National Health Insurance Administration Research Articles

Adverse pregnancy outcomes in women with Behçet's disease: population-based registry linkage study in Taiwan.

To estimate the risks of adverse pregnancy outcomes in women with Behçet's disease (BD) METHODS: Data collected by the Taiwan National Health Insurance Administration between 2001 and 2012 was used for our study. A total of 2,350,339 pregnancies from the Taiwan National Health Insurance database and birth registry were identified. Maternal history of BD in women was ascertained. A comparison was made to determine whether BD increased the risk of health issues associated with pregnancy and fetal outcomes. Using an adjusted generalized estimating equation model, we estimated the odds ratios (ORs) and 95% confidence intervals (CIs) for fetal-neonatal and maternal outcomes. There were 99 pregnancies in women with BD and 2,350,240 pregnancies in women without BD. The OR and 95% CI of puerperal cerebrovascular disorders were 12.08 (1.7-85.9), and those of gestational diabetes were 1.89 (1.1-3.25). Both were higher than the values in general pregnant women after adjusting for age, infant sex, urban residence, income, occupation, birth year, and Charlson Comorbidity Index. However, there were no adverse fetal outcomes in pregnant women with BD. Patients with BD have no significant risks of multiple complications except for puerperal cerebrovascular disease and gestational diabetes during pregnancy. Close monitoring of blood sugar is suggested. Furthermore, neonatal outcomes were not influenced by BD. Key Points • Patients with Behçet's disease are at a risk of puerperal cerebrovascular disease and gestational diabetes during pregnancy. • The odds ratio and 95% confidence interval for puerperal cerebrovascular disorders were 12.08 (1.7-85.9), and those for gestational diabetes were 1.89 (1.1-3.25). • Pregnant patients with Behçet's disease have no risks of neonatal outcomes.

Cost-utility analysis of stereotactic body radiotherapy plus cetuximab in previously irradiated recurrent squamous cell carcinoma of the head and neck

ABSTRACT Background This study aimed to estimate the cost-utility of stereotactic body radiotherapy (SBRT) plus cetuximab for patients with previously irradiated recurrent squamous cell carcinoma of the head and neck. Methods We constructed a Markov health-state transition model to simulate costs and clinical outcomes of recurrent squamous cell carcinoma of the head and neck. Model parameters were derived from the published literature and the National Health Insurance Administration reimbursement price list. Incremental cost-effectiveness ratio and the net monetary benefit were calculated from a health payer perspective. The impact of uncertainty was modeled with one-way and probabilistic sensitivity analyses. Results In the base-case, SBRT plus cetuximab compared to SBRT alone resulted in an ICER of NT$ 840,455 per QALY gained. In the one-way sensitivity analysis, the utility of progression-free state for patients treated with SBRT plus cetuximab or SBRT alone and the cost of progression-free survival for SBRT+Cet were the most sensitive parameters in the model. Probabilistic sensitivity analysis showed that the probability of cost-effectiveness at a willingness-to-pay threshold of NT$ 2,252,340 per QALY was 100% for SBRT plus cetuximab but 0% for SBRT alone. Conclusions This study showed that SBRT+Cet was cost-effective and benefited patients with previously irradiated rSCCHN.

Existing Data Sources in Clinical Epidemiology: The Taiwan National Health Insurance Laboratory Databases.

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

Cost-Effectiveness of Mirogabalin for the Treatment of Diabetic Peripheral Neuropathic Pain in Taiwan

