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.

Type 2 diabetes mellitus is associated with increased mortality in Chinese patients receiving curative surgery for colon cancer.

BACKGROUND: We investigated the association between diabetes mellitus (DM) and the prognosis of patients with early colon cancer who had undergone curative surgery. METHODS: From three national databases of patients in Taiwan, we selected a cohort of colon cancer patients who had been newly diagnosed with stage I or stage II colon cancer between January 1, 2004 and December 31, 2008 and had undergone curative surgery. We collected information regarding DM (type 2 DM only), the use of antidiabetic medications, other comorbidities, and survival outcomes. The colon cancer-specific survival (CSS) and the overall survival (OS) were compared between patients with and without DM. RESULTS: We selected 6,937 colon cancer patients, among whom 1,371 (19.8%) had DM. The colon cancer patients with DM were older and less likely to receive adjuvant chemotherapy but had a similar tumor stage and grade, compared with colon cancer patients without DM. Compared with colon cancer patients without DM, patients with DM had significantly shorter OS (5-year OS: 71.0% vs. 81.7%) and CSS (5-year CSS: 86.7% vs. 89.2%). After adjusting for age, sex, stage, adjuvant chemotherapy, and comorbidities in our multivariate analysis, DM remained an independent prognostic factor for overall mortality (adjusted hazards ratio: 1.32, 95% confidence interval: 1.18-1.49), but not for cancer-specific mortality. Among the colon cancer patients who had received antidiabetic drug therapy, patients who had used insulin had significantly shorter CSS and OS than patients who had not. CONCLUSION: Among patients who receive curative surgery for early colon cancer, DM is a predictor of increased overall mortality.

Association of adjuvant antiviral therapy with risk of cancer progression and deaths in patients with hepatitis-B-virus-related hepatocellular carcinoma following curative treatment: a nationwide cohort study.

BACKGROUND: Limited information about tumor status and the time at which antiviral therapy was initiated may have influenced effect estimation in previous research. The aim of this study was to investigate the effect of antiviral therapies on HBV-related HCC progression and deaths in patients receiving curative treatment based on clear clinical-pathological cancer status and the association of start time of adjuvant antiviral therapy initiation and outcomes. METHODOLOGY: A nationwide inception cohort study of newly diagnosed HCC patients who suffered from viral hepatitis B and received curative HCC therapy as the first course of treatment were identified from the Taiwan Cancer Registry between January 1, 2004, and December 31, 2009. Matched Cox proportional hazards models based on propensity score matching and incorporated time-varying exposure were used to estimate adjusted hazard ratios and 95% confidence intervals (CIs). FINDINGS: Among 3,855 HCC patients with HBV, antiviral therapy was administered to 490 (12.7%) following curative treatment. Antiviral-treated patients had a higher percentage of young age, early stage, and smaller tumor size of HCC compared with untreated patients. After propensity score matching, treated patients demonstrated a higher risk of HCC progression (hazard ratio, 1.42; 95%CI, 1.20-1.69) and death from all causes (1.45; 1.15-1.82) than untreated patients. Similar results were also obtained in sub-cohort of patients who were alive with cancer-free status at least one year after receiving curative treatment and the sub-cohort of patients with liver resection. The interval length between initiation of antiviral therapy and first-line curative treatment did not show a significant association with all-cause mortality. CONCLUSIONS: This study found that adjuvant antiviral therapy did not reduce the risk of HCC progression or mortality in HBV-related HCC patients after cancer status adjusting.

The association of clinical guideline adherence and pay-for-performance among patients with diabetes.

