Acupressure reduces the severity of restless legs syndrome in hemodialysis patients: A cluster-randomized crossover pilot study.

BACKGROUND: Restless legs syndrome (RLS), a neurological disorder, often affects sleep quality in hemodialysis patients. This study aimed to evaluate acupressure's effect on the severity of RLS symptoms and sleep quality in hemodialysis patients with RLS. METHODS: This study is a cluster-randomized crossover pilot study. Patients were randomized to two sequences: acupressure for one month and observation for another month (AC); and observation for one month and acupressure for another month (CA). For the four-week acupressure intervention, patients received 36 min of acupressure three times weekly during their hemodialysis sessions. The acupoints were on the bilateral lower limbs, including Zusanli (ST36), Yanglingquan (GB34), Sanyinjiao (SP6), Xuanzhong (GB39), Chengshan (BL57), and Taichong (LR3). RLS severity and sleep quality (measured with the Pittsburgh sleep quality index, PSQI) were measured at baseline, month 1, and month 2. RESULTS: AC sequence (n = 14) was similar to the CA sequence (n = 9) in terms of gender, age, education, employment, marital status, comorbid disease, BMI, duration of dialysis, medication for RLS and insomnia, RLS severity, and PSQI. The general linear mixed model revealed no significant carryover effect on RLS severity, PSQI, and the seven subscales of PSQI. A significant treatment effect (acupressure) was only observed in RLS severity (p = 0.0013) but not in PSQI and the seven subscales. The significant period effect was observed in RLS severity (p = 0.0250) and the subscale of sleep disturbance (p = 0.0021). CONCLUSION: In hemodialysis patients with RLS, acupressure can alleviate the severity of RLS but cannot improve sleep quality.

Efficacy and safety of indigo naturalis ointment in Treating Atopic Dermatitis: A randomized clinical trial.

ETHNOPHARMACOLOGICAL RELEVANCE: Indigo naturalis, a herbal medicine with a history of use dating back to ancient times, may be a good alternative topical treatment for atopic dermatitis (AD). AIM OF THE STUDY: To provide empirical evidence of the efficacy and safety of Indigo naturalis ointment in treating AD. MATERIALS AND METHODS: In this randomized double-blind clinical trial, participants aged 6 to 65 years with AD affecting less than 40% of their body surface area (BSA) and an Investigator's Global Assessment (IGA) score of 2 to 4 were randomized (2:1) to receive either Lindioil ointment or a vehicle ointment twice daily for 6 weeks. The primary endpoint was the percentage change in the Eczema Area Severity Index (EASI) from baseline to week 6. Secondary endpoints were as follows: EASI improvement ≥50%, 75%, and 90%; IGA score; BSA affected by AD; pruritus severity; and Dermatology Life Quality Index. The safety assessment included adverse events (AEs), laboratory tests, and physical examinations. RESULTS: The Lindioil group (32 participants) and vehicle group (16 participants) achieved mean percentage EASI reductions of 49.9% ± 36.5% (95% CI 36.8%-63.1%) and 19.6% ± 52.2% (95% CI -8.2%-47.4%), respectively (P = 0.0235). The Lindioil group also showed greater improvement in every secondary assessment category. No significant AEs occurred. CONCLUSION: Indigo naturalis ointment is effective for treating mild to severe AD topically, and appears to be safe. This is the first clinical trial to provide evidence supporting topical indigo-based AD treatment. ClinicalTrials.gov identifier: NCT02669888.

Effectiveness and Safety of Four Direct Oral Anticoagulants in Asian Patients With Nonvalvular Atrial Fibrillation.

