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.

Effectiveness of Story-Centred Care Intervention Program in older persons living in long-term care facilities: A randomized, longitudinal study.

Depression is a common issue in institutionalized elderly people. The "Attentively Embracing Story" theory is applied to help individuals transform negative thoughts into positive, and reflect on spiritual healing. This study aimed to examine the effectiveness of a "Story-Centred Care Intervention Program" based on the "Attentively Embracing Story" theory in improving depressive symptoms, cognitive function, and heart rate variability in institutionalized elderly people. Seventy long-term care residents were recruited from two long-term care facilities and randomized into the story-centred care intervention (n = 35) and control groups (n = 35). We excluded five long-term care residents who did not complete the post-test measures and five long-term care residents who had interference events on the outcome measures. Finally, sixty long-term care residents (40 women and 20 men; age 84.3±5.98 years) were included in the final analysis. Data were collected at four times (pre-intervention and post-intervention, 1 and 3-month follow-up) and analyzed with the generalized estimating equation approach.Instruments, including Geriatric Depression Scale, Short Portable Mind Status Questionnaire, and a CheckMyHeart device to measure heart rate variability, were used in study. The degree of improvement in depressive symptoms was significantly higher in the story-centred care intervention group than in the control group after providing the story-centred care intervention program (p < .001) and at 1 and 3-month follow-up (p = .001, p = .006, respectively; GDS-15 score reduced 1.816 at the 3-month follow-up). Participants receiving the story-centred care intervention program showed significantly greater improvement than those in the control group in the cognitive function at 1and 3-month follow-up (p = .009, p = .024, respectively; SPMSQ score reduced 0.345 at the 3-month follow-up). The heart rate variability parameters (SDNN, RMSSD) did not show a statistically significant increase. However an increasing trend in the parameters was observed in the intervention group (SDNN increased 16.235ms at the 3-month follow-up; RMSSD increased 16.424 ms at the 3-month follow-up). In conclusions, the story-centred care intervention program was effective on the improvement of depressive symptoms and cognitive status in institutionalized elderly people.

Acute Respiratory Distress Syndrome in Patients Discharged From a Tertiary Hospital in Taiwan: Long-Term Survival and Prognostic Factors.

BACKGROUND: Acute respiratory distress syndrome (ARDS) carries significant morbidity and mortality. No previous studies have investigated the long-term outcomes of ARDS patients in Taiwan. OBJECTIVE: This study aimed to investigate the survival of ARDS patients after discharge from the hospital in Taiwan. METHODS: Medical records from 150 ARDS patients discharged alive from the intensive care unit from January 2004 to June 2009 were reviewed. Survival of these patients was followed for 5 years, and prognostic factors were identified. RESULTS: Cumulative survival rates were 81.4% at 6 months, 79.0% at 1 year, 67.2% at 2 years, and 45.7% at 5 years. Independent prognostic factors influencing both 1- and 5-year survival rates were age, previous lung disease, and disposition after discharge. For 5-year survival, renal disease was also an independent risk factor. DISCUSSION: The mortality rate of ARDS survivors after intensive care unit discharge is still high in Taiwan. Three independent risk factors were found to affect the overall survival of these patients.

Gender differences associated with pain characteristics and treatment in taiwanese oncology outpatients.

The purpose of this descriptive and comparative study was to examine gender differences relevant to pain intensity, opioid prescription patterns and opioid consumption in Taiwanese oncology outpatients. The 92 participants had been prescribed opioid analgesics for cancer-related pain at least once in the past week and were asked to complete the Brief Pain Inventory - Chinese questionnaire and to recall the dosage of each opioid analgesic that they had ingested within the previous 24 hours. For opioid prescriptions and consumption, all analgesics were converted to morphine equivalents. The results revealed a significant difference between males and female minimum pain thresholds (t = 2.38, p = 0.02) and current pain thresholds (t = 2.12, p = 0.04), with males reporting a higher intensity of pain than females. In addition, this study found that males tended to use prescribed opioid analgesics more frequently than females on the bases of both around the clock (ATC) (t = 1.90, p = 0.06) and ATC plus as needed (ATC + PRN) (t = 2.33, p = 0.02). However, there was no difference between males and females in opioid prescriptions on an ATC basis (t = 0.52, p = 0.60) or at an ATC + PRN basis (t = 0.40, p = 0.69). The results suggest that there may be a gender bias in the treatment of cancer pain, supporting the proposal of routine examination of the effect of gender on cancer pain management. These findings suggest that clinicians should be particularly aware of potential gender differences during pain monitoring and the consumption of prescribed opioid analgesics.

