Dynamic changes and lifetime effect of functional disability profiles for stroke patients: real-world evidence from South Korea.

PURPOSE: This work aimed to investigate the long-term dynamic changes of functional disabilities and estimate lifetime outcomes of different functional disabilities after a stroke, using real-world data from a nationally representative South Korean cohort. METHODS: Patients aged 18 and above with ischemic and hemorrhagic strokes were identified from the Korea Health Panel (KHP) data (2008-2018). Functional disabilities were repeatedly measured for patients aged 55 and over for the prevalence of disabilities associated with activities of daily living (ADL), and kernel smoothing means were estimated for each item. The lifetime survival function of stroke patients in Korea was adopted from another study utilizing the National Health Insurance Service of Korea's national sample cohort. By multiplying the disability-free proportion with the survival function throughout life, disability-free life expectancy (DFLE) for each ADL item was estimated. The loss-of-DFLE was calculated by subtracting the DFLE from age-, sex-, and calendar year-matched referents simulated from Korean life tables. RESULTS: The KHP dataset included 466 stroke patients. The overall functional disability needs increased over time after stroke diagnosis. DFLE was lowest for bathing (10.1 years for ischemic stroke and 12.8 years for hemorrhagic stroke), followed by those for dressing and washing. Loss-of-DFLE was highest for bathing for ischemic and hemorrhagic strokes (7.2 and 10.7 years, respectively), indicating that this task required the most assistance for stroke patients compared with the other tasks. DFLEs were slightly lower than the quality-adjusted life expectancy of stroke patients. CONCLUSION: Our findings provide valuable insights for resource allocation and policy decisions in long-term stroke care, potentially enhancing the quality of life for stroke survivors and caregivers.

Working retirees in Taiwan: examining determinants of different working status after retirement.

This study aims to investigate the factors influencing the work status of retirees after retirement, especially focusing on self-employment and unpaid work. Data was taken and analyzed from the "Taiwan Health and Retirement Study," a nationally representative sample of retired personnel aged 50-74 in 2015-2016. Four types of work status were classified after retirement: Fully retired, Paid work, Self-employment, and Unpaid work. Multinomial regression analysis was used to explore the factors related to participation in paid, self-employed, and unpaid work. Results show that pre-retirement occupation was significantly associated with paid work after retirement. For example, retirees in Taiwan who were employed by private enterprises or self-employed before retirement were more likely to engage in paid work after retirement than civil servants before retirement. Two other factors, namely pre-retirement job stress and work flexibility, prolong the careers of retired workers, especially in self-employment and unpaid work after retirement. Gender also significantly affects the choice of work after retirement. These findings can be used as a reference for future policies on the aging labor force.

Support for a hypothetical sugar-sweetened beverage tax in Taiwan.

Sugar-sweetened beverages (SSBs) are drinks that contain added sugar or sweeteners and provide calories with no additional nutrients, and some countries have imposed additional taxes on the SSBs to reduce consumption, which is considered an SSB tax policy. This study used a cross-sectional online survey to examine the patterns of public support for an SSB tax in Taiwan. The sample included 1617 adults aged ≥ 20 years, who answered the survey questionnaire between May 2020 and April 2021. The respondents were recruited using convenience sampling, but sampling weights were applied to represent the Taiwanese population. Generalized ordered logit models with sampling weights were used to examine the correlates of public support for an SSB tax. Results showed that ~60% of the respondents supported the SSB tax and 47% perceived the tax to be effective. The respondents who were aware of the perceived health risks of SSBs or those who believed that one should be partly responsible for the health impact of SSBs were more likely to show support for the SSB tax. In adjusted regression models, both one's perceived risk and perceived responsibility of SSBs were positively associated with the perceived effectiveness of the SSB tax after sociodemographic characteristics were controlled. These research findings show evidence that there is public support for implementing an SSB tax to reduce SSB consumption in Taiwan.

Late creation of vascular access increased post-hemodialysis mortality, hospitalization, and health-care expenditure: A population-based cohort study in Taiwan.

