Early predictors for maltreatment-related injuries in infancy and long-term mortality: a population-based study.

INTRODUCTION: Incidence, health consequences, and social burden associated with child maltreatment appeared to be borne disproportionately by very young children. We conducted a population-based data linkage study to explore child- and family-level factors that affect receiving different diagnoses of maltreatment injuries and investigate excessive mortality throughout toddlerhood. METHODS: We conducted a retrospective cohort study comprising 2.2 million infants born in 2004-2014 in Taiwan. Incident cases of child maltreatment were defined by hospitalization or emergency department visits for three heterogeneous diagnostic groups of maltreatment-related injuries (i.e., maltreatment syndrome, assaults, and undetermined causes) within 12 months after birth. The generalized linear model and landmark survival analyses were used to evaluate risk factors. RESULTS: An estimated 2.9‰ of infants experienced at least one maltreatment-related injury, with a three-year mortality rate of 1.3%. Low birthweight was associated with increased risk of receiving the diagnosis of three maltreatment injuries, particularly maltreatment syndrome (adjusted Incidence Rate Ratio [aIRR] = 4.08, 95% confidence interval [CI]: 2.93-5.68). Socially advantaged family condition was inversely linked with receiving the diagnosis of maltreatment syndrome and assaults (e.g., high income: aIRR = 0.55 and 0.47), yet positively linked with undetermined cause (aIRR = 2.05, 95% CI: 1.89-2.23). For infants exposed to maltreatment, low birth weight and non-attendance of postnatal care were highly predictive of fatality; low birthweight served as a vital predictor for premature death during toddlerhood (aIRR = 6.17, 95% CI: 2.36-15.4). CONCLUSIONS: Raising awareness of maltreatment-related injuries in infancy and predictors should be a priority for appropriate follow-up assessment and timely intervention.

Factors in Maintaining a Stable Patient-Physician Relationship among Individuals with Schizophrenia.

This study aimed to determine whether adequate continuity of care (COC) existed among individuals with schizophrenia, and what the associated determinants were. The National Health Insurance Research Database of Taiwan was used to identify individuals with newly diagnosed schizophrenia from 2000 to 2009. Two outcome indicators were first derived to conduct the continuity assessment based on the usual provider continuity (UPC) index and the continuity of care index (COCI). The average scores of the UPC and COCI were 0.78 and 0.67, respectively. Patients who have been hospitalized, with lower income, and unemployed had significantly poorer continuity of care. In addition, patients were cared for by higher caseload physicians, treated at mental health specialty institutions, and at hospital outpatient settings also experienced significantly poorer continuity. Patients cared for by middle-aged physicians, psychiatrists, and treated at private institutions had significantly better continuity of mental health care.

Utilization of Western medicine and traditional chinese medicine services by physicians and their relatives: the role of training background.

Despite extensive efforts to improve the attitude and practice of physicians with respect to complementary and alternative medicine (CAM), the role of training background on physician's own utilization of mainstream Western medicine (WM) and CAM remains unclear. We aimed to compare personal utilizations of WM and traditional Chinese medicine (TCM) among doctors trained in WM only, TCM only or both. A retrospective population-based study was conducted using the 2004 Taiwan's National Health Insurance data. A total of 103 879 doctors and their relatives and 2 623 658 other adults with equivalent socioeconomic status were analyzed. Ambulatory care utilization of WM and TCM services was compared using the following three measures: probability of any use, number of visits and total annual expenditure. Doctors who were trained in Western medicine only (WMDs) had the highest WM use, followed by doctors who were trained in both (WMD-CMDs), while Chinese medicine-trained doctors (CMDs) had the lowest use. For TCM use, a reverse pattern was observed. Similar patterns were found among doctors' relatives. Compared with other adults with equivalent socioeconomic status, both the CMDs and WMD-CMDs had a greater use of TCM services. For WM, although the WMDs' probability and frequency of usage were similar to other adults, they incurred considerably higher expenditure. The use of WM and TCM by doctors and their relatives was significantly associated with the training background of the doctors. This highlights the importance of how increasing knowledge and understanding of other medical discipline may influence a practitioner's care-providing behaviors.

