Bureau Of National Health Insurance Research Articles

The association of socioeconomic status on kidney transplant access and outcomes: a nationwide cohort study in Taiwan.

Conflicting evidence exists regarding the relationship between socioeconomic status and access tooroutcomes after kidney transplantation. This study analyzed the effects of individual and neighborhood socioeconomic status on kidney transplant access and outcomes in Taiwan. We used a retrospective cohort study design and performed comparisons using the Cox proportional hazards model after adjusting for risk factors. Data were collected from the National Health Insurance Bureau of Taiwan data (2003-2012). Patients with high individual and neighborhood socioeconomic status had higher chances of receiving kidney transplants than those with low individual and neighborhood socioeconomic status [adjusted hazard ratio (aHR) = 2.04; 95% CI: (1.81-2.31), p < 0.001]. However, there were no significant differences in post-transplant graft failure or patient mortality in Taiwan between individuals of varying socioeconomic status after five years. When we stratified kidney transplants by domestic and overseas transplantation, there were no significant differences in post-transplant mortality and graft failure, but individualswho received a kidney graft in Taiwanwith high individual and neighborhood socioeconomic status experienced lower risks of graft failure (aHR = 0.55; [95% CI 0.33-0.89], p = 0.017). A relevant disparity exists in accessing kidney transplantation in Taiwan, depending on individual and neighborhood socioeconomic status. However, resultspost transplantation were not different after five years. Improved access to waitlisting, education, and welfare support may reduce disparities.

Predicting the Onset of Diabetes with Machine Learning Methods.

The number of people suffering from diabetes in Taiwan has continued to rise in recent years. According to the statistics of the International Diabetes Federation, about 537 million people worldwide (10.5% of the global population) suffer from diabetes, and it is estimated that 643 million people will develop the condition (11.3% of the total population) by 2030. If this trend continues, the number will jump to 783 million (12.2%) by 2045. At present, the number of people with diabetes in Taiwan has reached 2.18 million, with an average of one in ten people suffering from the disease. In addition, according to the Bureau of National Health Insurance in Taiwan, the prevalence rate of diabetes among adults in Taiwan has reached 5% and is increasing each year. Diabetes can cause acute and chronic complications that can be fatal. Meanwhile, chronic complications can result in a variety of disabilities or organ decline. If holistic treatments and preventions are not provided to diabetic patients, it will lead to the consumption of more medical resources and a rapid decline in the quality of life of society as a whole. In this study, based on the outpatient examination data of a Taipei Municipal medical center, 15,000 women aged between 20 and 80 were selected as the subjects. These women were patients who had gone to the medical center during 2018-2020 and 2021-2022 with or without the diagnosis of diabetes. This study investigated eight different characteristics of the subjects, including the number of pregnancies, plasma glucose level, diastolic blood pressure, sebum thickness, insulin level, body mass index, diabetes pedigree function, and age. After sorting out the complete data of the patients, this study used Microsoft Machine Learning Studio to train the models of various kinds of neural networks, and the prediction results were used to compare the predictive ability of the various parameters for diabetes. Finally, this study found that after comparing the models using two-class logistic regression as well as the two-class neural network, two-class decision jungle, or two-class boosted decision tree for prediction, the best model was the two-class boosted decision tree, as its area under the curve could reach a score of 0.991, which was better than other models.

Constraining in reimbursement criteria and the adherence to anti-osteoporosis medications (AOMs) in Taiwan: Urbanization makes the difference

The Bureau of National Health Insurance in Taiwan implemented a new reimbursement scheme incorporating bone mineral density (BMD) criteria on Jan. 1, 2011. This study aimed to investigate a real-life 11-year secular trend of adherence in new AOMs users and evaluated the change of adherence to AOMs therapy in different urbanization areas after reimbursement criteria were restrained. We used Taiwan's National Health Insurance Research Database to identify new AOMs users as our study population. The AOMs in this study included denosumab, zoledronate, ibandronate, alendronate, raloxifene, and risedronate. The first prescription date of AOMs was defined as the cohort entry date. The adherence rates within one year after initiation were assessed. High adherence (≥75%) in the first year increased markedly after the new reimbursement scheme in 2011, changing from 31.8% in 2008, and 41.7% in 2011 to 54.2% in 2018. On the other hand, low adherence (<25%) decreased from 38.8% in 2008 to 14.6% in 2018. In addition, the switchers increased from 5.9% in 2008 to 9.3% in 2018, indicating a more flexible choice of AOMs. The proportion of high adherence to AOMs was highest in high-urbanization areas, and the proportion increased about two times from 30% in 2008 to 60% in 2018. The implementation of new reimbursement criteria in 2011 was associated with increased adherence to AOMs and the increase was most apparent in high-urbanization areas.