BACKGROUND/PURPOSE: The optimal timing of vascular access (VA) creation for hemodialysis (HD) and whether this timing affects mortality and health-care utilization after HD initiation remain unclear. Thus, we conducted a population-based study to explore their association. METHODS: We used Taiwan's National Health Insurance Research Database to analyze health-care outcomes and utilization in a cohort initiating HD during 2003-2013. We stratified patients by the following VA creation time points: >180, 91-180, 31-90, and ≤30 days before and ≤30 days after HD initiation and examined all-cause mortality, ambulatory care utilization/costs, hospital admission/costs, and total expenditure within 2 years after HD. Cox regression, Poisson regression, and general linear regression were used to analyze mortality, health-care utilization, and costs respectively. RESULTS: We identified 77,205 patients who started HD during 2003-2013. Compared with the patients undergoing VA surgery >180 days before HD initiation, those undergoing VA surgery ≤30 days before HD initiation had the highest mortality-15.92 deaths per 100-person-years, crude hazard ratio (HR) 1.56, and adjusted HR 1.28, the highest hospital admissions rates- 2.72 admission per person-year, crude rate ratio (RR) 1.48 and adjusted RR 1.32, and thus the highest health-care costs- US$31,390 per person-year, 7% increase of costs and 6% increase with adjustment within the 2-year follow-up after HD initiation. CONCLUSIONS: Late VA creation for HD can increase all-cause mortality, hospitalization, and health-care costs within 2 years after HD initiation. Early preparation of VA has the potential to reduce post-HD mortality and healthcare expenses for the ESKD patients.

Developing a shortened version of the dementia knowledge assessment scale (DKAS-TC) with a sample in Taiwan: an item response theory approach.

BACKGROUND: The 25-item Dementia Knowledge Assessment Scale (DKAS2) is a widely used tool for measuring knowledge of dementia. To increase the applicability of the Chinese-language version of the tool (DKAS-TC) for the general public, this study aimed to develop a shortened version using the item response theory (IRT) approach. METHODS: A total of 401 participants voluntarily completed a Chinese-language version of the DKAS2 questionnaire (DKAS-TC) at the start of dementia awareness training courses in 2020 and 2021. The four Rasch family models were used to analyze the dimensionality of the shortened scale (the DKAS-s) and to confirm its accuracy in measuring dementia knowledge. RESULTS: The results justified supported the use of a dichotomous response scale for responding to the DKAS-s and demonstrated good fit of the data to a Rasch model with the four dimensions of "Causes and Characteristics", "Communication and Engagement", "Care Needs", and "Risks and Health Promotion". Moreover, we shortened the DKAS-TC by selecting items that had both above-average discriminative ability and above-average information. The DKAS-s retained 64.13% of the information contained in the DKAS-TC, resulting in a 16-item scale which retained four items in each of the original four dimensions. The DKAS-s also correlated highly (≥0.95) with the DKAS-TC and exhibited a sizeable range of difficulty of dementia knowledge. CONCLUSIONS: The DKAS-s is expected to be more efficient in field settings while retaining an acceptable level of psychometric properties when used as a survey instrument to measure the general public's knowledge of dementia.

Effects of continuity of care on hospitalizations and healthcare costs in older adults with dementia.

INTRODUCTION: People with dementia have high rates of hospitalization, and a share of these hospitalizations might be avoidable with appropriate ambulatory care, also known as potentially preventable hospitalization (PAH). This study investigates the associations between continuity of care and healthcare outcomes in the following year, including all-cause hospitalization, PAHs, and healthcare costs in patients with dementia. METHODS: This is a longitudinal retrospective cohort study of 69,658 patients with dementia obtained from the Taiwan National Health Insurance Research Database. The Continuity of Care Index (COCI) was calculated to measure the continuity of dementia-related visits across physicians. The PAHs were classified into five types as defined by the Medicare Ambulatory Care Indicators for the Elderly (MACIEs). Logistic regression models were used to examine the effect of COCI on all-cause hospitalizations and PAHs, while generalized linear models were used to analyze the effect of COCI on outpatient, hospitalization, and total healthcare costs. RESULTS: The high COCI group was significantly associated with a lower likelihood of all-cause hospitalization than the low COCI group (OR = 0.848, 95%CI: 0.821-0.875). The COCI had no significant effect on PAHs but was associated with lower outpatient costs (exp(ß) = 0.960, 95%CI: 0.941 ~ 0.979), hospitalization costs (exp(ß) = 0.663, 95%CI: 0.614 ~ 0.717), total healthcare costs (exp(ß) = 0.962, 95%CI: 0.945-0.980). CONCLUSION: Improving continuity of care for dementia-related outpatient visits is recommended to reduce hospitalization and healthcare costs, although there was no statistically significant effect of continuity of care found on PAHs.

