Health-related inequalities in out-of-pocket expenditure under universal health coverage in Taiwan: A cross-sectional decomposition analysis.

OBJECTIVES: Studies have investigated income-related inequality in out-of-pocket expenditure (OOPE) on health care but less is known about health-related inequality of OOPE distribution. This study analysed the relationship between health-related inequality and OOPE and the factors contributing to OOPE inequality in Taiwan. METHODS: We developed a household OOPE questionnaire and conducted a nationally representative cross-sectional survey of households in Taiwan between January and August 2022, using two-stage probability proportional-to-size sampling based on a national address registry in Taiwan. We calculated a concentration index to determine OOPE inequality in health. We then identified factors contributing to OOPE inequality in health distribution by performing a decomposition analysis. RESULTS: A total of 657 people responded to the survey (81.4% response rate). The two largest categories of OOPE were spending on curative care and on medical goods and pharmaceuticals, with concentration indices of -0.265 (p < .001), -0.272 (p = .006) and -0.227 (p = .003), respectively, indicating that the OOPE burden fell disproportionately on people with poor health. Socioeconomic status explained significant proportions of inequality in total, curative and medical goods and pharmaceuticals OOPE. Utilisation of health care increased the OOPE burden among people with poor health while having private health insurance worked in the opposite direction. CONCLUSION: In Taiwan, people in poor health faced a disproportionately high OOPE burden, indicating that the National Health Insurance scheme may not meet their needs for health care. There is a need for policies to take account of the different factors affecting health inequalities in OOPE in order to enhance equity in Taiwan's universal health system.

Medical care use and mortality rate after the onset of disability: A 6-year follow-up study based on national data in Taiwan.

BACKGROUND: The onset of disability is a major health challenge, and people with disability can be particularly underserved in the years immediately after the disability onset. OBJECTIVE: To analyze the excess mortality rate of people with recent-onset disability and their health-care utilization during the period after disability onset (1-6 years after onset). METHODS: We used whole-population claims data from 2015 to 2020 (for approximately 23 million individuals) from Taiwan's National Health Insurance (NHI) system. These NHI claims data were linked to the National Death Records and National Disability Registry. Each individual with a disability was followed until their death or December 31, 2020. The age-standardized mortality rate and outpatient and inpatient utilization were compared between individuals with and without disability. Finally, Cox regressions were estimated to determine excess mortality for the individuals with disability. RESULTS: The age-standardized mortality rates for the people with disability and those without disability were 1020.35/10,000 and 463.83/10,000, respectively. The people with disability utilized significantly more medical care under the NHI system. Mortality rates differed substantially among disability types. The Cox regression revealed a hazard ratio of 1.47 (95% CI = 1.46, 1.48) for all-cause mortality for people with disability, and significant sex differences in mortality risk were observed for some causes of death. CONCLUSION: According to the excess mortality rates within 6 years of disability onset observed in this study, the NHI may not be sufficient to reduce health disparity between people with and without disabilities. In addition, specific characteristics of each type of disability should be considered.

Medication adherence in patients with type 2 diabetes after disability onset: a difference-in-differences analysis using nationwide data.

BACKGROUND: Effectively managing the coexistence of both diabetes and disability necessitates substantial effort. Whether disability onset affects adherence to type 2 diabetes medication remains unclear. This study investigated whether disability onset reduces such adherence and whether any reduction varies by disability type. METHODS: This study used the National Disability Registry and National Health Insurance Research Database from Taiwan to identify patients with type 2 diabetes who subsequently developed a disability from 2013 to 2020; these patients were matched with patients with type 2 diabetes without disability onset during the study period. Type 2 diabetes medication adherence was measured using the medication possession ratio (MPR). A difference-in-differences analysis was performed to determine the effect of disability onset on the MPR. RESULTS: The difference-in-differences analysis revealed that disability onset caused a reduction of 5.76% in the 1-year MPR (P < 0.001) and 13.21% in the 2-year MPR (P < 0.001). Among all disability types, organ disabilities, multiple disabilities, rare diseases, and a persistent vegetative state exhibited the largest reductions in 2-year MPR. CONCLUSIONS: Policies aimed at improving medication adherence in individuals with disabilities should consider not only the specific disability type but also the distinct challenges and barriers these patients encounter in maintaining medication adherence.

