Physician Compliance With a Computerized Clinical Decision Support System for Anemia Management of Patients With End-stage Kidney Disease on Hemodialysis: Retrospective Electronic Health Record Observational Study.

BACKGROUND: Previous studies on clinical decision support systems (CDSSs) for the management of renal anemia in patients with end-stage kidney disease undergoing hemodialysis have previously focused solely on the effects of the CDSS. However, the role of physician compliance in the efficacy of the CDSS remains ill-defined. OBJECTIVE: We aimed to investigate whether physician compliance was an intermediate variable between the CDSS and the management outcomes of renal anemia. METHODS: We extracted the electronic health records of patients with end-stage kidney disease on hemodialysis at the Far Eastern Memorial Hospital Hemodialysis Center (FEMHHC) from 2016 to 2020. FEMHHC implemented a rule-based CDSS for the management of renal anemia in 2019. We compared the clinical outcomes of renal anemia between the pre- and post-CDSS periods using random intercept models. Hemoglobin levels of 10 to 12 g/dL were defined as the on-target range. Physician compliance was defined as the concordance of adjustments of the erythropoietin-stimulating agent (ESA) between the CDSS recommendations and the actual physician prescriptions. RESULTS: We included 717 eligible patients on hemodialysis (mean age 62.9, SD 11.6 years; male n=430, 59.9%) with a total of 36,091 hemoglobin measurements (average hemoglobin and on-target rate were 11.1, SD 1.4, g/dL and 59.9%, respectively). The on-target rate decreased from 61.3% (pre-CDSS) to 56.2% (post-CDSS) owing to a high hemoglobin percentage of >12 g/dL (pre: 21.5%; post: 29%). The failure rate (hemoglobin <10 g/dL) decreased from 17.2% (pre-CDSS) to 14.8% (post-CDSS). The average weekly ESA use of 5848 (SD 4211) units per week did not differ between phases. The overall concordance between CDSS recommendations and physician prescriptions was 62.3%. The CDSS concordance increased from 56.2% to 78.6%. In the adjusted random intercept model, the post-CDSS phase showed increased hemoglobin by 0.17 (95% CI 0.14-0.21) g/dL, weekly ESA by 264 (95% CI 158-371) units per week, and 3.4-fold (95% CI 3.1-3.6) increased concordance rate. However, the on-target rate (29%; odds ratio 0.71, 95% CI 0.66-0.75) and failure rate (16%; odds ratio 0.84, 95% CI 0.76-0.92) were reduced. After additional adjustments for concordance in the full models, increased hemoglobin and decreased on-target rate tended toward attenuation (from 0.17 to 0.13 g/dL and 0.71 to 0.73 g/dL, respectively). Increased ESA and decreased failure rate were completely mediated by physician compliance (from 264 to 50 units and 0.84 to 0.97, respectively). CONCLUSIONS: Our results confirmed that physician compliance was a complete intermediate factor accounting for the efficacy of the CDSS. The CDSS reduced failure rates of anemia management through physician compliance. Our study highlights the importance of optimizing physician compliance in the design and implementation of CDSSs to improve patient outcomes.

Mortality among acute myocardial infarction patients admitted to hospitals on weekends as compared with weekdays in Taiwan.

Weekend effect has been considered to be associated with poorer quality of care and patient's survival. For acute myocardial infarction (AMI) patients, the question of whether patients admitted during off-hours have worse outcomes as compared with patients admitted during on-hours is still inconclusive. We conducted this study to explore the weekend effect in AMI patients, using a nationwide insurance database in Taiwan. Using Taiwan National Health Insurance (NHI) claims database, we designed a retrospective cohort study, and extracted 184,769 incident cases of AMI through the NHI claims database between January 2006 and December 2014. We divided the patients into weekend admission group and weekday admission group. Patients were stratified as ST elevation/non-ST elevation AMI and receiving/not receiving percutaneous coronary intervention (PCI). We used a logistic regression model to examine the relative risk of in-hospital mortality and 1-year mortality which were obtained from the Taiwan National Death Registry between study groups. We found no difference between weekend group and weekday group for risk of in-hospital mortality (15.8% vs 16.2%, standardized difference 0.0118) and risk of 1-year mortality (30.2% vs 30.9%, standardized difference 0.0164). There was no statistically significant difference among all the comparisons through the multivariate logistic regression analysis adjusting for all the covariates and stratifying by the subtypes of AMI and whether or not executing PCI during hospitalization. As for AMI patients in Taiwan, admission on weekends or weekdays did not have a significant impact on either in-hospital mortality or 1-year cumulative mortality.

