Support for a hypothetical sugar-sweetened beverage tax in Taiwan.

Sugar-sweetened beverages (SSBs) are drinks that contain added sugar or sweeteners and provide calories with no additional nutrients, and some countries have imposed additional taxes on the SSBs to reduce consumption, which is considered an SSB tax policy. This study used a cross-sectional online survey to examine the patterns of public support for an SSB tax in Taiwan. The sample included 1617 adults aged ≥ 20 years, who answered the survey questionnaire between May 2020 and April 2021. The respondents were recruited using convenience sampling, but sampling weights were applied to represent the Taiwanese population. Generalized ordered logit models with sampling weights were used to examine the correlates of public support for an SSB tax. Results showed that ~60% of the respondents supported the SSB tax and 47% perceived the tax to be effective. The respondents who were aware of the perceived health risks of SSBs or those who believed that one should be partly responsible for the health impact of SSBs were more likely to show support for the SSB tax. In adjusted regression models, both one's perceived risk and perceived responsibility of SSBs were positively associated with the perceived effectiveness of the SSB tax after sociodemographic characteristics were controlled. These research findings show evidence that there is public support for implementing an SSB tax to reduce SSB consumption in Taiwan.

Late creation of vascular access increased post-hemodialysis mortality, hospitalization, and health-care expenditure: A population-based cohort study in Taiwan.

BACKGROUND/PURPOSE: The optimal timing of vascular access (VA) creation for hemodialysis (HD) and whether this timing affects mortality and health-care utilization after HD initiation remain unclear. Thus, we conducted a population-based study to explore their association. METHODS: We used Taiwan's National Health Insurance Research Database to analyze health-care outcomes and utilization in a cohort initiating HD during 2003-2013. We stratified patients by the following VA creation time points: >180, 91-180, 31-90, and ≤30 days before and ≤30 days after HD initiation and examined all-cause mortality, ambulatory care utilization/costs, hospital admission/costs, and total expenditure within 2 years after HD. Cox regression, Poisson regression, and general linear regression were used to analyze mortality, health-care utilization, and costs respectively. RESULTS: We identified 77,205 patients who started HD during 2003-2013. Compared with the patients undergoing VA surgery >180 days before HD initiation, those undergoing VA surgery ≤30 days before HD initiation had the highest mortality-15.92 deaths per 100-person-years, crude hazard ratio (HR) 1.56, and adjusted HR 1.28, the highest hospital admissions rates- 2.72 admission per person-year, crude rate ratio (RR) 1.48 and adjusted RR 1.32, and thus the highest health-care costs- US$31,390 per person-year, 7% increase of costs and 6% increase with adjustment within the 2-year follow-up after HD initiation. CONCLUSION: Late VA creation for HD can increase all-cause mortality, hospitalization, and health-care costs within 2 years after HD initiation. Early preparation of VA has the potential to reduce post-HD mortality and healthcare expenses for the ESKD patients.

Estimating time and transportation costs associated with lung cancer screening and diagnostic lung procedures in Taiwan: a cross-sectional survey in a medical centre.

OBJECTIVES: Earlier research has evaluated the non-medical costs after lung cancer diagnosis. This study estimated the time costs and transportation costs associated with low-dose CT (LDCT) screening and diagnostic lung procedures in Taiwan. DESIGN: Cross-sectional study. SETTING: A tertiary referral medical centre. PARTICIPANTS AND INTERVENTIONS: The study participants were individuals aged 50-80 years who underwent LDCT screening or diagnostic lung procedures between 2021 and 2022. Participants completed a questionnaire including items on time spent on receiving care, time spent on travel and its cost and time taken off from work by the participant and any accompanying caregiver. OUTCOME MEASURES: Time costs were valued using the age- and sex-specific average daily wage for employed participants/caregivers. Costs of informal healthcare sector consisted of time cost of the participant, transportation cost and time cost of the caregiver. RESULTS: A total of 209 participants who underwent LDCT screening (n=84) or non-surgical (n=12) or surgical (n=113) diagnostic lung procedures for the first time were enrolled. Considering the purchasing power parity, the average costs of informal healthcare sector were US$126.4 (95% CI 101.6 to 151.2), US$290.7 (95% CI 106.9 to 474.5) and US$749.8 (95% CI 567.3 to 932.4), respectively, for LDCT screening, non-surgical procedures and surgical procedures. CONCLUSIONS: This study estimated time and transportation costs associated with LDCT screening and diagnostic lung procedures, which could be used for future analysis of cost-effectiveness of lung cancer screening in Taiwan.