Long-Term Effect of Systemic Comorbidity on Glaucoma Medication Adherence.

PURPOSE: To determine whether systemic comorbidity is associated with reduced adherence to glaucoma medication and whether this decrease varies according to the number of comorbidity and the time after glaucoma onset. DESIGN: Cohort study. METHODS: Setting: Population-based. STUDY POPULATION: All patients with confirmed newly diagnosed glaucoma in one or both eyes were identified using National Health Insurance (NHI) claims data from Taiwan. OBSERVATION PROCEDURE: Individuals with newly diagnosed glaucoma were followed up for 5 years from onset. The study period was from January 1, 2011, to December, 31, 2020. Patient comorbidities were identified using the Deyo-Charlson Comorbidity Index. Adherence was measured using the medication possession ratio (MPR). The MPR was calculated by dividing the total number of days a patient had a supply of glaucoma medication by 365. Data for the MPR were extracted from NHI outpatient and drug records. RESULTS: This study included a total of 50 408 patients. Compared with patients without comorbidity, patients with at least 1 comorbidity exhibited higher MPR in the first 2 years following glaucoma onset. However, their MPR decreased in the long term, specifically in the fourth and fifth years after onset. Additionally, the degree of nonadherence increased with the number of comorbidities. Patients with ≥4 comorbidities had significantly lower glaucoma medication adherence, with reductions of 6.4% (P = .033) and 11.8% (P < .001) in the fourth and fifth years after glaucoma onset, respectively. CONCLUSION: The presence of comorbidity can reduce glaucoma medication adherence by up to 12% in the long term. More comorbidities may increase the burden of managing chronic diseases; as a result, treatment for glaucoma may not receive priority due to the absence of clear symptoms of the condition.

Ophthalmic health care needs of children with disabilities.

BACKGROUNDS: Although vision care is crucial for pediatric eye health, research on vision care utilization by children with disabilities remains limited. Furthermore, no study has investigated the variations among various disability types and the interaction between disability status and age. METHODS: All children with disabilities listed in the Taiwan National Disability Registry during the study period (2015-2019) were matched by age and sex at a 1:4 ratio with children without disabilities. Vision care needs were measured on the basis of (1) the number of outpatient ophthalmology visits, (2) total medical costs associated with outpatient ophthalmology visits, and (3) whether ophthalmic care was provided. Generalized estimating equation models were estimated to determine the relationships between utilization, disability status, and age. RESULTS: Significant differences in needs between various disability types were identified. Other than children with visual disability, children with facial disability and balance abnormalities also had considerable needs. Children with intellectual disabilities, which constituted the most common disability type (29.4% in 2019), had fewer visits (mean = 1.38, SD = 2.12) and lower medical costs, compared with the averages for all children with disabilities. Care utilization shared an inverted U-shaped relationship with age. CONCLUSIONS: Children with disabilities have higher vision care needs, which vary by disability type and age. Such needs are greater at younger ages and decreases after the ages of 9-10 years. Policies should be specific to disability type and age to ensure vision care needs are met.

Decomposition of socioeconomic inequalities in glaucoma knowledge in Taiwan.