Contributions of diabetic macro-vascular complications and hip fracture to depression onset in elderly patients with diabetes: an 8-year population-based follow-up study.

OBJECTIVE: To prospectively examine the roles of diabetic macro-vascular complications and hip fracture in association with depression onset in Taiwan's elderly diabetic population. METHODS: A representative sample of elderly diabetic patients (n=144,216) identified in 2000 were linked to National Health Insurance claims (2000-2007) to ascertain the diagnoses of depression in both outpatient and inpatient settings. The person-year approach with Poisson assumption was used to estimate the hazard rates. Using Cox proportional hazard regression model, we evaluated the relative risk of depression in relation to diabetic macro-vascular complications and hip fracture. The additive effects from the above medical conditions were also assessed. RESULTS: The 8-year cumulative risk of depression was 5.08%, representing an incidence density of 8.40 per 1000 patient-years. Hazard ratio (HR) with 95% confidence interval (CI) for the elderly diabetes associated with cardiovascular disease (CVD), hip fracture, and lower extremity amputation was 1.13 (1.04-1.23), 1.10 (0.91-1.34), and 1.25 (0.95-1.65), respectively. Additionally, we found that the more the complications or hip fracture, the higher the risk of depression onset in elderly diabetes. CONCLUSION: The increased number of diabetic macro-vascular complications and hip fracture is significantly associated with a higher risk of depression onset in elderly diabetes. Future studies should be conducted to assess the feasibility and cost-effectiveness of intensive depression screening program in elderly diabetes suffering from macro-vascular complications and hip fracture.

Factors affecting trajectory patterns of self-rated health (SRH) in an older population--a community-based longitudinal study.

Self-rated health (SRH) is considered a relevant and important predictor for major health outcomes in the older population. SRH status may interact with certain factors and change over a person's lifetime. In this study, we sought to characterize profiles of older people over time by constructing prototypical trajectories of the variable of interest, namely SRH. The underlying assumption was that the collection of observed individual trajectories could be efficiently summarized by a smaller set of latent clusters of those trajectories. Data was obtained from the Longitudinal Survey of Health and Living Status of the Elderly in Taiwan, which was conducted between 1989 and 2003 and included five separate waves of survey. A total of 3937 subjects aged 60 or older (2251 males and 1686 females) comprised the major analytic cohort. Latent Class Growth Analysis (LCGA) was used to identify developmental classes of trajectory patterns in SRH. The results showed that during a 14-year period, SRH developed five major longitudinal trajectories. Less than one-third of the older population was able to maintain their formerly good or moderate health status; when change occurred, decline was more likely than improvement. In addition, LCGA indicated that many demographic characteristics, as well as physical and psychological propensities, were associated with poor SRH in the older population. Specifically, these factors played a role in involving baseline SRH level and its trend toward deterioration in later life. Health care professionals must understand the various longitudinal patterns and factors affecting SRH trajectories if they are to develop programs aimed at maintaining the older population's health and well-being.

Association of doctor specialty with diabetic patient risk of hospitalization due to diabetic ketoacidosis: a national population-based study in Taiwan.

OBJECTIVES: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus, and its risks can be largely reduced by adequate and high-quality ambulatory diabetic care. The aim of this study is to assess the risk and frequency of developing DKA in relation to the specialty of doctors who provide diabetes cares. METHODS: In searching for possible episodes of hospitalization due to DKA (ICD-9-CM: 250.1), we used a prospective cohort design in which 500,867 diabetic patients identified in the 1997 National Health Insurance (NHI) ambulatory care data set of Taiwan were linked to the 1997-2006 NHI inpatient claims data. The study subjects were categorized into four groups according to doctor specialty. A logistic regression model was used to assess the risk and frequency of DKA admission in relation to doctor's specialty. RESULTS: Compared with the patients routinely cared by endocrinologists, those not consistently cared by endocrinologists had significantly increased odds ratios (ORs) of DKA admission, ranging between 1.51 and 2.12. Moreover, the adjusted OR of the higher DKA admission frequency (≥ 0.133 times/person-year) for the patients not regularly cared by endocrinologists was also significantly increased, between 4.45 and 6.93. CONCLUSIONS: Doctor specialty significantly influenced the risk and frequency of DKA admission in diabetes patients in Taiwan. Local health care administrators and policy makers should therefore consider promoting the quality of diabetes care provided by non-endocrinologists.