Pay-for-performance and continuity of care synergistically reduced amputation of lower extremity in patients with diabetes: a population-based cohort study.

BACKGROUND: Diabetic foot is a common and costly complication of diabetes. No existing study has looked at the effect of continuity of care on amputations of diabetes (DM) patients while considering pay-for-performance (P4P) participation. We investigated the impact of the P4P program and the continuity of care index (COCI) on the incidence of lower extremity amputations (LEA) among diabetics in Taiwan. METHODS: This was a population-based cohort study using insurance claims data from 1997 to 2013. We selected 15,650 DM patients in the P4P program along with age- and sex-matched non-P4P participants at a 1:4 ratio. Time-weighted average (TWA) of the COCI was calculated and included in the time-dependent Cox proportional hazard models to examine the impact of P4P and COCI on the risk of LEA, while controlling for individual and area level characteristics. RESULTS: During four-year follow-up, 1816 subjects experienced LEA. The cumulative LEA hazard rate of the P4P group (n = 153) was significantly lower than that of the non-P4P group (n = 1663) (hazard ratio = 0.37, 95% CI = 0.31-0.43, p < 0.0001, by log-rank test). In the time-dependent Cox proportional hazard model, the adjusted hazard ratios (aHR) for the P4P group was 0.35, (p < 0.0001). With the low COCI (< 0.360) group as the reference, the aHR of LEA was 0.49 (p < 0.0001) for the middle COCI group, (p < 0.0001), and the aHR of LEA for the high COCI (≥0.643) group was 0.23 (p < 0.0001). CONCLUSIONS: Participating in the P4P program and increasing COCI might reduce the risk of amputation for DM patients, independently and synergistically.

Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities.

OBJECTIVE: To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada. TARGET POPULATION: This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline. OUTCOMES: Safe and compassionate care for people with physical disabilities who are giving birth. BENEFITS, HARMS, AND COSTS: Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth. EVIDENCE: A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

Urban-rural disparity in lower extremities amputation in patients with diabetes after nearly two decades of universal health Insurance in Taiwan.

BACKGROUND: To assess the prevalence of urban-rural disparity in lower extremities amputation (LEA) among patients with diabetes and to explore whether patient-related or physician-related factors might have contributed to such disparity. METHODS: This was a population-based study including patients with diabetes aged ≥55 years from 2009 to 2013. Among them, 9236 received LEA. Data were retrieved from Taiwan's National Health Insurance (NHI) claims. A multiple Poisson regression model was also employed to assess the urban-rural difference in LEA prevalence by simultaneously taking into account socio-demographic variables and density of practicing physicians. RESULTS: Between 2009 and 2013, the annual prevalence of LEA declined from 30.4 to 20.5 per 10,000 patients. Compared to patients from urban areas, those who lived in sub-urban and rural areas suffered from a significantly elevated prevalence of LEA, with a prevalence rate ratio (PRR) of 1.47 (95% CI, 1.39-1.55) and 1.68 (95% CI, 1.56-1.82), respectively. The density of physicians who presumably provided diabetes care can barely explain the urban-rural disparity in LEA prevalence. CONCLUSIONS: Although the universal health insurance has largely removed financial barriers to health care, the urban-rural disparity in LEA prevalence still exists in Taiwan after nearly two decades of the NHI program.

