Effects of the Time of Hospice and Palliative Care Enrollment before Death on Morphine, Length of Stay, and Healthcare Expense in Patients with Cancer in Taiwan.

We aimed to investigate the effects of the time from hospice and palliative care enrollment to death on the quality of care and the effectiveness and trend of healthcare utilization in patients with terminal cancer. Data on the cancer-related mortality rates between 2005 and 2018 reported in the National Health Insurance Research Database in Taiwan were obtained. The effect of hospice and palliative care enrollment at different timepoints before death on healthcare utilization was explored. This retrospective cohort study included 605,126 patients diagnosed with terminal cancer between 2005 and 2018; the percentage of patients receiving hospice and palliative care before death increased annually. Terminal cancer patients who enrolled in hospice and palliative care at different timepoints before death received higher total morphine doses; the difference in the total morphine doses between the two groups decreased as the time to death shortened. The difference in the total morphine doses between the groups gradually decreased from 2005 to 2018. The enrolled patients had longer hospital stays; the length of hospital stays for both groups increased as the time to death lengthened, but the difference was not significant. The enrolled patients incurred lower total medical expenses, but the difference between the two groups increased as the time to death shortened.

Educational attainment affects the diagnostic time in type 2 diabetes mellitus and the mortality risk of those enrolled in the diabetes pay-for-performance program.

Most patients are diagnosed as having diabetes only after experiencing diabetes complications. Educational attainment might have a positive relationship with diabetes prognosis. The diabetes pay-for-performance (P4P) program-providing comprehensive, continuous medical care-has improved diabetes prognosis in Taiwan. This retrospective cohort study investigated how educational attainment affects the presence of diabetes complications at diabetes diagnosis and mortality risk in patients with diabetes enrolled in the P4P program. From the National Health Insurance Research Database, we identified patients aged >45 years who had received a new diagnosis of type 2 diabetes during 2002-2015; they were followed up until the end of 2017. We next used logistic regression analysis to explore whether the patients with different educational attainments had varied diabetic complication risks at diabetes diagnosis. The Cox proportional hazard model was employed to examine the association of different educational attainments in people with diabetes with mortality risk after their enrollment in the P4P program. The results indicated that as educational attainment increased, the risk of diabetes complications at type 2 diabetes diagnosis decreased gradually. When type 2 diabetes with different educational attainments joined the P4P program, high school education had the highest effect on reducing mortality risk; however, those with ≤ 6th grade education had the lowest impact.

Impact of chronic hepatitis on cardiovascular events among type 2 diabetes patients in Taiwan pay-for-performance program.

To investigate the impact of chronic hepatitis on cardiovascular events in patients with type 2 diabetes mellitus (T2DM). This nationwide retrospective cohort study included 152,709 adult patients (> 20 years) with T2DM enrolled in the National Health Insurance Diabetes Pay-for-Performance Program from 2008 to 2010 and followed up until the end of 2017. Patients were categorized into groups with hepatitis B, hepatitis C, fatty liver disease, and patients without chronic hepatitis. The incidence of cardiovascular events in patients with T2DM and hepatitis C (79.9/1000 person-years) was higher than that in patients with diabetes combined with other chronic hepatitis, or without chronic hepatitis. After adjusting for confounding factors, T2DM with fatty liver (adjusted hazard ratio [HR]: 1.10; 95% confidence interval [CI]: 1.07-1.13) and hepatitis C (adjusted HR: 1.09; 95% CI: 1.03-1.12) demonstrated a significantly higher risk of cardiovascular events. The adjusted visit-to-visit coefficient of variation of HbA1c and fasting blood glucose were associated with a high risk of cardiovascular events (HRs of the highest quartile were 1.05 and 1.12, respectively). Chronic hepatitis affects cardiovascular events in adult patients with T2DM. Glucose variability could be an independent risk factor for cardiovascular events in such patients.

Impact of Socioeconomic Status on Cancer Incidence Risk, Cancer Staging, and Survival of Patients with Colorectal Cancer under Universal Health Insurance Coverage in Taiwan.

