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OBJECTIVE: Hospice care ensures better end-of-life quality by relieving terminal symptoms. Prior research has indicated that hospice care could prolong survival and reduce end-of-life medical expenditures among patients with cancer. However, the dearth of studies on the effects of hospice care type and use sequence on survival time and end-of-life medical expenditures substantiates the need for investigation. DATA SOURCES AND STUDY SETTING: Two million random records were obtained from the National Health Insurance Research Database. STUDY DESIGN: We estimated the effects of the type and sequence of hospice care use on survival time and medical expenditures among advanced cancer patients. This was a cross-sectional study. DATA COLLECTION/EXTRACTION METHODS: Patient data were collected from 2 million random records provided by the National Health Insurance Research Database of Taiwan. We included people with cancer and excluded patients under 20 years of age; 2860 patients remained after matching. PRINCIPAL FINDINGS: The results indicated that the average survival time of patients who received inpatient palliative care (1022 days) was significantly shorter than that of patients who did not receive palliative care (P < 0.001), but the health care expenditure during the entire course of cancer therapy was not the lowest. Interestingly, patients who received inpatient palliative care had the lowest health care expenditure at 1 year or month before the end of life (P < 0.001). CONCLUSION: The type and sequence of palliative care affected the survival time and health care expenditures of cancer patients. Receiving palliative care did not prolong survival but rather reduced health care expenditures. The sequence of receiving palliative care significantly affected health care expenditures.

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AIM: To evaluate the association between the number of co-morbidities, all-cause mortality and public health system expenditure in patients with type 2 diabetes (T2D) across different age groups. MATERIALS AND METHODS: A retrospective observational study of T2D patients using electronic health records in Hong Kong was conducted. Patients were stratified by age (< 50, 50-64, 65-79, ≥ 80 years) and the number of co-morbidities (0, 1, 2, 3, ≥ 4), defined using the Charlson Comorbidity Index and prevalent chronic diseases identified in local surveys. The association between the number of co-morbidities, all-cause mortality and direct medical costs was examined using Cox proportional hazard regression and the gamma generalized linear model with log link function. RESULTS: A total of 262 212 T2D patients with a median follow-up of 10 years were included. Hypertension and dyslipidaemia were the most common co-morbidities in all age groups. After age stratification, cardiovascular diseases dominated the top pair of co-morbidities in the older age groups (65-79 and ≥ 80 years), while inflammatory and liver disease were predominant among younger individuals. Compared with co-morbidity-free T2D patients, the hazard ratios (95% CI) of death for patients aged younger than 50 and 80 years or older with two co-morbidities were 1.31 (1.08-1.59) and 1.25 (1.15-1.36), respectively, and increased to 3.08 (2.25-4.21) and 1.98 (1.82-2.16), respectively, as the number of co-morbidities increased to four or more. Similar trends were observed for medical costs. CONCLUSIONS: Age-specific co-morbidity patterns were observed for patients with T2D. A greater number of co-morbidities was associated with increased mortality and healthcare costs, with stronger relationships observed among younger patients.

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Nutritional and dietary advice is the foundation of diabetes management. Unfortunately, such advice is seen in terms of intrusion and restriction of lifestyle, rather than as a health promoting intervention. This can be corrected by incorporating happiness into dietary modification. Culinary happiness can be defined as the process of sharing dietary, nutritional, and cooking advice, while ensuring the happiness associated with eating remains intact. The concept of culinary happiness includes all domains of culinary science: the procurement, preparation, plating and preservation of food.

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OBJECTIVE: To estimate the number of general practice-appropriate attendances in a remote emergency department and explore the reasons for patients' choice of service. DESIGN: A four-step case study approach was adopted, focusing on hospital emergency department (ED) attendances that were potentially manageable in general practice. SETTING: A large, remote community with substantial populations of Indigenous peoples and fly-in, fly-out mining industry workers. The ED is experiencing rapid growth in demand for services for lower urgency. PARTICIPANTS: Patients attending the emergency department with lower urgency problems. INTERVENTIONS: ED attendance data for 2016 were reviewed to identify lower urgency presentations. Patient records for 400 randomly selected presentations were subject to deeper analysis. A prospective survey was conducted over 6 months of 369 ED patients with lower urgency presentations. MAIN OUTCOME MEASURES: The proportion of patients attending the ED with GP-appropriate problems and influences on their decisions to attend the ED. RESULTS: About 48% of all attendances met the agreed definition of GP-appropriate problems. About half of presentations were during the normal work hours and about half of patients stated that GP services were unavailable. Younger age, lack of information about local GP services, and perceptions of convenience contributed significantly to seeking ED care. CONCLUSION: Increasing the availability of GP services alone is unlikely to be sufficient to change service utilisation. Strategies should include raising community awareness of how and when to utilise the appropriate service, understanding different models of care, and the need to register with a general practice.

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This opinion piece discusses the concept of social insulin resistance, and helps create a comprehensive biopsychosocial model of insulin resistance. Social insulin resistance is defined as a negative attitude, present in some social groups, directed towards avoidance or rejection of insulin therapy. The various aspects of social insulin resistance are described in detail. This important construct has both clinical and public health relevance, and will help plan strategies to improve the acceptance and usage of insulin in diabetes care.