An Integrated Community-Based Blood Pressure Telemonitoring Program - A Population-Based Observational Study.

Background: Home blood pressure telemonitoring (BPT) has been shown to improve blood pressure control. A community-based BPT program (the Health+ program) was launched in 2015 in an urban area around a medical center. Objectives: To examine the impact of the BPT program on the use of medical resources. Methods: We conducted a retrospective propensity-score (PS)-matched observational cohort study using the National Health Insurance Research Database (NHIRD) 2013-2016 in Taiwan. A total of 9,546 adults with a high risk of cardiovascular disease participated in the integrated BPT program, and 19,082 PS-matched controls were identified from the NHIRD. The primary and secondary outcome measures were changes in 1-year emergency department visit rate, hospitalization rate, duration of hospital stay, and healthcare costs. Results: The number of emergency department visits in the Health+ group significantly reduced (0.8 to 0.6 per year vs. 0.8 to 0.9 per year, p < 0.0001) along with a significant decrease in hospitalization rate (43.7% to 21.3% vs. 42.7% to 35.3%, p < 0.001). The duration of hospital stay was also lower in the Health+ group (4.3 to 3.3 days vs. 5.3 to 6.5 days, p < 0.0001). The annual healthcare costs decreased more in the Health+ group (USD 1642 to 1169 vs. 1466 to 1393 per year, p < 0.001), compared with the controls. Subgroup analysis of the Health+ group revealed that the improvements in outcomes were significantly greater among those who were younger and had fewer comorbidities, especially without diabetes or hypertension. Conclusions: A community-based integrated BPT program may improve patients' health outcomes and reduce healthcare costs.

Burden of mental disorders in children in the general population and in health facilities: discrepancies in years lived with disability based on national prevalence estimates between populations receiving care or not.

Little is known about the discrepancies in the burden of child mental disorders based on differences in prevalence between populations with and without care. Identifying such discrepancies may help to elucidate the unmet needs related to child mental disorders. We compared the years lived with disability (YLD) between children with and without care for mental disorders using a representative national survey, Taiwan's National Epidemiological Study of Child Mental Disorders (TNESCMD), and a national health facility database, the Taiwan National Health Insurance Research Database (TNHIRD). The comorbidity-adjusted YLD rate ratio (RR) was reported to quantify the YLD discrepancy. The overall YLD rate for all mental disorders in the TNESCMD was 9.05 times higher than that in the TNHIRD with the lowest and highest YLD RRs for autism spectrum disorder (RR 3.51) and anxiety disorders (RR 360.00). Unlike the YLD proportion explained by attention-deficit/hyperactivity disorder and autism spectrum disorder, the proportions explained by anxiety disorders and conduct disorder/oppositional defiant disorder relative to the total YLD were relatively lower in the TNHIRD than in TNESCMD and the Global Burden of Disease 2016. The discrepancies in YLD between populations with and without care in child mental disorders ranged from ± 55% to 99% and had an overall value of ± 80.1%. High YLD discrepancies in child mental disorders between estimates based on the general population and those in health facilities suggest significant unmet needs for care in child mental disorders and that estimates of disease burden that rely heavily on a single source may result in unreliable results.

A Simple Risk Score for Predicting Neurologic Outcome in Out-of-Hospital Cardiac Arrest Patients After Targeted Temperature Management.

OBJECTIVES: Although several risk factors for outcomes of out-of-hospital cardiac arrest patients have been identified, the cumulative risk of their combinations is not thoroughly clear, especially after targeted temperature management. Therefore, we aimed to develop a risk score to evaluate individual out-of-hospital cardiac arrest patient risk at early admission after targeted temperature management regarding poor neurologic status at discharge. DESIGN: Retrospective observational cohort study. SETTING: Two large academic medical networks in the United States. PATIENTS: Out-of-hospital cardiac arrest survivors treated with targeted temperature management with age of 18 years old or older. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Based on the odds ratios, five identified variables (initial nonShockable rhythm, Leucocyte count < 4 or > 12 K/µL after targeted temperature management, total Adrenalin [epinephrine] ≥ 5 mg, lack of oNlooker cardiopulmonary resuscitation, and Time duration of resuscitation ≥ 20 min) were assigned weighted points. The sum of the points was the total risk score known as the SLANT score (range 0-21 points) for each patient. Based on our risk prediction scores, patients were divided into three risk categories as moderate-risk group (0-7), high-risk group (8-14), and very high-risk group (15-21). Both the ability of our risk score to predict the rates of poor neurologic outcomes at discharge and in-hospital mortality were significant under the Cochran-Armitage trend test (p < 0.001 and p < 0.001, respectively). CONCLUSIONS: The risk of poor neurologic outcomes and in-hospital mortality of out-of-hospital cardiac arrest survivors after targeted temperature management is easily assessed using a risk score model derived using the readily available information. Its clinical utility needed further investigation.