This study examined the impact of socioeconomic status on colorectal cancer risk, staging, and survival under the National Health Insurance (NHI) system in Taiwan. Monthly salary and education level were used as measures of socioeconomic status to observe the risk of colorectal cancer among individuals aged 40 years or above in 2006-2015 and survival outcomes of patients with colorectal cancer until the end of 2016. Data from 286,792 individuals were used in this study. Individuals with a monthly salary ≤Q1 were at a significantly lower incidence risk of colorectal cancer than those with a monthly salary >Q3 (HR = 0.80, 95% CI = 0.74-0.85), while those with elementary or lower education were at a significantly higher risk than those with junior college, university, or higher education (HR = 1.18, 95% CI = 1.06-1.31). The results show that socioeconomic status had no significant impact on colorectal cancer stage at diagnosis. Although salary was not associated with their risk of mortality, patients with colorectal cancer who had elementary or lower education incurred a significantly higher risk of mortality than those who had junior college, university, or higher education (HR = 1.39, 95% CI = 1.07-1.77). Education level is a significant determinant of the incidence risk and survival in patients with colorectal cancer, but only income significantly impacts incidence risk.

Effects of Body Mass Index and Pay-for-Performance Program on Risk of Death in Patients with Type 2 Diabetes: A Nationwide Cohort Study.

BACKGROUND: The diabetes patients enrolled in the pay-for-performance (P4P) program demonstrate reduced risk of death. Body mass index (BMI) is a risk factor of all-cause death. This study investigates the effects of BMI and P4P on the risk of death in type 2 diabetes patients. METHODS: This is a retrospective cohort study. The study population includes the 3-wave National Health Interview Survey in Taiwan. A total of 6354 patients with diabetes aged ≥ 20 years were enrolled and followed up until the end of 2014. RESULTS: The highest mortality rate per 1000 person-years was 61.05 in the underweight patients with diabetes. A lower crude death rate was observed in the P4P participants than non-P4P participants. The risk of death was 1.86 times higher in the underweight patients with diabetes than that in the normal weight group (95% CI: 1.37-2.53) and was lower in the P4P participants, as compared to the non-participants (HR: 0.55, 95% CI: 0.44-0.69). The most significant effect of joining the P4P program in reducing death risk was found in the underweight patients with diabetes (HR: 0.11, 95% CI: 0.04-0.38), followed by the obesity group (HR: 0.30, 95% CI: 0.17-0.52). CONCLUSIONS: Different effects of joining the P4P program on reducing death risk were observed in the underweight and obesity groups. We strongly recommend that patients with diabetes and without healthy BMIs participate in the P4P program.

Characteristics and related factors of emergency department visits, readmission, and hospital transfers of inpatients under a DRG-based payment system: A nationwide cohort study.

OBJECTIVES: Taiwan has implemented the Diagnosis Related Groups (DRGs) since 2010, and the quality of care under the DRG-Based Payment System is concerned. This study aimed to examine the characteristics, related factors, and time distribution of emergency department (ED) visits, readmission, and hospital transfers of inpatients under the DRG-Based Payment System for each Major Diagnostic Category (MDC). METHODS: We conducted a retrospective cohort study using data from the National Health Insurance Research Database (NHIRD) from 2012 to 2013 in Taiwan. Multilevel logistic regression analysis was used to examine the factors related to ED visits, readmissions, and hospital transfers of patients under the DRG-Based Payment System. RESULTS: In this study, 103,779 inpatients were under the DRG-Based Payment System. Among these inpatients, 4.66% visited the ED within 14 days after their discharge. The factors associated with the increased risk of ED visits within 14 days included age, lower monthly salary, urbanization of residence area, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, Diseases and Disorders of the Kidney and Urinary Tract (MDC11) conferred the highest risk of ED visits within 14 days (OR = 4.95, 95% CI: 2.69-9.10). Of the inpatients, 6.97% were readmitted within 30 days. The factors associated with the increased risk of readmission included gender, age, lower monthly salary, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, the inpatients with Pregnancy, Childbirth and the Puerperium (MDC14) had the highest risk of readmission within 30 days (OR = 20.43, 95% CI: 13.32-31.34). Among the inpatients readmitted within 30 days, 75.05% of them were readmitted within 14 days. Only 0.16% of the inpatients were transferred to other hospitals. CONCLUSION: The study shows a significant correlation between Major Diagnostic Categories in surgery and ED visits, readmission, and hospital transfers. The results suggested that the main reasons for the high risk may need further investigation for MDCs in ED visits, readmissions, and hospital transfers.

The effect of pay for performance on risk incidence of hip fracture in type 2 diabetic patients: a nationwide population-based cohort study.

