Factors Associated With the Utilization of Outpatient Virtual Clinics: Retrospective Observational Study Using Multilevel Analysis.

BACKGROUND: Although the COVID-19 pandemic has accelerated the adoption of telemedicine and virtual consultations worldwide, complex factors that may affect the use of virtual clinics are still unclear. OBJECTIVE: This study aims to identify factors associated with the utilization of virtual clinics in the experience of virtual clinic service implementation in Taiwan. METHODS: We retrospectively analyzed a total of 187,742 outpatient visits (176,815, 94.2%, in-person visits and 10,927, 5.8%, virtual visits) completed at a large general hospital in Taipei City from May 19 to July 31, 2021, after rapid implementation of virtual outpatient clinic visits due to the COVID-19 pandemic. Data of patients' demographic characteristics, disease type, physicians' features, and specialties/departments were collected, and physicians' opinions regarding virtual clinics were surveyed and evaluated using a 5-point Likert scale. Multilevel analysis was conducted to determine the factors associated with the utilization of virtual clinics. RESULTS: Patient-/visit-, physician-, and department-level factors accounted for 67.5%, 11.1%, and 21.4% of the total variance in the utilization of virtual clinics, respectively. Female sex (odds ratio [OR] 1.27, 95% CI 1.22-1.33, P<.001); residing at a greater distance away from the hospital (OR 2.36, 95% CI 2.15-2.58 if distance>50 km, P<.001; OR 3.95, 95% CI 3.11-5.02 if extensive travel required, P<.001); reimbursement by the National Health Insurance (NHI; OR 7.29, 95% CI 5.71-9.30, P<.001); seeking care for a major chronic disease (OR 1.33, 95% CI 1.24-1.42, P<.001); the physician's positive attitude toward virtual clinics (OR 1.50, 95% CI 1.16-1.93, P=.002); and visits within certain departments, including the heart center, psychiatry, and internal medicine (OR 2.55, 95% CI 1.46-4.46, P=.004), were positively associated with the utilization of virtual clinics. The patient's age, the physician's age, and the physician's sex were not associated with the utilization of virtual clinics in our study. CONCLUSIONS: Our results show that in addition to previously demonstrated patient-level factors that may influence telemedicine use, including the patient's sex and distance from the hospital, factors at the visit level (insurance type, disease type), physician level (physician's attitude toward virtual clinics), and department level also contribute to the utilization of virtual clinics. Although there was a more than 300-fold increase in the number of virtual visits during the pandemic compared with the prepandemic period, the majority (176,815/187,742, 94.2%) of the outpatient visits were still in-person visits during the study period. Therefore, it is of great importance to understand the factors impacting the utilization of virtual clinics to accelerate the implementation of telemedicine. The findings of our study may help direct policymaking for expanding the use of virtual clinics, especially in countries struggling with the development and promotion of telemedicine virtual clinic services.

Evaluating the comparative efficiency of medical centers in Taiwan: a dynamic data envelopment analysis application.

BACKGROUND: People in Taiwan enjoy comprehensive National Health Insurance coverage. However, under the global budget constraint, hospitals encounter enormous challenges. This study was designed to examine Taiwan medical centers' efficiency and factors that influence it. METHODS: We obtained data from open sources of government routine publications and hospitals disclosed by law to the National Health Insurance Administration, Ministry of Health and Welfare, Taiwan. The dynamic data envelopment analysis (DDEA) model was adopted to estimate all medical centers' efficiencies during 2015-2018. Beta regression models were used to model the efficiency level obtained from the DDEA model. We applied an input-oriented approach under both the constant returns-to-scale (CRS) and variable returns-to-scale (VRS) assumptions to estimate efficiency. RESULTS: The findings indicated that 68.4% (13 of 19) of medical centers were inefficient according to scale efficiency. The mean efficiency scores of all medical centers during 2015-2018 under the CRS, VRS, and Scale were 0.85, 0.930, and 0.95,respectively. Regression results showed that an increase in the population less than 14 years of age, assets, nurse-patient ratio and bed occupancy rate could increase medical centers' efficiency. The rate of emergency return within 3-day and patient self-pay revenues were associated significantly with reduced hospital efficiency (p < 0.05). The result also showed that the foundation owns medical center has the highest efficiency than other ownership hospitals. CONCLUSIONS: The study results provide information for hospital managers to consider ways they could adjust available resources to achieve high efficiency.

