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Dengue, a mosquitoborne flavivirus infection, is increasingly a disease of older adults who are more likely to have chronic diseases that confer risk for severe outcomes of dengue infection. In a population-based study in Taiwan, adjusted risks for dengue-related hospitalization, intensive care unit admission, and death increased progressively with age.

Abstract Background Few studies have made longitudinal comparisons between frailty phenotype (FP) and frailty index (FI) changes. We aimed to investigate frailty status changes defined by FP and FI concurrently, and to compare the associated factors and incident disability among different combination of FI and FP trajectory groups. Methods Data on respondents aged over 50 who completed the 1999, 2003 and 2007 Taiwan Longitudinal Study on Aging (TLSA) surveys (n = 2807) were excerpted. Changes of FI, FP and major time-dependent variables were constructed by group-based trajectory modeling. Logistic regression was used to investigate the associated factors and relationships with incident disability among different frailty trajectories. Results We identified four FP trajectories – stably robust, worsened frailty, improved frailty, and stably frail and three FI trajectories – stable FI, moderate increase FI and rapid increase FI. Lower self-rated health, mobility impairment, and depressed mood were associated with unfavorable FP and FI changes (all p

Abstract Background Losing a child to death is one of the most stressful life events experienced in adulthood. The aim of the current study is to investigate parental risk of seeking treatment for major depression disorders (MDD) after a child’s death and to explore whether such connection may operate differentially by parents’ prior medical condition. Methods We studied a retrospective cohort of 7245 parents (2987 mothers and 4258 fathers) identified in the National Health Insurance Research Database of Taiwan (NHIRD) who had lost a child with age between 1 and 12 years. For comparison, the parents of 1:4 birth year- and gender-matched non-deceased children were retrieved (16,512 mothers and 17,753 fathers). Gender-specific Cox regression analyses were performed to estimate risk. Results Nearly 5.0% and 2.4% of bereaved mothers and fathers sought treatment for MDD within three years after a child’s death, significantly higher than 0.8% and 0.5% in the non-bereaved parents. With covariate adjustment, the hazard ratio (HR) for maternal and paternal seeking treatment for MDD was estimated 4.71 (95% confidence interval [CI]: 3.35–6.64) and 1.93 (95% CI: 1.27–2.95), respectively. The increased risk of MDD varied by prior disease history; specifically, the increased risk of seeking treatment for MDD was especially prominent for those without chronic physical condition (CPC) (e.g., mothers with CPC: aHR = 2.38, 95% CI: 1.56–3.65 vs. no CPC: aHR = 9.55, 95% CI: 6.17–14.79). Conclusions After the death of a child, parental elevated risk of MDD was especially prominent for the women and those without prior medical condition. Effective strategies addressing bereavement may require family-based, integrated physical and mental healthcare and even extended counseling service.

Background: The literature on the association between diabetes severity and cancer risk is limited and inconclusive. The study aimed to evaluate the association between the adapted Diabetes Complications Severity Index (aDCSI) and the duration of type 2 diabetes and cancer risk. Methods: Patients ages 20 years or older with newly diagnosed type 2 diabetes between January 1, 2007, and December 31, 2011, were identified from Taiwan National Health Insurance claims data. Standardized incidence ratios (SIR) were calculated to compare cancer incidence in people with diabetes with that in the general population. Poisson regression was used to examine whether SIRs differed by age, sex, aDSCI, and duration of diabetes. Results: A total of 756,547 patients were included, with a median follow-up of 8.8 years. Excluding the first year after diagnosis, the SIR for overall cancer was 1.18 [95% confidence interval (CI) 1.17-1.19]. Higher aDCSI was associated with increased SIRs for overall [SIR ratio 1.03 (1.02-1.03) per point increase], head and neck (1.03; 1.01-1.04), liver (1.04; 1.03-1.05), pancreas (1.03; 1.00-1.05), kidney (1.13; 1.10-1.15), and leukemia (1.09; 1.06-1.13). There was no association between aDCSI and colorectal, extrahepatic biliary tract, uterus and thyroid cancer, and a negative association with breast cancer (0.97; 0.95-0.98). Type 2 diabetes duration was associated with increased SIRs for overall [1.01 (1.00-1.02) per year increase], head and neck (1.03; 1.01-1.05), and liver cancer (1.04; 1.02-1.05). Conclusions: The heterogeneity in the association between diabetes severity and diabetes-related cancers suggests diverse underlying connections. [ABSTRACT FROM AUTHOR]

