Exploring the effects of acceptable palliative care models on survival time and healthcare expenditure among patients with cancer: a national longitudinal population-based study.

OBJECTIVE: Hospice care ensures better end-of-life quality by relieving terminal symptoms. Prior research has indicated that hospice care could prolong survival and reduce end-of-life medical expenditures among patients with cancer. However, the dearth of studies on the effects of hospice care type and use sequence on survival time and end-of-life medical expenditures substantiates the need for investigation. DATA SOURCES AND STUDY SETTING: Two million random records were obtained from the National Health Insurance Research Database. STUDY DESIGN: We estimated the effects of the type and sequence of hospice care use on survival time and medical expenditures among advanced cancer patients. This was a cross-sectional study. DATA COLLECTION/EXTRACTION METHODS: Patient data were collected from 2 million random records provided by the National Health Insurance Research Database of Taiwan. We included people with cancer and excluded patients under 20 years of age; 2860 patients remained after matching. PRINCIPAL FINDINGS: The results indicated that the average survival time of patients who received inpatient palliative care (1022 days) was significantly shorter than that of patients who did not receive palliative care (P < 0.001), but the health care expenditure during the entire course of cancer therapy was not the lowest. Interestingly, patients who received inpatient palliative care had the lowest health care expenditure at 1 year or month before the end of life (P < 0.001). CONCLUSION: The type and sequence of palliative care affected the survival time and health care expenditures of cancer patients. Receiving palliative care did not prolong survival but rather reduced health care expenditures. The sequence of receiving palliative care significantly affected health care expenditures.

Disparities in the medical expenditures of patients with cancer and concomitant mental disorder: analyzing the effects of diagnosis sequence order.

BACKGROUND: Cancer is the leading cause of death in Taiwan. Medical expenditures related to cancer accounted for 44.8% of all major illness insurance claims in Taiwan. Prior research has indicated that the dual presence of cancer and mental disorder in patients led to increased medical burden. Furthermore, patients with cancer and concomitant mental disorder could incur as much as 50% more annual costs than those without. Although previous studies have investigated the utilization of patients with both diseases, the effects of morbidity sequence order on patient costs are, however, uncertain. This study explored medical expenditures linked with the comorbidity of cancer and mental disorder, with a focus on the impact of diagnosis sequence order. METHODS: This population-based retrospective matched cohort study retrieved patients with cancer and mental disorder (aged ≥ 20 years) from the Ministry of Health and Welfare Data Science Center 2005-2015 database. 321,045 patients were divided based on having one or both diseases, as well as on the sequence of mental disorder and cancer diagnosis. Study subjects were paired with comparison counterparts free of both diseases using Propensity Score Matching at a 1:1 ratio. Annual Cost per Patient Linear Model (with a log-link function and gamma distribution) was used to assess the average annual cost, covarying for socio-demographic and clinical factors. Binomial Logistic Regression was used to evaluate factors associated with the risk of high-utilization. RESULTS: The "Cancer only" group had higher adjusted mean annual costs (NT$126,198), more than 5-times that of the reference group (e^ß: 5.45, p < 0.001). However, after exclusion of patients with non-cancer and inclusion of diagnosis sequence order for patients with cancer and concomitant mental disorder, the post-cancer mental disorder group had the highest expenditures at over 13% higher than those diagnosed with only cancer on per capita basis (e^ß: 1.13, p < 0.001), whereas patients with cancer and any pre-existing mental disorder incurred lower expenditures than those with only cancer. The diagnosis of post-cancer mental disorder was significantly associated with high-utilization (OR = 1.24; 95% CI: 1.047-1.469). Other covariates associated with high-utilizer status included female sex, middle to old age, and late stage cancer. CONCLUSION: Presence of mental disorder prior to cancer had a diminishing effect on medical utilization in patients, possibly indicating low medical compliance or adherence in patients with mental disorder on initial treatments after cancer diagnosis. Patients with post-cancer mental disorder had the highest average annual cost. Similar results were found in the odds of reaching high-utilizer status. The follow-up of cancer treatment for patients with pre-existing mental disorders warrants more emphasis in an attempt to effectively allocate medical resources.

