The Effects of Shared Decision Making on Different Renal Replacement Therapy Decisions in Patients With Chronic Kidney Disease.

BACKGROUND: The prevalence and incidence of end-stage renal disease (ESRD) in Taiwan are the highest of any country in the world. The different renal replacement therapies that are adopted by patients with ESRD significantly affect their social roles and daily life. However, because of the complexities of different renal replacement therapies, patients may be unsure of which to choose. PURPOSE: The aim of this study was to explore the effectiveness of a shared decision-making (SDM) program regarding different renal replacement therapies for patients with chronic kidney disease. METHODS: A quasi-experimental design was conducted at two similar regional hospitals in Miaoli County, Taiwan. One hospital hosted the intervention group, and the other hospital hosted the control group. The 31 participants in the intervention group took part in a SDM program. The 36 control group participants took part in the pre-ESRD care program. Data collection included demographic and disease characteristics, decisional conflict scale, and decision self-efficacy scale. Results were analyzed using independent t test, Fisher's exact test, generalized estimating equation, and paired t tests. RESULTS: The study results revealed that the intervention group experienced a significant increase in decision self-efficacy and a significant decrease in decisional conflict at 1 month after receiving the SDM intervention in comparison to before and immediately after receiving the intervention. Moreover, the intervention group had higher decision self-efficacy and lower decisional conflict than the control group. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The SDM program may be an effective intervention for complex decision-making processes, such as the process involved in making renal replacement treatment decisions. The SDM program group intervention improved decisional conflict and decision self-efficacy. Thus, to improve patients' decision-making processes, the application of an SDM program focused on the personal values and opinions of patients with ESRD will be necessary. Physicians and case managers of patients with ESRD should act in complementary and cooperative roles in SDM programs.

The impact of nurse working hours on patient safety culture: a cross-national survey including Japan, the United States and Chinese Taiwan using the Hospital Survey on Patient Safety Culture.

BACKGROUND: A positive patient safety culture (PSC) is one of the most critical components to improve healthcare quality and safety. The Hospital Survey on Patient Safety Culture (HSOPS), developed by the US Agency for Healthcare Research and Quality, has been used to assess PSC in 31 countries. However, little is known about the impact of nurse working hours on PSC. We hypothesized that long nurse working hours would deteriorate PSC, and that the deterioration patterns would vary between countries. Moreover, the common trends observed in Japan, the US and Chinese Taiwan may be useful to improve PSC in other countries. The purpose of this study was to clarify the impact of long nurse working hours on PSC in Japan, the US, and Chinese Taiwan using HSOPS. METHODS: The HSOPS questionnaire measures 12 sub-dimensions of PSC, with higher scores indicating a more positive PSC. Odds ratios (ORs) were calculated using a generalized linear mixed model to evaluate the impact of working hours on PSC outcome measures (patient safety grade and number of events reported). Tukey's test and Cohen's d values were used to verify the relationships between nurse working hours and the 12 sub-dimensions of PSC. RESULTS: Nurses working ≥60 h/week in Japan and the US had a significantly lower OR for patient safety grade than those working <40 h/week. In the three countries, nurses working ≥40 h/week had a significantly higher OR for the number of events reported. The mean score on 'staffing' was significantly lower in the ≥60-h group than in the <40-h group in all the three countries. The mean score for 'teamwork within units' was significantly lower in the ≥60-h group than in the <40-h group in Japan and Chinese Taiwan. CONCLUSIONS: Patient safety grade deteriorated and the number of events reported increased with long working hours. Among the 12 sub-dimensions of PSC, long working hours had an impact on 'staffing' and 'teamwork within units' in Japan, the US and Chinese Taiwan.

Early utilization of hypertonic peritoneal dialysate and subsequent risks of non-traumatic amputation among peritoneal dialysis patients: a nationwide retrospective longitudinal study.

