Risk factors associated with death in a 12-month cohort analysis of tuberculosis patients: 12-month follow-up after registration.

The aim of the study was to investigate the risk of death for 12 months follow-up after registration of tuberculosis (TB), using a nationwide population-based retrospective cohort study. A total of 33851 new TB cases were enrolled from 2006 to 2008. Of these, 5584 (16.5%) patients died during the follow-up period because of TB, and 4224 (12.5%) patients died because of other causes. Multivariate survival analysis revealed that age, HIV, chronic kidney disease, stroke, cancer, and chronic liver disease and cirrhosis were significant risk factors associated with death. Patients of age 0 to 64 years with HIV, chronic kidney disease, cancer, stroke, chronic liver disease and cirrhosis, or diabetes had a higher risk of death than those without these comorbidities. The majority of the TB patients in Taiwan died because of causes other than TB, and death often occurred in the first 2 months after TB registration. Therefore, medical care and case management for those with comorbidities are advised to prevent death during TB treatment.

Changes in causes of death and associated conditions among persons with HIV/AIDS after the introduction of highly active antiretroviral therapy in Taiwan.

To assess the pattern of change in the causes of death among HIV/AIDS patients in Taiwan after the introduction of highly active antiretroviral therapy (HAART), national HIV/AIDS registry data were linked with cause of death and health insurance claims data from 1994 to 2002 for analysis. Although HIV/AIDS remained the leading underlying cause of death among HIV/AIDS patients during the study period (552/752 = 73.4%), an increased proportion of deaths was due to non-HIV/AIDS causes (other infectious diseases, cancers, liver diseases, etc.) after the introduction of HAART in 1997. Deaths from suicide increased threefold, from three (1.5% of total) in 1994-1996 to 14 (4.8%) in 2000-2002. Most AIDS-related conditions associated with death (cryptococcosis, cachexia/wasting, dementia/encephalopathy, etc.) decreased in frequency from 1998-2000 to 2001-2002. Nonetheless, some AIDS-related conditions associated with death remained stable or increased in frequency, such as candidiasis, tuberculosis, and non-Hodgkin's lymphoma. In conclusion, as the duration of survival increased, the likelihood of suicide also increased. More effort is required to address the mental health of HIV/AIDS patients as a part of therapy.

Quality competition among hospitals: the effects of perceived quality and perceived expense on health care consumers.

Quality of care rather than price is the main concern in health care. However, does price not matter at all? To investigate what quality and cost factors influence whether patients perceive health care services as expensive and will recommend a hospital to other patients, the authors analyzed data from a national survey of patients in Taiwan in 2002. A total of 6725 subjects returned questionnaires. Results from logistic regression models showed that (1) a patient's perception of expense was determined simultaneously with the perceived quality and the out-of-pocket price of care, (2) a patient's perception of hospital quality appeared to be the most important determinant for recommending a hospital, and(3) while the out-of-pocket price did not affect a patient's recommendation, the perceived expense of the services did. The perceived value rather than the price itself-is the essence of quality competition in Taiwan's health care market.

Estimated prevalence of osteoporosis from a Nationwide Health Insurance database in Taiwan.

Approximately 9.24% of the Taiwanese population is aged 65 years or older. Among them, osteoporosis is a major problem, along with it associated age-related fractures. We investigated the prevalence of osteoporosis in 1996-2001 by sampling Taiwan's National Health Insurance (NHI) database. Data from 102,763 men (51.27%) and 97,654 women (48.73%) were evaluated. In this cohort, osteoporosis was recorded in each yearly dataset if the codes 733.0 or 733.00-733.09 were found on a search of the administrative or outpatient sub-databanks. A stable estimated prevalence of osteoporosis was calculated according to Taiwan's NHI sampling data from 1999 to 2001. The results showed a trend toward increasing proportions of coded osteoporosis with age, more predominantly in the female population. The averaged prevalence of osteoporosis, between 1999 and 2001, in those aged > or = 50 years was 1.63% for men and 11.35% for women. These estimates were lower than those reported elsewhere for Taiwan and for Japan but more equal to that in the Mexican American sub-population of the United States. In conclusion, the prevalence of osteoporosis is underestimated in the NHI database. Policymakers should be aware of this finding and allocate resources accordingly.