ObjectivesTo assess the cost-effectiveness of 30 mg of mirogabalin versus no treatment or 300 mg of pregabalin in patients with diabetic peripheral neuropathic pain (DPNP) from a third-party perspective in Taiwan. MethodsA Markov model, developed with cycles of 2-week and a 1-year timeframes, consisted of 3 health states: mild, moderate, and severe pain. Average daily pain score (ADPS) was assessed at the end of each 2-week cycle. All patients entered the model in moderate (4 ≤ ADPS < 7) or severe (7 ≤ ADPS ≤ 10) pain health states. At the end of each cycle, patients remained in their assigned health state or transitioned to a different health state according to their pain score change. Efficacy data were informed by the pivotal phase III clinical trial (J303, NCT02318706) or by a network meta-analysis. Utility values were obtained from published literature, and resource use and cost data from Taiwanese clinical experts and Taiwan National Health Insurance Administration. One-way sensitivity, scenario, and probabilistic analyses were conducted to test the robustness of the results. ResultsA head-to-head analysis demonstrated that 30 mg of mirogabalin is a cost-effective treatment option versus placebo for DPNP. The base-case deterministic analysis estimated quality-adjusted life years (QALY) gains of 0.02 at an incremental cost of 9697 New Taiwan dollars (NT$) (equal to $323) versus placebo (incremental cost-effectiveness ratio [ICER]: 489 310 NT$/QALY [$15 860/QALY]). Mirogabalin was also cost-effective compared with 300 mg of pregabalin (ICER: 18 476 NT$/QALY [$600/QALY]). Sensitivity and scenario analyses results confirmed the robustness. ConclusionEconomic analysis suggests that mirogabalin 30 mg, a potent and selective α2δ ligand, is a cost-effective treatment option for DPNP in Taiwan, with an ICER below the willingness-to-pay threshold.

Impact of team-based community healthcare on preventable hospitalisation: a population-based cohort study in Taiwan

ObjectivesThe objective of this study was to explore the impact of Taiwan’s Family Practice Integrated Care Project (FPICP) on hospitalisation.DesignA population-based cohort study compared the hospitalisation rates for ambulatory care...

Lessons learned from the reimbursement policy for immune checkpoint inhibitors and real-world data collection in Taiwan.

This paper describes the reimbursement policy for immune checkpoint inhibitors in Taiwan and provides a perspective to improve the quality, consistency, and transparency of decision making. Global trends for cancer treatment have shifted from chemotherapies to targeted therapies and immuno-oncology (IO) medicine, leading to significant increases in treatment costs. To enhance the accessibility of advanced therapy, the Taiwan National Health Insurance Administration announced two pathways for high-cost medicine: the managed entry agreement and a set of general rules of reimbursement submission for high-cost drugs. To further manage the financial burden on Taiwan's national health insurance system, the policy makers introduced novel inhibitory drugs for cancer immune checkpoints, subject to a maximum annual budget of NT$800 million (≈US$26.7 million). In April 2019, a national registry was established for patients undergoing cancer immunotherapy. Clinical characteristics, treatment duration, toxicity, and the outcome of the postcheckpoint inhibitor treatments were recorded. By analyzing real-world data, we assess the therapeutic effect of IO treatment in Taiwanese patients, thereby enabling payers to adjust payment regulations and rules for reimbursement. The Health Technology Assessment Team plays an important role in drawing upon the evidence to support policy making. Under an implemented cost-management mechanism, Taiwan's high-cost drug policy has enabled patients to access new medicines and maximized patient benefits.

Continuity of care: evaluating a multidisciplinary care model for people with early CKD via a nationwide population-based longitudinal study

ObjectivesTo control and prevent the burdens associated with chronic kidney disease (CKD), Taiwan’s National Health Insurance Administration (NHIA) launched the ‘early-CKD programme’ in 2011 to extend care and education to...

Implantable cardioverter defibrillator therapy is cost effective for primary prevention patients in Taiwan: An analysis from the Improve SCA trial.

