Discrepancies Among Hospitals and Regions in the Provision of Low-Value Care.

BACKGROUND: Low-value care is a critical issue in terms of patient safety and fiscal policy; however, little has been known in Asia. For the purpose of better understanding the extent of low-value care on a national level, the utilization, costs and associated characteristics of selected international recommendations were assessed in this study. METHODS: This retrospective cohort study used the National Health Insurance claims data during 2013-2017 to evaluate the low-value care utilization. Adult beneficiaries who enrolled in the National Health Insurance program and received at least one of the low-value services in hospitals were included. We measured seven procedures derived from the international recommendations at the hospital level, and a composite measure was created by summing the total utilization of selected services to determine the overall prevalence and corresponding cost. The generalized estimating equation model was adopted to estimate the association. RESULTS: A total of 1,970,496 episodes of low-value care was identified among 1,218,146 beneficiary-year observations and 2,054 hospital-year observations. Overall, the utilization rate of the composite measure increased from 150.70 to 186.23 episodes per 10,000 beneficiaries with the growth in cost from US$5.40 to US$6.90 million. Low-value care utilization was proportional to the volume of outpatient visits and length of stay. Also, hospitals with a large volume of outpatient visits (aOR [95% CI], 2.10 [1.26 to 3.49] for Q2- Q3, 2.88 [1.45 to 5.75] for ≥Q3) and a higher proportion of older patients (aOR [95% CI], 1.06 [1.02 to 1.11]) were more likely to have high costs. CONCLUSION: The utilization and corresponding cost of low-value care appeared to increase annually despite the relatively lower prevalence compared to other countries. Multicomponent interventions such as recommendations, de-implementation policies and payment reforms are considered effective ways to reduce low-value care. Repeated measurements would be needed to evaluate the effectiveness of interventions.

Diagnostic Accuracy of the FRAIL Scale, Groningen Frailty Indicator, Tilburg Frailty Indicator, and PRISMA-7 for Frailty Screening Among Older Adults in Community Settings: A Systematic Review and Network Meta-Analysis.

BACKGROUND AND OBJECTIVES: This study aimed to investigate the diagnostic accuracy of four questionnaire-based tools (i.e., the FRAIL scale, Groningen Frailty Indicator [GFI], Tilburg Frailty Indicator [TFI], and PRISMA-7) for screening frailty in older adults. RESEARCH DESIGN AND METHODS: The 4 databases comprising the Cumulative Index to Nursing and Allied Health Literature, Embase, PubMed, and ProQuest were searched from inception to June 20, 2023. Study quality comprising risks of bias and applicability was assessed via a QUADAS-2 questionnaire. A bivariate network meta-analysis model and Youden's index were performed to identify the optimal tool and cutoff points. RESULTS: In total, 20 studies comprising 13 for FRAIL, 7 for GFI, 6 for TFI, and 5 for PRISMA-7 were included. Regarding study quality appraisal, all studies had high risks of bias for study quality assessment domains. Values of the pooled sensitivity of the FRAIL scale, GFI, TFI, and PRISMA-7 were 0.58, 0.74, 0.66, and 0.73, respectively. Values of the pooled specificity of the FRAIL scale, GFI, TFI, and PRISMA-7 were 0.92, 0.77, 0.84, and 0.86, respectively. The Youden's index was obtained for the FRAIL scale with a cutoff of 2 points (Youden's index = 0.65), indicating that the FRAIL scale with a cutoff of 2 points was the optimal tool for frailty screening in older adults. DISCUSSION AND IMPLICATIONS: The FRAIL scale comprising 5 self-assessed items is a suitable tool for interview older adults for early frailty detection in community settings; it has the advantages of being short, simple, and easy to respond to.

Iron deficiency in Taiwanese patients with heart failure and reduced ejection fraction.

