Trace analysis of therapeutic inertia and subsequent hemoglobin A1c outcomes in a 2-year cohort study.

OBJECTIVE: Our understanding of therapeutic inertia in diabetes care is incomplete in terms of an assessment across a nationwide population. The key objectives of this investigation were to measure therapeutic inertia and link this phenomenon to the important surrogate outcome of hemoglobin A1c (HbA1c) control in a nationwide cohort. PATIENTS AND METHODS: We performed a retrospective cohort study over 18 months. Laboratory and prescription data were collected for 41,948 patients (women: 53.1%) with diabetes who had at least two HbA1c results. The association between treatment intensity and glycemic control, using the change in HbA1c during the observation period, and whether the HbA1c outcome was greater than 9% were examined. RESULTS: Among the patients who exhibited a secondary HbA1c result exceeding 9%, 8,630 (78.26%) had undergone intensified therapy at the time of the index HbA1c measurement, and among these patients, the incidence ratio of the last HbA1c outcome exceeding 9% after 6 to 18 months was 0.779-fold (95% Cl 0.728 to 0.834) greater than those who had not received intensified therapy (p < .001). CONCLUSIONS: After tracking patient data for a particular period, we found that patients with diabetes who received intensified therapy achieved surrogate outcomes of HbA1c control that were more favorable.

Risk of Myocardial Infarction and Ischemic Stroke after Dental Treatments.

The association between invasive dental treatments (IDTs) and a short-term risk of myocardial infarction (MI) and ischemic stroke (IS) remains controversial. Bacterial dissemination from the oral cavity and systemic inflammation linked to IDT can induce a state of acute vascular dysfunction. The aim of study is to investigate the relation of IDTs to MI and IS by using case-only study designs to analyze data from a large Taiwanese cohort. A nationwide population-based study was undertaken by using the case-crossover and self-controlled case series design to analyze the Taiwanese National Health Care Claim database. Conditional logistic regression model and conditional Poisson regression model were used to estimate the risks of MI/IS. In addition, we used burn patients as negative controls to explore the potential effect of residual confounding. In total, 123,819 MI patients and 327,179 IS patients in the case-crossover design and 117,655 MI patients and 298,757 IS patients were included in the self-controlled case series design. Results from both study designs showed that the risk of MI within the first 24 wk after IDT was not significantly different from or close to unity except for a modest risk during the first week for patients without other comorbidities (odds ratios [95% confidence intervals] of 1.31 [1.08-1.58] and 1.15 [1.01-1.31] for 3 d and 7 d, respectively). We also observed no association between IDTs and IS, or the risk ratio was close to unity. IDTs did not appear to be associated with a transient risk of MI and IS in the Taiwanese population, with consistent findings from both case-only study designs. However, we cannot exclude that dental infections and diseases may yield a long-term risk of MI and IS.

Prescription trends and the selection of initial oral antidiabetic agents for patients with newly diagnosed type 2 diabetes: a nationwide study.

OBJECTIVES: The aim of this study was to examine the characteristics of patients, physicians, and medical facilities, and their association with prescriptions that do not include metformin as the initial oral antidiabetic agent. STUDY DESIGN: Observational, cross-sectional study. METHODS: Patients with incident type 2 diabetes between January 1, 2006, and December 31, 2010, were identified from the Taiwan National Insurance Research Database. We describe trends in the initial prescription of antidiabetic medications that do not contain metformin during the study period. A multivariable logistic model and a multilevel linear model were used in the analysis of factors at a range of levels (patient, physician, and medical facility), which may be associated with the selection of oral antidiabetic drugs. RESULTS: During the study period, the proportion of prescriptions that did not include metformin declined from 43.8% to 26.2%. Male patients were more likely to obtain non-metformin prescriptions (adjusted odds ratio [OR]: 1.15; 95% confidence interval [CI]: 1.08-1.23), and the likelihood that a patient would be prescribed a non-metformin prescription increased with age. Physicians aged ≥35 years and those with specialties other than endocrinology tended to prescribe non-metformin prescriptions. Metformin was less commonly prescribed in for-profit hospitals (adjusted OR: 1.34, 95% CI: 1.11-1.61) and hospitals in smaller cities (adjusted OR: 1.28, 95% CI: 1.05-1.57) and rural areas (adjusted OR: 1.83, 95% CI: 1.32-2.54). CONCLUSIONS: Disparities continue to exist in clinical practice with regard to the treatment of diabetes. These inequalities appear to be linked to a variety of factors related to patients, physicians, and medical facilities. Further study will be required to understand the effects of continuing medical education in enhancing adherence to clinical guidelines.