Exploring the efficiency of hospital and pharmacy utilizations in Taiwan: An application of dynamic network data envelopment analysis

BackgroundBuilding continuity of care by enabling optimal collaboration between hospitals and community pharmacies is critical. However, existing research on healthcare efficiency has largely focused on hospital services, and few studies have evaluated hospital services alongside pharmaceutical services. ObjectiveTo set up a dynamic network production model to assess the divisional efficiency of hospital and pharmacy utilizations and to investigate the dynamic changes and spatial differences for a more productive utilization of healthcare services. MethodsA dynamic network data envelopment analysis was applied on two interdependent healthcare divisions, hospitals and community pharmacies, in order to assess utilization efficiencies in both divisions simultaneously. Subsequent analyses were performed with a set of decision making units consisting of Taiwan's cities. Data were gathered from the Ministry of Health and Welfare and the Bureau of National Health Insurance, spanning 2014–2019. ResultsThe mean scores for overall healthcare, hospital, and pharmacy among cities were 81.9%, 89.2%, and 76.7% respectively. It appears that pharmacy is not very efficient, possibly because of the low rate of prescription release. A 13.26% reduction in pharmacists in the pharmacy sector is suggested, but the number of community pharmacies remains the same in cities and counties in 2019, based on the results of the slack-based measure. The bootstrapped-truncated regression indicated the different business districts had statistically significant determinants of overall efficiency, including hospital efficiency and pharmacy efficiency. ConclusionsThis study illustrated the inefficient operations of most hospital and pharmacy divisions in Taiwan's southern cities. It is hoped to draw the government's attention to the existing inefficiency in the allocation of healthcare and pharmaceutical resources. For future studies, a dynamic network model can be adapted to introduce the Malmquist productivity index in order to compare divisional productivity changes over time. Other topics for future research include handling undesirable outputs (quality variables) and information on input/output prices.

Exposure to Proton Pump Inhibitors and the Risk of Incident Asthma in Patients with Coronary Artery Diseases: A Population-Based Cohort Study

We aimed to determine the association between proton pump inhibitor (PPI) use and incident asthma in patients with coronary artery disease (CAD). This nationwide cohort study collected claims data from the Taiwanese Bureau of National Health Insurance from 2004 to 2013. The primary outcome, i.e., the risk of incident asthma, was assessed by estimating hazard ratios (HRs) and 95% confidence intervals (CIs). The adjusted HR of asthma development was estimated using the Cox regression model. Sensitivity and subgroup analyses were also conducted. A total of 8894 PPI users and 12,684 H2-receptor antagonist (H2RA) users were included in patients with CAD. Compared with H2RA use, an increased risk of incident asthma was found between PPI use and the risk of incident asthma in patients with CAD after adjusting for sex, age, urbanization, and low income (HR: 1.41; 95% CI: 1.04–1.89). The sensitivity analysis results were consistent with the main analysis results. However, the subgroup analysis revealed no association of incident asthma in patients with diabetes mellitus, hyperlipidemia, stroke, allergic rhinitis, pneumonia, cancer, or depression in the PPI group compared with those in the H2RA group. In conclusion, PPI use increased the risk of asthma development in patients with CAD.

A Decision Support System with Artificial Intelligence and Natural Language Processing to Mitigate the Deduction Rate of Health Insurance Claims

Globally, 20% to 40% of medical resources are wasted, which could be avoided through professional audit of health insurance claims. The professional audit can pinpoint excessive use of unnecessary medicines and medical examinations. Taiwan’s National Health Insurance Bureau (TNHIB) deducts the weight that medical resources carry if regarded as unnecessary or abused when examining health insurance claims. The ratio of the deducted weight to the total weight claimed by a hospital is defined as the health insurance claim deduction rate (HICDR). A high HICDR increases the operating expenses of the hospital. In addition, it takes the hospital many resources to prepare and file appeals for the deduction. This study aims to: (1) minimize the weight deducted by the TNHIB for a hospital; and (2) facilitate efficient appeals to claim denials. It is expected that HICDR will be reduced through big data analytics. In this study, evidence-based medicine (EBM) is involved to clarify the debate, dilemmas, conflicts of interests in examining health insurance claims. A natural language method—latent Dirichlet allocation (LDA), was used to analyze patients’ medical records. The topics derived from the LDA are used as factors in the logistic regression model to estimate the probability of each claim to be deducted. The experimental results on various medical departments show that the proposed predictive model can produce accurate results, and lead to more than 41.7% reduction to the deduction of the health insurance claims. It is equivalent to more than a 750 thousand NT dollars saving per year. The efficiency of application is validated compared to the manual process that is time-consuming and labor intensive. Moreover, it is expected that this study will supplement the insufficiency of traditional methods and propose a new and effective solution to reduce the deduction rate.

