Elsevier Editorial System(tm) for Research in Developmental Disabilities Manuscript Draft
Manuscript Number:
Title: Comparison of outpatient services between elderly people with intellectual disabilities and the general elderly population in Taiwan
Article Type: Research Paper
Keywords: Ambulatory health care, outpatient care, intellectual disability, medical costs Corresponding Author: Dr Shang-Wei Hsu, PhD
Corresponding Author's Institution: First Author: Shang-Wei Hsu, PhD
Order of Authors: Shang-Wei Hsu, PhD; Jin-Ding Lin, PhD; Po-Huang Chiang, PhD; Yu-Chia Chang, MS; Ho-Jui Tung, PhD
Abstract: This study aims to analyze the ambulatory visit frequency and medical expenditures of the general elderly population versus the elderly with intellectual disabilities in Taiwan, while examining the effects of age, gender, urbanization and copayment status on ambulatory utilization. A cross-sectional study was conducted to analyze data from 103,183 national health insurance claimants aged 65 or older. A total of 1,469 had a principal diagnosis of mental retardation (intellectual disability) and claimed medical outpatient services in 2007. The average number of ambulatory visits was 30.1±23.1, which is much higher than in the United States and other developed countries, and the mean annual visits of the elderly with intellectual disabilities was significantly higher than the general population in Taiwan (35.2±28.7 vs. 30.0±23.1). Age and copayment status affected outpatient visit frequency. The mean medical expenditure per visit and the mean annual outpatient cost were 1,146.5±4,497.7 NT$ and 34,533.7±115,891.7 NT$, respectively. Male beneficiaries tended to have higher average annual medical expenses and mean medical expenses per visit than female beneficiaries. The three most frequent principal diagnoses at ambulatory visits were circulatory system diseases, musculoskeletal system and connective tissue diseases and digestive system diseases. We conclude that the elderly with intellectual disabilities had higher demand than the general population for healthcare services, and the NHI program lowers the barrier to care for populations with special needs.
6 March, 2012
Johnny L. Matson, Ph.D.
Editor-in-Chief, Research in Developmental Disabilities
Professor, Department of Psychology, Louisiana State University Baton Rouge, LA 70803, USA
Dear Professor Matson:
We are very pleased to submit the manuscript ‘Comparison of outpatient services between elderly people with intellectual disabilities and the general elderly population in Taiwan’ to RIDD. The present manuscript has been English edited by Elsevier Language Webshop thoroughly, and it has not been previously published and has not been submitted elsewhere currently. We are requesting review and possible publish this manuscript on your excellent journal, and look forward to your good news.
Yours truly
Jack J. Lin, Ph.D. Professor & Dean
School of Public Health, National Defense Medical Center Taipei, Taiwan
Shang-Wei Hsu, Ph.D. Assistant Professor
Department of Healthcare Administration, Asia University, Taichung, Taiwan
Research highlights:
► To analyze the ambulatory visit frequency and medical expenditure of general population and ID elderly in Taiwan. ► The annual ambulatory visits and medical expenditure in people with ID are much higher than the general population ► The elderly people with ID had higher demand than general population in healthcare
service, the NHI program should lower the barrier for population with special needs.
Comparison of outpatient services between elderly people with
intellectual disabilities and the general elderly population in Taiwan
Shang-Wei Hsu a,b,*, Jin-Ding Lin c, Po-Huang Chiang d, Yu-Chia Chang a, Ho-Jui Tung a
a
Department of Healthcare Administration, Asia University, Taichung, Taiwan b
Department of Public Health, China Medical University, Taichung, Taiwan c
School of Public Health, National Defense Medical Center, Taipei, Taiwan d
Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
*
Corresponding author at: Department of Healthcare Administration, Asia University, No.500, Lioufeng Rd., Wufeng, Taichung 41354, Taiwan
Tel.: +886 4 23323456#6312; fax: + 886- 4 23321206 E-mail: victor_h@asia.edu.tw (S.-W. Hsu)
*Manuscript
Abstract
This study aims to analyze the ambulatory visit frequency and medical expenditures of the general elderly population versus the elderly with intellectual disabilities in Taiwan, while examining the effects of age, gender, urbanization and copayment status on ambulatory utilization. A cross-sectional study was conducted to analyze data from 103,183 national health insurance claimants aged 65 or older. A total of 1,469 had a principal diagnosis of mental retardation (intellectual disability) and claimed medical outpatient services in 2007. The average number of ambulatory visits was 30.1±23.1, which is much higher than in the United States and other developed countries, and the mean annual visits of the elderly with intellectual disabilities was significantly higher than the general population in Taiwan (35.2±28.7 vs. 30.0±23.1). Age and copayment status affected outpatient visit frequency. The mean medical expenditure per visit and the mean annual outpatient cost were 1,146.5±4,497.7 NT$ and 34,533.7±115,891.7 NT$, respectively. Male beneficiaries tended to have higher average annual medical expenses and mean medical expenses per visit than female beneficiaries. The three most frequent principal diagnoses at ambulatory visits were circulatory system diseases, musculoskeletal system and connective tissue diseases and digestive system diseases. We conclude that the elderly with intellectual disabilities had higher demand than the general population for healthcare services, and the NHI program lowers the barrier to care for populations with special needs.
