Trend of Urban-Rural Disparities in Hospice Utilization in Taiwan

Aims

The palliative care has spread rapidly worldwide in the recent two decades. The development of hospice services in rural areas usually lags behind that in urban areas. The aim of our study was to investigate whether the urban-rural disparity widens in a country with a hospital-based hospice system.

Methods

From the nationwide claims database within the National Health Insurance in Taiwan, admissions to hospices from 2000 to 2006 were identified. Hospices and patients in each year were analyzed according to geographic location and residence.

Results

A total of 26,292 cancer patients had been admitted to hospices. The proportion of rural patients to all patients increased with time from 17.8% in 2000 to 25.7% in 2006. Although the numbers of beds and the utilizations in both urban and rural hospices expanded rapidly, the increasing trend in rural areas was more marked than that in urban areas. However, still two-thirds (898/1,357) of rural patients were admitted to urban hospices in 2006.

Conclusions

The gap of hospice utilizations between urban and rural areas in Taiwan did not widen with time. There was room for improvement in sufficient supply of rural hospices or efficient referral of rural patients.     

The Association between Individual Income and Aggressive End-of-Life Treatment in Older Cancer Decedents in Taiwan

Objectives

To examine the association of individual income and end of life (EOL) care in older cancer decedents in Taiwan.

Design

Retrospective cohort study.

Setting

National Health Insurance Research Database (NHIRD) in Taiwan.

Participants

28,978 decedents >65 years were diagnosed with cancer and died during 2009-2011 in Taiwan. Of these decedents, 10941, 16535, and 1502 were categorized by individual income as having low, moderate, and high SES, respectively.

Main outcome measures

Indicators of aggressiveness of EOL care: chemotherapy use before EOL, more than one emergency department (ER) visit, more than one hospital admission, hospital length of stay >14 days, intensive care unit (ICU) admission, and dying in a hospital.

Results

Low individual income was associated with more aggressive EOL treatment (estimate -0.30 for moderate income, -0.27 for high income, both p<0.01). The major source of aggressiveness was the tendency for older decedents with low income to die in the acute care hospital. The indicators had an increasing trend from 2009 to 2011, except for hospital stay >14 days.

Conclusions

Low individual income is associated with more aggressive EOL treatment in older cancer decedents. Public health providers should make available appropriate education and hospice resources to these decedents and their families, to reduce the amount of aggressive terminal care such decedents receive.     

Trend Analysis and Outcome Prediction in Mechanically Ventilated Patients: A Nationwide Population-Based Study in Taiwan

Objective

To investigate the relationship between changes in patient attributes and hospital attributes over time and to explore predictors of medical utilization and mortality rates in mechanical ventilation (MV) patients in Taiwan.

Background

Providing effective medical care for MV patients is challenging and requires good planning and effective clinical decision making policies. Most studies of MV, however, have only analyzed a single regional ventilator weaning center or respiratory care unit, high-quality population-based studies of MV trends and outcomes are scarce.

Methods

This population-based cohort study retrospectively analyzed 213,945 MV patients treated during 2004-2009.

Results

During the study period, the percentages of MV patients with the following characteristics significantly increased: age ≦ 65 years, treatment at a medical center, and treatment by a high-volume physician. In contrast, the percentages of MV patients treated at local hospitals and by low-volume physicians significantly decreased (P<0.001). Age, gender, Deyo-Charlson co-morbidity index, teaching hospital, hospital level, hospital volume, and physician volume were significantly associated with MV outcome (P<0.001). Over the 6-year period analyzed in this study, the estimated mean hospital treatment cost increased 48.8% whereas mean length of stay decreased 13.9%. The estimated mean overall survival time for MV patients was 16.4 months (SD 0.4 months), and the overall in-hospital 1-, 3-, and 5-year survival rates were 61.0%, 36.7%, 17.3%, and 9.6%, respectively.

Conclusions

These population-based data revealed increases in the percentages of MV patients treated at medical centers and by high-volume physicians, especially in younger patients. Notably, although LOS for MV patients decreased, hospital treatment costs increased. Healthcare providers and patients should recognize that attributes of both the patient and the hospital may affect outcomes.     

Cost per QALY (Quality-Adjusted Life Year) and Lifetime Cost of Prolonged Mechanical Ventilation in Taiwan

Introduction

Patients who require prolonged mechanical ventilation (PMV) are increasing and producing financial burdens worldwide. This study determines the cost per QALY (quality-adjusted life year), out-of-pocket expenses, and lifetime costs for PMV patients stratified by underlying diseases and cognition levels.