Effect of Early Supplemental Formula Intervention on Body Weight and Hyperbilirubinemia in Neonates During 72 h After Birth.

Background: The full breastfeeding may lead to insufficient milk intake of newborns and increase the rate of body weight loss (BWL). Severe BWL was generally believed as a cause of significant hyperbilirubinemia in newborn babies. The study aimed to investigate the effect if early supplemental feeding in newborns with birth weight loss at the first 3 days after birth could decrease the rate of hyperbilirubinemia 72 h of birth. Methods: A total of 395 neonates with gestational age >37 weeks and birth body weight >2500g were prospectively collected between 2016 and 2018. We analyzed 280 neonates with BWL rate reaching the predictive value (4.5%, 7.5%, and 8% on the first, second, third day after birth, respectively) for subsequent hyperbilirubinemia after 72 hours after birth. The enrolled cases were divided into four subgroups as interventional consecutive milk supplement for 0, 1, 2, and 3 days after birth for further analysis Results: For newborns with BWL reaching the predictive value on the first day after birth, the serum bilirubin levels were lower in the experimental group than those in the non-involved control group (p < 0.05). For newborns with three consecutive days of interventional milk supplementation, the serum bilirubin levels at the 72 h after birth showed the lowest levels compared with the other sub-groups with two consecutive days and one consecutive day of interventional milk supplementation (p < 0.05). Moreover, there was a significantly decreasing trend in the consecutive days of interventional milk supplementation (p < 0.05). Conclusion: Newborns with BWL over 4.5% on the first day after birth receiving early intervention milk supplementation could significantly reduce serum bilirubin levels at the 72 h after birth. The more days of consecutive milk supplementation after birth may lead to the lower the 72 h serum bilirubin levels. It is recommended to early and consecutive milk supplementation after birth to be an effective way in reducing serum bilirubin levels.

Mortality of major cardiovascular emergencies among patients admitted to hospitals on weekends as compared with weekdays in Taiwan.

BACKGROUND: Several studies have found a so-called weekend effect that patients admitted at the weekends had worse clinical outcomes than patients admitted at the weekdays. We performed this retrospective cohort study to explore the weekend effect in four major cardiovascular emergencies in Taiwan. METHODS: The Taiwan National Health Insurance (NHI) claims database between 2005 and 2015 was used. We extracted 3811 incident cases of ruptured aortic aneurysm, 184,769 incident cases of acute myocardial infarction, 492,127 incident cases of ischemic stroke, and 15,033 incident cases of pulmonary embolism from 9,529,049 patients having at least one record of hospitalization in the NHI claims database within 2006 ~ 2014. Patients were classified as weekends or weekdays admission groups. Dates of in-hospital mortality and one-year mortality were obtained from the Taiwan National Death Registry. RESULTS: We found no difference in in-hospital mortality between weekend group and weekday group in patients with ruptured aortic aneurysm (45.4% vs 45.3%, adjusted odds ratio [OR] 1.01, 95% confidence interval [CI] 0.87-1.17, p = 0.93), patients with acute myocardial infarction (15.8% vs 16.2%, adjusted OR 0.98, 95% CI 0.95-1.00, p = 0.10), patients with ischemic stroke (4.1% vs 4.2%, adjusted OR 0.99, 95% CI 0.96-1.03, p = 0.71), and patients with pulmonary embolism (14.6% vs 14.6%, adjusted OR 1.02, 95% CI 0.92-1.15, p = 0.66). The results remained for 1 year in all the four major cardiovascular emergencies. CONCLUSIONS: We found no difference in either short-term or long-term mortality between patients admitted on weekends and patients admitted on weekdays in four major cardiovascular emergencies in Taiwan.

Gender Difference in Intraocular Pressure and Incidence of Metabolic Syndrome: A Community-Based Cohort Study in Matsu, Taiwan.