Keywords: Ambulatory health care, outpatient care, intellectual disability, medical
1. Introduction
Several studies have confirmed that individuals with intellectual disabilities (ID) have poorer health than their non-disabled peers, and suffer from conditions such as
psychiatric disorders, seizure disorders, dental problems, gastrointestinal disorders, osteoporosis and Helicobacter pylori (Beange & Lennox, 1998; Beange, McElduff, & Baker, 1995; Böhmer et al., 1997; Center, Beange, & McEjduff, 1998; Sutherland, Couch, & Iacono, 2002). The US Surgeon General’s report concluded that people with ID have a greater variety of health care needs compared to those of the same age and gender in the general population (US Department of Health and Social Services, 2002). In the Netherlands, adults with ID were found to be 2.5 times more likely to be
diagnosed with health problems than the general population (van Shrojenstein
Lantman-de Valk et al., 2000). Our previous studies revealed that individuals with ID had a higher risk of ill health, poorer health status, and a greater prevalence of multiple physical diseases than the general population of Taiwan (Lin, Yen, Li, & Wu, 2005; Lin et al., 2007; Lin et al., 2009; Yen, Lin, Loh, Shi, & Hsu, 2009; Lin, Lin, & Lin, 2010; Lin, Lin, Lin, Chang, et al., 2010; Yen & Lin, 2010; Lin & Lin, 2011; Lin, Wu, Lin, Lin, & Chu, 2011; Yen et al., 2012). The results of the POMONA study confirm that there are disparities in health between people with ID and the general population (Pomona, 2008).
With improvements in medical care and prolongations of life expectancy, the population with ID is growing (Chen, Chou, Lin, Wu, & Lin, 2012; Janicki, Dalton, Henderson, & Davidson, 1999; Patja, Iivanainen, Vesala, Oksanen, & Ruoppila, 2000), and increased use of medical services is inevitable. Data from the US Census Bureau showed that the older population usually accounts for a larger proportion of a country’s health care costs as compared with younger age groups (US Census Bureau, 2012). According to BNHI Taiwan, the elderly population accounted for 10.4% of total NHI beneficiaries, but 21% of outpatient visits and 39.3% of total medical expenditures, with 65.7% of them under ambulatory care service (BNHI, 2011).
People with developmental disabilities carry a greater burden of diseases and
a significant economic impact on society and family (Lin et al., 2009; Lin, Lin, Yen, Loh, & Chwo, 2009; Hsu et al., 2009; Yen, Lin, Loh, Shi, & Hsu, 2009; Lin, Lin, Hsieh, & Lin, 2010; Lin, Lin, & Lin, 2010; Lin, Lin, Lin, & Hsu, 2010; Lin, Lin, Lin, & Lai, 2010; DeRigne, 2011; Lai, Hung, Lin, Chien, & Lin, 2011; Lin, Lee, Lin, Lin, et al., 2011; Hsu, Yen, Hung, Lin, et al., 2012). The National Health Insurance program (NHI) was implemented in Taiwan in 1995. It is a compulsory social insurance program and covered 99.48% of the population in Taiwan at the end of 2008, and ninety-two percent of the medical institutions in Taiwan were affiliated with the NHI in 2010 (BNHI, 2011). The purpose of our study was to compare and analyze the patterns of ambulatory care visits of elderly people and the elderly with ID in Taiwan in 2007. We hope the findings may provide evidence for health policymaking, especially for the elderly with ID.
2. Methods
The present study compared ambulatory utilization by the elderly between the general population and those with ID in Taiwan by means of a cross-sectional analysis of a national health insurance dataset, provided by the National Health Research Institute. The detailed structure of the claims data sets is described on the NHIRD web site. A two-step cryptographic scrambling technique was applied to protect individual identities before being released to researchers. Theoretically, it is impossible to query the data alone to identify individuals at any level using this database (NHRI, 2010). These data sets contained the ambulatory care clinic and emergency department visit files, including dates of visits, medical care facilities, patients’ gender, dates of birth, the three major diagnoses (as coded in the International Classification of Disease, Ninth Revision, Clinical Modification [ICD-9-CM] format) and the medical expenses for each visit from all medical care institutions under contract with the BHNI of Taiwan. The dataset
included 103,183 random national health insurance beneficiaries, aged 65 years who claimed outpatient services in the year 2007. All study subjects were divided into three age groups: the young-elderly (65-74 years old), middle-elderly (75-84 years old) and old-elderly (85 years old and older). Among the claimants, 1,469 had a principal
the residential area was stratified into seven levels based on the method developed by the National Health Research Institute, Taiwan.This method has been adopted as the
sampling design reference of the 2005 National Health Interview Survey (NHIS) in Taiwan (Liu et al., 2006) and other studies (Chung, Lee, Kao, & Lin, 2008). We also calculated the frequency distribution of principal diagnoses at all visits by ICD-9-CM chapter.