Abstract Background A common challenge for free-access systems is that people may bypass primary care and seek secondary care through self-referral. Taiwan’s government has undertaken various initiatives to mitigate bypass; however, little is known about whether the bypass trend has decreased over time. This study examined the extent to which patients bypass primary care for treatment of common diseases and factors associated with bypass under Taiwan’s free-access system. Methods This repeated cross-sectional study analyzed data from Taiwan’s National Health Insurance Research Database. A random sample of 1 million enrollees was drawn repeatedly from the insured population during 2000–2017. To capture visits beyond the community level, the bypass rate was defined as the proportion of self-referred visits to the top two levels of providers, namely academic medical centers and regional hospitals, among all visits to all providers. Subgroup analyses were conducted for visits with a single diagnosis. Logistic regressions were used to investigate factors associated with bypass. Results The standardized bypass rate for all diseases analyzed exhibited a decreasing trend. In 2017, it was low for common cold (0.7–1.3%), moderate for hypertension (14.0–29.5%), but still high for diabetes (32.0–47.0%). Moreover, the likelihood of bypass was higher for male, patients with higher salaries or comorbidities, and in areas with more physicians practicing in large hospitals or less physicians working in primary care facilities. Conclusions Although the bypass trend has decreased over time, continuing efforts may be required to reduce bypass associated with chronic diseases. Both patient sociodemographic and market characteristics were associated with the likelihood of bypass. These results may help policymakers to develop strategies to mitigate bypass.

Background Antibiotic treatment for dengue is likely considerable and potentially avoidable but has not been well characterized. This study aimed to assess antibiotic prescribing for confirmed dengue cases in outpatient and inpatient settings and to identify associated patient, physician and contextual factors. Methods 57,301 adult dengue cases reported in Taiwan between 2008–2015 were analyzed. We assessed both outpatient and inpatient claims data of dengue patients from a week before to a week after their dengue infections were confirmed under Taiwan’s National Health Insurance program. A multivariable logistic regression with generalized estimating equations was used to estimate the probability of antibiotic prescribing in dengue patients. Results Overall, 24.6% of dengue patients were prescribed an antibiotic during the 14 day-assessment period. Antibiotics were prescribed in 6.1% and 30.1% of outpatient visits and inpatient admissions, respectively. Antibiotic prescriptions were reduced by ~50% in epidemic years. Among inpatients, advanced age, females, and major comorbidities were risk factors for receipt of an antibiotic; antibiotics were used in 26.0% of inpatients after dengue was diagnosed. Significant differences in antibiotic prescribing practices were observed among physicians in outpatient settings but not in inpatient settings. Conclusions In addition to patient and physician demographic characteristics, contextual factors such as care setting and during epidemics significantly influenced prescription of antibiotics. Characterization of prescribing patterns should help direct programs to curb antibiotic prescribing. Author summary Antimicrobial resistance is a growing global public health threat. The non-specific clinical manifestations of dengue overlap with signs and symptoms of other febrile illnesses common to tropical and subtropical zones making differential diagnosis between dengue and bacterial infections difficult, hence, leading to potentially unnecessary antibiotic prescribing. However, our understanding of factors underlying antibiotic prescribing for dengue is rather limited. Taiwan has experienced periodic dengue outbreaks and has a comprehensive national health insurance database including reliable infectious diseases surveillance and prescribing records. The findings in Taiwan show that other than commonly known patient characteristics, provider and contextual factors play a significant role. Physician’s age and practice setting were significant factors influencing the decision to prescribe antibiotics, particularly in outpatient visits. The likelihood of prescribing an antibiotic to dengue patients was reduced by more than 50% in medical visits occurring after the dengue infection was confirmed. Understanding patient, provider and contextual factors in antibiotics prescription for dengue infections can provide insights for improved antibiotic stewardship and unnecessary antibiotic treatment for dengue.