OBJECTIVES: Glaucoma knowledge is strongly associated with medication adherence and preventive behavior. Studies have frequently reported socioeconomic inequalities in glaucoma knowledge. This study aimed to decompose such inequalities. Decomposition analysis enables the design of policies directly targeting the underlying causes of inequality. METHODS: We performed a cross-sectional survey from January 1, 2019 to June 30, 2019, at the departments of ophthalmology of 2 medical centers belonging to a hospital chain in northern Taiwan. Socioeconomic inequalities in glaucoma knowledge were ranked based on 3 aspects of socioeconomic status (SES): (1) education, (2) income, and (3) self-perceived financial status. The concentration index was calculated and decomposed using decomposition analysis. Elasticity and marginal effects were estimated for each decomposed factor. RESULTS: In total, 1,203 patients completed the survey. Both measures of glaucoma knowledge and overall glaucoma knowledge score significantly contributed to the progressivity of knowledge inequalities (pro-high-SES inequalities). The concentration index for overall knowledge score with respect to education was 0.166 (p<0.001). Both objective and subjective measures of SES were associated with pro-high-SES inequalities. Our decomposition analysis revealed that demographic factors and attitudinal factors such as the level of concern regarding developing glaucoma contributed significantly to SES-based inequalities in glaucoma knowledge. CONCLUSIONS: Our decomposition analysis provided empirical evidence regarding the underlying causes of SES-based inequalities in glaucoma knowledge. Efforts to improve glaucoma knowledge should consider specific factors that drive SES-based inequalities, such as age, sex, and concern about vision health, to ultimately achieve low SES-based inequalities.

Trends in the prevalence of common ocular conditions and comparison of ophthalmic outpatient utilisation related to these conditions in children with and without various types of disabilities: analysis of nationwide population-based data from Taiwan, 2014-2019.

OBJECTIVE: The study objectives were to investigate trends in the prevalence of common ocular conditions among children with and without disabilities; to compare the prevalence of these conditions in children with various disabilities; and to compare ophthalmic outpatient utilisation related to these ocular conditions in children with and without disabilities. DESIGN: Repeated cross-sectional nationwide population-based study. SETTING: Nationwide analysis in Taiwan based on National Health Insurance (NHI) claims data and the National Disability Registry, from 2014 to 2019. PARTICIPANTS: All children (aged under 18 years) with a disability in any given year between 2014 and 2019 were included in our analysis. All children with a disability (experimental group) were matched 1:1 with a child of the same age without a disability (control group). Data regarding the children's disability type and status and ocular conditions were obtained from the National Disability Registry and NHI database of Taiwan. OUTCOME MEASURES: (1) The prevalence of myopia, strabismus, astigmatism, amblyopia and hyperopia over time; (2) the prevalence of myopia, strabismus, astigmatism, amblyopia and hyperopia in children with various disabilities; and (3) the association between disability and the use of outpatient vision care. All outcome measures were assessed using data from 2014 to 2019. RESULTS: Among children with disability, the prevalence of myopia increased from 15.97% in 2014 to 18.07% in 2019. The prevalence of strabismus (2.06-3.90%), astigmatism (8.25-9.24%), amblyopia (4.13-4.95%) and hyperopia (3.36-4.58%) also increased over the study period in children with disabilities. The prevalence of strabismus, astigmatism, amblyopia and hyperopia was significantly higher in children with disabilities than in those without disabilities in all years. For example, in 2019, the prevalence values for strabismus, astigmatism, amblyopia and hyperopia were 3.90%, 9.24%, 4.95% and 4.58%, respectively, among children with disabilities, and 0.67%, 5.84%, 1.33% and 1.70%, respectively, for those without disabilities. The prevalence of these conditions varied considerably across disability types. For example, in 2019, the prevalence of strabismus was highest in children with visual disabilities (10.66%; p<0.001); these children also exhibited a high prevalence of amblyopia (24.34%; p<0.001). The prevalence of myopia was high in children with autism (24.77%), but the prevalence of other ocular conditions was not elevated in this group. Regression results indicated that for myopia, children with disability had 0.48 fewer outpatient clinic visits than those without disability (p<0.001). CONCLUSIONS: The prevalence of common ocular conditions and the corresponding vision care required vary across types of disabilities among children. Healthcare policies must account for children at high risk of various ocular conditions, including those with less common disabilities.