Background: We aimed to assess the effect of intraocular pressure (IOP) on incident metabolic syndrome (MetS) using a longitudinal follow-up of screening cohort in contrast to most of previous studies addressing the association between both. Methods: The empirical data were derived from a community-based integrated screening program in Matsu during the period 2003 to 2010. A total of 1347 participants older than 30 years were enrolled in this study. With the enrollment of 1056 participants with MetS free at baseline, the cohort with IOP measurement in 2003 were followed up over time to identify incident MetS to elucidate the temporal sequence of both. Results: The statistically significant effect noted was that elevated IOP (≥15 mmHg vs. <15 mmHg) had 1.46-fold risk for developing incident MetS (adjusted relative ratio [aRR]: 1.46; 95% confidence interval [CI]: 1.08-1.99) for both sex combined, particularly in men (aRR: 1.66; 95% CI: 1.13-2.45) but not in women. The finding that elevated IOP occurred before the presence of high blood pressure was noted in both men and women, whereas men with elevated IOP may be concomitant with more individual components (severity) of MetS earlier than women with elevated IOP. Conclusions: Elevated IOP leading to the risk for incident or severe MetS was noted in men but not in women. Evidence on this temporal sequence revealed the possibility of showing signs of elevated IOP before the development of MetS, which indicates the necessity of monitoring IOP in routine health check-up for prevention of MetS-related chronic diseases.

Do informed consumers in Taiwan favour larger hospitals? A 10-year population-based study on differences in the selection of healthcare providers among medical professionals, their relatives and the general population.

OBJECTIVES: Exploring whether medical professionals, who are considered to be 'informed consumers' in the healthcare system, favour large providers for elective treatments. In this study, we compare the inclination of medical professionals and their relatives undergoing treatment for childbirth and cataract surgery at medical centres, against those of the general population. DESIGN: Retrospective study using a population-based matched cohort data. PARTICIPANTS: Patients who underwent childbirth or cataract surgery between 1 January 2004 and 31 December 2013. PRIMARY AND SECONDARY OUTCOMES MEASURES: We used multiple logistic regression to compare the ORs of medical professionals and their relatives undergoing treatment at medical centres, against those of the general population. We also compared the rate of 14-day re-admission (childbirth) and 14-day reoperation (cataract surgery) after discharge between these groups. RESULTS: Multivariate analysis showed that physicians were more likely than patients with no familial connection to the medical profession to undergo childbirth at medical centres (OR 5.26, 95% CI 3.96 to 6.97, p<0.001), followed by physicians' relatives (OR 2.68, 95% CI 2.20 to 3.25, p<0.001). Similarly, physicians (OR 1.63, 95% CI 1.21 to 2.19, p<0.01) and their relatives (OR 1.43, 95% CI 1.13 to 1.81, p<0.01) were also more likely to undergo cataract surgery at medical centres. Physicians also tended to select healthcare providers who were at the same level or above the institution at which they worked. We observed no significant difference in 14-day re-admission rates after childbirth and no significant difference in 14-day reoperation rates after cataract surgery across patient groups. CONCLUSIONS: Medical professionals and their relatives are more likely than the general population to opt for service at medical centres. Understanding the reasons that medical professionals and general populations both have a preferential bias for larger medical institutions could help improve the efficiency of healthcare delivery.

Differences in the outcomes of adjuvant chemotherapy for colon cancer prescribed by physicians in different disciplines: a population-based study in Taiwan.

OBJECTIVES: One feature unique to the Taiwanese healthcare system is the ability of physicians other than oncologists to prescribe systemic chemotherapy. This study investigated whether the care paths implemented by oncologists and non-oncologists differ with regard to patient outcomes. SETTING: Data from the Taiwan Cancer Registry and National Health Insurance Database were linked to identify patients with colon cancer who underwent colectomy as first treatment within 3 months of diagnosis and adjuvant chemotherapy between 2005 and 2009. PARTICIPANTS AND METHODS: Postoperative patients who underwent adjuvant chemotherapy were included in this study. The exclusion criteria included patients with stage IV disease, a positive surgical margin and early disease recurrence. Among the patients presenting with multiple primary cancers, we also excluded patients who were diagnosed with colon cancer but for whom this was not the first primary cancer. The variables included sex, age, comorbidities, disease stage, chemotherapy cycle and changes in treatment regimen as well as the specialty of treatment providers and their case volume. Cox regression models and Kaplan-Meier analysis were used to examine differences in outcomes in the matched cohorts. RESULTS: We examined 3534 patients who were prescribed adjuvant chemotherapy by physicians from different disciplines. In terms of 5-year disease-free survival, no significant difference was observed between the groups of oncologists or surgeons among patients with stage II (90.02%vs88.99%) or stage III (77.64%vs79.99%) diseases. Patients who were subjected to changes in their chemotherapy regimens presented recurrence rates higher than those who were not. CONCLUSIONS: The discipline of practitioners is seldom taken into account in most series. This is the first study to provide empirical evidence demonstrating that the outcomes of patients with colon cancer do not depend on the treatment path, as long as the selection criteria for adjuvant chemotherapy is appropriate. Further study will be required before making any further conclusions.