Health information system for community-based multiple screening in Keelung, Taiwan (Keelung Community-based Integrated Screening No. 3).

BACKGROUND: Community-based multiple screening for common cancers and chronic diseases has increasingly gained attention. However, as infrastructure and evaluation system are more diversified and complicated compared with single screening, the development of a novel health information system is paramount. METHODS: The main goal of our health information system was to support the multiple screening program not only from technical aspect but also from a broad range of perspectives including quality assurance system, organized features appertaining to screening, economic evaluation (cost-effectiveness or cost-utility analysis), epidemiological applications, behavior risk factor surveillance system, and social impact due to the introduction of the Keelung Community-Based Integrated Screening (KCIS) program. RESULTS: Health information system was designed and programmed on the basis of the demand derived from KCIS within which five cancers and three chronic diseases were included. In addition to the detailed description of infrastructure and process, design, relevant database and security involved in health information system, an innovative and extensive evaluation system in accordance with the main goals was included in our health information system. CONCLUSION: Our information system proposed several aspects regarding organized screening system that has never been addressed in computerized system supporting for single screening. These included quality assurance system, organization features, co-morbidity profiles, epidemiological applications and social and economic considerations.

Intussusception in Taiwanese children: analysis of incidence, length of hospitalization and hospital costs in different age groups.

BACKGROUND AND PURPOSE: This study investigated the characteristics of intussusception in Taiwanese children of different age groups, including the incidence, length of hospitalization and hospital costs. METHODS: Children with a diagnosis of intussusception who were hospitalized from 1999 through 2001 were identified from a nationwide health insurance claims database. The incidence of intussusception was calculated by age, gender, and season. Length of hospitalization and hospital costs were also analyzed. RESULTS: A total of 6988 cases of intussusception were identified in Taiwan from 1999 to 2001. Among them, 4859 cases occurred in children below 15 years of age. The average incidence among children below age 15 years was 34.5 per 100,000, with a peak incidence of 118.8 per 100,000 observed among children younger than 24 months old. The highest incidence of intussusception in Taiwanese children occurred between 12 and 24 months of age. According to the data for patients below 15 years of age hospitalized for intussusception in year 2000, males were more likely to be affected than females (61.3% vs 38.7%). Intussusception-related hospitalizations were rare in infants in the first few months of life, increased in those 6 to 12 months old, and peaked among children 1 to 3 years old. Among the 952 patients with intussusception admitted to hospitals in 2000, 297 (31.2%) received surgery, incurring higher median medical costs (New Taiwan Dollars [NT dollars] 42,265 or US dollars 1234) and longer median hospital stay (6.2 days) than the 655 patients who did not require surgery (NT dollars 6290 or US dollars 185 for hospitalization of 2.4 days). CONCLUSIONS: The study found that the incidence of intussusception peaked in the second year of life in Taiwanese children. There was also a male predominance and lack of seasonal variation in incidence.

Incidence of tuberculosis in mountain areas and surrounding townships: dose-response relationship by geographic analysis.

PURPOSE: The incidence of tuberculosis (TB) in Taiwan is known to be high in aboriginal mountain areas and low in the surrounding non-mountain areas. The aim of this study was to assess whether TB incident cases in the surroundings of mountain areas decreased with distance from foci of mountain areas. METHODS: The mountain areas in Taiwan are adjacent to each other and divided into four geographic groups. Townships with high TB incidence in each group were treated as the foci of TB infection. The surrounding townships were then classified, by distance away from foci, into three levels: < 20 km, 20 to 40 km, and 40 to 60 km. Data were obtained on a total of 84,366 TB cases from 1991 to 1997 from the Taiwan Tuberculous Disease Registry Center. RESULTS: The incidence of TB in each of the four groups was significantly higher in the mountain areas compared with non-mountain areas, with relative risks ranging from 8.4 (95% confidence interval [CI], 7.8-9.1) for the southern group to 15.0 (95% CI, 13.4-16.9) for the northern group. Relative risks for surrounding townships decreased with distance in all four groups. Such a gradient relationship was statistically significant. CONCLUSIONS: A significant dose-response relationship between distance from townships with a high incidence of TB and the incidence of TB in the surrounding areas has been demonstrated.

