RESUMEN
OBJECTIVES: Studies have investigated income-related inequality in out-of-pocket expenditure (OOPE) on health care but less is known about health-related inequality of OOPE distribution. This study analysed the relationship between health-related inequality and OOPE and the factors contributing to OOPE inequality in Taiwan. METHODS: We developed a household OOPE questionnaire and conducted a nationally representative cross-sectional survey of households in Taiwan between January and August 2022, using two-stage probability proportional-to-size sampling based on a national address registry in Taiwan. We calculated a concentration index to determine OOPE inequality in health. We then identified factors contributing to OOPE inequality in health distribution by performing a decomposition analysis. RESULTS: A total of 657 people responded to the survey (81.4% response rate). The two largest categories of OOPE were spending on curative care and on medical goods and pharmaceuticals, with concentration indices of -0.265 (p < .001), -0.272 (p = .006) and -0.227 (p = .003), respectively, indicating that the OOPE burden fell disproportionately on people with poor health. Socioeconomic status explained significant proportions of inequality in total, curative and medical goods and pharmaceuticals OOPE. Utilisation of health care increased the OOPE burden among people with poor health while having private health insurance worked in the opposite direction. CONCLUSION: In Taiwan, people in poor health faced a disproportionately high OOPE burden, indicating that the National Health Insurance scheme may not meet their needs for health care. There is a need for policies to take account of the different factors affecting health inequalities in OOPE in order to enhance equity in Taiwan's universal health system.
Asunto(s)
Financiación Personal , Gastos en Salud , Cobertura Universal del Seguro de Salud , Humanos , Taiwán , Estudios Transversales , Cobertura Universal del Seguro de Salud/estadística & datos numéricos , Femenino , Masculino , Gastos en Salud/estadística & datos numéricos , Persona de Mediana Edad , Adulto , Financiación Personal/estadística & datos numéricos , Factores Socioeconómicos , Anciano , Disparidades en el Estado de Salud , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/economíaRESUMEN
BACKGROUND: Effectively managing the coexistence of both diabetes and disability necessitates substantial effort. Whether disability onset affects adherence to type 2 diabetes medication remains unclear. This study investigated whether disability onset reduces such adherence and whether any reduction varies by disability type. METHODS: This study used the National Disability Registry and National Health Insurance Research Database from Taiwan to identify patients with type 2 diabetes who subsequently developed a disability from 2013 to 2020; these patients were matched with patients with type 2 diabetes without disability onset during the study period. Type 2 diabetes medication adherence was measured using the medication possession ratio (MPR). A difference-in-differences analysis was performed to determine the effect of disability onset on the MPR. RESULTS: The difference-in-differences analysis revealed that disability onset caused a reduction of 5.76% in the 1-year MPR (P < 0.001) and 13.21% in the 2-year MPR (P < 0.001). Among all disability types, organ disabilities, multiple disabilities, rare diseases, and a persistent vegetative state exhibited the largest reductions in 2-year MPR. CONCLUSIONS: Policies aimed at improving medication adherence in individuals with disabilities should consider not only the specific disability type but also the distinct challenges and barriers these patients encounter in maintaining medication adherence.
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Diabetes Mellitus Tipo 2 , Humanos , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Pacientes , Bases de Datos Factuales , Cumplimiento de la Medicación , Programas Nacionales de SaludRESUMEN
National estimates of out-of-pocket health-care expenditures (OOP-HCEs) that use comparable international guidelines based on A Systems of Health Accounts (SHA) are generally unavailable in Taiwan. International comparable OOP are essential for designing universal health-coverage (UHC) policy. We designed an SHA-based household OOP questionnaire. A nationally representative cross-sectional survey was then conducted from January to August 2022. The final questionnaire was completed by 657 households and 1969 individuals. The total OOPs were divided into expenditures related to curative care (HC.1), rehabilitative care (HC.2), long-term care (HC.3), ancillary services (HC.4), and medical goods (HC.5). National estimates were calculated by accounting for the complex survey design. Variance was estimated through Taylor series linearization. The concentration index was calculated using household income as the ranking variable. We then identified factors contributing to the inequality in OOP distribution by household income. National estimates revealed an OOP of NT$424 billion, which accounted for 29.6% of Taiwan's national health expenditure in 2021. Private health insurance (PHI) reimbursements accounted for 9.0% of the total OOP. The OOPs for curative care and medical goods accounted for 50.1% and 39.0% of the total OOP, respectively. The OOPs after PHI reimbursements were progressive (concentration index = 0.103, P = 0.012). The frequency of medical-care use and the number of medical visits negatively affected progressive OOPs. International comparable OOPs revealed that under the Taiwanese National Health Insurance (NHI), OOPs can still be high. However, the NHI might have caused OOPs to be progressive from the perspective of income but regressive from the perspective of health status. Countries striving for UHC should consider the redistribution effect of public health insurance and possible inequalities in health.