Statistical analysis was performed with SAS 9.2 for Windows (SAS Institute Inc., Cary, NC, USA). The following variables were included in the analysis to identify demographic characteristics and to compare ambulatory utilization: age group, gender, urbanization and copayment status. Statistical methods included frequencies, percentages, t-tests, ANOVA, and logistic regression.
3. Results
The demographic characteristics of the two elderly groups are presented in Table 1. With regards to the age distribution, we found the intellectual disability group (mean age = 72.6±6.6 years) was significantly younger than the general population (mean age = 74.2±6.8 years). The more populous metropolitan areas had a higher population distribution of individuals with ID than the rural areas in Taiwan. The ID group had a higher proportion of social welfare recipients then the general population.
Through stepwise logistic regression analysis, we found that age group, gender, residence urbanization level and copayment status were all factors that affected the population distribution of elderly people with intellectual disabilities (Table 2). Compared with the general population, the ratio of young-elderly with ID was higher than that of the middle-elderly and old-elderly (OR = 0.662, 95% CI = 0.588 - 0.744, OR = 0.599, 95% CI = 0.482 - 0.744, respectively). Females had a higher prevalence of ID than males (OR = 1.113, 95% CI = 1.003-1.235), individuals living in level I, II and IV urbanized areas reported a lower prevalence of ID than individuals living in level VII urbanized areas (OR = 0.772, 95% CI = 0.613 - 0.971, OR = 0.758, 95% CI = 0.601 - 0.956, OR = 0.720, 95% CI = 0.596 - 0.911, respectively), and the proportion of social welfare recipients in the intellectual disability group was much higher than in the general
population (OR = 5.353, 95% CI = 4.091 - 7.005).
Table 3 provides the average annual number of ambulatory visits and the relationship between mean visit frequencies and variables. The average number of ambulatory visits was 30.1±23.1, and the mean annual visits of the elderly with intellectual disabilities were significantly higher than in the general population (35.2±28.7 vs. 30.0±23.1). Results of factorial ANOVA show that age group and copayment status affected annual outpatient visits. The middle-elderly population had the highest mean frequency of ambulatory visits in both groups, and social welfare recipients.
The mean medical expenditure per visit of the study population was 1146.5±4497.7 NT$ (1 US$ = 30 NT$), and the cumulative annual cost was 34533.7±115891.7 NT$. The differences and influential factors on mean medical expenses per ambulatory visit between groups are displayed in Table 4. The average medical expense per outpatient service of the general population was 1146 NT$, and for their counterparts, it was 1164 NT$. Outcomes of factorial ANOVA show that age group, gender, urbanization and copayment status affected mean medical expenses per ambulatory visit. Table 5 shows the mean annual ambulatory medical expense per person between groups. The elderly with ID spent more annually on outpatient expenses than the general elderly population (41,075 vs. 34,439); only copayment status contributed to this difference after factorial ANOVA analysis.
Circulatory system diseases, musculoskeletal system and connective tissue diseases and digestive system diseases were the top three primary diagnoses of elderly ambulatory visits in both groups (Table 6). However, the three most frequent diagnoses between other pairs of groups were different (Table 7). The three most frequent diagnoses of general young-elderly and middle-elderly were essential hypertension (ICD-9-CM code: 401), diabetes mellitus (ICD-9-CM code: 250) and acute upper airway infection (ICD-9-CM code: 465); for the old-elderly, the diagnoses were essential hypertension, diabetes mellitus and functional digestive disorders not classified elsewhere (ICD-9-CM code: 564). The three most frequent diagnoses of the young-elderly with ID were diabetes mellitus, essential hypertension and acute upper airway infection; for the middle-elderly, the diagnoses were diabetes mellitus, osteoarthrosis (ICD-9-CM code: 715) and essential
hypertension; for the old-elderly, they were essential hypertension, osteoarthrosis, and dementias (ICD-9-CM code: 290).
4. Discussion
Our study used the NHI claims database to compare ambulatory care utilization by the general elderly population and elderly people with ID in Taiwan. This is the first study using such a comprehensive database to analyze and compare the ambulatory utilization patterns between two elderly groups.
The mean annual outpatient service numbers for Canada, the United States, and the United Kingdom were 10.2, 7.1, and 4.9, respectively (Nie, Wang, Shawn, Moineddin, & Upshur, 2010; National Center for Health Statistics, 2006; Kennerfalk, Ruigómez, Wallander, Wilhelmsen, & Johansson, 2002). Our results showed that both the general population and the elderly with ID in Taiwan had significantly higher average annual outpatient service numbers than previous studies. These findings suggest that the medical services demand for those with ID is higher than that of the general population. Taiwan’s NHI provides availability and accessibility of medical care services for the older
population, especially for disabled people. Low copayments and a poor referral system may contribute to the high frequency of ambulatory visits (Chen, Chou, & Hwang, 2005).