OBJECTIVES: Diabetes mellitus (DM) increases the risk of hip fracture. The literature rarely discusses the importance of pay-for-performance (P4P) programs for the incidence of hip fractures in patients with type 2 DM (T2DM). This study aimed to examine the impact of the P4P program on hip fracture risk in patients with T2DM. METHODS: This retrospective cohort study focused on data from T2DM patients aged 45 and older between 2001 and 2012. We continued to track these data until 2013. The data were collected from the National Health Insurance Research Database in Taiwan. To minimize selection bias, T2DM patients were divided into P4P enrollees and non-enrollees. Propensity score matching by greedy matching technique (1:1 ratio) was used to include 252,266 participants. A Cox proportional hazard model was performed to examine the impact of the P4P program on hip fracture risk. We used the bootstrap method to perform sensitivity analysis by random sampling with replacement. RESULTS: Our results showed that the risk of hip fracture in P4P enrollees was 0.92 times that of non-enrollees. (hazards ratio [HR] = 0.92; 95% confidence interval [CI]: 0.85-0.99). P4P enrollees who received regular treatment had lower risk in the first 4 years (HR = 0.90; 95%CI: 0.84-0.96) but no statistically significant difference after 4-year enrollment (HR = 0.99; 95%CI: 0.93-1.06). There was no statistically significant difference in the effect of hip fractures between P4P non-enrollees and P4P enrollees with irregular treatment (HR = 0.94, 95%CI: 0.87-1.03). Through sensitivity analysis, the results also showed P4P enrollees had a lower risk of hip fracture compared to P4P non-enrollees (mean HR = 0.919; 95% CI: 0.912-0.926). Stratified analysis showed that patients without DM complications (DCSI = 0) who enrolled in P4P had lower risks of hip fractures than the non-enrollees (HR = 0.90; 95% CI: 0.82-0.98). CONCLUSION: T2DM patients enrolled in P4P program can reduce the risks of hip fracture incidence. Early inclusion of patients without DM complications in the P4P program can effectively reduce hip fractures.

Cost-benefit analysis, cost-effectiveness analysis, and impact of antiepileptic drugs on the risk of fracture in patients with epilepsy: A nationwide cohort study.

PURPOSE: Although nonenzyme-inducing antiepileptic drugs (nEIAEDs) are accepted for the treatment of epilepsy, few studies have examined the costs, benefits, and cost-effectiveness of nEIAEDs in relation to the incidence of fracture among patients with epilepsy. In the present study, we performed cost-benefit and cost-effectiveness analyses comparing the influence of enzyme-inducing AEDs (EIAEDs) and nEIAEDs on the risk of fracture in this population. METHODS: A total of 4864 patients with epilepsy were classified into EIAED and nEIAED groups. Propensity score matching was applied to reduce the influence of selection bias. Clinical outcomes were measured in relation to AED fee, medical expenses associated with epilepsy and fracture, and the total number of fractures. Cost-benefit and cost-effectiveness analyses were performed for all patients. RESULTS: Patients in the unmatched EIAED cohort (n = 3686) were older and had more comorbidities. After matching, the cohorts exhibited similar features (n = 2432 each). Fracture risk was lower in the nEIAED group than in the EIAED group (HR = 0.70). The additional medical expense of nEIAEDs in fractures and epilepsy for 2 years per person was 107,731 New Taiwan dollars (NT$). The additional cost for nEIAEDs to reduce one event of fracture was $14,789,421 NT$. CONCLUSIONS: Patients with epilepsy using nEIAEDs had a lower risk of fracture than those using EIAEDs. However, the cost-benefit ratio and cost-effectiveness of such treatment were lower in the nEIAED group than in the EIAED group.

Assessment of the Risk of Oral Cancer Incidence in A High-Risk Population and Establishment of A Predictive Model for Oral Cancer Incidence Using A Population-Based Cohort in Taiwan.

We aimed to assess the risk of oral cancer incidence in a high-risk population, establish a predictive model for oral cancer among these high-risk individuals, and assess the predictive ability of the constructed model. Individuals aged ≥30 years who had a habit of smoking or betel nut chewing and had undergone oral cancer screening in 2010 or 2011 were selected as study subjects. The incidence of oral cancer among the subjects at the end of 2014 was determined. The annual oral cancer incidence among individuals with a positive screening result was 624 per 100,000 persons, which was 6.5 times that of the annual oral cancer incidence among all individuals screened. Male sex, aged 45-64 years, divorce, low educational level, presence of diabetes, presence of other cancers, high comorbidity severity, a habit of smoking or betel nut chewing, and low monthly salary were high-risk factors for oral cancer incidence (p < 0.05). The area under the curve of the predictive model for oral cancer incidence was 0.73, which indicated a good predictive ability. Therefore, the oral cancer screening policy for the high-risk population with a habit of smoking and/or betel nut chewing is beneficial for the early diagnosis of oral cancer.