Developing a shortened version of the dementia knowledge assessment scale (DKAS-TC) with a sample in Taiwan: an item response theory approach.

BACKGROUND: The 25-item Dementia Knowledge Assessment Scale (DKAS2) is a widely used tool for measuring knowledge of dementia. To increase the applicability of the Chinese-language version of the tool (DKAS-TC) for the general public, this study aimed to develop a shortened version using the item response theory (IRT) approach. METHODS: A total of 401 participants voluntarily completed a Chinese-language version of the DKAS2 questionnaire (DKAS-TC) at the start of dementia awareness training courses in 2020 and 2021. The four Rasch family models were used to analyze the dimensionality of the shortened scale (the DKAS-s) and to confirm its accuracy in measuring dementia knowledge. RESULTS: The results justified supported the use of a dichotomous response scale for responding to the DKAS-s and demonstrated good fit of the data to a Rasch model with the four dimensions of "Causes and Characteristics", "Communication and Engagement", "Care Needs", and "Risks and Health Promotion". Moreover, we shortened the DKAS-TC by selecting items that had both above-average discriminative ability and above-average information. The DKAS-s retained 64.13% of the information contained in the DKAS-TC, resulting in a 16-item scale which retained four items in each of the original four dimensions. The DKAS-s also correlated highly (≥0.95) with the DKAS-TC and exhibited a sizeable range of difficulty of dementia knowledge. CONCLUSIONS: The DKAS-s is expected to be more efficient in field settings while retaining an acceptable level of psychometric properties when used as a survey instrument to measure the general public's knowledge of dementia.

Effects of continuity of care on hospitalizations and healthcare costs in older adults with dementia.

INTRODUCTION: People with dementia have high rates of hospitalization, and a share of these hospitalizations might be avoidable with appropriate ambulatory care, also known as potentially preventable hospitalization (PAH). This study investigates the associations between continuity of care and healthcare outcomes in the following year, including all-cause hospitalization, PAHs, and healthcare costs in patients with dementia. METHODS: This is a longitudinal retrospective cohort study of 69,658 patients with dementia obtained from the Taiwan National Health Insurance Research Database. The Continuity of Care Index (COCI) was calculated to measure the continuity of dementia-related visits across physicians. The PAHs were classified into five types as defined by the Medicare Ambulatory Care Indicators for the Elderly (MACIEs). Logistic regression models were used to examine the effect of COCI on all-cause hospitalizations and PAHs, while generalized linear models were used to analyze the effect of COCI on outpatient, hospitalization, and total healthcare costs. RESULTS: The high COCI group was significantly associated with a lower likelihood of all-cause hospitalization than the low COCI group (OR = 0.848, 95%CI: 0.821-0.875). The COCI had no significant effect on PAHs but was associated with lower outpatient costs (exp(ß) = 0.960, 95%CI: 0.941 ~ 0.979), hospitalization costs (exp(ß) = 0.663, 95%CI: 0.614 ~ 0.717), total healthcare costs (exp(ß) = 0.962, 95%CI: 0.945-0.980). CONCLUSION: Improving continuity of care for dementia-related outpatient visits is recommended to reduce hospitalization and healthcare costs, although there was no statistically significant effect of continuity of care found on PAHs.

Pay-for-performance and continuity of care synergistically reduced amputation of lower extremity in patients with diabetes: a population-based cohort study.