Potentially preventable hospital readmissions after patients' first stroke in Taiwan.

Readmission is an important indicator of the quality of care. The purpose of this study was to explore the probabilities and predictors of 30-day and 1-year potentially preventable hospital readmission (PPR) after a patient's first stroke. We used claims data from the National Health Insurance (NHI) from 2010 to 2018. Multinomial logistic regression was used to assess the predictors of 30-day and 1-year PPR. A total of 41,921 discharged stroke patients was identified. We found that hospital readmission rates were 15.48% within 30-days and 47.25% within 1-year. The PPR and non-PPR were 9.84% (4123) and 5.65% (2367) within 30-days, and 30.65% (12,849) and 16.60% (6959) within 1-year, respectively. The factors of older patients, type of stroke, shorter length of stay, higher Charlson Comorbidity Index (CCI), higher stroke severity index (SSI), regional hospital, public and private hospital, and hospital in the lower urbanized area were associated significantly with the 30-day PPR. In addition, the factors of male, hospitalization year, and monthly income were associated significantly with 1-year PPR. The ORs of long-term PPR showed a decreasing trend since implementing the national health insurance post-acute care (PAC) program in 2014 and a dramatic drop in 2018 after the government expanded the long-term care plan-LTC 2.0 in 2017. The results showed that better discharge planning, implementing post-acute care programs and long-term care plan-LTC 2.0 may benefit the care of stroke patients and help reduce long-term readmission in Taiwan.

Cost-effectiveness of immune checkpoint inhibitors in the treatment of non-small-cell lung cancer as a second line in Taiwan.

Objectives: To evaluate the cost-effectiveness of immune checkpoint inhibitors versus docetaxel in patients with advanced non-small-cell lung cancer. Methods: A Markov model was constructed to simulate the clinical outcomes and costs of advanced non-small-cell lung cancer. Clinical outcomes data were derived from randomized clinical trials. Drug acquisition cost and other health resource use were obtained from the claim data of a tertiary hospital and the National Health Insurance. The outcome was an incremental cost-effectiveness ratio expressed as cost per quality-adjusted life year gained. One-way and probabilistic sensitivity analyses were performed to evaluate the uncertainty of the model parameters. Results: In the base case, patients treated with immunotherapies in the second line were associated with higher costs and higher mean survival. The incremental costs per quality-adjusted life year gained for pembrolizumab, nivolumab, or atezolizumab compared to docetaxel were NT$416,102, NT$1,572,912 and NT$1,580,469, respectively. Conclusion: The results showed that pembrolizumab was more cost effective than nivolumab and atezolizumab compared with docetaxel as a second-line regimen for patients with previously treated advanced non-small-cell lung cancer at willingness to pay threshold in Taiwan.

Plain language summary Lung cancer is the first leading cause of cancer death in Taiwan. About 75% of patients have advanced disease at the time of diagnosis (stage III/IV) with a median survival of 13.2 months. Most non-small-cell lung cancer (NSCLC) patients are usually diagnosed at a late stage. The conventional chemotherapy, surgery or radiation regimens may not be of significant benefits. Fortunately, newer immunotherapies or targeted therapies have improved the 5-year survival rates of advanced NSCLC from 15 to 50% with high cost. This study aimed to assess if the newer targeted therapies are cost effective and provide 'value for money' compared with chemotherapy in NSCLC patients with advanced stage. A cost­effectiveness model was created based on the data from the real-world and published phase III randomized controlled trials. The results showed that pembrolizumab is more cost effective than nivolumab and atezolizumab compared with docetaxel as a second-line regimen for patients with previously treated advanced NSCLC at willingness to pay threshold in Taiwan.

Cost-effectiveness analysis of olaparib and niraparib as maintenance therapy for women with recurrent platinum-sensitive ovarian cancer.