The immediate effects of the severe acute respiratory syndrome (SARS) epidemic on childbirth in Taiwan.

BACKGROUND: When an emerging infectious disease like severe acute respiratory syndrome (SARS) strikes suddenly, many wonder the public's overwhelming fears of SARS may deterred patients from seeking routine care from hospitals and/or interrupt patient's continuity of care. In this study, we sought to estimate the influence of pregnant women's fears of severe acute respiratory syndrome (SARS) on their choice of provider, mode of childbirth, and length of stay (LOS) for the delivery during and after the SARS epidemic in Taiwan. METHODS: The National Health Insurance data from January 01, 2002 to December 31, 2003 were used. A population-based descriptive analysis was conducted to assess the changes in volume, market share, cesarean rate, and average LOS for each of the 4 provider levels, before, during and after the SARS epidemic. RESULTS: Compared to the pre-SARS period, medical centers and regional hospitals dropped 5.2% and 4.1% in market share for childbirth services during the peak SARS period, while district hospitals and clinics increased 2.1% and 7.1%, respectively. For changes in cesarean rates, only a significantly larger increase was observed in medical centers (2.2%) during the peak SARS period. In terms of LOS, significant reductions in average LOS were observed in all hospital levels except for clinics. Average LOS was shortened by 0.21 days in medical centers (5.6%), 0.21 days in regional hospitals (5.8%), and 0.13 days in district hospitals (3.8%). CONCLUSION: The large amount of patients shifting from the maternity wards of more advanced hospitals to those of less advanced hospitals, coupled with the substantial reduction in their length of maternity stay due to their fears of SARS could also lead to serious concerns for quality of care, especially regarding a patient's accessibility to quality providers and continuity of care.

Computer-aided disease prediction system: development of application software with SAS component language.

AIMS: The intricacy of predictive models associated with prognosis and risk classification of disease often discourages medical personnel who are interested in this field. The aim of this study was therefore to develop a computer-aided disease prediction model underpinning a step-by-step statistics-guided approach including five components: (1) data management; (2) exploratory analysis; (3) type of predictive model; (4) model verification; (5) interactive mode of disease prediction using SAS 8.02 Windows 2000 as a platform. METHODS: The application of this system was illustrated by using data from the Swedish Two-County Trial on breast cancer screening. The effects of tumour size, node status, and histological grade on breast cancer death using logistic regression model or survival models were predicted. A total of 20 questions were designed to exemplify the usefulness of each component. We also evaluated the system using a controlled randomized trial. Times to finish the above 20 questions were used as endpoint to evaluate the performance of the current system. User satisfaction with the current system such as easy to use, the efficiency of risk prediction, and the reduction of barrier to predictive model was also evaluated. RESULTS: The intervention group not only performed more efficiently than the control group but also satisfied with this application software. CONCLUSIONS: The MD-DP-SOS system characterized by menu-driven style, comprehensiveness, accuracy and adequacy assessment, and interactive mode of disease prediction is helpful for medical personnel who are involved in disease prediction.

Antibiotic prescribing by ambulatory care physicians for adults with nasopharyngitis, URIs, and acute bronchitis in Taiwan: a multi-level modeling approach.

