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We aimed at evaluating the relationship between medication and treatment effectiveness in a home care setting among patients with schizophrenia. Patients with schizophrenia hospitalized between 2004 and 2009 with a primary International Classification of Diseases, Ninth Revision, Clinical Modification code of 295 were identified from Psychiatric Inpatient Medical Claims Data released by the National Health Research Institute in Taiwan. Patients who joined the home care program after discharge and were prescribed long-acting injection (LAI) (the LAI group) or oral antipsychotic medications (the oral group) were included as study subjects. The final sample for the study included 810 participants in the LAI group and 945 in the oral group. Logistic regression was performed to examine the independent effect of LAI medication on the risk for rehospitalization within the 12-month observation window after controlling for patient and hospital characteristics and propensity score quintile adjustment. The unadjusted odds ratio for rehospitalization risk was 0.80 (confidence interval, 0.65-0.98) for the LAI group compared to the oral group. The adjusted odds ratio was further reduced to 0.78 (confidence interval, 0.63-0.97). Results remained unchanged when the propensity score quintiles were entered into the regression for further adjustment. In a home care setting, patients treated with long-acting antipsychotic agents are at a significantly lower risk for psychiatric rehospitalization than those treated with oral medication. Consequently, LAI home-based treatment for the prevention of schizophrenia relapse may lead to substantial clinical and economic benefits.

Background Psoriasis is associated with significant economic burdens. Data regarding costs for psoriasis patients in Taiwan are not available. Objective To estimate the economic burden of psoriasis in Taiwan. Methods Psoriasis patients and their controls were identified from the 2006 National Health Insurance (NHI) research database, and differences in annual healthcare utilization and costs between psoriasis cases and controls were predicted by two-part models and generalized linear models. Face-to-face interviews were conducted in five hospital settings to collect information on out-of-pocket payments and productivity losses associated with seeking care. All analyses were stratified by the severity level of psoriasis. Results From the payer’s perspective, the NHI cost associated with moderate to severe psoriasis (sPsO) was NT$41,525 and that with mild psoriasis (mPsO) was NT$14,816. Adding the out-of-pocket payments (NT$13,095 for sPsO and NT$7237 for mPsO) and the loss of productivity (NT$6203 for sPsO and NT$2750 for mPsO), the annual total cost for sPsO was NT$60,823 and that for mPsO was NT$24,803. Conclusion Psoriasis is associated with significant economic burdens in Taiwan. Effective treatment of the disease could produce substantial savings in healthcare resources and gains in productivity.

Aims Heart failure is among the most frequent complications of patients on long-term haemodialysis. The benefits of renin–angiotensin system (RAS) blockade on the outcomes of these patients have yet to be determined. Methods and results We conducted a nationwide observational study using data from the Taiwan National Health Insurance claims database, between 1999 and 2010. We enrolled patients aged ≥35 years with new-onset heart failure [diagnosed by International Classification of Diseases, 9th revision, clinical modification (ICD-9-CM) codes] under treatment with medications. New users of a RAS blocker (RASB; i.e. an ACE inhibitor or an ARB used as monotherapy or dual therapy) were selected to compare with non-RASB users. We used Cox proportional hazards regression with and without propensity score adjustment to compare the risk of 3-year all-cause and cardiovascular mortality. Stratified analyses and RASB therapy duration as a time-dependent covariate were also performed. In all, 4771 were treated with an RASB (n = 3024) or without an RASB (n = 1747). RASB users had a higher prevalence of hypertension and diabetes, and a higher number of hospitalization. Among RASB users, 1148 deaths (38.0%) occurred during 5272 person-years of follow-up compared with 734 deaths (42.0%) among non-RASB users during 2683 person-years of follow-up. Three-year mortality rates were 45.4% and 49.1% for patients receiving and those not receiving an RASB, respectively (log-rank test, P < 0.001). Adjusted hazard analysis revealed that RASB therapeutic effects remained significant on all-cause [hazard ratio (HR) 0.8; 95% confidence interval (CI) 0.72–0.89; P < 0.001] and cardiovascular mortality (HR 0.76; 95% CI 0.64–0.90; P < 0.01). Conclusions RASB therapy reduced all-cause and cardiovascular mortality in heart failure patients on long-term haemodialysis.

