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Background Approximately 40% of pancreatic tumors smaller than 2 cm are missed at abdominal CT. Purpose To develop and to validate a deep learning (DL)-based tool able to detect pancreatic cancer at CT. Materials and Methods Retrospectively collected contrast-enhanced CT studies in patients diagnosed with pancreatic cancer between January 2006 and July 2018 were compared with CT studies of individuals with a normal pancreas (control group) obtained between January 2004 and December 2019. An end-to-end tool comprising a segmentation convolutional neural network (CNN) and a classifier ensembling five CNNs was developed and validated in the internal test set and a nationwide real-world validation set. The sensitivities of the computer-aided detection (CAD) tool and radiologist interpretation were compared using the McNemar test. Results A total of 546 patients with pancreatic cancer (mean age, 65 years ± 12 [SD], 297 men) and 733 control subjects were randomly divided into training, validation, and test sets. In the internal test set, the DL tool achieved 89.9% (98 of 109; 95% CI: 82.7, 94.9) sensitivity and 95.9% (141 of 147; 95% CI: 91.3, 98.5) specificity (area under the receiver operating characteristic curve [AUC], 0.96; 95% CI: 0.94, 0.99), without a significant difference (

This paper provides an introduction to laboratory databases established by Taiwan National Health Insurance Administration (NHIA) since 2015 and released for research since June 2017. The National Health Insurance (NHI) is a government-run single-payer program introduced in 1995 that now covers more than 99% of 23 million Taiwanese citizens. To prevent duplication of medication prescriptions and laboratory test and examination prescriptions, contracted health care providers are required to upload the results of laboratory tests and reports of examinations to the NHIA. The cumulative number of laboratory test results was 5.64 billion from January 2015 to the end of August 2020 for 602 types of test. There are 35 variables for each laboratory test result stored in the databases that can be used for research. However, different hospitals might use different format in reporting the results. The researchers therefore have to develop algorithms to include and exclude incompatible records and to determine whether the results are positive or negative (normal or abnormal). The NHIA suggests that researchers release their source codes of algorithms so that other researchers can modify the codes to improve inter-study comparability. Through the unique personal identification number, the laboratory data can be linked to NHI inpatient and outpatient claims data for further value-added analyses. Non-Taiwanese researchers can collaborate with Taiwan researchers to access the NHI laboratory databases.

Medical technology is undergoing rapid transformations, and the classifications of medical devices have also expanded greatly; therefore, it is necessary to develop appropriate reimbursement policies and pricing mechanisms in a timely manner. This paper aims to introduce the reimbursement coverage and pricing rules for medical devices in Taiwan. In addition, this paper identifies and evaluates available health technology assessments (HTA) and literature on published websites concerning medical device decision-making processes and pricing systems in South Korea and Japan, which are near Taiwan and have similar reimbursement coverage processes. Reimbursement policy and pricing mechanisms are constantly being revised in Taiwan, Japan, and South Korea. Recently, all three countries attempted to establish new reimbursement coverage decision-making and pricing rules, adopting a differentiated approach based on the level of evidence required for the appropriated reimbursement in terms of a feasible evaluation mechanism for providing patients with more effective medical devices. This article is expected to contribute to providing references to new reimbursement coverage decision-making and pricing rules.

The National Health Insurance Administration (NHIA) began a pilot telemedicine program for people in remote areas after the Ministry of Health and Welfare expanded the eligibility for telemedicine. The impact of the COVID-19 pandemic on the healthcare system also accelerated the inclusion of telemedicine in the scheme. This chapter discusses how 5G facilitates telemedicine services; for example, the virtual National Health Insurance (NHI) card could bring comprehensive medical service to more settings, such as home-based medical care, by virtualizing the identification process.The NHI played a pivotal role in Taiwan’s battle against COVID-19. Besides providing travel history, occupation, contact history, and cluster to medical providers on the NHI MediCloud systems, the NHI virtual private network system was used to distribute medical masks through contracted pharmacies in the early stage of the pandemic. Moreover, the NHIA pulled in data, including vaccination history and polymerase chain reaction test results, from the NHI database to the NHI Express app so that the public can manage their health promptly. The last part of the chapter discusses Taiwan’s successful story of opening data to the private sectors to carry out the name-based medical mask distribution system.