BACKGROUND: Imprudent prescribing of antibiotics in ambulatory care in Asia is of great concern. However, an adequate understanding of factors associated with antibiotic prescribing patterns in Asia has not been achieved. OBJECTIVE: Our aim was to identify patient and physician characteristics that influence antibiotic prescribing for adults with nasopharyngitis (common colds), upper respiratory tract infections (URIs) or bronchitis in Taiwan. METHODS: Generalized Estimating Equations (GEE) were used to analyze all 128,260 episodes of common colds, URIs and bronchitis generated by a random sample of 137,935 adult National Health Insurance (NHI) beneficiaries (> or = 18 years old) in Taiwan in 2000. RESULTS: Multivariate analysis results revealed substantial variations across different physician groups. Physician age and accreditation level of the physician's practice setting were the characteristics most associated with prescribing of antibiotics at the initial encounters for these episodes of care. Urban practising physicians (adjusted OR 1.69, 95% CI 1.29-2.21) and those who were self-dispensing or with on-site pharmacists (adjusted OR 1.32, 95% CI 1.19-1.46) were also higher prescribers of antibiotics for adults. Other significant physician predictors included physician specialty, patient volume, and ownership of practice setting. CONCLUSIONS: Results suggest that both accessibility to updated medical information and economic incentives of the attending physician may shape prescribing of antibiotics in ambulatory care in Taiwan. Interventions should be developed to influence these modifiable factors to reduce antibiotic prescriptions of questionable value.

Evaluating the comparability of different grouping schemes for mortality and morbidity.

Comparison of mortality and morbidity is a commonly used method in health related studies. The International Classification of Disease (ICD) consists of thousands of codes for classifying cause of death and disease categories. A grouping scheme is needed to cluster related categories into a meaningful and manageable number for comparative purposes. Different kinds of grouping schemes have been used; nevertheless, little is known about the comparability among different grouping schemes. In this study, we compared seven grouping schemes; five for mortality and two for morbidity. We found poor comparability between different grouping schemes. Different schemes covered different ranges of codes. Some schemes used the same title, but included different ranges of codes. Features of newly developed grouping schemes were to group disease categories of similar characteristics across traditional ICD chapters and to group disease categories based on health care needs, instead of those based merely on etiology or organ system. Different grouping schemes were developed to reveal the unique mortality and morbidity pattern of different geographical areas. Different grouping logic was used by different grouping schemes. Therefore, it is difficult to make a good comparison between different schemes. An investigator tabulating the mortality or morbidity figures based on a given grouping scheme should explicitly define the exact ICD codes included. Any user of data derived from different grouping schemes, especially for comparisons between countries, should be cautious about the comparability problems.

Prevalence and incidence of schizophrenia among national health insurance enrollees in Taiwan, 1996-2001.

As many as 96% of all residents of Taiwan have been enrolled in the National Health Insurance (NHI) program since 1996. The NHI database was used to examine the prevalence and incidence of schizoprenia. The National Health Research Institute provided a database of 200 432 random subjects, about 1% of the population, for study. By means of exclusion criteria, a random sample of 136 045 subjects as a fixed cohort dated from 1996-2001 was obtained. Those study subjects who had at least one service claim during these years for either ambulatory or inpatient care, with a principal diagnosis of schizophrenia, were identified. The cumulative prevalence increased from 3.34 per 1000 to 6.42 per 1000 from 1996 to 2001. The annual incidence density decreased from 0.95 per 1000/year to 0.45 per 1000/year from 1997 to 2001. Male subjects had higher treated prevalence in younger age groups than did female subjects. Higher prevalence was associated with the 25-44 and 45-64 age groups, insurance amount less than US$640, the eastern region, and suburban areas. Lower incidence was associated with the 45-64 age group. Higher incidence was associated with insurance amount less than US$640, and the eastern region. According to the trends of cumulative prevalence and incidence density, the treated prevalence and incidence rate will be approximate to community rates gradually. Most persons with schizophrenia had received treatment in Taiwan after the NHI program was implemented. Future studies should focus on outcome and cost evaluation.

Use of health care services and costs of psychiatric disorders among National Health Insurance enrollees in Taiwan.