Demographics and medical disorders associated with smoking: a population-based study.

BACKGROUND: Few studies have investigated factors associated with smoking behaviors. In this population-based study, we investigated demographics and medical comorbid diseases to establish a prediction model for smoking behaviors by using the National Health Interview Survey (NHIS) and National Health Insurance Research Database (NHIRD). METHODS: We enrolled individuals aged ≥40 years who had participated in the NHIS in 2001, 2005, and 2009. We identified the smoking behaviors of the study participants in the NHIS. Smoking behaviors were divided into ever smokers (current smokers and ex-smokers) and nonsmokers (never smokers).We defined medical comorbid disorders of the study participants by using medical claim data from the NHIRD. We used multivariable logistic regression models to calculate the adjusted odds ratio and 95% confidence interval for variables associated with smoking. The significant variables in the multivariable model were included in the receiver operating characteristic curves (ROC) to predict the sensitivity and specificity of the model. RESULTS: In total, 26,375 participants (12,779 men and 13,596 women) were included in the analysis. The prevalence of smoking was 39.29%. The mean ages of the 16,012 nonsmokers were higher than those of the 10,363 smokers (57.86 ± 12.92 years vs. 53.59 ± 10.82 years). Men outnumbered women among smokers (68.18% vs. 31.82%). Male sex, young age and middle age, being insured categories, residence in suburban areas, and chronic obstructive pulmonary disease (COPD) were independent factors associated with smoking. The area under the ROC curve of these significant factors to predict smoking behaviors was 71.63%. CONCLUSION: Sex, age, insured categories, residence in suburban areas, and COPD were associated with smoking in people.

Sleep disorders associated with risk of prostate cancer: a population-based cohort study.

BACKGROUND: Disrupted sleep rhythms may lead to cancer development. We conducted a population-based cohort study to evaluate the incidence and risk of prostate cancer in patients with sleep disorders (SDs). METHODS: Patients newly diagnosed with SDs between 2000 and 2010 were enrolled from the Taiwan Longitudinal Health Insurance Database. A non-SD cohort age-matched (5-y intervals), comorbidities, and medications was randomly sampled from the general population at a 1:1 ratio. The follow-up period extended from the index date of SDs to the diagnosis of prostate cancer, censoring, or the end of 2013. We used Cox proportional hazards models to calculate the risk of prostate cancer. RESULTS: In total, 41,444 patients were enrolled in each cohort. The mean age of the SD cohort was 48.0 years and that of the non-SD cohort was 47.8 years, with 58.2% of both cohorts aged younger than 50 years. The incidence of prostate cancer increased with age. The overall incidence of prostate cancer was higher in the SD cohort than in the non-SD cohort (9.56 vs 6.36 per 10,000 person-y), with an adjusted hazard ratio of 1.42 (95% CI = 1.20-1.69). Age-specific analysis revealed a 1.35-fold increased risk of prostate cancer in the patients aged ≥65 years in the SD cohort compared with the non-SD counterparts (95% CI = 1.10-1.65). CONCLUSIONS: Patients with SDs are associated with increased risk of prostate cancer.

Incidence and risk of venous thromboembolism in patients following appendectomy: a nationwide cohort study.