BACKGROUND: Diabetic foot is a common and costly complication of diabetes. No existing study has looked at the effect of continuity of care on amputations of diabetes (DM) patients while considering pay-for-performance (P4P) participation. We investigated the impact of the P4P program and the continuity of care index (COCI) on the incidence of lower extremity amputations (LEA) among diabetics in Taiwan. METHODS: This was a population-based cohort study using insurance claims data from 1997 to 2013. We selected 15,650 DM patients in the P4P program along with age- and sex-matched non-P4P participants at a 1:4 ratio. Time-weighted average (TWA) of the COCI was calculated and included in the time-dependent Cox proportional hazard models to examine the impact of P4P and COCI on the risk of LEA, while controlling for individual and area level characteristics. RESULTS: During four-year follow-up, 1816 subjects experienced LEA. The cumulative LEA hazard rate of the P4P group (n = 153) was significantly lower than that of the non-P4P group (n = 1663) (hazard ratio = 0.37, 95% CI = 0.31-0.43, p < 0.0001, by log-rank test). In the time-dependent Cox proportional hazard model, the adjusted hazard ratios (aHR) for the P4P group was 0.35, (p < 0.0001). With the low COCI (< 0.360) group as the reference, the aHR of LEA was 0.49 (p < 0.0001) for the middle COCI group, (p < 0.0001), and the aHR of LEA for the high COCI (≥0.643) group was 0.23 (p < 0.0001). CONCLUSIONS: Participating in the P4P program and increasing COCI might reduce the risk of amputation for DM patients, independently and synergistically.

A Culture-Based Strategy Is More Cost Effective Than an Empiric Therapy Strategy in Managing Pediatric Helicobacter pylori Infection.

Background: Helicobacter pylori infection is a major cause of peptic ulcers and gastric cancer. This study aimed to compare the eradication rate and essential costs of culture-based and empiric therapy strategies in treating pediatric H. pylori infection. Methods: We retrospectively enrolled patients aged <18 years with a diagnosis of H. pylori infection who received esophagogastroduodenoscopy at two medical centers in southern Taiwan from 1998 to 2018. Patients with positive cultures and minimum inhibitory concentration test results were allocated to a culture-based strategy, and those with negative cultures or without culture as an empiric therapy strategy. We collected demographic data and eradication rates, and calculated the total essential costs of treating a hypothetical cohort of 1,000 pediatric patients based on the two strategies. Results: Ninety-six patients were enrolled, of whom 55 received a culture-based strategy and 41 received an empiric therapy strategy. The eradication rates with the first treatment were 89.1 and 75.6% in the culture-based and empiric therapy strategy, respectively. There were no significant differences in age, sex, and endoscopic diagnosis between the two strategies. For every 10% increase in those receiving a culture-based strategy, the total cost would have been reduced by US$466 in a hypothetical cohort of 1,000 patients. For every 10% increase in successful eradication rate, the total cost was reduced by US$24,058 with a culture-based strategy and by US$20,241 with an empiric therapy strategy. Conclusions: A culture-based strategy was more cost effective than an empiric therapy strategy in treating pediatric H. pylori-infected patients.

Urban-rural disparity in lower extremities amputation in patients with diabetes after nearly two decades of universal health Insurance in Taiwan.

BACKGROUND: To assess the prevalence of urban-rural disparity in lower extremities amputation (LEA) among patients with diabetes and to explore whether patient-related or physician-related factors might have contributed to such disparity. METHODS: This was a population-based study including patients with diabetes aged ≥55 years from 2009 to 2013. Among them, 9236 received LEA. Data were retrieved from Taiwan's National Health Insurance (NHI) claims. A multiple Poisson regression model was also employed to assess the urban-rural difference in LEA prevalence by simultaneously taking into account socio-demographic variables and density of practicing physicians. RESULTS: Between 2009 and 2013, the annual prevalence of LEA declined from 30.4 to 20.5 per 10,000 patients. Compared to patients from urban areas, those who lived in sub-urban and rural areas suffered from a significantly elevated prevalence of LEA, with a prevalence rate ratio (PRR) of 1.47 (95% CI, 1.39-1.55) and 1.68 (95% CI, 1.56-1.82), respectively. The density of physicians who presumably provided diabetes care can barely explain the urban-rural disparity in LEA prevalence. CONCLUSIONS: Although the universal health insurance has largely removed financial barriers to health care, the urban-rural disparity in LEA prevalence still exists in Taiwan after nearly two decades of the NHI program.