Effect of the Integrated Prospective Payment Program on Family Members' Knowledge and Acceptance of Hospice Care of Patients on Prolonged Mechanical Ventilation.

BACKGROUND: We sought to evaluate the effect of an integrated prospective payment program (IPP) on knowledge of hospice care and willingness to participate in hospice care among family members of patients on prolonged mechanical ventilation (PMV). METHODS: Between November 2013 and April 2014, we used paper-based survey questionnaires from 64 institutions to evaluate knowledge, willingness, and related factors among the main caregivers of patients on PMV regarding hospice care and to determine whether their decisions for the patients were affected by the IPP. RESULTS: The average ages of the respondents and patients on PMV were 51.9 y and 70.8 y respectively; 70.6% of the respondents knew about the Hospice Palliative Care Act (HPCA), and 42.3% of the medical staff had introduced hospice care-related information to patients and caregivers in Taiwan. Among the caregiver respondents, 67.6% agreed to write a letter of intent regarding the choice of hospice care or limited life-sustaining treatment. In total, 66.2% (16.1 + 50.1%) of the respondents agreed to hospice care for their family members (ie, the patients on PMV) when the condition was terminal. The factors of greater HPCA knowledge among the patients on PMV were IPP participation, female sex, and coma status. Factors leading to higher levels of HPCA knowledge included age ≥ 65 y being married, higher income, awareness of the law, and being introduced to hospice care by medical staff. CONCLUSIONS: High levels of hospice care knowledge were unrelated to willingness to participate. HPCA knowledge was greater in the IPP group than in the non-IPP group; however, there was no significant difference in the willingness to agree to hospice care. It is recommended that individuals be encouraged to express their medical decisions.

Pay-for-performance programmes reduce stroke risks in patients with type 2 diabetes: a national cohort study.

OBJECTIVES: A pay-for-performance (P4P) programme is a management strategy that encourages healthcare providers to deliver high quality of care. In Taiwan, the P4P programme has been implemented for diabetes, and certified diabetes physicians voluntarily enrol patients with diabetes into the P4P programme. The objectives of this study were to compare the risk of stroke and its related factors in patients with type 2 diabetes who were enrolled in a P4P programme compared with those who were not. STUDY DESIGN: This study is a natural experiment in Taiwan. A retrospective cohort investigation was conducted from 2002 to 2013, which included 459 726 patients with type 2 diabetes, who were grouped according to P4P enrolment status following a propensity score matching process. METHODS: We reviewed patients ≥45 years of age newly diagnosed with type 2 diabetes mellitus (DM) from the National Health Insurance Research Database in Taiwan. A Cox proportional hazards model was used to compare the relative risk of stroke between patients with type 2 DM enrolled in the P4P programme and those who were not enrolled. RESULTS: Compared with the patients not enrolled, there was a significantly lower stroke risk in P4P participants (HR=0.97, 95% CI 0.95 to 0.99). Although a significantly lower risk of haemorrhagic stroke was observed (HR=0.87, 95% CI 0.82 to 0.93) in P4P participants, no statistically significant difference for the risk of ischaemic stroke between P4P and non-P4P patients (HR=0.99, 95% CI 0.97 to 1.02) was found. Following stratification analysis, a significantly reduced stroke risk was observed in male patients with type 2 diabetes, but not in women. CONCLUSIONS: Participants in Taiwan's Diabetes P4P programme displayed a significantly reduced stroke risk, especially haemorrhagic stroke. We recommend the continual promotion of this programme to the general public and to physicians.

Effects of pay for performance on risk incidence of infection and of revision after total knee arthroplasty in type 2 diabetic patients: A nationwide matched cohort study.

