Assessment of the herpes zoster risk among renal transplant recipients administered the influenza vaccine.

BACKGROUND: Reactivation of the latent varicella-zoster virus can cause herpes zoster (HZ) infection, and renal transplant recipients undergoing immunosuppressive therapy are particularly susceptible to this condition. This study aims to evaluate the potential increase in HZ incidence following influenza vaccination among this specific patient population. METHODS: This study was a population-based, retrospective, self-controlled case series. Data were retrieved from Taiwan's National Health Insurance Research Database spanning the years 2008 to 2017. Patients diagnosed with HZ within a 6-month period before and after receiving the influenza vaccine were eligible for inclusion. Two distinct time intervals were defined for analysis: the initial 15 days and 30 days following vaccination were categorized as risk intervals, while all other periods served as control intervals. Incidence rate ratios (IRRs) were computed to compare HZ incidence during the risk intervals with that during the control intervals. RESULTS: This study encompassed a cohort of 4,222 renal transplant recipients who had received the influenza vaccine. Among this group, 67 recipients were subsequently diagnosed with HZ. The IRR during both the initial 15 days (IRR = 0.63; 95 % CI, 0.23-1.89) and the first 30 days (IRR = 1.50; 95 % CI, 0.71-3.16) following influenza vaccination did not demonstrate a statistically significant increase when compared to the post-exposure observation times. Comparable results were also observed when comparing these IRR values to the pre-exposure observation times. The subgroup analysis, stratified by age, sex, and underlying medical conditions (including cancer and autoimmune diseases), revealed that the IRRs did not exhibit statistically significant differences. CONCLUSIONS: No significant association between the influenza vaccine and an elevated risk of HZ was detected. The administration of annual influenza vaccines appears to be a reasonable practice for renal transplant recipients.

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.

Synergy between the pay-for-performance scheme and better physician-patient relationship might reduce the risk of retinopathy in patients with type 2 diabetes.

AIMS/INTRODUCTION: This study investigated whether participation by patients with type 2 diabetes in Taiwan's pay-for-performance (P4P) program and maintaining good continuity of care (COC) with their healthcare provider reduced the likelihood of future complications, such as retinopathy. MATERIALS AND METHODS: The analysis used longitudinal panel data for newly diagnosed type 2 diabetes from the National Health Insurance claims database in Taiwan. COC was measured annually from 2003 to 2013, and was used to allocate the patients to low, medium and high groups. Cox regression analysis was used with time-dependent (time-varying) covariates in a reduced model (with only P4P or COC), and the full model was adjusted with other covariates. RESULTS: Despite the same significant effects of treatment at primary care, the Diabetes Complications Severity Index scores were significantly associated with the development of retinopathy. After adjusting for these, the hazard ratios for developing retinopathy among P4P participants in the low, medium and high COC groups were 0.594 (95% confidence interval [CI] 0.398-0.898, P = 0.012), 0.676 (95% CI 0.520-0.867, P = 0.0026) and 0.802 (95% CI 0.603-1.030, P = 0.1062), respectively. Thus, patients with low or median COC who participated in the P4P program had a significantly lower risk of retinopathy than those who did not. CONCLUSIONS: Diabetes care requires a long-term relationship between patients and their care providers. Besides encouraging patients to participate in P4P programs, health authorities should provide more incentives for providers or patients to regularly survey patients' lipid profiles and glucose levels, and reward the better interpersonal relationship to prevent retinopathy.

A population-based analysis of use and outcomes of laparoscopic bariatric surgery across socioeconomic groups in Taiwan.

BACKGROUND: With the growing development of minimally invasive techniques for the treatment of morbid obesity, laparoscopic bariatric surgery (LBS) is increasingly performed. This study aimed to assess the association between patients' socioeconomic status (SES) and the likelihood of undergoing LBS and related outcomes in Taiwan. METHODS: This nationwide population-based study was conducted by using data from Taiwan's National Health Insurance Research Database. A total of 3678 morbidly obese patients aged 18 years and older who underwent conventional open bariatric surgery or LBS were identified between 2004 and 2011. Regression analyses were performed using generalized estimating equation (GEE) models to account for the nesting of patients within physician to assess patients' SES category associated with the use of LBS and related outcomes. Odds ratios (ORs) and 95 % confidence intervals (CIs) were estimated. RESULTS: Compared with those with medium and low SES (84.6 % and 80.2 %), patients with high SES (88.1 %) had the highest percentage of undergoing LBS (P < 0.001). After adjusting for patient demographics, institution and surgeon characteristics, the multivariate GEE analysis revealed that the highest likelihood of undergoing LBS was noted in morbidly obese patients with high SES (OR = 1.45, 95 % CI 1.10-1.90), followed by those with medium SES (OR = 1.27, 95 % CI 1.04-1.56). In addition, patients with high SES had slightly lower length of hospital stay (LOS; OR = 0.90, 95 % CI 0.82-0.99) and hospital treatment cost (OR = 0.93, 95 % CI 0.87-0.99) than their counterparts after adjustment. CONCLUSIONS: The increased likelihood of undergoing LBS and lower LOS and hospital treatment cost were noted among morbidly obese patients with higher SES. This finding suggests there is the need to improve clinical practice and reduce health disparities in the surgical treatment of morbidly obese patients.