Transforming stress program on medical students' stress mindset and coping strategies: a quasi-experimental study.

OBJECTIVE: Stress is a significant concern in medical education, and identifying effective ways to deal with stress may help with students' mental health and professional development. This study aimed to examine the effects of the Transforming Stress Program (TSP) amongst first-year medical students on their stress mindset and coping strategies when confronted with stressors. METHODS: We conducted a quasi-experimental study at the University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam. A total of 409 first-year students at the Faculty of Medicine were divided into intervention group (205 students) and control group (204 students). The 10-week TSP was delivered as an extra-curricular course. The training adopts psychoeducation based on Dialectical Behavioral Therapy with mindfulness as a fundamental practice incorporated into each component of the program. The intervention group received the training in the first semester; the control group received identical program in the second semester. Stress Mindset Measurement and Brief Coping Orientation to Problems Experienced were measured before the intervention (T0), immediately after intervention on Intervention group (T1), and six months after intervention on Intervention group (T2). RESULTS: At T1, the intervention group showed 65% improvements in stress mindset scores and increases in coping strategies scores in six domains (Problem solving, Social support, Humor, Religion, Venting, and Self-distraction) and decreases in three (Avoidance, Substance use, and Self-blame). The effect sizes were significant in all outcomes (Cohen's d > 0.2). Measurements of the control group did not change significantly in the same period. At T2, effects of the TSP were found decreased in some domains (Avoidance, Substance use, and Self-blame) compared to T1, but largely remained significantly better than T0. CONCLUSIONS: The TSP is a feasible and effective approach that significantly enhanced medical students' stress mindset and coping strategies. Some effects were still observable 6 months after the intervention. The relatively intensive intervention requires support of the school administration and staff.

Risk and dose-response relationship of diabetes mellitus for endophthalmitis after cataract surgery in a nationwide cohort study in Taiwan.

BACKGROUND: To investigate the risk of endophthalmitis after cataract surgery in patients with diabetes mellitus (DM) and evaluate the dose-response relationship. METHODS: This retrospective cohort study enrolled patients who underwent bilateral cataract surgeries from 2000 to 2017 in Taiwan National Health Insurance Research Database. The endophthalmitis rates within 3 months after cataract surgery were compared between DM and non-DM cohorts using a generalised estimating equation. The diabetes complications severity index (DSCI) score was adopted to assess the dose-response effect on the endophthalmitis rate. RESULTS: A total of 883 398 patients (1 766 796 eyes) were included. Patients with DM had an increased risk of endophthalmitis after cataract surgery than patients without DM (0.261% vs. 0.242%, adjusted odds ratio = 1.09, 95% confidence interval = 1.03-1.16). The higher endophthalmitis rate in the DM group than in the non-DM group remains after excluding those with prior vitrectomy or intravitreal injection (IVI), and took IVI between the cataract surgery and endophthalmitis (p = 0.0156, 0.0048, and 0.0139). There was a significant dose-response relationship on the likelihood of endophthalmitis in DM patients when DCSI score >10. The endophthalmitis rate is highest among DM complications in patients with metabolic disorders (0.342%). CONCLUSION: DM was a risk factor for endophthalmitis after cataract surgery after adjusting for age, sex, common systemic disorders, and excluding those with prior vitrectomy or IVI and having IVI between cataract surgery and endophthalmitis. A dose-response relationship was noted in DM patients with a DCSI score >10.

Changes in anisometropia by age in children with hyperopia, myopia, and antimetropia.