Hsin-Hua Chen,1–6 Der-Yuan Chen,1–3,6–8 Yi-Ming Chen,1–3 Chao-Hsiun Tang9 1Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China; 2School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China; 3Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China; 4Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taiwan, Republic of China; 5Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan, Republic of China; 6School of Medicine, Chung-Shan Medical University, Taichung, Taiwan, Republic of China; 7Institute of Biomedical Science, Chung-Hsing University, Taichung, Taiwan, Republic of China; 8Department of Medical Education, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China; 9School of Health Care Administration, Taipei Medical University, Taipei, Taiwan, Republic ofChina Objective: To compare drug discontinuation risk between adalimumab (ADA) and etanercept (ETN) treatment among anti-tumor necrosis factor (anti-TNF)-naïve rheumatoid arthritis (RA) patients, in particular the influence of concomitant dose of methotrexate (MTX).Methods: This retrospective nationwide population-based cohort study identified 4,592 anti-TNF-naïve RA patients in whom ETN (n=2,609) or ADA (n=1,983) was initiated using National Health Insurance claims data. After adjustment for prior medication, concomitant medication, and baseline demographic data, the relative risk of drug discontinuation in ADA users compared with ETN users was quantified by calculating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) using Cox proportional hazard regression analyses, stratified by the follow-up time (≤1 year, >1 year) and/or concomitant MTX dose (≤10 mg/wk, >10 mg/wk).Results: ADA users had a higher risk of drug discontinuation compared with ETN users during the first year of follow-up (aHR, 1.13; 95% CI, 1.01–1.27), but not during all treatment periods (aHR, 1.06; 95% CI, 0.98–1.16) or after 1 year (aHR, 0.99; 95% CI, 0.87–1.13). However, ADA users had a significantly higher risk of drug discontinuation compared with ETN users among patients on concomitant MTX >10 mg/wk during all treatment periods (aHR, 1.27; 95% CI, 1.10–1.47), during the first year of follow-up (aHR, 1.48; 95% CI, 1.22–1.78), or after 1 year (aHR, 1.42; 95% CI, 1.06–1.90), but not among patients on concomitant MTX 0–10 mg/wk.Conclusion: This population-based cohort study demonstrated a modification effect of concomitant MTX dose on the relative risk of anti-TNF discontinuation for ADA compared with ETN among anti-TNF-naïve RA patients. However, the lack of exact cause of anti-TNF discontinuation limited causal inference of such a concomitant MTX dose-related modification effect. Keywords: adalimumab, etanercept, methotrexate, rheumatoid arthritis, treatment disconti­nuation

Migraine is associated with a significant economic burden in Western countries. However, there is limited information regarding the impact of the cost of migraine in Asia.To quantify and compare the direct medical costs of refractory migraine (RM) and other migraine, using health insurance claims data in Taiwan.A retrospective matched case-control study was conducted utilizing data from the Taiwan National Health Insurance Research Database. RM cases were defined as patients with at least 1 neurological outpatient visit with a primary or secondary International Classification of Diseases, Ninth Revision, Clinical Modification code of 346.11 (common migraine with intractable migraine, so stated), diagnosed by certified neurologists in medical centers during 2007-2008. The first control group was the non-migraineurs matched with cases at a 4:1 ratio by age, gender, urbanization level of the residence, and income. The second control group was patients with other migraine types (346.00, 346.10, 346.20, 346.80, and 346.90) matched with cases at a 4:1 ratio by age, gender, and hospital setting. Medical utilization and costs within 365 days after the index visit date were assessed using a 2-part model. The exchange rate for US $1 was NT $32.50.Patients with RM had significantly higher total medical costs compared with non-migraineurs (NT $57,932 [US $1783] vs. NT $26,817 [US $825]; P .001) or other migraineurs (NT $54,678 [US $1682] vs. NT $38,397 [US $1181]; P .001). The mean drug costs for those with RM were also higher than for non-migraineurs (NT $19,752 [US$608] vs. NT $8660 [US $266]; P .001) or those with other migraine (NT $17,623 [US $542] vs. NT $10,088 [US $310]; P .001). In addition, we reviewed the charts of all patients with an outpatient department diagnostic code of 346.11 (n = 98) at our hospital (Taipei Veterans General Hospital, a medical center in Taiwan) in 2007. Of these patients, 88 (90%) fulfilled the Silberstein-Lipton criteria for chronic migraine, i.e.,15 headache days per month and presence of a history of migraine.Refractory migraineurs in Taiwan had significantly higher medical costs than either non-migraineurs or those with other migraine diagnoses.