Surgery may lead to poor blood flow and hypercoagulation. Few studies have investigated the incidence of venous thromboembolism (VTE) in Asian patients following appendectomy. We conducted a nationwide cohort study to investigate the risk of VTE in patients who underwent appendectomy compared with those who did not in Taiwan. We studied the entire hospitalized population in Taiwan from 2000 to 2012, with a follow-up period extending to the end of 2013. We identified patients who underwent appendectomy in Taiwan's National Health Insurance Research Database as the appendectomy cohort, and selected a nonappendectomy cohort from the general population that was 4:1 frequency-matched by age (5-year interval), sex, and index year for each appendectomy case. We used Cox models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for symptomatic VTE in the appendectomy cohort for comparison with the nonappendectomy cohort. The appendectomy cohort exhibited a higher incidence of symptomatic VTE than the nonappendectomy cohort (5.90 vs. 3.29 per 10,000 person-years). After adjustment for covariates, a 1.68-fold HR for symptomatic VTE was observed in the appendectomy cohort (95% CI 1.56-1.81). Compared with the nonappendectomy cohort, the patients who underwent open appendectomy had a 1.73-fold increased adjusted HR for symptomatic VTE (95% CI 1.61-1.87). Laparoscopic appendectomy was not significantly associated with symptomatic VTE. An 8.15-fold higher adjusted HR for VTE was observed in patients who underwent appendectomy within the first month after surgery compared with the nonappendectomy cohort. Open appendectomy carried an increased risk of symptomatic VTE. Laparoscopic appendectomy was not significantly associated with symptomatic VTE.

Is incentive spirometry beneficial for patients with lung cancer receiving video-assisted thoracic surgery?

BACKGROUND: The effectiveness of Incentive spirometry (IS) in patients undergoing video-assisted thoracic surgery (VATS) remains lacking. We conducted a population-based study to investigate the effectiveness of IS on patients with lung cancers following VATS. METHODS: We identified patients newly diagnosed with lung cancer who underwent surgical resection by VATS or thoracotomy from the years 2000 to 2008 in the Longitudinal Health Insurance Database. Exposure variable was the use of IS during admission for surgical resection by VATS or thoracotomy. Primary outcomes included hospitalization cost, incidence of pneumonia, and length of hospital stay. Secondary outcomes included the frequency of emergency department (ED) visits and hospitalizations at 3-month, 6-month, and 12-month follow-ups after thoracic surgery. RESULTS: We analyzed 7549 patients with lung cancer undergoing surgical resection by VATS and thoracotomy. The proportion of patients who were subjected to IS was significantly higher in those who underwent thoracotomy than in those who underwent VATS (68.4% vs. 53.1%, P < 0.0001). After we controlled for potential covariates, the IS group significantly reduced hospitalization costs (- 524.5 USD, 95% confidence interval [CI] = - 982.6 USD - -66.4 USD) and the risk of pneumonia (odds ratio = 0.55, 95% CI = 0.32-0.95) compared to the non-IS group following VATS. No difference in ED visit frequency and hospitalization frequency at 3-month, 6-month, and 1-year follow-up was noted between the IS and the non-IS groups following VATS. CONCLUSIONS: The use of IS in patients with lung cancers undergoing VATS may reduce hospitalization cost and the risk of pneumonia.

Increased risk of acute coronary syndrome in patients with bronchiectasis: A population-based cohort study.

BACKGROUND AND OBJECTIVE: There are few studies on the relationship between bronchiectasis and acute coronary syndrome (ACS). We conducted a population-based cohort study to assess whether bronchiectasis was associated with an increased risk of ACS. METHODS: We identified 3521 patients diagnosed with bronchiectasis between 2000 and 2010 (bronchiectasis cohort) and frequency matched them with 14 084 randomly selected people without bronchiectasis from the general population (comparison cohort) according to sex, age and index year using the Longitudinal Health Insurance Database. Both cohorts were followed until the end of 2010 to determine the ACS incidence. Hazard ratios of ACS were measured. RESULTS: Based on 17 340 person-years for bronchiectasis patients and 73 639 person-years for individuals without bronchiectasis, the overall ACS risk was 40% higher in the bronchiectasis cohort (adjusted hazard ratio (HR) = 1.40; 95% CI: 1.20-1.62). Compared with those in the comparison cohort with one respiratory infection-related emergency room (ER) visit per year, the ACS risk was 5.46-fold greater in bronchiectasis patients with three or more ER visits per year (adjusted HR = 5.46, 95% CI: 4.29-6.96). Patients with bronchiectasis and three or more respiratory infection-related hospitalizations per year had an 8.15-fold higher ACS risk (adjusted HR = 8.15, 95% CI: 6.27-10.61). CONCLUSION: Bronchiectasis patients, particularly those experiencing frequent exacerbations with three or more ER visits and consequent hospitalization per year, are at an increased ACS risk.