Background/purpose: This study hypothesized that low ‘felt trust’ from patients may induce resident burnout. The authors developed and validated a scale to measure physician felt trust from patients and surveyed residents in Taiwan to estimate the prevalence of burnout, and to verify the association between felt trust and burnout. Methods: Residents in Taiwan were surveyed between November 2015 and May 2016. The Chinese version occupational burnout inventory and the four-item ‘physician-felt-trust-from-patient’ (PFTFP) scale were used to measure burnout and physician felt trust. Generalized linear model with generalized estimating equation with burnout as the dependent variable was employed to estimate the association between physician felt trust and burnout while adjusting other potential confounders. Results: There were 1016 questionnaires returned (response rate 67.8%). The prevalence of personal burnout and client-related burnout were 44.0% and 14.8%. The PFTFP scale demonstrated adequate internal consistency (Chrobach's α 0.68) and favorable construct validity. Residents feeling less trusted from patients had significantly more burnout, especially client-related burnout, which showed a strong dose–response pattern. Residents having longer work hours or consecutive work hours and higher psychological job demands experienced more burnout, especially personal burnout. Residents with self-reported medical errors in recent 3 months had more client-related but not personal burnout. Conclusion: The prevalence of burnout among residents in Taiwan was high, especially personal burnout. The validity of the PFTFP scale is satisfactory. Strategies in improving wellbeing of residents shall not overlook the importance of positive social capital such as resident's feeling of patient trust. Keywords: Burnout, Professional, Trust, Taiwan, Internship and residency

Abstract Background Care-seeking behavior is widely acknowledged to have strong influences on health outcomes among individuals with chronic conditions including diabetes. Despite its dynamic nature, care seeking behavior are often considered as time invariant in most studies. The likelihood of patients changing their regularity and source of chronic care over time is often neglected. This study aimed to determine the long-term trajectories of care-seeking patterns of both care-seeking regularity and health provider choices; and their associated factors among patients with type 2 diabetes under the National Health Insurance (NHI) program in Taiwan. Methods We utilized population-based data from the National Health Insurance Research Database (NHIRD) in Taiwan. Three thousand, nine hundred and eighty-seven adult patients with newly diagnosed type 2 diabetes in 1999 were enrolled in the cohort. We assessed their trajectories of regular care visits and sources of diabetes care from 2000 to 2010. A group-based trajectory model was applied. Results Seven distinct groups of long-term care-seeking patterns were identified. Only 51.44% of patients with newly diagnosed diabetes had regularly visited their providers over time. Among them, 56.41 and 16.09% had persistently sought care from generalized and specialized providers, respectively. 27.50% had sought care from different levels of providers. Patients who were male, elderly, low-income, and had a higher baseline diabetes severity were significantly more likely to either continue with their irregular care-seeking behavior or fail to maintain their regular care seeking behavior over time. Those who were younger, had a higher socioeconomic status, and lived in an urban area were significantly more likely to persistently seek care from specialized care settings. Conclusions This study is the first population-based assessment of long-term care-seeking behaviors of type 2 diabetes patients under a single-payer system with a comprehensive benefit coverage. The most alarming finding was that, despite the existence of the comprehensive universal health insurance coverage in Taiwan, almost 50% of patients did not seek or maintain regular visits to providers over time as recommended. Understanding variations in the long-term trajectories of care adherence and sources of care may help to identify gaps in diabetes care management.

Objectives Emergency services utilisation is a critical policy concern. The paediatric population is the main user of emergency department (ED) services, and the main contributor to low acuity (LA) ED visits. We aimed to describe the trends of ED and LA ED visits under a comprehensive, universal health insurance programme in Taiwan, and to explore factors associating with potentially unnecessary ED utilisation.Design and setting We used a population-based, repeated cross-sectional design to analyse the full year of 2000, 2005, 2010 and 2015 National Health Insurance claims data individually for individuals aged 18 years and under.Participants We identified 5 538 197, 4 818 213, 4 401 677 and 3 841 174 children in 2000, 2005, 2010 and 2015, respectively.Primary and secondary outcome measures We adopted a diagnosis grouping system and severity classification system to define LA paediatric ED (PED) visits. Generalised estimating equation was applied to identify factors associated with LA PED visits.Results The annual LA PED visits per 100 paediatric population decreased from 10.32 in 2000 to 9.04 in 2015 (12.40%). Infectious ears, nose and throat, dental and mouth diseases persistently ranked as the top reasons for LA visits (55.31% in 2000 vs 33.94% in 2015). Physical trauma-related LA PED visits increased most rapidly between 2000 and 2015 (0.91–2.56 visits per 100 population). The dose–response patterns were observed between the likelihood of incurring LA PED visit and either child’s age (OR 1.06–1.35 as age groups increase, p

