Projection of Supply and Demand of the Physical Therapy Manpower in Taiwan for the Next Twenty Years: Part I. Current Status and Productivity of Physical Therapists and Physical Therapist Assistants

Background and purposes: The purposes of this study were 1) to describe the general productivity and productivities in 4 special fields (neurological, orthopedic, pediatric, and cardiopulmonary) of physical therapists (PT) and physical therapist assistants (PTA) in Taiwan, and 2) to explore the association between characteristics of PT/PTA and productivity. Method: Questionnaire was mailed to the members of all PT and PTA associations in Taiwan. The total mailing number of questionnaire for PT and PTA were 2466 and 1117, respectively. The content of this questionnaire included basic demographic data and information in clinical work. Survey period was between September, 2002 and December, 2002. Results: Total returned questionnaires were 764 from PT and 269 from PTA. General productivity for aPT was 21.39 patients per day, assuming working 8 hours per day. For each specialization field, the productivity of neurological, orthopedic, pediatric, cardiop­ ulmonary patients of each PT per day was 19.72 (sd=9.50), 24.98 (sd=11.07), 15.55 (sd=8.75), and 21.42 (sd=10.63), respectively. For the association between PT characteristics and productivity, working place and PT\u27 s gender were significantly associated with general productivity. PT\u27s age, educational level, and working place were significantly associated with neurological and pediatric productivities. Working experience was also significantly associated with neurological productivity. PT\u27 s characteristics were not significantly associated with orthopedic and cardiopulmonary productivity. General productivity for a PTA was 29.75 patients per day. The productivity of neurological, orthopedic, pediatric, cardiopulmonary patients of each PTA per day was 22.29 (sd=9.50), 35.07 (sd=11.07), 19.48 (sd=8.75), and 19.55 (sd=10.63), respectively. Only PTA\u27s education level was signifi­cantly associated with orthopedic productivity. There were no other significant associations between any of the PTA\u27s characteristics and productivity. Conclusion: This study repported the current status of clincial practice in PT and PTA. There will be a series of articles investigating the projection of supply and demand of physical therapy manpower for the next twenty years

Is clopidogrel better than aspirin following breakthrough strokes while on aspirin? A retrospective cohort study.

ObjectiveThere is insufficient evidence on which to base a recommendation for optimal antiplatelet therapy following a stroke while on aspirin. The objective was to compare clopidogrel initiation vs aspirin reinitiation for vascular risk reduction among patients with ischaemic stroke on aspirin at the time of their index stroke.DesignRetrospective.SettingWe conducted a nationwide cohort study by retrieving all hospitalised patients (≥18 years) with a primary diagnosis of ischaemic stroke between 2003 and 2009 from Taiwan National Health Insurance Research Database.ParticipantsAmong 3862 patients receiving aspirin before the index ischaemic stroke and receiving either aspirin or clopidogrel after index stroke during follow-up period, 1623 were excluded due to a medication possession ratio <80%. Also, 355 were excluded due to history of atrial fibrillation, valvular heart disease or coagulopathy. Therefore, 1884 patients were included in our final analysis.InterventionsPatients were categorised into two groups based on whether clopidogrel or aspirin was prescribed during the follow-up period. Follow-up was from time of the index stroke to admission for recurrent stroke or myocardial infarction, death or the end of 2010.Primary and secondary outcome measuresThe primary end point was hospitalisation due to a new-onset major adverse cardiovascular event (MACE: composite of any stroke or myocardial infarction). The leading secondary end point was any recurrent stroke.ResultsCompared to aspirin, clopidogrel was associated with a lower occurrence of future MACE (HR=0.54, 95% CI 0.43 to 0.68, p<0.001, number needed to treat: 8) and recurrent stroke (HR=0.54, 95% CI 0.42 to 0.69, p<0.001, number needed to treat: 9) after adjustment of relevant covariates.ConclusionsAmong patients with an ischaemic stroke while taking aspirin, clopidogrel initiation was associated with fewer recurrent vascular events than aspirin reinitiation

