Incidence, life expectancy and prognostic factors in cancer patients under prolonged mechanical ventilation: a nationwide analysis of 5,138 cases during 1998-2007.

INTRODUCTION: This study is aimed at determining the incidence, survival rate, life expectancy, quality-adjusted life expectancy (QALE) and prognostic factors in patients with cancer in different organ systems undergoing prolonged mechanical ventilation (PMV). METHODS: We used data from the National Health Insurance Research Database of Taiwan from 1998 to 2007 and linked it with the National Mortality Registry to ascertain mortality. Subjects who received PMV, defined as having undergone mechanical ventilation continuously for longer than 21 days, were enrolled. The incidence of cancer patients requiring PMV was calculated, with the exception of patients with multiple cancers. The life expectancies and QALE of patients with different types of cancer were estimated. Quality-of-life data were taken from a sample of 142 patients who received PMV. A multivariable proportional hazards model was constructed to assess the effect of different prognostic factors, including age, gender, type of cancer, metastasis, comorbidities and hospital levels. RESULTS: Among 9,011 cancer patients receiving mechanical ventilation for more than 7 days, 5,138 undergoing PMV had a median survival of 1.37 months (interquartile range [IQR], 0.50 to 4.57) and a 1-yr survival rate of 14.3% (95% confidence interval [CI], 13.3% to 15.3%). The incidence of PMV was 10.4 per 100 ICU admissions. Head and neck cancer patients seemed to survive the longest. The overall life expectancy was 1.21 years, with estimated QALE ranging from 0.17 to 0.37 quality-adjusted life years for patients with poor and partial cognition, respectively. Cancer of liver (hazard ratio [HR], 1.55; 95% CI, 1.34 to 1.78), lung (HR, 1.45; 95% CI, 1.30 to 1.41) and metastasis (HR, 1.53; 95% CI, 1.42 to 1.65) were found to predict shorter survival independently. CONCLUSIONS: Cancer patients requiring PMV had poor long-term outcomes. Palliative care should be considered early in these patients, especially when metastasis has occurred.

Improved survival for an integrated system of reduced intensive respiratory care for patients requiring prolonged mechanical ventilation.

BACKGROUND: The introduction of reduced respiratory care may lead to worse long-term outcomes for patients undergoing prolonged mechanical ventilation (PMV) for more than 21 days. The objective of this study was to determine the survival for an integrated system of reduced intensive respiratory care (ISRIRC) by the Taiwan Bureau of National Health Insurance, in patients requiring PMV. METHODS: A 10-year retrospective study was performed in a 1,000-bed teaching hospital in Taiwan. A total of 633 consecutive PMV patients transferred from the hospital between 1998 and 2007 were enrolled. Medical records were reviewed to collect the clinical data, which were linked to the National Death Certification Database to ascertain subject survival. Kaplan-Meier estimates were performed, and a Cox proportional hazards model was constructed. We further conducted a corroboration study and retrieved a systematically randomized nationwide sample of PMV subjects with combined septicemia and shock, and compared the survival functions of those who were treated before and after the integrated system, including 228 and 2,677 subjects, respectively. RESULTS: The survival rates at 3 months, 6 months, and 1 year were 60.0%, 44.0%, and 30.0%, respectively. The 1-year survival rates of the subjects before and after ISRIRC were 21.0% and 37.2%, respectively (P = .04). The factors associated with better survival were younger age, absence of cirrhosis, and establishment of the ISRIRC. A comparison of the 4-year survival in the larger random sample of PMV subjects with combined septicemia and shock before and after ISRIRC also showed a significant improvement. CONCLUSIONS: With the improvement of PMV technology in the early 2000s, the establishment of ISRIRC seems to be associated with an improved survival rate for subjects under PMV.

The impact of dialysis-requiring acute kidney injury on long-term prognosis of patients requiring prolonged mechanical ventilation: nationwide population-based study.