BACKGROUND: Iron deficiency (ID) is a common comorbidity among patients with heart failure and reduced ejection fraction (HFrEF), and is associated with poorer outcomes independent of anemia. This study aimed to evaluate the prevalence and prognostic significance of ID in Taiwanese patients with HFrEF. METHODS: We included HFrEF patients from two multicenter cohorts at different periods. The multivariate Cox regression analysis was applied to assess the risk of outcomes associated with ID, accounting for the varying risk of death. RESULTS: Of the 3612 patients with HFrEF registered from 2013 to 2018, 665 patients (18.4%) had available baseline iron profile measurements. Of these, 290 patients (43.6%) were iron deficient; 20.2% had ID+/anemia+, 23.4% ID+/anemia-, 21.5% ID-/anemia+, and 34.9% ID-/anemia-. Regardless of anemia status, patients with coexisting ID had a higher risk than those without ID (all-cause mortality: 14.3 vs 9.5 per 100 patient-years, adjusted hazard ratio [HR] 1.33; 95% confidence interval [CI], 0.96-1.85; p = 0.091; cardiovascular mortality: 10.5 per 100 patient-years vs 6.1, adjusted HR 1.54 [95% CI, 1.03-2.30; p = 0.037]; cardiovascular mortality or first unplanned hospitalization for HF: 36.7 vs 19.7 per 100 patient-years, adjusted HR 1.57 [95% CI, 1.22-2.01; p < 0.001]). Among patients eligible for treatment in the IRONMAN trial design (43.9%), parenteral iron therapy was estimated to reduce heart failure hospitalizations and cardiovascular deaths by 13.7 per 100 patient-years. CONCLUSION: Iron profiles were tested in less than one-fifth of the Taiwanese HFrEF cohort. ID was present in 43.6% of tested patients and was independently associated with poor prognosis in these patients.

Symptom Clusters in Lymphoma Survivors Before, During, and After Chemotherapy: A Prospective Study 
.

OBJECTIVES: To explore symptom clusters (SCs) in lymphoma survivors before, during, and after chemotherapy. . SAMPLE & SETTING: 61 lymphoma survivors from a medical center in central Taiwan were enrolled in the study. . METHODS & VARIABLES: A prospective observational study design was adopted. The MD Anderson Symptom Inventory was used to measure symptoms. The 13 symptoms assessed by the MD Anderson Symptom Inventory were evaluated after diagnosis and before chemotherapy (T1), after the fourth cycle of chemotherapy (T2), and after completion of chemotherapy (T3). Data were analyzed using mean, frequency, and latent profile analysis. . RESULTS: Three SCs were identified at T1, four at T2, and three at T3. Fatigue was the predominant symptom in each SC for the participants over time. Fatigue, disturbed sleep, and numbness constituted an SC at T2 and T3. An SC consisting of multiple psychological symptoms was found only at T1. IMPLICATIONS FOR NURSING: This study describes methods for grouping SCs. An SC of fatigue, disturbed sleep, and numbness was identified at T2 and T3. By familiarizing themselves with this SC, clinicians can be attentive to patients' concurrent symptoms and implement early prevention measures and timely symptom management.

Development and Psychometric Testing of the Clinical Reasoning Scale Among Nursing Students Enrolled in Three Types of Programs in Taiwan.

BACKGROUND: There is no instrument currently available to assess the essential nursing competency of clinical reasoning (CR). PURPOSE: The purpose of this study was to develop and test the psychometric properties of CR assessment instrument appropriate for use with nursing students across different types of programs. METHODS: H. M. Huang et al.'s (2018) Framework of Competencies of Clinical Reasoning for Nursing Students was used to guide this study. Two rounds of Delphi study and confirmatory factor analysis (CFA) were conducted to test content and construct validity. Internal consistency was tested for reliability. RESULTS: The four-domain, 16-item Likert-scale Clinical Reasoning Scale (CRS) was developed. One thousand five hundred four nursing students currently enrolled in three different types of nursing programs completed the CRS. The content validity index was .85-1.0, the CFA indicated goodness of fit, and the Cronbach's α score range was .78-.89. CONCLUSION: The CRS is a valid and reliable tool for assessing CR in nursing students in different types of nursing program.

Identifying differential trajectories and predictors for depressive symptoms in adolescents using latent class growth analysis: A population-based cohort study.

INTRODUCTION: This study investigated the differential trajectories and relevant determinants of depressive symptoms in adolescents by following cohorts that included junior, senior, and vocational high school adolescents, over a 3-year period in Taiwan. METHODS: Longitudinal data were obtained from 575 adolescents who participated in the Taiwan Adolescent to Adult Longitudinal Study. Data analysis included latent class growth with time-varying covariate, univariate, and multivariate analysis. RESULTS: A three-class ("low but increasing trajectory," "moderate and stable trajectory," and "high but decreasing trajectory") model fit the data of the cohort. Our findings indicated that 29%, 38%, and 33% of the adolescents were in the low but increasing, moderate and stable, and high but decreasing trajectories, respectively. After confounders were controlled for, bullying experiences were identified as a risk factor for depressive symptoms. The protective factors against depressive symptoms included resilience and peer and social support. CONCLUSIONS: The transitions between different educational stages critically influence the depressive symptoms of adolescents, and the adolescents follow different depressive trajectories, that have different etiology. Therefore, identifying adolescents at high risk for depression and designing student-centered intervention programs through individualized and multidimensional assessment of depressive symptoms are crucial for adolescents.