Owens (2008) found that older women tend to use more health care services and spend more on health care expenditures than men because of the increased incidence of
postmenopausal-related disease, such as cerebral vascular disease, breast cancer, and osteoporosis during their longer life span. Turk et al. (2010) found that mean consultation rates with general practitioners for adults with learning disabilities were lower than for the general population; increased age, female gender and having a paid caregiver were associated with greater use of GP services. Results of the current study showed that the general population had a similar trend with previous reports, in that females used outpatient services more frequently than males (Bertakis, Azari, Helms, Callahan, & Robbins, 2000; Lin, Hwang, Chen, Chen, & Hwang, 2011; Sung, Hung, & Chen, 2008). However, for the ID group, males had a higher outpatient visit frequency than females. Further studies are needed to explore gender differences in outpatient utilization among
the elderly with intellectual disabilities.
One population-based study conducted in Ontario, Canada indicated that increasing age is associated with increased utilization of health care services (Nie, Wang, Shawn, Moineddin, & Upshur, 2008). However, our results revealed that the middle-elderly of both groups had the highest number of mean annual ambulatory visits, which is consistent with two previous studies in Taiwan (Lin et al, 2011; Sung et al, 2008). This may be because the middle-elderly have better physical strength than the old-elderly (Lin et al, 2011).
This study found male subjects had higher mean medical expenses per visit than female subjects (1,239.6 NT$ vs. 1,053.4 NT$), which is consistent with a previous Taiwanese study (Lin et al, 2011). However, it contradicts the results of a US study (Woolhandler & Himmelstein, 2007). Taiwan’s NHI provides comprehensive outpatient medical services, including drugs, consultations, treatments, medical supplies, diagnosis, and dispensing services. As a consequence, medical expenditures vary based on disease, severity of disease and category of contracted medical care institution. Accordingly, the variation in medical expense among each beneficiary is significant, and it is difficult to make comparisons with other insurance systems.
Lin et al. (2011) found that acute upper airway infections were a common complaint of the elderly in outpatient visits. The present study found chronic disease was a common diagnosis at ambulatory visits of the elderly with ID and the general elderly population. Results from the United States (Schappert & Burt, 2006) and Sweden (Jörgensen, Johansson, Kennerfalk, Wallander, & Svärdsudd, 2001) showed that the three most common diagnoses at ambulatory care visits were chronic diseases. The outbreak of SARS in 2003 may have affected outpatient utilization in 2004. More data are needed to investigate this phenomenon.
The strength of the current study is the use of a nationwide health insurance claim database to access and compare healthcare resource utilization between the general population and those with ID. Previous medical utilization studies in Taiwan were mostly based on sampling the population with interviews or self-reported data, which may have a small sample size and is error-prone. This study did not address patterns of drug
prescription, treatment fees and other fees covered by the NHI in elderly ambulatory care services, to show the relationship between expenditures and the variables discussed. Further studies are needed to explore these important issues.
In conclusion, the mean frequency of ambulatory visits of older people in Taiwan was high, especially in the middle-elderly group. Health education and preventive services should focus on circulatory, digestive, and musculoskeletal diseases, which accounted for over forty percent of the primary diagnoses of ambulatory visits among the elderly.
Acknowledgments
The authors declare that they have no conflicts of interest with regard to the content of this article. This study is based on part of the project from National Health Insurance Research (PH-100-PP-27), and the data were provided by the Bureau of National Health Insurance, Department of Health, and managed by National Health Research Institutes. The interpretation and conclusions contained herein do not represent those of the Bureau of National Health Insurance, the Department of Health, or the National Health Research Institutes.
References
Beange, H., & Lennox, N. (1998). Physical aspects of health in the learning disabled. Current Opinion in Psychiatry, 11, 531-534.
Beange, H., McElduff, A., & Baker, W. (1995). Medical disorders of adults with mental retardation: a population study. American Journal of Mental Retardation, 99, 595-604.
Böhmer, C. J., Klinkenberg-Knol, E. C., Kuipers, E. J., Niezen-de Boer, M.C., Schreuder, H., Schuckink-Kool, F., & et al. (1997). The prevalence of Helicobacter pylori infection among inhabitants and healthy employees of institutes for the intellectually disabled. American Journal of Gastroenterology, 92, 1000-1004.
Bertakis, K.D., Azari, R., Helms, J., Callahan, E. J., & Robbins, J. A. (2000). Gender Differences in the Utilization of Health Care Services.
Journal of Family Practice,
49, 147-152.
Bureau of National Health Insurance. National Health Insurance in Taiwan 2011. http://www.nhi.gov.tw/English/webdata/webdata.aspx?menu=11&menu_id=290&webd
ata_id=2974&WD_ID=290 [accessed 12.15.11].