BACKGROUND: Diabetes mellitus management is one of the most challenging health care issues in Taiwan. To improve guideline adherence and the quality of diabetes care, the diabetes mellitus pay-for-performance (DM-P4P) program was introduced in 2001. This study examined the effects of the DM-P4P program on guideline adherence among patients with diabetes. METHODS: This cross-sectional study used National Health Insurance (NHI) claim data to assess guideline adherence among three groups of patients with diabetes: patients enrolled in the DM-P4P program, patients not enrolled but treated by DM-P4P-participating physicians, and patients treated by non-P4P physicians. Guideline adherence measures included hemoglobin A1c, blood glucose, lipid, serum creatinine, alanine transaminase, urinalysis, and eye examinations. Multiple logistic regression with generalized estimated equation approach were used to assess the effect of the DM-P4P program while controlling for patient and physician characteristics. RESULTS: A total of 520,804 patients were included in the analysis. Patients enrolled in the DM-P4P program were more likely to receive all of the guideline-recommended tests/examinations than patients treated by non-P4P physicians. Patients who were not enrolled in the program but who were treated by DM-P4P-participating physicians were more likely to receive three of the seven recommended tests/examinations than were those treated by non-P4P physicians. CONCLUSION: When physicians participated in the P4P program, this increased the likelihood that patients would receive guideline-recommended tests or examinations. Increasing the DM-P4P participation rates for physicians and patients are important and worthwhile objectives that can assist in the effort to more effectively manage diabetes in the general population.

The effect of weather on peritoneal dialysis (PD) prescription: seasonal variation in PD dialysate utilization.

BACKGROUND: There have been no reports on peritoneal dialysis (PD) solution utilization since this treatment was developed in the 1920s. The aim of the present investigation was to investigate if weather affects PD prescription. STUDY DESIGN AND METHODS: This 10-year observational study used the Taiwan National Health Insurance Research Database. SETTING AND PARTICIPANTS: Claims for different concentrate PD dialysate were analyzed monthly. 2.5% and 4.25% PD solutes were defined as hypertonic solutions. PREDICTOR: Monthly outdoor mean temperature. Outcome and Measurement: The relationship between monthly mean of PD dialysate utilization and monthly outdoor temperature was analyzed by linear regression. Monthly mean PD dialysate utilization amount in 4 quarters was analyzed by ANOVA. RESULTS: During the 10-year study period, a clear seasonal variation in PD dialysate was observed. This seasonal variation was present regardless of age, gender, and the presence of hypertension, diabetes, and dyslipidemia. Monthly mean temperature was positively correlated to 1.5% dialysate utilization amount (r = 0.559, p < 0.001) and negatively correlated to 2.5% (r = -0.533, p < 0.001) and 4.25% (r = -0.410, p < 0.001) dialysate utilization amount. In longitudinal follow-up, hypertonic PD fluid utilization was higher in diabetic patients than in nondiabetic patients from the beginning of treatment. Thereafter, it increased rapidly and reached a plateau within 1 year. LIMITATIONS: Analysis of ultrafiltration amount, blood pressure, and body weight was unfeasible due to the nature of the database. CONCLUSION: The utilization of differential strengths of PD solutions has a seasonal cyclic pattern, with more hypertonic PD solution utilized in winter and more hypotonic PD solution in summer.

Use of diagnosis-based risk adjustment models to predict individual health care expenditure under the National Health Insurance system in Taiwan.

BACKGROUND AND PURPOSE: Diagnostic information has been extensively studied and employed in the prediction of risk adjusted capitation payments in some countries. Nevertheless, few studies have been dedicated to the development of diagnosis-based risk adjusters in Taiwan. The purposes of this study were to develop outpatient diagnosis-based risk adjusters for a model of Taiwan's National Health Insurance (NHI) system and to evaluate the predictability of the risk adjustment models generated utilizing these adjusters. METHODS: Using a 2% random sample of 371,620 NHI enrollees, 5 risk adjustment models--i.e., demographic, inpatient diagnostic information outpatient diagnostic information, full diagnostic information, and prior utilization models--were evaluated with respect to predictive R2 and predictive ratios. While inpatient diagnosis-based risk adjusters were borrowed from previous research, outpatient diagnosis-based risk adjusters, referred to as Taiwan Ambulatory Spending Groups (TASGs), were developed based on 1996 claims data. RESULTS: The values of predictive R2 for the 5 risk adjustment models showed that the inclusion of outpatient diagnostic information considerably improved the predictability of the risk adjustment models for Taiwan's NHI system. Moreover, the predictive ratios revealed that the full diagnostic information model would reimburse different risk subgroups more fairly than the demographic, inpatient diagnostic information, and outpatient diagnostic information models and also outperform the prior utilization model with respect to disease risk groups. CONCLUSIONS: The risk adjustment model including the TASG risk adjusters can significantly improve predictability and can be employed to assess the NHI's current and proposed reform measures.