The determinants of obstetricians' willingness to undertake delivery by vaginal birth after cesarean section in Taiwan.

BACKGROUND: Babies are sometimes delivered by cesarean section (CS) to women eligible for trial of labor after a cesarean (TOLAC) due to a fear of complications during the delivery process. This view is especially widespread in Taiwan, as evidenced by the extremely low rate (<5%) of vaginal birth after cesarean section (VBAC). To improve the safety and quality of childbirth and the obstetrical practice environment, this study aimed to identify ways to contain the ever-increasing rate of CS by investigating the determinants for TOLAC from the viewpoint of obstetricians. METHODS: A specially designed questionnaire was employed that incorporated the perceived risk of VBAC, institutional managerial attitude, and obstetricians' personal characteristics. Face-to-face surveys were conducted with obstetricians from across Taiwan. Regression analysis was used as appropriate. RESULTS: Among the 231 recruited obstetricians, 86.7% were willing to undertake VBAC, but only 71.4% had actually done so. Obstetricians with a more risk-tolerant personality were more likely to undertake VBAC. Institutional characteristics, such as the time it takes to transfer a woman from the delivery table to the operating table (table to table) and the general facilities of the hospital to handle delivery complications resulting from VBAC were also key determinants for attempting VBAC. CONCLUSION: In Taiwan, a country with a low birthrate, obstetricians need to be risk-tolerant to undertake VBAC. This phenomenon is probably due to underinvestment in facilities for vaginal delivery and thus a general perception that VBAC is risky. The study's results will potentially help medical institutions to adopt appropriate guidelines and build incentive structures to achieve a higher VBAC rate.

Vaginal Birth after Cesarean Section in Taiwan: A Population-Based Study.

The rate of vaginal birth after cesarean section (VBAC) is extremely low in Taiwan probably due to the high perceived risk of trial of labor after a cesarean (TOLAC). To promote the benefits associated with vaginal birth, this study provides evidence to potentially assist relevant public authorities adopt appropriate guidelines or optimize health insurance reimbursement policies to achieve a higher VBAC rate. Employing the National Health Insurance (NHI) Claim Data, this study analyzes women's adoptions of birth-giving methods for those who had previous cesarean section (CS) experiences. Empirical methods include logit, probit, and hierarchical regression models controlling women's demographics, incentive indicators, as well as hospital and obstetrician characteristics. Taiwan continues to have a decreasing trend in VBAC rate even with an increase in NHI payment for vaginal birth delivery in 2005, which stimulated a surge in VBAC rate only temporarily. Factors that significantly influence women's adoption of VBAC include institution-specific random effects, weekend admission, comorbidities during pregnancy, and income and fertility of women. Change in service payment from National Health Insurance (NHI) to healthcare providers constitutes an effective policy in directing clinical practices in the short term. Constant and systematic policy review should be undertaken to promote safe and beneficial medical practices. The results of the study suggest that women's adoption of birth-giving method is dominated by non-medical considerations. Significant institution-specific effects imply that women might not be well-informed regarding their optimal birth-giving choice. Health education and training programs for hospital personnel should be kept up to date to better serve society.

Does Computerized Physician Order Entry Benefit from Dynamic Structured Data Entry? A Quasi-Experimental Study.

BACKGROUND: With advancements in information technology, computerized physician order entry (CPOE) and electronic Medical Records (eMR), have become widely utilized in medical settings. The predominant mode of CPOE in Taiwan is free text entry (FTE). Dynamic structured data entry (DSDE) was introduced more recently, and has increasingly drawn attention from hospitals across Taiwan. This study assesses how DSDE compares to FTE for CPOE. METHODS: A quasi-experimental study was employed to investigate the time-savings, productivity, and efficiency effects of DSDE in an outpatient setting in the gynecological department of a major hospital in Taiwan. Trained female actor patients were employed in trials of both entry methods. Data were submitted to Shapiro-Wilk and Shapiro-Francia tests to assess normality, and then to paired t-tests to assess differences between DSDE and FTE. RESULTS: Relative to FTE, the use of DSDE resulted in an average of 97% time saved and 55% more abundant and detailed content in medical records. In addition, for each clause entry in a medical record, the time saved is 133% for DSDE compared to FTE. CONCLUSION: The results suggest that DSDE is a much more efficient and productive entry method for clinicians in hospital outpatient settings. Upgrading eMR systems to the DSDE format would benefit both patients and clinicians.