BACKGROUND: Whether four direct oral anticoagulants (DOACs) are superior to warfarin in Asian patients with nonvalvular atrial fibrillation (NVAF) remains unclear. METHODS: This nationwide retrospective cohort study was based on data from Taiwan's National Health Insurance Research Database from June 1, 2012, to December 31, 2017, covering patients with NVAF taking edoxaban (n = 4,577), apixaban (n = 9,952), rivaroxaban (n = 33,022), dabigatran (n = 22,371), and warfarin (n = 19,761). Propensity score weighting was used to balance covariates across study groups. Patients were followed up until occurrence of study outcomes or end date of study. RESULTS: Edoxaban, apixaban, and rivaroxaban were associated with a lower risk of ischemic stroke/systemic embolism than warfarin. All DOACs had a lower risk of major bleeding than warfarin. Apixaban was associated with a lower risk of major bleeding than rivaroxaban and dabigatran, whereas the risk of major bleeding was comparable between edoxaban and apixaban. The reduced risks of thromboembolism/major bleeding for the four DOACs persisted in high-risk subgroups, including those with chronic kidney disease, elderly patients (age ≥ 75 years), secondary stroke prevention, or CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, previous stroke/transient ischemic attack, vascular disease, age 65-74 years, and female sex) ≥ 4. A total of 2,924 (64%), 6,359 (64%), 31,108 (94%), and 19,821 (89%) patients received low-dose edoxaban (15-30 mg/d), apixaban (2.5 mg bid), rivaroxaban (10-15 mg/d), and dabigatran (110 mg bid), respectively. The effectiveness/safety outcomes with the four low-dose DOACs compared with warfarin were consistent with the main analysis. CONCLUSIONS: In the largest real-world practice study among Asian patients with NVAF, four DOACs were associated with a comparable or lower risk of thromboembolism, and a lower risk of bleeding than warfarin. There was consistency even among high-risk subgroups and whether standard-or low-dose regimens were compared.

Endophthalmitis Incidence of Cancer Patients After Cataract Surgery: A Nationwide Matched Cohort Study in Taiwan.

PURPOSE: To compare the incidence rate of endophthalmitis after cataract surgery between cancer cohort and matched noncancer cohort. DESIGN: Matched cohort study. METHODS: Patients with cataract surgery of both eyes among a nationwide cancer cohort and 1:1 matched noncancer cohort were enrolled from the years 1998 to 2012 in the Taiwan National Health Insurance Research Database. Both the cancer group and the control group were followed for 3 months after the cataract surgery to obtain the rate of endophthalmitis. RESULTS: There were 23 362 patients each in the cancer cohort and in the matched noncancer cohort. The mean age of receiving first cataract surgery was 71 years. The mean duration of receiving cataract surgery was 4.3 years after cancer diagnosis. The mean duration between 2 cataract surgeries was 8-9 months. The rate of endophthalmitis within 3 months after cataract surgery was similar between the 2 study groups: 2.4‰ (95% confidence interval = 1.9‰-2.8‰) for the cancer group and 2.3‰ (95% confidence interval = 1.9‰-2.8‰) for the noncancer group, respectively (P = .892). CONCLUSIONS: Cancer patients have a similar risk of endophthalmitis following cataract surgery as the noncancer population, and the current study suggests that cataract surgery can be considered as appropriately indicated for cancer patients.

Urate-lowering treatment and risk of total joint replacement in patients with gout.

Objectives: To examine whether gout is an independent risk factor for total joint replacement (TJR) and whether urate-lowering treatment (ULT) reduces this risk. Methods: Using the Taiwan National Health Insurance database and the UK Clinical Practice Research Datalink, 74 560 Taiwan patients and 34 505 UK patients with incident gout were identified and age and sex matched to people without gout. Cox proportional hazards models and condition logistic regression were used to examine the risk of TJR in gout patients and the association between cumulative defined daily dose (cDDD) of ULT and TJR. Results: The prevalence rates of TJR in the patients at the time of diagnosis of gout and in people without gout were 1.16% vs 0.82% in Taiwan and 2.61% vs 1.76% in the UK. After a gout diagnosis, the incidence of TJR was higher in the patients with gout compared with those without (3.23 vs 1.91 cases/1000 person-years in Taiwan and 6.87 vs 4.61 cases/1000 person-years in the UK), with adjusted HRs of 1.56 (95% CI 1.45, 1.68) in Taiwan and 1.14 (1.05, 1.22) in the UK. Compared with patients with gout with <28 cDDD ULT, the adjusted ORs for TJR were 0.89 (95% CI 0.77, 1.03) for 28-90 cDDD, 1.03 (0.85, 1.24) for 90-180 cDDD and 1.12 (0.94, 1.34) for >180 cDDD ULT in Taiwan. In the UK, the respective ORs were 1.09 (0.83, 1.42), 0.93 (0.68, 1.27) and 1.08 (0.94, 1.24). Conclusion: This population-based study provides evidence from two nation populations that gout confers significant TJR risk, which was not reduced by current ULT.

