Comparison of Labor and Delivery Complications and Delivery Methods Between Physicians and White-Collar Workers.

To evaluate labor and delivery complications and delivery modes between physicians and white-collar workers in Taiwan, this retrospective population-based study used data from Taiwan's National Health Insurance Research Database. We compared 1530 physicians aged 25 to 50 years old who worked and had singleton births between 2007 and 2013 with 3060 white-collar workers matched by age groups, groups of monthly insured payroll-related premiums, previous cesarean delivery, perinatal history anemia, and gestational diabetes mellitus. The logistic regression models were used to assess the labor and delivery complications between the two groups. Multivariate analysis revealed that physicians had a significantly higher risk of placenta previa (odds ratio (OR) 1.35, 95% confidence interval (CI) 1.08-1.69) and other malpresentation (OR 1.86, 95% CI 1.45-2.39) than white-collar workers, whereas they had a significantly lower risk of placental abruption (OR 0.53, 95% CI 0.40-0.71), preterm delivery (OR 0.75, 95% CI 0.61-0.92), and premature rupture of membranes (OR 0.72, 95% CI 0.59-0.88). Increased risks of some adverse labor and delivery complications were observed among physicians, when compared to white-collar workers. These findings suggest that working women should take preventative action to manage occupational risks during pregnancy.

Reinforcement of Tobacco Control and Reduction in Medical Utilization for Asthma in Taiwan: A Population-Based Study.

Environmental air quality can affect asthma control and the development of overt asthmatic manifestations. In this population-based study, we investigated the effect of reinforcing a smoking ban in Taiwan through the enactment of the Tobacco Hazards and Prevention Act (THPA) on healthcare utilization rate by asthmatics. Analysis was performed based on data relevant to non-hospitalized asthmatic patients with insurance claims between 2005 and 2013 from the National Health Insurance Research Database of Taiwan, reported data on Asian dust storms, and penalty rates for violations of the tobacco ban. Poisson regression showed that the risk for outpatient visits for asthma was lower after enactment of the THPA (RR = 0.98, 95% CI = 0.98-0.99), with a yearly trend of a reduced risk (RR = 0.99, 95% CI = 0.99-1.00), also lower in geographic regions with medium (RR = 0.79, 95% CI = 0.79-0.80) and high (RR = 0.91, 95% CI = 0.91-0.92) penalty rates. Subgroup analysis showed that asthma visit rates were reduced in both male and female groups after the enactment of the THPA. The risk of an asthma ER visit was increased after the enactment of the amended THPA (RR = 1.07, 95% CI = 1.05-1.09), although the yearly trend was not significant (RR = 1.00, 95% CI = 1.00-1.00). The risk of emergency room visits for asthma was significantly reduced in regions with medium (RR = 0.68, 95% CI = 0.68-0.69) and high (RR = 0.75, 95% CI = 0.74-0.76) penalty rates. Subgroup analysis showed that the visit rates were similar in both male and female groups. The effectiveness of reinforcing the smoking ban warrants further policies aimed at further reducing passive smoking.

Spatial vulnerability under extreme events: a case of Asian dust storm's effects on children's respiratory health.

Asian dust storm (ADS) events have raised concerns regarding their adverse impact on human health. Whether ADS events can result in the heterogeneity of health impacts on children across space and time has not been studied. The goal of this study is to examine the spatial vulnerability impact of ADS events on children's respiratory health geographically and to analyze any patterns related to ADS episodes. From 1998 to 2007, data from both preschool children's and schoolchildren's daily respiratory clinic visits, gathered from patients located in 41 districts of Taipei City and New Taipei City, are analyzed in a Bayesian spatiotemporal model in order to investigate the interaction between spatial effects and ADS episodes. When adjusting for the temporal effect, air pollutants, and temperature, the spatial pattern explicitly varies during defined study periods: non-ADS periods, ADS periods, and post-ADS periods. Compared to non-ADS periods, the relative rate of children's respiratory clinic visits significantly reduced 0.74 to 0.99 times in most districts during ADS periods, while the relative rate rose from 1.01 to 1.11 times in more than half of districts during post-ADS periods, especially in schoolchildren. This spatial vulnerability denotes that the significantly increased relative rate of respiratory clinic visits during post-ADS periods is primarily located in highly urbanized areas for both children's populations. Hence, the results of this study suggest that schoolchildren are particularly more vulnerable to the health impacts of ADS exposure in terms of higher excessive risks over a larger spatial extent than preschool children, especially during post-ADS periods.