As the world's population ages, the number of people receiving total knee arthroplasty (TKA) has been on the rise. Although patients with diabetes mellitus are known to face greater risks of TKA postoperative infection and revision TKA owing to diabetic complications, studies on whether such patients' participation in pay for performance (P4P) programs influences the incidence rates of TKA postoperative infection or revision TKA are still lacking. This study examined the 2002-2012 data of Taiwan's National Health Insurance Research Database to conduct a retrospective cohort analysis of diabetic patients over 50 years old who have received TKA. To reduce any selection bias between patients joining and not joining the P4P program, propensity score matching was applied. The Cox proportional hazards model was used to examine the influence of the P4P program on TKA postoperative infection and revision TKA, and the results indicate that joining P4P lowered the risk of postoperative infection (HR = 0.91, 95% CI: 0.77-1.08), however, which was not statistically significant, and significantly lowered the risk of revision TKA (HR = 0.53, 95% CI: 0.39-0.72). Being younger and male, having multiple comorbid conditions or greater diabetic severity, receiving care at regional or public hospitals, and not having a diagnosis of degenerative or rheumatoid arthritis were identified as factors for higher risk of TKA postoperative infection for patients with diabetes. As for the risk of revision TKA, postoperative infection and being younger were identified as factors for a significantly higher risk (p < 0.05).

Impact of the pay-for-performance program on lower extremity amputations in patients with diabetes in Taiwan.

Patients with diabetes are at a high risk of lower extremity amputations and may have a reduced life expectancy. Taiwan has implemented a diabetes pay-for-performance (P4P) program providing team care to improve the control of disease and avoid subsequent complications. Few studies investigated the effects of adopting a nationalized policy to decrease amputation risk in diabetes previously. Our study aimed to analyze the impact of the P4P programs on the incidence of lower extremity amputations in Taiwanese patients with diabetes.This was a population-based cohort study using the Taiwan National Health Insurance Research Database (which provided coverage for 98% of the total population in Taiwan) from 1998 to 2007. Patients with diabetes were identified based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes. We linked procedure codes to inpatient claims to identify patients hospitalized for nontraumatic lower extremity amputations.A total of 9738 patients with diabetes with amputations were enrolled (mean age ± standard deviation: 64.4 ±â€Š14.5 years; men: 63.9%). The incidence of nontraumatic diabetic lower extremity amputations decreased over the time period studied (3.79-2.27 per 1000 persons with diabetes). Based on the Cox proportional hazard regression model, male sex (hazard ratio: 1.83, 95% confidence interval [CI] 1.76-1.92), older age, and low socioeconomic status significantly interact with diabetes with respect to the risks of amputation. Patients who did not join the P4P program for diabetes care had a 3.46-fold higher risk of amputation compared with those who joined (95% CI 3.19-3.76).The amputation rate in Taiwanese diabetic patients decreased over the time period observed. Diabetes in patients with low socioeconomic status is associated with an increased risk of amputations. Our findings suggested that in addition to medical interventions and self-management educations, formulate and implement of medical policies, such as P4P program, might have a significant effect on decreasing the diabetes-related amputation rate.

Propensity score-matching analyses on the effectiveness of integrated prospective payment program for patients with prolonged mechanical ventilation.

OBJECTIVES: An integrated delivery system with a prospective payment program (IPP) for prolonged mechanical ventilation (PMV) was launched by Taiwan's National Health Insurance (NHI) due to the costly and limited ICU resources. This study aimed to analyze the effectiveness of IPP and evaluate the factors associated with successful weaning and survival among patients with PMV. METHODS: Taiwan's NHI Research Database was searched to obtain the data of patients aged ≥17 years who had PMV from 2006 to 2010 (N=50,570). A 1:1 propensity score matching approach was used to compare patients with and without IPP (N=30,576). Cox proportional hazards modeling was used to examine the factors related to successful weaning and survival. RESULTS: The related factors of lower weaning rate in IPP participants (hazard ratio [HR]=0.84), were older age, higher income, catastrophic illness (HR=0.87), and higher comorbidity. The effectiveness of IPP intervention for the PMV patients showed longer days of hospitalization, longer ventilation days, higher survival rate, and higher medical costs (in respiratory care center, respiratory care ward). The 6-month mortality rate was lower (34.0% vs. 32.9%). The death risk of IPP patients compared to those non-IPP patients was lower (HR=0.91, P<0.001). CONCLUSIONS: The policy of IPP for PMV patients showed higher survival rate although it was costly and related to lower weaning rate.

Survival and medical utilization of children and adolescents with prolonged ventilator-dependent and associated factors.