OBJECTIVE: We evaluated the cost-effectiveness of olaparib and niraparib as maintenance therapy for patients with platinum-sensitive recurrent ovarian cancer.Methods: A decision analysis model compared the costs and effectiveness of olaparib and niraparib versus placebo for patients with or without germline BRCA mutations. Resource use and associated costs were estimated from the 2020 National Health Insurance Administration reimbursement price list. Clinical effectiveness was measured in progression-free survival per life-years (PFS-LY) based on the results of clinical trials SOLO2/ENHOT-Ov21 and ENGOT-OV16/NOVA. The incremental cost-effectiveness ratio (ICER) was estimated from a single-payer perspective. RESULTS: In the base case, olaparib was the more cost-effective treatment regimen. The ICERs for olaparib and niraparib compared to placebo were NT$1,804,785 and NT$2,340,265 per PFS-LY, respectively. Tornado analysis showed that PFS and the total resource use cost of niraparib regimen for patients without gBRCA were the most sensitive parameters impacting the ICER. The ICERs for both drugs in patients with a gBRCA mutation were lower than in patients without a gBRCA mutation. Probabilistic sensitivity analysis indicated that olaparib was more cost-effective than niraparib at the willingness-to-pay threshold of NT$2,602,404 per PFS life-year gained. CONCLUSION: Olaparib was estimated to be less cost and more effective compared to niraparib as maintenance therapy for patients with recurrent platinum-sensitive ovarian cancer.

Short-, Mid-, and Long-Term Associations Between PM2.5 and Stroke Incidence in Taiwan.

OBJECTIVE: To investigate the association between the risk of stroke and exposure to particulate matter with an aerodynamic diameter less than 2.5 µm (PM2.5) over various exposure periods. METHODS: This was a nationwide population-based case-control study in which 10,035 incident patients with a primary diagnosis of ischemic stroke each were matched with two randomly selected controls for sex, age, Charlson Comorbidity Index, year of stroke diagnosis, and level of urbanization. Multiple logistic models adjusted for potential confounders were used to assess the association of PM2.5 with ischemic stroke incidence. RESULTS: There were significant short-term, medium-term, and long-term relationships between PM2.5 exposure and ischemic stroke incidence. CONCLUSIONS: This study supports existing evidence that PM2.5 should be considered a risk factor for ischemic stroke.

Cost-utility analysis of stereotactic body radiotherapy plus cetuximab in previously irradiated recurrent squamous cell carcinoma of the head and neck.

BACKGROUND: This study aimed to estimate the cost-utility of stereotactic body radiotherapy (SBRT) plus cetuximab for patients with previously irradiated recurrent squamous cell carcinoma of the head and neck. METHODS: We constructed a Markov health-state transition model to simulate costs and clinical outcomes of recurrent squamous cell carcinoma of the head and neck. Model parameters were derived from the published literature and the National Health Insurance Administration reimbursement price list. Incremental cost-effectiveness ratio and the net monetary benefit were calculated from a health payer perspective. The impact of uncertainty was modeled with one-way and probabilistic sensitivity analyses. RESULTS: In the base-case, SBRT plus cetuximab compared to SBRT alone resulted in an ICER of NT$ 840,455 per QALY gained. In the one-way sensitivity analysis, the utility of progression-free state for patients treated with SBRT plus cetuximab or SBRT alone and the cost of progression-free survival for SBRT+Cet were the most sensitive parameters in the model. Probabilistic sensitivity analysis showed that the probability of cost-effectiveness at a willingness-to-pay threshold of NT$ 2,252,340 per QALY was 100% for SBRT plus cetuximab but 0% for SBRT alone. CONCLUSIONS: This study showed that SBRT+Cet was cost-effective and benefited patients with previously irradiated rSCCHN.

Evaluating the Operational Efficiency and Quality of Tertiary Hospitals in Taiwan: The Application of the EBITDA Indicator to the DEA Method and TOBIT Regression.