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Gastos en Salud , Programas Nacionales de Salud , Humanos , Taiwán , Estudios Transversales , Seguro de SaludRESUMEN
This study identified the trajectories of instrumental and emotional perceived social support (PSS) from 1996 to 2003 and investigated the associated risk of mortality in bereaved older adults in Taiwan. The study analyzed 1,188 bereaved older adults who had experienced loss of a spouse, a child, or both before 1996 from the Taiwan Longitudinal Study on Aging. More favorable trajectories of PSS are associated with lower mortality risk in bereaved older adults. Compared with the spousal or dual bereavement, the parental bereavement benefited more from consistently high instrumental PSS. The present study revealed that consistently high emotional PSS had a stronger protective effect on mortality risk for a widow or widower than did consistently high instrumental support. The findings of this study can serve as an empirical reference to inform social policies and clinical practices for bereaved older adults in culturally similar societies.
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Aflicción , Humanos , Anciano , Estudios Longitudinales , Taiwán , Esposos/psicología , Apoyo SocialRESUMEN
Diabetes-Related Preventable Hospitalization (DRPH) has been identified as an important indicator of efficiency and quality of the health system and can be modified by social determinants. However, the spatial disparities, clustering, and relationships between DRPH and social determinants have rarely been investigated. Accordingly, this study examined the association of DRPH with area deprivation, densities of certificated diabetes health-promoting clinics (DHPC) and hospitals (DHPH), and the presence of elderly social services (ESS) using both statistical and spatial analyses. Data were obtained from the 2010-2016 National Health Insurance Research Database (NHIRD) and government open data. Township-level ordinary least squares (OSL) and geographically weighted regression (GWR) were conducted. DRPH rates were found to be negatively associated with densities of DHPC (ß = -66.36, p = 0.029; 40.3% of all townships) and ESS (ß = -1.85, p = 0.027; 28.4% of all townships) but positively associated with area deprivation (ß = 2.96, p = 0.002; 25.6% of all townships) in both OLS and GWR models. Significant relationships were found in varying areas in the GWR model. DRPH rates are high in townships of Taiwan that have lower DHPC densities, lower ESS densities, and greater socioeconomic deprivation. Spatial analysis could identify areas of concern for potential intervention.
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Diabetes Mellitus , Determinantes Sociales de la Salud , Anciano , Diabetes Mellitus/epidemiología , Hospitalización , Humanos , Análisis Espacial , Taiwán/epidemiologíaRESUMEN
BACKGROUND: Childhood adversities (CAs) have been linked with unfavorable development; however, the chronic trajectories of multiple CAs and possible heterogeneous effects are understudied. OBJECTIVES: This study examined the trajectories of multiple CAs and their associations with mental health outcomes in adolescence and investigated the buffering effect of parenting practices. PARTICIPANTS AND SETTING: We used population-representative data from the Taiwan Education Panel Survey (2005 and 2007, n = 10,416). METHODS: This study was based on retrospectively self-reporting of six CAs, namely physical abuse, family economic hardship, parental problematic drinking, parental catastrophic health problems, parental divorce, and parental death, at three developmental periods: early childhood, middle childhood, and early adolescence. Group-based multitrajectory modeling and multiple regressions were used to identify distinct trajectories of multiple CAs and evaluate the association estimates. RESULTS: A total of four trajectory groups were identified: increasing family economic hardship (12.3 %), chronic physical abuse (3.3 %), chronic parental problematic drinking (2.8 %), and low adversity (81.6 %). The chronic physical abuse group had the highest levels of depressive symptoms (ß = 6.61, p < .001) and suicidal ideation (Adjusted Odds Ratio [AOR] = 2.67, p < .001), whereas the chronic parental problematic drinking group had the highest level of substance abuse (AOR = 4.59, p < .001). Positive parental practices buffered the harmful effects of increasing family economic hardship in late adolescence, particularly for depressive symptoms and substance abuse. CONCLUSIONS: Adverse mental health outcomes varied among groups with distinct multiple CA trajectories. The provision of social services to train or support positive parenting practices in families experiencing economic hardship is a potentially valuable resilience strategy.