Risk and Protective Profile of Men Who Have Sex With Men Using Mobile Voluntary HIV Counseling and Testing: Latent Class Analysis.

BACKGROUND: Mobile voluntary counseling and testing (VCT) for HIV has been carried out to improve the targeting of at-risk populations and HIV case detection for men who have sex with men (MSM). However, the HIV-positive detection rate using this screening strategy has declined in recent years. This may imply unknown changes in risk-taking and protective features jointly influencing the testing results. These changing patterns in this key population remain unexplored. OBJECTIVE: The aim of this study was to identify the nuanced group classification of MSM who underwent mobile VCT using latent class analysis (LCA), and to compare the difference in characteristics and testing results between subgroups. METHODS: A cross-sectional research design and purposive sampling were applied between May 21, 2019, and December 31, 2019. Participants were recruited by a well-trained research assistant through social networking platforms, including the most popular instant messenger app Line, geosocial network apps dedicated to MSM, and online communities. Mobile VCT was provided to participants at an assigned time and place. Demographic characteristics and risk-taking and protective features of the MSM were collected via online questionnaires. LCA was used to identify discrete subgroups based on four risk-taking indicators-multiple sexual partners (MSP), unprotected anal intercourse (UAI), recreational drug use within the past 3 months, and history of sexually transmitted diseases-and three protective indicators-experience of postexposure prophylaxis, preexposure prophylaxis use, and regular HIV testing. RESULTS: Overall, 1018 participants (mean age 30.17, SD 7.29 years) were included. A three-class model provided the best fit. Classes 1, 2, and 3 corresponded to the highest risk (n=175, 17.19%), highest protection (n=121, 11.89%), and low risk and low protection (n=722, 70.92%), respectively. Compared to those of class 3, class 1 participants were more likely to have MSP and UAI within the past 3 months, to be ≥40 years of age (odds ratio [OR] 2.197, 95% CI 1.357-3.558; P=.001), to have HIV-positive results (OR 6.47, 95% CI 2.272-18.482; P<.001), and a CD4 count ≤349/µL (OR 17.50, 95% CI 1.223-250.357; P=.04). Class 2 participants were more likely to adopt biomedical preventions and have marital experience (OR 2.55, 95% CI 1.033-6.277; P=.04). CONCLUSIONS: LCA helped derive a classification of risk-taking and protection subgroups among MSM who underwent mobile VCT. These results may inform policies for simplifying the prescreening assessment and more precisely recognizing those who have higher probabilities of risk-taking features but remain undiagnosed targets, including MSM engaging in MSP and UAI within the past 3 months and those ≥40 years old. These results could be applied to tailor HIV prevention and testing programs.

The determinants of health-related quality of life among patients with newly diagnosed lung cancer in Taiwan: A cross-sectional study.

BACKGROUND: Although considered one of the most important prognostic factors for lung cancer patients, the health-related quality of life (HRQOL) of the newly diagnosed lung cancer population remains scarcely focused on in the literature. Therefore, we aimed to identify the determinants of HRQOL among newly diagnosed lung cancer patients in Taiwan. METHODS: Two hundred and fifty patients newly diagnosed with lung cancer were recruited from a medical center in northern Taiwan through convenience sampling. Four structured questionnaires, including the Taiwanese version of the MD Anderson symptom inventory (MDASI-T), the Taiwanese version of the Pittsburgh Sleep Quality Index (PSQI-T), the International Physical Activity Questionnaire-Short Form (IPAQ-SF), and the World Health Organization Quality of Life-BREF (WHOQOL-BREF), were used to collect data. Further, a multivariate stepwise linear regression was conducted to determine the independent risk factors for HRQOL. A p value of less than 0.05 was considered statistically significant. RESULTS: The patients (mean age was 61.04 years, 51.2% male, 94.0% non-small-cell lung cancer, 56.4% stage IIIB-IV) had moderate levels of HRQOL among the physical, psychological, social, and environmental domains, as well as overall QOL. HRQOL was not correlated with married status, religion, and comorbidity. Gender, age, family income, smoking status, cancer stage, ECOG PS scores, PA, symptom burden (severity and interference), and PSQI global scores were correlated with HRQOL. Notably, symptom severity was the dominant negative predictor affecting the psychological and environmental domains of QOL (ß = -4.313 and -3.500, respectively), accounting for 23.2% and 14.6% of the variance, respectively. On the other hand, symptom interference was the dominant negative predictor affecting the physical and social domains of QOL, as well as overall QOL (ß = -3.592, -1.984, and -0.150, respectively), accounting for 44.4%, 15.0%, and 24.1% of the variance, respectively. CONCLUSION: Newly diagnosed lung cancer patients suffered symptom severity and interference that significantly impaired their HRQOL; particularly, symptom interference affected the physical domain of QOL. Healthcare professionals should pay more attention to cancer-related symptom severity, symptom interference, and HRQOL changes when caring for newly diagnosed lung cancer patients.