Training effect of a stationary preprogrammed target dummy on visual response time and contest performance of karate athletes.

BACKGROUND: Response time (RT) is crucial in karate athletes and can be trained. The aim of this study was to compare standing eye-hand RT and contest performance in nonelite karate athletes who underwent 6 weeks of training using either a stationary preprogrammed target dummy (experimental group) or traditional karate instruction (control group). METHODS: Forty male nonelite karate athletes (20 in each group) were recruited. Standing RT and contest performance was assessed before and after training. Attack RT (eye-hand or eye-leg) and success rate were measured in the experimental group only during training. RESULTS: Age, years of karate practice, Body Mass Index, and standing RT before training did not significantly differ between groups. In the control group, standing RT was significantly improved in the dominant hand after training (25.62±24.18 ms, P=0.0003), but there was no significant improvement in standing RT of the nondominant hand and karate contest score. In the experimental group, standing RT was significantly faster after training (improvement in dominant hand: 69.84±50.85 ms, P<0.0001; improvement in nondominant hand: 68.94±59.43 ms, P<0.0001), and the karate contest score was significantly improved (P=0.0234). During the training period, mean attack RT improved from 1047.4 ms in week1 to 944.9 ms in week6 (P<0.001). However, the success rate gradually decreased from 89.3% (week 1) to 62.4% (week 6) (P<0.001). CONCLUSIONS: A 6-week training using a stationary preprogrammed target dummy improved contest performance and standing RT in both the dominant and nondominant hands of nonelite karate athletes. Improvements of RT in the dominant hand were also seen in the control group.

Thromboembolic, Bleeding, and Mortality Risks of Rivaroxaban and Dabigatran in Asians With Nonvalvular Atrial Fibrillation.

BACKGROUND: It is unclear whether the non-vitamin K antagonist oral anticoagulant agents rivaroxaban and dabigatran are superior to warfarin for efficacy and safety outcomes in Asians with nonvalvular atrial fibrillation (NVAF). OBJECTIVES: The aim of this study was to compare the risk for thromboembolic events, bleeding, and mortality associated with rivaroxaban and dabigatran versus warfarin in Asians with NVAF. METHODS: A nationwide retrospective cohort study was conducted of consecutive patients with NVAF taking rivaroxaban (n = 3,916), dabigatran (n = 5,921), or warfarin (n = 5,251) using data collected from the Taiwan National Health Insurance Research Database between February 1, 2013 and December 31, 2013. The propensity score weighting method was used to balance covariates across study groups. Patients were followed until the first occurrence of any study outcome or the study end date (December 31, 2013). RESULTS: A total of 3,425 (87%) and 5,301 (90%) patients were taking low-dose rivaroxaban (10 to 15 mg once daily) and dabigatran (110 mg twice daily), respectively. Compared with warfarin, both rivaroxaban and dabigatran significantly decreased the risk for ischemic stroke or systemic embolism (p = 0.0004 and p = 0.0006, respectively), intracranial hemorrhage (p = 0.0007 and p = 0.0005, respectively), and all-cause mortality (p < 0.0001 and p < 0.0001, respectively) during the short follow-up period. In comparing the 2 non-vitamin K antagonist oral anticoagulant agents with each other, no differences were found regarding risk for ischemic stroke or systemic embolism, intracranial hemorrhage, myocardial infarction, or mortality. Rivaroxaban carried a significantly higher risk for hospitalization for gastrointestinal bleeding than dabigatran (p = 0.0416), but on-treatment analysis showed that the risk for hospitalized gastrointestinal bleeding was similar between the 2 drugs (p = 0.5783). CONCLUSIONS: In real-world practice among Asians with NVAF, both rivaroxaban and dabigatran were associated with reduced risk for ischemic stroke or systemic embolism, intracranial hemorrhage, and all-cause mortality without significantly increased risk for acute myocardial infarction or hospitalization for gastrointestinal bleeding compared with warfarin.

Identification of subclinical transmission of vancomycin-resistant enterococcus within an intensive care unit in Taiwan.