Impact of hospitalization on medication adherence estimation in claims data.

WHAT IS KNOWN AND OBJECTIVE: Pharmacy claims are commonly used to assess medication adherence. It is unclear how different approaches to handling hospitalizations compare to the gold standard of using outpatient and inpatient drug data. This study aimed to compare the impact of different approaches to handling hospitalizations on medication adherence estimation in administrative claims data. METHODS: We identified ß-blocker initiators after myocardial infarction (MI) and statin initiators regardless of hospitalization histories in the population-based, Taiwan database, which includes outpatient and inpatient drug claims data. Adherence to ß-blockers or to statins during a 365-day follow-up period was estimated in outpatient pharmacy claims using the proportion of days covered (PDC) in three ways: ignoring hospitalizations (PDC1); subtracting hospitalized days from the denominator (PDC2); and assuming drug use on all hospitalized days (PDC3). We compared these to an approach that incorporated inpatient drug use (PDC4). We also used a hypothetical example to examine variations across approaches in several scenarios, such as increasing hospitalized days. RESULTS AND DISCUSSION: Mean 365-day PDC was 74% among 1729 post-MI ß-blocker initiators (range: 73.1%-74.9%) and 44% among 69 435 statins initiators (range: 43.5%-44.0%), which varied little across approaches. Differences across approaches increased with increasing number of hospitalized days. For patients hospitalized for >28 days, mean difference across approaches was >15%. PDC3 consistently yielded the highest value and PDC1 the lowest. WHAT IS NEW AND CONCLUSIONS: On average, different approaches to handling hospitalizations lead to similar adherence estimates to the gold standard of incorporating inpatient drug use. When patients have many hospitalization days during follow-up, the choice of approach should be tailored to the specific setting.

Cardiovascular risks associated with second-line oral antidiabetic agents added to metformin in patients with Type 2 diabetes: a nationwide cohort study.

AIM: To compare the cardiovascular risks associated with second-line oral antidiabetic agents added to initial metformin therapy in a large nationwide observational study. METHODS: We conducted a nationwide retrospective cohort study using the Taiwan National Health Insurance database. A total of 36 118 users of different add-on oral antidiabetic agents (sulphonylureas, glinides, pioglitazone, α-glucosidase inhibitors and dipeptidyl peptidase-4 inhibitors) after initial metformin therapy were included in the analysis. The reference group was sulphonylureas added to metformin, the most commonly used combination regimen. The main outcomes of interest were hospitalizations for any cardiovascular event including acute myocardial infarction, congestive heart failure and ischaemic stroke. In the main analysis, all patients were followed within their initiation groups until the study end, disregarding any changes in treatment status over time. RESULTS: In intention-to-treat analyses, there was no difference in the risk of any cardiovascular event among the add-on combination treatment groups, but significantly lower risks of acute myocardial infarction were found for the glinides plus metformin treatment group (crude hazard ratio 0.52, adjusted hazard ratio 0.39; 95% CI 0.20-0.75) and for the α-glucosidase inhibitors plus metformin treatment group (crude hazard ratio 0.63, adjusted hazard ratio 0.54; 95% CI 0.31-0.95). No difference in risk of congestive heart failure or ischaemic stroke risk was found among the combination treatment groups. In secondary as-treated analyses, similar but less significant associations were found as compared with the primary intention-to-treat analyses for all treatment groups. CONCLUSION: There were no differences in overall cardiovascular risks among several add-on second-line oral antidiabetic agents; however, glinide plus metformin and α-glucosidase inhibitors plus metformin combination therapies might be associated with lower risks of acute myocardial infarction.