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This communication is an interesting and off-beat take on the concept of theranostics, as applied to diabetes care. It proposes the use of the term diabeto-theranostics, to define the combined use of diagnostic and therapeutic modalities, so as to create individualized or personalized treatment strategies in persons with diabetes. Historical examples such as the chlorpropamide challenge test and modern innovations such as genotyping are described. The rubrics of gluco-phenotype, endo-phenotype, metabolic phenotype, glucagon: insulin ratio, and adenosine monophosphate activated protein kinase (AMPK) status in planning glucose lowering therapy are explained. Novel concepts such as psycho-theranostics and electro-theranostics in diabetes are discussed.

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This opinion piece describes a cricket-based analogy, the Glycaemic Sixer, for diabetes care. The hexad lists six glycaemic parameters which must be targeted to achieve optimal cardiovascular outcomes. All six parameters, i.e., fasting glucose, post prandial glucose, glycosylated haemoglobin, avoidance of hypoglycaemia, avoidance of nocturnal hypoglycaemia, and minimization of glycaemic variability, are associated with cardiovascular outcomes. Hence, equal attention must be paid to all these while planning strategies and choosing drugs for diabetes management. The Glycaemic Sixer promotes safety along with efficacy, and supports institution of individualized, patient centred care, using evidence-based therapeutic agents.

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diabetes care in Malaysia. Objective: We audited the quality of care for patients with type 2 diabetes mellitus (T2DM) attending our diabetes clinic at a public hospital. Methods: A structured review of the outpatient clinic cards, prescriptions and laboratory results was conducted for patients attending the diabetes clinic at Sibu Hospital in October and November 2014. Results: For the total of 233 patients who were audited, the levels of fasting blood sugar, blood pressure, body mass index and fasting lipid profile were satisfactory at 99.1%, 99.6%, 92.6% and 99.6% respectively. 79.7% of the subjects had had HbA1c performed at least once over the previous six months. Only 25.8% had annual foot screening, while the eye screening rate was 71.2% and the albuminuria screening rate was 93.6%. For outcome measures, the mean (SD) HbA1c level was 9.2% (1.91%), with 13 patients (6.7%) having HbA1c less than 6.5%; 36.4% of participants achieved BP < 130/80 mmHg; and 69.4% had LDL < 2.6 mmol/L. The majority of the patients were overweight or obese (91.4%). Conclusions: Overall, the performance of diabetic care processes at our hospital was satisfactory, except for foot examination. The glycaemic and weight control among the subjects were suboptimal and warrant an optimised and comprehensive approach on the part of the management.

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OBJECTIVE: This study was to investigate the factors that influence the propensity of Koreans in choosing care settings of dementia patients. METHODS: This study analyzed the data from the '2014 Nationwide Survey on Dementia Awareness of Koreans' that was conducted by the National Institute of Dementia. Korean's perception of care burden for dementia was measured with grading on its types. Also its influences on preference for care between facilities and homes were evaluated using multivariate analysis with socio-demographic characteristics. RESULTS: In terms of preferred care settings, respondents preferred facilities over homes in case of themselves and their family, respectively 77.5% and 68.2%. The preference for facilities was significantly influenced by the respondents' age for both themselves and their family. Additionally, the perception of relatively higher emotional and physical burden compared to economic burden significantly influenced preference for facilities for their family. CONCLUSION: Improving public awareness and setting-up a practical social supporting system are needed to reduce emotional and physical burden as well as economic burden of dementia. Furthermore, building up an appropriate and safer communities for dementia patients and their caregivers is much demanded for reducing their burdens.

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CONTEXT: Patient satisfaction is of increasing importance and recognized as an important indicator for quality of care. It is influenced by the patients, physicians and practice's characteristics. The literature on diabetes has increasingly focused on the quality of care and its measurement. The relationship between the quality of diabetes care and patient satisfaction is poorly understood and it requires further elaboration. AIMS: The aim of this study is to Identify the underlying factors influencing patient's satisfaction with the diabetes care, to assess whether comprehensive diabetes management that provided in diabetic clinic improves satisfaction and glycemic control. SETTINGS AND DESIGN: Cross-sectional study Family Medicine and Diabetic Clinics at King Abdul-Aziz Medical City. MATERIALS AND METHODS: A total of 230 type two diabetic patients attending their follow-up were requested to fill the questionnaire. The questionnaire identified patients, doctors and practice related factors. STATISTICAL ANALYSIS USED: SPSS 16 with appropriate statistical test. RESULTS: The response rate was 85%. Mean hemoglobin A1c (HbA1c) level was 0.087 ± 0.020. Around half of the patients were having high satisfaction rate of (>60%). Doctor's communication ranked the highest satisfaction level among other factors. However, no association between satisfaction with other patient's characteristics and HbA1c. CONCLUSIONS: Physicians play a major role in promoting higher level of satisfaction by good communication with their patients. More efforts are needed to improve certain aspects of diabetic care such as: Patient's education and periodic physical examination. Although the present study did not show any association between satisfaction and important outcome like HbA1c, more studies are needed to explore such complex relationship. To obtain more significant results a bigger sample size might be needed.