Cost-Effectiveness Analysis of Oral Anticoagulants in Stroke Prevention among Patients with Atrial Fibrillation in Taiwan.

BACKGROUND: Non-vitamin K oral antagonist anticoagulants (NOACs) have been widely used in stroke prevention in atrial fibrillation (SPAF). The aim of this study was to compare the pharmacoeconomic impact of oral anticoagulants (OACs) including warfarin, dabigatran, rivaroxaban, apixaban, and edoxaban in SPAF in Taiwan. METHODS: A decision tree, Markov model, and multiple sensitivity analyses were used to project the lifetime costs and quality-adjusted life years (QALYs) of OACs. Transitional probabilities were derived from a systematic review and network meta-analysis for Asian populations. Utilities and costs were obtained from published studies and the Taiwan National Health Insurance Research Database. Threshold of the willingness to pay (WTP) at USD 20,000 was applied to evaluate the results. RESULTS: In base-case analysis, warfarin had the lowest cost at $13,363 ± 4,036, and edoxaban 60 mg produced the most QALYs at 11.92 ± 1.98. The incremental cost-effectiveness ratios of dabigatran 150 and 110 mg, rivaroxaban 20 and 15 mg, apixaban 5 mg, and edoxaban 60 mg versus warfarin were $6,415, $4,225, $4,115 and $5,458 per QALY gained, respectively. Monte Carlo analysis revealed that dabigatran 150 and 110 mg, rivaroxaban 20 and 15 mg, apixaban 5 mg and edoxaban 60 mg were most cost-effective at 21.9%, 27.1%, 23.6%, and 27.4% of $20,000 compared to warfarin. CONCLUSIONS: From a Taiwan national payer perspective, all NOACs are cost-effective substitutes for warfarin in SPAF. However, the likelihood of cost-effective iterations for NOACs is highly driven by their market prices at the time and different WTP thresholds of policymakers.

Predictors of caregiver burden and care costs for older persons with dementia in Taiwan.

ABSTRACTObjectives:As a degenerative disease, the progression of dementia needs continued care provision and poses both psychological and financial burden for family caregivers of persons with dementia (PWD). This study seeks to compare predictors of care costs and caregiver burden, and to identify modifiable factors that could alleviate the burden faced by dementia caregivers. METHODS: This study interviewed 231 PWD-caregiver dyads in a dementia clinic at a teaching hospital in southern Taiwan in 2013. A follow-up study was conducted a year later, and 167 dyads completed the second interview. Data collected included PWD characteristics, caregiver characteristics, relationship to PWD, and social support to caregivers. Caregiver burden was measured with the Zarit Burden Interview instrument. The association between each predictor variable and cost of care and caregiver burden scores was examined using linear mixed models. RESULTS: Predictors of care costs were found to be different from predictors of caregiver burden: functional declines measured by Katz's activities of daily living (ADL) scale were associated with total cost as compared to behavioral disturbance measured by Neuropsychiatric Inventory (NPI), which showed no impact on care costs. However, NPI was a significant predictor of caregiver burden. Caregivers who were better-off financially also reported significantly lower caregiver burden. CONCLUSIONS: Since predictors of care costs were different from the predictors of caregiver burden, providing training to caregivers in addressing PWD's behavioral disturbance and proving financial assistance to low income caregivers could be effective in reducing caregiver burden.

Measurement invariance across educational levels and gender in 12-item Zarit Burden Interview (ZBI) on caregivers of people with dementia.