Offspring birth weight and risk of mortality from diabetes in mothers.

BACKGROUND: Mothers with lower birth weight (LBW) offspring have been found to be associated with cardiovascular disease (CVD) morbidity, which shares many risk factors with diabetes. Aims To investigate the relation between offspring birth weight and maternal risk of mortality from diabetes. METHODS: A total of 1 400 383 singletons of primigravida registered in Taiwan between 1978 and 1987 were followed to the end of 2006. The offspring birth weight was assessed with and without standardisation for the gestational age of offspring. Cox model was used to estimate the HR of maternal diabetes mortality in relation to offspring birth weights. RESULTS: Altogether, 812 (5.8%) mothers died of diabetes. Mothers with LBW (<2500 g) and macrosomia (>4000 g) offspring were both at increased risks of mortality from diabetes with HR 1.76 (95% CI 1.46 to 2.19) and 2.86 (95% CI 2.32 to 3.53), respectively. Similar results were seen while birth weight was standardised for gestational age. CONCLUSIONS: This cohort study found that mothers with LBW and macrosomia offspring had an increased mortality risk of diabetes. This relationship could be attributable to the possible pathway of intergenerational effects or maternal insulin resistance due to maladaptation to pregnancy.

Predictors of psychiatric readmissions in the short- and long-term: a population-based study in Taiwan.

OBJECTIVES: To explore the risks and rates of readmission and their predictors 14 days, one year, and five years after discharge for the psychiatric population in Taiwan. METHODS: This was a prospective study based on claims from 44,237 first-time hospitalized psychiatric patients discharged in 2000, who were followed for up to five years after discharge. The cumulative incidence and incidence density of readmission were calculated for various follow-up periods after discharge, and Cox proportional hazard models were generated to identify the significant predictors for psychiatric readmission. RESULTS: The less than 14-day, one-year, and five-year cumulative incidences were estimated at 6.1%, 22.3%, and 37.8%, respectively. The corresponding figures for incidence density were 4.58, 1.04, and 0.69 per 1,000 person-days, respectively. Certain factors were significantly associated with increased risk of readmission irrespective of the length of follow-up, including male gender, length of hospital stay >15 days, economic poverty, a leading discharge diagnosis of schizophrenia/affective disorders, and residence in less-urbanized regions. Compared to children/adolescents, young adults (20-39 years) were significantly associated with increased risks of

The experiences among older Taiwanese women facing a new diagnosis of breast cancer.

BACKGROUND: Breast cancer is one of the most common types of cancer among women. Older women have differences in physical conditions and culture backgrounds compared with young age, which may influence their experiences in facing the diagnosis and treatment for breast cancer. OBJECTIVE: The objective of the study was to explore the experiences of older Taiwanese women when they first faced a new diagnosis of breast cancer. METHODS: A qualitative design was used. Fourteen women, aged 65 to 91 years, with a new diagnosis of breast cancer were interviewed within a month after they completed the first course of treatment at a cancer hospital in northern Taiwan. RESULTS: Content analysis of the interviews revealed 5 themes: the delay in seeking medical help, the impact caused by the initial diagnosis, facing the threat from cancer and its treatments, the battle against the illness, and living with breast cancer. CONCLUSION: Participants simultaneously faced physical discomfort, shock, denial, fear, worry, and hopelessness. Fortunately, despite these difficulties, they were encouraged to battle and live with breast cancer through the caring and support of family and by seeking information, searching for alternative therapies, practicing religion, readjusting their attitude to face the illness, getting back to a normal life, and appreciating the lives they have. IMPLICATIONS FOR PRACTICE: It is vital to assist older Taiwanese women to go to the physician earlier when they find something abnormal in their breast. Children, female relatives, and friends have important roles in helping them face the disease and treatment of breast cancer.