Impact of Targeted Therapy on the Quality of End-of-Life Care for Patients With Non-Small-Cell Lung Cancer: A Population-Based Study in Taiwan.

CONTEXT: Targeted therapies with epidermal growth factor receptor tyrosine kinase inhibitors have been widely used in the treatment of advanced non-small-cell lung cancer (NSCLC). However, little research has focused on the use of targeted therapies at the end of life (EOL). OBJECTIVES: This study investigated the determinants of receiving targeted therapy during the last month of life and how targeted therapies affect the quality of EOL care. METHODS: We conducted a retrospective population-based study using a cancer registry and National Health Insurance claims data among 42,678 Taiwanese NSCLC decedents in 2005-2012. Propensity score matching and generalized linear mixed models were used to estimate associations. RESULTS: We identified 3439 (21.3%) NSCLC patients who received targeted therapy within 30 days of death. Younger age, adenocarcinoma histology, postdiagnosis survival exceeding six months, and later year of death were associated with receiving targeted agents at EOL. The odds increased when patients were treated by pulmonologists or oncologists or in district hospitals or facilities with a higher case volume. Patients who were prescribed targeted therapy near death were significantly more likely to undergo aggressive EOL care (odds ratio = 2.35, 95% CI = 1.83-3.02) including multiple emergency department visits, hospitalization exceeding 14 days, admission to intensive care units, use of intubation and mechanical ventilation, cardiopulmonary resuscitation, and late hospice referrals. CONCLUSIONS: Targeted therapy at EOL should be considered a quality-of-care indicator. Guidance in the cessation of targeted therapy and the ongoing monitoring of practice initiatives are warranted. The decision-making processes associated with EOL care also require further investigation.

Quality of life of breast cancer survivors following breast-conserving therapy versus mastectomy: a multicenter study in Taiwan.

BACKGROUND: Breast cancer is the most common female malignancy worldwide. The aim of this study was to investigate the influence of surgical procedures and quality-of-care (QoC) on quality-of-life (QoL) among breast cancer survivors who underwent breast-conserving therapy (BCT) or mastectomy, and to identify provider- and patient-related factors pertaining to QoL. METHOD: In this cross-sectional study, structured-questionnaires were distributed among breast cancer survivors in 19 hospitals. QoL was evaluated using the European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30) and the breast cancer specific module (EORTC QLQ-BR23). QoC is indicated by adherence to the core measures stipulated for the treatment of breast cancer. Multiple regression and hierarchical linear modeling were used for multivariate analysis. RESULTS: A total of 544 female survivors of Stage 0-III breast cancer were included, among whom 217 (39.9%) underwent BCT and 327 (60.1%) underwent mastectomy. Surgical modality does not appear to have a notable impact on any QoL domains except body image; i.e. patients who underwent BCT reported better body image (diff = 11.20, P < 0.001), particularly at 1-5 years after the initial treatment. Independent factors including age, education, employment, marital status, income, chemotherapy, duration since treatment, recurrence status, primary hospital accreditation level and location all appear to be correlated to QoL. CONCLUSION: Patients with breast cancer should be informed of differences in QoL when discussing treatment options. Furthermore, physicians should recognize that the impact of surgical treatment modality on QoL may vary according to patients' sociodemographic and clinical characteristics.

Discretionary decisions and disparities in receiving drug-eluting stents under a universal healthcare system: A population-based study.

