Association between teriparatide treatment persistence and adherence, and fracture incidence in Taiwan: analysis using the National Health Insurance Research Database.

UNLABELLED: Medication persistence and adherence are critical for osteoporosis outcomes. Using the Taiwan National Health Insurance Research Database, we found that persistence and adherence to teriparatide were low in Taiwanese patients with osteoporosis and that greater persistence and adherence were associated with a lower incidence of hip and other nonvertebral fractures. INTRODUCTION: The purpose of this study was to determine the persistence and adherence to teriparatide treatment in Taiwanese patients with osteoporosis, and to examine the association between persistence and adherence to teriparatide with fracture risks. METHODS: Medical and pharmacy claims for 4,692 patients with vertebral or hip fractures and teriparatide prescriptions between 2005 and 2008 were identified (Taiwan National Health Insurance Research Database). Persistence was the time from the start of treatment to the first 90-day gap between two teriparatide prescriptions. Adherence was the number of teriparatide pens (each pen is used over 1 month) prescribed over 24 months. Association of persistence and adherence to teriparatide with fracture incidence was assessed using adjusted Cox proportional hazards models. RESULTS: The proportion of patients persisting with teriparatide for >6 months and >12 months was 44.6 and 24.9 %, respectively. Over 24 months, 53.6 % of patients were adherent for >6 months and 33.9 % were adherent for >12 months. Patients persisting for >12 months had a significantly lower incidence of hip (adjusted hazard ratio [HR], 0.61 [95 % confidence interval (CI), 0.40-0.93], P = 0.0229) and nonvertebral fracture (HR, 0.79 [95 % CI, 0.63-0.99], P = 0.0462) compared with those who persisted for ≤12 months. Patients adherent for >12 months had a lower incidence of hip (HR, 0.66 [95 % CI, 0.46-0.96], P = 0.0286) and nonvertebral fracture (HR, 0.81 [95 % CI, 0.66-0.99], P = 0.0377) compared with those adherent for ≤12 months. CONCLUSIONS: Persistence and adherence to teriparatide over 24 months were low in Taiwanese patients with osteoporosis; greater adherence and persistence were associated with a lower incidence of nonvertebral fractures.

Definition, risk factors and outcome of prolonged surgical intensive care unit stay.

There is no generally accepted definition for a "prolonged surgical intensive care unit (SICU) stay". The aims of the current study were to: (1) define prolonged SICU stay; (2) identify risk factors of prolonged SICU stay; and (3) identify risk factors of hospital mortality in patients with a prolonged SICU stay. All SICU patients aged >16 years and with an intensive care unit (ICU) stay longer than three days without ICU readmission between 1 January 2004 and 30 November 2006 at the National Taiwan University Hospital were recruited to the study. A total of 2598 patients were recruited. ICU stay >16 days was defined as a prolonged SICU stay since rates of ICU mortality, hospital mortality and mortality one year after ICU discharge remained stationary after ICU stay was >16 days. A multivariate logistic regression model identified factors associated with a prolonged SICU stay, including age more than 70 years old, (odds ratio 1.587, 95% confidence interval 1.246 to 2.022), increasing pre-ICU hospital days (odds ratio 1.009, 95% confidence interval 1.003 to 1.015), admission from emergency (odds ratio 1.925, 95% confidence interval 1.455 to 2.548), use of mechanical circulation support (odds ratio 2.314, 95% confidence interval 1.458 to 3.674) and renal replacement therapy (odds ratio 5.140, 95% confidence interval 3.781 to 6.987). A multivariate logistic regression model identified factors associated with ICU mortality in patients with ICU stay >16 days, including renal replacement therapy (odds ratio 4.780, 95% confidence interval 2.687 to 8.504). An ICU stay >16 days could be used to define prolonged SICU stay when hospital and one-year mortality rates are considered. Prevention of organ failure requiring renal replacement therapy might prove a useful goal to avoid prolonged ICU stay and even hospital mortality.

Home-based trunk-strengthening exercise for osteoporotic and osteopenic postmenopausal women without fracture--a pilot study.