The National Health Insurance (NHI) database in Taiwan was used to detect the use of health care services and the costs of psychiatric disorders among NHI enrollees. Data were analyzed for 126,146 enrollees. Four categories were used for enrollees: no psychiatric disorder, a minor psychiatric disorder, a major psychiatric disorder without catastrophic illness registration, and a major psychiatric disorder with catastrophic illness registration (which eliminates copayments). Compared with enrollees with a minor psychiatric disorder, those with a major psychiatric disorder, either with or without catastrophic illness registration, had higher use and costs of mental health care services. Compared with enrollees without a psychiatric disorder, those with a minor psychiatric disorder or a major psychiatric disorder without catastrophic illness registration had higher use and costs of non-mental health care services. Both the mental and general health care of persons with psychiatric disorders are important.

Who is at risk of death in an earthquake?

Although, theoretically, the impacts of a disaster are not randomly distributed across health and socioeconomic classes, empirical evidence of this claim is scarce. In a population-based cohort study, the authors identified risk factors for mortality from the September 21, 1999, Taiwan earthquake, which occurred in the middle of the night. Among 297,047 earthquake victims in central Taiwan who experienced partial or complete dwelling damage, 295,437 (noncases) survived the earthquake and 1,610 (cases) died between September 21 and October 31, 1999. Odds ratios were adjusted for both micro-level individual variables and macro-level neighborhood variables. People with mental disorders (odds ratio (OR) = 2.0, 95% confidence interval (CI): 1.1, 3.5), people with moderate physical disabilities (OR = 1.7, 95% CI: 1.2, 2.3), and people who had been hospitalized just prior to the earthquake (OR = 1.4, 95% CI: 1.2, 1.7) were the most vulnerable. The degree of vulnerability increased with decreasing monthly wage (measured in New Taiwanese dollars (NT$)) (NT$20,000 approximately NT$39,999: OR = 1.5, 95% CI: 1.1, 2.1;

Changes before and after a policy to restrict antimicrobial usage in upper respiratory infections in Taiwan.

The Bureau of National Health Insurance (BNHI) of Taiwan issued a new reimbursement regulation effective from 1 February 2001 forbidding the use of antimicrobials in ambulatory patients with upper respiratory infections (URI) without evidence of bacterial infection. We evaluated the effect of this regulation by analysing changes in the types of infections diagnosed and the amount of antibiotics prescribed in 1999, 2000 and 2001. Between 1999 and 2001, antimicrobials for respiratory infections decreased from 18.0 to 9.97 DDD/1000 per day or by 44.6% (P=0.0000+). Antimicrobials for URI decreased from 8.32 in 1999 to 3.28 DDD/1000 per day in 2001 or by 60.6% (P=0.0000+); from 2000 to 2001 the decrease was 55.8%. Reduction of antimicrobials for URI from 1999 to 2001 accounted for 62.8% of the reduction of antimicrobials in respiratory infections or 51.3% of the total reduction of antimicrobials. Reduction in aminopenicillins was responsible for most of the decrease.

Antimicrobial usage in ambulatory patients with respiratory infections in Taiwan, 2001.

BACKGROUND AND PURPOSE: Excess use of antimicrobials by ambulatory patients is a determinant of antimicrobial resistance. This study investigated the types of illnesses for which antimicrobials were prescribed and the amounts prescribed with special emphasis on respiratory infections for the year in which the Bureau of National Health Insurance (BNHI) enforced a policy to restrict antimicrobials for upper respiratory infections. The number of ambulatory patients seen and the types of ambulatory facilities in Taiwan were also described. METHODS: Raw data were obtained from the BNHI database on every 500 th visit in 2001. Medical diagnoses were categorized according to the ICD-9-CM system. Antimicrobial consumption was expressed in defined daily doses per 1000 population per day (DDD/1000/day). RESULTS: Among the population of 22.3 million in Taiwan, there were 285.8 million ambulatory patient visits (12.8 per person), including 108.9 million visits (4.9 per person) for respiratory infections, of which 62.7 million (2.8 per person) were for upper respiratory infections (URI). Antimicrobial consumption was 19.83 DDD/1000/day [standard error (SE), 0.00055], of which 9.97 DDD/1000/day (SE, 0.00047) were for respiratory infections and 4.03 DDD/1000/day (0.00055) were for URI. 23.6% of visits for URI entailed a prescription for antimicrobials. About two-thirds (66.5%) of ambulatory patients were seen in clinics, mostly private ones, and 67.6% of all antimicrobials were received there. Aminopenicillins and cephalosporins constituted 35.2% and 19.5%, respectively, of antimicrobials prescribed. CONCLUSIONS: Despite the new BNHI rule restricting antimicrobial usage for URI, Taiwan still has an excessive number of ambulatory patient visits, especially for respiratory infections and URI. The majority of antimicrobials used were for URI. They were mostly prescribed in private clinics rather than hospital outpatient departments.