Can aspirin reduce the risk of colorectal cancer in people with diabetes? A population-based cohort study.

AIM: To evaluate whether aspirin can reduce the risk of colorectal cancer in people with diabetes. METHODS: We studied ≥ 30-year-old people with diabetes, included in the Longitudinal Health Insurance Database 2005 in Taiwan, who were treated with hypoglycaemic drugs. We used a time-varying Cox regression model to adjust for immortal time bias and to estimate the adjusted hazard ratio and 95% CI for the association between aspirin use and colorectal cancer occurrence. RESULTS: We studied a total of 60 828 people with diabetes (31 176 men and 29 652 women). Their mean (sd) age was 58.72 (13.33) years. A total of 26 494 people were taking aspirin. Aspirin use 3-5 times/week (moderate frequency) for > 5 years (long duration) was found to reduce the risk of colorectal cancer by 46% (hazard ratio 0.54, 95% CI 0.34-0.86). Aspirin use > 5 times/week (high frequency) for 4-5 years (moderate duration) and > 5 years reduced the risk of colorectal cancer by 56 and 68%, respectively (hazard ratio 0.44, 95% CI 0.24-0.80; hazard ratio 0.32, 95% CI 0.20-0.50). Low frequency (≤ 2 times/week) and/or short duration (≤ 3 years) of aspirin use did not reduce the risk of colorectal cancer. CONCLUSIONS: Aspirin use with high frequency and long duration reduced the risk of colorectal cancer in people with diabetes in a frequency- and duration-dependent manner, whereas low frequency and/or short duration of aspirin use did not. The dosage, frequency and duration of aspirin use that are sufficient to prevent the incidence of colorectal cancer in people with diabetes require further study.

Pattern analysis and variations in the utilization of antihypertensive drugs in Taiwan: a six-year study.

BACKGROUND: In the last few years there have been changed in the pattern of consumption of antihypertensive drugs in other countries. Factors causing this variability include differences in the effectiveness of detection, guidelines for the management of hypertension, and differences in national health insurance systems among countries. AIM: The aim of this study was to reveal patterns in the use of antihypertensive drugs in Taiwan over a six year period (2001 to 2006) and compare these results with data from other countries. MATERIALS AND METHODS: This study performed descriptive analysis of data from the National Health Insurance Research Database (NHIRD) of Taiwan, and compared these findings with similar findings from around the world. Quantities were standardized using the defined daily dose (DDD) per 1000 inhabitants per day (DID) in accordance with WHO anatomical therapeutic classification and DDD measurement methodology. RESULTS: The total number of DDDs prescribed in Taiwan increased from 0.66 billion in 2001 to 1.08 billion in 2006, representing 80.6 and 129.2 DID in 2001 and 2006, respectively. This indicates a significant increase in the prescription of antihypertensive drugs in Taiwan over this period. The average annual increase ranged from 10.7% for calcium channel blockers (CCBs) to 22.1% for angiotensin II receptor blockers (ARBs). All of these patterns were statistically significant (p < 0.05). The rapid increase in the use of ARBs resulted in its surpassing ACEIs with the second highest DID (21.9) in 2006. Though the proportional use of CCBs and ARBs has increased significantly, the use of thiazide diuretics remains low. CONCLUSIONS: The consumption of antihypertension drugs in Taiwan increased during the period studied and the highest average annual increases were for ARBs and CCBs. Overall consumption of antihypertension drugs also increased in other countries, but differences in the relative increase for each class of drug suggest that further study may be required to clarify the origins and causes.

Predicting methicillin resistance among community-onset Staphylococcus aureus bacteremia patients with prior healthcare-associated exposure.