This study estimates the efficiency of 19 tertiary hospitals in Taiwan using a two-stage analysis of Data Envelopment Analysis (DEA) and TOBIT regression. It is a retrospective panel-data study and includes all the tertiary hospitals in Taiwan. The data were sourced from open information hospitals legally required to disclose to the National Health Insurance (NHI) Administration, Ministry of Health and Welfare. The variables, including five inputs (total hospital beds, total physicians, gross equipment, fixed assets net value, the rate of emergency transfer in-patient stay over 48 h) and six outputs (surplus or deficit of appropriation, length of stay, the total relative value units [RVUs] for outpatient services, total RVUs for inpatient services, self-pay income, modified EBITDA) were adopted into the Charnes, Cooper and Rhodes (CCR) and Banker, Charnes and Cooper (BCC) model. In the CCR model, the technical efficiency (TE) from 2015-2018 increases annually, and the average efficiency of all tertiary hospitals is 96.0%. In the BCC model, the highest pure technical efficiency (PTE) was in 2018 and the average efficiency of all medical centers is 99.1%. The average scale efficiency of all medical centers was 96.8% in the BBC model, meaning investment can be reduced by 3.2% and the current production level can be maintained with a fixed return to scale. Correlation coefficient analysis shows that all variables are correlated positively; the highest was the number of beds and the number of days in hospital (r = 0.988). The results show that TE in the CCR model was similar to PTE in the BCC model in four years. The difference analysis shows that more hospitals must improve regarding surplus or deficit of appropriation, modified EBITDA, and self-pay income. TOBIT regression reveals that the higher the bed-occupancy rate and turnover rate of fixed assets, the higher the TE; and the higher number of hospital beds per 100,000 people and turnover rate of fixed assets, the higher the PTE. DEA and TOBIT regression are used to analyze the other factors that affect medical center efficiency, and different categories of hospitals are chosen to assess whether different years or different types of medical centers affect operational performance. This study provides reference values for the improvable directions of relevant large hospitals' inefficiency decision-making units through reference group analysis and slack variable analysis.

Association between continuity of care and long-term mortality in Taiwanese first-ever stroke survivors: An 8-year cohort study.

BACKGROUND: Continuity of care is considered to be an important principle of stroke care; however, few analyses of empirically related outcomes have been reported. OBJECTIVE: This study examined the correlation between the continuity of care for outpatients after a stroke event and the survival of stroke patients over the year following hospital discharge. RESEARCH DESIGN: Data from the Taiwan National Health Insurance Database were used in this study. We defined stroke as the ICD-9-CM codes 430 to 437, and all patients were followed up regarding their survival for at least one year. The modified modified continuity index (MMCI) was used as the indicator of continuity of care. Cox proportional hazard models with robust sandwich variance estimates were employed to analyze the correlation between continuity of care and stroke-related death. RESULTS: A total of 9,252 stroke patients were included in the analysis. Those patients who had a high and a completed COC had a higher percentage of survival (97.25% and 95.39%) compared to the other two groups. After controlling for other variables, compared with the low-level continuity of care group, the moderate-level, high-level and completed continuity of care groups still showed a significantly lower risk of death HR (95% CI) were: 0.63 (0.49-0.80), 0.56 (0.40-0.79) and 0.50 (0.39-0.63), respectively. CONCLUSION: Continuity of care may increase the survival among stroke patients and therefore plays an important role in management of stroke after survival.

Real-world cost-effectiveness of drug-eluting stents vs. bare-metal stents for coronary heart disease-A five-year follow-up study.

OBJECTIVE: To evaluate the cost-effectiveness of using drugeluting stents (DES) compared to bare-metal stents (BMS) for coronary heart disease (CHD). DATA SOURCES/STUDY SETTING: Data were obtained from the National Health Insurance Longitudinal Health Insurance Database, which contains claims data for 1,000,000 beneficiaries. The data were randomly sampled from all beneficiaries. STUDY DESIGN: A retrospective claims data analysis. DATA COLLECTION/EXTRACTION METHODS: Patients with stable coronary heart disease who underwent coronary stent implantation from 2007 to 2008 were recruited and followed to the end of 2013. After a 2:1 propensity score matched by gender, age, stent number, and the Charlson comorbidity index (CCI), 852 patients with 568 stents in the BMS group and 284 stents in the DES group were included. The cumulative medical costs for both matched groups were estimated with the Kaplan-Meier Sample Average (KMSA), and then the incremental cost-effectiveness ratio (ICER) was estimated. PRINCIPAL FINDINGS: The ICER of DES vs. BMS was NT$ 663,000 per cardiovascular death averted and NT$ 238,394 per cardiovascular death or coronary event averted in five years from the insurer perspective. CONCLUSION: Percutaneous coronary intervention (PCI) with DES was a more cost-effective strategy than PCI with BMS for CHD patients during the five-year follow-up.

Risks of hepatocellular carcinoma and cirrhosis-associated complications in patients with rheumatoid arthritis: a 10-year population-based cohort study in Taiwan.