Sleep disorders associated with risk of rheumatoid arthritis.

BACKGROUND: Immune disorders impair sleep quality and sleep disorders (SDs) may derange immune function. PURPOSE: The study evaluated the incidence and risk of rheumatoid arthritis (RA) in patients with SDs using a nationwide cohort. METHODS: We recognized the patients with SDs from 1998 to 2002 by using the Taiwan National Health Insurance Research Database. One control patient for each SD patient was randomly selected and matched based on the proportion of age, sex, and index year. We calculated the person years of follow-up for each participant from the index date to RA diagnosis, censoring, or until December 31, 2011. The risk of RA was estimated by using Cox models incorporating demographics and comorbidities. RESULTS: We enrolled 65,754 patients with SDs and 65,753 controls and followed for 637,906 and 662,514 person-years, respectively. The patients with SDs exhibited a 1.49-fold greater risk of RA development compared with the comparison cohort when we adjusted for covariates. The patients with sleep apnea (SA) showed the greatest incidence density rate of RA, followed by those with non-apnea SDs and the non-SD cohort (4.11, 3.29, and 2.15 per 10,000 person-years, respectively). The SA cohort had a 2.56-fold adjusted hazard ratio (aHR) of RA (95% confidence interval [CI] = 1.11-5.91) and the non-apnea SD cohort had a 1.47-fold aHR of RA (95% CI = 1.18-1.84) compared with the non-SD cohort. Women with SDs presented a considerable risk of developing RA. CONCLUSIONS: This nationwide cohort study indicates that SDs are associated with the risk of RA development.

Increased risk of congestive heart failure in patients with acetaminophen poisoning: A nationwide cohort study.

Acetaminophen poisoning increases cytochrome P450 2E1 expression and reactive oxygen species production, which may lead to maladaptive myocardial remodeling and congestive heart failure (CHF). We conducted a nationwide cohort study to investigate the incidence and risk of CHF in patients with acetaminophen poisoning. We identified a cohort of adult patients with newly diagnosed acetaminophen poisoning in the inpatient claims of the Taiwan National Health Insurance Research Database for the 1998-2011 period. A comparison cohort was frequency matched at a 4:1 ratio for sex, age and index year. All patients were followed up until the occurrence of CHF, withdrawal from the National Health Insurance program, or December 31, 2011. Cox proportional hazards models were employed to calculate the risk of CHF in the acetaminophen poisoning cohort compared with the comparison cohort, and the hazard ratios with 95% confidence intervals are presented. A total of 3546 and 14 184 patients with and without acetaminophen poisoning were followed up for a total of 25 856 and 102 119 person-years, respectively. The overall incidence of CHF was higher in the acetaminophen poisoning cohort than in the comparison cohort (8.12 vs. 5.19 per 10 000 person-years). After adjustment for covariates, the acetaminophen poisoning cohort exhibited a 1.59-fold higher risk of CHF (adjusted hazard ratio = 1.59; 95% confidence interval = 1.43-1.75) than did the comparison cohort. Patients with acetaminophen poisoning exhibited a significantly higher risk of CHF compared with the comparison cohort. Clinicians should follow up heart function in patients with acetaminophen poisoning.

DMARD use is associated with a higher risk of dementia in patients with rheumatoid arthritis: A propensity score-matched case-control study.