Bureau of National Health Insurance. Statistical Annual Reports.
http://www.nhi.gov.tw/English/webdata/webdata.aspx?menu=11&menu_i
d=296&webdata_id=1942&WD_ID=296 [accessed
2011.12.15].Center, J., Beange, H., & McEjduff, A. (1998). People with mental retardation have an increased prevalence of osteoporosis: A population study. American Journal of Mental Retardation, 103, 19-28.
Chen, T.J., Chou, L.F., & Hwang, S.J. (2006). Patterns of ambulatory care utilization in Taiwan.BMC Health Services Research, 6, 54.
Chen, Y. C., Chou, Y. C., Lin, L. P., Wu, C. L., & Lin, J. D. (2012). Long term trend analysis of geographical disparity in aging and disability: Taiwanese population approach. Research in Developmental Disabilities, 32, 350-356.
Chung, K. H., Lee, H. C., Kao, S., & Lin, H. C. (2008) Urbanicity and Methods of Suicide: A Nationwide Population-based Study. Journal of Urban Health, 85,
136-145.
DeRigne, L. (2011). The Employment and Financial Effects on Families Raising
Children With Special Health Care Needs: An Examination of the Evidence. Journal of Pediatric Health Care, in press.
Hsu, S. W., Lin, Y. W., Chwo, M. J., Huang, H C., Yen, C. F. et al. (2009) Emergency department utilization and determinants of use by 0- to 6-year-old children with disabilities in Taipei. Research in Developmental Disabilities, 30, 774-781.
Hsu, S. W., Yen, C. F., Hung, W. J., Lin, L. P., Wu, C. L., & Lin, J. D. (2012). The risk of metabolic syndrome among institutionalized adults with intellectual disabilities. Research in Developmental Disabilities, 33, 615-620.
Janicki, M. P., Dalton, A. J., Henderson, C., & Davidson, P. (1999). Mortality and morbidity among older adults with intellectual disability: Health services considerations. Disability and Rehabilitation, 21, 284-294.
Jörgensen, T., Johansson, S., Kennerfalk, A., Wallander, M. A., Svärdsudd, K.(2001) Prescription drug use, diagnoses, and healthcare utilization among the elderly. Annals of Pharmacotherapy, 35, 1004-9.
Kennerfalk, A., Ruigómez, A., Wallander, M.A., Wilhelmsen, L., & Johansson, S. (2002). Geriatric drug therapy and healthcare utilization in the United Kingdom. Annals of Pharmacotherapy, 36, 797-803.
Lai, C. I., Hung, W. J., Lin, L. P., Chien, W. C., & Lin, J. D. (2011). A retrospective population-based data analyses of inpatient care use and medical expenditure in people with intellectual disability co-occurring schizophrenia. Research in Developmental Disabilities, 32, 1226-1231.
Lin, L. P., Lee, J. T., Lin, F. G., Lin, P. Y., Tang, C. C.,Chu, C., Wu, C. L., & Lin, J. D. (2011). Disability and hospital care expenses among national health insurance beneficiaries: Analyses of population-based data in Taiwan. Research in Developmental Disabilities, 32, 1589-1595.
Lin, L. P., & Lin, J. D. (2011). Perspective on intellectual disability in Taiwan: Epidemiology, policy and services for children and adults. Current Opinion in Psychiatry, 24, 413-418.
Lin, J. D., Lin, L. P., Hsieh, M., & Lin, P. Y. (2010). Preliminary findings of serum creatinine and estimated glomerular filtration rate (eGFR) in adolescents with intellectual disabilities. Research in Developmental Disabilities, 31, 1390-1397. Lin, J. D., Lin, P. Y., & Lin, L. P. (2010). Universal hepatitis B vaccination coverage in
children and adolescents with intellectual disabilities. Research in Developmental Disabilities, 31, 338-344.
Lin, J. D., Lin, P. Y., Lin, L. P., Chang, Y. Y., Wu, S. R., & Wu, J. L. (2010). Physical activity and its determinants among adolescents with intellectual disabilities. Research in Developmental Disabilities, 31, 263-269.
Lin, J. D.,Lin, P. Y., Lin,L. P., Hsu, S. W., Loh, C. H., Yen, C. F., Fang, W.H., Chien, W. C., Tang, C. C , & Wu, C. L. (2010). Prevalence and associated risk factors of anemia in children and adolescents with intellectual disabilities. Research in Developmental Disabilities, 31, 25-32.
Lin, J. D., Lin, P. Y., Lin, L. P., Hsu, S. W., Yen, C. F., Fang, W. H., et al. (2009). Serum uric acid, hyperuricemia and body mass index in children and adolescents with intellectual disabilities. Research in Developmental Disabilities, 30,
1481-1489.