BACKGROUND: Prolonged mechanical ventilation (PMV) is increasingly common worldwide, consuming enormous healthcare resources. Factors that modify PMV outcome are still obscure. METHODS: We selected patients without preceding mechanical ventilation within the one past year and who developed PMV during index admission in Taiwan's National Health Insurance (NHI) system during 1998-2007 for comparison of mortality and resource use. They were divided into three groups: (1) patients with end-stage renal diseases (ESRD) before the index admission for PMV onset; (2) patients with dialysis-requiring acute kidney injury (AKI-dialysis) during the hospitalization course; and (3) patients without AKI or with non dialysis-requiring AKI during the hospitalization course (non-AKI). We used a random-effects logistic regression model to identify factors associated with mortality. RESULTS: Compared with the other two groups, patients with AKI-dialysis had significantly longer mechanical ventilation, more frequent use of vasopressors, longer intensive care unit/hospital stay and higher inpatient expenditures during the index admission. Relative to non-AKI patients, patients with AKI-dialysis had an elevated mortality hazard; the adjusted relative risk ratios were 1.51 (95% confidence interval [CI]:1.46-1.56), 1.27 (95% CI: 1.23-1.32), and 1.10 (95% CI: 1.08-1.12) for mortality rates at discharge, 3 months, and 4 years after PMV, respectively. Patients with AKI-dialysis also consumed significantly higher total in-patient expenditure than the other two patient groups (p<0.001). CONCLUSIONS: Among patients that need PMV care during an admission, the presence of de novo AKI requiring dialysis significantly increased short and long term mortality, and demand for health care resources.

Cost per QALY (quality-adjusted life year) and lifetime cost of prolonged mechanical ventilation in Taiwan.

INTRODUCTION: Patients who require prolonged mechanical ventilation (PMV) are increasing and producing financial burdens worldwide. This study determines the cost per QALY (quality-adjusted life year), out-of-pocket expenses, and lifetime costs for PMV patients stratified by underlying diseases and cognition levels. METHODS: A nationwide sample of 50,481 patients with continual mechanical ventilation for more than 21 days was collected during 1997-2007. After stratifying the patients according to specific diagnoses, a latent class analysis (LCA) was performed to categorise PMV patients with multiple co-morbidities into several homogeneous groups. The survival functions were estimated for individual groups using the Kaplan-Meier method and extrapolated to 300 months through a semi-parametric method. The survival functions were adjusted using an EQ-5D utility value derived from a convenience sample of 142 PMV patients to estimate quality-adjusted life expectancies (QALE). Another convenience sample of 165 patients was used to estimate the out-of-pocket expenses. The lifetime expenditures paid by the single-payer National Health Insurance (NHI) system and patients' families were estimated by multiplying average monthly expenditures by the survival probabilities and summing the values over lifetime. RESULTS: PMV therapy costs more than 100,000 U.S. dollars (USD) per QALY for all patients with poor cognition. For patients with partial cognition, PMV therapy costs less than 56,000 USD per QALY for those with liver cirrhosis, intracranial or spinal cord injuries, and 57,000-69,000 USD for patients with multiple co-morbidities under age of 65. The average lifetime cost of PMV was usually below 56,000 USD. The out-of-pocket expenses were often more than one-third of the total cost of treatment. CONCLUSIONS: PMV treatment for patients with poor cognition would cost more than 5 times Taiwan's GDP (gross domestic products), or less cost-effective. The out-of-pocket expenses for PMV provision should also be considered in policy decision.

Idiopathic pulmonary fibrosis in Taiwan - a population-based study.