Vancomycin and teicoplanin are the two most used glycopeptides for the treatment of methicillin-resistant Staphylococcus aureus (MRSA). Vancomycin is suspected to have more nephrotoxicity but this has not been clearly established. The aim of this study was to assess its nephrotoxicity by a consensus definition of acute kidney injury (AKI): the risk (R), injury (I), failure (F), loss and end-stage renal disease (RIFLE) classification.Patients with MRSA bacteraemia who were prescribed either vancomycin or teicoplanin between 2003 and 2008 were classified. Patients who developed AKI were classified by RIFLE criteria. Variables such as comorbidities, laboratory data and medical cost information were also obtained from the database. Outcomes determined were: (i) the rate of nephrotoxicity and mortality; and (ii) the association of nephrotoxicity with the length of hospital stay and costs.The study included 190 patients (vancomycin 33, teicoplanin 157). Fifteen patients on vancomycin and 27 patients on teicoplanin developed AKI (P = 0.0004). In the vancomycin group, four, eight and three patients were classified to RIFLE criteria R, I and F, respectively. In the teicoplanin group, 17, nine and one patient were classified to RIFLE criteria R, I and F, respectively. Kaplan-Meier analysis showed significant difference in time to nephrotoxicity for the vancomycin group compared to the teicoplanin group. No significant differences were found between the groups in terms of total mortality, length of hospital stay and costs.The study data suggest that vancomycin is associated with a higher likelihood of nephrotoxicity using the RIFLE classification.

Background Bipolar disorder (BD) is a costly disease with a high rate of vasculometabolic comorbidities. The aims of this study were to explore the 1-year treatment cost, including total medical and non-psychiatric services, and the prevalence of vasculometabolic comorbidities in individuals with BD. Methods A nationwide population-based dataset, covering the years 2006 and 2007, was obtained from the Taiwan National Health Insurance claims database. The study sample comprised patients discharged from hospitals between 1 January 2006 and 31 December 2007. Annual non-psychiatric and total medical costs and vasculometabolic comorbidities were examined. Generalized linear models were used to examine the medical costs, and conditional logistic regression analyses were carried out to test the prevalence of vasculometabolic comorbidities in people with BD and to compare this with that found in matched controls. Results The total medical cost was 11-fold higher (New Taiwan [NT] $227,040 vs. NT$20,461), and the non-psychiatric medical cost was 1.7-fold higher (NT$33,173 vs. NT$19,406) with regard to the individuals with BD vs. the matched controls. The prevalence of vasculometabolic comorbidities was significantly higher in the individuals with BD than in the controls (ratio ranging from 1.86 to 4.06). Conclusions Both the non-psychiatric healthcare utilization and the prevalence of vasculometabolic comorbidities are higher with regard to individuals with BD vs. their matched controls. Therefore, treatment of BD should integrate medical and psychiatric care to decrease the impact of medical comorbidities, which may also decrease the overall medical cost.

We examined a nationwide population-based dataset of patients with bipolar disorder (BD) hospitalized in Taiwan, with our analyses focusing on one-year medical costs and relapse rates. The data for this study, covering the years 2006 and 2007, were obtained from the Taiwan National Health Insurance (NHI) claims database. The study sample comprised BD patients who were discharged from hospitals between January 1 and December 31, 2006. Annual medical costs and relapse rates were described; the Kaplan-Meier method and the generalized linear models were carried out to examine the risk factors associated with cases of relapse. The annual medical costs associated with relapses among the study sample were found to be approximately 7.6 times the average per-capita NHI expenditure in Taiwan in 2006 (US$4,354 versus US$574), with a one-year relapse rate of 55%. Those patients between 20 and 60 years old with a medication possession ratio of80 and with depressive episodes during the recruitment period were identified as being at risk of relapse. Bipolar disorder, which is a very costly disease, is associated with both poor medication adherence rates and frequent recurrences. Targeting drug adherence issues during maintenance treatment may well provide a valuable opportunity to reduce the risk of such recurrences.

There is no large-scale population-based study to clarify the association between major adverse cardiovascular events (MACEs) and pre-eclampsia/eclampsia. A population-based Taiwanese cohort study was performed in 1,132,064 parturients from 1999 to 2003 using a dataset linking birth certificates and National Health Insurance hospital discharge data. Sociodemographic factors and obstetric complications were used in multivariate logistic regression models to determine adjusted hazard ratios of pre-eclampsia/eclampsia on risks of MACEs and mortality during pregnancy to at least the third year postpartum. Incidence rates of MACEs and all maternal mortality in women with pre-eclampsia/eclampsia were 16.21 and 40.38 per 100,000 patients per year, respectively. Women with pre-eclampsia/eclampsia had a 13.0-fold higher incidence of myocardial infarction, a 8.3-fold higher incidence of heart failure, a 14.5-fold higher incidence of stroke, a 12.6-fold higher incidence of MACEs, a 7.3-fold higher incidence of MACEs without stroke, a 2.3-fold higher incidence of MACE-related deaths, and a 6.4-fold higher incidence of overall death than women without pre-eclampsia/eclampsia. Kaplan-Meier survival curve discriminated in MACEs, nonstroke MACEs, MACE related death and overall death. In conclusion, women with pre-eclampsia/eclampsia have a significantly higher risk of MACEs, especially myocardial infarction and stroke, during pregnancy and their risk remains significant to ≥36 months postpartum. Our results suggest that women with pre-eclampsia/eclampsia should be closely monitored during pregnancy and for up to ≥3 years postpartum.