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Experiencias Adversas de la Infancia/psicología , Maltrato a los Niños/psicología , Responsabilidad Parental , Adolescente , Conducta del Adolescente , Adulto , Experiencias Adversas de la Infancia/estadística & datos numéricos , Niño , Maltrato a los Niños/estadística & datos numéricos , Divorcio , Femenino , Humanos , Masculino , Persona de Mediana Edad , Padres , Estudios Retrospectivos , Factores Socioeconómicos , Trastornos Relacionados con Sustancias/psicología , Ideación Suicida , Encuestas y Cuestionarios , Taiwán , Adulto JovenRESUMEN
Achieving universal health insurance coverage is a major objective for many countries. Taiwan implemented its National Health Insurance (NHI) program with universal coverage in 1995. This study investigates whether the NHI program affects the level and structures of out-of-pocket (OOP) health expenditures. We used data from the Taiwan Survey of Family Income and Expenditure released by the Directorate-General of Budget, Accounting and Statistics. We identified a case and a control group and then employed coarsened exact matching to match the two groups using several available variables. We then conducted a difference-in-difference analysis and determined that there was a statistically significant negative effect on OOP expenditure that was attributable to NHI (a reduction of 2.11 percentage points in total household expenditure). The largest reductions were found in health care services (-1.63%) and pharmaceuticals (-0.45%). We found a statistically significant positive effect on purchases of private insurance related to health care, which was attributable to NHI (an increase of 0.96 percentage points in household budget share). In addition, we discovered that the NHI program had a greater impact on households of a lower socioeconomic status compared with higher socioeconomic status households. The structure of OOP payments in the post-NHI period remained similar to that of the pre-NHI period in the full sample but varied slightly depending on the educational level of the head of the household.
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Composición Familiar , Financiación Personal/estadística & datos numéricos , Programas Nacionales de Salud/estadística & datos numéricos , Servicios de Salud/estadística & datos numéricos , Humanos , Seguro de Salud/economía , Seguro de Salud/estadística & datos numéricos , Medicamentos bajo Prescripción/economía , Factores Socioeconómicos , TaiwánRESUMEN
AIM: Human life expectancy has increased steadily over the past two centuries. In the context of aging, resilience appears to be central to improving quality of life and preserving independence in later years. The present study investigated multifaceted changes and their association with mortality in older people in Taiwan. METHODS: The present study used older participants aged 60 years or older from the first and second waves (1989 and 1993) of the longitudinal Survey of Health and Living Status of the Elderly in Taiwan. Multifaceted changes comprised chronic conditions, self-rated health, activities of daily living, depression, life satisfaction, social engagement and religious activity. "Positive change" was defined as stable or improving indicator scores from 1989 to 1993. Logistic regressions and Cox proportional hazard models were used to examine associations of positive changes with sociodemographic characteristics and with mortality. RESULTS: The percentages of positive changes in indicators of respondents ranged from 47% for activities of daily living to 78% for religious activity. The probability of positive changes for chronic conditions, life satisfaction, social engagement, and religious activity were lower in men, singles, less educated and the oldest respondents than in their counterparts. Lower mortality rates were observed in respondents with positive changes of self-rated health (HR = 0.72), activities of daily living (HR = 0.67), life satisfaction (HR = 0.85) and religious activity (HR = 0.79). CONCLUSIONS: Various changes were valid predictors of mortality in old age. None of the multifaceted aspects of change should be overlooked when designing policies for aging well and active aging in later life. Geriatr Gerontol Int 2017; 17: 959-966.