BACKGROUND: The hemodialysis (HD) population has a particularly high incidence of amputation, which is likely associated with decreased tissue oxygenation during HD. However, information about the risk factors leading to amputation in peritoneal dialysis (PD) patients is limited. Here, we have investigated the association between the use of hypertonic peritoneal dialysate (HPD) and subsequent amputation in PD patients. METHODS: Based on the data from the Taiwan National Health Insurance research database, this observational cohort study enrolled 203 PD patients who had received HPD early during treatment and had not undergone amputation and 296 PD controls who had not undergone amputation. Subjects were followed through until the end of 2009 and the event rates of new non-traumatic amputation were compared between groups. RESULTS: The incidence of amputation was 3 times higher for the HPD cohort than for the comparison cohort (23.68 vs. 8.01 per 1000 person-years). The hazard ratio (HR) for this group, estimated using a multivariable Cox model, was 2.48 (95% confidence interval [CI] = 1.06-5.79). The HR for patients with both diabetes and early adoption of HPD increased to 44.34 (95% CI = 5.51-357.03), compared to non-HPD non-diabetic PD controls. CONCLUSION: Early utilization of HPD in PD patients is associated with increasing risk of amputation; this risk considerably increases for those with concomitant diabetes.

The characteristics of patient safety culture in Japan, Taiwan and the United States.

BACKGROUND: Quality and safety issues are receiving growing attention. Patient safety culture (PSC) plays an important role in patient safety. The characteristics of PSC in various countries, each with a different set of values, have not been determined sufficiently. The aim of this study is to investigate the characteristics of PSC in Japan, Taiwan and the U.S. METHODS: A cross-sectional survey was conducted in Japan and Taiwan using the Hospital Survey on PSC (HSOPS) questionnaire developed by the U.S. Agency for Healthcare Research and Quality (AHRQ). Data from Japan and Taiwan were also compared with the U.S. "2010 HSOPS Comparative Database" provided by AHRQ. RESULTS: Valid response rates in Japan, Taiwan and the U.S. were 66.5% (6,963/10,466), 85.7% (10,019/11,692) and 35.2% (291,341/827,424), respectively. The proportion of respondents with some experience of event reporting during the past 12 months was highest in Japan. In general, U.S. healthcare workers were likely to evaluate their PSC higher than that in Japan or Taiwan. The attitude of continuous improvement in Japan and event reporting of near misses in Taiwan were rated as low. In the U.S., staffing was rated as high. CONCLUSIONS: The results suggest that PSC varies among different countries, and the cultural setting of each country should be given special consideration in the development of effective intervention plans to improve PSC. Additional investigations with improved methodology and a common protocol are required to accurately compare PSCs among countries.

A comparative assessment of survival between propensity score-matched patients with peritoneal dialysis and hemodialysis in Taiwan.

Studies comparing mortality for Asian populations with end-stage renal disease (ESRD) on hemodialysis (HD) and peritoneal dialysis (PD) are limited. We compared mortality between patients treated with PD and HD in Taiwan, the population with the highest incidence of ESRD worldwide. Using the population-based insurance claims data of Taiwan from 1997 to 2006, we identified 4721 patients treated with PD and randomly selected 4721 patients treated with HD who were frequency-matched to the PD patients based on their propensity scores. In follow-up analyses we measured mortalities and hazard ratios associated with comorbidities in 2 different 5-year cohorts (1997-2001 and 2002-2006).In the 10-year period from 1997 to 2006, the overall mortality rates were similar in patients treated with PD and in patients treated with HD (12.0 vs. 11.7 per 100 person-years, respectively), with a PD-to-HD hazard ratio of 1.02 (95% confidence interval [CI], 0.96-1.08). In the first 5-year period (1997-2001), the hazard ratio for mortality was higher for PD (1.33; 95% CI, 1.21-1.46), but there was no difference between PD and HD in the 2002-2006 cohort. Of note, younger patients who received PD had better survival than younger patients who received HD; this was especially true for patients aged younger than 40 years.In summary, in this Asian population, no significant survival differences were noted between propensity score-matched PD and HD patients. The selection of a dialysis modality must be tailored to the individual patient. Studies in which patients who are appropriate for either modality are randomly assigned to HD or PD may provide helpful information to clinicians and patients.