Effects of a Multifactorial Fall Prevention Program on Fall Incidence and Physical Function in Community-Dwelling Older Adults With Risk of Falls

Objective: To evaluate effects of a multifactorial fall prevention program on fall incidence and physical function in community-dwelling older adults. ;Design: Multicenter randomized controlled trial. ;Setting: Three medical centers and adjacent community health centers. ;Participants: Community-dwelling older adults (N=616) who have fallen in the previous year or are at risk of falling. ;Interventions: After baseline assessment, eligible subjects were randomly allocated into the intervention group (IG) or the control group (CG), stratified by the Physiological Profile Assessment (PPA) fall risk level. The IG received a 3-month multifactorial intervention program including 8 weeks of exercise training, health education, home hazards evaluation/modification, along with medication review and ophthalmology/other specialty consults. The CG received health education brochures, referrals, and recommendations without direct exercise intervention. ;Main Outcome Measures: Primary outcome was fall incidence within 1 year. Secondary outcomes were PPA battery (overall fall risk index, vision, muscular strength, reaction time, balance, and proprioception), Timed Up & Go (TUG) test, Taiwan version of the International Physical Activity Questionnaire, EuroQo1-5D, Geriatric Depression Scale (GDS), and the Falls Efficacy Scale-International at 3 months after randomization. ;Results: Participants were 76 +/- 7 years old and included low risk 25.6%, moderate risk 25.6%, and marked risk 48.7%. The cumulative 1-year fall incidence was 25.2% in the IG and 27.6% in the CG (hazard ratio=.90; 95% confidence interval, .66-1.23). The IG improved more favorably than the CG on overall PPA fall risk index, reaction time, postural sway with eyes open, TUG test, and GDS, especially for those with marked fall risk. ;Conclusions: The multifactorial fall prevention program with exercise intervention improved functional performance at 3 months for community-dwelling older adults with risk of falls, but did not reduce falls at 1-year follow-up. Fall incidence might have been decreased simultaneously in both groups by heightened awareness engendered during assessments, education, referrals, and recommendations. Archives of Physical Medicine and Rehabilitation 2013;94:606-15 (C) 2013 by the American Congress of Rehabilitation Medicin

Functional mobility and its contributing factors for older adults in different cities in Taiwan

Impaired mobility is one of the primary causes of declined functional capacity in old age. The timed up-and-go test (TUG), a common mobility test, has been studied extensively in Western countries. The purposes of this study were to compare and identify factors associated with TUG performance in older adults with impaired mobility and living in different cities in Taiwan. Methods: Older adults living in Taipei, Tainan, and Niaosong cities were screened for mobility impairments and then recruited. A series of questionnaires and physical and functional tests were used to obtain information and measurements for potential contributing factors and TUG. Regression analysis was conducted to determine factors contributing to TUG. Results: A total of 413 older adults participated in the study. The mean TUG was 14.3 seconds for participants across the three cities, and was significantly shorter in Tainan. Age, number of medications, fear of falling, depression, high intensity activity time, reaction time, single leg stance time, and functional reach distance were found to have significant contribution. These factors accounted for approximately half of the variance in TUG. The regression equations were not equal for the different cities, with depression being the only common determinant. Conclusion: Taiwanese older adults with mobility problems living in different cities performed differently in TUG and the contributing factors were also different. These findings indicate a need of further studies examining older adults in different environments