BACKGROUND/PURPOSE: Although rheumatoid arthritis (RA) has been linked to several important malignancies, data for the risks of hepatocellular carcinoma (HCC) in patients with RA are scarce. We aimed to examine the risk of HCC and cirrhosis-associated complications and the use of biologics in a national representative RA sample in Taiwan. METHODS: All study subjects aged ≥ 18 years in the Taiwan National Health Insurance program between January 1, 2000, and December 31, 2009 were enrolled. We matched RA and non-RA subjects by propensity scores in a 1:1 ratio. Our primary outcome was a diagnosis of HCC and cirrhosis-associated complications during a 10-year follow-up period. The risk of outcomes was represented as a hazard ratio (HR) calculated in Cox proportional hazard regression models. RESULTS: 24,245 RA and 24,245 non-RA subjects were included in the primary outcome analysis. Mean overall person-years (PY) of follow-up were 116,608 PY for the RA cohort, and 234,280 PY for the non-RA cohort. The overall incidence of HCC and cirrhosis-associated complications was lower in the RA cohort than in the non-RA cohort (0.66% vs. 1.41% HCC events and 1.45% vs. 1.95% cirrhosis-associated complications events during 10-year follow-up). The HRs adjusted for age, sex, the frequency of medical visits, and CCI were 0.57 (0.46-0.71) for HCC and 0.67 (0.59-0.76) for HCC and cirrhosis-associated complications. Although immunomodulatory agents may alter the risk of malignancy, use of biologics did not increase HCC risk in RA patients. CONCLUSIONS: RA is associated with a reduced risk of developing HCC and cirrhosis-associated complications. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02880306.

Statins decrease the risk of decompensation in hepatitis B virus- and hepatitis C virus-related cirrhosis: A population-based study.

Statin use decreases the risk of decompensation and mortality in patients with cirrhosis due to hepatitis C virus (HCV). Whether this beneficial effect can be extended to cirrhosis in the general population or cirrhosis due to other causes, such as hepatitis B virus (HBV) infection or alcohol, remains unknown. Statin use also decreases the risk of hepatocellular carcinoma (HCC) in patients with chronic HBV and HCV infection. It is unclear whether the effect can be observed in patients with pre-existing cirrhosis. The goal of this study was to determine the effect of statin use on rates of decompensation, mortality, and HCC in HBV-, HCV-, and alcohol-related cirrhosis. Patients with cirrhosis were identified from a representative cohort of Taiwan National Health Insurance beneficiaries from 2000 to 2013. Statin users, defined as having a cumulative defined daily dose (cDDD) ≥28, were selected and served as the case cohort. Statin nonusers (<28 cDDD) were matched through propensity scores. The association between statin use and risk of decompensation, mortality, and HCC were estimated. A total of 1350 patients with cirrhosis were enrolled. Among patients with cirrhosis, statin use decreased the risk of decompensation, mortality, and HCC in a dose-dependent manner (P for trend <0.0001, <0.0001, and 0.009, respectively). Regression analysis revealed a lower risk of decompensation among statin users with cirrhosis due to chronic HBV (adjusted hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.25-0.62) or HCV infection (HR, 0.51; 95% CI, 0.29-0.93). The lowered risk of decompensation was of borderline significance among statin users with alcohol-related cirrhosis (HR, 0.69; 95% CI, 0.45-1.07). CONCLUSION: Statin use decreases the decompensation rate in both HBV- and HCV-related cirrhosis. Of borderline significance is a decreased decompensation rate in alcohol-related cirrhosis. (Hepatology 2017;66:896-907).

Comparison of Clinical Outcomes in Patients Undergoing Coronary Intervention with Drug-Eluting Stents or Bare-Metal Stents: A Nationwide Population Study.