Differential Nonenrollment of Taiwanese Children in School-Based Substance Use Prevention Studies: A Multilevel Analysis.

OBJECTIVE: The present study investigated the extent to which individual and school characteristics may differentially affect parental consent and child assent in the enrollment of a school-based substance use prevention study in Taiwan. METHOD: This study linked field notes on response and consent status during enrollment of the school-based prevention study with administrative survey data reported by the targeted students when they were in fourth grade (age 10-11) (N = 2,560; 53% male, 97.8% matched). The outcome variables, defined by the combined status of parental consent/child assent, were nonresponse and negative, discordant, and positive consent. Individual characteristics included family (parental education, employment) and child (psychological/behavioral, substance use) factors. Aggregate school-level substance use and percentage of aboriginal students and nonnative parents served as school-level factors. Multilevel multinomial regression analyses were performed. RESULTS: Successful consent was obtained from only 820 students (32%). Male gender and feeling neglected by families were associated with failing to respond (adjusted odds ratio = 1.78 and 1.71, respectively). Higher parental educational attainment reduced the odds of negative consent by 30%, whereas having unemployed parents increased the odds of discordant consent by 326%. Children attending schools with a higher percentage of indigenous students were two times more likely to have nonresponse, negative consent, and discordant consent. CONCLUSIONS: Nonresponse to the consent request or negative consent appeared to be associated with disadvantaged background and unfavorable parent-child interaction. This suggests complex pathways underlying ascertainment and a need to modify the consent practices in school-based prevention studies involving minors, especially in schools with higher ethnic minority composition.

Suicide attempts and death among heroin-involved women seeking methadone treatment in Taiwan.

BACKGROUND: The present study aims to profile the hazard fluctuation of suicide attempts and deaths among heroin-involved women seeking methadone maintenance treatment (MMT) and to investigate sociodemographic and clinical factors predicting the time to have suicidal behaviors. METHODS: We identified a retrospective cohort comprising 2780 women receiving methadone treatment in the period of 2012-2016. Healthcare records were obtained from Taiwan's National Health Insurance Research Database, and suicide deaths were ascertained from the national death register. Competing risk survival analyses were used to estimate the risk of suicide attempts and deaths within one year and three years of MMT enrollment. RESULTS: A total of 1.2 % of MMT-treated women ever visited hospital for suicide attempt, and 0.5 % died by confirmed suicide. The risk of treated suicide attempt reached its peak at the end of the 8th month after methadone initiation, whereas the risk of confirmed suicide death was relatively stable during the first one and a half years. A history of treated depressive disorders appears to be the strongest risk predictor for treated suicide attempts (Adjusted Hazard Ratio [aHR] = 3.45; 95 % CI = 1.66-7.19) and confirmed suicide death (aHR = 3.47; 95 % CI = 1.20-10.0). Retaining in methadone treatment may significantly lower the hazard of probable suicide death by 52 %. CONCLUSIONS: Women with heroin use disorders should receive careful attention for suicide risk at intake assessment and over the course of treatment and recovery. Preventive strategies should target unmet clinical and social needs and evaluate gender-specific barriers for treatment engagement.

Variation in the cervical cancer screening compliance among women with disability.

OBJECTIVE: To investigate the relationship between the level of disability and regular Pap smear testing among women in Taiwan and explore how this relationship may vary with the various levels of physician availability. METHODS: This population-based cohort study followed a total of 5,469,581 women from Taiwan, who were 30 years old or older in 2001 and covered the period January 2001 to December 2003. Of the total study population, 184,701 individuals were women with disability. Gynecologist-obstetrician/general practitioner to female population ratio was used as an indicator of physician availability. Multiple logistical regression models were used. RESULTS: After adjusting for age, socioeconomic status, racial group, residence area and physician availability, women with severe disability (OR = 0.38; 95% CI: 0.38, 0.39) were the least likely to undergo Pap smear testing. Women with moderate disability (OR = 0.59; 95% CI: 0.58, 0.60) and mild disability (OR = 0.88; 95% CI: 0.86, 0.89) were also significantly less likely to undergo a routine test than women without disability. Women residing in the areas with the greatest physician availability (OR = 0.93; 95% CI: 0.93, 0.94) were significantly less likely to undergo a Pap test than those in the areas with the lowest level of resource availability. The disparity in routine screening between women with and without disability remained across the different levels of physician availability. CONCLUSIONS: In Taiwan, women with disability were found to be at higher risk of lower compliance than women without disability. The gap between women with and without disability persisted across different levels of physician availability.