BACKGROUND: Patients with rheumatoid arthritis (RA) exhibit an increased risk of dementia. Disease-modifying antirheumatic drugs (DMARDs) are commonly used to slow RA progression, but studies investigating the relationship between DMARDs and dementia in patients with RA are lacking. We investigated the relationship between DMARDs and dementia in patients with RA. METHODS: Using the National Health Insurance Research Database, patients aged ≥20years, who were newly diagnosed with RA between 2000 and 2011 were identified. Patients with RA who had dementia comprised the dementia group, and patients with RA who did not have dementia comprised the control group. The groups were matched at a 1:1 ratio by the propensity score. DMARDs were categorized into conventional synthetic DMARDs (csDMARDs) and biological DMARDs (bDMARDs). Logistic regression models were used to calculate the odds ratio and 95% confidence interval (CI) to evaluate the association between DMARD use and the risk of dementia in patients with RA. RESULTS: A total of 957 patients with RA and dementia, and 957 patients with RA but not dementia, were enrolled. The risk of dementia was determined to be 1.63-fold higher in patients with RA with csDMARD use than in those without csDMARD use (95% CI=1.33-2.00). No significant risk of dementia was observed in patients with RA who used bDMARDs compared with their counterparts. However, patients with RA who used hydroxychloroquine, methotrexate, and sulfasalazine exhibited significant risks of dementia, irrespective of cumulative exposure days. CONCLUSION: Patients with RA who used csDMARDs exhibit significant association with dementia.

Incidence and risk of acute coronary syndrome in patients with acute pancreatitis: A nationwide cohort study.

BACKGROUND: Studies on the relationship between acute pancreatitis (AP) and acute coronary syndrome (ACS) are scant. We conducted a nationwide cohort study to investigate the incidence and risk of ACS in patients with AP. METHODS: We enrolled patients newly diagnosed with AP between 2000 and 2010 from the Taiwan National Health Insurance Research Database and randomly selected a control cohort without a history of AP after frequency-matching for age, sex, and index year at a ratio of 4:1 for each patient with AP. The follow-up period was from the index date of new AP diagnosis to the diagnosis of ACS, censoring, or the end of 2011. RESULTS: We assessed 87 068 patients in the AP cohort and 348 272 participants in the control cohort for 508 991 and 2 301 317 person-years, respectively. The AP cohort exhibited a higher overall incidence of ACS than the control cohort (5.44 vs 3.03 per 1000 person-y). After adjustment for sex, age, and comorbidities, the AP cohort exhibited a 1.24-fold higher adjusted hazard ratio (aHR) of ACS (95% confidence interval = 1.19-1.30) than did the control cohort. When stratified by age, the patients with AP aged ≤39 years presented a 2.37-fold higher aHR of ACS than did their corresponding controls (95% CI = 1.88-2.99). Approximate one third of ACS developed within 1 month of AP occurrence. CONCLUSIONS: This nationwide cohort study indicated that patients with AP are at an increased risk of ACS compared with those without AP.

Free radicals and antioxidant enzymes in older adults after regular senior elastic band exercising: an experimental randomized controlled pilot study.

AIM: The aim of this study was to pilot test the effects of regular senior elastic band exercises on the generation of free radicals and antioxidant enzyme activities in older adults. BACKGROUND: Long-term regular exercises have positive health promotion outcomes. On the contrary, high-intensity, high-speed and short-term exercises in older adults may increase free radicals and cause chronic disease and ageing effect. DESIGN: A prospective randomized controlled pilot study. METHODS: Data were collected during 2012. Twenty-five older adults were recruited from a community care centre, southern Taiwan and were randomly assigned to either an experimental or control group. Twenty-two participants completed the study: experimental group (n = 10) and control group (n = 12). The experimental group performed 6-month senior elastic band exercises while the control group kept regular daily routines. Both groups received blood tests (thiobarbituric acid-reacting substances and glutathione peroxidase) 30 minutes before the study began and 1 hour after the final intervention treatment. RESULTS: At the end of the 6-month senior elastic band exercises, no statistically significant differences in thiobarbituric acid-reacting substances and glutathione peroxidase values between the experimental and control groups. No significant differences existed in both thiobarbituric acid-reacting substances and glutathione peroxidase values before and after the 6-month senior elastic band exercises either. CONCLUSIONS: Regular senior elastic band exercises did not increase the generation of free radicals and antioxidant enzyme activities. Senior elastic band exercises have the potential to be promoted among older adults in the community as an exercise option without adverse effects on free radicals and have potential for mitigating ageing and increasing disease control.