Implantable cardiac defibrillators (ICDs) for primary prevention (PP) of sudden cardiac arrest (SCA) are well-established but underutilized globally. The Improve SCA study has identified a cohort of patients called 1.5 primary prevention (1.5PP) based on PP patients with the presence of certain risk factors. We evaluated the cost-effectiveness of ICD therapy compared to no ICD among the PP population and the subset of 1.5PP patients in Taiwan. A Markov model was run over a lifetime time horizon from the Taiwan payer perspective. Mortality and utility estimates were obtained from the literature (PP) and the IMPROVE SCA trial (1.5PP). Cost inputs were obtained from the Taiwan National Health Insurance Administration (NHIA), Ministry of Health and Welfare. We used a willingness-to-pay (WTP) threshold of NT$2,100,000, as established through standard WTP research methods and in alignment with World Health Organization recommendations. The total discounted costs for ICD therapy and no ICD therapy were NT$1,664,259 and NT$646,396 respectively for PP, while they were NT$2,410,603 and NT$905,881 respectively for 1.5PP. Total discounted QALYs for ICD therapy and no ICD therapy were 6.48 and 4.98 respectively for PP, while they were 10.78 and 7.71 respectively for 1.5PP. The incremental cost effectiveness ratio was NT$708,711 for PP and NT$441,153 for 1.5PP, therefore ICD therapy should be considered cost effective for PP and highly cost effective for 1.5PP. ICD therapy compared to no ICD therapy is cost-effective in the whole PP population and highly cost-effective in the subset 1.5PP population in Taiwan.

Constructing a Novel Early Warning Algorithm for Global Budget Payments

The National Health Insurance Administration of Taiwan has implemented global budget payments, the Diagnosis-Related Group (DRG) inpatient diagnosis-related group payment system, and the same-disease payment system, in order to decrease the financial burden of medical expenditure. However, the benefit system reduces the income of doctors and hospitals. This study proposed an early warning payment algorithm that applies data analytics technology to diabetes hospitalization- and treatment-related fees. A model was constructed based on the characteristics of the Exponentially Weighted Moving Average (EWMA) algorithm to develop control charts, which were first employed using the 2001–2017 health insurance statistical database released by the Department of Health Insurance (DHI). This model was used to simulate data from inpatients with diabetes, to create an early warning algorithm for diagnosis-related groups’ (DRGs’) medical payments as well as to measure its accuracy. This study will provide a reference for the formulation of payment policies by the DHI.

Team-based care improves quality of diabetes care -Family Practice Integrated Care Project in Taiwan

BackgroundThe Family Practice Integrated Care Project (FPICP) is a team-based program in Taiwan initiated in 2003. This study investigates the influence of FPICP on the quality of diabetes care.MethodsThis population-based cohort study used Taiwan’s National Health Insurance Administration data on FPICP (fiscal year 2015–2016, with follow-up duration of one year). Participants included diabetic patients aged ≥30 in primary care clinics.We used conditional logistic regression modeling of patient characteristics and annual diabetes examinations and compared FPICP participants with non-participating candidates. Main outcome measures included completion of annual diabetes examinations, including glycated hemoglobin (A1c), low-density lipoprotein (LDL), urine microalbumin (MAU), routine urinalysis (UR), and fundus examination (FE).ResultsThe sample included 298,208 FPICP participants and 478,778 non-participating candidates. After 1:1 propensity score matching, the examination completion rates for FPICP participants and non-participants, respectively, were 94.4% versus 93.6% in A1c, 84.2% versus 83.8% in LDL, 61.9% versus 60.1% in MAU, 59.2% versus 58.0% in UR, and 30.1% versus 32.4% in FE.ConclusionOur findings indicate that a program like FPICP helps improve the quality of diabetes care through regular examinations of Alc, LDL, MAU, and UR.

Impact of the Requirement of Bone Mineral Density Evidence on Utilization of Anti-osteoporosis Medications, Clinical Outcome and Medical Expenditures of Patient With Hip Fracture in Taiwan.