The impact of the SARS epidemic on the utilization of medical services: SARS and the fear of SARS.

Using interrupted time-series analysis and National Health Insurance data between January 2000 and August 2003, this study assessed the impacts of the severe acute respiratory syndrome (SARS) epidemic on medical service utilization in Taiwan. At the peak of the SARS epidemic, significant reductions in ambulatory care (23.9%), inpatient care (35.2%), and dental care (16.7%) were observed. People's fears of SARS appear to have had strong impacts on access to care. Adverse health outcomes resulting from accessibility barriers posed by the fear of SARS should not be overlooked.

Body temperature monitoring and SARS fever hotline, Taiwan.

In Taiwan, a temperature-monitoring campaign and hotline for severe acute respiratory syndrome (SARS) fever were implemented in June 2003. Among 1,966 calls, fever was recorded in 19% (n = 378); 18 persons at high risk for SARS were identified. In a cross-sectional telephone survey, 95% (n = 1,060) of households knew about the campaign and 7 households reported fever.

Impact of separating drug prescribing and dispensing on provider behaviour: Taiwan's experience.

In many Asian countries, physicians both prescribe and dispense drugs. This practice is hypothesized to have caused high drug expenditure and widespread prescription of antibiotics in Asia. Recently, Taiwan implemented the separation policy on an experimental basis. This paper's objective is to empirically evaluate the impact of Taiwan's reform to separate drug prescribing and dispensing on drug expenditure and total health expenditure. The research design consists of a pre/post comparison of the experimental with the control sites (difference-in-difference). Separation policy was implemented in Kaohsung and Taipei in March 1997, and expanded to Chia-yi and Taichung in March 1998. Changes in drug prescription behaviour before and after implementation in these two pairs of experimental cities were compared to Hsin-chu and Tainan (control), where separation policy was not implemented during the study period. To reduce resistance, providers in experimental sites were allowed to hire on-site pharmacists and dispense drugs through them if they chose to do so. Our study sample consists of all outpatient visits to clinics in the study sites between December 1996 and June 1998, with a total of 55.23 million claim records. The drug prescription rate, drug expenditure and total health expenditure per visit were the main outcome measures. We found that the probability of prescription and drug expenditure per visit were, respectively, 17-34% and 12-36% less among visits to clinics without on-site pharmacists, compared with the control sites. However, no difference in total health expenditure was found between these two types of visits. Hence, the separation policy could be effective in reducing drug expenditure and affecting prescription behaviour, but is less certain as a policy for reducing total health expenditure. We also found that the policy has practically no effect on clinics that have on-site pharmacists.

Outbreak of Stevens-Johnson syndrome/toxic epidermal necrolysis associated with mebendazole and metronidazole use among Filipino laborers in Taiwan.

OBJECTIVES: This study sought to identify the risk factors associated with an outbreak of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) among Filipino laborers in Taiwan. METHODS: Forty-six SJS/TEN patients were matched to 92 controls according to month of arrival in Taiwan, sex, and age. RESULTS: The odds ratio for development of SJS/TEN was 9.5 (95% confidence interval [CI] = 3.9, 23.9) among workers who had used both metronidazole and mebendazole sometime in the preceding 6 weeks. In addition, a gradient increase in the occurrence of SJS/TEN was found with an increasing level of exposure to metronidazole. CONCLUSIONS: This outbreak highlights the risk of SJS/TEN resulting from the use of both metronidazole and mebendazole and the need for control measures.