BACKGROUND: This study took advantage of a large population-based database of the Taiwan National Health Insurance (NHI) to investigate the epidemiology of idiopathic pulmonary fibrosis (IPF) in Taiwan. METHODS: This is a retrospective cohort study based on secondary analysis of prospectively collected data in the NHI system and governmental data on death registry in Taiwan during 1997-2007. By using the broad and narrow definitions for IPF, we estimated incidence and prevalence rates of IPF, and its associated clinical outcomes. RESULTS: The estimates of annual IPF incidence rates became more stable after 2000, ranging between 0.9 and 1.6 cases per 100,000 persons. The prevalence rates became more than twofold from 2000 to 2007 (from 2.8 to 6.4 cases per 100,000 persons for the broad definition, and from 2.0 to 4.9 cases per 100,000 persons for the narrow definition). Men of age older than 75 years had markedly higher incidence and prevalence rates than other groups. Around 40% of all incidences and about 30% of prevalent cases occurred in this population group. The median survival time after IPF diagnosis was 0.9 year (interquartile range (IQR), 0.2-2.5 years) and 0.7 year (IQR, 0.1-2.3 years) for the broad and narrow definitions, respectively. Progression of IPF was the leading cause of death, followed by cancer. CONCLUSIONS: In Taiwan, elderly men were the major group suffering from IPF. Survival time was short after IPF diagnosis, and the poor survival was largely attributable to quick IPF progression after diagnosis.

Outcomes of prolonged mechanic ventilation: a discrimination model based on longitudinal health insurance and death certificate data.

BACKGROUND: This study investigated prognosis among patients under prolonged mechanical ventilation (PMV) through exploring the following issues: (1) post-PMV survival rates, (2) factors associated with survival after PMV, and (3) the number of days alive free of hospital stays requiring mechanical ventilation (MV) care after PMV. METHODS: This is a retrospective cohort study based on secondary analysis of prospectively collected data in the national health insurance system and governmental data on death registry in Taiwan. It used data for a nationally representative sample of 25,482 patients becoming under PMV (> = 21 days) during 1998-2003. We calculated survival rates for the 4 years after PMV, and adopted logistic regression to construct prediction models for 3-month, 6-month, 1-year, and 2-year survival, with data of 1998-2002 for model estimation and the 2003 data for examination of model performance. We estimated the number of days alive free of hospital stays requiring MV care in the immediate 4-year period after PMV, and contrasted patients who had low survival probability with all PMV patients. RESULTS: Among these patients, the 3-month survival rate was 51.4%, and the 1-year survival rate was 31.9%. Common health conditions with significant associations with poor survival included neoplasm, acute and unspecific renal failure, chronic renal failure, non-alcoholic liver disease, shock and septicaemia (odd ratio < 0.7, p < 0.05). During a 4-year follow-up period for patients of year 2003, the mean number of days free of hospital stays requiring MV was 66.0 in those with a predicted 6-month survival rate < 10%, and 111.3 in those with a predicted 2-year survival rate < 10%. In contrast, the mean number of days was 256.9 in the whole sample of patients in 2003. CONCLUSIONS: Neoplasm, acute and unspecific renal failure, shock, chronic renal failure, septicemia, and non-alcoholic liver disease are significantly associated with lower survival among PMV patients. Patients with anticipated death in a near future tend to spend most of the rest of their life staying in hospital using MV services. This calls for further research into assessing PMV care need among patients at different prognosis stages of diseases listed above.

Life expectancies and incidence rates of patients under prolonged mechanical ventilation: a population-based study during 1998 to 2007 in Taiwan.

INTRODUCTION: The present study examined the median survival, life expectancies, and cumulative incidence rate (CIR) of patients undergoing prolonged mechanical ventilation (PMV) stratified by different underlying diseases. METHODS: According to the National Health Insurance Research Database of Taiwan, there were 8,906,406 individuals who obtained respiratory care during the period from 1997 to 2007. A random sample of this population was performed, and subjects who had continuously undergone mechanical ventilation for longer than 21 days were enrolled in the current study. Annual incidence rates and the CIR were calculated. After stratifying the patients according to their specific diagnoses, latent class analysis was performed to categorise PMV patients with multiple co-morbidities into several groups. The life expectancies of different groups were estimated using a semiparametric method with a hazard function based on the vital statistics of Taiwan. RESULTS: The analysis of 50,481 PMV patients revealed that incidence rates increased as patients grew older and that the CIR (17 to 85 years old) increased from 0.103 in 1998 to 0.183 in 2004 before stabilising thereafter. The life expectancies of PMV patients suffering from degenerative neurological diseases, stroke, or injuries tended to be longer than those with chronic renal failure or cancer. Patients with chronic obstructive pulmonary disease survived longer than did those co-morbid with other underlying diseases, especially septicaemia/shock. CONCLUSIONS: PMV provides a direct means to treat respiratory tract diseases and to sustain respiration in individuals suffering from degenerative neurological diseases, and individuals with either of these types of conditions respond better to PMV than do those with other co-morbidities. Future research is required to determine the cost-effectiveness of this treatment paradigm.