Creating value in health care through big data: opportunities and policy implications.

Big data has the potential to create significant value in health care by improving outcomes while lowering costs. Big data's defining features include the ability to handle massive data volume and variety at high velocity. New, flexible, and easily expandable information technology (IT) infrastructure, including so-called data lakes and cloud data storage and management solutions, make big-data analytics possible. However, most health IT systems still rely on data warehouse structures. Without the right IT infrastructure, analytic tools, visualization approaches, work flows, and interfaces, the insights provided by big data are likely to be limited. Big data's success in creating value in the health care sector may require changes in current polices to balance the potential societal benefits of big-data approaches and the protection of patients' confidentiality. Other policy implications of using big data are that many current practices and policies related to data use, access, sharing, privacy, and stewardship need to be revised.

Effects of age and disc area on optical coherence tomography measurements and analysis of correlations between optic nerve head and retinal nerve fibre layer.

BACKGROUND: The aim here was to investigate whether optic nerve head (ONH) parameters or retinal nerve fibre layer (RNFL) thickness correlate with age or disc area and whether the neuroretinal rim correlates with RNFL thickness. METHODS: This cross-sectional study enrolled 133 healthy subjects and analysed one randomly selected eye of each subject. All measurements of ONH parameters (including neuroretinal rim, disc and cup areas and cup-to-disc ratios) and RNFL thickness (global and quadrants) were taken by a single experienced operator using optical coherence tomography (OCT). RESULTS: Of the rim parameters analysed, average nerve width (the height of the nerve fibre bundle) was independent of age or disc area (p > 0.05). Disc area correlated positively with cup area (p < 0.05) but not with cup-to-disc ratios (p > 0.05). Of the RNFL thickness measurements analysed, temporal RNFL was independent of both age and disc area (p > 0.05). According to the analysis of the correlation between RNFL thickness and neuroretinal rim, global or non-temporal RNFL correlated positively with horizontal integrated rim width (p < 0.05, F > 4.000) and temporal RNFL was independent of all rim parameters (p > 0.05, F < 4.000). CONCLUSION: Aging effect on neuroretinal rim loss or RNFL thickness change is non-uniform, and age is not a constant confounder when using OCT. The temporal RNFL is independent of age, disc area and neuroretinal rim.

Financial incentives and use of Cesarean delivery: Taiwan birth data 2003 to 2007.

OBJECTIVES: The Cesarean section (CS) rate in Taiwan has exceeded 30% since 2000. To lower the CS rate, the Bureau of National Health Insurance in Taiwan raised the payment for vaginal delivery (VD) in May 2005, and also increased the insured's copayment for elective CS in May 2006. This study clarifies the influences of these financial incentives, and explores whether the 2 policies lowered the CS rate. STUDY DESIGN: The materials used are birth cases obtained from a systematic sampling of the original inpatient claim data in the National Health Insurance research database between 2003 and 2007. The empirical analysis of this study groups the birth data into 4 types: VD, unplanned CS, planned CS, and elective CS. METHODS: The 4 delivery types represent the dependent variable. A multinomial logistic regression model was adopted as the empirical method. The policy changes, hospital attributes, and insured status were considered independent variables. RESULTS: Results indicate that the supply-side policy change in May 2005 reduced the number of CS cases. However, the policy effect was not very significant, and the CS rate decreased mainly because of planned CS cases. The demand-side policy change in May 2006 did not lower the rate of elective CS. CONCLUSIONS: The results imply that the financial incentives were not the main consideration for both the demand and supply sides. To encourage more VDs and lower the CS rate, the authorities could consider mechanisms other than adjusting the payment or changing the copayment.

An immunocompromised woman with severe molluscum contagiosum that responded well to topical imiquimod: a case report and literature review.

Molluscum contagiosum is a common condition that often occurs in children, sexually active young adults, and immunocompromised patients. Generally, molluscum contagiosum lesions are self-limited. They often resolve spontaneously. We report a severe case of genital molluscum contagiosum in a patient with Sjögren syndrome. Her vulvar lesions responded to topical 5% imiquimod cream.