Readmission, mortality, and first-year medical costs after stroke

Background: Stroke is the leading cause of adult disability and mortality in Taiwan, resulting in a tremendous burden on the healthcare system. The purpose of this study was to characterize disease burden by evaluating readmissions, mortality, and medical cost during the first year after acute stroke under the National Health Insurance (NHI) program. Methods: This retrospective cohort study extracted information about patients hospitalized with acute stroke from claims data of 200,000 randomly sampled NHI enrollees in Taiwan, with a 1-year follow-up duration. The incidence of the first-year adverse events (AEs) indicated by readmissions or mortality, and the amount of the first-year medical cost (FYMC) were assessed with predictive factors explored. Additionally, we also estimated the cost per life and life-year saved. Results: There were 2368 first-ever stroke patients in our study, including those with subarachnoid hemorrhage (SAH) 3.3%, intracerebral hemorrhage (ICH) 17.9%, ischemic stroke (IS) 49.8%, and transient ischemic attack/other ill-defined cerebrovascular diseases (TIA/unspecified) 29.0%; each stroke type was identified with an all-cause AE of 59.0%, 63.0%, 48.6%, and 46.8%, respectively. Readmissions were mainly because of acute recurrent stroke or the late effects of previous stroke, respiratory disease/infections, heart/circulatory disease, and diseases of the digestive system. Advanced age, hemorrhagic stroke type, respiratory distress/infections, and greater comorbidities were predictive of increased AE risk. Admission to neurology/rehabilitation wards, undertaking neurosurgery, or use of inpatient/outpatient rehabilitation was less likely to incur AEs. Initial hospitalization, readmission, and ambulatory care constituted 44%, 29%, and 27%, respectively, of FYMC with the initial length of stay being the most reliable predictor. The FYMCs were NT $217,959,$246,358, $168,003, and$122,084 for SAH, ICH, IS, and TIA/unspecified, respectively. The cost per life saved were estimated to be NT $435,919,$384,028, $196,281, and$138,888, whereas cost per life-year saved were estimated to be NT$43,926,$48,019, $97,830, and$188,770 for SAH, ICH, IS, and TIA/unspecified, respectively. Conclusion: Half of the patients encountered readmission or death during the first year after stroke. Patients with advanced age, more complications, or comorbidities during initial stay tended to be highly vulnerable to AE occurrence, whereas TIA/unspecified stroke carried no less risk for AEs. FYMC or estimated cost per life saved for IS or TIA/unspecified was lower relative to SAH or ICH; however, their estimated cost per life-year saved became higher because of reduced life expectancy

Is clopidogrel better than aspirin following breakthrough strokes while on aspirin? A retrospective cohort study.

ObjectiveThere is insufficient evidence on which to base a recommendation for optimal antiplatelet therapy following a stroke while on aspirin. The objective was to compare clopidogrel initiation vs aspirin reinitiation for vascular risk reduction among patients with ischaemic stroke on aspirin at the time of their index stroke.DesignRetrospective.SettingWe conducted a nationwide cohort study by retrieving all hospitalised patients (≥18 years) with a primary diagnosis of ischaemic stroke between 2003 and 2009 from Taiwan National Health Insurance Research Database.ParticipantsAmong 3862 patients receiving aspirin before the index ischaemic stroke and receiving either aspirin or clopidogrel after index stroke during follow-up period, 1623 were excluded due to a medication possession ratio <80%. Also, 355 were excluded due to history of atrial fibrillation, valvular heart disease or coagulopathy. Therefore, 1884 patients were included in our final analysis.InterventionsPatients were categorised into two groups based on whether clopidogrel or aspirin was prescribed during the follow-up period. Follow-up was from time of the index stroke to admission for recurrent stroke or myocardial infarction, death or the end of 2010.Primary and secondary outcome measuresThe primary end point was hospitalisation due to a new-onset major adverse cardiovascular event (MACE: composite of any stroke or myocardial infarction). The leading secondary end point was any recurrent stroke.ResultsCompared to aspirin, clopidogrel was associated with a lower occurrence of future MACE (HR=0.54, 95% CI 0.43 to 0.68, p<0.001, number needed to treat: 8) and recurrent stroke (HR=0.54, 95% CI 0.42 to 0.69, p<0.001, number needed to treat: 9) after adjustment of relevant covariates.ConclusionsAmong patients with an ischaemic stroke while taking aspirin, clopidogrel initiation was associated with fewer recurrent vascular events than aspirin reinitiation