Lin, J. D.,Lin, P. Y., Lin, L. P., Lai, C. I., Leu, Y. R., Yen, C. F., Hsu, S. W., Chu, C. M., Wu, C. L., & Chu, C. (2010). Spinal and limb abnormalities in adolescents with intellectual disabilities. Research in Developmental Disabilities, 31, 686-691. Lin, J. D., Lin, Y. W., Yen, C. F., Loh, C. H., & Chwo, M. J. (2009). Received,
understanding and satisfaction of National Health Insurance premium subsidy scheme by families of children with disabilities: A census study in Taipei City. Research in Developmental Disabilities, 30, 275-283.
Lin, J. D., Loh, C. H., Choi, I. C., Yen, C. F., Hsu, S. W., Wu, J. L., et al. (2007). High outpatient visits among people with intellectual disabilities caring in a disability institution in Taipei: A 4-year survey. Research in Developmental Disabilities, 28, 84-93.
Lin, J. D., Wu, C. L., Lin, P. Y., Lin, L. P., & Chu, C. (2011). Early onset ageing and service preparation in people with intellectual disabilities: Institutional managers'
perspective. Research in Developmental Disabilities, 32, 183-193.
Lin, J. D., Yen, C. F., Li, C. W., & Wu, J. L. (2005). Health, healthcare utilization and psychiatric disorder in people with intellectual disability in Taiwan. Journal of Intellectual Disability Research, 49, 86-94.
Lin, P. Y., Lin, L. P., & Lin, J. D. (2010). Hypertension, hyperglycemia, and hyperlipemia among adolescents with intellectual disabilities. Research in Developmental Disabilities, 31, 545-550.
Lin, Y.T., Hwang, S.J., Chen, L.K., Chen, T.J., & Hwang, I.H. (2011). Ambulatory health care utilization of the older people under the National Health Insurance in Taiwan. Journal of Clinical Gerontology & Geriatrics, 2, 53-57.
Liu, C.Y., Hung, Y.T., Chuang, Y.L., Chen, Y.J., Weng, W.S., Liu, J.S,. & Liang, K.Y. (2006). Incorporating development stratification of Taiwan townships into sampling design of large scale health interview survey. Journal of Health Management, 4, 1-22.
Mustard, C. A., Kaufert, P., Kozyrskyj, A., & Mayer, T.(1998). Sex Differences in the Use of Health Care Services. New England Journal of Medicine, 338:1678-1683. National Center for Health Statistics. Health, United States, 2006 with chart book on
trends in the health of Americans. Washington, DC: National Center for Health Statistics; 2006. p. 110-11.
Nie, J. X., Wang, L., Shawn, C., Moineddin, R., & Upshur, R. E. (2008).Health care service utilization among the elderly: findings from the Study to Understand the Chronic Condition Experience of the Elderly and the Disabled (SUCCEED project). Journal Evaluation in Clinical Practice, 14:1044-9.
Nie, J.X., Wang, L., Shawn, C., Moineddin, R., & Upshur, R.E. (2010). A
population-based cohort study of ambulatory care service utilization among older adults. Journal Evaluation in Clinical Practice, 16:825-31.
Owens, G.M. (2008). Gender difference in health care expenditures, resource utilization and quality of life. Journal of Managed Care Pharmacy, 14, S2-S6.
Patja, K., Iivanainen, M., Vesala, H., Oksanen, & Ruoppila, I. (2000). Life expectancy of people with intellectual disability: a 35-year follow-up study. Journal of Intellectual
Disability Research, 44, 591-599.
Pomona. (2008). POMONA II: Health indicators for people with intellectual disabilities: Using an indicator set (Final report). Available from:
http://www.pomonaproject.org[accessed 01.09.12].
van Schrojenstein Lantman-De Valk, M. J. H., Metsemakers, F. M. J., Haveman, M. J. & Crebolder, F. J. M. H. (2000). Health problems in people with intellectual disability in general practice: A comparative study. Family Practice, 17, 405-407.
Schappert, S. M, & Burt, C. W. (2006). Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 2001-02. National Center for Health Statistics. Vital Health Stat 13, 1-66.
Schellhorn M, Stuck AE, Minder C, Beck JC. Health services utilization of elderly Swiss: evidence from panel data. Health Economics, 2000, 533-45.
Sung, W.C., Hung, C.T., & Chen, W.Y. (2008) Medical utilization and comorbidity among aging population in Taiwan. Taiwan Journal of Gerontological Health Research, 4,75-87.
Sutherland, G., Couch, M.A., & Iacono, T. (2002) Health issues for adults with developmental disability. Research in Developmental Disabilities, 23: 422-445. Turk, V., Kerry, S., Corney, R., Rowlands, G., & Khattran, S. (2010). Why some adults
with intellectual disability consult their general practitioner more than others. Journal of Intellectual Disability Research, 54, 833-842.
US Census Bureau.Statistical abstract of the United States: 2012. Washington, DC: US Census Bureau. Available from: http://www.census.gov/compendia/statab/2012/ tables/12s0168.pdf. [accessed 01.03.12].
US Department of Health and Human Services. (2002). Closing the Gap: A National Blueprint to Improve the Health of Persons with Mental Retardation. Report of the Surgeon General’s Conference on Health Disparities and Mental Retardation. US Department of Health and Human Sevices, Washington DC.