BACKGROUND: The aim of this propensity score-matched cohort study was to investigate the prognostic impacts of drug-eluting stents (DES) and bare-metal stents (BMS) in patients undergoing percutaneous coronary intervention (PCI). METHODS: We conducted a retrospective cohort study based on the National Health Insurance program. Patients who had undergone coronary stenting between Jan. 2007 and Dec. 2008 were recruited and monitored until the end of 2010. Subjects with either BMS or DES were matched 2:1 by propensity score, which adjusted for age, sex, stent number and Charlson comorbidity index (CCI). The Kaplan-Meier method and Cox regression models were used for prognostic analyses. RESULTS: Among a total of 966 patients with a mean age of 66 years, 644 subjects had BMS and 322 subjects had DES. The incidence of myocardial infarction (MI) and death were significantly lower in the DES group as compared with the BMS group for the three-year follow-up duration. With adjustments for age, sex, premium-based monthly salary, levels of hospital care, stent number, CCI, medications, and acute coronary syndrome presentation in the index hospitalization, use of DES rather than BMS was associated with reduced adverse coronary events (hazard ratio and 95% confidence interval: 0.55, 0.38-0.81 in the whole population, and 0.44, 0.26-0.73 in the subgroup patients with stable coronary artery disease). CONCLUSIONS: Implantation of DES was related to better outcomes than for BMS, in terms of reducing MI and mortality after PCI. The survival benefit for patients with DES was even greater in patients with stable coronary artery disease.

The real-world cost-effectiveness of adjuvant trastuzumab in HER-2/neu-positive early breast cancer in Taiwan.

BACKGROUND: Trastuzumab was considered a cost-effective adjuvant treatment for HER 2-positive early breast cancer. Since 2010, the Taiwanese National Health Insurance (NHI) has started to reimburse for 1-year adjuvant treatment. This study aims to provide an updated cost-effectiveness analysis from the NHI perspective, which explores assumptions about long-term cardiac toxicity and treatment benefit of 1-year adjuvant treatment sequentially after chemotherapy. METHODS: A Markov model was used to evaluate the cost-effectiveness of 1-year adjuvant trastuzumab for HER-2/neu positive early breast cancer over a 20-year life-time horizon. A probability sensitivity analysis using Monte Carlo simulation was performed to characterize uncertainties in the expected outcomes, which are expressed as an incremental costs effectiveness ratio (ICER, cost/QALY). A willingness-to-pay threshold of 3-times the per capita gross domestic product was adopted according to the WHO definition. The Taiwan per capita gross domestic product in 2015 was US$22,355; thus, a threshold was considered as NT$2,011,950 (US$67 065, 1USD =30 NTD in 2015). RESULTS: The model showed that adjuvant trastuzumab treatment in HER-2/neu positive early breast cancer yielded 1.631 quality-adjusted life-years (QALY) compared with no trastuzumab treatment. The ICER was US $51,863 per QALY gained in the base-case scenario. The Monte Carlo simulation by varying all variables simultaneously demonstrated that the probability of cost-effectiveness at the willingness-to-pay threshold of US$67,065 was 50% for 1-year adjuvant trastuzumab. CONCLUSIONS: From this real-world study, 1-year adjuvant trastuzumab treatment is likely to be a cost-effective therapy for patients with HER-2 positive breast cancer at the willingness-to-pay threshold of 3-times GDP per capita in Taiwan.

Association of Rheumatoid Arthritis and Hepatitis B Infection: A Nationwide Nested Case-Control Study From 1999 to 2009 in Taiwan.

Rheumatoid arthritis (RA) is a disorder with altered immunologic function and increased risks of infection, while the association between HBV and RA remains largely unknown.To determine the prevalence and risk of HBV infection in patients with RA, 2 cohort datasets were sourced from Taiwan's National Health Insurance Research Database to capture National Health Insurance claims data between 1999 and 2009. One set was a specially requested RA subject's dataset extracted from the whole 23 million beneficiaries, and a total of 38,969 aged ≧18 years RA subjects were identified (RA cohort). The other one was a randomly selected 1 million patients' longitudinal dataset, and from which an additional 701,476 aged ≧18 years non-RA subjects were identified (non-RA cohort). An epidemiological approach was used to compare the prevalence and risk for HBV infection between RA and non-RA subjects.During the followed interval between 1999 and 2009, 3260 in RA cohort and 63,588 in non-RA cohort had a diagnosis of HBV infection. The annual age- and sex-standardized prevalence of HBV infection in the RA cohort was generally higher than that in the non-RA cohort. The RA patients had a higher HBV period prevalence than did the non-RA subjects (RA vs. non-RA = 69.9 vs. 60.1 cases per 1000 subjects). Compared with the non-RA cohort, the RA cohort had an increased risk of HBV infection after adjustment for potential prognostic factors (1.13, 95% CIs: 1.08-1.17).RA patients are characterized by an increased risk of HBV infection than non-RA subjects.

