a decline to 22,351 in 2010. Overall, 5406 fewer hysterectomies (-19.5%) were performed in 2010 when compared with those performed in 1999. The number of hysterectomies performed decreased from 1997 to 2010 for precancerous lesions (-55.6%), chronic pelvic pain (-35.2%), uterine leiomyoma (-13.1%), and uterine prolapse (-7.2%). However, the utilization of hysterectomy increased for endometriosis (+76.3%) and gynecologic cancer (+22.7%) during the same time frame. CONCLUSION: The clinical utilization and primary indications of hysterectomy changed substantially in Taiwan from 1997 to 2010. The continued monitoring of changes in hysterectomy rates will be critical for understanding the appropriate indications for hysterectomy and oophorectomy, the emergence of alternative managements for uterine disorders, and future trends in women's reproductive health.