With the sharply escalating medical expenses, the National Health Insurance Administration (NHIA) has implemented a number of programs to contain expenditure, deliver patient-centered health care, and meet the medical needs of the super-aged society that Taiwan will face in the future.Taiwan has followed the steps of many advanced countries to separate medicine and pharmacy to promote medication safety. In this chapter, we describe various obstacles and contingent approaches to implementing a policy that is quite against the social norm. The outcome was analyzed to evaluate the effect of this controversial policy. To connect long-term care seamlessly after hospital discharge, discharge planning and follow-up management fees are covered by the National Health Insurance (NHI). The NHIA has also endeavored to encourage two-way referrals in the tiered medical care structure since 2017, hoping to improve the efficiency of the overall healthcare system through the redistribution of workload and the continuity of health care. Therefore, in addition to increasing the reimbursement for hospitalization and emergency treatment, differences in co-payment for referral visits from different levels of hospitals were applied to encourage better healthcare-seeking behavior. We also discuss the decision-making process of the on-going co-payment adjustment at the end of the chapter.

This chapter explains why National Health Insurance Administration (NHIA) decoupled the premium payment and right to health care to safeguard the medical right of the financially disadvantaged. Furthermore, various programs have been carried out to improve the accessibility and comprehensiveness of medical care for residents of remote and offshore islands. The National Health Insurance (NHI) has also progressively covered orphan drugs to meet the medical needs of patients with rare diseases.In addition to eliminating geographic and economic health disparity, the NHIA strives to improve health literacy and knowledge of the health insurance system of the public. “My Health Bank” was launched to enable its users to query personal medical and health information in real time to encourage self-health management and enhance the safety and quality of medical care. The NHI was introduced to elementary school pupils to acquaint the younger generation with its concept and have a more profound influence.

This chapter provides an overview of Taiwan’s National Health Insurance (NHI) system. In 1995, major social insurance programmes, such as labour insurance, government employee health insurance and farmers’ insurance, were merged and enlarged to form the NHI to deliver universal health coverage. Since its inception, the payment system of the NHI is the fee-for-service method. Moreover, most of the health care is provided by private sectors, and there are no restrictions on patients seeking medical care. Owing to the high medical accessibility, the volume of outpatient services is high, and the National Health Insurance Administration (NHIA) has to develop various measures to maintain its financial stability. Several strategies have been implemented by the NHIA for health equity, and the NHI MediCloud system, the NHI card and ‘My Health Bank’ were provided to ensure patients’ safety and enhance healthcare quality.

The National Health Insurance (NHI) is compulsory and provides universal health coverage to all citizens of Taiwan and those who have had a registered domicile, as well as foreigners holding alien residence certificates in Taiwan for 6 months. The right of the insured to access medical care is protected, whether they suffer from illness, injury or require reproductive care. This chapter introduces the financial structure of the NHI, enrolment eligibility and how the premiums are calculated for different insured groups and their insured units. The collection of supplementary premiums, which correlate additional premium contribution with non-salary-based income, is also explained. To maintain the financial independence and liability system of the NHI, by law, the premium rate is reviewed annually. Hence, the actuarial calculation of the premium rate plays a crucial role.