Cost-Effectiveness Analysis of Oral Anticoagulants in Stroke Prevention among Patients with Atrial Fibrillation in Taiwan.

BACKGROUND: Non-vitamin K oral antagonist anticoagulants (NOACs) have been widely used in stroke prevention in atrial fibrillation (SPAF). The aim of this study was to compare the pharmacoeconomic impact of oral anticoagulants (OACs) including warfarin, dabigatran, rivaroxaban, apixaban, and edoxaban in SPAF in Taiwan. METHODS: A decision tree, Markov model, and multiple sensitivity analyses were used to project the lifetime costs and quality-adjusted life years (QALYs) of OACs. Transitional probabilities were derived from a systematic review and network meta-analysis for Asian populations. Utilities and costs were obtained from published studies and the Taiwan National Health Insurance Research Database. Threshold of the willingness to pay (WTP) at USD 20,000 was applied to evaluate the results. RESULTS: In base-case analysis, warfarin had the lowest cost at $13,363 ± 4,036, and edoxaban 60 mg produced the most QALYs at 11.92 ± 1.98. The incremental cost-effectiveness ratios of dabigatran 150 and 110 mg, rivaroxaban 20 and 15 mg, apixaban 5 mg, and edoxaban 60 mg versus warfarin were $6,415, $4,225, $4,115 and $5,458 per QALY gained, respectively. Monte Carlo analysis revealed that dabigatran 150 and 110 mg, rivaroxaban 20 and 15 mg, apixaban 5 mg and edoxaban 60 mg were most cost-effective at 21.9%, 27.1%, 23.6%, and 27.4% of $20,000 compared to warfarin. CONCLUSIONS: From a Taiwan national payer perspective, all NOACs are cost-effective substitutes for warfarin in SPAF. However, the likelihood of cost-effective iterations for NOACs is highly driven by their market prices at the time and different WTP thresholds of policymakers.

Estimating Life Expectancy and Lifetime Healthcare Costs for Alzheimer's Disease in Taiwan: Does the Age of Disease Onset Matter?

BACKGROUND: People with early onset Alzheimer's disease (EOAD) seem to suffer greater impact. But there is a lack of population-based studies on loss of life expectancy (LE) and lifetime healthcare costs. OBJECTIVES: We conducted this study to estimate LE, expected years of life lost (EYLL), and lifetime healthcare costs for Alzheimer's disease (AD) in Taiwan stratified by onset age and gender, using a method which integrates the product of the survival function and the mean cost function over a lifetime horizon. METHODS: We linked the National Health Insurance datasets with the National Mortality Registry and extrapolated the survival to lifetime to estimate the mean cumulative costs since the date of the first AD diagnosis using medical claims between 2001 and 2012. RESULTS: A total of 21,615 mild to moderate AD patients (including 20,358 late-onset (LOAD) and 1,257 EOAD) were recruited. The average onset age for EOAD was 61 years old, while that of LOAD was 78. Although the LE of EOAD was 4.8 years longer than that of LOAD due to younger age, the EYLL for the former was 8.7 years versus 1.7 years for the latter. EOAD also had higher lifetime healthcare costs than the LOAD group (USD$37,957±2,403 versus 33,809±786). CONCLUSIONS: Since EOAD patients had both higher EYLL and lifetime healthcare costs than LOAD, future studies should pay more attention to the needs of EOAD patients.

Predictors of caregiver burden and care costs for older persons with dementia in Taiwan.