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Pueblo Asiatico , Mortalidad , Resiliencia Psicológica , Actividades Cotidianas , Anciano , Femenino , Evaluación Geriátrica , Estado de Salud , Humanos , Estudios Longitudinales , Masculino , Satisfacción Personal , Calidad de Vida , Factores Socioeconómicos , TaiwánRESUMEN
BACKGROUND: Several studies have investigated the effects of pay-for-performance (P4P) initiatives. However, little is known about whether patients with multiple chronic conditions (MCC) would benefit from P4P initiatives similarly to patients without MCC. OBJECTIVES: The objective of this study was to compare the effects of the diabetes mellitus pay-for-performance (DM-P4P) program on the quality of diabetic care between type 2 diabetic patients with and without MCC. METHODS: This study used data from Taiwan's Longitudinal Health Insurance Database 2005. Of this cohort, 52,276 diabetic patients were identified. To address potential selection bias between the intervention and comparison groups, the propensity score matching method was used. Generalized estimating equations were applied to analyze the difference-in-difference model to examine the effect of the intervention, the DM-P4P program. RESULTS: The disease-specific DM-P4P program had positive impacts on process and outcome indicators of health care quality regardless of patients' MCC status. Diabetic patients with MCC experienced a significantly larger decrease in the admission rate of diabetes-related ambulatory care sensitive conditions after the P4P enrollment over time compared with patients without MCC. CONCLUSIONS: The positive impacts on use of diabetes-related services were comparable between diabetic patients with and without MCC. Most importantly, for MCC patients, the disease-specific DM-P4P program had a stronger positive impact on health outcomes. Hence, the commonly observed phenomenon of "cherry picking" in implementing P4P strategies may lead to disparities in the quality of diabetic care between diabetic patients with and without MCC.
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Complicaciones de la Diabetes/terapia , Diabetes Mellitus Tipo 2/terapia , Reembolso de Incentivo/estadística & datos numéricos , Adulto , Anciano , Enfermedad Crónica/terapia , Diabetes Mellitus Tipo 2/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Calidad de la Atención de Salud/estadística & datos numéricos , Reembolso de Incentivo/normas , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVES: The aim of this article is to present the preliminary impact of a medication monitoring program, PharmaCloud, in Taiwan and analyze the embedded factors that have contributed to the performance thereof. This article also compared PharmaCloud with similar international programs in order to draw lessons learned. METHODS: The five domains of the RE-AIM framework - reach, effectiveness, adoption, implementation, and maintenance - were examined using qualitative and quantitative data. A difference-in-differences model was applied to analyze the quantitative impact of PharmaCloud on drug utilization and drug expenses. The qualitative impact was evaluated by document analysis based on field reports from the participating medical institutions. RESULTS: Reach and adoption: although all of the major hospitals adopted PharmaCloud and some of the hospitals had high inquiry rates, more time and incentives are needed to raise the overall inquiry rate. Effectiveness: during the study period of 3 months, the number of medications per prescription declined in the intervention group was 0.15 more than that of the general population, and the drug expense per person declined in the intervention group was NT $567 (US $18.9) more than that of the general population. The potential savings could be between 2% and 5% of the total pharmaceutical expenditure. Medication duplication was found to have decreased more in the intervention group. IMPLEMENTATION: a variety of innovations in care delivery are being developed in which the pharmacists play a more significant role. Maintenance: the embedded National Health Insurance would lend strong support for PharmaCloud to grow and thrive. CONCLUSION: PharmaCloud owes its effectiveness to the embedded National Health Insurance (NHI) program, which is universal and provides a comprehensive benefit package including more than 16,000 prescription drugs. An effective medication program is one that operates under the principle of universality and comprehensiveness, facilitates innovations, and has a substantial level of interoperability with the intra-hospital health information systems.
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Nube Computacional/estadística & datos numéricos , Registros Electrónicos de Salud/estadística & datos numéricos , Prescripción Electrónica/estadística & datos numéricos , Sistemas de Entrada de Órdenes Médicas/estadística & datos numéricos , Sistemas de Medicación en Hospital/estadística & datos numéricos , Sistemas de Información en Farmacia Clínica , Registro Médico Coordinado/métodos , Taiwán , Interfaz Usuario-Computador , Revisión de Utilización de RecursosRESUMEN
Experiencing a low socioeconomic status (SES) throughout the life course has been reported to be correlated with poor health outcomes. Several studies have suggested that income, wealth, and perceptions of economic status are associated with increased risk of death among elderly people. Few studies have investigated the association between lifetime SES and mortality among elderly adults. The analysis in this study was based on 2310 elderly adults for whom SES data from the four phases of the longitudinal survey of Health and Living Status of the Elderly in Taiwan (1989, 1993, 1996, and 1999) were available, and who were alive in 1999. The SES measures included in the analysis were annual income, the household wealth, and the self-perceived economic satisfaction. A group-based trajectory modelling approach was employed to create SES trajectories. Cox proportional hazard models were employed to examine the association between SES trajectories and 8-year all-cause mortality (1999-2007). Irrespective of whether income, wealth, or self-perceived economic satisfaction was used, the elderly adults with consistently low SES trajectory throughout early old age were independently and significantly associated with higher hazards of mortality than were those in a consistently high SES trajectory. Downward or upward mobility of income and wealth were associated with increased hazard of mortality. However, decreased self-perceived economic satisfaction was not significantly associated with increased hazard of mortality. According to the results, the strong distinction between trajectory patterns of income, wealth, and self-perceived economic satisfaction among elderly adults indicate that neither should be overlooked when investigating the role of SES mobility in mortality. Retirement policies or strategies for maintaining and promoting favorable SES in early old age may benefit the health of elderly adults later in life.