The changes of parental functioning of the patients with bipolar disorder and major depression since discharging from hospital: A longitudinal study.

AIMS AND OBJECTIVES: This study examined the changes in patients' parental functioning and the associated factors, including manic, depressive symptoms and social support from before discharge to 6 months post-discharge. BACKGROUND: For parents with bipolar disorder and major depression, parenting is a recovery factor for patients, but little research examines the dynamic parental functioning from acute hospitalisation to a remission stage. DESIGN: A longitudinal design was used. The STROBE Checklist were used in presenting this research. METHODS: Participants were inpatients with bipolar disorder or major depression (n = 33) recruited within one week before discharge from the acute psychiatric ward in Taiwan. Data on parental functioning was collected four times: before discharge (T1), the 1st (T2), the 3rd (T3) and the 6th (T4) months of post-discharge. Baseline parental functioning before admitting to the acute word was retrospectively assessed at T0. The questionnaires included positive and negative domains of parenting practice, hypomanic/manic symptoms, depressive symptoms and social support. Generalised estimating equations were applied for data analysis. RESULTS: The negative parenting domains (poor monitoring, inconsistent discipline) decreased during hospitalisation but increased at one month post-discharge, except corporal punishment at 3-months discharge. The positive parenting domains (parental involvement and nurturance/responsiveness) did not recovery to baseline. While clinical symptoms remained stable during 6 months post-discharge, social support decreased at 3 and 6 months post-discharge. Higher depressive symptoms and low social support were associated with positive parenting domains but not related to negative parenting domains. Manic symptoms were not associated with positive or negative parenting domains. CONCLUSIONS: Positive parenting domains did not fully return to the usual situation during 6 months post-discharge. RELEVANCE TO CLINICAL PRACTICE: Parenting functioning recovery program targeting at the impacts of depressive symptoms on the parenting functioning and insufficient social support is needed from hospitalisation to post-discharge.

Predicting readmission due to severe hyperglycemia after a hyperglycemic crisis episode.

AIM: This study aimed to investigate the readmission pattern and risk factors for patients who experienced a hyperglycemic crisis. METHODS: Patients admitted to MacKay Memorial Hospital for diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS) between January 2016 and April 2019 were studied. The timing of the first readmission for hyperglycemia and other causes was recorded. Kaplan-Meier analysis was used to compare patients with hyperglycemia and all-cause readmissions. Cox regression was used to identify independent predictors for hyperglycemia and all-cause readmission post-discharge. RESULTS: The study cohort included 410 patients, and 15.3 % and 46.3 % of them had hyperglycemia and all-cause readmissions, respectively. The DKA and HHS group showed a similar incidence for hyperglycemia, with the latter group showing a higher incidence of all-cause readmissions. The significant predictors of hyperglycemia readmissions included young age, smoking, hypoglycemia, higher effective osmolality, and hyperthyroidism in the DKA group and higher glycated hemoglobin level in the HHS group. CONCLUSIONS: Patients who experienced DKA and HHS had similar hyperglycemia readmission rates; however, predictors in the DKA group were not applicable to the HHS group. Designing different strategies for different types of hyperglycemic crisis is necessary for preventing readmission.

Clinical outcomes and cumulative healthcare costs of TAVR vs. SAVR in Asia.

