Characteristics of Frequent Attenders Compared with Non-Frequent Attenders in Primary Care: Study of Remote Communities in Taiwan.

Frequent attenders (FAs) have an impact on the medical resources and the quality of care. In Taiwan, the characteristics of FAs remain unclear in primary care. Outpatient data were screened from a central clinic within six surrounding fishing villages in northeastern Taiwan in 2017. FAs were defined as those who made >18 visits in one year, and those who made ≤18 visits were defined as non-frequent attenders (NFAs). Data of FAs and NFAs were collected and compared. The major diagnoses were reported using International Classifications of Diseases, Tenth Edition (ICD-10) codes. A total of 1586 subjects and 9077 visits were enrolled, including 119 FAs and 1467 NFAs. FAs had a more advanced age compared to NFAs. Both FAs and NFAs had more visits in summer. FAs had consumed high prescriptions and related costs. FAs also had higher therapeutic and first visit costs than NFAs. Comparing with age- sex-matched NFAs, FAs were positively associated with musculoskeletal diseases (M00-M99), hematological diseases (D50-D89), endocrine diseases (E00-E90), and mental disorders (F00-F99). Large-scale local datasets and suitable definitions of FAs for Taiwanese subjects are needed.

The Primary Care of Immigrant Workers and Their Associated Characteristics within A Taiwanese Fishing Community.

In Taiwan, immigrant workers play an important role in fisheries but they are easily ignored by society. The health problems and associated characteristics of immigrant workers in fisheries remain unclear. Descriptive and retrospective analyses were performed. Outpatient data were collected from a primary care clinic for six fishing villages in North Eastern Taiwan between 1 August 2016 and 31 July 2017. The data of immigrant workers was recorded and compared with that of natives. A total of 241 immigrant workers and 1342 natives were enrolled. Compared with the natives, the immigrant workers had a significantly younger age, male predominance, and fewer mean visits per year. The immigrant worker's visits tended to be more highly focused during the third quarter of the year. Immigrant workers paid more registration fees and self-payment, but they paid less on diagnosis fees, oral medication, laboratory exams and had reduced total costs. The top five diagnoses for immigrant workers were respiratory diseases (38.3%), trauma (15.2%), musculoskeletal diseases (11.2%), skin-related diseases (9.5%), and digestive diseases (9.1%). Immigrant workers were positively correlated with infectious/parasitic diseases, and negatively correlated with medical consults and endocrine/metabolic diseases. Immigrant workers were also positively associated with registration fees and self-payment, but negatively correlated with diagnosis fees and total costs (all p < 0.05). The distribution of skin diseases and trauma were affected by age and sex as opposed to ethnic group. Immigrant status' health issues should be given more attention.

The Impact of Hemodialysis on Terminal Cancer Patients in Hospices: A Nationwide Retrospective Study in Taiwan.

OBJECTIVE: Hemodialysis (HD) is the most common renal replacement therapy for patients with end-stage renal disease in Taiwan. The use of HD in hospice care and its impact on terminal cancer patients remains unclear. METHODS: Using claim data from the Taiwan National Health Insurance Research Database, all patients who died from cancer and claim data of their terminal admissions in hospice from 2007 to 2010. Those with a comorbid diagnosis of renal failure or who had health insurance claims data for HD were enrolled. RESULTS: A total of 5482 subjects were identified, of whom 4484 received HD and 998 did not. The HD group was significantly correlated with a younger age and high costs of terminal hospice admission. After adjusting for age and gender, the HD group was positively associated with a long hospice stay, in-hospice death, bone/connective tissue/breast cancers, and secondary/metastatic cancers, but negatively associated with genitourinary cancer. Compared with Department of Health/municipal hospitals, patients at both national and private university-affiliated hospitals were less likely to undergo HD. CONCLUSIONS: For terminal cancer patients under hospice care, HD was associated with a younger age, long terminal hospice stay, and high medical costs. Some types of cancers were associated with HD. University-affiliated hospitals played significant roles in non-HD renal supportive care. In-hospice HD is still common in Taiwan. Dialysis withdrawal and alternative care have space to promoting in hospice care.

Place of death for hospice-cared terminal patients with cancer: A nationwide retrospective study in Taiwan.