Redistributive effects of the National Health Insurance on physicians in Taiwan: a natural experiment time series study.

BACKGROUND: Previous studies have evaluated the effects of various health manpower policies but did not include full consideration of the effect of universal health insurance on physician re-distribution. This study examines the effects of implementing National Health Insurance (NHI) on the problem of geographic mal-distribution of health providers in Taiwan. METHODS: Data on health providers and population between 1971 and 2001 are obtained from relevant governmental publications in Taiwan. Gini coefficients derived from the Lorenz curve are used under a spline regression model to examine the impact of the NHI on the geographic distribution of health providers. RESULTS: The geographic distribution equality of the three key health providers has improved significantly after the implementation of NHI program. After accounting for the influences of other confounding factors, Gini coefficients of the three key providers have a net reduction of 1.248% for dentists, 0.365% for western medicine physicians, and 0.311% for Chinese medicine physicians. Overall, the absolute values of the three key providers' Gini coefficients also become close to one another. CONCLUSIONS: This study found that NHI's offering universal health coverage to all citizens and with proper financial incentives have resulted in more equal geographic distributions among the key health care providers in Taiwan.

Asian dust storm elevates children's respiratory health risks: a spatiotemporal analysis of children's clinic visits across Taipei (Taiwan).

Concerns have been raised about the adverse impact of Asian dust storms (ADS) on human health; however, few studies have examined the effect of these events on children's health. Using databases from the Taiwan National Health Insurance and Taiwan Environmental Protection Agency, this study investigates the documented daily visits of children to respiratory clinics during and after ADS that occurred from 1997 to 2007 among 12 districts across Taipei City by applying a Bayesian structural additive regressive model controlled for spatial and temporal patterns. This study finds that the significantly impact of elevated children's respiratory clinic visits happened after ADS. Five of the seven lagged days had increasing percentages of relative rate, which was consecutively elevated from a 2-day to a 5-day lag by 0.63%∼2.19% for preschool children (i.e., 0∼6 years of age) and 0.72%∼3.17% for school children (i.e., 7∼14 years of age). The spatial pattern of clinic visits indicated that geographical heterogeneity was possibly associated with the clinic's location and accessibility. Moreover, day-of-week effects were elevated on Monday, Friday, and Saturday. We concluded that ADS may significantly increase the risks of respiratory diseases consecutively in the week after exposure, especially in school children.

Estimated effects of Asian dust storms on spatiotemporal distributions of clinic visits for respiratory diseases in Taipei children (Taiwan).

BACKGROUND: Increases in certain cause-specific hospital admissions have been reported during Asian dust storms (ADS), which primarily originate from north and northwest China during winter and spring. However, few studies have investigated the relationship between the ADS and clinic visits for respiratory diseases in children. OBJECTIVE: We investigated the general impact to children's health across space and time by analyzing daily clinic visits for respiratory diseases among preschool and schoolchildren registered in 12 districts of Taipei City during 1997-2007 from the National Health Insurance dataset. METHODS: We applied a structural additive regression model to estimate the association between ADS episodes and children's clinic visits for respiratory diseases, controlling for space and time variations. RESULTS: Compared with weeks before ADS events, the rate of clinic visits during weeks after ADS events increased 2.54% (95% credible interval = 2.43, 2.66) for preschool children (≤ 6 years of age) and 5.03% (95% credible interval = 4.87, 5.20) for schoolchildren (7-14 years of age). Spatial heterogeneity in relative rates of clinic visits was also identified. Compared with the mean level of Taipei City, higher relative rates appeared in districts with or near large hospitals and medical centers. CONCLUSION: To our knowledge, this is the first population-based study to assess the impact of ADS on children's respiratory health. Our analysis suggests that children's respiratory health was affected by ADS events across all of Taipei, especially among schoolchildren.

Cultural implications of differing rates of medically indicated and elective cesarean deliveries for foreign-born versus native-born taiwanese mothers.