Multiple sclerosis increases the risk of venous thromboembolism: a nationwide cohort analysis.

OBJECTIVES: The purpose of this study was to evaluate the effects of multiple sclerosis (MS) on the risk of venous thromboembolism (VTE) development. METHODS: We identified patients diagnosed with MS in Taiwan between 1998 and 2010 using the National Health Insurance Research Database and the Catastrophic Illness Patient Database (RCIPD). Each MS patient was frequency matched to 4 controls according to age, sex and the year of MS registration to the RCIPD. Patients with a history of VTE and incomplete information of age and sex were excluded. All patients were followed up from the index year until VTE diagnosis, loss to follow-up or the end of 2010. We calculated the hazard ratios (HRs) and 95% confidence intervals (CIs) of VTE in the MS and comparison cohorts using Cox proportional hazards regression models. RESULTS: We followed up 1238 MS patients and 4952 comparison patients for approximately 6437 and 27 595 person-years, respectively. After adjusting for age, sex and comorbidities, the MS patients exhibited a 6·87-fold increased risk of VTE compared with the control patients. Women with MS were associated with an 11·1-fold increased risk of VTE development compared with the non-MS women (95% CI: 2·70-45·5). The MS patients aged < 50 years exhibited a 14·8-fold increased risk of developing VTE compared with age-matched patients in the comparison cohort (95% CI: 2·99-73·4). The risk of VTE development increased with the duration of hospitalization stay. CONCLUSION: MS patients are associated with significantly greater risk of developing VTE compared with non-MS patients.

BMI and all-cause mortality among middle-aged and older adults in Taiwan: a population-based cohort study.

OBJECTIVE: The present study investigates the relationship between BMI and all-cause mortality among middle-aged and older adults with or without pre-existing diseases. DESIGN: A population-based cohort study. SETTING: The Taiwan Longitudinal Study on Aging is a nationwide prospective cohort study comprising a representative random sample of middle-aged and older adults. The study period was 1996-2007. SUBJECTS: We followed 4145 middle-aged and older adults, totalling 42,353 person-years. RESULTS: Overweight and mildly obese participants showed a 16% and 30% decrease in the risk of death, respectively, compared with those of normal weight after adjusting for potential covariates (e.g. demographic characteristics, health behaviour, co-morbidities and physical function). Underweight adults showed a 1.36-fold increased adjusted hazard ratio of death compared with normal-weight adults. Adults with a BMI of 27.0-28.0 kg/m(2) showed a significantly lower adjusted hazard ratio of all-cause mortality rate compared with adults who had normal BMI values when they had coexisting hypertension or diabetes (adjusted hazard ratio = 0.50; 95% CI 0.30, 0.81 for hypertension and adjusted hazard ratio=0.41; 95% CI 0.18, 0.89 for diabetes). CONCLUSIONS: The study demonstrates that underweight people have a higher risk of death, and overweight and mildly obese people have a lower risk of death, compared with people of normal weight among middle-aged and older adults. An optimal BMI may be based on the individual, who exhibits pre-existing diseases or not.

Validation of overnight oximetry to diagnose patients with moderate to severe obstructive sleep apnea.