Background: Since 2011, Taiwan’s National Health Insurance Administration (NHIA) issued a regulation on the reimbursement to anti-osteoporosis medications (AOMs). This study aimed to evaluate the impact of this regulation in reimbursement on the utilization of AOMs, clinical outcomes and associated medical expenditures of patients with incident hip fractures. Methods: By using the National Health Insurance Research Database (NHIRD), patients with incident hip fracture from 2006 to 2015 were identified as our study cohort. Patients younger than 50 years old or prescribed with AOMs within one year prior to incident fracture were excluded. Outcomes of interest were quarterly estimates of the proportion of patients who received bone mineral density (BMD) examination, who were prescribed AOMs, as well as who encountered subsequent osteoporotic fracture-related visits and associated medical expenditures. Particularly, age- and gender specific estimates were reported. An interrupted time series study design with segmented regression model was used to quantitatively explore the impact of the changes of the reimbursement criteria on the level (immediate) and trend (long-term) changes of these outcomes. Results: Our study enrolled 118 493 patients with incident hip fracture with those patients aged older than 80 years old accounting for the largest proportion. A significantly decreased trend of AOMs prescription rates was observed immediately post regulation except for female aged between 65 and 80, while the long-term pattern showed no significant difference. However, the percentage of patients encountered subsequent osteoporotic fracture-related visit was not statistically different between pre- and post-regulation periods. Noteworthy, the policy regulation was associated with an increasing trend of osteoporotic fracture associated medical expenditures, especially for patients older than 80 years old.Conclusion: The regulation on the reimbursement for AOMs decreased the prescribing rate of AOMs immediately although the effect did not sustain thereafter. However, higher subsequent osteoporotic fracture-related medical expenditures were introduced, especially among those very old population.

Mitigate risks of medication interruption due to COVID-19 for elderly with chronic diseases.

Chronic conditions are the leading causes of death and disability worldwide.1 According to the definition by Taiwan National Health Insurance Administration (NHI), refill prescriptions for chronic diseases are those given to patients who are diagnosed by physicians but are under stable condition with no need to adjust medication in the short run. Physicians can issue 3-month or longer refill prescriptions for patients with chronic diseases; there are currently 100 types of chronic diseases.2 COVID-19 virus can be transmitted to others within minutes of exposure and mortality rate among elderly with chronic diseases is higher than for other age groups.3-5 It is important to ensure mitigation risk of COVID-19 virus infecting the elderly who visit the hospital for refill prescription; it also has an impact on whether patients are willing to come back to the hospital where they got the prescription for long-term treatment. Kaohsiung Municipal Ta-Tung Hospital (KMTTH) is a regional teaching hospital with 428 beds and serves averagely 2845 daily prescriptions; 94.9% of patients had not yet used reservation service by the end of 2019. The elderly still went to the hospital and waited for the medicines. Since COVID-19 outbreak, the rate of patients with prescriptions for chronic diseases returning for medicines shows a downward trend. Compared with the same period last year, before January, and during mid-January to mid-February, there were no statistically significant differences between patients' genders, clinical departments visited, or residence (P > .05). However, there was a statistically significant decrease in the old elderly patients (aged above 75) returning to hospital for medicines (P = .002) (Table 1). Out of concern over infection by COVID-19 patients in hospital, elderly patients with prescriptions for chronic diseases stopped coming back to the hospital for medicines, causing medication interruption, resulting in further risks of change in medical conditions. Therefore, KMTTH set up “outdoor dispensary counters for fast drug receipt” on February 25, 2020 in well-ventilated locations outside the hospital. With or without reservation in advance, patients or their relatives can get drugs for the second and third months dispersed by the pharmacists as long as they show a valid NHI Smart Card and the original physicians' prescriptions in accordance with rules and regulations by the NHI. Those drugs are dispensed and stored at the pharmacy before delivery Good Dispersing Practice for ensuring fill a prescription accuracy and storage safety. One month after the dispensary counters measure was implemented, by April 1, 2020, compared with the same period the previous year, there were no statistically significant differences (P > .272) in the number of elderly patients with chronic diseases returning to the hospital for medicines, their genders, clinical departments visited or their residences. Based on the analysis above, for reducing the impact of COVID-19 on elderly with chronic diseases and mitigating risk of prescription drugs shortage, to set up outdoor dispensary counters for drug receiving without need to enter hospital should be one of the requisite measures for drug dispensing services during epidemics. The authors declare no conflicts of interest.