OBJECTIVES: To investigate whether a 12-week home-based programme of trunk-strengthening exercise could benefit spinal mobility, function and quality of life for osteoporotic and osteopenic postmenopausal women without fracture. DESIGNS: Randomized controlled clinical trial. SETTING: Department of Physical Therapy in National Taiwan University Hospital. SUBJECTS: Twenty-eight postmenopausal women (mean age 60.3+/-9.3 years) diagnosed with osteoporosis or osteopenia without fracture history were recruited for this study. Subjects were randomly assigned into exercise or control groups, each consisting of 14 subjects. INTERVENTIONS: The 12-week exercise programme included strengthening routines for the trunk extensor and flexor muscles. The subjects performed three sets of 10 repetitions for each of the exercises, with programmes carried out three times per day at home. MAIN OUTCOME MEASUREMENTS: Muscular strength, spinal range of motion (ROM) and motion velocity, Oswestry Disability Questionnaire (ODQ) and quality of life (QOL) were measured before the start and after completion of the exercise programme. RESULTS: Statistically significant improvements were demonstrated in spinal ROM and motion velocity in the sagittal and frontal planes for the exercise group (p<0.05). Further, the strength of the trunk flexors and extensors increased after exercise training (p<0.05). ODQ measure was significantly reduced in the exercise group (p<0.05), while the controls showed no significant change. Subjects in the exercise group showed better satisfaction in some domains of the Short-Form-36 Health Survey quality of life questionnaire (p<0.05). CONCLUSIONS: This 12-week home-based trunk-strengthening exercise programme could improve trunk mobility and strength, and enhance QOL in osteoporotic and osteopenic postmenopausal women without vertebral fracture. Future study should recruit more cases or more severe subjects to verify the results.

Spinal performance and functional impairment in postmenopausal women with osteoporosis and osteopenia without vertebral fracture.

Previous studies have paid much attention to the impact on functional impairment or quality of life from vertebral fractures secondary to osteoporosis, but little research has addressed the function of osteoporotic women without fractures. The purposes of this study were: (1) to describe spinal performance and functional impairment in postmenopausal women with osteoporosis and osteopenia without vertebral fracture, and (2) to investigate the relationship between them. Thirty postmenopausal women diagnosed as having osteoporosis or osteopenia were recruited who fulfilled the following criteria: (1) menopause for at least 6 months; (2) no vertebral fracture; (3) no medication that would interfere with calcium intake. Measurements included assessment of functional impairment and spinal performance including trunk extension/flexion isokinetic strength, spinal range of motion (ROM) and movement velocity in three planes (sagittal, frontal and transverse). The results showed that spinal ROM and velocity were significantly reduced in the osteoporosis group compared with the osteopenia group ( p<0.05), but no significant difference in trunk strength was shown. Functional impairment level showed a slight difference between the two groups ( p = 0.042). There was a significant correlation between spinal ROM and motion velocity with bone mineral density; however, functional impairment correlated with motion velocity only in the transverse plane (trunk rotation) ( p<0.05). Spinal strength did not show any correlation with other parameters. It was concluded that spinal motion performance declined and functional impairment increased in relation to the severity of bone mineral loss in postmenopausal women without vertebral fracture, but their physical performance was not correlated with functional impairments.

Effectiveness of a multidisciplinary rehabilitation program in elderly patients with hip fractures.

BACKGROUND AND PURPOSE: Hip fracture is a significant health challenge to the elderly, with a high risk of complications, long hospital stay, and functional deterioration. The purpose of this study was to evaluate the effectiveness of a multidisciplinary rehabilitation program (MRP) in older patients with hip fractures. METHODS: A before-and-after quasi-experimental design was used. Data were collected at a large teaching hospital in Taipei. The first 105 consecutive patients admitted received conventional care (control group). The next 50 consecutive patients received physical therapy, nurse-supervised exercise, and discharge planning (intervention group). Subjects were assessed upon admission, on the fourth postoperative day, and on the discharge day. The 155 patients recruited met the following criteria: 60 years of age or older, and hospitalized to receive either closed reduction and internal fixation, or hip arthroplasty. RESULTS: Compared with the control group, the intervention group had a shorter average hospital stay (9.9 vs 11.6 days, p = 0.01), earlier ambulation (5.7 vs 6.5 days postoperatively), and a lower rate of bowel incontinence (4.0% vs 23.8%) and pressure sores (14.0% vs 24.8%) during hospitalization. The intervention group experienced less decline in mobility (relative to pre-fracture status) than the control group. No significant difference was found in other outcome variables between the control and intervention groups. CONCLUSIONS: The findings of this study indicate that an MRP involving physical therapy, nurse-supervised exercise, and discharge planning positively affects health outcomes in older patients with hip fractures.

Estimation of expected utility gained from the helmet law in Taiwan by quality-adjusted survival time.