To develop and validate prediction rules to identify the risk of methicillin-resistant Staphylococcus aureus (MRSA) infection among community patients who have healthcare-associated (HA) exposure and S. aureus bacteremia. A total of 1,166 adults with community-onset S. aureus bacteremia were retrospectively enrolled. The background prevalence of community MRSA infection was extrapolated from 392 community-associated S. aureus bacteremia (CA-SAB) patients without HA exposure. Complete and clinical risk scores were derived and tested using data from 774 healthcare-associated S. aureus bacteremia (HA-SAB) patients. The risk scores were modeled with and without incorporating previous microbiological data as a model predictor and stratified patients to low-, intermediate-, and high-risk groups for MRSA infection. The clinical risk score included five independent predictors and the complete risk score included six independent predictors. The clinical and complete risk scores stratified 32.7 % and 42.0 % of HA-SAB patients to the low-risk group for MRSA infection respectively. The prevalence of MRSA infection in score-stratified low-risk groups ranged from 16.3 % to 23.3 %, comparable to that of CA-SAB patients (13.8 %). Simple decision rules allow physicians to stratify the risk of MRSA infection when treating community patients with prior HA exposure and possible S. aureus infection.

Nationwide population-based epidemiologic study of rheumatoid arthritis in Taiwan.

OBJECTIVES: Epidemiological studies of rheumatoid arthritis in Asia are rare. The aim of this research was to study the epidemiology and associated medical expenses of rheumatoid arthritis in Taiwan. METHODS: Cases of rheumatoid arthritis, based on the 1987 American College of Rheumatology criteria, were retrieved from the National Health Insurance Research Database with corresponding International Classification of Diseases, Ninth Revision code (ICD-9) 714.0 from January 2000 to December 2007, and limited to those 16 years and older. Age- and sex-specific incidences were estimated by dividing the incidence number by population data obtained from the Department of Statistics, Ministry of the Interior. RESULTS: There were a total of 40,995 cases. The average age-adjusted annual incidence rate was 15.8 per 100,000. The adjusted incidence rates were very stable at 20.9-25.2/100,000/year and 7.0-8.2/100,000/year for females and males, respectively, during the study period. The adjusted average incidence ratio of females/males was 3.1. The age-specific incidence peaked in the 60-64 and 70-74 year age groups for females and males, respectively. The adjusted prevalence rate increased steadily during the study period from 57.7/100,000 in 2000 to 99.6/100,000 in 2007. The average total yearly expense per patient increased from 1,155 United States Dollars (USD) in 2000 to 1,821 USD in 2007. Sicca syndrome (ICD-9 code 710.2) was the most common co-existing ICD-9 code. CONCLUSIONS: This is the first incidence study based on the 1987 American College of Rheumatology criteria in Asia. The prevalence rate based on these criteria was lower than in previous Asia studies. The medical expenses increased continuously.

A randomised controlled study of risperidone and olanzapine for schizophrenic patients with neuroleptic-induced acute dystonia or parkinsonism.

The objective of this study was to compare the effects of risperidone and olanzapine in schizophrenic patients with intolerant extrapyramidal side effects (EPS) on first generation antipsychotics. We conducted an 8-week, rater-blinded, flexible dose study. Seventy patients with schizophrenia, who met the DSM-IV research criteria of having neuroleptic-induced acute dystonia or parkinsonism, were randomly assigned to risperidone or olanzapine group. The primary outcome was a comparison of the incidence of concomitant anticholinergic drugs usage between the groups to manage their acute dystonia and parkinsonism. The average doses of risperidone and olanzapine from baseline to study end point were 1.8-3.5 mg/day and 7.7-11.7 mg/day, respectively. There were no significant differences in demographic data, severity of EPS or psychotic symptoms between the groups at baseline assessment. Patients taking risperidone had significantly higher incidence of using anticholinergic drugs to manage acute dystonia or parkinsonism overall during the study (OR = 5.17, 95%CI = 1.49-17.88, P = 0.013). There was no significant between-group difference in the changing of rating scales of EPS and psychotic symptoms. The results of our study favour olanzapine as a better choice in schizophrenic patients with intolerant EPS. Double-blinded, fixed dose and different ethnical study for EPS-intolerant schizophrenic patients is needed to confirm the results of our study.