The impact of introducing biologics to patients with rheumatoid arthritis in Taiwan: a population-based trend study.

AIM: The biologics used to treat rheumatoid arthritis (RA) patients with a catastrophic illness certificate have been free without co-payment since 2003 in Taiwan. The purpose of this study was to explore the trend of health care expenditures and the cost of biologics for the treatment of RA patients between 1999 and 2009. METHODS: This study used a specially requested nation-wide RA patient claim dataset from National Health Insurance program. We identified all patients by both the primary diagnosis code ICD-9-CM 714.0 and the catastrophic illness certificate for RA. A total of 30 013 patients were recorded in the treated RA cohort from 1999 to 2009.The growth rates before and after introducing biologics were compared and tested. RESULTS: We found that from 1999 to 2009 the adjusted incidence rate for RA stably increased. Drug costs accounted for 53.2-70.3% of the total medical cost during the study period. There was a significant increase in biologics cost, climbing rapidly from 2.8% in 2003 to 60.4% of the total drug cost in 2009. The growth rate of outpatient drug costs was much higher after the introduction of biologics (2003-2009), which was 207.8% versus 42.0% as compared to the earlier period (1999-2002). Biologics such as etanercept, adalimumab and rituximab, were the crucial factors responsible for this increase in drug cost. CONCLUSIONS: The financial impact of adopting new biologics on healthcare costs is a critical issue that needs to be addressed by the National Health Insurance.

Risk of major depression in patients with chronic renal failure on different treatment modalities: A matched-cohort and population-based study in Taiwan.

The influence of different treatment modalities on the risk of developing major depression in patients with chronic renal failure (CRF) is not well understood. We aimed to explore the incidence of major depression among patients with CRF who were on different dialysis modalities, who had received renal transplantation (RT), and those who had not yet received any of the aforementioned renal replacement therapies. We conducted a population-based retrospective cohort study using a national health insurance research database. This study investigated 89,336 study controls, 17,889 patients with chronic kidney disease on conservative treatment, 3823 patients on hemodialysis (HD), 351 patients on peritoneal dialysis (PD), and 322 patients who had RT. We followed all individuals until the occurrence of major depression or the date of loss to follow-up. The PD group had the highest risk (hazard ratio [HR] 2.43; 95% confidence interval [CI] 1.26-4.69), whereas the RT group had the lowest risk (HR 0.18; 95% CI 0.03-1.29) of developing major depression compared with the control group. Patients initiated on PD had a higher risk of developing major depression than patients initiated on HD (pairwise comparison: HR 2.20; 95% CI 1.09-4.46). Different treatment modalities are associated with different risks of developing major depression in patients with CRF. Among renal replacement therapies, patients who have had RT have the lowest risk of developing major depression. Patients who initiate renal therapy on PD may have a higher risk of major depression compared with patients who initiate renal therapy on HD.

Trend and factors associated with healthcare use and costs in type 2 diabetes mellitus: a decade experience of a universal health insurance program.

BACKGROUND: Little is known about how a universal National Health Insurance program with cost-containment strategies affect costs and quality of diabetes care. OBJECTIVES: To examine the trends of healthcare use and costs for patients with type 2 diabetes mellitus (T2DM) in Taiwan over the last decade, and to identify factors associated with high healthcare cost and poor diabetes care. RESEARCH DESIGN: We delineated the pattern of healthcare use and costs for T2DM in 2000-2010. Generalized linear and logistic regression models were used to identify factors associated with medical costs and diabetes care. SUBJECTS: Representative adult T2DM patients and age-matched and sex-matched nondiabetes individuals were selected from the 2000, 2005, and 2010 National Health Insurance Research Databases. MEASURES: Healthcare use included physician visits, hospital admissions, and antidiabetic drug prescriptions. Indicators of diabetes management included completeness of recommended diabetes tests and medication adherence, assessed using medication possession ratio. RESULTS: The total healthcare cost per diabetes patient was approximately 2.8-fold higher than that for nondiabetes individual. The growth of healthcare cost per diabetes patient was significantly contained by about 3694 New Taiwan dollars (3.6%) between 2005 and 2010, but diabetes care improved over the decade. Diabetes duration, income, place of residence, continuity of care, and enrollment to a pay-for-performance program were associated with healthcare costs and diabetes management. Some public health measures implemented to support diabetes care were also discussed. CONCLUSIONS: Healthcare costs could be controlled without sacrificing the quality of diabetes care by implementing pay-for-performance programs and effective health policies favorable for diabetes care.