Objectives The study aims to apply the contingent valuation method to elicit the willingness-to-pay (WTP), and measure the value of a statistic life (VSL), for human papillomavirus (HPV) vaccine in Taiwan. Methods A total of 512 questionnaires were completed on women aged 20 to 55 years with at least one daughter, during March through May 2007. The respondents' WTP for the vaccines was elicited by double-bounded binary-choice questions under two scenarios: one was to protect themselves from cervical cancer (CC) and the other was for their daughter(s). The WTP was modeled as a function of the respondents' knowledge score, attitudes toward CC and HPV vaccine, the vaccination outcome scenarios, and individual characteristics. A log-normal survival model was constructed and the maximum-likelihood method was used for estimation. Results The median regression-adjusted WTP was estimated at US$1098 to US$1233 (US$913–1004) for vaccinating the daughter (mother); and the VSL was estimated at approximately US$0.65 to US$4.09 (US$0.56–3.16) million for vaccinating the daughter (mother). Conclusions The study results provided important evidences on the monetary value women placed on a HPV vaccine, and the differential benefits between vaccinating the women and their daughters.

Objective: Paternal characteristics have never been considered in the relation between maternal schizophrenia and adverse pregnancy outcomes. The aim of our study was to consider different paternal ages while investigating the relation between maternal schizophrenia and low birth weight (LBW), using a nationwide population-based dataset. Method: Our study used data from the 2001 to 2003 Taiwan National Health Insurance Research Dataset and birth certificate registry. A total of 543 394 singleton live births were included. We performed multivariate logistic regression analyses to explore the relation between maternal schizophrenia and the risk of LBW, taking different paternal age groups into account (aged 29 years or younger, 30 to 39 years, and 40 years and older), and after adjusting for other characteristics of infant, mother, and father as well as the difference between the parent's ages. Results: Mothers with schizophrenia had a higher percentage of LBW infants than mothers who did not (11.8%, compared with 6.8%). For infants whose mothers had schizophrenia, the adjusted odds ratios of LBW were 1.47 (95% CI 1.02 to 2.27, P Conclusions: The relation between LBW and maternal schizophrenia is modified by paternal age. More attention should be paid to the interaction of paternal characteristics and maternal psychiatric disorders in producing adverse pregnancy outcomes. Can J Psychiatry. 2010;55(6):377-385. Clinical Implications * Maternal schizophrenia was not a significant predictor for LBW for children born to fathers aged 29 years and younger. * We found that mothers with schizophrenia were at an increased risk of having LBW infants only if fathers were aged 30 years or older. * For infants whose mothers did not have schizophrenia, the adjusted odds ratios of LBW was 1.47 (95% CI 1.02 to 2.27, P Limitations * Information such as parents' smoking history, substance abuse, alcohol consumption, nutrition, and body mass index are not available through ourdatasets. * The dataset does not allow us to account for differences in schizophrenia severity among patients. Key Words: schizophrenia, parental schizophrenia, paternal schizophrenia Abbreviations used in this article LBW low birth weight NHI National Health Insurance NHIRD NHI Research Dataset Although women with schizophrenia have long been reported to have an increased risk of adverse pregnancy outcomes,1 no consensus has been reached. McNeil2 observed no difference in adverse birth outcomes for mothers with schizophrenia, compared with unaffected mothers. However, in a meta-analysis of 14 studies conducted before 1990, Sacker et al3 concluded the incidence of excessive LBW risk among neonates to mothers with schizophrenia, compared with mothers in the general population. Recently, a large register-based Danish study4 reported an increased risk of LBW among women with schizophrenia. Nilsson et al5 also confirmed this finding using different inclusion criteria (that is, diagnosis before childbirth and hospitalization during pregnancy) for mothers with schizophrenia and adjusting for possible risk factors (for example, socioeconomic status or smoking during pregnancy). The sources of discrepancy in these studies2'3'6 are likely to include different definitions and severities of schizophrenia and varieties in study designs and sample sizes. …