Poverty related risk for potentially preventable hospitalisations among children in Taiwan.

BACKGROUND: This study investigated the incidence of potentially preventable hospitalisations in the first two years of life among children in the National Health Insurance (NHI) system of Taiwan. It also examined income disparities in potentially preventable hospitalisations across four economic categories: below a government-established poverty line and low-, middle-, and upper-income. Five major diseases causing potentially preventable hospitalisations were investigated: gastroenteritis and dehydration, asthma and chronic bronchitis, acute upper respiratory infections, lower respiratory infections, and acute injuries and poisonings. METHODS: NHI data on enrolee registrations and use of ambulatory and hospital care by all children born between July 1, 2003 and June 30, 2004 (n = 218,158) was used for the study. The negative binomial regression method was used to identify factors associated with total inpatient care and the severity level for various types of potentially preventable hospitalisations during the first two years of life. RESULTS: This study found high inpatient expenses for lower respiratory infections for children in all income categories. Furthermore, results from the multivariate analysis indicate that children in the lowest economic category used inpatient care to a much greater extent than better-off children for problems considered potentially avoidable through primary prevention or through timely outpatient care. This was especially true for acute injuries and poisonings and for lower respiratory infections. On average, and controlling for other variables, a child in poverty spent 6.1 times more days in inpatient care for acute injuries and poisonings (p < 0.01) and 2.7 times more days for lower respiratory infections (p < 0.01) before age two, compared with a similarly-aged high-income child. The results also suggest a connection between economic status and the severity of a condition causing a potentially avoidable hospital admission. On average, length of stay for each admission for gastroenteritis and dehydration for children in poverty was 1.3 times that for high-income children (p < 0.01). Both the ratios for lower respiratory infections and for acute upper respiratory infections were 1.2 (p < 0.01 for both). CONCLUSIONS: There were high hospital admission rates and lengths of stays for lower respiratory infections among young children in all income categories. Hospital care use of young children in the poorest category was significantly higher for acute injuries and poisonings as well as for lower respiratory infections, compared with those of better-off children. The findings suggest the need for increased attention to these two disease types. It particularly calls for more research on the causes of high hospital care use for lower respiratory infections and on the reasons for large economic disparities in hospital care use for acute injuries and poisonings.

Imputed food insecurity as a predictor of disease and mental health in Taiwanese elementary school children.

This study investigated the association between food insecurity and Taiwanese children's ambulatory medical care use for treating eighteen disease types linked to endocrine and metabolic disorders, nutrition, immunity, infections, asthma, mental health, injury, and poisoning. We used longitudinal data in the Taiwan National Health Insurance scheme (NHI) for 764,526 elementary children, and employed approximate NHI data to construct three indicators imputed to food insecurity: low birth weight status, economic status (poverty versus non-poverty), and time of year (summer break time versus semester time). We compared ambulatory care for these diseases between children with low birth weight and those not, and between children living in poverty and those not. A difference-in-differences method was adopted to examine the potential for a publicly- funded lunch program to reduce the harmful health effects of food insecurity on poor children. We found that children in poverty were significantly more likely to have ambulatory visits linked with diabetes, inherited disorders of metabolism, iron deficiency anemias, ill-defined symptoms concerning nutrition, metabolism and development, as well as mental disorders. Children with low birth weight also had a significantly higher likelihood of using care for other endocrine disorders and nutritional deficiencies, in addition to the above diseases. The study failed to find any significant effect of the semester school lunch program on alleviating the harmful health effects of food insecurity for poor children, suggesting that a more intensive food program or other program approaches might be required to help poor children overcome food insecurity and its related health outcomes.