Cost-utility analysis of inotuzumab ozogamicin for relapsed or refractory B cell acute lymphoblastic leukemia from the perspective of Taiwan's health care system.

We conduct a cost-utility analysis of inotuzumab ozogamicin (INO) versus chemotherapy as the standard of care (SOC) for adults with relapsed or refractory B cell acute lymphoblastic leukemia. A Markov model incorporating transition probabilities between health states was applied to simulate disease progression. The model inputs, including overall survival, progression-free survival, and utility parameters, were obtained from the INO-VATE ALL trial and literatures. The Taiwan Cancer Registry Database and the Health and Welfare Database were utilized to identify the patient cohort and medical costs from the perspective of National Health Insurance Administration. The lifetime medical costs (in 2017 US dollars), quality-adjusted life years (QALYs) gained, and associated incremental cost-effectiveness ratio (ICER) were the main study outcomes. The lifetime medical costs for INO and SOC were $176,795 and $69,496, and the QALYs gained were 2.25 and 0.84, respectively. The ICER for INO versus SOC was $76,044 per QALY gained, which is slightly more than three times Taiwan's gross domestic product per capita (i.e., $73,224). Favorable economic results for INO versus SOC were found with an increased time horizon for model simulation, less discounting for the future benefit, and higher stem cell transplantation (SCT) rate after INO treatment; and among patients aged less than 55years, with no SCT history, or in the first salvage treatment. INO versus SOC has higher costs but is more effective. The use of INO is favorable for patients in the early treatment course and when more future benefit associated with INO is considered.

PCN93 A COST-EFFECTIVENESS ANALYSIS OF TRASTUZUMAB-CONTAINING TREATMENT SEQUENCES FOR HER-2 POSITIVE METASTATIC BREAST CANCER PATIENTS IN TAIWAN

Treatment options for HER-2-positive metastatic breast cancer (mBC) patients have expanded markedly since trastuzumab approval in 1998. Several other regimens are now available, including pertuzumab plus trastuzumab plus docetaxel, T-DM1, capecitabine plus lapatinib, and trastuzumab plus lapatinib. This study assesses the cost-effectiveness of four treatment sequences for HER-2-positive mBC according to the Taiwanese National Health Insurance Administration (TNHIA).

Where to buy face masks? Survey of applications using Taiwan's open data in the time of coronavirus disease 2019.

Background:The coronavirus disease 2019 (COVID-19) had spread rapidly since late December 2019. Personal protective equipment was essential to prevent transmission. Owing to shortage of face masks, Taiwan government began to implement quasi rationing on February 6, 2020, by allowing each resident to purchase two masks in seven days. Taiwan National Health Insurance Administration offered online data with real-time updates on face mask availability in all contracted pharmacies and selected local health centers. Based on the open data, numerous software applications quickly emerged to assist the public in finding sales locations efficiently.Methods:Up until March 15, 2020, the Public Digital Innovation Space of Taiwan government had recorded 134 software applications of face mask availability, and 24 software applications were excluded due to defect, duplicate, and unavailability. These applications were analyzed according to platform, developer type, and display mode.Results:Of the 110 valid software applications, 67 (60.9%) applications were deployed on websites, followed by 21 (19.1%) on social networking sites, 19 (17.3%) as mobile applications, and 3 (2.7%) in other modes. Nearly two thirds (n = 70) of applications were developed by individuals, one third (n = 37) by commercial companies, only two applications by central and local governments, and one by a nongovernmental organization. With respect to the display mode, 47 (42.7%) applications adopted map-view only, 41 (37.3%) adopted table-view only, and 19 (17.3%) adopted both modes. Of the remaining three applications, two offered voice user interfaces and one used augmented reality.Conclusion:Taiwan’s open data strategy facilitated rapid development of software applications for information dissemination to the public during the COVID-19 crisis. The transparency of real-time data could help alleviate the panic of the public. The collaborative contributions from the grassroots in disasters were priceless treasures.

