The Impact of Nationwide Education Program on Clinical Practice in Sepsis Care and Mortality of Severe Sepsis: A Population-Based Study in Taiwan

<div><p>Objectives</p><p>We investigated the effect of a nationwide educational program following surviving sepsis campaign (SSC) guidelines. Physicians’ clinical practice in sepsis care and patient mortality rate for severe sepsis were analyzed using a nationally representative cohort.</p> <p>Methods</p><p>Hospitalizations for severe sepsis with organ failure from 1997 to 2008 were extracted from Taiwan’s National Health Insurance Research Database (NHIRD), and trends in sepsis incidence and mortality rates were analyzed. A before-and-after study design was used to evaluate changes in the utilization rates of SSC items and changes in severe sepsis mortality rates occurred after a national education program conducted by the Joint Taiwan Critical Care Medicine Committee since 2004. A total of 39,706 hospitalizations were analyzed, which consisted of a pre-intervention cohort of 14,848 individuals (2000-2003) and a post-intervention cohort of 24,858 individuals (2005-2008).</p> <p>Results</p><p>The incidence rate of severe sepsis increased from 1.88 per 1,000 individuals in 1997 to 5.07 per 1,000 individuals in 2008. The cumulative mortality rate decreased slightly from 48.2% for the pre-intervention cohort to 45.9% for the post-intervention cohort. The utilization rates of almost all SSC items changed significantly between the pre-intervention and post-intervention cohorts. These changes of utilization rates were found to be associated with mild reduction in mortality rate.</p> <p>Conclusion</p><p>The nationwide education program through a national professional society has a significant impact on physicians’ clinical practice and resulted in a slight but significant reduction of severe sepsis mortality rate.</p> </div

Annual incidence rates and observed mortality rates for hospitalizations with severe sepsis with organ failure between 1997 and 2008 in Taiwan.

<p>(The nationwide SSC program was launched in 2004.)</p

Effects of utilization rate changes for items in the SSC guidelines on changes in mortality rates in Taiwan (pre-intervention cohort (2000-2003, before SSC program) vs. post-intervention cohort (2005-2008, after SSC program), n=39,706).

<p>Effects of utilization rate changes for items in the SSC guidelines on changes in mortality rates in Taiwan (pre-intervention cohort (2000-2003, before SSC program) vs. post-intervention cohort (2005-2008, after SSC program), n=39,706).</p

Utilization rate changes for items in the SSC guidelines before and after the SSC program was implemented in Taiwan.

<p>(pre-intervention cohort (2000-2003, before SSC program) vs. post-intervention cohort (2005-2008, after SSC program), n=39,706).</p

Flowchart of sample selection and classification.

<p>(“Mixed” refers to the use of a combination of zolpidem and other non-BZDs or non-BZDs and BZDs).</p

The Use of Hypnotics and Mortality - A Population-Based Retrospective Cohort Study

<div><p>Background</p><p>Sleep disorders, especially chronic insomnia, have become major health problem worldwide and, as a result, the use of hypnotics is steadily increasing. However, few studies with a large sample size and long-term observation have been conducted to investigate the relationship between specific hypnotics and mortality.</p><p>Methods</p><p>We conducted this retrospective cohort study using data from the National Health Insurance Research Database in Taiwan. Information from claims data including basic characteristics, the use of hypnotics, and survival from 2000 to 2009 for 1,320,322 individuals were included. The use of hypnotics was divided into groups using the defined daily dose and the cumulative length of use. Hazard ratios (HRs) were calculated from a Cox proportional hazards model, with two different matching techniques to examine the associations.</p><p>Results</p><p>Compared to the non-users, both users of benzodiazepines (HR = 1.81; 95% confidence interval [CI] = 1.78–1.85) and mixed users (HR = 1.44; 95% CI = 1.42–1.47) had a higher risk of death, whereas the users of other non-benzodiazepines users showed no differences. Zolpidem users (HR = 0.73; 95% CI = 0.71–0.75) exhibited a lower risk of mortality in the adjusted models. This pattern remained similar in both matching techniques. Secondary analysis indicated that zolpidem users had a reduced risk of major cause-specific mortality except cancer, and that this protective effect was dose-responsive, with those using for more than 1 year having the lowest risk.</p><p>Conclusions</p><p>The effects of different types of hypnotics on mortality were diverse in this large cohort with long-term follow-up based on representative claims data in Taiwan. The use of zolpidem was associated with a reduced risk of mortality.</p></div

Estimated zolpidem usage from 2000 to 2009 in Taiwan.

<p>(Estimates were calculated by dividing the annual cost by the average price for a zolpidem tablet. Source: Bureau of National Health Insurance in Taiwan).</p