Incidence of and predictors for short-term readmission among preterm low-birthweight infants.

BACKGROUND: Readmission temporally close to discharge can best reflect the quality of care received in the last hospitalization, and has been considered a valuable indicator for the quality of care received. The aim of the present study was to investigate the incidence of and predictors for readmission within 31 days after discharge among preterm low-birthweight (PLBW) infants (ICD-9-code: 765.0x) in Taiwan. METHODS: Based on Taiwan's National Health Insurance claim data, a population-based cohort including a total of 18,421 PLBW infants born and hospitalized in 2000-02, was analyzed. The cumulative incidence rate (CIR) of readmission and the hazard ratio of readmission in relation to potential predictors were calculated. RESULTS: The total number of participants readmitted within 15 or 31 days after discharge was 1763 and 2484, representing a CIR of 9.6% and 13.5%, respectively. Significant predictors for readmission within 15 or 31 days were essentially similar. Male gender, weight <1000 g, presence of congenital abnormalities, and lung disease were significant risk factors for readmission. Shorter length of hospital stay (<35 days) was associated with a reduced risk of readmission, and there were significant geographic and hospital variations of readmission, with higher rates noted in the most urbanized area and at regional hospitals. CONCLUSION: The short-term readmission rate among Taiwanese PLBW infants is higher than in Western countries. Future studies should be conducted to investigate the causes of apparent geographic and hospital variations of readmission rates in order to make more specific interpretations.

Correlates of consequences of intergenerational caregiving in Taiwan.

AIM: This paper is a report of a study to test a theoretical model of factors related to consequences of intergenerational caregiving among Taiwanese caregivers of cognitively impaired ageing relatives. BACKGROUND: With the ageing of the population worldwide, care of elders has become a pressing issue. Intergenerational caregiving behaviours may reflect cultural values and beliefs, but create conflict for adult children between traditional obligations to ageing parents and the capacity to provide care. METHODS: Adult caregivers (n = 130) of cognitively impaired ageing relatives were recruited from three home care agencies in northern Taiwan between September 2003 and February 2004. Role and attachment theories were combined to extend the understanding of the consequences of intergenerational caregiving. RESULTS: Caregiving consequences (role strain and role reward) were not polar opposites on a unidimensional continuum. Caregiver role conflict and role performance had positive relationships with role strain, whereas caregiving resources and role expectation had an inverse relationship. For caregiver role reward, only role performance and secure-attached style were positively correlated. Role demand was not a statistically significant predictor of either role strain or role reward. Furthermore, secure-attached style explained additional variance in role strain and role reward. Moderating effects involving secure attachment with other predictors of role strain and role reward were supported. CONCLUSION: By incorporating role and attachment theories, our model gives a more complete view of intergenerational caregiving in an Asian culture. These findings may be applicable to other countries with Chinese populations.

Creating avenues for relative empowerment (CARE): a pilot test of an intervention to improve outcomes of hospitalized elders and family caregivers.

The purpose of this pilot study was to evaluate the effectiveness of a family caregiver-focused intervention program (CARE) on the outcomes of hospitalized elders and their family caregivers. A randomized clinical trial was conducted with 49 family caregivers of hospitalized elders in a university medical center in upstate New York. Driven by self-regulation and role theories, the two-phase CARE program consisted of: (a). a mutual agreement consisting of family caregiving activities during hospitalization; and (b). audiotaped information regarding emotional responses and possible complications associated with an elderly patient's hospitalization as well as instructions for effectively participating in the elder's hospital care. The comparison program consisted of information about hospital services and policies. CARE elders had fewer incidents of acute confusion reported by family caregivers during hospitalization and fewer depressive symptoms at 2 weeks and 2 months posthospitalization than did the comparison group. CARE family caregivers participated more in the care of their hospitalized elders and had higher scores on role rewards prior to hospital discharge. Findings from this study support the need for further testing of the CARE intervention with family caregivers to determine its effectiveness on outcomes of hospitalized elders and their family caregivers.