OBJECTIVES: One of the main objectives behind the expansion of insurance coverage is to eliminate disparities in health and healthcare. However, researchers have not yet fully elucidated the reasons for disparities in the use of high-cost treatments among patients of different occupations. Furthermore, it remains unknown whether discretionary decisions made at the hospital level have an impact on the administration of high-cost interventions in a universal healthcare system. This study investigated the adoption of drug-eluting stents (DES) versus bare metal-stents (BMS) among patients in different occupations and income levels, with the aim of gauging the degree to which the inclination of health providers toward treatment options could affect treatment choices at the patient-level within a universal healthcare system. DESIGN AND PARTICIPANTS: We adopted a cross-sectional observational study design using hierarchical modeling in conjunction with the population-based National Health Insurance database of Taiwan. Patients who received either a BMS or a DES between 2007 and 2010 were included in the study. RESULTS: During the period of study, 42,124 patients received a BMS (65.3%) and 22,376 received DES (34.7%). Patients who were physicians or the family members of physicians were far more likely to receive DES (OR: 3.18, CI: 2.38-4.23) than were patients who were neither physicians nor in other high-status jobs (employers, other medical professions, or public service). Similarly, patients in the top 5% income bracket had a higher probability of receiving a DES (OR: 2.23, CI: 2.06-2.47, p < .001), than were patients in the lowest income bracket. After controlling for patient-level factors, the inclination of hospitals (proportion of DES>50% or between 25% and 50%) was shown to be strongly associated with the selection of DESs (OR: 3.64 CI: 3.24-4.09 and OR: 2.16, CI: 2.01-2.33, respectively). CONCLUSIONS: Even under the universal healthcare system in Taiwan, socioeconomic disparities in the use of high-cost services remain widespread. Differences in the care received by patients of lower socioeconomic status may be due to the discretionary decisions of healthcare providers.

Risk of ischemic stroke during the initiation period of α-blocker therapy among older men.

BACKGROUND: Alpha-blockers are notorious for their first-dose effect of acute hypotension during the early initiation period. Because acute cerebral hypoperfusion may precipitate an episode of ischemic stroke, we aimed to provide a quantitative estimate of the risk of ischemic stroke during the early initiation period of α-blocker therapy, using a self-controlled case series design. METHODS: We identified all men aged 50 years or more as of 2007 who were incident users of α-blockers and had a diagnosis of ischemic stroke during the 2007-2009 study period using claims data from Taiwan's National Health Insurance claims database. The first day on which the α-blocker was prescribed was the index date. We partitioned different risk periods according to their relationship to the index date (pre-exposure risk periods 1 and 2 = ≤ 21 d and 22-60 d before index date, respectively; post-exposure risk periods 1 and 2 = ≤ 21 d and 22-60 d after index date, respectively); the remainder of the study period was defined as the unexposed period. We estimated the incidence rate ratio (IRR) of ischemic stroke in each risk period relative to the unexposed period using a conditional Poisson regression model. RESULTS: A total of 7502 men were included. Compared with the risk in the unexposed period, the risk of ischemic stroke was increased in post-exposure risk period 1 among all patients in the study population (adjusted IRR 1.40, 95% confidence interval [CI], 1.22-1.61) and among patients without concomitant prescriptions for other antihypertensive agents (adjusted IRR 2.11, 95% CI 1.73-2.57). INTERPRETATION: Alpha-blocker therapy was associated with an increased risk of ischemic stroke during the early initiation period, especially among patients who were not taking other antihypertensive agents.

Young patients with colorectal cancer have increased risk of second primary cancers.

OBJECTIVE: Because the number of long-term survivors of colorectal cancer has increased, second primary cancer has become an important issue. However, previous studies were heterogeneous in design, and few data for Asia-Pacific area were available. METHODS: This was a retrospective population-based study conducted using the national database of the Taiwan Cancer Registry. Patients who have histology-proven primary colon cancer and rectal cancer from 1995 to 2005 were enrolled in this study. All second primary cancer events had to be histology proven. The standardized incidence ratio of second primary cancer was used as an indicator. Standardized incidence ratio was counted as the number of observed second primary cancer divided by the expected number of cancer cases in the general population. RESULTS: A total of 65 648 eligible index patients were enrolled, and 3810 second primary cancer events were identified. The standardized incidence ratio for all of the patients was 1.03 (95% confidence interval: 0.99-1.06), which implied that the risk of second primary cancer was not significantly elevated in the index patients compared with that of the general population. The standardized incidence ratio for the patients aged <50, 50-70 and >70 years was 2.52 (95% confidence interval: 2.28-2.78), 1.18 (95% confidence interval: 1.12-1.23) and 0.80 (95% confidence interval: 0.76-0.84), respectively. In young patients (aged <50 years), the standardized incidence ratio increase was statistically significant and persisted for over 10 years and this significantly increased across all subgroups. The small intestine, the large intestine, the female genital organs and the lungs were the most common sites of second primary cancer in young patients. CONCLUSIONS: Young patients with colorectal cancer have an increased risk of developing second primary cancer.