Limited evidence reveals an elevated mortality risk in offspring of psychiatric patients after infancy. This nationwide population-based study in Taiwan aimed to investigate mortality risk in preschool children up to age 5 whose parents have severe mental illness.Three nationwide population-based data sets were linked. A total of 3,166 children with one or both parents having schizophrenia or an affective disorder were identified, together with a comparison cohort of 25,328 children matched with the study group in terms of maternal age and year of delivery. Cox proportional hazard regressions were performed to compute hazard ratios, with adjustment for sociodemographic characteristics and maternal medical comorbidities.During the preschool years, 54 (1.7%) deaths were documented among offspring of parents with severe mental illness and 155 (0.6%) in the comparison cohort. Parental mental illness was independently associated with a risk of death nearly 2.4 times higher (95% CI=1.72-3.28) than in the comparison cohort. The association was even more marked for unnatural causes of death, in which the mortality risk was 8.35 times greater (95% CI=4.04-17.24) in children of affected parents than in the comparison cohort. The proportional mortality rates were as high as 20.4% and 11.1% for accident and homicide, respectively, among offspring exposed to parental mental illness.An elevated mortality risk, especially from unnatural causes of death, was identified for offspring of parents with severe mental illness during the preschool years in an Asian society. There is an urgent need for multidisciplinary team approaches and risk management strategies to support psychiatric patients who are having difficulty with the transition to parenthood.

The primary aim of this study was to evaluate the maternal and child healthcare needs of new immigrants in Taiwan. Results will be used to reflect upon the services which the government is currently providing, and to determine if further investigation may be required to establish whether or not the health care quality currently provided by public health nurses succeeds in meeting the needs of new immigrants. Face-to-face interviews were undertaken by public health nurses on 1,068 women from Mainland China, and a further 1,068 women from other Southeast Asian countries, all of whom were randomly selected from the 12 administrative districts of Taipei. Information on the healthcare information needs of mothers and children (10 items), psychological distress variables, health status and socio-demographic variables of both the new immigrants and their Taiwanese spouses were collected via a structured questionnaire, of which a total of 1,829 completed copies were returned. Chi-square tests were performed to examine differences in both healthcare needs and psychological distress levels amongst different new immigrant ethnic groups. Logistic regressions were subsequently performed with the adjusted odds ratios (ORs) then being calculated to examine the differential effects of the healthcare needs of the different ethnic groups of new immigrants. The needs of the Vietnamese immigrants were found to be significantly different from those of the Mainland Chinese immigrants in all items, with the former needing Chinese communication assistance particularly at those times when they received medical treatment (p＜.001) and assistance from local health centers (p＜.001). Amongst the group of new Indonesian immigrants, the need for Chinese communication assistance when receiving medical treatment (p＜.001) was the only item significantly different from the group of Mainland Chinese immigrants. Cultural competence in public health nursing education should not be deemphasized in Taiwan. Within the public sector, there is a clear need to create and implement partnerships between the public and private sectors on the overall issue of new immigrants within the community. Results strongly suggest that public health nurses should be aware of how to meet the healthcare needs of different new immigrant ethnic groups in order to help them integrate into Taipei society.

This study aims to identify the changing trends of different surgical types for female stress urinary incontinence (SUI) and the distribution amongst various providers’ characteristics. A total of 17,532 women who had undergone surgery for SUI during 1996–2005 were identified from the National Health Insurance Research Database for analysis. Retropubic urethropexy (RPU) was the most common surgical type (43%), followed by tension-free mid-urethral sling (MUS; 24%), and traditional pubovaginal sling (15%). MUS had an annual growth rate of 20.5%, whilst traditional pubovaginal sling was reduced by 11.3% annually after 2002. RPU was the most common procedure by both gynecologists and urologists. Gynecologists performed more Kelly plications, whereas urologists performed more traditional pubovaginal sling. MUS was more commonly performed in medical centers than in regional and local hospitals. There has been a notable growth and changing trend in various surgical types for female SUI in Taiwan.

55 Background: Pain assessment and management had been adopted as an important criteria in hospital accreditation in Taiwan. National health insurance database may help to determine factors influencing patterns of strong opioid use in advanced cancer patients in their final 12 months of life. Methods: Cancer patients who died from cancer during 2008-2011 were included in the analysis. Data in prescription of strong opioids during their last 12 months of life were collected and analyzed using National Health Insurance Research Database (NHIRD). Patient’s characteristics, such as cancer types, birthdate and gender, as well as information on the provider’s characteristics, such as specialty, gender and age of the physician, the ownership and level of accreditation of the hospital, and the level of urbanization of the hospital where it is located, were also retrieved and included as the controlled variables in the analysis. Results: Of the 162,679 cancer deaths, 57,578 were prescribed strong opioids in their last year of life (35.4 percent). Strong opioid prescription steadily decreased with the corresponding increase in patient age. Besides there are difference in different cancer types. Association with prescription prevalence has also been noted among physician characteristics such as subspecialty, gender and age, as well among hospital characteristics, such as public vs private and accreditation level. Conclusions: There are significant difference in strong opioids prescription among different care providers for advanced cancer patients. Information from this study can guide further efforts in improving supportive care and education for advanced cancer care providers.