BACKGROUND: Hospice care has been part of the Taiwan health-care system for 20 years. Detailed information on the place of death for terminal cancer patients is lacking. Impending death discharge (IDD) is unique in Taiwan, and our study aims to compare IDD with in-hospice death among terminal cancer patients under hospice care. METHODS: This retrospective study used claims data of decedents of cancer from the National Health Insurance Research Database of Taiwan from 2007 to 2010. RESULTS: Of the 22,720 cancer decedents enrolled, 6316 had claims data marked with IDD and 16,404 with in-hospice death. Those with IDD were older; had a shorter hospice stay; and higher rates of gastrointestinal, peritoneal, and pulmonary cancers. The mean daily health-care expenditure was higher in those with IDD, however, the total expenditure of terminal hospice admission was lower than those dying in hospices. Patients who were treated at public hospitals had a higher rate of in-hospice death than those treated at private hospitals. Patients with IDD were positively correlated with increasing age and shorter hospice stay. Patients with IDD were positively correlated with private hospitals, especially religious corporation-based hospitals. Male sex, oropharyngeal cancer, bone/connective/breast cancers, and secondary/metastatic cancers were negatively correlated with IDD. CONCLUSION: Patients with IDD have characteristics distinct from those dying in hospices. Advanced age and short hospice stays were common in those with IDD, and in-depth investigations were needed. As a unique predying process in Taiwan, relevant health-care issues regarding IDD are warranted for further investigations.

Noncancer hospice care in taiwan: a nationwide dataset analysis from 2005 to 2010.

UNLABELLED: Abstract Background: The National Health Insurance program (NHI) in Taiwan has provided hospice services since 2000, and it was expanded to noncancer illnesses in September 2009. The issues of noncancer hospice care and the impact of the expanded hospice policy remain unclear. METHODS: Data were collected retrospectively from claims data of hospice admissions using the NHI Research Database of 2005-2010. RESULTS: A total of 359 noncancer subjects and 412 hospice admissions were enrolled; 1795 age- and gender-matched cancer patients and 2578 hospice admissions were selected as a comparison group. Noncancer hospice care increased markedly after the third quartile of 2009. The most common noncancer diagnosis was "other diseases of the lung" (23.9%). The noncancer subjects had a significantly lower frequency of admissions, lower Charlson Comorbidity Index (CCI) scores, shorter hospice stay, and higher mortality rate than the cancer subjects. Family physicians provided the majority of hospice services in both groups. Acute low respiratory conditions (ALRC) were the most common acute comorbidity in deceased subjects. The noncancer decedents had more ALRC, sepsis/bacteremia, nontraumatic shock, acute myocardial infarctions, and esophageal varicose bleeding than the comparison group. The mean inpatient charges differed insignificantly between both groups. The noncancer subjects correlated negatively with CCI (odds ratio [OR] 0.59 in all hospice admissions; 0.63 in decedents), but positively with a hospice stay ≤3 days, mortality, sepsis/bacteremia, ALRC, nontraumatic shock, and acute myocardial infarctions compared with the cancer subjects (OR 1.42, 1.98, 2.24, 2.36, 2.17, and 11.68, respectively, adjusted by CCI). CONCLUSIONS: The expanded palliative care policy has impacted positively on noncancer hospice care in Taiwan. The terminal noncancer patients had higher risks for short hospice stay, sepsis, nontraumatic shock, and respiratory and heart problems than the cancer subjects. Early referral to hospices is required for terminal patients in Taiwan. The CCI had a limited role for cost/severity evaluations of hospice care.

Investigations of the pediatric hospice care in Taiwan: 2005 to 2010.

BACKGROUND: The utilization of pediatric hospice care remains unclear in Taiwan. METHODS: Data were analyzed from the claims of hospice admissions in patients aged 18 years or younger using the National Health Insurance Research Database from 2005 to 2010. RESULTS: A total of 91 patients and 136 admissions were enrolled (male-female = 50:41; mean 11.6 years old). In all, 62 patients were admitted once, including 47 patients who died. All the patients had cancer, with brain cancer (40.7%) accounting the most . Among acute comorbidities, neurological complications (16.2%) were mostly accounted. Family physicians provided most (64.7%) of the hospice services. Hospice stay ≤3 days correlated positively with death in hospices (odds ratio = 2.922, 95% confidence interval = 1.268-6.730). CONCLUSIONS: Pediatric hospice care revealed characteristics different from adults. Underlying late referrals were prevalent. There is space to promote the utilization of hospices for terminally ill pediatric patients.

The utilization of hospice care among patients with motor neuron diseases: the experience in Taiwan from 2005 to 2010.

