Comparison of intuitive assessment and palliative care screening tool in the early identification of patients needing palliative care.

The intuitive assessment of palliative care (PC) needs and Palliative Care Screening Tool (PCST) are the assessment tools used in the early detection of patients requiring PC. However, the comparison of their prognostic accuracies has not been extensively studied. This cohort study aimed to compare the validity of intuitive assessment and PCST in terms of recognizing patients nearing end-of-life (EOL) and those appropriate for PC. All adult patients admitted to Taipei City Hospital from 2016 through 2019 were included in this prospective study. We used both the intuitive assessment of PC and PCST to predict patients' 6-month mortality and identified those appropriate for PC. The c-statistic value was calculated to indicate the predictive accuracies of the intuition and PCST. Of 111,483 patients, 4.5% needed PC by the healthcare workers' intuitive assessment, and 6.7% had a PCST score ≥ 4. After controlling for other covariates, a positive response 'yes' to intuitive assessment of PC needs [adjusted odds ratio (AOR) = 9.89; 95% confidence interval (CI) 914-10.71] and a PCST score ≥ 4 (AOR = 6.59; 95%CI 6.17-7.00) were the independent predictors of 6-month mortality. Kappa statistics showed moderate concordance between intuitive assessment and PCST in predicting patients' 6-month mortality (k = 0.49). The c-statistic values of the PCST at recognizing patients' 6-month mortality was significantly higher than intuition (0.723 vs. 0.679; p < 0.001). As early identification of patients in need of PC could improve the quality of EOL care, our results suggest that it is imperative to screen patients' palliative needs by using a highly accurate screening tool of PCST.

Use and Cost-Effectiveness of a Telehealth Service at a Centralized COVID-19 Quarantine Center in Taiwan: Cohort Study.

BACKGROUND: Telehealth is a recommended method for monitoring the progression of nonsevere infections in patients with COVID-19. However, telehealth has not been widely implemented to monitor SARS-CoV-2 infection in quarantined individuals. Moreover, studies on the cost-effectiveness of quarantine measures during the COVID-19 pandemic are scarce. OBJECTIVE: In this cohort study, we aimed to use telehealth to monitor COVID-19 infections in 217 quarantined Taiwanese travelers and to analyze the cost-effectiveness of the quarantine program. METHODS: Travelers were quarantined for 14 days at the Taiwan Yangmingshan quarantine center and monitored until they were discharged. The travelers' clinical symptoms were evaluated twice daily. A multidisciplinary medical team used the telehealth system to provide timely assistance for ill travelers. The cost of the mandatory quarantine was calculated according to data from the Ministry of Health and Welfare of Taiwan. RESULTS: All 217 quarantined travelers tested negative for SARS-CoV-2 upon admission to the quarantine center. During the quarantine, 28/217 travelers (12.9%) became ill and were evaluated via telehealth. Three travelers with fever were hospitalized after telehealth assessment, and subsequent tests for COVID-19 were negative for all three patients. The total cost incurred during the quarantine was US $193,938, which equated to US $894 per individual. CONCLUSIONS: Telehealth is an effective instrument for monitoring COVID-19 infection in quarantined travelers and could help provide timely disease management for people who are ill. It is imperative to screen and quarantine international travelers for SARS-CoV-2 infection to reduce the nationwide spread of COVID-19.

A Flexible Lockdown by Integrating Public Health and Economic Reactivation to Response the Crisis of COVID-19: Responses to Comments by Alvaro J Idrovo on "An Examination on the Transmission of COVID-19 and the Effect of Response Strategies: A Comparative Analysis".

We greatly appreciate Idrovo's comments on our research and wish to specifically respond to his comments. Idrovo indicates that rapid increases in the number of confirmed cases in the past few weeks were observed in Latin America, where some countries had implemented stringent lockdowns for more than three months since the second half of March 2020. In his comments, Idrovo expresses his suspicion on the reality of lockdowns implemented in Latin America and worries about the negative impacts of lockdowns on economies. We thank the Editor for providing us with the opportunity to respond to Idrovo's comments and explain parts of our study.

Association of exercise with all-cause mortality in older Taipei residents.

BACKGROUND: Human life expectancy has increased rapidly in recent decades. Regular exercise can promote health, but the effect of exercise on mortality is not yet well understood. OBJECTIVE: To investigate the association of exercise with mortality in the older people. METHODS: We used data from annual health check-ups of the older citizens of Taipei in 2006. Participants were interviewed by trained nurses using a structured questionnaire to collect data on demographics and lifestyle behaviours. Overnight fasting blood was collected for measuring blood glucose, liver and renal function and lipid profiles. Exercise frequency was categorised into no exercise, 1-2 times in a week and more than 3-5 times in a week. All-cause mortality was ascertained from the National Registration of Death. All participants were followed up until death or December 312012, whichever came first. Kaplan-Meier curves and Cox proportional hazard analysis were used to investigate the association between exercise and all-cause mortality. RESULTS: In total, 42,047 older people were analysed; 22,838 (54.32%) were male and with a mean (SD) age of 74.58 (6.32) years. Kaplan-Meier curves of all-cause mortality stratified by exercise frequency demonstrated significant findings (Log-rank P < 0.01). Multivariate Cox regression analysis showed that older people with higher exercise levels had a significantly decreased risk of mortality (moderate exercise HR = 0.74, 95% CI: 0.68-0.81, high exercise HR = 0.65, 95% CI: 0.59-0.70) after adjusting for potential confounders, with a significant trend (P for trend<0.01). CONCLUSIONS: Older people with increased exercise levels had a significantly decreased risk of all-cause mortality.