The study aimed to assess the number of medically indicated and elective cesarean deliveries among foreign-born and native-born mothers in Taiwan. National Health Insurance (NHI) inpatient datasets in Taiwan between 2001 and 2003 showed 673,830 singleton deliveries, of which 66,687 were to foreign-born mothers and 607,143 were to Taiwan-born mothers. Univariate and multivariate logistic regression models were used to estimate the likelihood of using inpatient services for medically indicated and elective cesarean delivery. During the study period, foreign-born mothers were significantly less likely to undergo medically indicated (odds ratio [OR], 0.82; 95% confidence interval (95% CI), 0.79-0.85) and elective (OR, 0.50; 95% CI, 0.47-0.53) cesarean delivery than Taiwan-born mothers after adjusting for clinical and nonclinical factors. Foreign-born mothers aged 18-50 years are less likely to undergo medically indicated and elective cesarean delivery under Taiwan's NHI coverage. As the birth rate for immigrant women increases, cross-cultural maternity care during pregnancy and childbirth for immigrant mothers needs to be addressed.

Offspring birth weight and parental cardiovascular mortality.

BACKGROUND: Mothers bearing small offspring are at increased risk of cardiovascular disease (CVD) mortality. The cardiovascular risk for fathers of small offspring is, however, inconclusive. Very few studies with sufficiently large sample sizes have been conducted to specifically differentiate the maternal/paternal CVD risk in association with offspring birth weight in the same population. METHODS: This study followed 1,400,383 primigravida and their spouses with singleton births registered in Taiwan between 1978 and 1987 to the end of 2006. By linking to the mortality registry, the hazards ratio (HR) of parental cardiovascular mortality was measured in relation to lower offspring birth weights. RESULTS: The covariate-adjusted HR and 95% confidence interval (CI) of CVD mortality for 1 standard deviation higher offspring birth weight was reduced (HR = 0.89; 95% CI: 0.85-0.94) for mothers, but less obvious for fathers (HR = 0.97; 95% CI: 0.95-1.00). Analyses of the categorical offspring birth weights revealed that the association between bearing low-birth-weight offspring (<2500 g) and CVD mortality was also stronger in mothers (adjusted HR = 1.85; 95% CI: 1.67-2.18) than in fathers (adjusted HR = 1.13; 95% CI: 1.03-1.24). On standardizing the birth weight for gestational age, the observed associations persisted, although these associations were relatively weak. CONCLUSIONS: This large cohort analysis confirmed that the bearing of smaller size infants is associated with a stronger elevated risk for CVD mortality in mothers than in fathers. Women who have had a lower birth-weight offspring can be targeted for CVD-prevention measures.

Incidence of ambulatory care visits among female nursing staff in Taiwan: a claim data-based retrospective cohort analysis.

AIMS: To investigate the incidence of ambulatory care visits among female nursing staff in Taiwan. BACKGROUND: Literature frequently indicates increased risks of needlestick injury and musculoskeletal disorders among practicing nurses. With increased workload in the healthcare system, nursing staff could also be vulnerable to other diseases. DESIGN: A retrospective cohort study design including 27,624 female nursing staff with a contract with Taiwan's National Health Insurance (NHI) programme between 2001-2004. METHODS: Information on ambulatory care visits was retrieved from the NHI claim data. Comparison groups included other female medical personnel and active non-medical working women. Incidence rates of ambulatory care visits were calculated using person-year approach. Rate ratio adjusted for potential confounders was estimated from the Poisson regression model. RESULTS: The nurse cohort developed a total of 781,352 ambulatory care visits, representing an incidence rate of 85,285/10(4) person-years. Compared with the other female medical personnel, female nurses had significantly elevated incidence of genitourinary [adjusted rate ratio (ARR) = 1.20], circulatory (ARR = 1.14), mental (ARR = 1.12), infectious/parasitic diseases (ARR = 1.11) and pregnancy/birth complications (ARR = 1.07). Significantly increased incidence sustained for both infectious/parasitic diseases and pregnancy/birth complications as the nurse cohort was compared with the active non-medical working women. The nurses, on the contrary, had significantly lower ARRs than the comparison groups of neoplasm, injury, metabolic, respiratory, digestive and musculoskeletal diseases. CONCLUSIONS: Female nurses had increased incidences of certain types of systemic illness when compared with other medical personnel and with women working outside of the health industry. Whether the findings found in this study were region specific or could be applicable to other nations, requires further investigations. RELEVANCE TO CLINICAL PRACTICE: Policy makers and hospital administrators must not overlook nurses' potentially unseen health problems. A mandatory periodical physical examination for nursing staff must be considered.

Risks and causes of hospitalizations among physicians in Taiwan.