Objective: The study aimed to update the utilization trend and characterize the trachelectomy for benign and precancerous indications in Taiwanese women by comparing associated women, surgeon, and hospital-related characteristics. Materials and methods: We conducted a population-based trend study using inpatient admission claims data from Taiwan's National Health Insurance program from 1998 to 2013. After excluding those who had prior subtotal hysterectomy, women who underwent trachelectomy for benign and precancerous indications were compared by age at surgery (younger than 40 years, n = 130; 40 and 59 years, n = 429; and 60 years or older, n = 439). Trend analysis by age groups and indication was performed for the utilization of trachelectomy. A separate descriptive analysis was also performed to evaluate the surgeon's total trachelectomy case volume during the study period. Results: A total of 998 women who underwent trachelectomy for benign and precancerous indications were included in the study cohort. The overall utilization increased considerably by 100% over the study period. The most common indications for trachelectomy were genital prolapse (75.2%) and precancerous cervical lesion (21.0%). The majority of trachelectomies were performed with concomitant colporrhaphy for genital prolapse among older women without comorbid illness or any prior catastrophic illness. Most women (62.9%) were operated by a relatively small number of surgeons with high case volume (12.6%) during the study period. Compared to women older than 40 years, younger women had less comorbidities, more likely to be treated at private medical institution by surgeons of high case volume, and were less likely to undergo concomitant anterior and posterior colporrhaphy. Conclusions: The overall utilization of trachelectomy for benign and precancerous indications has increased over the past 16-years from 1998 to 2013, particularly among older Taiwanese women without comorbid illness or any prior catastrophic illness.

Objective: To describe the nationwide trends in the utilization of trachelectomy among Taiwanese women with surgically resectable cervical cancer over the past decade, and to compare associated demographic characteristics, in-hospital complications and related outcomes using a population-based dataset from 1998 to 2013. Materials and methods: We conducted a population-based, cohort study using inpatient admission claims data of Taiwan's National Health Insurance program. Women who underwent trachelectomy for cervical cancers were compared by age at surgery (younger than 40 years, 40–59 years, and 60 years or older). Results: Our study cohort consisted of 156 women. The overall utilization increased considerably during the study period, particularly in younger women aged 30–39 years. Compared with older women who had trachelectomy, women younger than 40 years were diagnosed more frequently in the later years of study (2007–2013, 69.9% vs 37.3%), were treated more frequently at medical centers (89.0% vs 60.2%) by physicians aged 55 years or older (50.7% vs 22.9%) with high case volume (50.7% vs 26.5%), were less likely to undergo concomitant surgeries for bilateral oophorectomy (1.4% vs 21.7%) and lysis of peritoneal adhesion (2.7% vs 24.1%), and were more likely to undergo lymph node excision (74.0% vs 47.0%) (P

Objective: Although uterine corpus cancer has been the most common malignancy of the female genital tract in many countries, the lifetime risk of this cancer has not yet been determined among Taiwanese women. The purpose of the study was to describe the change in incidence and the lifetime risk of uterine corpus cancer over a 20-year period from 1991 to 2010 in Taiwan. Materials and methods: We conducted a population-based registry study using the released database (available online) from the Taiwan Cancer Registry. Results: A total of 15,542 women newly diagnosed with uterine corpus cancer were included in this study. The total number of this cancer increased by 5.7-fold from 1991 to 2010. The annual age-specific rate nearly doubled during the past decade (2001–2010) when compared with the previous decade (1991–2000). Incidence rates were highest in women aged 50–59 years, and increasing incidence rates were observed in each age strata starting from 40 years to 85 years and more, after the year 2000. The lifetime risk of being diagnosed with uterine corpus cancer was 0.39% in 1991–1995, 0.54% in 1996–2000, 0.73% in 2001–2005, and 1.12% in 2006–2010 among Taiwanese women. Conclusion: According to the observed changes in incidence rate, the burden of uterine corpus cancer in the general female population is expected to increase in the near future. From a public-health perspective, care providers should develop strategies for the prevention, early detection, and intervention to reduce the rapidly increasing incidence of uterine corpus cancer in Taiwan.