Inadequate prenatal care utilization among women with and without methadone-treated opioid use disorders in Taiwan.

AIMS: The present study aims to investigate the utilization pattern of prenatal care and correlates for women with opioid use disorders (OUD) in Taiwan. METHOD: Using the data linkage between the Methadone Maintenance Treatment (MMT) register with national health insurance, national birth notification system, and birth registration system, we identified 1712 pregnancies with 20 or more gestational weeks from women enrolled in the MMT (heroin-exposed: receiving no methadone treatment during pregnancy, n = 1053 by 882 women; methadone-treated: receiving methadone for at least one day during pregnancy, n = 659 by 574 women) and their 1:10 matched pregnancies from 17,060 women without substance use disorder in the period of 2004-2013. The generalized linear mixed models with negative binomial and logit distributions were performed to evaluate the relationship between individual sociodemographic, health, and addiction treatment characteristics with the number of prenatal visits and receiving prenatal care in the first trimester (i.e., early entry). FINDINGS: Eighteen percent of pregnancies by women with OUD received no prenatal services and 21% had started prenatal care in the first trimester as compared with 1% and 46% in pregnancies by women without substance use disorders. For pregnancies by women with OUD, methadone treatment was not linked associated with prenatal care visits (adjusted relative risk [aRR] = 1.02; 95% = 0.92, 1.12). For methadone-treated pregnancies, treatment enrollment before pregnancy and spousal methadone treatment elevated prenatal visits by 8% and 18% (0.48 and 1.08 visits, respectively). Additionally, HIV infection (adjusted odds ratio [aOR] = 0.30, 95% CI = 0.10, 0.83) and prior delivery (aOR = 0.05, 95% CI = 0.01, 0.19) significantly reduced the odds of early entry into prenatal care. CONCLUSION: Integrating addiction treatment programs with prenatal care is urgently needed to increase adequate prenatal care for pregnant women with OUD, especially the multiparous ones.

Excess mortality in children born to opioid-addicted parents: A national register study in Taiwan.

BACKGROUND: Young offspring of individuals with opioid use disorders have great exposure to a wide array of social disadvantages and stressors. This study aimed to investigate excess mortality before the age of six and predictors of premature death in children born to opioid-involved parents. METHODS: A total of 3210 children born between 2004 and 2009 to parents with opioid use disorders (roughly a quarter of whom were born after parental methadone treatment enrollment) were identified in Taiwan. Information concerning sociodemographic characteristics, history of medical condition, and survival status was obtained through data linkage with the National Health Insurance Database and death registration. The age-, birth year-, and sex-adjusted standardized mortality ratios (SMRs) and survival analyses were used to assess risk estimates and evaluate predictors. RESULTS: The overall SMR for children with opioid-involved parents was 2.31 (95% confidence interval [CI] = 1.68-3.10), with the estimate reaching 4.23 (95% CI = 2.37-6.97) when the causes of death were unnatural (e.g., injury and accident). The most salient predictors of premature death were low birth weight and paternal opioid problem severity, which increased risk of premature death 2.5--5.2-fold (all P < 0.05). Being born after parents enrolled in methadone treatment was slightly associated with a reduced risk of death in those mothered by opioid users (adjusted hazard ratio = 0.30). CONCLUSION: The elevated risk of premature death in the offspring of opioid-addicted parents suggests the need to prioritize resource allocation to safeguard this marginalized and vulnerable segment of the pediatric population.

Disparities in appendicitis rupture rate among mentally ill patients.