OBJECTIVES: To assess the causes and cause-specific risks of hospitalization among physicians in Taiwan. DATA SOURCE: The data used in this study were retrieved from filed claims and registries of the National Health Insurance Research Database. A cohort of 33,380 physicians contracted with the national insurance program between 1997 and 2002 were linked to the information on the inpatient claim data for hospitalization. STUDY DESIGN: The physicians' incidence density of hospitalization was compared with that of the general population, other health personnel, and nurses to compute the calendar year-, age-, and gender-standardized hospitalization ratios (SHRs). A multivariate log-linear model was also used to assess the effects of gender, age, type of contract, and specialty on the risks of hospitalization. PRINCIPAL FINDINGS: Compared with the general population, physicians experienced significantly reduced risks of all causes (SHR=54.5, 95 percent confidence interval [CI] 53.4-55.5) and all major cause-specific hospitalizations, especially mental disorders (SHR=6.9, 95 percent CI 5.8-8.4). On the other hand, compared with other health personnel, physicians had a small but significantly higher risk of all causes of hospitalization (SHR=107.8, 95 percent CI 105.1-110.6). Higher risks of hospitalization were also noted for neoplasms (SHR=108.9, 95 percent CI 102.0-116.3) and diseases of the respiratory system (SHR=114.2, 95 percent CI 107.3-121.5). In addition to the above diagnoses, physicians also had significantly higher risks for genitourinary and musculoskeletal system and connective tissue problems than nurses. Compared with their physician colleagues, female physicians, young (<30 years) and older (> or =60 years) physicians, and those working with the health institutions and programs were at elevated risks of hospitalization for all causes as well as for certain specific diseases. CONCLUSIONS: Physicians in Taiwan are at higher risks of developing specific diseases compared with their allied health colleagues. As the health of physicians is vital to the quality of care, Taiwanese health policy analysts should recognize that increased patient volume and satisfaction with public health care should not be achieved at the expense of physicians' health.

Belief in ghost month can help prevent drowning deaths: a natural experiment on the effects of cultural beliefs on risky behaviours.

Studies have suggested that cultural beliefs, such as those underlying religious social occasions and superstitions, have both positive and negative effects on mortality rates. Many people in Southern China believe that there are wandering ghosts who were released from hell during the lunar month of July (ghost month: mostly August in the Gregorian calendar): people therefore avoid unnecessary risky activities during ghost month. The aim of this study was to examine whether unintentional drowning deaths decreased during ghost month, using a matched control design and mortality data of Taiwan between 1981 and 2005. Results show that overall days-adjusted monthly death rate in ghost month days in Gregorian August was 1.37 (per 1,000,000). This was significantly lower than those in non-ghost month days, which was 1.67. The mean number of deaths in ghost months was lower than that in the matched controls, which was -3.2 deaths (-2.6 to -3.5) during weekends and -4.5 deaths (-2.2 to -7.2) during weekdays. The differences were more prominent in men than in women. For other main causes of death, we did not find persistent significant differences throughout the four matched controls. In conclusion, our findings support the death-dip hypothesis. Possible mechanisms are that people who believe in the ghost month might either decrease their exposure to water-related activities or involve themselves less in risky behaviours during ghost month, as a kind of risk compensation, consequently resulting in a reduction in the number of drowning deaths. As such we conclude that cultural factors should be taken into consideration when designing injury prevention programs.

Relationship between ambient air pollution and hospital admissions for cardiovascular diseases in kaohsiung, taiwan.

This study was undertaken to determine whether there is an association between air pollutants levels and increased number of hospital admissions for cardiovascular diseases (CVD) in Kaohsiung, Taiwan. Hospital admissions records for CVD and ambient air contaminant data collected from monitoring station in Kaohsiung were obtained for the period 1997-2000. The relative risk of hospital admission for CVD was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant model, on warm days (> or =25 degrees C) statistically significant positive associations were found between levels of particular matter of < 10 microm aerodynamic diameter (PM10), nitrogen dioxide (NO2), carbon monoxide (CO), and ozone (O3). On cool days (< 25 degrees C), all pollutants except O3 were significantly associated with increased CVD admissions. For the two-pollutant model, CO and O3 were both significant in combination with each of the other four contaminants on warm days. PM10 and NO2 remained significantly associated with elevated CVD admissions on warm days. On cool days, CO and NO2 remained statistically significant in all the two-pollutant models. This study provides evidence that higher levels of ambient contaminants, particularly CO, increase the risk of increased hospital admissions for CVD.