Background Ankylosing spondylitis (AS) is a form of arthritis that affects the spine. The spinal joints are inflamed causing severe pain and discomfort. Severe effects of AS can include new bone formation on the spine causing immobility. It is associated with decreased quality-of-life in its patients, and pharmacological and non-pharmacological treatments are available. Objectives This research aims to estimate the economic burden of AS in Taiwan. Methods The National Health Insurance Research Database (NHIRD), a claims-based dataset encompassing 99% of Taiwan9s population, was utilized. The costs and quantities of the direct economic burden were calculated based on 2011 data of NHIRD. We identified AS patients and a control cohort matched 1:4 on demographic and clinical covariates to calculate the incremental cost related to AS. We used a micro-costing approach for direct health care costs by estimating the quantities and prices of cost categories. Direct costs included surgeries, hospitalizations, medical devices and materials, lab tests, and drugs. Costs were presented in 2014 USD (1 USD =30.09 TWD). Results A total of 12,783 AS patients were included in the database with incremental total direct cost of $18,002,445 due to AS. This resulted in an average incremental direct cost of $1,408 per AS patient. Within direct costs, the largest burdens were associated with medication ($15,884,949; 88.24%), lab tests ($1,432,333; 7.96%), surgery ($329,471; 1.83%), medical devices and materials ($305,609; 1.7%) and ward usage ($50,084; 0.28%). Medications are broken down by class in table 1. Conclusions The economic burden of AS in Taiwan is driven by medication costs and lab tests. Efficient management of AS may reduce the utilization and treatment costs associated with the disease. Disclosure of Interest B. C. Wang Grant/research support from: Pfizer, C.-H. Tang Grant/research support from: Pfizer, W. Furnback Grant/research support from: Pfizer, J. P. Ney: None declared, Y.-W. Yang Employee of: Pfizer Taiwan, C.-H. Fang Employee of: Pfizer Taiwan, W.-S. Chen: None declared

Background Over the past decade, about one-third of all births nationwide in Taiwan were delivered by cesarean section (CS). Previous studies in the US and Europe have documented the need for risk adjustment for fairer comparisons among providers. In this study, we set out to determine the impact that adjustment for patient-specific risk factors has on CS among different physicians in Taiwan. Methods There were 172,511 live births which occurred in either hospitals or obstetrics/gynecology clinics between 1 January and 31 December 2003, and for whom birth certificate data could be linked with National Health Insurance (NHI) claims data, available as the sample for this study. Physicians were divided into four equivalent groups based upon the quartile distribution of their crude (actual) CS rates. Stepwise logistic regressions were conducted to develop a predictive model and to determine the expected (risk-adjusted) CS rate and 95% confidence interval (CI) for each physician. The actual rates were then compared with the expected CS rates to see the proportion of physicians whose actual rates were below, within, or above the predicted CI in each quartile. Results The proportion of physicians whose CS rates were above the predicted CI increased as the quartile moved to the higher level. However, more than half of the physicians whose actual rates were higher than the predicted CI were not in the highest quartile. Conversely, there were some physicians (40 of 258 physicians) in the highest quartile who were actually providing obstetric care that was appropriate to the risk. When a stricter standard was applied to the assessment of physician performance by excluding physicians in quartile 4 for predicting CS rates, as many as 60% of physicians were found to have higher CS rates than the predicted CI, and indeed, the CS rates of no physicians in either quartile 3 or quartile 4 were below the predicted CI. Conclusion Overall, our study found that the comparison of unadjusted CS rates might not provide a valid reflection of the quality of obstetric care delivered by physicians, and may ultimately lead to biased judgments by purchasers. Our study has also shown that when we changed the standard of quality assessment, the evaluation results also changed.