Anisometropia is a unique condition of both eyes and it is associated with vision problems such as amblyopia and reduced stereoacuity. Previous studies have not reported its change pattern by age and its correlation with the refractive condition of both eyes. This study aims to compare the changes in anisometropia by age in children with hyperopia, myopia, and antimetropia. In total, 156 children were included. Children aged 3-11 years with anisometropia ≥ 1.00 D were followed up for ≥ 1 year with ≥ 2 visits at two medical centers in Taiwan. Refractive errors by cycloplegic autorefractometry, best-corrected visual acuity, eye position, and atropine use were recorded. The children were divided into hyperopic, myopic, and antimetropic groups. The results showed that anisometropia decreased in children aged < 6 years (3.34-2.96 D; P = 0.038) and increased in older children (2.16-2.55 D; P = 0.005). In children aged 3, 4, 5, and 6 years, the mean anisometropia was higher in children with myopia and antimetropia than in those with hyperopia (P = 0.005, 0.002, 0.001, and 0.011, respectively). The differences were not significant in children aged > 6 years (all P > 0.05). The factors associated with changes in anisometropia were age, refractive group, amblyopia, and strabismus. Anisometropia decreased with age in children younger than 6 years, and the changes in anisometropia was found in children with myopia and antimetropia.

Effects of disability on income and income composition.

BACKGROUND: Income composition is highly associated with individual financial sustainability and income inequality at the macro level. Although studies have investigated the effects of disability on wage income, few studies have investigated the effects of disability on income composition or on various types of income other than wage income. METHODS: We sampled 72,000 households using tax data sourced from the Taiwan Ministry of Finance in 2015. Data for each household member were traced back to 1999. We identified 23,346 individuals with disabilities and matched them with 34,145 individuals without disabilities. Eight income types were identified. A two-way fixed-effect analysis was performed to determine the effects of disability on changes in each income type. Fractional probit models were estimated to determine the effects of disability on the proportion of each income type in total income at different ages. RESULTS: Wage income constitutes the largest proportion of income in Taiwan. The total income is estimated to increase by 10.4% (P < 0.001) after disability onset. Moreover, most income categories did not experience a decline following the onset of disability. We also noted a significant interaction effect between disability status and age on the proportion of each income type in total income. CONCLUSION: The effect of disability on income varied across different sources of income. The income composition observed for the individuals with disabilities changed considerably at various ages. Accordingly, policies should be designed to ensure long-term sustainability of income sources for individuals with disabilities.

Income-related inequality in out-of-pocket health-care expenditures under Taiwan's national health insurance system: An international comparable estimation based on A System of Health Accounts.

National estimates of out-of-pocket health-care expenditures (OOP-HCEs) that use comparable international guidelines based on A Systems of Health Accounts (SHA) are generally unavailable in Taiwan. International comparable OOP are essential for designing universal health-coverage (UHC) policy. We designed an SHA-based household OOP questionnaire. A nationally representative cross-sectional survey was then conducted from January to August 2022. The final questionnaire was completed by 657 households and 1969 individuals. The total OOPs were divided into expenditures related to curative care (HC.1), rehabilitative care (HC.2), long-term care (HC.3), ancillary services (HC.4), and medical goods (HC.5). National estimates were calculated by accounting for the complex survey design. Variance was estimated through Taylor series linearization. The concentration index was calculated using household income as the ranking variable. We then identified factors contributing to the inequality in OOP distribution by household income. National estimates revealed an OOP of NT$424 billion, which accounted for 29.6% of Taiwan's national health expenditure in 2021. Private health insurance (PHI) reimbursements accounted for 9.0% of the total OOP. The OOPs for curative care and medical goods accounted for 50.1% and 39.0% of the total OOP, respectively. The OOPs after PHI reimbursements were progressive (concentration index = 0.103, P = 0.012). The frequency of medical-care use and the number of medical visits negatively affected progressive OOPs. International comparable OOPs revealed that under the Taiwanese National Health Insurance (NHI), OOPs can still be high. However, the NHI might have caused OOPs to be progressive from the perspective of income but regressive from the perspective of health status. Countries striving for UHC should consider the redistribution effect of public health insurance and possible inequalities in health.

Adherence of those With Self-Reported Glaucoma in the United States to Eye Examination Visits.