How long can patients with mild or moderate Alzheimer's dementia maintain both the cognition and the therapy of cholinesterase inhibitors: a national population-based study.

The aims of this study were to evaluate the duration of acetylcholinesterase inhibitors (AChEI) utilization as well as the patients' cognition maintenance. This study was using panel data from the Bureau of National Health Insurance (BNHI) of Taiwan from 2001 to 2004. Patients with mild or moderate AD were prescribed AChEI (donepezil, rivastigmine, or galantamine). By the regulation of BNHI, if the score of Mini-Mental Status Examination worsened by more than two points or clinical dementia rating (CDR) worsened by one or more grades in the follow-up every half year, the AChEI treatment would be terminated. Kaplan-Meier product-limit method was used to estimate duration of drug utilization. Regression model was performed to analyse the factors affecting the discontinuation of AChEI treatment. Our results showed female are more and younger than male in mild to moderate Alzheimer's dementia. The mean duration of use of AChEI was 432 days. Only 9.6% of patients maintained stable cognition tests results with continued drug refill for more than 3 years. Discontinuation rate in older patients (age > or =76 years) was higher than those in younger age (P = 0.0009). The average duration for AChEI therapy is around 14 months. The elderly are at high risk for treatment discontinuation.

Organization-based performance measures of cancer care quality: core measure development for breast cancer in Taiwan.

The purpose of the study was to develop organization-based core performance measures (CPMs) for breast cancer patients treated in hospitals that participated in cancer quality improvement programmes in Taiwan. CPMs were developed in three stages that included a preparation, a consensus building stage, and two stages of stakeholder feedback. Three criteria and seven subcriteria were applied in the development process. Indicators listed in a Delphi questionnaire were based on a literature search, indicators developed by relevant institutions and discussion by authors. Each indicator needed to meet inclusion criteria as a final indicator. Evidence-based guidelines, expert opinions from panel group, 27 hospitals and empirical data were all applied to develop and revise the core measures. Fifteen out of 28 indicators were selected and modified after the three stages. There were two pre-treatment indicators for screening and diagnosis, nine treatment-related indicators, and four monitoring-related indicators. Six indicators were supported by evidence level I, and four indicators by level II evidence. The CPMs for breast cancer can be developed systematically and be applied for internal quality improvement and external surveillance. Our experience can be extended to other cancer sites and adapted to link with pay for performance or certification program in cancer care.

Influence of solution acidity and CaCl2 concentration on the removal of heavy metals from metal-contaminated rice soils.

Soil washing is considered a useful technique for remediating metal-contaminated soils. This study examined the release edges of Cd, Zn, Ni, Cr, Cu or Pb in two contaminated rice soils from central Taiwan. The concentrations exceeding the trigger levels established by the regulatory agency of Taiwan were Cu, Zn, Ni and Cr for the Ho-Mei soil and Pb for the Nan-Tou soil. Successive extractions with HCl ranging from 0 to 0.2 M showed increased release of the heavy metals with declining pH, and the threshold pH value below which a sharp increase in the releases of the heavy metals was highest for Cd, Zn, and Ni (pH 4.6 to 4.9), intermediate for Pb and Cu (3.1 to 3.8) and lowest for Fe (2.1), Al (2.2) and Cr (1.7) for the soils. The low response slope of Ni and Cr particularly for the rice soils make soil washing with the acid up to the highest concentration used ineffective to reduce their concentrations to below trigger levels. Although soil washing with 0.1 M HCl was moderately effective in reducing Cu, Pb, Zn and Cd, which brought pH of the soils to 1.1+/-0.1 (S.D.), the concurrent release of large quantities of Fe and Al make this remediation technique undesirable for the rice soils containing high clay. Successive washings with 0.01 M HCl could be considered an alternative as the dissolution of Fe and Al was minimal, and between 46 to 64% of Cd, Zn, and Cu for the Ho-Mei soil and 45% of Pb in the Na-Tou soil were extracted after four successive extractions with this dilute acid solution. The efficacy of Cd extraction improved if CaCl2 was added to the acid solution. The correlation analysis revealed that Cr extracted was highly correlated (P < 0.001) with Fe extracted, whereas the Cu, Ni, Zn, Cd or Pb extracted was better correlated (P < 0.001) with Al than with Fe extracted. It is possible that the past seasonal soil flooding and drainage in the soils for rice production was conducive to incorporating Cr within the structure of Fe oxide, thereby making them extremely insoluble even in 0.2 M HCl solution. The formation of solid solution of Ni with Al oxide was also possible, making it far less extractable than Cd, Zn, Cu, or Pb with the acid concentrations used.