Hydronephrosis in patients with cervical cancer is an indicator of poor outcome: A nationwide population-based retrospective cohort study.

Cervical cancer is a common malignancy in women. The presence of hydronephrosis in patients with cervical cancer can be a challenging clinical problem. The appropriate management of these patients and the prediction of their outcomes are concerns among gynecologists, urologists, medical oncologists, radiation oncologists, and nephrologists. We enrolled a total of 2225 patients with cervical cancer over a 12-year period from the nationwide database of Taiwan's National Health Insurance Bureau. Among them, 445 patients had concomitant hydronephrosis. The remaining 1780 patients without hydronephrosis were randomly enrolled as a control group for the analysis of associated factors. The results indicated that the proportions of patients with hypertension, chronic kidney disease, and diabetes were significantly higher in the hydronephrosis group. The hydronephrosis group showed a higher all-cause mortality than the non-hydronephrosis group (adjusted hazard ratio 3.05, 95% confidence interval 2.24–4.15, P < .001). The rates of nephrectomy and stone disease were also significantly higher in the hydronephrosis group. A higher percentage of other cancers was also observed in the hydronephrosis group than in the non-hydronephrosis group (12.36% vs 8.99%, respectively). This study shows that cervical cancer with hydronephrosis may have a higher morbidity and mortality than cervical cancer without hydronephrosis. Other factors such as human papilloma virus vaccination, smoking, and cancer staging need to be further studied.

Association of acute pyelonephritis with double-J ureteral stenting: a nationwide population-based case control study

Objective Urinary Tract Infections (UTIs) due to ureteral catheters has been frequently seen. The risk factors of this include both timing and those of the female gender. However, the association of Acute Pyelonephritis (APN) with use of ureteral DJ stents has rarely been investigated. Materials and Methods: This study enrolled a total of 6,459 patients who were being treated with a ureteral catheter over a 10 year period from the nationwide database of Taiwan’s National Health Insurance Bureau. From these subjects, episodes of APN were found in a total of 500 patients. Additionally, 2,000 patients without APN were randomly enrolled as a control group in order to analyze the associated factors. Results The results indicate that the percentage of those with regards gender, age, duration of implantation, ureteral stent type, hypertension, T2DM, presence of urinary tract infection, benign prostate hyperplasia and pregnancy status were significantly statistically higher in APN patients than non-APN patients. APN did not associate with the use of antibiotics, urolithiasis, chronic kidney disease, malignancy, or uric acid stone in patients with a ureteral catheter. Conclusion: In conclusion, patients with a ureteral catheter associated with APN should be given close attention with regards to the above risk factors. Early removal of the catheter is the best policy for the prevention of APN.

A study on drug innovation lag in Taiwan

Drug lag, also known as drug innovation lag, can be categorized into marketing lag and reimbursement lag. This study investigates the trend and factors influencing drug innovation lag in Taiwan, and makes a comparison with major countries like USA, Canada, Japan, and Europe on marketing lag. The reimbursement lag in the National Health Insurance (NHI) of Taiwan is also explored. This is a retrospective study covering a total of 347 new drugs that were reimbursed by the Bureau of National Health Insurance (BNHI) from 1996 to 2002. Data collection includes time of regulatory approval, type of innovation, country of origin, and time and price of reimbursement by BNHI. The time of new drug approvals in study countries was obtained from relevant websites for comparison. The drug lag index between Taiwan and study countries was also analyzed. Data were analyzed by SPSS software for frequency distribution and multiple regressions. We found that new drugs are predominantly imported, and 30.5 months in Taiwan. Most of the new drugs were of me-too nature; only very few could be classified as breakthrough new drugs. In terms of marketing lag, USA was the shortest (5.6 months), followed by European countries (8.2 months), Canada (18.0 months), and Taiwan (30.5 months). The reimbursement lag was 11.7 months on average after product license granted by DOH, yet it was not affected by the NHI reimbursement price. The drug lag index from smallest to largest was: the USA (0.14), Europe (0.21), Canada (0.45), and Taiwan (0.76). Drug marketing lag is a serious issue in Taiwan. The average marketing lag of 30.5 months could be attributed to the fact that nearly all new drugs were of foreign origins. The average time after DOH's regulatory approval to NHI reimbursement was as long as 11.7 months. The government should re-examine the current function of the regulatory and reimbursement systems. More specifically, the health authorities should focus on faster regulatory process for breakthrough medicines instead of approving only "me-too new drugs".