Over the course of a year, more than 20,000 patients in Taiwan require prolonged mechanical ventilation (PMV). Data from the National Health Insurance Research Database for patients between 2005 and 2011 were used to conduct a retrospective analysis on ventilator dependence. The study subjects were PMV patients aged <17 years in Taiwan. A multiple regression model employing general estimating equations was applied to investigate the factors affecting the use of medical resources by children and adolescent PMV patients. A Cox proportional hazard model was incorporated to explore the factors affecting the survival of these patients. Data were collected for a total of 1,019 children and adolescent PMV patients in Taiwan. The results revealed that the average number of outpatient visits per subject was 32.1 times per year, whereas emergency treatments averaged 1.56 times per year per subject and hospitalizations averaged 160.8 days per year per subject. Regarding average annual medical costs, hospitalizations accounted for the largest portion at NT$821,703 per year per subject, followed by outpatient care at NT$123,136 per year per subject and emergency care at NT$3,806 per year per subject. The demographic results indicated that the patients were predominately male (61.24%), with those under 1 year of age accounting for the highest percentage (36.38%). According to the Kaplan-Meier curve, the 1-year and 5-year mortality rates of the patients were approximately 32% and 47%, respectively. The following factors affecting the survival rate were considered: age, the Charlson Comorbidity Index (CCI), diagnosis type necessitating ventilator use, and whether an invasive ventilator was used. This study investigated the use of medical resources and the survival rates of children and adolescent PMV patients. The findings of this study can serve as a reference for the National Health Insurance Administration in promoting its future integrated pilot projects on ventilator dependency.

Patients with diabetes in pay-for-performance programs have better physician continuity of care and survival.

OBJECTIVES: This study investigated the effects of physician continuity, measured as the Continuity of Care Index (COCI) score, on the survival of patients with diabetes, including both pay-for-performance (P4P) participants and nonparticipants. STUDY DESIGN: This was a retrospective, nationwide population-based analysis of 396,838 patients with diabetes, with 198,419 subjects each in the P4P participant and nonparticipant groups, from 1997 to 2009, in Taiwan. METHODS: The data presented in this study are secondary data obtained from the 1997 to 2009 National Health Insurance Research Database published by the Taiwan National Health Research Institute. Survival status and physician continuity were the dependent variables. Multiple regression analysis was used to examine the factors related to physician continuity among patients with diabetes. The Cox proportional hazard model was used to explore the related factors that affected the survival status of the patients with diabetes. RESULTS: After controlling for the other related factors, the COCI score of the P4P participants was 0.227 higher than that of the nonparticipants (P <.05). Compared with patients with a low COCI score (≤50%), the hazard ratio (HR) of mortality of patients with a high COCI score (>50%) was 0.47 (95% confidence interval [CI], 0.46-0.48). Compared with nonparticipants, the HR of mortality of P4P participants was 0.43 (95% CI, 0.41-0.44). CONCLUSIONS: Patients with diabetes with higher physician continuity had a lower HR of mortality. P4P participants had higher physician continuity and a lower HR of mortality.

Utilization of tooth filling services by people with disabilities in Taiwan.

BACKGROUND: The oral condition of people with disabilities has considerable influence on their physical and mental health. However, nationwide surveys regarding this group have not been conducted. For this study, we used the National Health Insurance Research Database to explore the tooth filling utilization among people with disabilities. METHODS: Using the database of the Ministry of the Interior in 2008 which included people with disabilities registered, we merged with the medical claims database in 2008 of the Bureau of National Health Insurance to calculate the tooth filling utilization and to analyze relative factors. We recruited 993,487 people with disabilities as the research sample. RESULTS: The tooth filling utilization was 17.53 %. The multiple logistic regression result showed that the utilization rate of men was lower than that of women (OR = 0.78, 95 % CI = 0.77-0.79) and older people had lower utilization rates (aged over 75, OR = 0.22, 95 % CI = 0.22-0.23) compared to those under the age of 20. Other factors that significantly influenced the low tooth filling utilization included a low education level, living in less urbanized areas, low economic capacity, dementia, and severe disability. CONCLUSION: We identified the factors that influence and decrease the tooth-filling service utilization rate: male sex, old age, low education level, being married, indigenous ethnicity, residing in a low urbanization area, low income, chronic circulatory system diseases, dementia, and severe disabilities. We suggest establishing proper medical care environments for high-risk groups to maintain their quality of life.