Frequencies of hepatitis B and C infections among haemodialysis and peritoneal dialysis patients in Asia-Pacific countries: analysis of registry data.

BACKGROUND: The impact of dialysis modality on the rates and types of infectious complications has not been well studied. The aim of the present investigation was to evaluate the rates of hepatitis C virus (HCV) and hepatitis B virus (HBV) infections in peritoneal dialysis (PD) and haemodialysis (HD) patients in the Asia-Pacific region. METHODS: The study included the most recent period-prevalent data recorded in the national or regional dialysis registries of the 10 Asia-Pacific countries/areas (Australia, New Zealand, Japan, China, Taiwan, Korea, Thailand, Hong Kong, Malaysia and India), where such data were available. Longitudinal data were also available for all incident Australian and New Zealand patients commencing dialysis between 1 April 1995 and 31 December 2005. Rates of HCV and HBV infections were compared by chi-square, Poisson regression and Kaplan-Meier survival analyses, as appropriate. RESULTS: Data were obtained on 201,590 patients (HD 173,788; PD 27,802). HCV seroprevalences ranged between 0.7% and 18.1% across different countries and were generally higher in HD versus PD populations (7.9% +/- 5.5% versus 3.0% +/- 2.0%, P = 0.01). Seroconversion rates on dialysis were also significantly higher in HD patients (incidence rate ratio PD versus HD 0.33, 95% CI 0.13-0.75). HCV infection was highly predictive of mortality in Japan (relative risk 1.37, 95% CI 1.15-1.62, P = 0.003) and in Australia and New Zealand (adjusted hazards ratio 1.29, 95% CI 1.05-1.58). HBV infection data were limited, but less clearly influenced by dialysis modality. CONCLUSIONS: Dialysis modality selection significantly influences the risk of HCV infection experienced by end-stage renal failure patients in the Asia-Pacific region. No such association could be identified for HBV infection.

The suicide mortality rates between 1997-1998 and 2000-2001 in Nantou County of Taiwan following the earthquake of September 21 in 1999.

The paper aims to show the different suicide mortality rate between 1997-1998 and 2000-2001 in Nantou County of Taiwan with earthquake on September 21 (often referred to as the "9-21 earthquake") in 1999. In additional, it also identifies the preventive strategies for the high-risk suicide population. The age-standardized mortality rates for suicide in Nantou County were calculated for the years 1997-1998 and 2000-2001. The suicide standardized mortality ratio (SMR for townships in Nantou were calculated by "type of township" as the standard rate). There is a statistically significant difference in male suicide rates for the years prior to the earthquake (1997-1998) when pooled and compared to the suicide rates for the years after the earthquake (2000-2001). The rate for four age groups (under 25, 25-44, 45-64, 65 and above) all increased, yet all but one (the group of age 45-64) was not statistically significant. The male SMR has slightly increased after the 9-21 earthquake. Yet there are no statistical significances in most townships, except in Kaohsiung and Puli after the 9-21 earthquake. The Kaohsiung SMRs were 1.36 (95% CI: 0.54-2.80) before the earthquake (1997-1998) and 2.01 (95% CI: 1.04-3.52) after the earthquake (2000-2001). The SMRs before and after the earthquake in the Puli Township were 1.51 (95% CI: 0.95-2.29) to 1.56 (95% CI: 1.03-2.27). This study suggests that monitoring high-risk population, especially males or 45-64 years of age who experienced the highest statistically significant suicide rate in this study. The study provides support for providing both the psychological restoration program and, to the extent feasible, financial support for the unemployed as useful public health strategies for suicide prevention in Taiwan.