BACKGROUND: Polysomnography (PSG) is treated as the gold standard for diagnosing obstructive sleep apnea (OSA). However, it is labor-intensive, time-consuming, and expensive. This study evaluates validity of overnight pulse oximetry as a diagnostic tool for moderate to severe OSA patients. METHODS: A total of 699 patients with possible OSA were recruited for overnight oximetry and PSG examination at the Sleep Center of a University Hospital from Jan. 2004 to Dec. 2005. By excluding 23 patients with poor oximetry recording, poor EEG signals, or respiratory artifacts resulting in a total recording time less than 3 hours; 12 patients with total sleeping time (TST) less than 1 hour, possibly because of insomnia; and 48 patients whose ages less than 20 or more than 85 years old, data of 616 patients were used for further study. By further considering 76 patients with TST < 4 h, a group of 540 patients with TST ≥ 4 h was used to study the effect of insufficient sleeping time. Alice 4 PSG recorder (Respironics Inc., USA) was used to monitor patients with suspected OSA and to record their PSG data. After statistical analysis and feature selection, models built based on support vector machine (SVM) were then used to diagnose moderate and moderate to severe OSA patients with a threshold of AHI = 30 and AHI = 15, respectively. RESULTS: The SVM models designed based on the oxyhemoglobin desaturation index (ODI) derived from oximetry measurements provided an accuracy of 90.42-90.55%, a sensitivity of 89.36-89.87%, a specificity of 91.08-93.05%, and an area under ROC curve (AUC) of 0.953-0.957 for the diagnosis of severe OSA patients; as well as achieved an accuracy of 87.33-87.77%, a sensitivity of 87.71-88.53%, a specificity of 86.38-86.56%, and an AUC of 0.921-0.924 for the diagnosis of moderate to severe OSA patients. The predictive outcome of ODI to diagnose severe OSA patients is better than to diagnose moderate to severe OSA patients. CONCLUSIONS: Overnight pulse oximetry provides satisfactory diagnostic performance in detecting severe OSA patients. Home-styled oximetry may be a tool for severe OSA diagnosis.

Asthma increases pulmonary thromboembolism risk: a nationwide population cohort study.

Studies on the association between asthma and pulmonary thromboembolism are considerably limited. We investigated whether pulmonary embolism is associated with asthma using a nationwide cohort study. We identified 31,356 patients with newly diagnosed asthma in 2002-2008 and 125,157 individuals without asthma randomly selected from the general population, frequency matched by age, sex and index year using the National Health Insurance Research Database. Both cohorts were followed-up until the end of 2010 to measure the incidence of pulmonary embolism. Cox proportional hazards regression analysis was used to measure the hazard ratio of pulmonary embolism for the asthmatic cohort, compared with the nonasthmatic cohort. We followed 186,182 person-years for asthmatic patients and 743,374 person-years for nonasthmatic subjects. The hazard ratio of pulmonary embolism was 3.24 for the asthmatic cohort, compared with the nonasthmatic cohort after adjusting for sex, age, comorbidities and oestrogen supplementation. The risk of developing pulmonary embolism significantly increased with the increased frequency of asthma exacerbation and hospitalisation. This nationwide cohort study suggests that the risk of developing pulmonary embolism is significantly increased in asthmatic patients compared to the general population. Frequent asthma exacerbation and hospitalisation are significantly associated with pulmonary embolism risk.

Rheumatoid arthritis increases the risk of deep vein thrombosis and pulmonary thromboembolism: a nationwide cohort study.

OBJECTIVE: Studies on the association between rheumatoid arthritis (RA) and deep vein thrombosis (DVT) and pulmonary thromboembolism (PE) are scarce. This study identifies the effects of RA on the risks of developing DVT and PE in a nationwide prospective cohort study. METHODS: We studied the entire Taiwan population from 1998 to 2008, with a follow-up period extending to the end of 2010. We identified patients with RA using the catastrophic illness registry of the Taiwan National Health Insurance Research Database (NHIRD). We also selected a comparison cohort that was randomly frequency-matched by age (each 5-year span), sex and index year from the general population. We analysed the risks of DVT and PE using Cox proportional hazards regression models, including sex, age and comorbidities. RESULTS: From 23.74 million people in the cohort, 29 238 RA patients (77% women, mean age of 52.4 years) and 1 16 952 controls were followed 1 93 753 and 7 92 941 person-years, respectively. The risk of developing DVT and PE was 3.36-fold and 2.07-fold, respectively, in patients with RA compared with patients without RA, after adjusting for age, sex and comorbidities. The multiplicative increased risks of DVT and PE were also significant in patients with RA with any comorbidity. CONCLUSIONS: This nationwide prospective cohort study demonstrates that DVT and PE risks significantly increased in patients with RA compared with those of the general population.

Systemic sclerosis increases the risks of deep vein thrombosis and pulmonary thromboembolism: a nationwide cohort study.