PRCIS: The adherence of American patients with self-reported glaucoma to the follow-up recommendations is extremely low. Estimated adherence rate is lower than that obtained by previous studies that did not use a US nationally representative sample. PURPOSE: To evaluate adherence to ophthalmic outpatient follow-up visits and vision examinations in the American population aged 40 years or above. METHODS: The percentage of American patients aged≥40 years who adhered to glaucoma treatment guidelines was estimated using 2015-2019 Medical Expenditure Panel Survey (MEPS) data. Adherence was defined according to the International Council of Ophthalmology guidelines. We also compared individuals with and without self-reported glaucoma who have made at least one ophthalmic outpatient visit and at least 1 vision examination visit within a year. Differences in means and percentages were estimated to account for the covariance due to the complex sampling design. RESULTS: Approximately 4.4 million people aged or above 40 years had self-reported glaucoma in 2019 (3.21%). The rate of prevalence significantly differed with race, with Black people having the highest prevalence in all studied years. Only 7.1% (95% CI: 0.049-0.102) and 2.67% (95% CI: 0.0137-0.0519) of this population underwent at least 1 ophthalmic outpatient examination or 1 vision examination per year. Older age, never married status, higher education, eye conditions, and diabetes were significantly associated with a higher probability of ophthalmic health care use. CONCLUSIONS: Adherence to follow-up among patients with self-reported glaucoma in this population-level study was lower than that in previously reported American, non-nationally representative studies. Barriers to adherence at the population level should be assessed to inform the design of future policy or program interventions.

Burnout, mental health, physical symptoms, and coping behaviors in healthcare workers in Belize amidst COVID-19 pandemic: A nationwide cross-sectional study.

BACKGROUND: Healthcare workers are vulnerable to burnout, especially during the COVID-19 pandemic in the low resource settings. Belize is a small Central American developing country known for its chronic healthcare worker shortage and this is the first study to assess burnout prevalence and its associated factors among healthcare workers in Belize. AIM: To evaluate the prevalence of burnout and its associated factors in HCWs in Belize covering multiple domains (mental health, physical symptoms, and coping behaviors) during the COVID-19 pandemic. METHODS: A cross-sectional survey that was developed and validated by a panel of experts was delivered online to all the healthcare workers in Belize from September to November 2021. Burnout was assessed using Copenhagen Burnout Inventory. Depression and anxiety screening was carried out using the Patient Health Questionnaire - 2 (PHQ-2) and Generalized Anxiety Disorder 2-item (GAD-2). Burnout associated factors were estimated using logistic regression models. FINDINGS: Of the total of 263 participants, 27.76% had overall burnout: 56.65% had personal, 54.37% had work-related, and 19.39% had patient-related burnout. Burnout was positively associated with anxiety (OR: 3.14 [1.67, 5.92]), depression (OR: 4.45 [2.30, 8.61]), intentions of quitting their jobs (OR: 2.59 [1.49, 4.51]), health status worsening (OR: 2.21 [1.26, 3.87]), multiple physical symptom presentation (OR: 1.19, [1.10, 1.29]), and use of multiple maladaptive coping behaviors (OR: 1.66, [1.30, 2.12]). INTERPRETATION: Healthcare workers in Belize showed substantial levels of burnout which were significantly associated with using maladaptive coping behaviors, presenting multiple physical symptoms, quitting their jobs, health status worsening, and other mental health issues. These findings should be used to develop and implement programs such as regular health check-ups, health promotion awareness campaigns, and worker recruitment strategies which would improve the working conditions, quality of life, and psychological well-being of our healthcare workers.

A Comparison of Visual Quality and Contrast Sensitivity between Patients with Scleral-Fixated and In-Bag Intraocular Lenses.