The Prognostic Impact of Type 2 Diabetes Mellitus on Early Cervical Cancer in Asia.

BACKGROUND: Many studies have shown that type 2 diabetes mellitus (DM) increases the risk for several types of cancer but not cervical cancer (CC). Although DM and insulin-like growth factor 1 have preclinical and clinical implications for CC, less is known about the prognostic impact of DM on patients with early stage CC. PATIENTS AND METHODS: We used the nationwide Taiwan Cancer Registry database to collect the characteristics of stage I-IIA cervical cancer patients diagnosed between 2004 and 2008. DM and other comorbidities were retrieved from the National Health Insurance database. Cervical cancer-specific survival (CSS) and overall survival (OS) times of patients according to DM status were estimated using the Kaplan-Meier method. We used a Cox proportional hazards model to calculate adjusted hazard ratios (HRs) for the effects of DM and other risk factors on mortality. RESULTS: A total of 2,946 patients had primary stage I-IIA CC and received curative treatments, and 284 (9.6%) had DM. The 5-year CSS and OS rates for patients with DM were significantly lower than those without DM (CSS: 85.4% vs. 91.5%; OS: 73.9% vs. 87.9%). After adjusting for clinicopathologic variables and comorbidities, DM remained an independent unfavorable prognostic factor for CSS (adjusted HR: 1.46) and OS (adjusted HR: 1.55). CONCLUSION: In Asian patients with early cervical cancer, DM is an independent unfavorable prognostic factor influencing both OS and CSS, even after curative treatments. IMPLICATIONS FOR PRACTICE: Type 2 diabetes mellitus (DM) increases the incidence of several types of cancer but not cervical cancer (CC); however, less is known about the impact of DM on patients who already have CC. This study suggests that DM may increase the risk of cancer recurrence and death for early stage CC patients, even after curative treatments. Incorporating DM control should be considered part of the continuum of care for early stage CC patients, and close surveillance during routine follow-up in this population is recommended.

The relationship between smoking status and health-related quality of life among smokers who participated in a 1-year smoking cessation programme in Taiwan: a cohort study using the EQ-5D.

OBJECTIVE: To assess the relationship between smoking status and health-related quality of life 1 year after participation in a smoking cessation programme in Taiwan. DESIGN: A cohort study of smokers who voluntarily participated in a smoking cessation programme with two follow-up assessments of smoking status via telephone interview, conducted 6 months and 1 year after finishing the smoking cessation programme. SETTING: Hospitals and clinics providing smoking cessation services. PARTICIPANTS: A total of 3514 participants completed both telephone interviews, which represents a response rate of 64%. After the interviews, participants were divided into four groups according to their smoking status: (1) long-term quitters: participants who had quit tobacco use for 1 year; (2) short-term quitters: participants who had been smoking for at least 6 months and then quit tobacco for 6 months after participating in the programme; (3) relapsed smokers: participants who relapsed into tobacco use after ceasing tobacco use for 6 months; and (4) continuing smokers: participants who failed to quit smoking for at least 1 year, despite participating in the programme. INTERVENTIONS: The Outpatient Smoking Cessation Service of Taiwan provides counselling and pharmacotherapy to individuals seeking to quit smoking. PRIMARY OUTCOMES: The health-related quality of life of the participants was measured using an approved Chinese version of the EuroQol-5D-3L (EQ-5D-3L) descriptive system. RESULTS: After controlling for sex, age, education, marital status, job status, monthly income and disease status at baseline, our results revealed that long-term (OR=0.61 (0.48 to 0.77)) and short-term (OR=0.65 (0.54 to 0.79)) quitters experienced less anxiety and depression than did continuing smokers. CONCLUSIONS: Our study provides evidence to support claims that all quitters, regardless of whether they stop smoking for 6 months or 1 year, have better quality of life with regard to anxiety or depression.

Risk of hip/femur fractures during the initiation period of α-adrenoceptor blocker therapy among elderly males: a self-controlled case series study.