OBJECTIVES: Few Asian studies have evaluated the risks of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) in patients with SSc. We conducted a nationwide population-based cohort study to evaluate how SSc affected the incidence of DVT and PTE in Taiwan. METHODS: We identified patients with an SSc diagnosis in Taiwan between 1998 and 2010 using the Catastrophic Illness Patient Database and the National Health Insurance Research Database. Each SSc patient was frequency matched to four control patients based on age, sex and index year and all patients were observed from the index date until the appearance of a DVT or PTE event or 31 December 2010. We calculated the hazard ratios and 95% CIs of DVT and PTE in the SSc and comparison cohorts using the Cox proportional hazards regression model. RESULTS: We observed 1895 SSc patients and 7580 control patients for ∼10,128 and 46,488 person-years, respectively. The mean ages of the SSc and comparison cohorts were 50.3 and 49.9 years, respectively. After adjusting for age, sex and co-morbidities, the risks of DVT and PTE among the SSc patients were 10.5- and 7.00-fold higher than those of the control patients. The probability of developing DVT and PTE increased in the years following the SSc diagnosis. CONCLUSION: SSc patients exhibited a significantly higher risk of developing DVT and PTE compared with the general population. Thus multidisciplinary teams should guide the assessment, treatment and holistic care of SSc patients.

Increased stroke risk among adult asthmatic patients.

BACKGROUND: We conducted a nationwide population-based cohort study to investigate the effects of asthma on the risk of stroke development in an Asian population. MATERIALS AND METHODS: Newly diagnosed asthmatic patients aged ≥ 18 years were identified, and asthma-free controls were randomly selected from the general population and frequency matched according to age, sex and index year using records obtained from the National Health Insurance Research Database between 2000 and 2010. Both cohorts were followed up until the end of 2011 to measure the incidence of stroke. The risk of stroke was analysed using Cox proportional hazard regression models, including factors such as sex, age and comorbidities. RESULTS: We followed the asthmatic patients for 104 697 person-years and followed the nonasthmatic people for 426 729 person-years. The incidence density rate of stroke increased in all of the groups of asthmatic patients compared with that of the controls when stratified according to sex, age and comorbidities. The hazard ratio (HR) of stroke was 1·37-fold greater for the asthmatic cohort, compared with that for the nonasthmatic cohort, after adjusting for sex, age and comorbidities. The adjusted HR of developing stroke substantially increased with older age and the increased frequency of asthmatic exacerbation and hospitalization. The patients receiving beta-2 agonists as a treatment exhibited a significantly greater risk of stroke compared with the patients receiving only inhaled corticosteroids, after adjusting for covariates. CONCLUSION: Asthma may be an independent risk factor for stroke, and its severity exhibits a dose response of stroke development.

Exposure to Fine Particulate Matter Increases Risk of Diabetes Mellitus: A Population-Based Cohort Study.

OBJECTIVE: This nationwide cohort study aimed to examine the association between PM2.5 and diabetes mellitus (DM) risk. METHODS: We recorded annual average PM2.5 exposure levels at participants' locations. PM2.5 concentrations were categorized into quartiles: Q1 (<29.5 µg/m 3 ), Q2 (29.5-33.3 µg/m 3 ), Q3 (33.4-41.2 µg/m 3 ), and Q4 (>41.2 µg/m 3 ). RESULTS: A total of 158,038 patients (69,688 men and 88,350 women) were enrolled. Diabetes mellitus incidence increased with higher annual PM2.5 concentrations (2.81 in Q1, 3.06 in Q2, 3.65 in Q3, and 3.89 in Q4 per 10,000 person-years). After adjusting for confounders, patients exposed to PM2.5 in Q2, Q3, and Q4 had adjusted hazard ratios of 1.14 (95% CI: 1.05-1.23), 1.40 (95% CI: 1.30-1.50), and 1.42 (95% CI: 1.32-1.53), respectively, for developing DM compared with those exposed to Q1-PM2.5 concentrations. CONCLUSIONS: This study observed an increased risk of DM associated with PM2.5 exposure.