Increased periprosthetic hip and knee infection projected from 2014 to 2035 in Taiwan

BackgroundPeriprosthetic joint infection (PJI) is a disastrous complication associated with hip and knee arthroplasty. The literature suggests that the economic consequences associated with treating PJI are substantial. Our study aimed to investigate the past trends of PJI rates, and to estimate the projected number of PJI cases, consequent bed-day requirements, and medical expenses in Taiwan up to year 2035. MethodsA nationwide epidemiological study was conducted using the inpatient database of the Bureau of National Health Insurance from 2004 through 2013. Patients with the International Classification of Disease-Clinical Modification, ninth revision (ICD9-CM) code 99,666 (PJI) who had received surgical treatment including debridement, removal of hip or knee prosthesis, or revision of total hip/knee arthroplasty (THA/TKA) were identified. Projections were performed with Poisson regression on historical incidence rates in combination with projections of arthroplasty numbers from 2014 to 2035. ResultsA total of 4935 hip (1871) and knee (3064) PJIs were identified between 2004 and 2013. The rates of PJI were 2.46% for hip arthroplasty and 1.63% for knee arthroplasty. The number of PJIs was expected to increase markedly with time from 728 in 2013 to 3542 in 2035 (a 4.87-fold increase). The bed-day requirements for treating PJI was 17,205 in 2013 and is expected to be 82,509 bed-days in 2035 (a 4.79-fold increase). The total hospitalization cost will increase 4.86-fold by 2035. ConclusionsThe number of PJI cases is increasing rapidly due to the increasing numbers of arthroplasty surgery and the cumulative number of latent infection. This may place a large economic burden on the health care system.

Gender differences in major adverse cardiovascular outcomes among aged over 60 year-old patients with atherosclerotic cardiovascular disease: A population-based longitudinal study in Taiwan.

Atherosclerotic cardiovascular disease (ASCVD) including cerebrovascular disease (CVD), coronary artery disease (CAD), and peripheral arterial disease (PAD), contributes to the major causes of death in the world. Although several studies have evaluated the association between gender and major adverse cardiovascular outcomes in old ASCVD patients, the result is not consistent. Hence, we need a large-scale study to address this issue.This retrospective cohort study included aged over 60 year-old patients with a diagnosis of ASCVD, including CVD, CAD, or PAD, from the database contained in the Taiwan National Health Insurance Bureau during 2001 to 2004. The matched cohort was matched by age, comorbidities, and medical therapies at a 1:1 ratio. A total of 9696 patients were enrolled in this study, that is, there were 4848 and 4848 patients in the matched male and female groups, respectively. The study endpoints included acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, in-hospital mortality, and so on. In multivariate Cox regression analysis in matched cohort, the adjusted hazard ratios (HRs) for female group in predicting acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality were 0.67 (P < .001), 0.73 (P = .0015), 0.78 (P < .001), 0.59 (P < .001), and 0.77 (P = .0007), respectively.In this population-based propensity matched cohort study, age over 60 year-old female patients with ASCVD were associated with lower rates of acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality than male patients. Further prospective studies may be investigated in Taiwan.