The virtual National Health Insurance (NHI) card not only represents digitization but also enables contactless health care during the pandemic. Under the process of full-scale digitization, the National Health Insurance Administration (NHIA) continues to refine the health service delivery measures, especially in the field of home-based medical care and telemedicine.Under the personal data protection regulation, the NHI data are opened for academic research purposes. More than 6550 published journal articles have utilized the NHI data, and these articles are made searchable online to support health policy management and clinical research. The NHI medical images combined with the application of artificial intelligence (AI) are the cornerstones of Taiwan’s smart health care. Domestic research teams are eligible to use the NHI database to verify or build their AI models after their research proposals are approved by the Management Council of the AI Application of NHI Data. The NHIA also plans to use NHI big data to develop digital patient decision aids by establishing a two-way digital interaction model to address the concerns of the healthcare providers and the public. By comparing the secondary use of health data in different countries, Taiwan is seeking a balance between innovation and conservative policies and is creating an environment that ensures the well-being of the next generation.

Ji-An Liang,1,2,* Po-Chang Lee,3,* Chun-Ping Ku,3,* William Tzu-Liang Chen,2,3,* Chih-Yuan Chung,4 Yu-Cheng Kuo,1,2 Szu-Hsien Chou,5 Chia-Chin Li,6 Chun-Ru Chien1,2,6 1Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan; 2School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; 3Department of Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan; 4Department of Medical Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan; 5Department of Medical Imaging, China Medical University Hsinchu Hospital, Hsinchu, Taiwan; 6Department of Radiation Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan*These authors contributed equally to this workCorrespondence: Chun-Ru ChienSchool of Medicine, College of Medicine, China Medical University, No. 91 Hsueh-Shih Road, North District, Taichung, 40402, TaiwanTel +886-4-22052121-7450Fax +886-4-22052121-7460Email d16181@gmail.comPurpose: Image-guided radiotherapy (IGRT) is an advanced radiotherapy technique to improve the radiotherapy delivery. We aimed to compare the overall survival (OS) for localized breast cancer (LBC) patient treated with adjuvant conventional fractionated radiotherapy (CFRT) using IGRT vs those without IGRT via a population-based analysis.Patients and Methods: Eligible LBC patients diagnosed between 2011 and 2013 were identified via the Taiwan Cancer Registry. We used propensity score (PS) weighting to balance observable potential confounders between groups. The hazard ratio (HR) of death and other outcomes were compared between IGRT and non-IGRT. We also evaluated OS in various supplementary analyses.Results: Our primary analysis included 6490 patients in whom covariates were well balanced after PS weighing. The HR for death when IGRT was compared with non-IGRT was 1.02 (95% confidence interval 0.80– 1.31, P = 0.86). There were also no significant differences in the supplementary analyses.Conclusion: We found that OS of LBC patients treated with adjuvant CFRT was not statistically different between those treated with IGRT versus without IGRT. This was the first study in this regard to our knowledge but randomized controlled trials were needed to confirm our finding.Keywords: breast cancer, effectiveness, image-guided radiotherapy

Background Low infection and case-fatality rates have been thus far observed in Taiwan. One of the reasons for this major success is better use of big data analytics in efficient contact tracing and management and surveillance of those who require quarantine and isolation. Objective We present here a unique application of big data analytics among Taiwanese people who had contact with more than 3000 passengers that disembarked at Keelung harbor in Taiwan for a 1-day tour on January 31, 2020, 5 days before the outbreak of coronavirus disease (COVID-19) on the Diamond Princess cruise ship on February 5, 2020, after an index case was identified on January 20, 2020. Methods The smart contact tracing–based mobile sensor data, cross-validated by other big sensor surveillance data, were analyzed by the mobile geopositioning method and rapid analysis to identify 627,386 potential contact-persons. Information on self-monitoring and self-quarantine was provided via SMS, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests were offered for symptomatic contacts. National Health Insurance claims big data were linked, to follow-up on the outcome related to COVID-19 among those who were hospitalized due to pneumonia and advised to undergo screening for SARS-CoV-2. Results As of February 29, a total of 67 contacts who were tested by reverse transcription–polymerase chain reaction were all negative and no confirmed COVID-19 cases were found. Less cases of respiratory syndrome and pneumonia were found after the follow-up of the contact population compared with the general population until March 10, 2020. Conclusions Big data analytics with smart contact tracing, automated alert messaging for self-restriction, and follow-up of the outcome related to COVID-19 using health insurance data could curtail the resources required for conventional epidemiological contact tracing.

