Relationship between overweight and obesity and insufficient micronutrient intake: a nationwide study in Taiwan.

The aim of the present study is to examine whether overweight or obese people in Taiwan have an inadequate intake of selected micronutrients. A population-based study was conducted using data from the Nutrition and Health Survey in Taiwan (NAHSIT) 2013-2016. We evaluated fourteen nutrient intakes using the 24 h dietary recall method. The dietary reference intake (DRI) adherence was estimated by the prevalence of participants whose intake was lower than the recommended dietary allowance (RDA) or adequate intakes (AIs) for selected micronutrients. Body mass index (BMI) ≥ 27 kg/m2 and waist circumference (WC), with men having WC ≥ 90 cm or women having WC ≥ 80 cm, were defined as obesity. A total of 3075 participants aged 19 years and above were included. After adjusting for confounders, we found that obese women have a lower DRI adherence of vitamin C (odds ratio (OR) 0⋅73, 95 % confidence interval (CI) 0⋅56, 0⋅95) and magnesium (OR 0⋅72, 95 % CI 0⋅54, 0⋅95), compared with normal-weight women. Obese men have a higher DRI adherence of vitamin B3 (OR 1⋅70, 95 % CI 1⋅29, 2⋅23), iron (OR 1⋅46, 95 % CI 1⋅06, 2⋅00) and zinc (OR 1⋅41, 95 % CI 1⋅07, 1⋅85), compared with normal-weight men. Similar findings were found using WC to define obesity. We conclude that obese women may have insufficient intakes of vitamin A, vitamin C and magnesium.

Impact of dialysis reimbursement policies on care outcomes in peritoneal dialysis patients in Taiwan.

The number of treated end stage renal disease (ESRD) patients worldwide has rapidly grown. To prolong their lives ESRD patients require transplantation or dialysis treatment. Limited donor availability has caused most of the ESRD patients to rely on either hemodialysis (HD) or peritoneal dialysis (PD). Taiwan had the highest prevalence rate worldwide and sought to increase the PD utilization through a series of reimbursement incentives. This study evaluated the effect of those policy initiatives. A retrospective longitudinal study using a before-and-after analysis was conducted. ESRD patients initiating either PD or HD were identified from the entire population of Taiwan NHI's beneficiaries. PD patients, before and after the PD-encouraging initiatives, were matched through a propensity score technique, and the change in PD technical failure was analyzed. HD patients were also matched as the control group to assess the impact on PD mortality. The competing risk regression approach for survival analysis was adopted. The results indicate the increase in PD utilization during this period was also accompanied by increases in both technique failure and mortality. Since PD shifts more burden of care to patients, efforts to increase its utilization may require an increase in the education of providers and patients to benefit more effectively. It may also require an increase in staff to provide ongoing training and support as the policy unfolds.

Effects of Erythropoietin Payment Policy on Cardiovascular Outcomes of Peritoneal Dialysis Patients: Observational Study.

BACKGROUND: The change in the reimbursement policy of erythropoietin administration to patients receiving peritoneal dialysis by the Taiwan National Health Insurance (NHI) system provided a natural experimental venue to examine whether cardiovascular risk differs when maintaining the hematocrit (Hct) level below or above 30%. OBJECTIVE: The aim of this study was to analyze the impact of loosening the erythropoietin payment criteria for peritoneal dialysis patients on their cardiovascular outcomes. METHODS: Two cohorts of incident peritoneal dialysis patients were identified according to the time before and after relaxation of the NHI's erythropoietin payment criteria, designated cohort 1 (n=1759) and cohort 2 (n=2981), respectively. The cohorts were matched according to propensity scores (1754 patients in each cohort) and then followed up for cardiovascular events, which were analyzed with Cox regressions. RESULTS: For the composite cardiovascular endpoint, patients in cohort 2 had a significantly lower risk than those in cohort 1. However, subgroup analysis showed that this risk reduction was observed only in patients with diabetes. CONCLUSIONS: After loosening erythropoietin payment criteria, reduced cardiovascular risks were observed, particularly for patients with diabetes. These results indicate that it is crucial to maintain an Hct level above 30% to reduce the cardiovascular risk in patients with diabetes undergoing peritoneal dialysis.

Out-of-pocket costs and productivity losses in haemodialysis and peritoneal dialysis from a patient interview survey in Taiwan.