The objective of this study was to empirically estimate the expected utility gained from the implementation of the 1997 helmet law in Taiwan by using quality-adjusted survival time (QAST). We randomly selected 400 out of 8221 registered cases of head injury and successfully interviewed 99 cases with the index of health-related quality of life (IHRQ). The function of IHRQ was then multiplied with the corresponding survival function to obtain the QAST for head injury. The total utility gained from the helmet law in Taipei within 1 year was estimated by multiplying the expected loss of utility per patient with the number of prevented cases. The results showed that after 80 months of follow-up, the QAST of the injured population was 66.3 quality-adjusted life-months (QALMs), while that of the reference population was 78.7 QALMs. We extrapolated the QAST for total life expectancy by simulating the survival of head injury cases using the life table data from the general population. The life-long utility loss of a head injury case was found to be 4.8 quality-adjusted life-years (QALY). The number of prevented cases during the first year of enforcement of the helmet law was estimated to be 1300 cases in Taipei, which amounted to 6240 QALYs gained. For lack of data, we were unable to calculate the possible gain from helmet on reduction of severity among nonfatal cases with head injury, and the estimation was only a lower bound. We concluded that the QAST approach is a feasible approach applicable to health policy decision-making, especially in cost-utility analysis.

Quality of life of spinal cord injured patients in Taiwan: a subgroup study.

The major purposes of this study were to assess the quality of life (QOL) of spinal cord injured patients, and to assess the possible factors affecting the QOL. The survey was conducted from 1992-1993 by mailed questionnaires to members of Spinal Cord Injury Association of the Republic of China. There were 347 quality responses with the mean age of 37.5 +/- 10.2 years old and the mean duration of illness of 7.8 +/- 6.8 years. The questionnaire included five domains, physical mobility, environment-transportation, psychosocial adjustment, education and economics for a total of 39 items. Each item contained a rating of 'importance' and 'satisfaction'. The quality of life index (QLI) was calculated by multiplying the satisfaction score with the importance score, then dividing by the possible highest score. The major results included: (1) the subjects had mild to moderate dissatisfaction with most items in five domains except psychosocial adjustment: (2) quality of life in those with complete tetraplegia (QLI = -0.41) and incomplete tetraplegia (QLI = -0.31) was significantly lower than that of those with complete paraplegia (QLI = -0.13) and incomplete paraplegia (QLI = -0.04); (3) both the severity of injury and the post-injury working status were the major factors affecting the life quality of spinal cord injured patients in Taiwan.

Age-period-cohort analysis of motor vehicle mortality in Taiwan, 1974-1992.

The aim of this study was to examine the effects of age, calendar period of death and birth cohort in motor vehicle mortality in Taiwan over the period 1974-1992. A log-linear model modified from the method of Osmond and Gardner (Stat. Med. 1: 245-259; 1982) was used. Age turned out to be a significant predictor of motor vehicle mortality. The most risky group (over 70 years) had 27.1 and 16.3 times the mortality of the least risky group (5-9 years, 10-14 years) for males and females respectively. The period effect showed a continuously increasing mortality trend since 1974 in females. The pattern in males is similar except that it has slightly leveled off in recent years. The birth cohorts at the highest risk of motor vehicle death were those born between 1979 and 1983 for both sexes. However, males born between 1929 and 1933 also had a high mortality. This analysis provided a better understanding of the trend of mortality from motor vehicle crashes.

Estimation of expected quality adjusted survival by cross-sectional survey.

To compare both mortality and quality of life (QOL) across different illnesses, we propose an estimator to calculate the expected quality adjusted survival (QAS) by multiplying the QOL into the survival function. While the survival function can be determined by the usual life table method, the QOL data can be collected by a cross-sectional survey among patients who are currently surviving. The area under the QAS curve is thus the expected utility of health of the specific illness, which may take a common unit of quality adjusted life year ready for outcome evaluation and policy decision. A simulation is performed to demonstrate that the proposed estimator and its standard error are relatively accurate. The limitations and guidelines for using this estimator are also discussed.

Isokinetic study of muscle strength in osteoarthritic knees of females.

The present investigation was aimed at assessing the difference in peak torque between normal and osteoarthritic (OA) knees in females. Fifty-five female osteoarthritic patients with 85 osteoarthritic knees were studied. Thirty-three normal females of similar age were also collected as a control group. The muscle torque of the knee flexor and extensor was assessed by a Cybex II dynamometer. The speed of isokinetic contraction was set at 30 RPM, 5 RPM, and 0 RPM. The muscle torque of the affected knee in patients with unilateral osteoarthritis was found to be significantly greater than that of those with bilateral osteoarthritis (p less than 0.05). The peak torque of OA patients at the faster speed (30 RPM) showed significant deterioration with age. Compared with the value for controls, the deficit of peak torque in geriatric patients was significant (p less than 0.05), especially at the faster speed (30 RPM). The decrease in extensor torque in OA knees tended to be greater than that of flexor torque, especially in patients less than 51 years of age at 5 RPM and 0 RPM. Age, duration of illness and the grading of X-ray change accounted for isokinetic torque differences in osteoarthritic knees.