BACKGROUND: The nature and extent of how patients with motor neuron diseases (MNDs) utilize hospice care in Taiwan remains unclear. This study aims to investigate the use of hospice care in Taiwan by patients with MND, and those factors that affect the extent, the cost, and the quality of their hospice treatment and care. METHODS: We analyzed data from hospice care inpatient claims of MNDs, using the National Health Insurance Research Database of Taiwan during 2005-2010. RESULTS: Thirty patients and 58 related discharges were enrolled into our study, which consisted of 13 males and 17 females, with a mean age 58.3 years. Of that total, 27 of them (90%) had amyotrophic lateral sclerosis, and four (13.3%) had comorbid cancers; 17 died during hospice care. Acute low respiratory conditions (31.0%) accounted for the most common acute comorbidity. Noninvasive ventilation care was performed in only 13 (22.4%) of the discharges. In contrast to nasogastric intubation (40 discharges, 69.0%), no gastrostomy/jejunostomy was noted. These procedures bore no relationship to results observed in the discharges. Family physicians provided most inpatient hospice services (74.1%). Respiratory problems were the major causes of death (70.6% of decedents). The mean inpatient costs of hospice care were noticeably reduced from previously established nationwide mean costs. CONCLUSION: Hospice care can save costs for patients with terminal MNDs, and family physicians play a valuable role in caring for these patients. However, respiratory and feeding problems are prevalent, yet there are proven benefits when noninvasive ventilation care and gastrostomy/jejunostomy are promoted.

Characteristics of comorbidities and costs among patients who died from systemic lupus erythematosus in Taiwan.

INTRODUCTION: Systemic lupus erythematosus (SLE) is prevalent among young female adults, particularly in Asia. In Taiwan, features of end-of-life SLE patients remain unclear. MATERIAL AND METHODS: Data regarding SLE patients whose hospitalization ended up with death were collected and analyzed from the repository of the National Health Insurance Research Database, Taiwan, from 2005 to 2007. RESULTS: A total of 302 subjects were enrolled and the majority of these were young to middle-aged women (45.8 ±18.5 years); only one third of them were treated by rheumatologists. Eight patients (2.6%) with comorbid cancers received hospice care. Sepsis/bacteremia (42.1%) was the major acute comorbidity. Nephropathy/nephritis (35.1%) represented the major chronic comorbidity. Among 27 subjects with comorbid cancers, gynecological cancers were the most common (18%). Among the inpatient costs, the cost of prescriptions accounted for the majority (21.7 ±11.5%). Under a multivariate logistic regression, advanced age (≥ 65 years) correlated positively with acute lower respiratory conditions (ALRC) and diabetes mellitus (DM), and male gender correlated negatively with nephropathy/nephritis. The nephropathy/nephritis correlated positively with hospital stays > 14 days. The ALRC was closely associated with acute respiratory failure, but not with shock. However, shock was closely associated with hospital stays ≥ 14 days and sepsis/bacteremia. Cancer development was inversely correlated to nephropathy/nephritis, acute respiratory failure, and shock (all p < 0.05). CONCLUSIONS: The end-of-life SLE patients revealed aforementioned characteristics and relationships. Sepsis/bacteremia, acute respiratory failure, and ALRC contributed most frequently to the ultimate death of acutely ill SLE patients.

Impact of hospice care on end-of-life hospitalization of elderly patients with lung cancer in Taiwan.

BACKGROUND: This study investigated the impact of hospice care on end-of-life elderly patients with lung cancer in Taiwan. METHODS: Data were collected from deceased inpatients with lung cancer who were at least 65 years old, using the National Health Insurance Research Database of 2004. RESULTS: A total of 1282 patients were enrolled, of whom 277 (21.6%) received hospice care (hospice-care group) and the other 1005 (78.4%) received general acute ward care (control group). The patients' age, gender, and institution of hospitalization did not differ significantly between the two groups, and most of the patients had chosen medical centers and their affiliated hospices for terminal care. The hospice-care group had a significantly shorter hospital stay and lower costs of hospitalization than the control group, with patients cared for primarily by family physicians and radiation oncologists (all p<0.05). The hospice-care group had an elevated incidence of co-morbid diabetes mellitus, higher scores on the Charlson Comorbidity Index, fewer acute lower respiratory conditions, and fewer invasive procedures than the control group (all p<0.05). Natural opium alkaloids were the most commonly prescribed drugs in the hospice-care group, whereas parenteral solutions were most frequently requested in the control group. CONCLUSION: Hospice care has provided a humane and cost-efficient pathway for end-of-life elderly patients with lung cancer. Parenteral nutrition/hydration should be limited for terminal care patients. Opioids should be promoted for the relief of pain and dyspnea in acute ward care. Family physicians and radiation oncologists play important roles in hospice care. Compared with the prevalence of hospice care in the United Kingdom and other developed countries, hospice care in Taiwan is in the position to be expanded.