Risk of tuberculosis, serious infection and lymphoma with disease-modifying biologic drugs in rheumatoid arthritis patients in Taiwan.

AIM: To determine the risk of adverse events in rheumatoid arthritis (RA) patients treated with biological disease-modifying anti-rheumatic drugs (bDMARD) versus traditional DMARDs (tDMARD). METHOD: This retrospective study used Taiwan's National Health Insurance Research Database to capture data for adult patients diagnosed with RA between 1 January 1999 and 31 December 2009 and treated with tDMARD or bDMARD. The endpoints were patients with cases of an inpatient serious bacterial infection (SBI), diagnosis of tuberculosis (TB) or lymphoma. Within the bDMARD cohort, individual bDMARDS with adequate data were also compared (adalimumab and etanercept). Propensity-score matching was used to adjust for significant (P ≤ 0.05) patient characteristics. Incidence rate ratios (IRR) of SBI/TB/lymphoma cases versus non-cases were adjusted for exposure time (rate per 100,000 patient-years) and 95% confidence intervals were constructed to assess whether IRRs differed from 1.0. RESULTS: Of 34,947 potential patients, 7888 tDMARD, 3459 bDMARD (including 1492 etanercept and 746 adalimumab) patients were matched for analysis. A total of 2150 cases were identified and of these 1711 were SBI, 406 as TB and 33 as lymphoma. For all cases except SBI, the IRR (95% CI) was higher for bDMARD versus tDMARD (SBI 1.04 [0.89-1.19]; TB 2.67 [2.12-3.34]; lymphoma 3.24 [1.37-7.06]). Excepting lymphoma, IRR was higher for adalimumab versus etanercept (SBI 1.83 [1.19-2.77]; TB 2.35 [1.29-4.15]; lymphoma 1.49 [0.03-18.66]). CONCLUSIONS: There was a higher risk for specified infections and lymphoma with bDMARD versus tDMARD and adalimumab versus etanercept.

The association of fatigue, comorbidity burden, disease activity, disability and gross domestic product in patients with rheumatoid arthritis. Results from 34 countries participating in the Quest-RA program.

OBJECTIVES: The aim is to assess the prevalence of comorbidities and to further analyse to which degree fatigue can be explained by comorbidity burden, disease activity, disability and gross domestic product (GDP) in patients with rheumatoid arthritis (RA). METHODS: Nine thousands eight hundred seventy-four patients from 34 countries, 16 with high GDP (>24.000 US dollars [USD] per capita) and 18 low-GDP countries (<24.000 USD) participated in the Quantitative Standard monitoring of Patients with RA (QUEST-RA) study. The prevalence of 31 comorbid conditions, fatigue (0-10 cm visual analogue scale [VAS] [10=worst]), disease activity in 28 joints (DAS28), and physical disability (Health Assessment Questionnaire score [HAQ]) were assessed. Univariate and multivariate linear regression analyses were performed to assess the association between fatigue and comorbidities, disease activity, disability and GDP. RESULTS: Overall, patients reported a median of 2 comorbid conditions of which hypertension (31.5%), osteoporosis (17.6%), osteoarthritis (15.5%) and hyperlipidaemia (14.2%) were the most prevalent. The majority of comorbidities were more common in high-GDP countries. The median fatigue score was 4.4 (4.8 in low-GDP countries and 3.8 in high-GDP countries, p<0.001). In low-GDP countries 25.4% of the patients had a high level of fatigue (>6.6) compared with 23.0% in high-GDP countries (p<0.001). In univariate analysis, fatigue increased with increasing number of comorbidities, disease activity and disability in both high- and low-GDP countries. In multivariate analysis of all countries, these 3 variables explained 29.4% of the variability, whereas GDP was not significant. CONCLUSIONS: Fatigue is a widespread problem associated with high comorbidity burden, disease activity and disability regardless of GDP.