PURPOSE: To analyze visual quality and contrast sensitivity in patients after intraocular lens (IOL) implantation with sutured scleral fixation. SETTING: Chang Gung Memorial Hospital, Taoyuan, Taiwan. DESIGN: Retrospective observational study. METHODS: Data on the refractive outcome, visual acuity, and subjective visual symptoms in patients with scleral-fixated or in-bag IOL implantation were collected from September 2019 to March 2020. We also investigated patients' postoperative higher-order aberrations (HOAs) and dysphotopsia using a wavefront aberrometer and glaretester, respectively. The following values were compared: corrected distance visual acuity, spherical equivalent, root mean square values for aberrations, and contrast sensitivity. RESULTS: A total of 23 eyes implanted with scleral-fixated IOL and 74 eyes with in-bag IOL were studied. The mean postoperative spherical equivalent and logarithm of the minimum angle of resolution after scleral fixation were -1.09 ± 3.32 D and 0.20 ± 0.17, respectively. The ocular HOAs were higher in the scleral-fixation group than in the in-bag group (p = 0.001). Contrast sensitivity was negatively associated with age, and it was similar between the two groups after controlling for the age effect. CONCLUSIONS: Ocular HOAs and refractive errors were higher in the scleral-fixation group than in the in-bag group. However, no significant difference was noted in contrast sensitivity between advanced scleral fixation and in-bag IOL implantation.

Prediction of residual astigmatism in cataract surgery at different diameter zones using optical biometry measurement.

The studies for astigmatism prediction error at different diameters using optical biometry are scant. We investigated patients who underwent cataract surgery with monofocal, nontoric intraocular lens (IOL) from 2017 through 2019 in a medical center. Patients with prior refractive surgeries, corneal opacity, or surgical complications were excluded. Corneal astigmatism (CA) was measured using AL-Scan at 2.4- and 3.3-mm diameter zones and calculated using the Barrett toric calculator preoperatively and postoperatively. The mean absolute error and centroid prediction error for the two zones were computed using double-angle plots. In total, 101 eyes of 76 patients were analyzed. Mean patient age was 68.7 ± 9.3 years and mean preoperative CA power was 0.7 ± 0.5 D. The overall centroid prediction error a 3.3 mm (0.09 ± 0.58 D@25) was significantly lower than that at 2.4 mm (0.09 ± 0.68 D@87) on the X-axis (P = 0.003). The 3.3-mm measurement also had a lower centroid prediction error than the 2.4-mm did for eyes with against-the-rule (ATR) and oblique astigmatism (P = 0.024; 0.002 on X-axis, respectively). The 3.3-mm measurement provided a more accurate CA estimation than the 2.4-mm did, particularly for ATR astigmatism. Diameter zone and astigmatism type should be considered crucial to precise astigmatism calculation.

Association Between Visual Impairment and Health Care Use.

PURPOSE: To determine the association between visual impairment (VI) and medical care use. DESIGN: Population-based cohort study. METHODS: The study cohort included individuals from 2007 to 2017. The Disability Registry was used to identify all patients aged ≥20 years who newly developed visual disability. All patients were observed until they became visually impaired (case group). They were then matched with 2 control groups: (1) people with nonvisual disability and (2) people without any disability. The main outcome measures were (1) ophthalmic outpatient and inpatient use and (2) nonophthalmic outpatient and inpatient use. RESULTS: Compared with people with nonvisual disability, those with visual disability demonstrated a lower nonophthalmic outpatient costs (-NT$42,841, P < .001) and outpatient visits (-2.8 times). However, the opposite was noted for ophthalmic use, where people with visual disability used more medical care compared with people with other types of disability and people without disability. An age-stratified analysis revealed that visual disabilities had an age-related dose-response effect on the reception of nonophthalmic care and a slight nonlinear effect on the receipt of ophthalmic care. CONCLUSIONS: Studies investigating the effect of VI on medical use should differentiate aggregate use into different types. Use of ophthalmic and nonophthalmic care for people with VI should be compared with that of people with other types of disability and people without disability.