盧信銘博士後研究員 國家衛生研究院群體健康科學研究所 2011 臺灣人口學會年會暨學術研討會 April 28-29, 2011

1. Transitions to different care settings or death among recipients ofprolonged mechanic ventilation:A trajectory model based on longitudinal health insurance and death certificate data 盧信銘博士後研究員 國家衛生研究院群體健康科學研究所 2011臺灣人口學會年會暨學術研討會 April 28-29, 2011

2. Definitions of prolonged mechanical ventilation (PMV) • The definition accepted by most physicians and researchers in this field: use for at least 21 consecutive days under the condition of using for at least 6 hours a day • The Taiwan Bureau of National Health Insurance also adopts this standard.

3. NHI financial burden from PMV care • The yearly total number of PMV patients in 2004 and 2005 reached 30,000 (0.13% of the Taiwan population), and the total reimbursement approached 27 billion NT dollars, an amount around 6% of total annual NHI budget. • In 2009, per-capita annual NHI expenses for PMV patients = • 33 times that for all enrollees • 56 times of per-capita annual premium (13,188 Taiwan dollars)

4. Controversial issues related to extensive use of mechanical ventilation (MV) services • Cost-effectiveness • Cost-utility • Distributive justice in healthcare allocation • Humanity in treating patients

5. Study purposes • To examine transitions to different care settings or death among recipients of PMV • To investigate factors associated with the probabilities of moving to various care settings or death after being under a state of PMV Reference data helpful for (1) improving patient-clinician and family-clinician communication regarding care planning for PMV patients, (2) advancing pathways of PMV care in the current IDS system, and (3) formulating programs in regard to end-of-life care and long-term care.

6. Longitudinal NHI data on prognosis and healthcare expenditures among PMV patients • Data for all patients with new PMV episodes in 1998-2006 • SAS programming to transform raw NHI data and death certificate data into individual longitudinal data • Long-term follow-up research on disease patterns, healthcare use patterns, mortality, functional status and healthcare expenditures among PMV patients • Follow-up until death or the end of 2007 (possible extension of follow-up time later)

8. Data for this study • Data for the 35,369 patients who fell into a state with PMV in years from 2002 to 2007 (better data for identifying RCC and RCW settings after 2002) • We categorized patients into different groups on the basis of the care setting (including ICU, RCC, RCW, and GW) at the time of becoming under PMV, and followed each patient until death or the end of 2007, • 6 post-PMV states were defined: death, ICU, RCC, RCW, GW, and alive in a non-hospital setting

9. Factors associated with the 1-month, 6-month, and 1-year transition probabilities • Using multinomial logit regression to determine factors associated with the 1-month, 6-month, and 1-year transition probabilities of moving to various settings after the PMV onset, given a specific care setting at the time of PMV onset • Potential predictors: • hospital characteristics at the PMV onset (hospital type, hospital location) • individual demographics (gender, age, NHI registration location) • PMV incidence year • socioeconomic conditions (position of NHI registration, salary class in NHI registration) • diseases at the PMV onset (excluding respiratory failure)

13. Conclusions (1) • High mortality after PMV incidence • Persistent low chance of being alive in a non-hospital setting among PMV patients • While the death rate for patients in the GW setting at PMV incidence was lower than those in a more intensive care setting, the substantial proportion of patients moving to an ICU setting soon after the PMV onset highlights a necessity of investigating appropriate pathways of care for ventilator-dependent patients. • While patients initially in a RCW setting generally had lower mortality in the first year after PMV incidence, this group of patients also had the smallest chance to live in a non-hospital setting after receiving PMV.

14. Conclusions (2) • The following diseases were significantly linked to transitions to death or back to an ICU setting from a less intensive care setting: septicemia, shock, neoplasm, coagulation and hemorrhagic disorders, acute and unspecific renal failure, chronic renal failure, and non-alcoholic-related liver disease. • Among patients staying in the GW setting at the PMV onset, some diseases increased likelihood of transferring to the ICU setting within one month: coagulation and hemorrhagic disorders, non-alcoholic-related liver disease, intracranial injury, acute and unspecific renal failure, shock, septicemia, heart valve disorders, acute myocardial infarction and coronary atherosclerosis, other diseases of the digestive system, and chronic renal failure.

15. Future research • Select key explanatory variables identified by our multinomial logit regression analysis, such as age and significantly influencing diseases for death and post-PMV ICU care • Use these factors to construct a Markov chain model to generate richer reference data on transitions all the way through the post-PMV lifespan

16. 謝謝聆聽!敬請指教!