Letter from Taiwan
Journal
Respirology
Journal Volume
23
Journal Issue
5
Pages
535-537
Date Issued
2018
Author(s)
Abstract
Respirology and Asian Pacific Society of Respirology (APSR) represent a remarkable array of countries, cultures and lung disease profiles in the Asia-Pacific Region. There are often interesting changes, developments, controversies and problems that occur in the Region that go unappreciated—and often unnoticed—by others in this region. The Editors-in-Chief felt that this presented an opportunity to get to know more about our Region whilst providing some entertaining reading. It is our hope that our readers will enjoy the 'Letter', look forward to reading it and ultimately offer to contribute and help to inform us of what is happening in their 'backyard'. Correspondence and opinions about the 'Letter' are welcomed. In Taiwan, COPD is an underdiagnosed and undertreated disease. The average annual prevalence of COPD in Taiwan, based on National Health Insurance medical reimbursement claims from 1996 to 2002, was 2.48%, with a rate up to 8.83% in those older than 70 years of age.1 A study of the impact of COPD in the Asia-Pacific region—the Epidemiology and Impact of COPD (EPIC) Asia population-based survey—used telephone or face-to-face interviews in 6000 residents of the Asia-Pacific and detected a prevalence rate of 9.5% in 207 Taiwan subjects. Another telephone random sampling survey with a long questionnaire in 6600 Taiwan participants revealed a 6.1% prevalence rate. However, only one-third of them had received regular medical treatment.2 COPD ranks as the seventh cause of death in Taiwan, with a mortality rate of 27.5/105 in 2014. An analysis of national mortality and population data from Taiwan showed a gradual increase in mortality rate during the 1990s. Although the hospitalization rate of COPD decreased gradually during this time to an annual rate of 4.2%, the in-hospital mortality rate for COPD patients requiring hospitalization was 4% and the 1-year mortality rate was high, up to 22%. Patients with COPD commonly had co-morbidities such as hypertension or cardiovascular diseases (36.1%), diabetes mellitus (11.9%), tuberculosis (3.7%), cancer (3.2%) and stroke (1.7%).2 Healthcare utilization is common in patients with higher COPD assessment test (CAT) scores, higher modified Medical Research Council Dyspnea Scale (mMRC) scores and having more than one co-morbidity.2 Overall, the loss of life year expectancy due to COPD was 11 years. To improve the health and treatment outcomes of COPD patients, the Bureau of National Health Insurance (NHI) implemented a Pay for Performance (P4P) programme for COPD in April 2017. This new programme provides financial incentives to motivate the participation of physicians who are able to establish patient-centred care within their service and to enhance the value of patient monitoring and management. The main objectives of this new payment programme are to offer a comprehensive care system, improve quality of health care, as well as reduce emergency department visits, intensive care unit (ICU) admission and cost burden of COPD. Hospitals/clinics that enrolled in the programme could receive extra payments for case management, smoking cessation success, execution of pulmonary rehabilitation, medication adherence and reduction in COPD-related emergency visits and hospitalizations. The Taiwan COPD Clinical Treatment Guideline is used to establish a unified standard for physicians and provide evidence-based analyses of individual agents commonly used in the treatment of COPD. The Taiwan Society of Pulmonary and Critical Care Medicine (TSPCCM) is responsible for conducting training certification classes to improve skills and knowledge among physicians, case managers and respiratory therapists. Patients' decision aid and self-management tools are also provided by TSPCCM. T-COPD, the network referral system, creates a direct communication link between primary care providers and specialist reviewers. Public health campaigns are launched to raise awareness and education. This P4P programme aims to provide a comprehensive care system and create a trilateral win-win situation for patients, physicians and insurers. Another major problem is lung cancer, which has shown a threefold increase in incidence in the last 30 years. In 2014, the incidence of lung cancer for male was 43.3/105 and 28.0/105 for females. Lung cancer is the leading cause of cancer death in Taiwan. In 2014, there were 12 462 new cases and 9167 deaths (a mortality rate of 34.4/105 for males and 17.3/105 for females). Cigarette smoking is the main risk factor for lung cancer, especially in males. Because of the tobacco control programmes, the smoking rate in the adult population has decreased substantially in the past 20 years (from 59.4% for males in 1991 to 29.9% in 2013), the incidence of male lung cancer decreased from 46/105 in 2009 to 43.3/105 in 2014. Although females are predominantly non-smokers (the smoking rate remains constant at around 5%), the incidence of female lung cancer increased steadily from 26/105 in 2009 to 28/105 in 2014, with more than 90% of female lung cancer patients being never-smokers. Overall, in the 2011–2014 Cancer Registry Database, 52% of all lung cancer patients were never-smokers. Adenocarcinoma is the major histological subtype of lung cancer in smokers (48%) and never-smokers (83%). Female adenocarcinoma rates (24/105) were higher than for male adenocarcinoma (22/105), male squamous cancer (10/105) and female squamous cancer (1/105) in 2014. Up to 60% of the newly diagnosed lung cancer are stage IV. After the report of National Lung Screening Trial (NLST) in 2011,3 the cost-effectiveness of implementing low dose computed tomography (LDCT) screening for lung cancer in Taiwan has been evaluated. For the NLST population, the incremental cost-effectiveness ratio (ICER) for computed tomography screening was US$19 695 per quality-adjusted life year (QALY). The ratio falls to US$10 953 per QALY if the stage distribution was the same as that in the NELSON trial.4 However, the targeted population of the NLST only accounts for 8% of the Taiwan population. As never-smokers become the dominant population of lung cancer in Taiwan, a screening strategy for never-smoker is currently under evaluation. The TAiwan Lung cancer scrEening in Neversmoker Trial (TALENT) aims to enrol 12 000 never-smokers with at least one of the pre-defined risk factors (family history, specific lung disease, cooking fume index, second hand smoking, etc.) to evaluate the cost-effectiveness of performing LDCT screen for the never-smoker population with specific risk factors. Currently, since LDCT programmes are incorporated into many health screen projects, the stage-shift effect is observed after 2011, the proportion of stage I disease increased from 13.8% in 2010 to 22.1% in 2015 and stage III/IV disease reduced from 76.5% in 2010 to 65.4% in 2015 (Fig. 1). The introduction of targeted agents into lung cancer treatment has significantly improved the outcomes of lung cancer patients. Being a population with high epidermal growth factor receptor (EGFR) mutation rate (60% in never-smoker adenocarcinoma),5 lung cancer patients in Taiwan enjoy the benefits of treatment with epidermal growth factor receptor tyrosine kinase inhibitor (EGFRTKI). The 5-year survival rate of lung cancer increased from 13.15% in 2006 to 20.15% in 2011. In National Taiwan University Hospital, the 5-year survival rate of stage IV increased from 3.7% in new patients of 1996–2000 to 14.6% in those of 2007–2010. The implementation and reimbursement issues of immunotherapy in lung cancer treatment are under discussion. Finally, the TSPCCM hosts the 23rd Congress of the Asian Pacific Society of Respirology (APSR) which will be held from 29 November to 2 December 2018 at the Taipei International Convention Center (TICC). Scientific programmes including plenary lectures, educational workshops, symposia and industry seminars will cover a wide range of fields—all focused on improving lung health worldwide. Further information can be found on the congress website (www.apsr2018.com) and abstract submission is now open. We encourage the participation of all APSR members and we look forward to welcoming you to APSR 2018 and Taipei, Taiwan!
SDGs
Publisher
Blackwell Publishing
Type
letter