BACKGROUND: Many studies have been carried out that focus on mental patients' access to care for their mental illness, but very few pay attention on these same patients' access to care for their physical diseases. Acute appendicitis is a common surgical emergency. Our population-based study was to test for any possible association between mental illness and perforated appendicitis. We hypothesized that there are significant disparities in access to timely surgical care between appendicitis patients with and without mental illness, and more specifically, between patients with schizophrenia and those with another major mental illness. METHODS: Using the National Health Insurance (NHI) hospital-discharge data, we compared the likelihood of perforated appendix among 97,589 adults aged 15 and over who were hospitalized for acute appendicitis in Taiwan between the years 1997 to 2001. Among all the patients admitted for appendicitis, the outcome measure was the odds of appendiceal rupture vs. appendicitis that did not result in a ruptured appendix. RESULTS: After adjusting for age, gender, ethnicity, socioeconomic status (SES) and hospital characteristics, the presence of schizophrenia was associated with a 2.83 times higher risk of having a ruptured appendix (odds ratio [OR], 2.83; 95% confidence interval [CI], 2.20-3.64). However, the presence of affective psychoses (OR, 1.15; 95% CI: 0.77-1.73) or other mental disorders (OR, 1.58; 95% CI: 0.89-2.81) was not a significant predictor for a ruptured appendix. CONCLUSION: These findings suggest that given the fact that the NHI program reduces financial barriers to care for mentally ill patients, they are still at a disadvantage for obtaining timely treatment for their physical diseases. Of patients with a major mental illness, schizophrenic patients may be the most vulnerable ones for obtaining timely surgical care.

Suicides after the 1999 Taiwan earthquake.

BACKGROUND: The impact of a disaster on extreme post-traumatic responses of the victims, such as suicide, remains unclear. We conducted this study to investigate the risk of committing suicide between victims and non-victims after the 1999 Taiwan earthquake. METHODS: This population cohort study linked the National Health Insurance files, family registration, and death certificates. It consists of the 3 432 705 residents aged >/=15 years of central Taiwan, 1998-2000. They were stratified into victims (n = 301 327) and non-victims (n = 3 131 378). Victims refer to those who lost co-resident family members, were injured, or experienced property loss during the earthquake. Non-victims refers to all others. The suicide rate was calculated for the period 2-15 months after the earthquake. Adjusted odds ratios were estimated with logistic regression. RESULTS: After adjusting for residential location, age, gender, major disease status, and level of urbanization, we found that victims were 1.46 times more likely than non-victims to commit suicide following an earthquake (95% CI: 1.11, 1.92). CONCLUSIONS: Given the large study population and individual information available to identify victim status, this study was able to detect a statistically significant earthquake effect on suicide rate. This effect on suicide might be diluted if only geographically based stratification were possible, as opposed to victim status stratifications. Mental health programmes or other preventive strategies might be more effective by specifically targeting victims rather than by simply targeting individuals living in earthquake-affected areas.

Screening for cervical cancer among female physicians and their relatives in Taiwan: a population-based comparative study.

BACKGROUND: This study compares the practice of having the recommended Pap smear test every 3 years among female physicians, female relatives of physicians, and general women of similar socio-economic background. METHODS: This population-based cohort study followed a total of 5,815,781 Taiwanese women from January 2001 to December 2003, who were 30 years of age or older in 2001. Of the total study population, 1950 were physicians and 27,441 were female relatives of physicians. Multiple logistical regression models were used. RESULTS: After adjusting for age, ethnic status, physical disability status, and place of residence, of those women whose monthly insurable income was greater than $NT 40,000, female physicians (OR 0.54, 95% CI: 0.50-060) were the least likely to have undergone at least one Pap smear test during the three-year study period. The physicians' relatives (OR 0.90, 95% CI: 0.87-0.92) were also significantly less likely to take routine Pap smear tests compared to general women with equivalent socio-economic background. CONCLUSIONS: The female physician is a major player in disease prevention with advanced knowledge of the benefits associated with the Pap smear test, but may not adhere any better to the recommendations than the general population.