ABSTRACTObjectives:As a degenerative disease, the progression of dementia needs continued care provision and poses both psychological and financial burden for family caregivers of persons with dementia (PWD). This study seeks to compare predictors of care costs and caregiver burden, and to identify modifiable factors that could alleviate the burden faced by dementia caregivers. METHODS: This study interviewed 231 PWD-caregiver dyads in a dementia clinic at a teaching hospital in southern Taiwan in 2013. A follow-up study was conducted a year later, and 167 dyads completed the second interview. Data collected included PWD characteristics, caregiver characteristics, relationship to PWD, and social support to caregivers. Caregiver burden was measured with the Zarit Burden Interview instrument. The association between each predictor variable and cost of care and caregiver burden scores was examined using linear mixed models. RESULTS: Predictors of care costs were found to be different from predictors of caregiver burden: functional declines measured by Katz's activities of daily living (ADL) scale were associated with total cost as compared to behavioral disturbance measured by Neuropsychiatric Inventory (NPI), which showed no impact on care costs. However, NPI was a significant predictor of caregiver burden. Caregivers who were better-off financially also reported significantly lower caregiver burden. CONCLUSIONS: Since predictors of care costs were different from the predictors of caregiver burden, providing training to caregivers in addressing PWD's behavioral disturbance and proving financial assistance to low income caregivers could be effective in reducing caregiver burden.

Can Persistence With Cholinesterase Inhibitor Treatment Lower Mortality and Health-Care Costs Among Patients With Alzheimer's Disease? A Population-Based Study in Taiwan.

Although cholinesterase inhibitors (ChEIs) have been proved to help reduce cognitive deterioration in patients with Alzheimer's disease (AD), their effects on survival remain inconclusive. This study aims to assess the effects of the persistent use of ChEIs on the risk of mortality in patients with AD. This population-based cohort study included 8614 patients having AD with ChEI prescription from 2002 to 2006 and followed until 2010. Kaplan-Meier curves and hazard ratios (HRs) of mortality were estimated in association with ChEI treatment duration and adherence. The average annual mortality rate per 100 person-years was 9.2 for the short-duration group (discontinued < 1 year) and 7.2 for the long-duration group (discontinued ≥ 2 years). Compared to the short-duration group, the long-duration group had a lower mortality (HR = 0.76, 95% confidence interval: 0.69-0.84) and shorter annual inpatient days. But the annual health-care costs did not differ significantly between the 2 groups.

Demographic and rural-urban variations in dental service utilization in Taiwan.

INTRODUCTION: This study assesses whether demographic and rural-urban variations in dental care service utilization still exist in Taiwan after 15 years of the implementation of universal health insurance coverage, which largely reduces financial barriers to dental care. METHODS: The data analysed in this cohort study were based on a random sample of one million beneficiaries retrieved from Taiwan's National Health Insurance Research Database (NHIRD) in 2005. The follow-up was made between 2005 and 2010. Poisson regression models were used to explore the associations of dental service utilization rates with urbanization and demographic characteristics. RESULTS: The highest and lowest rates of preventive dental care were obtained in people aged 55-64 years (579.2/1000 person-years) and <15 years (178.6/1000 person-years). The corresponding figures for curative care were 1592.0/1000 person-years (<15 years) and 757.2/1000 person-years (35-44 years). Compared with the people living in the least urbanized areas, those from the most urbanized areas presented significantly higher rates of preventive and curative dental services; a greater estimated rate ratio was noted for preventive services than for curative services (1.57 vs 1.42). CONCLUSIONS: The urban-rural disparity in dental care service utilization still exists after 15 years of the implementation of the national health insurance in Taiwan, suggesting that factors other than affordability may play roles in such disparity.

Measurement invariance across educational levels and gender in 12-item Zarit Burden Interview (ZBI) on caregivers of people with dementia.