OBJECTIVES: Postacute care (PAC) heavily relies on effective connection between acute and postacute providers. However, little is known about whether and to what extent providers' patient-sharing relationships influence patient outcomes. This study aimed to examine whether patients with stroke who were discharged to PAC hospitals with which the originating hospital had a strong patient-sharing relationship have a lower rate of rehospitalization and lower mortality risk. STUDY DESIGN: This population-based retrospective cohort study used the Taiwan National Health Insurance Research Database. A total of 1988 patients initially hospitalized for stroke between July 1, 2017, and June 30, 2018, who were newly discharged to 193 PAC hospitals from 175 originating hospitals were included. METHODS: We described the partnership between originating acute hospitals and PAC hospitals using tie strength and referral concentration. The main outcome included unplanned readmission and mortality. Hierarchical logistic regression analysis and Cox proportional hazards models were applied. RESULTS: A dose-response relationship was clearly observed between tie strength and patient outcomes. Patients with stroke who were discharged to a PAC hospital that had the strongest tie strength with the originating hospital were least likely to be readmitted and had the lowest mortality risk. Moreover, patients who received care from hospital pairs with highly or moderately concentrated referrals also had lower readmission and mortality risk. CONCLUSIONS: A greater number of shared patients and a more concentrated referral linkage between acute and PAC providers may reduce potential adverse outcomes in PAC patients. Instead of attaining more partners, PAC policies should encourage providers to strengthen their patientsharing relationship with their existing PAC partners. [ABSTRACT FROM AUTHOR]

Abstract Background Despite the progress in the Millennium Development Goals (MDGs) 4 and 5, inequity in the utilization of maternal, newborn and child health (MNCH) care services still remain high in sub-Saharan Africa (SSA). The continuum of care for MNCH that recognizes a tight inter-relationship between maternal, newborn and child health at different time periods and location is key towards reducing inequity in health. In this study, we explored the distributions in the utilization MNCH services in 12 SSA countries and further investigated the associations in the continuum of care for MNCH. Methods Using Demographic and Health Surveys data of 12 countries in SSA, structural equation modeling approach was employed to analyze the complex relationships in continuum of care for MNCH model. The Full Information Maximum Likelihood estimation procedure which account for the Missing at Random (MAR) and Missing Completely at Random (MCAR) assumptions was adopted in LISREL 8.80. The distribution of MNCH care utilization was presented before the estimated association in the continuum of care for MNCH model. Results Some countries have a consistently low (Mali, Nigeria, DR Congo and Rwanda) or high (Namibia, Senegal, Gambia and Liberia) utilization in at least two levels of MNCH care. The path relationships in the continuum of care for MNCH from ‘adequate antenatal care’ to ‘adequate delivery care’ (0.32) and to ‘adequate child’s immunization’ (0.36); from ‘adequate delivery care’ to ‘adequate postnatal care’ (0.78) and to ‘adequate child’s immunization’ (0.15) were positively associated and statistically significant at p

Objective: Gynecologists in Taiwan are lacking a comprehensive picture of the changes in clinical practice and indications of hysterectomy over a long period of time. The aims of this study were to examine the national trends in the utilization of hysterectomy and to explore changes in its utilization rate over a 14-year period from 1997 to 2010. Materials and methods: We conducted a population-based trend analysis using the claims data from the Taiwan's National Health Insurance program. Results: We identified a total of 341,993 women aged 20 years or older who underwent hysterectomy between 1997 and 2010. The total number of hysterectomies increased from 22,961 in 1997 to 27,757 cases in 1999, followed by a decline to 22,351 in 2010. Overall, 5406 fewer hysterectomies (−19.5%) were performed in 2010 when compared with those performed in 1999. The number of hysterectomies performed decreased from 1997 to 2010 for precancerous lesions (−55.6%), chronic pelvic pain (−35.2%), uterine leiomyoma (−13.1%), and uterine prolapse (−7.2%). However, the utilization of hysterectomy increased for endometriosis (+76.3%) and gynecologic cancer (+22.7%) during the same time frame. Conclusion: The clinical utilization and primary indications of hysterectomy changed substantially in Taiwan from 1997 to 2010. The continued monitoring of changes in hysterectomy rates will be critical for understanding the appropriate indications for hysterectomy and oophorectomy, the emergence of alternative managements for uterine disorders, and future trends in women's reproductive health.