Efforts to Reduce the Impact of Coronavirus Disease 2019 Outbreak on Radiation Oncology in Taiwan

Efforts to Reduce the Impact of Coronavirus Disease 2019 Outbreak on Radiation Oncology in Taiwan

Awareness of, attitude toward, and willingness to participate in pay for performance programs among family physicians: a cross-sectional study

BackgroundThe National Health Insurance Administration of Taiwan has introduced several pay-for-performance programs to improve the quality of healthcare. This study aimed to provide government with evidence-based research findings to help primary care physicians to actively engage in pay-for-performance programs.MethodsWe conducted a questionnaire survey among family physicians with age-stratified sampling from September 2016 to December 2017. The structured questionnaire consisted of items including the basic demographics of the surveyee and their awareness of and attitudes toward the strengths and/or weaknesses of the pay-for-performance programs, as well as their subjective norms, and the willingness to participate in the pay-for-performance programs. Univariate analysis and multivariate logistic regression analysis were performed to compare the differences between family physicians who participate in the pay-for-performance programs versus those who did not.ResultsA total of 543 family physicians completed the questionnaire. Among family physicians who participated in the pay-for-performance programs, more had joined the Family Practice Integrated Care Project [Odds ratio (OR): 2.70; 95% Confidence interval (CI): 1.78 ~ 4.09], had a greater awareness of pay-for-performance programs (OR: 2.37; 95% CI: 1.50 ~ 3.83), and a less negative attitude to pay-for-performance programs (OR: 0.50; 95% CI: 0.31 ~ 0.80) after adjusting for age and gender. The major reasons for family physicians who decided to join the pay-for-performance programs included believing the programs help enhance the quality of healthcare (80.8%) and recognizing the benefit of saving health expenditure (63.4%). The causes of unwillingness to join in a pay-for-performance program among non-participants were increased load of administrative works (79.6%) and inadequate understanding of the contents of the pay-for-performance programs (62.9%).ConclusionsTo better motivate family physicians into P4P participation, hosting effective training programs, developing a more transparent formula for assessing financial risk, providing sufficient budget for healthcare quality improvement, and designing a reasonable profit-sharing plan to promote collaboration between different levels of medical institutions are all imperative.

Cost-effectiveness of mirogabalin for the treatment of post-herpetic neuralgia in Taiwan

Objectives: To assess the cost-effectiveness of mirogabalin versus no treatment or pregabalin in patients with post-herpetic neuralgia (PHN) from a third-party perspective in Taiwan.Methods: A Markov model, which was developed with 2-week cycles and 1-year time horizon from the Taiwanese National Health Insurance Administration perspective, consisted of three health states: “mild,” “moderate,” and “severe” pain. Average daily pain score (ADPS) was assessed at the end of each cycle. Patients either remained in, or transitioned from, their assigned health state to a different state according to their pain score changes. All patients entered the model in “moderate” (4 ≤ ADPS <7) or “severe” (7 ≤ ADPS ≤ 10) pain health states. Efficacy data was informed by the pivotal Phase III trial, or by a network meta-analysis (NMA). Utility values were obtained from published literature and cost data from Taiwanese clinical experts and the Taiwan National Health Insurance Administration, using 2018 New Taiwan dollar (NT$). Probabilistic analysis was conducted to test the robustness of base case results.Results: Head-to-head analysis showed mirogabalin 30 mg to be cost-effective versus placebo in PHN. The deterministic analysis estimated a quality-adjusted life years gain of 0.041 at an ICER of NT$11,231 (US$365) versus no treatment (ICER: NT$274,567 [US$8,900]). In the NMAs, mirogabalin was cost-effective compared to pregabalin 150 mg (ICER: NT$515,881 [US$16,720]) and 300 mg (ICER: NT$201,671 [US$6,535]). Mirogabalin 30 mg dominated pregabalin 600 mg. Results from sensitivity and scenario analyses confirmed these results.Conclusion: Mirogabalin 30 mg, a potent and selective α2δ ligand, is a cost-effective treatment option for PHN in Taiwan, with ICERs below the willingness-to-pay threshold.