Woolhandler, S., & Himmelstein, D. U. (2007). Consumer directed healthcare: except for the healthy and wealthy it’s unwise. Journal of General Internal Medicine, 22, 879-881.
Yen, C. F., Hsu, S. W., Loh, C. H., Fang, W. H., Wu, C. L., Chu, C., & Lin, J. D. (2012). Analyses on seasonal influenza vaccine uptake among children and adolescents with an intellectual disability. Research in Developmental Disabilities, 33, 704-710. Yen, C. F., & Lin, J. D. (2010). Factors for healthy food or less-healthy food intake
among Taiwanese adolescents with intellectual disabilities. Research in Developmental Disabilities, 31, 203-211.
Yen, C. F., Lin, J. D., Loh, C. H., Shi, L., & Hsu, S. W. (2009). Determinants of
prescription drug use by adolescents with intellectual disabilities in Taiwan. Research in Developmental Disabilities, 30, 1354-1366.
Table 1
Demographic characteristics of those with intellectual disabilities and the general population.
Variables General population
N (%) Intellectual disability N (%) ÷2test Age group p<0.0001 1. Young-elderly 57178 (56.21) 976 (66.44) 2. Middle-elderly 35859 (35.25) 403 (27.43) 3. Old-elderly 8677 (8.53) 90 (6.13) Average age (Mean±SD)* 74.2±6.8 72.6±6.6 Gender 1. Female 52252 (51.37) 790 (53.78) p=0.0669 2. Male 49462 (48.63) 679 (46.22) Urbanization level p=0.0003 I (highest urbanized) 24722 (24.31) 346 (23.55) II 23539 (23.14) 323 (21.99) III 15102 (14.85) 217 (14.77) IV 22274 (21.90) 290 (19.74) V 4037 (3.97) 59 (4.02) VI 6859 (6.74) 140 (9.53) VII (lowest urbanized) 5181 (5.09) 94 (6.40) Copayment p<0.0001 Catastrophic disease 2651 (2.61) 38 (2.59) Social welfare 828 (0.81) 60 (4.08) Yes 98235 (96.58) 1371 (93.33) Total 101714 1469 * t-test, p<.05.
Table 2
Logistic regression analysis of the population distribution of intellectual disabilities in Taiwan.
Variables Odds ratio 95% Confidence interval p value
Age group 1. Middle-elderly 0.662 0.588 0.744 <.0001 2. Old-elderly 0.599 0.482 0.744 <.0001 3. Young-elderly (ref.) 1 Gender 1. Female 1.113 1.003 1.235 0.0430 2. Male (ref.) 1 Urbanization level 1. I 0.772 0.613 0.971 0.0273 2. II 0.758 0.601 0.956 0.0195 3. III 0.799 0.626 1.021 0.0724 4. IV 0.720 0.569 0.911 0.0061 5. V 0.807 0.518 1.121 0.2008 6. VI 1.124 0.863 1.464 0.3853 7. VII (ref.) 1 Copayment 1. Catastrophic disease 1.040 0.752 1.439 1.439 2. Social welfare 5.353 4.091 7.005 7.005 3. Yes (ref.) 1
Table 3
Comparison of mean annual visits per person between the general elderly population and those with intellectual disabilities.
Variables General population a Intellectual disability Factorial ANOVA 30.0± 23.1 35.2± 28.7 p<0.0001b Age group p=0.0002 1. Young-elderly 28.7±22.2 32.9±27.8 2. Middle-elderly 32.6±24.5 42.2±30.2 3. Old-elderly 28.2±22.5 29.7±26.7 Gender p=0.0609 1. Female 30.4±22.4 34.2±26.1 2. Male 29.7±23.9 36.6±31.4 Urbanization level p=0.1818 1. I 30.3±23.3 36.3±25.5 2. II 30.8±23.9 34.1±29.6 3. III 29.8±22.7 37.6±32.1 4. IV 29.5±22.6 34.8±31.6 5. V 28.7±21.7 31.0±23.1 6. VI 30.0±22.3 33.4±23.6 7. VII 29.6±22.8 37.2±28.9 Copayment p=0.0141 1. Catastrophic disease 31.8±23.6 36.0±24.6 2. Social welfare 37.8±31.1 36.6±32.8 3. Yes 30.3±23.0 34.9±28.2 a
Data are expressed as mean±SD. b
Table 4
Comparison of mean medical expense per visit between the general elderly population and those with intellectual disabilities.