BACKGROUND: The Zarit Burden Interview (ZBI) is a commonly used self-report to assess caregiver burden. A 12-item short form of the ZBI has been developed; however, its measurement invariance has not been examined across some different demographics. It is unclear whether different genders and educational levels of a population interpret the ZBI items similarly. Therefore, this study aimed to examine the measurement invariance of the 12-item ZBI across gender and educational levels in a Taiwanese sample. METHODS: Caregivers who had a family member with dementia (n = 270) completed the ZBI through telephone interviews. Three confirmatory factor analysis (CFA) models were conducted: Model 1 was the configural model, Model 2 constrained all factor loadings, Model 3 constrained all factor loadings and item intercepts. Multiple group CFAs and the differential item functioning (DIF) contrast under Rasch analyses were used to detect measurement invariance across males (n = 100) and females (n = 170) and across educational levels of junior high schools and below (n = 86) and senior high schools and above (n = 183). RESULTS: The fit index differences between models supported the measurement invariance across gender and across educational levels (∆ comparative fit index (CFI) = -0.010 and 0.003; ∆ root mean square error of approximation (RMSEA) = -0.006 to 0.004). No substantial DIF contrast was found across gender and educational levels (value = -0.36 to 0.29). CONCLUSIONS: The ZBI is appropriate for combined use and for comparisons in caregivers across gender and different educational levels in Taiwan.

Demographic and rural-urban variations in dental service utilization in Taiwan.

INTRODUCTION: This study assesses whether demographic and rural-urban variations in dental care service utilization still exist in Taiwan after 15 years of the implementation of universal health insurance coverage, which largely reduces financial barriers to dental care. METHODS: The data analysed in this cohort study were based on a random sample of one million beneficiaries retrieved from Taiwan's National Health Insurance Research Database (NHIRD) in 2005. The follow-up was made between 2005 and 2010. Poisson regression models were used to explore the associations of dental service utilization rates with urbanization and demographic characteristics. RESULTS: The highest and lowest rates of preventive dental care were obtained in people aged 55-64 years (579.2/1000 person-years) and <15 years (178.6/1000 person-years). The corresponding figures for curative care were 1592.0/1000 person-years (<15 years) and 757.2/1000 person-years (35-44 years). Compared with the people living in the least urbanized areas, those from the most urbanized areas presented significantly higher rates of preventive and curative dental services; a greater estimated rate ratio was noted for preventive services than for curative services (1.57 vs 1.42). CONCLUSIONS: The urban-rural disparity in dental care service utilization still exists after 15 years of the implementation of the national health insurance in Taiwan, suggesting that factors other than affordability may play roles in such disparity.

Association of intrinsic capacity and medication non-adherence among older adults with non-communicable diseases in Taiwan.

OBJECTIVES: Medication non-adherence among older adults with non-communicable diseases (NCDs) remains prevalent worldwide, which causes hospitalization and mortality. Our study aimed to examine the association of medication non-adherence with level of overall intrinsic capacity (IC), pattern of IC, and specific IC component among older adults with NCDs. METHODS: A cross-sectional questionnaire-based survey of 1268 older adults aged 60 years and above was conducted in 2022 in southern Taiwan. Among them, 894 suffered from 1 more NCD were included in this study. The Integrated Care for Older People Screening Tool for Taiwanese and the Adherence to Refills and Medication Scale were used to assess IC and medication non-adherence, respectively. Latent class analysis (LCA) was used to identify patterns of IC impairment, and binary logistic regression was used to assess the association between medication non-adherence and IC. RESULTS: Older adults in the moderate (score: 1-2) or low (score≧3) overall IC groups were more likely to experience medication non-adherence (moderate: adjusted odds ratio (aOR) 1.57 [95% CI: 1.05-2.36]; low: 2.26 [1.40-3.67]). The "physical and nutritional impairments accompanied by depressive symptoms" group was associated with statistically higher odds of medication non-adherence (aOR 1.66 [1.01-2.73]). Older adults with cognitive impairment, hearing loss, or depressive symptoms showed greater likelihood of medication non-adherence (cognitive impairment: aOR 1.53 [1.03-2.27]; hearing loss: aOR 1.57 [1.03-2.37]; depressive symptoms: aOR 1.81 [1.17-2.80]). CONCLUSIONS: Intervention for improving medication non-adherence among older adults with NCDs should consider IC.

An Evaluation of Virtual Care for Gestational Diabetes Using the Quadruple Aim Framework: Assessment of Patient and Provider Experience, Cost, and Clinical Outcomes.