Activation of the transient receptor potential M2 channel and poly(ADP-ribose) polymerase is involved in oxidative stress-induced cardiomyocyte death.

Overproduction of reactive oxygen species is one of the major causes of cell death in ischemic-reperfusion (I/R) injury. In I/R animal models, electron microscopy (EM) has shown mixed apoptotic and necrotic characteristics in the same cardiomyocyte. The present study shows that H(2)O(2) activates both apoptotic and necrotic machineries in the same myocyte and that the ultrastructure seen using EM is very similar to that in I/R animal studies. The apoptotic component is caused by the activation of clotrimazole-sensitive, NAD(+)/ADP ribose/poly(ADP-ribose) polymerase (PARP)-dependent transient receptor potential M2 (TRPM2) channels, which induces mitochondrial [Na(+)](m) (and [Ca(2+)](m)) overload, resulting in mitochondrial membrane disruption, cytochrome c release, and caspase 3-dependent chromatin condensation/fragmentation. The necrotic component is caspase 3-independent and is caused by PARP-induced [ATP](i)/NAD(+) depletion, resulting in membrane permeabilization. Inhibition of either TRPM2 or PARP activity only partially inhibits cell death, while inhibition of both completely prevents the ultrastructural changes and myocyte death.

Post-radiation Pap smear for Chinese patients with cervical cancer: a ten-year follow-up.

BACKGROUND: To study the performance of routine follow-up Pap smears after curative radiotherapy (RT) for Chinese cervical cancer (CC) patients. METHODS: In 1996, 50 patients with non-metastatic CC received curative RT. Forty-six patients had routine follow-up Pap smears and constituted the study group. Details regarding clinical characteristics were retrospectively abstracted. Pap smear results were obtained via national Pap smear database linkage and chart review. The Pap smear results during recurrence-free survival (RFS) were analyzed and compared with clinical outcomes to study the performance characteristics. RESULTS: After 34 (2 approximately 105) months' median follow-up, the clinical outcomes were isolated central recurrence (ICR), other recurrence (OR), and no evidence of disease (NED) for six, 20, and 20 patients, respectively. During 22 months' median RFS (range 2-105), 422 Pap smears (including missing data, n = 33) were performed. Most of the Pap smear results were within normal limits (65.8%) or benign (reactive changes or atrophy with inflammation) (25.2%). Atypical cells, low-grade squamous intraepithelial lesion (LSIL), high-grade intraepithelial lesion (HSIL), and carcinoma were found in ten (2.6%), 11 (2.8%), 11 (2.8%), and three (0.8%) specimens, respectively. Follow-up of the 21 atypical cells/LSIL smears among seven patients revealed five NED with normal/benign smears, one NED with HSIL and one OR with HSIL. Follow-up of the 11 HSIL smears among four patients revealed two ICR, one OR and one NED with HSIL. Follow-up of the three carcinoma smears revealed three ICR (one followed by HSIL in a repeat Pap smear before ICR). The sensitivity for the detection of ICR by carcinoma smears was 50%, with a specificity and positive predictive value (PPV) of 100%. CONCLUSION: Few (approximately 3%) of the routine follow-up Pap smears after CC patients receiving curative RT were HSIL/carcinoma, but most (4/6) of these patients turned out to be ICR.