Objectives: This study compared transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in terms of short- and long-term effectiveness. Methods: This retrospective cohort study based on nationwide National Health Insurance claims data and Cause of Death data focused on adult patients (n = 3,643) who received SAVR (79%) or TAVR (21%) between 2015 and 2019. Propensity score overlap weighting was applied to account for selection bias. Primary outcomes included all-cause mortality (ACM), hospitalization for heart failure, and a composite endpoint of major adverse cardiac events (MACE). Secondary outcomes included medical utilization, hospital stay, and total medical costs at index admission for the procedure and in various post-procedure periods. The Cox proportional-hazard model with competing risk was used to investigate survival and incidental health outcomes. Generalized estimation equation (GEE) models were used to estimate differences in the utilization of medical resources and overall costs. Results: After weighting, the mean age of the patients was 77.98 ± 5.86 years in the TAVR group and 77.98 ± 2.55 years in the SAVR group. More than half of the patients were female (53.94%). The incidence of negative outcomes was lower in the TAVR group than in the SAVR group, including 1-year ACM (11.39 vs. 17.98%) and 3-year ACM (15.77 vs. 23.85%). The risk of ACM was lower in the TAVR group (HR [95% CI]: 0.61 [0.44-0.84]; P = 0.002) as was the risk of CV death (HR [95% CI]: 0.47 [0.30-0.74]; P = 0.001) or MACE (HR [95% CI]: 0.66 [0.46-0.96]; P = 0.0274). Total medical costs were significantly higher in the TAVR group than in the SAVR in the first year after the procedure ($1,271.89 ± 4,048.36 vs. $887.20 ± 978.51; P = 0.0266); however, costs were similar in the second and third years after the procedure. The cumulative total medical costs after the procedure were significantly higher in the TAVR group than in the SAVR group (adjusted difference: $420.49 ± 176.48; P = 0.0172). Conclusion: In this real-world cohort of patients with aortic stenosis, TAVR proved superior to SAVR in terms of clinical outcomes and survival with comparable medical utilization after the procedure.

Trajectories of symptom severity predicts quality of life change in newly diagnosis lymphoma survivors: An initial study.

OBJECTIVE: This study aimed to explore the subgroups of symptom severity and impact of their trajectories on quality of life in lymphoma survivors. METHODS: Secondary data were analysed from a prospective study with four-time measures: before treatment (T1), during treatment (T2), treatment completion (T3) and 10 weeks after treatment (T4). Data were analysed using descriptive statistics, group-based trajectory model and generalised estimation equation. RESULTS: Fifty nine of 61 participants completed three-time measure (mean age = 60.43 years, male-predominant). The changes in symptom severity over time were divided into two subgroups: slight-stable group (n = 54, 89%) and mild-fickle group (n = 7, 11%). Pain, tiredness and sleeping trouble were the predominant symptoms. The quality of life change in the slight-stable group was significantly better than that of the mild-fickle group (B = 13.35, SE = 3.53, p < 0.001). The overall quality of life at T2, T3 and T4 was better than it was at T1. CONCLUSION: The different trajectories of symptom severity significantly influenced quality of life changes in lymphoma survivors. Healthcare providers must be aware that there is a group of lymphoma survivors with relatively severe symptoms when newly diagnosed, compared to the opposite. More attention must be paid to this group, in addition to providing in-time symptom management.

Different item characteristics of a mild cognitive impairment screening tool in the community-based Yilan Study: application of the item response theory.

BACKGROUND: This study aimed to use item response theory (IRT) to explore the item-by-item characteristics of a mild cognitive impairment (MCI) screening tool using community-based data. METHODS: The Yilan Study is a community-based study that has been conducted since 2012. Until March 2020, 2230 older adults were interviewed according to the household registration data. IRT was applied to determine the item-by-item distinctive characteristics of the Eight-item Interview to Differentiate Aging and Dementia (AD8). RESULTS: The MCI characteristics in the AD8 items have varying degrees of item response threshold. In all circumstances, item AD8-8, which is related to self-rated memory ability, had a low item response threshold. AD8-5 and AD8-7, which are related to the comparisons of time-oriented functional status, had slightly lower thresholds, especially for those aged 65-79 years or without activity limitations. Conversely, AD8-1, AD8-2, AD8-3, AD8-4, and AD8-6 had similar item response thresholds and discriminative power; these items have more detailed functional descriptions or examples for illustration. CONCLUSIONS: Concise and understandable elements are often expected in community-based screening tools. For community-based health screening and population empowerment in the early detection of MCI, assessment tool items with detailed functional descriptions and examples for illustration have similar validities in most of the population. Items related to self-rated memory ability might be less valid. More examples may be needed for items constructed for comparing time-oriented functional status, especially in extremely old adults and individuals with activity limitations.