OBJECTIVES: The total medical (economic) costs of haemodialysis (HD) and peritoneal dialysis (PD), including direct medical costs, out-of-pocket (OOP) costs and productivity losses, have become an important issue. This study aims to compare the direct non-medical costs and indirect medical costs of both modalities in Taiwan. DESIGN AND SETTING: This multicentre study included cross-sectional interviews of patients over 20 years old and articulate, who had been continuously receiving long-term HD or PD for more than 3 months between April 2015 and March 2016. Mann-Whitney U test, Wilcoxon rank-sum test and 1000 bootstrap procedures with replacement were used for analysis. OUTCOME MEASURES: Differences in OOP costs and productivity losses. RESULTS: There were 308 HD and 246 PD patients available for analysis. HD patients had significantly higher monthly OOP costs than PD patients after bootstrap procedures (NTD 5912 vs NTD 5225, p<0.001; NTD, new Taiwan dollars; 1 US dollar=30 NTD). Compared with PD patients, HD patients had higher monthly productivity losses after bootstrap procedures (NTD 14 150 vs NTD 11 611, p<0.001), resulting from more time spent seeking outpatient care (HD, 70.4 hours vs PD, 4.4 hours, p<0.001) and time spent by family caregivers for outpatient care (HD, 66.1 hours vs PD, 6.1 hours, p<0.001). The total costs per patient-month of HD and PD modalities, including OOP costs and productivity losses, were NTD 20 062 and NTD 16 836, respectively. CONCLUSIONS: The HD modality has higher OOP costs and productivity losses than the PD modality in Taiwan.

Relationship Between Lifestyles That Promote Health and Quality of Life in Patients With Chronic Schizophrenia: A Cross-Sectional Study.

BACKGROUND: Over the last few decades, an increasing number of studies have examined quality of life in patients with chronic schizophrenia. However, little research has addressed the relationship between lifestyles that promote health and quality of life issues in these patients. PURPOSE: The aim of this study was to investigate the relationships between lifestyles that promote health and quality of life in patients with chronic schizophrenia. METHODS: A cross-sectional study design was used. The study was conducted at 10 hospital-based psychiatric rehabilitation units in northern Taiwan. In total, 357 participants completed the World Health Organization Quality of Life-BREF and the Health-Promoting Lifestyle Profile. This study examined the relationships among the six domains of the Health-Promoting Lifestyle Profile and the four domains of the Quality of Life-BREF using canonical correlation analysis. Data collection occurred between April 2013 and April 2014. RESULTS: The results of the canonical correlation analysis showed that the Health-Promoting Lifestyle Profile domains of nutrition, health responsibility, self-actualization, interpersonal support, exercise, and stress management were significantly related to the Quality of Life-BREF results, specifically in the physical, psychological, and social relationships and environment domains. Two canonical correlations were identified (the canonical correlation coefficients were .622 and .317), which showed that 38.6% of the variance in lifestyles that promote health and quality of life was shared. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The results of this study may be useful to practitioners who are responsible for lifestyles that promote health and quality of life issues in patients with chronic schizophrenia.

A pay-for-performance program in Taiwan improved care for some diabetes patients, but doctors may have excluded sicker ones.

Many countries have implemented pay-for-performance programs to improve the quality of care. The structure of these programs, however, can have perverse consequences beyond improving care for patients. To investigate this possibility, we studied the pattern of enrollment of patients with diabetes in the first five years of a pay-for-performance program in Taiwan's National Health Insurance Program from 2001 through 2005. Taiwan's program did sharply improve quality of care for enrolled patients, producing 100 percent or nearly 100 percent adherence to all process measures. But at the same time, only a minority of the nation's patients with diabetes were enrolled, because the program's design encouraged physicians not to enroll their most complicated patients. By "cherry-picking" the healthiest patients most likely to perform well on selected measures, physicians were able to game the system and potentially reap the rewards of higher pay-for-performance payments without actually improving the care of all of their diabetic patients. Our study provides a cautionary tale, emphasizing the importance of proper program design so that quality is improved on the broadest scale.

Effects of glucose-free dialysis solutions on human peritoneal mesothelial cells.

BACKGROUND: Glucose-free dialysis solutions may be more biocompatible owing to the physiological pH and the lack of glucose degradation products, and the effects can be reflected by the changes in some markers of peritoneal mesothelial cells (PMC). METHOD: Peritoneal effluents were collected in 17 CAPD patients after one daily exchange of glucose-containing dialysate to Nutrineal (1.1% amino acid-based PDF), and human PMC were cultured from peritoneal effluent and treated with various peritoneal dialysis (PD) solutions. RESULTS: The level of cancer antigen 125 (CA125) in peritoneal effluent increased significantly after using Nutrineal for 3 months (p = 0.045), whereas that of procollagen I peptide (PICP) remained unaltered. Production of CA125 by human PMC showed a time-responsive increase after stimulation with Nutrineal and Extraneal (icodextran-based PDF). An increased expression of CA125 was observed in cultured human PMC treated with various PD solutions, and the increase induced by Nutrineal was lower than that induced by 4.25% Dianeal and Extraneal. A lower increase was also observed for lactate dehydrogenase (LDH). The levels of heat shock protein 70 (HSP70), however, were not altered. CONCLUSION: Nutrineal is more biocompatible to the peritoneal membrane than the conventional PD solutions tested herein, reflected by both the in vivo and in vitro response of CA125.