Redistributive effects of the National Health Insurance on physicians in Taiwan: a natural experiment time series study.

BACKGROUND: Previous studies have evaluated the effects of various health manpower policies but did not include full consideration of the effect of universal health insurance on physician re-distribution. This study examines the effects of implementing National Health Insurance (NHI) on the problem of geographic mal-distribution of health providers in Taiwan. METHODS: Data on health providers and population between 1971 and 2001 are obtained from relevant governmental publications in Taiwan. Gini coefficients derived from the Lorenz curve are used under a spline regression model to examine the impact of the NHI on the geographic distribution of health providers. RESULTS: The geographic distribution equality of the three key health providers has improved significantly after the implementation of NHI program. After accounting for the influences of other confounding factors, Gini coefficients of the three key providers have a net reduction of 1.248% for dentists, 0.365% for western medicine physicians, and 0.311% for Chinese medicine physicians. Overall, the absolute values of the three key providers' Gini coefficients also become close to one another. CONCLUSIONS: This study found that NHI's offering universal health coverage to all citizens and with proper financial incentives have resulted in more equal geographic distributions among the key health care providers in Taiwan.

Using the diamond model to prioritize 30 causes of death by considering both the level of and inequality in mortality.

OBJECTIVES: The diamond model considers two dimensions of criteria, i.e., the magnitudes of rates and the trends in rates, in order to prioritize different health issues for health policy decision-making. We aimed in this study to use the diamond model to prioritize 30 causes of death (COD) by considering both the level of and inequality in mortality for the setting of policy goals in Taiwan. METHODS: In the level of mortality diamond, the mortality rates of 30 COD of 2006-2008 were classified into three groups by statistical examination to construct the magnitude dimension of the diamond. The 30 COD were then classified into three groups according to statistical examination of the slope of the mortality trend from 1991-1993 to 2006-2008 according to linear regression to construct the trend dimension of the diamond. By considering the two above-described dimensions, each COD can be classified into one of the nine (3 by 3) grid cells in the diamond model, resulting in five levels of priority. The same method was used to construct an inequality in mortality (mortality rate ratio between the city/county with the highest and the lowest rate) diamond. RESULTS: In the level of mortality diamond, three COD were grouped in the first priority cell and seven in the second priority cell. However, only two COD were classified in the first priority cell and three in the second priority cell in the inequality in mortality diamond. Liver cirrhosis was the only COD in the first two priority cells in both diamonds. CONCLUSIONS: The diamond model is a useful tool for initial prioritization of health issues by considering two dimensions of criteria at the same time using existing data. Furthermore, by using the diamond shape to graphically present the prioritized results, the diamond model efficiently conveys prioritization information to the general public and stakeholders during policy debates.

The impact of universal National Health Insurance on population health: the experience of Taiwan.

BACKGROUND: Taiwan established a system of universal National Health Insurance (NHI) in March, 1995. Today, the NHI covers more than 98% of Taiwan's population and enrollees enjoy almost free access to healthcare with small co-payment by most clinics and hospitals. Yet while this expansion of coverage will almost inevitably have improved access to health care, however, it cannot be assumed that it will necessarily have improved the health of the population. The aim of this study was to determine whether the introduction of National Health Insurance (NHI) in Taiwan in 1995 was associated with a change in deaths from causes amenable to health care. METHODS: Identification of discontinuities in trends in mortality considered amenable to health care and all other conditions (non-amenable mortality) using joinpoint regression analysis from 1981 to 2005. RESULTS: Deaths from amenable causes declined between 1981 and 1993 but slowed between 1993 and 1996. Once NHI was implemented, the decline accelerated significantly, falling at 5.83% per year between 1996 and 1999. In contrast, there was little change in non-amenable causes (0.64% per year between 1981 and 1999). The effect of NHI was highest among the young and old, and lowest among those of working age, consistent with changes in the pattern of coverage. NHI was associated with substantial reductions in deaths from circulatory disorders and, for men, infections, whilst an earlier upward trend in female cancer deaths was reversed. CONCLUSIONS: NHI was associated in a reduction in deaths considered amenable to health care; particularly among those age groups least likely to have been insured previously.

Adverse pharmaceutical payment incentives and providers' behaviour: the emergence of GP-owned gateway pharmacies in Taiwan.