Determinants of the health care service choices of long-term mechanical ventilation patients: Applying andersen's behavioral model.

AIMS: The number of ventilator-dependent patients is rapidly increasing globally. As a result, long-term mechanical ventilation (LTMV) patients face the choice of receiving health care in respiratory care wards (RCWs) rather than at home. In this study, we applied Andersen's behavioral theoretical model (ABM) to investigate the determinants of the health care service decisions of patients receiving LTMV. METHODS: A cross-sectional research design and cluster random sampling were used to select 365 participants from nine RCWs and eight home care facilities in northern Taiwan. Data were collected in face-to-face interviews using a structured questionnaire. RESULTS: Of the predisposing factors, advanced age and an education level of at least junior high school influenced the choice to use RCW services. Being married, living with extended family, and medium or higher socioeconomic status were associated with the decision to use home care services. Of the enabling factors, patients with more caregivers, those whose family caregivers held strong beliefs about providing care, and those who perceived greater social support from health care providers were more likely to choose home care services. Of the need factors examined, poor cognitive function and higher dependence on assistance for activities of daily living (ADL) increased the probability of patients choosing RCW services. Hierarchical logistic regression analysis indicated that our final model accounted for 44.8% of the observed variance in health care service choice. CONCLUSIONS: ABM enables an improved understanding of the health care service choices of LTMV patients. Our findings also highlight the importance of rigorously assessing patient needs and helping patients choose the most appropriate health care service.

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.

Applying classification and regression tree analysis to identify risks of developing sarcopenia in the older population.

BACKGROUND AND OBJECTIVE: Variations in the risk factors for sarcopenia can lead to differences in the likelihood of developing sarcopenia among older adults; however, few studies have explored the interactions among the risk factors. This study examined the interactions among risk factors and identified a discriminative pathway for groups at risk of sarcopenia in community-dwelling older adults. METHODS: A cross-sectional study was conducted between July and August 2019 to recruit 200 older adults from an outpatient department of a hospital providing care for older people. Data on various risk factors, namely demographics (age, gender, education, comorbidities, and body mass index [BMI]), dietary habits (weekly consumption of milk, coffee, and meat), lifestyle behaviours (vitamin D supplementation, smoking, drinking, and physical activity), and depression symptoms were collected. Sarcopenia was defined according to the Asian Working Group for Sarcopenia criteria. A classification and regression tree (CART) model was used to examine interactions among these factors and identify groups at risk of sarcopenia. FINDINGS: The prevalence of sarcopenia was 38.5%. The CART model identified two end groups at differential risks of sarcopenia, with a minimum of one and a maximum of three risk factors. In the first group, low BMI (<18.5 kg/m2 ) was a predominant risk factor for sarcopenia among older people. In the second group, older adults with a normal BMI, aged ≥68 years, and without a regular walking habit had a higher probability of developing sarcopenia than did their counterparts. CONCLUSIONS: The interactive effects among older age, BMI, and walking may cause different probabilities of developing sarcopenia in the older population. IMPLICATIONS FOR PRACTICE: Older adults with a low or normal BMI but without a regular walking habit could be a predominant risk group for sarcopenia. The appropriate maintenance of body weight and regular walking activity is suggested to prevent sarcopenia in community-dwelling older adults.

Evaluating the effectiveness of population-based breast cancer service screening: an analysis of parsimonious patient survival information with the time-varying Cox model.

BACKGROUND: This study is aimed at estimating the unbiased effectiveness of population-based breast cancer service screening based on case survival information alone rather than large-scale individual screening data pursuant to the intention-to-treat principle of a randomized-controlled trial. METHODS: A novel time-dependent switched design with two modalities of cancer detection (screen-detected vs clinically detected) was proposed to evaluate the effectiveness of breast cancer screening. We used data on 767 patients from Kopparberg in the Swedish Two-County trial and on 78 587 patients in the Taiwan population-based service screening. We estimated the relative rate of the screen-detected vs the clinically detected with adjustment for both truncation and lead-time biases. The absolute effectiveness in terms of the number needed to screen (NNS) for averting one death from breast cancer was estimated. RESULTS: The relative rate of effectiveness was estimated as 33%, which was consistent with the 37% reported from the original Swedish randomized-controlled trial. The corresponding estimate for the Taiwan screening programme was 42%, which was also very close to that estimated using individual screening history data (41%). Both relative estimates were further applied to yield 446 and 806 of NNS for averting one death from breast cancer for the corresponding two data sets. CONCLUSION: The proposed time-dependent switched design and analysis with two modalities of case survival information provides a very efficient means for estimating the unbiased estimates of relative and absolute effectiveness of population-based breast cancer service screening dispensing with a large amount of individual screening history data.