Factors related to continuing care and interruption of P4P program participation in patients with diabetes.

OBJECTIVES: To examine factors that influenced continuing care participation in patients with diabetes and factors contributing to interrupted participation for patients with diabetes enrolled in a diabetes pay-for-performance (P4P) program in Taiwan. STUDY DESIGN: Retrospective cohort analysis. METHODS: Data were obtained from Taiwan's National Health Insurance Research Database on patients with a new confirmed diagnosis of type 2 diabetes during 2001 to 2008, selected as 1:1 propensity score-matched P4P program enrollees and nonenrollees (totaling 396,830). Logistic regression was performed to analyze factors associated with continuing care participation and with interrupted P4P program participation after enrollment. RESULTS: Among the patients with diabetes, P4P program enrollees were 4.27 times (95% CI, 4.19-4.36) more likely to participate in continuing care than nonenrollees. Factors affecting the participation of patients with diabetes in continuing care included P4P program enrollment status, personal characteristics, health status, characteristics of the main physician, and characteristics of the main healthcare organization. Interruption of P4P program participation occurred in 78,759 (44.33%) of the enrolled patients with diabetes and was correlated with male gender, younger age (< 35 years), residence in areas of highest urbanization, greater severity of diabetes complications, presence of catastrophic illness/injury, high service volume at the site of the main physician, older age (≥55 years) of the main physician, having a regional or private hospital as the main healthcare organization, and change of physician. CONCLUSIONS: Taiwan's diabetes P4P program increased continuing care participation in patients with diabetes. The rate of interruption of P4P program participation among enrolled patients with diabetes, at 44.33%, should be a focus of improvement for Taiwan's health authorities.

Temporal trends in primary and revision total knee and hip replacement in Taiwan.

BACKGROUND: Total joint replacement (TJR) accounts for a substantial proportion of the total expenditures for health care. Efficient utilization of health resources requires information regarding the trends of TJR. This study investigated the association of TJR with the demographic characteristics in Taiwan from 1998 to 2009. It also estimated the demand for total knee replacement (TKR) and total hip replacement (THR) in the next two decades. METHODS: International Classification of Diseases-9 (ICD-9) procedure codes were used to identify the data for primary and revision TKRs and THRs between the years 1998 and 2009 from Taiwan's National Health Insurance Research Database. Age- and sex-specific rates of such procedures were calculated. The trend in TJR rate and its future estimation were studied with regression analyses. RESULTS: From 1998 to 2009, the number of primary TKRs increased by 99.1% and that of primary THRs increased by 11.3%. The number of revision TKRs increased by 3.1% and that of revision THRs decreased by 13.2%. Compared with their respective rates in 2005, the rates of primary TKR and primary THR were projected to increase by 508.2% and 69.7%, respectively, in 2030. The rate of revision TKR was predicted to increase by 75.3% and that of revision THR to decrease by 36.1%. CONCLUSION: This study gives an insight into the current status burden of TJR in Taiwan. TJR rate projection would be useful for future planning of budget and resources for TJR in Taiwan.

Factors associated with free adult preventive health care utilization among physically disabled people in Taiwan: nationwide population-based study.

BACKGROUND: Few previous studies have specifically addressed the health care utilization situation of the physically disabled. This study aimed to investigate the utilization of free adult preventive health care for physically disabled people and its' affecting factors. METHODS: The data was obtained from three nationwide databases from 2006 to 2008. This study comprised 329,264 physically disabled people in Taiwan above the age of 40 who had eligible health checks during 2008. We employed descriptive statistics to analyze the use and rate of free preventive health care use by physically disabled adults. Logistic regression analysis was used to explore the factors that affect physically disabled adults' use of free adult preventive health care. RESULTS: 16.37% of the physically disabled adults used free adult preventive health care. Women (17.66%), married (17.16%), a junior high education level (17.89%), and mildly disabled adults (18.77%) had the highest use rate among various participant subgroups. The variables that significantly influenced the use of free adult preventive health care by the physically disabled included gender, age, education, marital status, urbanization of the residence areas, monthly payroll, aboriginal status, catastrophic illnesses status, relevant chronic diseases, and severity of disability. CONCLUSIONS: Physically disabled using preventive health care tend to be low. Governments should use the media to reinforce propagation and education of these services to specific, low-utilization groups, and encourage doctors to actively provide preventive health care to communities.