Impact of advanced age on inpatients with pyogenic liver abscess in Taiwan: a nationwide claim-based analysis.

BACKGROUND: Pyogenic liver abscess (PLA) is seen as an endemic disease in population of Taiwan. The impact of advanced age on inpatients with PLA remains unclear. METHODS: Data was collected and analyzed from claims of discharges by inpatients with PLA, using the National Health Insurance Research Database of 2007. RESULTS: A total of 2319 subjects and 2651 related discharges were enrolled, including 939 subjects/1077 discharges ≥65 years and 1380 subjects/1574 discharges <65 years. Subjects ≥65 years had significantly higher ratios of females to males, nephropathy, biliary tract diseases, liver cirrhosis and gastroenterological cancers than those <65 years. Hepatic/intra-hepatic duct cancers accounted for the most comorbid gastroenterological cancers. Discharged of subjects ≥65 years had longer hospital stays, more in-hospital death/critical discharge, and a higher ratio of acute low respiratory conditions (ALRC) and urological infections than those of subjects <65 years (p<0.05). The inpatient costs for subjects ≥65 years were significantly higher than those for subjects age<65 years in blood products, hemodialysis and total hospitalization. Co-morbidities, such as nephropathy, biliary tract diseases, liver cirrhosis, gastroenterological cancers, ALRC and urological infections were predictive variables associated with age ≥65 years in patients with PLA, as were being female and in-hospital death/critical discharge. Nephropathy and gastroenterological cancers were predictive variables associated with poor prognosis (in-hospital death/critical discharge) in both PLA patients age < and ≥65 years (p<0.05). Diabetes mellitus featured predominantly, but had no impact on distribution and prognosis. CONCLUSION: Advanced age (≥65 years) had an impact on the aforementioned characteristics and predictive variables in inpatients with PLA. Physicians should pay attention and treat aged PLA patients with greater care, especially those cares with comorbid nephropathy or gastroenterological cancers.

Characteristics of human immunodeficiency virus infections among the elderly in Taiwan: a nationwide study.

BACKGROUND: Information regarding human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS) in the elderly of Taiwan is limited. This study looked into the aforementioned issues. METHODS: Data from the National HIV/AIDS Registry, relating to individuals diagnosed in 2007, were analyzed. RESULTS: Among 1,975 HIV-infected individuals diagnosed in 2007, the elderly group (age ≧50 years) consisted of 153 subjects and the younger (control) group (age 15-39 years) consisted of 1,458 individuals. Some markers, such as primarily males/local Taiwanese, being unemployed, one third of subjects infected by means of intravenous drug use, and primarily diagnosed in hospitals, were similar between the two groups. The elderly group had more married, divorced, and separated individuals, and widows/widowers than the younger group. The causes of death differed insignificantly between the two groups. The younger group had more variety than the elderly group in distribution of occupations. Fewer prison-diagnosed HIV, high ratio of individuals developing AIDS, heterosexuals, high mortality, and unsupported marital status were significant markers of elderly HIV-infected subjects. CONCLUSION: In Taiwan, elderly HIV infections have reflected the aforementioned characteristics. Some specific issues concerning elderly HIV infections, such as heterosexual predominance, high mortality and fewer men who have sex with men, are similar with reports from other countries. These characteristics can guide possible directions of social and health care interventions.

The characteristics of acute pyelonephritis in geriatric patients: experiences in rural northeastern Taiwan.

Acute pyelonephritis causes hospitalization and is a commonly-ignored cause of death in geriatric patients. It has been well studied in young-adult populations but rarely in geriatric populations. The aim of our study was to analyze the characteristics of acute pyelonephritis in geriatric patients. The electronic admission records of a community hospital in northeastern Taiwan were retrospectively screened from July 1, 2003 to June 30, 2006. The basic characteristics, laboratory findings and infectious microorganisms of all subjects were evaluated. Sixty-five subjects (mean age 71.6 +/- 4.9 years; range 65-84 years) and 73 admission records contributed by them were enrolled. These 65 subjects, including one who died in hospital, were predominantly female (52 subjects; 80%). Twenty-two subjects (33.8%) had co-existing diabetes mellitus, 9 subjects (13.8%) had co-existing tumors, and 19 subjects (29.2%) had a history of intra-abdominal surgery. The admission records revealed right kidney involvement (52.1%), co-existing urolithiasis (50.7%) and admission to wards of internal medicine (57.5%). Urological procedures were performed on 20 (27.4%) of all 73 admission records. Escherichia coli was the most common infecting microorganism (19.2% of all records; 42.4% of records with positive microorganism culture). Hemoglobin < 10 g/dl was a significant predictive factor for both hospital stay > 7 days and serum creatinine > 2.0 mg/dl (p = 0.003 and 0.002, respectively). Positive microorganism culture was also a significant predictive factor for hospital stays > 7 days (p < 0.001). In our geriatric patients with acute pyelonephritis, low hemoglobin levels implied co-existing renal insufficiency and prolonged hospitalization. Positive microorganism culture also implied prolonged hospitalization.