BACKGROUND Low infection and case-fatality rates have been thus far observed in Taiwan. One of the reasons for this major success is better use of big data analytics in efficient contact tracing and management and surveillance of those who require quarantine and isolation. OBJECTIVE We present here a unique application of big data analytics among Taiwanese people who had contact with more than 3000 passengers that disembarked at Keelung harbor in Taiwan for a 1-day tour on January 31, 2020, 5 days before the outbreak of coronavirus disease (COVID-19) on the Diamond Princess cruise ship on February 5, 2020, after an index case was identified on January 20, 2020. METHODS The smart contact tracing–based mobile sensor data, cross-validated by other big sensor surveillance data, were analyzed by the mobile geopositioning method and rapid analysis to identify 627,386 potential contact-persons. Information on self-monitoring and self-quarantine was provided via SMS, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests were offered for symptomatic contacts. National Health Insurance claims big data were linked, to follow-up on the outcome related to COVID-19 among those who were hospitalized due to pneumonia and advised to undergo screening for SARS-CoV-2. RESULTS As of February 29, a total of 67 contacts who were tested by reverse transcription–polymerase chain reaction were all negative and no confirmed COVID-19 cases were found. Less cases of respiratory syndrome and pneumonia were found after the follow-up of the contact population compared with the general population until March 10, 2020. CONCLUSIONS Big data analytics with smart contact tracing, automated alert messaging for self-restriction, and follow-up of the outcome related to COVID-19 using health insurance data could curtail the resources required for conventional epidemiological contact tracing.

Dengue fever is an important epidemic disease with a high prevalence in tropical and subtropical countries. We aimed to investigate the effects of a treatment integrating traditional Chinese (TCM) and Western medicines on dengue inpatients with warning signs (i.e., group B) according to the World Health Organization dengue classification in this retrospective cohort study of medical records. Inpatients who were treated with conventional Western therapies in the absence or presence of TCM were assigned to the control and treatment groups, respectively. Data were compared using an analysis of variance, general linear analysis, and chi-square test. The most common clinical symptoms and signs of dengue fever were fever and muscle ache. The treatment group patients were significantly more likely to present general weakness and poor appetite than the control group patients. Patients in the treatment group were more likely to experience stomachache than those in the control group. Moreover, comparisons of the changes in hemoglobin and alanine aminotransferase levels over time revealed significant differences between the patient groups. Zhu Ye Shi Gao Tang, Gui Pi Tang, Paeonia suffruticosa, and Clerodendrum cyrtophyllum were the most commonly administered TCM formula and single herbs in this study. Patients in the treatment group experienced a resolution of symptoms, signs, and laboratory data and were discharged smoothly, without deterioration to death or critical care. Our findings suggest that the integration of TCM and Western medicine may yield an appropriate treatment for dengue fever.

Background Those taking proton pump inhibitors (PPIs) might have a higher risk of acute kidney injury. The long-term safety, especially the PPI-associated chronic kidney disease (CKD) is the subsequent concern. Objective This study explores the potential relationship between using PPIs and CKD in Taiwan. Methods Using a database collated by the Taiwan National Health Insurance programme, we conducted a population-based case-controlled study to identify 16 704 cases of patients aged 20 years or older with newly diagnosed CKD between 2000 and 2013. 16 704 controls were randomly selected and were matched by sex, age and comorbidities. 'Use' of PPIs was defined as when subjects had received at least a prescription for PPIs before the index date. 'Non-use' was defined as subjects who had never received a prescription for PPIs before the index date. The odds ratio (OR) for CKD associated with the use of PPIs was estimated by a logistic regression model. Results The OR for CKD was 1.41 for subjects using PPIs [95% confidence interval (CI) 1.34, 1.48] compared with subjects who had never used PPIs. Almost all major types of PPIs present a weak association with increased odds of CKD in cumulative duration and dosage regression analysis. The OR in relation to cumulative duration (per month) of PPIs use was 1.02 (95% CI 1.01, 1.02) and the OR in relation to cumulative dosage (per microgram) of PPIs use was 1.23 (95% CI 1.18, 1.28). Conclusions Using PPIs presented 1.4-fold higher odds of CKD in Taiwan health insurance claims data analysis.