BACKGROUND/PURPOSE: Colonization, infection, and clonal dissemination of vancomycin-resistant enterococcus (VRE) have been reported in the literature. We aimed to investigate the incidence rate of VRE acquisition and route of transmission of VRE within the medical intensive care unit (ICU) to prove whether subclinical transmission occurs in medical ICUs. METHODS: Between March 1, 2012 and September 30, 2013, rectal cultures were obtained from all inpatients on admission and after admission to medical ICU. Strain types of VRE were determined by both multilocus sequence typing and pulsed-field gel electrophoresis. RESULTS: A total of 66 of the 405 rectal swab surveillance cultures obtained from 46 inpatients were positive for VRE, among which 27 inpatients were culture-positive for VRE on admission to medical ICU, and 19 inpatients were initially culture-negative but converted to culture-positive after admission. All isolates carried vanA gene consisting of 51 Enterococcus gallinarum, 13 Enterococcus faecium, and two Eenterococcus casseliflavus. Of the 51 E. gallinarum isolates, 40 were type ST 341, seven were ST 252, two were ST 78, and two were ST 64. The Enterococcus spp., MLST and PFGE subtypes were almost similar among these two groups of inpatients. Linezolid and tigecycline were most active against VRE in vitro. CONCLUSION: Subclinical VRE cross transmission may occur in ICU. Active surveillance and maximal barrier precautions of VRE are required at ICU with high colonization rate of VRE and shall be beneficial.

Efficacy and safety of Indigo naturalis extract in oil (Lindioil) in treating nail psoriasis: a randomized, observer-blind, vehicle-controlled trial.

Treating nail psoriasis is notoriously difficult and lacks standardized therapeutic regimens. Indigo naturalis has been demonstrated to be safe and effective in treating skin psoriasis. This trial was conducted to evaluate the efficacy and safety of refined indigo naturalis extract in oil (Lindioil) in treating nail psoriasis. Thirty-one outpatients with symmetrically comparable psoriatic nails were enrolled. Lindioil (experimental group) or olive oil (control group) was applied topically to the same subjects' two bilaterally symmetrical psoriatic nails twice daily for the first 12 weeks and then subjects applied Lindioil to both hands for 12 additional weeks. Outcomes were measured using Nail Psoriasis Severity Index (NAPSI) for five nails on one hand and for the single most severely affected nail from either hand. The results show a reduction of NAPSI scores for the 12-week treatment for the Lindioil group (49.8% for one hand and 59.3% for single nail) was superior to the reduction in the scores for the control group (22.9%, 16.3%, respectively). There were no adverse events during the 24 weeks of treatment. This trial demonstrates that Lindioil is a novel, safe and effective therapy for treating nail psoriasis.

Pyogenic liver abscess as a warning sign for primary liver cancer: a nationwide population-based study.

BACKGROUND: There have been no large-scale population-based studies to estimate the subsequent risk of primary liver cancer (PLC) among patients with pyogenic liver abscess (PLA). This study aimed to provide relevant data. MATERIALS AND METHODS: The Taiwan Longitudinal Health Insurance Database for the years 2000 and 2005 was used. The PLA group were adult inpatients who were newly diagnosed with PLA from 2000 to 2008. The control group was randomly selected and matched with the PLA group in terms of age, sex, and date in which medical treatment was sought other than for PLA. RESULTS: There were 1,987 patients each in the PLA and control groups. In total, 56 had PLC, 48 (2.4%, 601.5 per 100,000 person-years) from the PLA group, and 8 from the control group. After adjusting for potential covariates, the hazard ratio of PLC for the PLA group was 3.4 times that of the control group (95% confidence interval = 1.6-7.3, p <0.001). The PLC risk for the PLA group was significantly higher within the first year after PLA diagnosis (hazard ratio: 35.4) as compared with the control group and became insignificant (hazard ratio: 2.0, 95% confidence interval = 0.8-4.9) more than one year after PLA diagnosis. CONCLUSIONS: Patients with PLA have a higher rate of PLC than matched controls, especially within the first year after the diagnosis of PLA, suggesting PLA is a warning sign for PLC.

Treatment of psoriatic nails with indigo naturalis oil extract: a non-controlled pilot study.