AIMS: This study aimed to evaluate the risk of hip/femur fractures during the initiation period of α-adrenoceptor blocker therapy using the National Health Insurance claims database, Taiwan, with a self-controlled case series design. METHODS: All male beneficiaries aged over 50 years as of 2007, who were incident users of α-adrenoceptor blockers and also had a diagnosis of hip/femur fracture within the 2007-2009 study period were identified. The first day when the α-adrenoceptor blocker was prescribed was set as the index date. We partitioned the initial 21 day period following the index date as the post-exposure risk period 1, days 22-60 after the index date as the post-exposure risk period 2, the 21 day period prior to the index date as the pre-exposure risk period 1 and days 22-60 prior to the index date as the pre-exposure risk period 2. The remainder of the study period was defined as the unexposed period. The incidence rate ratio (IRR) of hip/femur fractures within each risk period compared with the unexposed period was estimated using a conditional Poisson regression model. RESULTS: A total of 5875 men were included. Compared with the unexposed period, the IRR of hip/femur fractures was 1.36 (95% confidence interval 1.06, 1.74, P = 0.017) within the post-exposure risk period 1 for patients without concomitant prescriptions of anti-hypertensive agents. CONCLUSIONS: Use of α-adrenoceptor blockers was associated with a small but significant increase in the risk of hip/femur fractures during the early initiation period in patients without concomitant prescriptions of anti-hypertensive agents.

Clinical outcomes in low risk coronary artery disease patients treated with different limus-based drug-eluting stents--a nationwide retrospective cohort study using insurance claims database.

The clinical outcomes of different limus-based drug-eluting stents (DES) in a real-world setting have not been well defined. The aim of this study was to investigate the clinical outcomes of three different limus-based DES, namely sirolimus-eluting stent (SES), Endeavor zotarolimus-eluting stent (E-ZES) and everolimus-eluting stent (EES), using a national insurance claims database. We identified all patients who received implantation of single SES, E-ZES or EES between January 1, 2007 and December 31, 2009 from the National Health Insurance claims database, Taiwan. Follow-up was through December 31, 2011 for all selected clinical outcomes. The primary end-point was all-cause mortality. Secondary end-points included acute coronary events, heart failure needing hospitalization, and cerebrovascular disease. Cox regression model adjusting for baseline characteristics was used to compare the relative risks of different outcomes among the three different limus-based DES. Totally, 6584 patients were evaluated (n=2142 for SES, n=3445 for E-ZES, and n=997 for EES). After adjusting for baseline characteristics, we found no statistically significant difference in the risk of all-cause mortality in three DES groups (adjusted hazard ratio [HR]: 1.14, 95% confidence interval [CI]: 0.94-1.38, p=0.20 in E-ZES group compared with SES group; adjusted HR: 0.77, 95% CI: 0.54-1.10, p=0.15 in EES group compared with SES group). Similarly, we found no difference in the three stent groups in risks of acute coronary events, heart failure needing hospitalization, and cerebrovascular disease. In conclusion, we observed no difference in all-cause mortality, acute coronary events, heart failure needing hospitalization, and cerebrovascular disease in patients treated with SES, E-ZES, and EES in a real-world population-based setting in Taiwan.

Comparative effectiveness of first-line platinum-based chemotherapy regimens for advanced lung squamous cell carcinoma.

BACKGROUND: Platinum-based chemotherapy is the standard first-line therapy for patients with advanced lung squamous cell carcinoma (SCC). We compared the effectiveness of first-line chemotherapy regimens. METHODS: We searched the database of the Taiwan Cancer Registry for patients with newly diagnosed advanced lung SCC from 2004 to 2007. Medication prescription data were retrieved from the database of National Health Insurance, Taiwan. We identified patients who received standard first-line platinum-based chemotherapy, which was defined as chemotherapy with a platinum (P) compound (cisplatin or carboplatin) in addition to 1 of the 4 chemotherapy agents, including gemcitabine (G), docetaxel (D), paclitaxel (T), and vinorelbine (V). Deaths were identified by searching the National Death Registry. Overall survival (OS) was compared between patients who underwent different therapies. RESULTS: In total, 2790 patients were identified; 983 patients (35.2%) received standard first-line chemotherapy with P and G (58.1%), D (14.5%), T (11.6%), or V (15.8%). Older patients (age ≥ 70 years) were less likely to receive P + D than P + G, P + T, or P + V (P = .018). Patients who received P + G, P + D, P + T, or P + V had similar OS (median, 8.9, 7.9, 9.5, and 8.2 months; P = .816). In multivariate analyses adjusting for age, sex, and stage, the first-line chemotherapy regimen was not a predictor for OS. With P + G as the reference group, the adjusted hazard ratios of P + D, P + T, and P + V were 1.03, 0.90, and 1.02, respectively (P = .710). CONCLUSIONS: In patients with advanced lung SCC, various regimens did not have a significant effect on survival outcomes.