Variables General population a Intellectual disability Factorial ANOVA 1146±4717.8 1164±3542.4 p=0.3724b Age group p=0.0021 1. Young-elderly 1139.6±5513.5 1124.4±3364.6 2. Middle-elderly 1161.7±3675.4 1201.5±3664.0 3. Old-elderly 1116.0±3085.5 1415.6±4654.9 Gender p=0.0077 1. Female 1100.2±3758.7 1187.1±3944.3 2. Male 1195.7±5569.7 1140.4±3046.0 Urbanization level p<0.0001 1. I 1273.2±6855.7 1227.9±3640.2 2. II 1188.9±3951.7 1299.7±3808.2 3. III 1126.2±3840.6 1074.4±2674.4 4. IV 1088.2±3770.3 1062.5±3019.5 5. V 937.1±3158.4 1241.3±4378.1 6. VI 979.9±3415.3 1278.1±5322.0 7. VII 1011.7±3558.2 829.6±1291.1 Copayment p<0.0001 1. Catastrophic disease 7782.7±16313.0 5654.6±13540.1 2. Social welfare 966.6±2283.6 995.4±1281.6 3. Yes 879.0±3271.1 929.6±1757.6 a
Data were expressed with mean±SD deviation. b
Table 5
Comparison of mean annual medical expenses per person between the general elderly population and those with intellectual disabilities.
Variables
General population a Intellectual disability Factorial ANOVA 34439.2±118328.3 41075±73135.5 p=0.0321b Age group p=0.4677 1. Young-elderly 32703.9±146394.6 37018.8±67971.8 2. Middle-elderly 37924.2±69377.8 50687.4±79846.5 3. Old-elderly 31471.5±54195.9 42027.0±90632.3 Gender p=0.7352 1. Female 33392.5±69899.5 40539.4±80961.8 2. Male 35545.0±153718.4 41699.0±62869.0 Urbanization level p=0.9945 1. I 38560.2±207999.3 44561.4±78820.4 2. II 36651.6±71575.7 44266.7±82885.4 3. III 33567.6±69942.0 40362.2±59454.7 4. IV 32085.5±66862.0 36871.8±60831.5 5. V 26899.3±55528.5 38517.0±84578.6 6. VI 29393.1±60563.0 42652.7±89406.8 7. VII 29938.2±64891.0 31179.6±35139.0 Copayment p=0.0170 1. Catastrophic disease 161962.8±230337.2 118866.3±186729.3 2. Social welfare 38014.1±52915.3 30775.8±86869.5 3. Yes 30967.7±112212.4 39370.0±65493.0 a
Data are expressed as mean±SD. b
Table 6
Comparison of the primary diagnoses of ambulatory care visits between the general elderly population and those with intellectual disabilities.
ICD-9 disease and injury category (ICD code) General population N (%)
Intellectual disability N (%)
Infectious and parasitic diseases (001-139) 89534 (1.56) 2083 (2.06)
Neoplasms (140-239) 114009 (1.98) 1459 (1.45)
Endocrine, nutritional and metabolic diseases, and immunity disorders (240-279)
524363 (9.12) 6952 (6.89)
Diseases of the blood and blood-forming organs (280-289) 21306 (0.37) 345 (0.34)
Mental disorders (290-319) 185889 (3.23) 8195 (8.12)
Diseases of the nervous system and sense organs (320-389) 572886 (9.96) 9207 (9.12) Diseases of the circulatory system (390-459) 1037069 (18.03) 15797 (15.65) Diseases of the respiratory system (460-519) 576221 (10.02) 10545 (10.45) Diseases of the digestive system (520-579) 628621 (10.93) 11044 (10.94) Diseases of the genitourinary system (580-629) 266524 (4.63) 4407 (4.37) Complications of pregnancy, childbirth, and the puerperium
(630-679)
343 (0.01) 15 (0.01)
Diseases of the skin and subcutaneous tissue (680-709) 195479 (3.40) 4195 (4.16) Diseases of the musculoskeletal system and connective tissue
(710-739)
713564 (12.41) 12078 (11.97)
Congenital anomalies (740-759) 6483 (0.11) 102 (0.10)
Certain conditions originating in the perinatal period (760-779) 142 (<0.01) 1 (<0.01) Symptoms, signs, and ill-defined conditions (780-799) 461192 (8.02) 8550 (8.47)
Injury and poisoning (800-999) 197492 (3.43) 3449 (3.42)
Supplementary classification of factors influencing health status and contact with health services (v01-v89)
158245 (2.75) 2505 (2.48)
Table 7
Comparison of the three most common primary diagnoses by ICD-9-CM code between the general elderly population and those with intellectual disabilities.
Age group
First most common
diagnosis %
Second most common
diagnosis % Third most common diagnosis %
General population
Young-elderly Essential hypertension 6.40 Diabetes mellitus 5.91 Acute upper airway infection 4.64
Middle-elderly Essential hypertension 6.53 Diabetes mellitus 5.01 Acute upper airway infection 3.64 Old-elderly Essential hypertension 6.51 Diabetes mellitus 3.50 Functional digestive disorders 3.31 Intellectual disability
Young-elderly Diabetes mellitus 4.75 Essential hypertension 4.64 Acute upper airway infection 3.92
Middle-elderly Diabetes mellitus 4.37 Osteoarthrosis 4.31 Essential hypertension 3.74