Detecting hospital behaviors of up-coding on DRGs using Rasch model of continuous variables and online cloud computing in Taiwan

BackgroundThis work aims to apply data-detection algorithms to predict the possible deductions of reimbursement from Taiwan’s Bureau of National Health Insurance (BNHI), and to design an online dashboard to send alerts and reminders to physicians after completing their patient discharge summaries.MethodsReimbursement data for discharged patients were extracted from a Taiwan medical center in 2016. Using the Rasch model of continuous variables, we applied standardized residual analyses to 20 sets of norm-referenced diagnosis-related group (DRGs), each with 300 cases, and compared these to 194 cases with deducted records from the BNHI. We then examine whether the results of prediction using the Rasch model have a high probability associated with the deducted cases. Furthermore, an online dashboard was designed for use in the online monitoring of possible deductions on fee items in medical settings.ResultsThe results show that 1) the effects deducted by the NHRI can be predicted with an accuracy rate of 0.82 using the standardized residual approach of the Rasch model; 2) the accuracies for drug, medical material and examination fees are not associated among different years, and all of those areas under the ROC curve (AUC) are significantly greater than the randomized probability of 0.50; and 3) the online dashboard showing the possible deductions on fee items can be used by hospitals in the future.ConclusionThe DRG-based comparisons in the possible deductions on medical fees, along with the algorithm based on Rasch modeling, can be a complementary tool in upgrading the efficiency and accuracy in processing medical fee applications in the discernable future.

Daclatasvir plus sofosbuvir, with or without ribavirin, is highly effective for all kinds of genotype-2 chronic hepatitis-C infection in Taiwan

Based on the previously published results, 12 weeks of sofosbuvir (SOF) 400 mg/day plus ribavirin (RBV), the current direct antiviral agent regimen reimbursed by Bureau-of National-Health-Insurance (BNHI) of Taiwan for genotype-2 chronic hepatitis C (CHC), is suboptimal in efficacy, especially for difficult-to-treat subpopulations such as liver cirrhosis, previous interferon (IFN) treatment failure, and high viral-load. This study aimed to evaluate the efficacy and safety of SOF plus daclatasvir (DCV) for Taiwanese genotype-2 CHC patients. Between March 2017 and December 2018, a total of 50 consecutive genotype-2 CHC patients who completed 12 weeks combination of SOF (400 mg/day) plus DCV (60 mg/day) with or without RBV by investigators were enrolled for analyses. When RBV was added, weight-based (800-1200 mg/day) approach was applied. Sustained virological response (SVR12) was defined by undetectable HCV RNA (<15 IU/mL) at the end and 12 weeks after completion of therapy. The mean age was 62.0 ± 11.4 years, 16 (32.0%) of them were males and 20 (40.0%) of them failed to previous IFN. Severity of liver diseases was as follows: ≤F2 fibrosis: 24.0%; F3 fibrosis: 40.0%, Child-Pugh A cirrhosis: 30.0%; and Child-Pugh B-C cirrhosis: 6.0%. The mean baseline HCV RNA level was 6.19 ± 0.91 log10 IU/mL and 30 (60.0%) had baseline HCV RNA ≥ 2 million IU/mL. The rates of undetectable HCV RNA (<15 IU/mL) at weeks 2, 4, and end-of-treatment were 40%, 94%, and 100%, respectively. Majority (66.7%) of patients with detectable HCV RNA at week 2 belonged to low-level viremia (<50 IU/mL). Subjective adverse events (AEs) and laboratory abnormalities were more common for patients combining RBV. Grades of AEs were generally mild and all patients finished therapy without interruption. After post-treatment follow-up, all 50 patients (100%) achieved SVR12. Our real-world cohort of Taiwan showed that a 12-week SOF/DCV-based treatment was well-tolerated and highly effective for genotype-2 CHC patients with or without liver cirrhosis.

High exposure to statins decrease the risk of new-onset dementia: A nationwide population-based longitudinal cohort study.

Several studies have shown that statin users have a lower risk of new-onset dementia (NOD) compared nonusers. However, other studies have shown opposite results. In this study, we investigated the association between the use of statins and the development of NOD.This was a longitudinal cohort study using data from claim forms submitted to the Taiwanese Bureau of National Health Insurance. The study included patients with NOD and non-NOD subjects from January 2002 to December 2013. We estimated the hazard ratios (HRs) of NOD associated with statin use, whereas nonuser subjects were used as a reference group.A total of 19,522 NOD cases were identified in 100,610 hyperlipidemic patients during the study period. The risk of NOD, after adjusting for sex, age, comorbidities, and concurrent medication, was lower among statin users than nonusers (HR 0.95, 95% CI [confidence interval] 0.94–0.96; P < .001). The adjusted HRs for NOD were 1.53 (95% CI, 1.45–1.62), 0.63 (95% CI, 0.57–0.71), and 0.34 (95% CI, 0.30–0.38) when the cumulative defined daily doses ranged from 28 to 365, 366 to 730, and more than 730 relative to nonusers, respectively.We concluded that statin use is associated with a decreased NOD risk. The protective effect of statins for NOD seemed to be related to high exposure to statins. This study also highlights that high exposure to statins has a dose-response effect on lowering NOD risk.