Methods

A nationwide sample of 50,481 patients with continual mechanical ventilation for more than 21 days was collected during 1997–2007. After stratifying the patients according to specific diagnoses, a latent class analysis (LCA) was performed to categorise PMV patients with multiple co-morbidities into several homogeneous groups. The survival functions were estimated for individual groups using the Kaplan-Meier method and extrapolated to 300 months through a semi-parametric method. The survival functions were adjusted using an EQ-5D utility value derived from a convenience sample of 142 PMV patients to estimate quality-adjusted life expectancies (QALE). Another convenience sample of 165 patients was used to estimate the out-of-pocket expenses. The lifetime expenditures paid by the single-payer National Health Insurance (NHI) system and patients'' families were estimated by multiplying average monthly expenditures by the survival probabilities and summing the values over lifetime.

Results

PMV therapy costs more than 100,000 U.S. dollars (USD) per QALY for all patients with poor cognition. For patients with partial cognition, PMV therapy costs less than 56,000 USD per QALY for those with liver cirrhosis, intracranial or spinal cord injuries, and 57,000–69,000 USD for patients with multiple co-morbidities under age of 65. The average lifetime cost of PMV was usually below 56,000 USD. The out-of-pocket expenses were often more than one-third of the total cost of treatment.

Conclusions

PMV treatment for patients with poor cognition would cost more than 5 times Taiwan''s GDP (gross domestic products), or less cost-effective. The out-of-pocket expenses for PMV provision should also be considered in policy decision.     

乳腺癌免疫组化检测在乳腺癌患者诊治中的意义分析

目的：探讨免疫组化检测在乳腺癌患者诊治中的价值。方法：随机选取2011年1月-2013年1月的68例经过空心穿刺活捡并病理确诊的乳腺癌患者为研究对象,均采用免疫组化检测ER、PR、P53、Bcl-2,全部采用CEF化疗方案治疗3个月后手术治疗,再运用免疫组化SP法检测化疗前后乳腺癌组织中以上指标的阳性表达率情况。结果：ER、PR化疗前后比较无统计学意义（P〉0．05）;而P53、Bcl-2比较有明显的差异性（P〈0．05）;ER、PR的阴性和阳性和疗效情况无明显差异性,而P53、Bcl-2的阴性和阳性表达和化疗的效果有明显的差异性,P〈0．05,具有统计学意义。结论：免疫组化检测中ER、PR对乳腺癌化疗前后无明显差异性,而化疗可通过抑制P53的表达来抑制乳腺癌增值并通过升高Bcl-2表达来调整肿瘤细胞分化。     

A Nation-Wide Cancer Registry-Based Study of Adenosquamous Carcinoma in Taiwan

BackgroundAdenosqamous carcinoma (ASC) is a rare disease involving various organs, yet there are no large-scale population-based comparative studies on ASC among different organs.MethodsThe incidence and overall survival of ASC among various organs in cases diagnosed in Taiwan from January 1, 2003 to December 31, 2010 were calculated and compared using data from the Taiwan Cancer Registry (TCR). The various organs were classified and divided into three different systems: the female reproductive, respiratory, and alimentary systems. Survival analysis were also compared among 30,850 patients diagnosed as ASC, adenocarcinoma (AC) or squamous cell carcinoma (SCC) in organs with frequent ASC.ResultsDuring the study period, a total of 576 ASC cases were diagnosed in Taiwan. The most common primary system was respiratory (73.8%), followed by alimentary (16.2%) and female reproductive (10%). The overall survival were significantly higher for cases involving the female reproductive system, followed by the respiratory and alimentary systems (P = 0.016). The median overall survival were worse in males than females for cases involving the respiratory system (22.4 vs. 31.8 months, P = 0.044). Multivariate analysis showed that age≧65, more advanced T and N categories were independent unfavorable prognostic factors of overall survival in ASC. ASC histology is an independent unfavorable prognostic factor compared with AC and SCC.ConclusionsASC at an old age and more advanced T and N categories were found to be associated with a poor prognosis.     