OBJECTIVE: Our aim in this study was to evaluate the impact of virtual care for gestational diabetes mellitus (GDM) in the context of the COVID-19 pandemic. METHODS: This multiple methods program evaluation used the Quadruple Aim Framework. The impact on patient experience, cost, and provider satisfaction was assessed using surveys and interviews. Chi-square and Poisson statistics were used to compare clinical outcomes before (April 2019 to February 2020) and after (May 2020 to March 2021) the shift to virtual care. RESULTS: Patient experience surveys were completed by 85 women. Most of them rated their virtual care experience as good or excellent (93%), with a preference for continued virtual visits in the future (84%). Most respondents felt virtual care saved them money (93%) and time (98%). Six health-care providers at the Diabetes in Pregnancy Clinic were interviewed and all believed the switch to virtual care was largely positive. Overall, interview transcripts revealed that health-care providers were happy with the transition, although nurses initially perceived an increased workload. There were no significant differences in rates of cesarean section procedures, macrosomia, neonatal intensive care unit admissions or the proportion of appointments at which insulin was initiated between in-person and virtual care patient outcomes. There was a decreased proportion of missed appointments after the switch to virtual care (6.15% vs 1.21%, p<0.0001). CONCLUSIONS: There has been high patient and provider satisfaction with virtual GDM care, with no difference in clinical outcomes and fewer missed appointments. Virtual GDM care should remain an option in the future.

A new care pathway to optimize gestational weight gain in twin pregnancies.

BACKGROUND: Maternal gestational weight gain is an important determinant of pregnancy outcomes and may have an even greater role in twin pregnancies because of their higher rate of pregnancy complications and greater nutritional demands. However, data on the optimal week-specific gestational weight gain in twin pregnancies and on interventions that should be applied in cases of inadequate gestational weight gain are limited. OBJECTIVE: This study aimed to determine whether a new care pathway that involves monitoring gestational weight gain using a week-specific chart, along with a standardized protocol for managing cases with inadequate gestational weight gain, can optimize maternal gestational weight gain in twin pregnancies. METHODS: In this study, patients with twin pregnancies followed in a single tertiary center between February 2021 and May 2022 were exposed to the new care pathway (postintervention group). Gestational weight gain and clinical outcomes were compared with those of a previously described cohort of patients with twins followed in our clinic before the implementation of the new care pathway (preintervention group). The new care pathway targeted patients and care providers and included educational material, a newly developed body mass index group-specific gestational weight gain chart, and a stepwise management algorithm in cases of inadequate gestational weight gain. The body mass index group-specific gestational weight gain charts were divided into 3 zones: (1) green zone (optimal gestational weight gain at 25th-75th centiles); (2) yellow zone (suboptimal gestational weight gain at 5th-24th or 76th-95th centiles); and (3) gray zone (abnormal gestational weight gain, at <5th or >95th centile). The primary outcome was the overall proportion of patients achieving optimal gestational weight gain at birth. RESULTS: A total of 123 patients were exposed to the new care pathway and were compared with 1079 patients from the preintervention period. Patients in the postintervention group were more likely to achieve optimal gestational weight gain at birth (60.2% vs 47.7%; adjusted odds ratio, 1.91; 95% confidence interval, 1.28-2.86) and were less likely to achieve low-suboptimal gestational weight gain (7.3% vs 14.7%; adjusted odds ratio, 0.41; 95% confidence interval, 0.20-0.85) or any suboptimal gestational weight gain (26.8% vs 34.8%; adjusted odds ratio, 0.60; 95% confidence interval, 0.39-0.93) at birth. In addition, patients in the postintervention group were less likely to have low-abnormal gestational weight gain anytime during gestation (18.9% vs 29.1%; P=.017) and were more likely to have normal gestational weight gain throughout pregnancy (21.3% vs 14.0%; P=.031) or high-abnormal gestational weight gain anytime during gestation (18.0% vs 11.1%; P=.025), suggesting that in comparison with standard care, the new care pathway is more effective in preventing patients from moving into the low-abnormal zone than the high-abnormal zone. Furthermore, the new care pathway was more effective than standard care in correcting high-suboptimal gestational weight gain and high-abnormal gestational weight gain. CONCLUSION: Our findings suggest that the new care pathway may be effective in optimizing maternal gestational weight gain in twin gestations, which may in turn contribute to better clinical outcomes. This is a simple, low-cost intervention that can be easily disseminated among providers caring for patients with twin pregnancies.