The occurrence of dural arteriovenous fistula (DAVF) is rare. The clinical manifestation varies and depends on the location and venous drainage pattern. We present a case of a 57-year-old man with a left transverse sinus DAVF along with sigmoid thrombosis, cortical venous reflux, and congestion, that initially presented as parkinsonism. The patient was alert and fully oriented; however, decreased facial expressions were noted. His left forearm showed rigidity and bradykinesia, and it was difficult for the patient to smoothly perform rapid alternating movement testing. His complaints about hearing a rhythmic bruit above the left ear, particularly when lying down, alerted the physician of the presence of vascular lesions. Magnetic resonance imaging and angiography confirmed the diagnosis of DAVF. The patient received a combined surgical and endovascular approach to permanently block the fistula blood flow. The motion and movement of his left upper limb improved after fistula embolization. Images at the 1-month follow-up showed a decrease in the volume of tortuous vessels, and the fistula was completely occluded.

This study aimed to evaluate the association between tamoxifen use and hip fractures in older women with breast cancer in Taiwan.We carried out a retrospective nationwide case-control study using the database of the Taiwan National Health Insurance Program. A total of 762 female patients with breast cancer aged ≥65 years newly diagnosed with hip fractures from 2000 to 2011 were identified for inclusion in the study. Additionally, 7620 female patients with breast cancer aged ≥65 years without hip fractures were randomly selected as controls. Patients were defined as having used tamoxifen if they had an existing prescription for tamoxifen before the index date. Patients were defined as having never used tamoxifen if they had never been given a prescription for tamoxifen before the index date. We used an unconditional logistic regression model to calculate the odds ratio and 95% confidence interval for the association between tamoxifen use and risk of hip fractures.After adjustment for confounding variables, compared with patients who did not use tamoxifen, the adjusted odds ratio of hip fracture was 2.29 for those who had used tamoxifen (95% confidence interval 1.92, 2.72). Furthermore, adjusted odds ratios were 2.74 (95% confidence interval 2.19, 3.42) among patients with a cumulative duration of tamoxifen use of3 years.Tamoxifen use is associated with increased risk of hip fractures among older women with breast cancer in Taiwan. Geriatr Gerontol Int 2019; 19: 56-60.

There were 1997 deceased donor renal transplants reported to the Taiwan Organ Registry and Sharing Center between April 1, 2005, and December 31, 2014. The median age of transplant recipients was 45 years, with most patients between 35 and 64 years old. The number of male patients was comparable to that of female patients. There were more blood type O patients than any other blood type. The 1-, 3-, and 5-year patient survival rates were 96%, 93%, and 89%, respectively. Graft survival rates at 1, 3, and 5 years were 94%, 88%, and 82%, respectively. Overall patient survival was significantly worse in patients with hepatitis B surface antigen (P = 0.0058). However, with respect to overall graft survival, there was no significant difference between patients with or without hepatitis B surface antigen (P = 0.100). Overall patient survival was significantly worse in patients with hepatitis C virus antibody (HCV Ab) compared to patients without HCV Ab (P0.0001). Likewise, overall graft survival was significantly worse in patients with HCV Ab compared to patients without HCV Ab (P0.0001). In order to promote willingness to be an organ donor, the following law was passed: if any person becomes a deceased organ donor, up to three of his or her blood relatives would have priority to receive a deceased donor organ should they be on the waiting list for transplantation. We do wish this organ allocation priority will be an incentive for deceased organ donors' families to think "to give is to take".