Impact of urinary catheterization on geriatric inpatients with community-acquired urinary tract infections.

BACKGROUND: Urinary tract infections commonly cause hospitalizations in community-dwelling geriatric populations. Our aim was to understand the impact of urinary catheterization on geriatric inpatients with community-acquired urinary tract infections (CAUTIs). METHODS: Retrospective analyses were performed using electronic discharge summaries in a rural community hospital of northeastern Taiwan in 2004. We screened data with ICD-9-CM codes and performed chart reviews on inpatients aged >or= 65 years with CAUTIs. RESULTS: A total of 294 subjects who experienced CAUTIs were enrolled; 114 subjects had urinary catheterization and the other 180 did not. The mean frequency of admission was 1.2 times (range, 1-4 times); 251 subjects were admitted only once. We reviewed and enrolled 348 records of CAUTIs. Subjects with urinary catheterization showed significantly more advanced age, more female predominance, higher immobility ratio, and more frequent admissions than those without urinary catheterization (p < 0.05). Records of urinary catheterization showed that subjects had longer hospital stays, higher pathogen isolation after culture, and less comorbid pyelonephritis than subjects without urinary catheterization (p < 0.05). The distribution of infecting microorganisms differed insignificantly between the 2 groups (p = 0.077). Female gender, hospitalization > 2 times, age >or=75 years, immobility, hospital stay > 7 days, and low prevalence of comorbid pyelonephritis served as significant predictive variables for urinary catheterization in subjects with CAUTIs. CONCLUSION: For geriatric inpatients, urinary catheterization must be evaluated cautiously before being performed. The impact of urinary catheterization on the distribution of microorganisms in CAUTIs was shown to be insignificant.

Health-related quality of life and impact of antiviral treatment in Chinese patients with chronic hepatitis C in Taiwan.

AIM: To evaluate health-related quality of life (HRQOL) in Chinese patients with chronic hepatitis C (CH-C), and the impact of antiviral treatment. METHODS: Short Form 36 (SF-36) Health-related Quality of Life Questionnaires to interview CH-C patients, and age- and sex-matched control subjects at outpatient clinics of a medical center in Taiwan were used. Data were transformed to scores for comparisons of eight major SF-36 domains. We also enrolled consecutive CH-C patients who completed one course of antiviral treatment (interferon alpha with ribavirin), and measured the HRQOL before, at the 12th wk of treatment, at the end of treatment, and at mo 6, after stopping the treatment to evaluate the impact of antiviral treatment. RESULTS: A total of 371 outpatients were enrolled, including 182 with CH-C and 189 age- and sex-matched subjects without CH-C. CH-C subjects had obviously lower educational status (P<0.01). Mean scores of domains in general health, physical functioning, role-physical, role-emotional, vitality, and mental health of the SF-36 were significantly lower in subjects with CH-C than those without CH-C (P<0.05). In an analysis of 47 CH-C patients who received and completed the whole course of antiviral treatment, mean scores of all domains were significantly lower at wk 12 of treatment compared to baseline. The scores returned to pretreatment values by the end of treatment, but were significantly increased at mo 6 after stopping the treatment. Among the 47 CH-C patients, 21 had sustained responses and 26 had non-sustained responses to antiviral treatment. Compared to pretreatment values, subjects with sustained responses had significantly lower social functioning scores at wk 12 of treatment, and scores for all SF-36 domains returned to pretreatment values, and increased significantly at mo 6 after stopping the treatment. For non-sustained virological responders, scores of all SF-36 domains significantly decreased at wk 12 of treatment, and did not increase significantly by the end of treatment, or at mo 6 after stopping the treatment when compared to the pretreatment values. CONCLUSION: HRQOL in CH-C patients is significantly impaired in most SF-36 domains. Antiviral treatment impaired HRQOL of CH-C subjects during early treatment, mainly in non-sustained virological responders, and improved at mo 6 after stopping the treatment, mainly in sustained virological responders.