The factors associated with inappropriate prescription patterns of benzodiazepines and related drugs among patients with dementia.

It has been emphasised that benzodiazepines and related drugs (BZDRs) should be used cautiously in people with dementia. The aim of this study was to identify factors associated with inappropriate prescription patterns of BZDRs including polypharmacy, long-term treatment and high doses among patients with dementia taking BZDRs. This was a retrospective chart review study of patients with dementia who were treated at the study hospital. The date that the patient was issued a catastrophic illness certificate from the National Health Insurance Administration was used as the index date. Medical records of the 2-year period after the index date were reviewed. A total of 308 patients with dementia were included in this study. Among them, 151 (49.0%) received at least one prescription of BZDRs. After adjusting for covariates, psychiatric comorbidities (adjusted odds ratio (aOR) = 4.74, 95% CI = 1.75-12.81), history of past suicidal behaviour (aOR = 4.25, 95% CI = 1.40-12.88) and long-term treatment with BZDRs (aOR = 3.38, 95% CI = 1.11-10.27) were associated with polypharmacy of BZDRs. Age (aOR = 1.05, 95% CI = 1.0-1.11) and polypharmacy (aOR = 3.57, 95% CI = 1.23-10.32) were associated with long-term treatment. Living with family (aOR = 3.33, 95% CI = 1.32-9.79) and fewer psychiatric admissions to the study hospital (aOR = 0.56, 95% CI = 0.36-0.86) were associated with treatment with high doses of BZDRs. Treatment with BZDRs is prevalent in patients with dementia. Inappropriate prescription patterns of BZDRs are not uncommon in these patients and may be interlinked.

Blockchain-Enabled iWellChain Framework Integration With the National Medical Referral System: Development and Usability Study.

BackgroundMedical referral is the transfer of a patient’s care from one physician to another upon request. This process involves multiple steps that require provider-to-provider and provider-to-patient communication. In Taiwan, the National Health Insurance Administration (NHIA) has implemented a national medical referral (NMR) system, which encourages physicians to refer their patients to different health care facilities to reduce unnecessary hospital visits and the financial stress on the national health insurance. However, the NHIA’s NMR system is a government-based electronic medical referral service, and its referral data access and exchange are limited to authorized clinical professionals using their national health smart cards over the NHIA virtual private network. Therefore, this system lacks scalability and flexibility and cannot establish trusting relationships among patients, family doctors, and specialists.ObjectiveTo eliminate the existing restrictions of the NHIA’s NMR system, this study developed a scalable, flexible, and blockchain-enabled framework that leverages the NHIA’s NMR referral data to build an alliance-based medical referral service connecting health care facilities.MethodsWe developed a blockchain-enabled framework that can integrate patient referral data from the NHIA’s NMR system with electronic medical record (EMR) and electronic health record (EHR) data of hospitals and community-based clinics to establish an alliance-based medical referral service serving patients, clinics, and hospitals and improve the trust in relationships and transaction security. We also developed a blockchain-enabled personal health record decentralized app (DApp) based on our blockchain-enabled framework for patients to acquire their EMR and EHR data; DApp access logs were collected to assess patients’ behavior and investigate the acceptance of our personal authorization-controlled framework.ResultsThe constructed iWellChain Framework was installed in an affiliated teaching hospital and four collaborative clinics. The framework renders all medical referral processes automatic and paperless and facilitates efficient NHIA reimbursements. In addition, the blockchain-enabled iWellChain DApp was distributed for patients to access and control their EMR and EHR data. Analysis of 3 months (September to December 2018) of access logs revealed that patients were highly interested in acquiring health data, especially those of laboratory test reports.ConclusionsThis study is a pioneer of blockchain applications for medical referral services, and the constructed framework and DApp have been applied practically in clinical settings. The iWellChain Framework has the scalability to deploy a blockchain environment effectively for health care facilities; the iWellChain DApp has potential for use with more patient-centered applications to collaborate with the industry and facilitate its adoption.