Low socio-economic status associated with increased risk of dengue haemorrhagic fever in Taiwanese patients with dengue fever: a population-based cohort study.

BACKGROUND: Evidence indicates that socio-economic status (SES) may affect health outcomes in patients with chronic diseases. However, little is known about the impact of SES on the prognosis of acute dengue. This nationwide cohort study determined the risk of dengue haemorrhagic fever (DHF) in Taiwanese dengue fever patients from 2000 to 2014. METHODS: From 1 January 2000, we identified adult dengue cases reported in the Taiwan Centers for Disease Control Notifiable Diseases Surveillance System Database. Dengue cases were defined as positive virus isolation, nucleic acid amplification tests or serological tests. Associations between SES and incident DHF were estimated using a Cox proportional hazards model. RESULTS: Of 27 750 dengue patients, 985 (3.5%) had incident DHF during the follow-up period, including 442 (4.8%) and 543 (2.9%) with low and high SES, respectively. After adjusting for age, sex, history of dengue fever and comorbidities, low SES was significantly associated with an increased risk of incident DHF (adjusted hazard ratio [AHR] 1.61 [95% confidence interval {CI} 1.42 to 1.83]). Rural-dwelling dengue patients had a higher likelihood of DHF complication than their urban counterparts (AHR 2.18 [95% CI 1.90 to 2.51]). CONCLUSIONS: This study suggests low SES is an independent risk factor for DHF. Future dengue control programs should particularly target dengue patients with low SES for improved outcomes.

Patient and provider factors associated with enrolment in the pre-end-stage renal disease pay-for-performance programme in Taiwan: a cross-sectional study.

OBJECTIVE: The incidence and prevalence of end-stage renal disease (ESRD) in Taiwan have been ranked the highest worldwide. Therefore, the National Health Insurance Administration has implemented the pre-ESRD pay-for-performance (P4P) programme since November 2006, which had significantly reduced the incidence of dialysis and all-cause mortality. This study aimed to identify the factors associated with the enrolment in the pre-ESRD P4P programme. DESIGN: Cross-sectional study. SETTING: The National Health Insurance research database 2007-2012 in Taiwan. PARTICIPANTS: Patients with prevalent pre-ESRD aged more than 18 years between January 2007 and December 2012 were enrolled. Patient demographics and hospital characteristics between P4P and non-P4P groups were compared. A logistic regression model was used to analyse the factors associated with P4P enrolment, and a generalised estimating equation was used to verify the results. PRIMARY OUTCOME MEASURE: Enrolment in the pre-ESRD P4P programme. RESULTS: In total, 82 991 patients were enrolled in the programme, with a 45.6% participation rate. Patients who were males (adjusted OR (AOR)=0.89, 95% CI=0.86 to 0.91) and employed (AOR=0.95, 95% CI=0.92 to 0.97) had a significantly lower probability to be enrolled in the programme. Older patients (66-75 years old, AOR=1.23, 95% CI=1.14 to 1.33) and those with higher Charlson Comorbidities Index (CCI 5+, AOR=4.01, 95% CI=3.55 to 4.53) tended to be enrolled in the programme, while those in the 76+ years age group were not (AOR=1.03, 95% CI=0.95 to 1.13). Hospitals located in the central (AOR=1.48, 95% CI=1.05 to 2.08) and Kao-Ping regions (AOR=1.62, 95% CI=1.18 to 2.22) also tended to enrol patients in the pre-ESRD P4P programme. Enrolment rates increased over time. CONCLUSION: Pre-ESRD patients of the female gender, greater age and more comorbidities were more likely to be enrolled in the pre-ESRD P4P programme. Healthcare providers and health authorities should focus attention on patients who are male, younger and with less comorbidities to improve the healthcare quality and equality for all pre-ESRD patients.

Impact of an antimicrobial stewardship program with multidisciplinary cooperation in a community public teaching hospital in Taiwan.

BACKGROUND: Reports of antimicrobial stewardship programs (ASPs) in community hospitals are limited, with the major focus on specific agents, small settings, or short time periods. Here we present the outcomes of cost control, consumption restraint, and quality of care after a 3-year multidisciplinary ASP in a 415-bed community public teaching hospital. METHODS: Three strategies for improving antimicrobial stewardship were implemented: education, clinical pharmacists-based intervention, and regular outcome announcement. The steering panel of the program was a committee composed of infection specialists, attending physicians, clinical pharmacists, nurses, and medical laboratorists. RESULTS: Semiannual data from July 2009 to June 2012 was analyzed. Antibiotic costs declined from $21,464 to $12,146 per 1,000 patient-days (-43.4%). Approximately $2.5 million was saved in 3 years, and estimated labor cost was $3,935 per month. Defined daily dose per 1,000 patient-days were diminished from 906.7 to 717.5 (-20.9%). Significant reductions were found in the consumption of aminoglycosides, first-generation cephalosporins, and aminopenicillins. However, through comprehensive auditing, increasing consumption of fourth-generation cephalosporins and fluoroquinolones was noticed. No significant difference in the quality of care (ie, length of stay, incidence of health care associated infections, and mortality) was observed. CONCLUSIONS: The multidisciplinary ASP was beneficial to reduce antibiotic cost and consumption. The strategies were practical and worthy to be recommended to community health care settings.