BACKGROUND: The Zarit Burden Interview (ZBI) is a commonly used self-report to assess caregiver burden. A 12-item short form of the ZBI has been developed; however, its measurement invariance has not been examined across some different demographics. It is unclear whether different genders and educational levels of a population interpret the ZBI items similarly. Therefore, this study aimed to examine the measurement invariance of the 12-item ZBI across gender and educational levels in a Taiwanese sample. METHODS: Caregivers who had a family member with dementia (n = 270) completed the ZBI through telephone interviews. Three confirmatory factor analysis (CFA) models were conducted: Model 1 was the configural model, Model 2 constrained all factor loadings, Model 3 constrained all factor loadings and item intercepts. Multiple group CFAs and the differential item functioning (DIF) contrast under Rasch analyses were used to detect measurement invariance across males (n = 100) and females (n = 170) and across educational levels of junior high schools and below (n = 86) and senior high schools and above (n = 183). RESULTS: The fit index differences between models supported the measurement invariance across gender and across educational levels (∆ comparative fit index (CFI) = -0.010 and 0.003; ∆ root mean square error of approximation (RMSEA) = -0.006 to 0.004). No substantial DIF contrast was found across gender and educational levels (value = -0.36 to 0.29). CONCLUSIONS: The ZBI is appropriate for combined use and for comparisons in caregivers across gender and different educational levels in Taiwan.

Economic Impact of Dementia by Disease Severity: Exploring the Relationship between Stage of Dementia and Cost of Care in Taiwan.

OBJECTIVE: Given the shortage of cost-of-illness studies in dementia outside of the Western population, the current study estimated the annual cost of dementia in Taiwan and assessed whether different categories of care costs vary by severity using multiple disease-severity measures. METHODS: This study included 231 dementia patient-caregiver dyads in a dementia clinic at a national university hospital in southern Taiwan. Three disease measures including cognitive, functional, and behavioral disturbances were obtained from patients based on medical history. A societal perspective was used to estimate the total costs of dementia according to three cost sub-categories. The association between dementia severity and cost of care was examined through bivariate and multivariate analyses. RESULTS: Total costs of care for moderate dementia patient were 1.4 times the costs for mild dementia and doubled from mild to severe dementia among our community-dwelling dementia sample. Multivariate analysis indicated that functional declines had a greater impact on all cost outcomes as compared to behavioral disturbance, which showed no impact on any costs. Informal care costs accounted for the greatest share in total cost of care for both mild (42%) and severe (43%) dementia patients. CONCLUSIONS: Since the total costs of dementia increased with severity, providing care to delay disease progression, with a focus on maintaining patient physical function, may reduce the overall cost of dementia. The greater contribution of informal care to total costs as opposed to social care also suggests a need for more publicly-funded long-term care services to assist family caregivers of dementia patients in Taiwan.

Variations in the persistence of health expenditures and the implications for the design of capitation payments in Taiwan.

OBJECTIVES: The National Health Insurance (NHI) system in Taiwan launched a trial capitation provider payment programme in 2011, with the capitation formula based on patients' average NHI expenditure in the previous year. This study seeks to examine the concentration and persistence of health care expenditure among the elderly, and to assess the performance of the current capitation formula in predicting future high-cost users. METHODS: This study analysed NHI expenditures for a nationally representative sample of people aged 65 years and over who took part in Taiwan's National Health Interview Survey, 2005. Expenditure concentration was assessed by the proportion of NHI expenditures attributable to four groups by expenditure percentile. Four transition probability matrixes examined changes in a person's position in the expenditure percentiles and generalized estimation equation models were estimated to identify significant predictors of a patient being in the top 10% of users. RESULTS: Between 2005 and 2009, the top 10% of users on average accounted for 55% of total NHI expenditures. Of the top 10% in 2005, 39% retained this position in 2006. However, expenditure persistence was the highest (77%) among the bottom 50% of users. NHI expenditure percentiles in both the baseline year and the prior year, and chronic conditions all significantly predicted future high expenditures. The model including chronic conditions performed better in predicting the top 10% of users (c-statistics increased from 0.772 to 0.904) than the model without. CONCLUSIONS: Given the increase in predictive ability, adding chronic conditions and baseline health care use data to Taiwan's capitation payment formula would correctly identify more high users.