The lifetime burden following stroke: Long term impact of stroke on survival and quality of life.

BACKGROUND: The absolute burden of stroke in Korea is ever growing. Many studies have explored the outcomes of mortality, quality of life (QOL), and/or economic burden with limited periods of observation. Relatively few have addressed the lifetime outcomes that are estimated beyond the limited observation period of study samples. AIMS: By combining QOL and the survival functions over a lifetime horizon, our aims were to estimate the quality-adjusted life expectancy (QALE) and loss-of-QALE of patients with ischemic and hemorrhagic stroke in South Korea, and to compare them between genders. METHODS: The survival function of stroke patients (n = 13,994) was estimated by the Kaplan-Meier's method from the National Health Insurance Service-National Sample Cohort of Korea (2002-2015), and then extrapolated to lifetime through a rolling-over algorithm. The QOL measurements, assessed by EuroQol 5-dimension (EQ-5D) questionnaire, of stroke patients (n = 474) were extracted from the Korea Health Panel (KHP, 2008-2018) to estimate the QALE. All stroke patients were categorized by sex and two types of stroke: ischemic and hemorrhagic. Age-, sex-, and calendar year-matched referents were simulated from the Korean life tables to be integrated with the general population's QOL from the KHP to estimate the QALE of the referents. We calculated the loss-of-QALE by comparing the above two sets of QALE. RESULTS: The QALE and loss-of-QALE for ischemic stroke were 10.8 and 6.1 QALYs (quality-adjusted life years), respectively, and 14.0 and 9.0 QALYs for hemorrhagic stroke. The loss-of-QALE in men was 3.0 QALYs larger than that of women with hemorrhagic stroke (p < 0.05), while the difference for ischemic stroke was much smaller and statistically insignificant at 0.6 QALYs. CONCLUSIONS: The lifetime impact of stroke in Korea is large, especially for males who survived hemorrhagic stroke. Future studies assessing the lifetime needs for long-term care of stroke patients are warranted to quantify the burden of stroke from the societal perspective.

Overall and cause-specific mortality in patients with dementia: a population-based cohort study in Taiwan.

OBJECTIVES: Information regarding the underlying causes of death (UCODs) and standardized mortality ratio (SMR) of dementia is instrumental in formulating medical strategies to prolong life in persons with dementia (PWD). We examined the leading UCODs among PWD and estimated the overall and cause-specific SMRs in relation to dementia in Taiwan. METHODS: Data were retrieved from 2 national datasets: the Taiwan Death Registry and the medical claim datasets of the National Health Insurance program. The observed person-years for each study participant were counted from the date of cohort enrollment to either the date of death or the final day of 2016. Sex-specific and age-specific SMRs were then calculated. RESULTS: The leading UCOD was circulatory disease, accounting for 26.0% of total deaths (n=3,505), followed by respiratory disease at 21.3% (n=2,875). PWD were at significantly increased risk of all-cause mortality (SMR, 2.01), with SMR decreasing with advancing age. A cause-specific analysis revealed that the highest SMRs were associated with nervous system diseases (SMR, 7.58) and mental, behavioral, and neurodevelopmental disorders (SMR, 4.80). Age appeared to modify SMR, suggesting that younger age at cohort enrollment was linked to higher SMRs for nearly all causes of mortality. CONCLUSIONS: Circulatory and respiratory diseases were the leading UCODs among PWD. The particularly elevated mortality due to nervous system diseases and mental disorders suggests that allocating more resources to neurological and psychiatric services is warranted. The elevated SMRs of various UCODs among younger PWD underscore the need for clinicians to pay particular attention to the medical care provided to these patients.