BACKGROUND: In the treatment of nail psoriasis, standardized therapeutic regimens are currently lacking. OBJECTIVE: To evaluate the therapeutic efficacy of indigo naturalis oil extract in patients with nail psoriasis. METHODS: Patients with nail psoriasis applied indigo naturalis oil extract on affected nails twice daily for 24 weeks. Efficacy was evaluated using the Nail Psoriasis Severity Index (NAPSI) and modified target NAPSI for the single most severely affected nail. RESULTS: Twenty-eight out of 32 patients completed the study. The mean NAPSI was 36.1 ± 14.7 at baseline and decreased to 14.9 ± 11.1 at week 24 while the mean modified target NAPSI was 11.7 ± 3.9 at baseline and decreased to 3.6 ± 3.2 at week 24. CONCLUSIONS: Indigo naturalis oil extract appeared to improve nail psoriasis. Although preliminary, these results indicate that it could provide a novel therapeutic option for nail psoriasis, a disease notoriously difficult to treat.

Quality of life in patients with psoriasis in northern Taiwan.

BACKGROUND: Psoriasis has a significant negative impact on quality of life. The aim of this study was to identify factors associated with the quality of life of patients with psoriasis in Taiwan. METHODS: A retrospective study analyzing data from psoriasis patients who visited the outpatient clinics in the Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital at Taipei, Taoyuan and Keelung from July 2009 to January 2010 was performed. RESULTS: A total of 480 patients who had completed the assessment of disease severity and the dermatology life quality index (DLQI) questionnaire were analyzed. Of these patients, 67.5% were men. The mean score on the DLQI was 9.16 ± 6.3 and 67% of all patients reported a moderate to extremely large impact on their quality of life (DLQI > 6). A higher psoriasis area and severity index (PASI), younger age and initial lesions on the nails significantly negatively impacted patients' quality of life. Smoking, alcohol intake and gender were also weakly correlated. CONCLUSION: The clinical severity, age and site of initial lesions are associated with negative impacts on the quality of life of patients with psoriasis. These findings provide significant new insights into factors that affect the life quality of patients with psoriasis in Taiwan.

Vascular response of Raynaud's phenomenon to nifedipine or herbal medication (duhuo-tisheng tang with danggui-sini tang): a preliminary study.

BACKGROUND: Raynaud's phenomenon (RP) is a common manifestation in connective tissue diseases. Calcium channel antagonists are most effective and frequently used for treating RP. This study compared the efficacy, digital vascular response, and tolerability between nifedipine and a combination of 2 Chinese herbal medications (duhuo-tisheng tang and danggui-sini tang) for treating RP. METHODS: This open-label non-randomized clinical trial included 47 connective tissue disease patients with RP. The herbal group and the nifedipine group included 26 and 21 patients, respectively. The duration of therapy was 4 weeks. Baseline and posttreatment laser Doppler blood flow imaging of both hands were performed at room temperature and after cold challenge. Nailfold capillary microscopy was performed at the baseline and after 4 weeks of therapy. Serum levels of soluble intercellular adhesion molecule-1 (sICAM-1), prostaglandin E2 (PGE2), nitrite (NO2), and nitrate (NO3), and plasma levels of endothelin-1 (ET-1) were also measured. Self-reported symptoms, using a visual analog scale (VAS) and a physician global assessment (PGA), were recorded at the baseline and after treatment. RESULTS: After 4 weeks of treatment, VAS scores improved (p = 0.0035) and the physician's global assessment of RP severity decreased in the nifedipine group (p = 0.0078) but not in the herbal group. Episodes of RP attacks decreased in the nifedipine group after treatment (p = 0.008). The nifedipine group had increased laser Doppler flow (116.3 +/- 70.7 AU) compared to the baseline (72.4 +/- 49.0 AU, p = 0.0008). Laser Doppler images improved at various time points after cold challenge in the nifedipine group after therapy. Laser Doppler flow in the herbal group did not significantly change with therapy. Capillary microscopy demonstrated no significant difference in enlargements, avascularity, or hemorrhagic spots between groups. Serum NO2 concentrations were higher in the nifedipine group than in the herbal group. Levels of sICAM-1, PGE2, NO3, and ET-1 after therapy were similar to those at the baseline in both groups. CONCLUSIONS: The digital vascular response in RP improved with nifedipine but was unchanged with a combination of the Chinese medicines Duhuo-Tisheng Tang and Danggui-Sini Tang.

Ding Chuan Tang, a Chinese herb decoction, could improve airway hyper-responsiveness in stabilized asthmatic children: a randomized, double-blind clinical trial.