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Renta/estadística & datos numéricos , Mortalidad/tendencias , Satisfacción Personal , Anciano , Anciano de 80 o más Años , Envejecimiento , Femenino , Estado de Salud , Humanos , Estudios Longitudinales , Masculino , Modelos de Riesgos Proporcionales , Autoimagen , Factores Socioeconómicos , Taiwán/epidemiologíaRESUMEN
The aim of this study is to evaluate the relationships between obesity and medical care expenditure among Taiwanese adults and to assess the influence of sex, age and socioeconomic status. Our study sample consisted of 12,250 adults aged 18 years or older from the 2001 National Health Interview Survey (NHIS), who had consented to the linking of their survey responses with their NHI claims records. Obesity was defined by Body Mass Index based on the WHO-Asia Pacific categories. Adjusted expenditure for obese class II and class I men were, respectively, 44.6% (95%CI: 27.1%-68.7%) and 39.5% (95%CI: 39.4%-41.2%) greater than normal weight men. For obese class II and class I women, the adjusted expenditure were, respectively, 93.3% (95%CI: 69.9%-114.6%) and 56.1% (95%CI: 50.4%-61.4%) greater than normal weight women. After adjusting for other factors, higher medical care expenditure was associated with a higher BMI for each age group. The relative magnitude of the association became more apparent as age increased. Annual medical care expenditure increased as the BMI increased among women, which was particularly apparent among low socioeconomic status women. On the other hand, the relationship between BMI and medical care expenditure in men varied by household income. In conclusion, there is a strong positive relationship between higher BMI and increased medical care expenditure and this varies according to sex, age and socioeconomic status. Our findings suggest that projections of future health care costs attributable to obesity will need to take into consideration the demographic make-up of the obese population.
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Índice de Masa Corporal , Costos de la Atención en Salud/estadística & datos numéricos , Obesidad/economía , Clase Social , Adolescente , Adulto , Factores de Edad , Anciano , Femenino , Encuestas Epidemiológicas , Humanos , Masculino , Persona de Mediana Edad , Obesidad/clasificación , Obesidad/complicaciones , Obesidad/epidemiología , Factores Sexuales , Factores Socioeconómicos , Taiwán/epidemiología , Adulto JovenRESUMEN
This paper measures and decomposes socio-economic inequality in general and mental health of Taiwan residents using concentration indices. The data from the 2001 Taiwanese National Health Interview Survey is based on multi-stage systematic sampling: 18,142 subjects aged 12 and above provided answers to questions on general and mental health domains of SF-36 Taiwan version. Significant inequalities favouring higher income groups emerge in both general and mental health, but these are particularly high for residents in remote areas. The decomposition analysis shows that in both areas income itself accounts for a significant and sizeable contribution (40-73%) of general and mental health inequality. The second largest contribution comes from inequality in education (15-22%) for general health and from employment status (17-18%) for mental health. Apart from these factors, age, and lifestyles are also important contributors for both general and mental health. We also find important regional disparities in income-related inequalities.
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Disparidades en el Estado de Salud , Indicadores de Salud , Renta/estadística & datos numéricos , Adolescente , Adulto , Anciano , Femenino , Accesibilidad a los Servicios de Salud , Humanos , Renta/clasificación , Masculino , Persona de Mediana Edad , Factores Socioeconómicos , TaiwánRESUMEN
In response to the introduction of global budgets, dentists might alter their supply behaviour, changing the number of visits, the amount of expenditure, and the type of services provided. We develop two-way fixed effects models to estimate these effects using a panel data constructed from outpatient dental care expenditures claims from the Taiwanese National Health Insurance system. The availability of a long panel allows us to estimate a "policy effect" for each dentist in the panel. The overall effect of global budgets is to constrain costs but there is evidence of a change in the mix of services. Male and younger dentists have higher policy effects than female and older dentists. Global budgets favour dentists in deprived areas and there is some evidence of increases in the expenditure per visit and the volume of composite resin fillings.