Trust in physicians has declined, and surveys of public opinion show a poor level of public trust in physicians. Commodification of health care has been speculated as a plausible driving force. We used cross-national data of 23 countries from the International Social Survey Programme 2011 to quantify health care commodification and study its role in the trust that patients generally place in physicians. A modified health care index was used to quantify health care commodification. There were 34 968 respondents. A question about the level of general trust in physicians and a 4-item “general trust in physicians” scale were used as our major and minor outcomes. The results were that compared with those in the reference countries, the respondents in the health care–commodified countries were approximately half as likely to trust physicians (odds ratio: 0.47, 95% confidence interval [CI]: 0.31-0.72) and scored 1.13 (95% CI: 1.89-0.37) less on the general trust scale. However, trust in physicians in the health care–decommodified countries did not differ from that in the reference countries. In conclusion, health care commodification may play a meaningful role in the deterioration of public trust in physicians.

Objetivo: Examinar se uma história de periodontite (PD) antes do tratamento antidiabético está associada a risco de ocorrência de artrite reumatoide (AR) em pacientes com diabetes melittus (DM) tratados de novo. Métodos: Fizemos um estudo retrospectivo populacional com os dados de reivindicações do National Health Insurance (NHI) de 1997-2009 referentes a um milhão de indivíduos representativos da totalidade de matriculados. Adultos com DM (≥ 20 anos) que iniciaram o tratamento antidiabético durante 2001-2009 foram classificados como pacientes DM tratados de novo. Identificamos 7.097 indivíduos DM com história de PD em um intervalo de um ano antes do tratamento antidiabético (data-índice). Na equiparação desses 7.097 indivíduos para idade por ocasião da data-índice, gênero e ano da data-índice, extraímos aleatoriamente 14.194 pacientes DM sem história de PD em um intervalo de um ano antes do tratamento antidiabético. As razões de risco ajustadas (aRR) com um intervalo de confiança (IC) de 95% foram calculadas mediante a aplicação do modelo de riscos proporcionais de Cox com o objetivo de quantificar a associação entre história de PD e risco de AR. Resultados: Em comparação com pacientes DM sem exposição à PD no intervalo de um ano antes do tratamento antidiabético, RR bruta e RR ajustada para AR entre pacientes DM e com exposição à PD no intervalo de um ano antes do tratamento antidiabético foram, respectivamente, 4,51 (IC 95%, 1,39-14,64) e 3,77 (IC 95%, 1,48-9,60). Conclusão: A exposição à PD no intervalo de um ano antes do tratamento antidiabético foi associada a maior risco de AR em pacientes DM tratados de novo. A ausência do status de tabagismo em nível individual é importante limitação desse estudo.

Objective: The aim of this study was to assess the benefits of the 2009 International Federation of Gynecology and Obstetrics (FIGO) staging system for survival of patients with Stage IIA1 and IIA2 cervical cancer (Cx Ca). Materials and Methods: A study cohort of 51 patients with Stage IIA Cx Ca was retrospectively collected from the 2004–2009 hospital-based, long-form Cx Ca data registry at Mackay Memorial Hospital (Taipei, Taiwan). The survivorship and overall survival were compared between these two groups (Stages IIA1 and IIA2) using log-rank test. Results: Thirty-six and 15 patients were classified into Stages IIA1 and IIA2, respectively. Stage IIA2 patients were younger than those with Stage IIA1 disease (mean age, 47.4 vs. 55.1 years, p = 0.008), but no significant difference was observed in confirmed pelvic lymph node status (21.4% vs. 38.5%, p = 0.280) between them. Although the 2-year and 5-year overall survival was better among Stage IIA1 patients, there was no significant difference in survival between Stage IIA1 and IIA2 groups (2-year, 90.6% vs. 77.8%; 5-year, 86.3% vs. 51.9%, p = 0.218). Conclusion: Although there was a trend in survival difference between Stage IIA1 and IIA2 patients, the difference was not statistically significant. The revised FIGO 2009 staging system for Cx Ca defines a group of Stage IIA patients with bulky tumor (Stage IIA2) that are generally younger than Stage IIA1 patients. It is sensible to investigate an alternate or enhanced treatment scheme for Stage IIA2 patients. Ideally, the treatment scheme should prevent unnecessary radical surgery if a patient can be exposed to either chemotherapy or radiotherapy, alone or in combination.