Traditional Chinese medicine has a long history of application in the treatment of bronchial asthma. Solid scientific evidence, however, is not available despite its widespread use among patients worldwide and in Taiwan. To assess the effect of Ding Chuan Tang (DCT) in airway hyper-responsiveness (AHR) on asthmatic children via randomized, double blind, placebo-controlled clinical trial. This study enrolled children who were aged 8-15 and diagnosed as mild to moderate persistent asthma patients. They were randomly allocated to receive 6.0 g DCT or placebo daily for 12 wk. Self-recorded daily symptom scores, medication scores, and morning and evening peak expiratory flow rates were returned at the monthly clinic. Pulmonary function test, methacholine challenge test, and serum inflammatory mediators were measured before and at the end of the trial. Fifty-two asthmatic children completed the clinical study. Twenty-eight patients were assigned to the treatment group and 24 to the placebo group. At the end of the treatment period, AHR determined by log PC(20) was significantly improved in the DCT group (0.51 +/- 1.05 mg/ml vs. 0.26 +/- 0.84 mg/ml, p = 0.034). The total clinical and medication reduced parameters showed improvement in the DCT group (p = 0.004). The AHR, symptom and medication scores in children with persistent asthma were significantly improved with DCT treat for 12 wk. The results suggested more stable airways achieved with such an add-on complementary therapy.

The add-on effects of Gynostemma pentaphyllum on nonalcoholic fatty liver disease.

CONTEXT: Other than weight reduction by dieting or physical activity, there are no well-documented medical treatments for fatty liver disease. OBJECTIVE: To evaluate the efficacy of the add-on Gynostemma pentaphyllum (GP) in research subjects with nonalcoholic fatty liver disease. DESIGN: A randomized, single-blind, controlled clinical trial. SETTING: Hospital-based clinic. PATIENTS: Fifty-six research subjects who were diagnosed with nonalcoholic fatty liver by abdominal ultrasound scanning. INTERVENTIONS: The treatment group and the control group followed a controlled diet for 2 months. After 2 months, the treatment group continued to diet and received 80 mL GP extraction for 4 months; the control group continued to diet and received a placebo capsule for 4 months. MAIN OUTCOME MEASURES: Body mass index (BMI), biochemistry data, and fatty liver score were measured at baseline, at 2 months, and at 6 months. RESULTS: After 2 months of dieting, BMI and most biochemistry data decreased in both study groups. There were no significant differences in BMI or biochemistry data at month 2 between the 2 study groups. At month 6, BMI, triglyceride, aspartate aminotransferase (AST), alanine aminotransferase, alkaline phosphatase, insulin (ALP), insulin resistance index (HOMA-IR), and fatty liver score were reduced in both groups. The treatment group saw significant reductions in BMI, AST, ALP, insulin, and HOMA-IR, however. Changes in uric acid levels in the 2 groups from month 2 to month 6 were statistically significant (P = .028) CONCLUSION: GP is an effective adjunct treatment to diet therapy for patients with nonalcoholic fatty liver disease.

The effect of changing reimbursement policies on quality of in-patient care, from fee-for-service to prospective payment.

OBJECTIVE: Using insurance claims for hemorrhoidectomies, we examined the effect of Taiwan's Bureau of National Health Insurance's case payment system, a fixed case payment rate method used to reimburse health care providers for in-patient care. DESIGN: This observational natural experimental study examined changes in medical care that occurred between two phases: the 9 months before case payment system was implemented on 1 October 1997 and the 9 months afterwards. The changes were analyzed by performing linear regressions with interaction between hospital type and the implementation of case payment system. SETTING: This study was based on total claim data from National Health Insurance. STUDY PARTICIPANTS: A total of 23 638 hemorrhoidectomy insurance claims. MAIN OUTCOME MEASURES: Length of stay, number of medical services, and number of drug prescriptions. Medical services were stratified into those that were considered minimal requirements and those considered optional by the Bureau of National Health Insurance. RESULTS: Over the 18-month period, the number of patients increased by 23.7%. After the case payment system was implemented, length of stay decreased by 0.59 days (P < 0.0001), the number of minimally required services increased by 2.19 to 4.24 items (P < 0.0001), the number of optional service items decreased by 0.32 items (P < 0.0001), and drug prescription decreased slightly by 0.58 to 0.99 items (P < 0.0001) per hospitalization. CONCLUSIONS: The case payment system successfully shortened length of stay without significantly sacrificing the provision of services.