Using Patient Health Profile Evaluation for Predicting the Likelihood of Retinopathy in Patients with Type 2 Diabetes: A Cross-Sectional Study Using Latent Profile Analysis.

Background: To determine whether long-term self-management among patients with type 2 diabetes mellitus has the risk of developing complications. Methods: We conducted a survey of self-management behavior using diabetes self-management scales (DMSES-C and TSRQ-d) from November 2019 to May 2020 linked with biomarkers (glucose, lipid profile, blood pressure, and kidney function), and the varying measure values were transformed into normal rate proportions. We performed latent profile analysis (LPA) to categorize the patient into different patient health profiles using five classes (C1-C5), and we predicted the risk of retinopathy after adjusting for covariates. Results: The patients in C1, C2, and C4 had a higher likelihood of retinopathy events than those in C5, with odds ratios (ORs) of 1.655, 2.168, and 1.788, respectively (p = 0.032). In addition, a longer duration of diabetes was correlated with an increased risk of retinopathy events as well as being elderly. Conclusions: Optimal biomarker health profiles and patients with strong motivation pertaining to their T2DM care yielded better outcomes. Health profiles portraying patient control of diabetes over the long term can categorize patients with T2DM into different behavior groups. Customizing diabetes care information into different health profiles raises awareness of control strategies for caregivers and patients.

Effectiveness of a Problem-Based Geropsychiatric Nursing Clinical Internship Program.

Clinical internships that effectively incorporate the care of older adults with mental health disorders are sparse in many countries, including Taiwan. This study investigated the effectiveness of a problem-based geropsychiatric clinical internship program for nursing students in Taiwan. We conducted a quasi-experimental study among 126 nursing students. Experimental and control groups received problem-based geropsychiatric and general psychiatric practice sessions, respectively. Knowledge, attitude, skills, and self-reflection were evaluated before (T1) and after (T2) measurements. There were no significant differences between the groups in knowledge, attitude, skills, and self-reflection at T1. At T2, knowledge was significantly higher in the experimental group (t = 2.39, p = 0.02). Attitude, skills, and self-reflection ability did not differ between the groups at T2. Our results showed that clinical problem-based approaches can be applied in geropsychiatric mental health nursing internship programs. The problem-based approach was helpful in improving nursing students' knowledge about psychiatric symptoms and the health problems of older adults with mental illness. However, it did not significantly enhance or change the attitudes, skills, or the ability to self-reflect among students.

[Multimedia Health Education on Insulin Injection Skills for Patients With Type 2 Diabetes].

BACKGROUND: Multimedia health education may be applied to improve self-care behaviors in patients. However, the long-term effects of multimedia health education on insulin injection performance have been insufficiently studied. PURPOSE: To evaluate the effect of a multimedia insulin pen-injector health education intervention on patients in terms of their insulin injection skills and glycated hemoglobin level and the time spent by nurses on insulin injection education. METHODS: Using a randomized controlled trial and two-group repeated-measures study design, patients with type 2 diabetes who were novice users of a Lantus, Levemir, or Novomix pen injector were recruited. A total of 72 patients, comprising 36 in a control group and 36 in an experimental group, participated in the study. The participants' injection skills were photographed using a smart phone. RESULTS: Patients in the experimental group earned higher scores for attaching a new needle, removing air bubbles, selecting the required dose, selecting a suitable injection site (abdomen, arms, thigh, or buttocks), and injection performance skills than those in the control group. However, no significant differences were found between the two groups in terms of HbA1c levels at 13 weeks after discharge. The time spent by nurses on delivering health education to the experimental group was 0.38 times that of the time spent on the control group. CONCLUSIONS: Multimedia health education may not only enhance patients' self-injection skills but also save on human resources and nursing hours. The findings of this study may provide references for healthcare providers in educating patients with diabetes regarding self-administering insulin pen injections.