Many people are concerned about that the quality of preventive care for patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is suboptimal. Taiwan, a hyperendemic area of chronic HBV and HCV infection, implemented a nationwide pay-for-performance (P4P) program in 2010, which aimed to improve the preventive care provided to HBV and HCV patients by increasing physicians' adherence to guidelines through financial incentives. The objective of this study was to evaluate the early effects of the P4P program on utilization of preventive services by HBV and HCV patients.Using a quasi-experimental design with propensity score matching method, we matched the HBV and HCV patients enrolled in the P4P program with non-enrollees in 2010, resulting in 21,643 patients in each group. Generalized estimating equations was applied to examine the difference-in-difference effects of P4P program enrollment on the utilization of three guideline-recommended preventive services (regular outpatient follow-up visits, abdominal ultrasonography (US) examinations, and aspartate aminotransferase and alanine aminotransferase (AST/ALT) tests by HBV and HCV patients.The P4P program enrollees were significantly more likely to attend twice-annual follow-up visits, to receive recommended US examinations and AST/ALT tests, than non-enrollees.The results of our preliminary assessment indicate that financial incentives offered by the P4P program was associated with a modest improvement in adherence to guidelines for better chronic HBV and HBC management.

Few studies have examined the contribution of treatment on the mortality of dementia based on a population-based study.To investigate the effects of anti-dementia and nootropic treatments on the mortality of dementia using a population-based cohort study.12,193 incident dementia patients were found from 2000 to 2010. Their data were compared with 12,193 age- and sex-matched non-dementia controls that were randomly selected from the same database. Dementia was classified into vascular (VaD) and degenerative dementia. Mortality incidence and hazard ratios (HRs) were calculated.The median survival time was 3.39 years (95% confidence interval [CI]: 2.88-3.79) for VaD without medication, 6.62 years (95% CI: 6.24-7.21) for VaD with nootropics, 3.01 years (95% CI: 2.85-3.21) for degenerative dementia without medication, 8.11 years (95% CI: 6.30-8.55) for degenerative dementia with anti-dementia medication, 6.00 years (95% CI: 5.73-6.17) for degenerative dementia with nootropics, and 9.03 years (95% CI: 8.02-9.87) for degenerative dementia with both anti-dementia and nootropic medications. Compared to the non-dementia group, the HRs among individuals with degenerative dementia were 2.69 (95% CI: 2.55-2.83) without medication, 1.46 (95% CI: 1.39-1.54) with nootropics, 1.05 (95% CI: 0.82-1.34) with anti-dementia medication, and 0.92 (95% CI: 0.80-1.05) with both nootropic and anti-dementia medications. VaD with nootropics had a lower mortality (HR: 1.25, 95% CI: 1.15-1.37) than VaD without medication (HR: 2.46, 95% CI: 2.22-2.72).Pharmacological treatments have beneficial effects for patients with dementia in prolonging their survival.

BackgroundThe private medical care sector is expanding in urban cities in Sub-Saharan Africa (SSA). However, people's health-care-seeking behaviors in this new landscape remain poorly understood; furthermore, distinguishing between public and private providers and among various types of private providers is critical in this investigation. This study assessed, by type, the healthcare providers urban residents in Burkina Faso visit, and their choice determinants.MethodWe conducted a population-based survey of a representative sample of 1,600 households in Ouagadougou from July to November 2011, consisting of 5,820 adults. We assessed the types of providers people typically sought for severe and non-severe conditions. We applied generalized estimating equations in this study.ResultsAmong those surveyed, 97.7% and 53.1% indicated that they seek a formal provider for treating severe and non-severe conditions, respectively. Among the formal provider seekers, 20.5% and 17.0% chose for-profit (FP) providers for treating severe and non-severe conditions, respectively. Insurance coverage was held by 2.0% of those surveyed. Possessing insurance was the strongest predictor for seeking FP, for both severe (odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.04-1.28), and non-severe conditions (OR = 1.22, 95% CI = 1.07-1.39). Other predictors included being a formal jobholder and holding a higher level education. By contrast, we observed no significant difference in predisposing, enabling, or need characteristics between not-for-profit (NFP) provider seekers and public provider seekers. Proximity was the primary reason for choosing a provider.ConclusionThe results suggested that FP providers play a crucial role in the urban healthcare market in SSA. Socioeconomic status and insurance status are significant predictors of provider choice. The findings can serve as a crucial reference for policymakers in response to the emergence of FP providers in SSA.

OBJECTIVES: To evaluate the associations of body mass index (BMI) with all-cause, cardiovascular disease (CVD), and expanded CVD mortality in the elderly. DESIGN: Observational cohort study. SETTING: Annual physical examination program for the elderly from 2006 to 2010. PARTICIPANTS: We included 77,541 Taipei residents aged ≥ 65 years (39,365 men and 38,176 women). MEASUREMENTS: BMI was categorized as underweight (BMI