Antithrombotic Treatment May Reduce Mortality Among New-Onset Atrial Fibrillation Patients with Gray-Zone Risk of Stroke.

In clinical practice, some atrial fibrillation (AF) patients were classified as having low and moderate stroke risk by the CHADS2 score (≤ 1) in 2001 but in 2012 they were not truly classified as low risk of stroke according to the CHA2DS2-VASc score (≥ 2) (defined gray zone). Therefore, a treatment gap exists in gray zone AF patients. This study aimed to evaluate whether gray zone AF patients could benefit from reduced all-cause mortality under antithrombotic treatment. This was a longitudinal cohort study performed using data from claim forms submitted to the Taiwan Bureau of National Health Insurance from January 2000 to December 2011. The new-onset AF patients consisted of a gray zone cohort with a total of 1237 patients being enrolled. The primary outcome was all-cause mortality between 2001 and 2011. Patients in the gray zone receiving antithrombotic treatment had a significant reduction in all-cause mortality [hazard ratio (HR): 0.21; 95% confidence interval (CI): 0.16-0.28] compared with the no treatment group [warfarin only: HR, 0.28 (95% CI, 0.15-0.52); warfarin + Aspirin: HR, 0.21 (95% CI, 0.15-0.30); and Aspirin only: HR, 0.22 (95% CI, 0.16-0.29) ]. All-cause mortality was notably increased when any of the following risk factors were present: age 65-74 years, age ≥ 75 years, chronic kidney disease, and vascular disease. We concluded that AF patients in the gray zone must receive either anticoagulant and/or antiplatelet treatment and there is a lower mortality in these groups during long-term follow-up. Further investigation is needed to observe whether the antithrombotic drugs have benefits for patients with AF with a CHA2DS2-VASc score < 2.

Geriatric trauma

Background: Geriatric trauma demands attention in aging societies. The trauma hospitalization rate gradually increases in elderly populations because they are more vulnerable to accidental injuries. High trauma admission rates among elderly groups led to further research about injury patterns and outcomes. We hope to understand more about the demographic patterns and mortality rate of geriatric trauma. Methods: Information about all injured in-hospital patients ≥64 years was retrieved from a claims dataset from 2007 to 2008 from the Bureau of National Health Insurance in Taiwan. Statistical analyses were conducted on the population-based dataset to discover the incidence, mortality rate, percentage of chronic illness, and associations among variables such as age group, gender, injury mechanism, injury severity, and mortality. Results: A total of 134,024 patients (28.2% of total inpatients' admissions) ≥64 years were admitted in 2007 and 2008; 45.0% were male patients, and 43.9% were rural residents. These resulted in 4120 deaths. Nearly 40.0% of patients had at least one chronic illness. Diabetes mellitus was the most common comorbidity (20.2%). Injury was most commonly caused by falls on the same level, followed by motorcycle accidents. A higher mortality rate was observed in the subgroup with higher injury severity scores. Logistic regression showed that the mortality rate was significantly higher in subgroups comprising patients aged 75–84 and >84 years, with higher Charlson index, and with mechanisms such as pedestrians hit by vehicles or falls from height. Conclusion: High trauma hospitalization rates among elderly people can be reduced. Choosing a target population for injury prevention policy is required to reduce the geriatric trauma hospitalization rate. A regionalized trauma system providing the elderly population with optimal trauma care is mandatory.

Postacute care model of stroke in one hospital.