Background:Between 1995 and 2001, the average cesarean section rates in Taiwan were as high as 33.34 percent. This study set out to determine the independent effects of paternal age on the likelihood of cesarean delivery among a sample of Taiwanese women. Methods:Logistic regressions were used to analyze 310,574 singleton deliveries by nulliparous women in Taiwan between 1999 and 2001, linking data abstracted from birth certificates and from the National Health Insurance claims database. After controlling for socioeconomic, pregnancy, and obstetric complications, as well as institutional factors, we investigated both maternal and paternal ages simultaneously, using the single category variable “parental age” to determine the differential age effects on the risk of cesarean delivery. Results:Taking 20- to 29-year-old couples as the reference group, we observed that the relative risks of cesarean delivery become progressively higher with advancing age of the mother. At the same time, within each maternal group, positive and significant variations in cesarean rates occurred for different paternal age groups. The respective increases in the relative risks of cesarean delivery for men aged 20–29, 30–34, 35–39, and 40 years or more, in conjunction with women aged 20–29, 30–34 and 35 or over, are 34 percent from 1.00 to 1.34, 18 percent from 1.51 to 1.69, and 16 percent from 2.03 to 2.19. Other confounding variables are also taken into account. Conclusions:Irrespective of maternal age, advancing paternal age also appears to be an additional independent factor that has a strong association with the increase in cesarean section rates. (BIRTH 33:1 March 2006)

Background We have found no study conducted outside of the United States on the association between physician volume and patient outcomes after coronary artery bypass graft surgery. The aim of this study is to examine the association between surgeon-hospital coronary artery bypass graft volume and patient outcomes using three-year population-based data on Taiwan. Methods This study uses the Taiwan National Health Insurance Research Database covering the period 2000 to 2002, with the study sample comprising 9,895 first-time coronary artery bypass graft admissions, treated by 316 surgeons in 46 hospitals. Results Of the sampled patients, 356 (3.6%) were discharged after death. Those patients treated by low-volume (1–50 cases) surgeons had significantly higher mortality rates than those treated by medium-volume (51–100 cases) surgeons (7.0% vs 3.8%), high-volume (101–150 cases) surgeons (7.0% vs 2.7%), or very-high-volume (≥ 151 cases) surgeons (7.0% vs 3.2%). However, hospital coronary artery bypass graft volume alone is an insufficient predictor of hospital in-patient deaths ( p = 0.078). The adjusted odds ratio of hospital in-patient deaths declined with increasing surgeon volume, with the odds of in-patient death for those patients treated by low-volume surgeons being 1.52 times those of medium-volume surgeons, 1.89 times those of high-volume surgeons, and 2.04 times those of very-high-volume surgeons. Conclusions We conclude that for all coronary artery bypass graft surgeries taking place in Taiwan, the skill and experience of individual surgeons is a more critical factor for patient outcome than either hospital equipment or surgical teams.

Background This study sets out to determine whether adjustments for specific patient caesarean delivery risk factors have an affect on the assessment of performance rates among the municipal hospitals of Taipei City. Methods Analysis of National Health Insurance (NHI) claims data, linked with birth certificate data, was undertaken on a cohort of 27,693 live births in the six general hospitals of the Taipei Medical Hospital System (TMHS) between 1999 and 2001. Using multivariable logistic regression modeling of the risk factors independently associated with caesarean deliveries, an expected caesarean delivery rate was constructed for each of the hospitals. By contrasting observed rates with expected rates to quantify the magnitude of the deviation from average practice, a measurement similar to relative risk (RR) was also constructed for each hospital. Results The observed rates for two of the six hospitals examined fell within the expected 95% confidence interval (CI), two were above the expected upper limit, and two were below the expected lower limit. The RR ranking of Hospitals A (RR = 1.08, CI = 1.01–1.15) and C (RR = 1.01, CI = 1.00–1.03) improved from first to second, and third to fourth, whilst the RR of Hospitals B (RR = 1.09, CI = 1.05–1.14) and D (RR = 1.02, CI = 0.99–1.06) worsened from second to first, and fourth to third, respectively. The RR rankings of Hospitals E (RR = 0.92, CI = 0.88–0.96) and F (RR = 0.80, CI = 0.77–0.84) were the same as the observed rates. Conclusions Caesarean delivery rate profiles, or hospital comparisons without risk adjustment, may be methodologically biased and may lead to unfair judgments by healthcare purchasers.