OBJECTIVES: We investigated whether a 2002 pharmaceutical payment reform policy, which provided adverse incentives, fostered an increase in market share of 'gateway pharmacies' (G-pharmacies--pharmacies owned, operated and located by the same clinics that prescribe medicines); what the financial impact of G-pharmacies to the clinics is; and what factors determine whether a clinic decides to open a G-pharmacy. METHODS: Using the database of the National Health Research Institutes, we collected secondary data on all of Taiwan's National Health Insurance prescription claims from pharmacies and clinics between 1997 and 2003. A G-pharmacy was defined as a pharmacy in which more than 70% of the prescriptions it filled came from the same clinic, which prescribed at least 900 prescriptions monthly, more than 70% of which were released to the pharmacy. Trend plot and frequency were used to analyse the distribution of G-pharmacy data. Logistic regression was used to explore what factors determined whether a clinic decided to open a G-pharmacy. RESULTS: After the 2002 reform, the percentage of total prescriptions filled by G-pharmacies reached 78.71%, the increase in percentage (15.23%) was the highest ever and significant (P < 0.01). The reform's adverse payment incentives resulted in a loss of NT$1.86 billion New Taiwan dollars to all clinics and resulted in a reduction in Taiwan's 2003 fee schedules under the global budget payment system. The decision to establish a G-pharmacy was associated with a clinic's being located in less urbanized areas, being a group practice, having higher patient volumes, being a general practitioner, and being privately owned. CONCLUSION: The 2002 reform's adverse incentive fostered a significant increase in the market share of G-pharmacies, and reduced the earnings of clinics which did not own them. It is necessary to break the link between profits from pharmaceutical sales and physician prescribing behaviour to prevent the conflict of interest in how medicines are prescribed.

Impacts of cost containment strategies on pharmaceutical expenditures of the National Health Insurance in Taiwan, 1996-2003.

INTRODUCTION: Pharmaceutical expenditure (PE) of the National Health Insurance (NHI) programme in Taiwan grew from 62.2 billion Taiwan new dollars (NT dollars) in 1996 to NT94.5 dollars billion in 2003.The government has been introducing many strategies to control PE since the inception of NHI including price adjustment based on the prices of international products or existing products (inter-brands comparison), or market price and volume survey; delegation of financial responsibility to regional bureaux; co-payment for outpatient drugs; generic grouping (the reference pricing scheme based on chemical equivalence); a global budget payment system for clinics and hospitals; and reduction in the flat daily payment rate of the drugs for clinics. The aim of this study was to evaluate the impact of these cost containment strategies on the PE of the NHI programme from 1996 to 2003. METHODS: To take the growth and seasonal trends of monthly PE into consideration, Box and Tiao's time-series event intervention analysis based on the Box-Jenkins auto-regressive integrated moving-average model was applied to evaluate the impact of various cost containment strategies on total and subsector (outpatient, inpatient, clinic and hospital sectors) PE. Monthly data of PE of the NHI programme from 1996 to 2003 (the dependent variables) were obtained from the Bureau of the NHI. Drugs prescribed by dentists and Chinese medical doctors at outpatient departments were excluded. RESULTS: After fitting the patterns of time series and controlling for the calendar effect of the Chinese New Year and the severe acute respiratory syndrome outbreak in 2003, three strategies (generic grouping, delegation of financial responsibility and reduction of the flat payment rate of clinics) were significantly associated with a reduction in PE. However, the hospital global budget strategy offset partial savings from these three strategies. Cumulative savings during the study period were estimated to be NT25.442 dollars billion (US0.80 dollars billion). Of all the strategies, generic grouping was the most effective although it had less effect on the clinic subsector. Neither drug co-payment nor price adjustment based on the international or inter-brand price comparison had significant impacts on PE. CONCLUSION: Generic grouping, reduction of the flat payment rate and delegation of financial responsibility were effective in controlling PE. A global budget alone would be unable to control PE without other direct financial incentives. Neither drug co-payment nor brand-specific price adjustment based on prices of international/existing products had a significant impact on PE.

Effects of global budgeting on the distribution of dentists and use of dental care in Taiwan.

OBJECTIVE: To examine the effects of global budgeting on the distribution of dentists and the use and cost of dental care in Taiwan. DATA SOURCES: (1) Monthly dental claim data from January 1996 to December 2001 for the entire insured population in Taiwan. (2) The 1996-2001 population information for the cities, counties and townships in Taiwan, abstracted from the Taiwan-Fukien Demographic Fact Book. STUDY DESIGN: Longitudinal, using the autocorrelation model. PRINCIPAL FINDINGS: Results indicated decline in dental care utilization, particularly after the implementation of dental global budgeting. With few exceptions, dental global budgeting did not improve the distribution of dental care and dentist supply. CONCLUSIONS: The experience of the dental global budget program in Taiwan suggested that dental global budgeting might contain dental care utilization and that several conditions might have to be met in order for the reimbursement system to have effective redistributive impact on dental care and dentist supply.