Cholangiocarcinoma presenting as pseudoachalasia and gastroparesis.

Cholangiocarcinoma most commonly presents as painless progressive jaundice. We report a case occurring in a 56-year-old Chinese woman with an unusual presentation of progressive dysphagia and vomiting. Oesophageal manometric and barium studies were indicative of achalasia, and computed tomography confirmed the presence of cholangiocarcinoma extending to the gastroesophageal junction and proximal lesser curve of the stomach. In this case, a constricting tumour at the gastroesophageal junction with probable invasion of the vagus nerves led to features of achalasia and gastroparesis.

Direct costs-of-illness of patients with diabetes mellitus in Taiwan.

The purpose of the present study was to examine the characteristics of healthcare costs for diabetic patients in Taiwan. The study analyzed claim data from the Bureau of National Health Insurance for the period from July 1997 to June 1998. There were 536159 documented diabetic patients who were treated within the universal healthcare system in Taiwan during this study period. The annual number of visits of these diabetic patients was 6.2% of the total outpatient visits of all patients due to all causes during the one-year study period. Diabetes-related problems were the causes of 25.2% of outpatient visits among diabetic patients, while 74.8% of visits were for causes unrelated to diabetes. The distribution of treatment for the diabetic patients was by oral hypoglycemic agents 88.3%, insulin only 6.9%, and a combination of insulin and oral agents 4.8%. Diabetic patients accounted for 4,724,711 hospital inpatient days during the study period, which was 22.1% of the total inpatient days in Taiwan. Of the inpatient admissions, 13.9% were for diabetes as the principal cause, 23.4% were for diabetes-related disease, and 62.7% were for causes unrelated to diabetes. The direct costs of healthcare for the documented diabetic patients was 11.5% of the total costs of healthcare in Taiwan, and was 4.3 times higher than the average costs of care for non-diabetic individuals.

An initial assessment of the feasibility and effectiveness of implementing diabetes shared care system in Taiwan--some experiences from I-Lan County.

Diabetes is the fifth leading cause of death in Taiwan and the burden of suffering is still increasing. Building a comprehensive and efficient health care system is crucial to improve the outcome of the diabetics. We implemented the first diabetes shared care system of Taiwan in I-Lan County since August 1996 under the support of Department of Health, the Executive Yuan. This county-wide system was named 'Lan-Yang Diabetes Shared Care System' by the regional steering committee. Regional guidelines for diabetes management were developed after extensive discussion. A multidisciplinary diabetes care team was organized through a training and certification process. Registered patients held diabetes passports to keep clinical record. Physicians of the system use shared referral protocols and sheets. By the end of June 1999, 99 medical professionals had completed their training for diabetes shared care and been certified. The shared care system awarded 26 clinics to hang the lamp signs with the system logo to make them distinguishable. Such clinics have now been available throughout 12 townships in I-Lan County. The number of registered patients carrying diabetes passport increased to 3484 and there was a community-based patient group in every township of I-Lan County. The amount of continuing diabetes clinical training delivered by the specialists to the primary care physicians and non-physician professionals increased to 1681 person-hours per year. The proportion of registered patients undertaking fundus examination within 1 year increased to 30.9%, checking urine micro-albumin to 28.0% and checking HbA(1c) 72.8%, respectively. Mean HbA(1c) value decreased from 8.7% in the first year to 7.9% in the third year. Our study showed that under the co-ordination by regional health bureau with integration of different levels of medical facilities, governmental sectors and non-governmental community resources, the diabetes shared care model is feasible in Taiwan. Through its implementation, quality of regional diabetes care has achieved preliminary improvement.