Objectives:The National Health Insurance Bureau of Taiwan has established a postacute care model of stroke (PAC-stroke). Patients with acute stroke occurring within the preceding 30 days and with modified Rankin scale (mRS) scores of 2–4 can be transferred to PAC hospitals for 6–12 weeks of rehabilitation. We conducted a retrospective review to explore the results of PAC-stroke.Materials and Methods:From April 2015 to December 2017, patients who transferred from our hospital to four PAC hospitals were reviewed. We evaluated their functional status using the mRS, Barthel index (BI), functional oral intake scale, EuroQoL-5D, Lawton–Brody instrumental activities of daily living scale, Berg balance test, usual gait speed, 6-min walk test, Fugl–Meyer sensory and motor assessments, mini-mental state examination, motor activity log quantity and quality tests, and concise Chinese aphasia test, before and after the PAC program.Results:A total of 53 patients with initial mRS score of 3 (6 patients) or 4 (47 patients) were enrolled, including 39 with cerebral infarction and 14 with cerebral hemorrhage, with a median age of 67 (mean: 68.3 ± 13.3) years. Seven patients had serious complications, including six cases of pneumonia and one fracture. The readmission rates within 14 days after transfer to the PAC hospital and in the overall PAC program were 3.8% and 13.2%, respectively. After exclusion of eight patients who dropped out early, 45 patients completed the PAC program. The median lengths of stay at the upstream hospital and PAC hospitals were 26 and 63 days, respectively. Improved mRS and BI scores were observed in 42% and 78% of the patients, respectively. The results of all 14 functional assessments improved significantly after the PAC program.Conclusion:Significant improvements in mRS and BI scores and all functional assessments within an average of 63 days of PAC hospital stay helped 73% of the patients to return home.

The Risk of Erectile Dysfunction Following Pelvic Angiographic Embolization in Pelvic Fracture Patients: A Nationwide Population-Based Cohort Study in Taiwan.

Pelvic fracture with hypovolemic shock is a known crucial injury in trauma patients. Pelvic fracture with vessel injury often leads to hemodynamic complications; in a trauma scenario, evidence of other systems being affected is often absent. Bleeding cessation and resuscitation are important for these types of trauma patients. For this purpose, pelvic angiographic embolization is frequently used. Multiple studies have reported that angiographic embolization may cause erectile dysfunction (ED) in hemodynamically stable patients with pelvic fracture. However, no study has evaluated a large patient cohort with a long-term follow-up. We hypothesized that angiographic embolization to control bleeding may compromise blood supply to the genitourinary organs or cause secondary neurogenic injury that increases the risk of ED. Our goal was to evaluate the risk of ED following pelvic fractures in male patients treated with pelvic angiographic embolization. We used data from the National Health Insurance Research Database (NHIRD) from 1997 to 2010 provided by the Bureau of National Health Insurance of the Department of Health in Taiwan. We collected disease histories from inpatient files. The disease diagnoses were based on the International Classification of Diseases (ICD), Ninth Revision, Clinical Modification. These data were all deidentified, and we did not contact the patients. As such, informed consent was not needed. Eighty-five and 82,802 patients were included in the case and control cohorts, respectively. All patients were aged 15-45, and the proportion of pelvic fracture locations was equal between the groups. After investigating the causes of ED among male patients aged 15-45 with pelvic fractures using logistic regression analysis in a generalized estimating equations model and after adjusting for the influence of confounders, we found that these patients had high risks (odds ratio (OR): 32.637; 95% confidence interval: 14.137-75.346; P < 0.001) of developing ED post-angiographic embolization. Male patients in Taiwan with pelvic fractures who undergo angiographic embolization to control bleeding have a higher risk of ED than those who do not undergo the procedure. Physicians should practice caution and inform patients of this connection before the procedure.

Letter from Taiwan

Letter from Taiwan

Children With Inguinal Hernia Repairs: Age and Gender Characteristics.

Objective. This study reports the age and gender characteristics of children with inguinal hernia repairs (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] Operation Codes 530-533). Methods. We used a retrospective cohort study design based on 2 data sources from 2007 to 2011 (the Bureau of National Health Insurance, Department of Health, Taiwan, and a local teaching children’s hospital database) and descriptive statistics to analyze the group’s age and gender differences as independent variables. Results. The gender ratio was 7 males to 1 female in the general population, whereas the gender ratio in children was 3.5 males to 1 female. Gender difference was found statistically significant in the age subgroup difference: boys (49.1%) were more than girls (39.3%) in ages 1 to 4, while girls (37.8%) were more than boys (23.7%) in ages 5 to 9. Based on the local hospital’s data, of those 611 (15%) children born and who received herniorrhaphy, 204 (33.4%) were born as preterm infants and 407 (66.6%) as term infants. The gender ratio among 204 children born prematurely and received herniorrhaphy was 3 males to 1 female. Of those 353 infants under 6 months who received herniorrhaphy, 155 (76%) were preterm infants while 198 (48.6%) were term infants. Conclusion. Early screening of inguinal hernia for children is important and should focus on those born prematurely, particularly those aged <6 months and boys.