A majority of studies examining the relationship between advancing maternal age and the likelihood of cesarean section (CS) use data from regional samples or from a limited number of medical institutions. This study uses population-based data from Taiwan to explore the relationship between maternal age and the likelihood of a CS.The National Health Insurance Research Database (NHIRD) on registries of medical facilities and board-certified physicians and monthly claim summaries for inpatients were used. In total, 502 524 singleton deliveries were included in the study. Multivariate logistic regressions were performed with the presence of CS as the dependent variable and maternal age (20, 20-29, 30-34 and34 years) as the independent variable. The study controlled for maternal indications, institution characteristics, maternal requests and attending physician characteristics.CS rates for the age groups20, 20-29, 30-34 and34 years were 17.7, 27.4, 37.4 and 47.5%, respectively. The regression analyses consistently showed that the likelihood of a CS significantly increased with advancing maternal age within each category of complication after adjusting for medical institution characteristics and characteristics of the attending physician.This study found that, after adjusting for maternal indications, and healthcare institution and physician characteristics, there was a significant relationship between advancing maternal age and an increased likelihood of a CS. This finding, together with the high CS rate of 32.1% in Taiwan, one of the highest reported in the world today, highlights an imperative need to devise interventions to reduce the frequency of CSs.

This article was written to determine the extent of consumers' needs for physician information and what information consumers use in decision making when selecting a physician.To collect data, a self-administered questionnaire was hand-delivered to 700 patients who visited the general surgery outpatient departments of seven hospitals during June 2003. A multiple logistic regression was conducted to identify the statistically significant factors related to patients' needs to use physician information.Of the respondents (N = 687), 74.7% felt they "greatly needed" or "needed" physician information. About 90% of respondents would "certainly" or "possibly" change physicians if the performances of their physicians shown by physician profiling were not as good as others. Respondents ranked the three most needed physician information as specialties, malpractice history, and overall patient satisfaction level. The multiple logistic regression showed that respondent's age, hospital level, personal monthly income, and whether they had compared medical care quality provided by neighborhood physicians had significant relationships with the respondent's needs for physician information after adjusting for other factors.This study found that 88.1% of respondents were in need of some amount of physician information. This is in light of calls for physician profiling from consumer-oriented organizations to assist consumers in selecting suitable physicians. It is recommended that the healthcare industry in Taiwan make a significant investment in a physician profiling system. The performance measures of this physician profiling system should be developed based on inputs from consumers, physicians, insurance companies, and researchers in this field.

The purposes of this paper were to examine whether patient dumping has occurred under the National Health Insurance and to explore hospital administrators' attitudes toward the practice of patient dumping in Taiwan.The study subjects were administrators in general hospitals that were accredited by the Taiwan Joint Commission on Hospital Accreditation as medical centers, regional hospitals, or district teaching hospitals in the years 2000 and 2001. A self-administered postal survey was conducted using a structured questionnaire mailed to 128 administrators in general hospitals.Of the respondents, 83 of 99 (83.8%) administrators perceived that patient dumping did occur in their service areas to a certain degree regardless of their hospital location, hospital level, or hospital ownership. A total of 67 of 74 (90.5%) administrators who attempted to answer the question on the prevalence of patient dumping perceived that different percentages (mean=13.27%) of hospitals transferred patients solely on economic considerations in their service areas. In addition, this study found that no statistically significant relationships existed between the administrators' perceived percentage of emergency patients received by their hospitals and hospital characteristics. However, there was a statistically significant relationship between the perceived percentage of inpatients received and hospital level (p = 0.007).According to the results of this study, we concluded that patient dumping is a serious and widespread problem in the healthcare industry in Taiwan. Patient dumping can jeopardize patient health and impair the financial integrity of receiving hospitals. Implementation of a case payment system may worsened the situation in Taiwan.

Case payment has been implemented since the beginning of Taiwan's National Health Insurance Program in 1995. This study selected patients undergoing a vaginal delivery to explore the relationships between maternal length of stay (LOS) and hospital characteristics under the case-payment system in Taiwan.The National Health Insurance Research Database of 1999 from Taiwan's National Health Research Institutes was used in this study. In total, 5456 patients who underwent a vaginal delivery in 1999 meeting the selection criteria were drawn from the database. A multiple regression analysis was performed in which LOS was regressed against the variables of hospital level, hospital location, hospital ownership, and teaching status.The regression model indicated that hospital level, hospital ownership, and hospital location were significantly related to LOS after adjustment for patient age, principal procedure, and the presence of a secondary diagnosis. The LOS for patients undergoing a vaginal delivery in private hospitals was shorter than those in public and non-profit proprietary hospitals. Patients admitted to medical centers or regional hospitals were more likely to have a longer mean LOS in comparison with their counterparts admitted to district hospitals. The LOS for patients hospitalized in northern Taiwan tended to be significantly longer on average than those in central and southern Taiwan.This study demonstrates that wide variations in LOS exist among hospitals in Taiwan under the case-payment system. It is recommended that the Bureau of the National Health Insurance develop a national system to monitor certain hospitals that have an unusually short LOS.