60例食管癌手术治疗诊治分析

目的：探讨胸段食管癌三种常用术式方法的选择原则、手术疗效及术后并发症的比较。方法：本研究选择临床确诊无广泛转移胸段食管癌60例,分别采用常规左胸入路手术20例,右胸、上腹部二切口手术18例和右胸、腹、颈部三切口手术22例,均为根治性手术,术中清扫淋巴结,并送病理检查。分析不同手术径路对食管癌治疗效果及术后并发症的影响。结果：本组研究病例全部顺利完成根治性手术,术中淋巴结活检检出有淋巴结转移25例,淋巴结转移率41.67%（25/60）。本研究组发生并发症患者13例,其中吻合口瘘4例,胃排空障碍4例,肺部并发症5例。其中通过右胸、腹、颈部三切口入路手术并发症最高,达41.25%,与其它组别相比均有明显差异,P〈0.05。结论：胸段食管癌手术方式的选择应因人而异,正确的选择有助于提高肿瘤切除率、淋巴结清扫率及降低肿瘤复发率,此外不同手术方式的个体化选择是降低术后并发症和提高生存质量的有效手段。     

紫杉醇在治疗晚期或复发性宫颈癌中的应用分析

为了探讨紫杉醇在治疗晚期或复发性宫颈癌中的疗效和安全性,为不适合手术或者放射治疗的患者(包括晚期或复发性宫颈癌患者)注射紫杉醇170 mg/m^2、卡铂5 mg·mL^-1·min^-1、贝伐珠单抗12 mg/kg治疗,每20 d一次,并记录期间的不良反应,直至疾病有所缓解或其毒性有所限制。总共有38名患者接受了平均8个治疗周期(范围2~25),中期随访值为18.5个月(范围2~29)。结果显示,19名患者(50.0%)经历完全反应,而15名患者经历(39.4%)部分反应,平均持续时间为6个月。3级和4级血液学毒性表现为中性粒细胞减少症15例(39.4%)、白细胞减少症13例(34.2%)、贫血症13例(34.2%)、血小板减少症11例(28.9%)。1名接受过骨盆照射的患者发生了2级直肠阴道瘘。本研究表明,紫杉醇、卡铂和贝伐单抗的组合对于晚期或复发性宫颈癌患者是有效且安全的。     

以化脓性肝脓肿为初始表现的原发性肝癌的临床特点及诊治体会

目的：探讨以化脓性肝脓肿（PLA）为初始表现的原发性肝癌（PLC）的临床特点,总结诊治体会。方法：回顾性分析哈尔滨医科大学附属第一医院肝脏外科2007年6月至2012年6月收治的10例以PLA为初始表现的PLC患者以及269例同期收入院的PLA患者的临床资料。结果：以PLA为初始表现的PLC患者可表现为发热、寒战、右上腹痛、恶心、呕吐、腹泻、体重减轻以及黄疸等。实验室检查显示以PLA为初始表现的PLC患者甲胎蛋白（AFP）和糖类抗原19-9（CA19—9）升高的比例显著高于PLA患者,但其他实验室检查的差异无统计学意义。患者除静脉抗生素治疗外均接受了有创治疗,生存时间最长为13个月,最短仅为2个月。结论：对于AFP及CA199升高的PLA患者要警惕伴发PLC的可能。肝脏增强CT检查对AFP及CA199正常的此类患者有较大的诊断价值。早期准确诊断,把握手术时机是提高此类患者预后的根本。     

11例恶性肿瘤继发性骨髓增生异常综合征病例分析

目的:分析恶性肿瘤继发骨髓增生异常综合征(Myelodysplastic Syndrome,MDS)病例资料,寻找肿瘤继发MDS关键致病因素,并为原发病治疗风险评估提供参考依据。方法:采用回顾性研究方法,查阅北京中医药大学东直门医院肿瘤血液科2007年1月-2012年4月MDS患者住院病例,区分原发、继发两种类型,并对继发性MDS病例资料进行综合分析。结果:按照MDS诊断标准,在明确诊断的75例患者中,原发性64例,肿瘤继发11例,占14.67%。11例患者均为中老年人群,其中,65岁以上老龄患者7例,占63.6%;70岁以上老龄患者5例,占45.45%。肿瘤继发MDS,尤其是老龄患者特征为严重合并症多,生存质量差,生存期短。致病原因有多方面因素,其中,放化疗联合应用可增加肿瘤继发MDS的风险性。结论:恶性肿瘤及其相关治疗易继发MDS,放化疗联合应用可增加其风险性;老龄患者继发MDS的机会明显增加,且预后不良。因此,对于老龄肿瘤患者要认真评估治疗受益和相关风险。