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Open Access

Research article

Hospice utilization during the SARS outbreak in Taiwan

Tzeng-Ji Chen*

1,2

, Ming-Hwai Lin

1,2

, Li-Fang Chou

3

and

Shinn-Jang Hwang

1,2

Address: 1Department of Family Medicine, Taipei Veterans General Hospital, Shih-Pai Road, Section 2, No 201, Taipei 11217, Taiwan, 2National

Yang-Ming University School of Medicine, Taipei, Taiwan and 3Department of Public Finance, National Chengchi University, Taipei, Taiwan

Email: Tzeng-Ji Chen* - tjchen@vghtpe.gov.tw; Ming-Hwai Lin - mhlin@vghtpe.gov.tw; Li-Fang Chou - lifang@nccu.edu.tw; Shinn-Jang Hwang - sjhwang@vghtpe.gov.tw

* Corresponding author

Abstract

Background: The severe acute respiratory syndrome (SARS) epidemic threw the world into

turmoil during the first half of 2003. Many subsequent papers have addressed its impact on health service utilization, but few have considered palliative (hospice) care. The aim of the present study was to describe changes in hospice inpatient utilization during and after the SARS epidemic in 2003 in Taiwan.

Methods: The data sources were the complete datasets of inpatient admissions during 2002 and

2003 from the National Health Insurance Research Database. Before-and-after comparisons of daily and monthly utilizations were made. Hospice analyses were limited to those wards that offered inpatient services throughout these two years. The comparisons were extended to total hospital bed utilization and to patients who were still admitted to hospice wards during the peak period of the SARS epidemic.

Results: Only 15 hospice wards operated throughout the whole of 2002 and 2003. In 2003,

hospice utilization began to decrease in the middle of April, reached a minimum on 25 May, and gradually recovered to the level of the previous November. Hospices showed a more marked reduction in utilization than all hospital beds (e.g. -52.5% vs. -19.9% in May 2003) and a slower recovery with a three-month lag. In total, 566 patients were admitted to hospice wards in May/June 2003, in contrast to 818 in May/June 2002. Gender, age and diagnosis distributions did not differ.

Conclusion: Hospice inpatient utilization in Taiwan was indeed more sensitive to the emerging

epidemic than general inpatient utilization. A well-balanced network with seamless continuity of care should be ensured.

Background

The severe acute respiratory syndrome (SARS) epidemic threw the world into turmoil during the first half of 2003 [1,2]. Since then, thousands of papers had been devoted to this novel virus, many have addressed its impact on health service utilization [3-8], but few have focused on

hospice palliative care [9]. When the fears declined and utilization data became available, we were able retrospec-tively to review the broad hospice situation during the SARS epidemic in Taiwan, one of the most heavily affected countries.

Published: 04 August 2006

BMC Health Services Research 2006, 6:94 doi:10.1186/1472-6963-6-94

Received: 28 April 2006 Accepted: 04 August 2006

This article is available from: http://www.biomedcentral.com/1472-6963/6/94 © 2006 Chen et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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The first inpatient hospice ward in Taiwan was established in 1990 [10]. By the end of 2004, there were 26 hospice wards with 424 beds and 42 units for hospice home care [11]. All hospice care programs in Taiwan until then had been hospital-based. A universal health insurance pro-gram started in Taiwan in 1995 and now covers nearly all inhabitants (21,984,415 beneficiaries at the end of 2003, equivalent to a coverage rate of 97.3%) [12]. During the early years of National Health Insurance (NHI), admis-sion to hospice wards was reimbursed on a fee-for-service basis, as in acute wards. The payment for services of nurses and other ancillary staff was included in the room fee. This method of reimbursement put the intensive-care hos-pice at a great disadvantage. After years of negotiation, the Bureau of National Health Insurance began to implement a special program for hospice wards in July 2000. The pay-ment changed to a per-diem lump sum and was generally improved. Any hospice ward was free to join the new pro-gram, which also had stricter requirements on personnel and facilities.

The first case of SARS in Taiwan was identified on 14 March 2003 [13]. Until 21 April, only 28 probable SARS cases were reported. After 22 April, the incidence abruptly increased and was associated primarily with health-care settings. Moreover, in many cities and regions of Taiwan, the infection spread from one hospital to several others. Five hospitals had to discontinue routine or emergency services totally. Stricter quarantine was implemented after 28 April. Real panic ensued in Taiwanese society. The last probable case was reported on 14 June, and Taiwan was removed from the list of SARS-affected countries by the World Health Organization on 5 July 2003 [14]. In retro-spect, the SARS epidemic in Taiwan had involved 668 probable cases with severe deterioration of pulmonary function and 181 deaths [15].

The aim of the current study was to describe the changes in hospice inpatient utilization during and after the SARS epidemic within the NHI program in Taiwan. Such quan-titative analyses might provide evidence for discussion in health policy-making and help with effective planning in the future.

Methods

Data sources

In 1999, the Bureau of National Health Insurance began to release all claims data to the public in electronic form under the National Health Insurance Research Database (NHIRD) project [16]. Since then, dozens of extracted datasets have been available to researchers. The identifica-tion numbers of persons and healthcare facilities in the datasets have been encrypted to protect privacy. The encryption is consistent across all datasets so that longitu-dinal comparisons are feasible. However, no linkage with

external databases and medical records was possible. Researchers who wish to access NHIRD datasets must sign a user agreement form indicating that they will obey rele-vant regulations and acknowledge the NHIRD in their publications.

In the current study, we used the complete inpatient admission datasets from 2000 to 2003 (DD{2000..2003} {01..12}.DAT). Each record in the admission file contains the data for one admission, including the re-coded identi-fication numbers of the patient and hospital, type of ben-efits, dates of admission and discharge, five discharge diagnoses, and items of expenditure. We also used the reg-istry for contracted medical facilities (HOSB2003.DAT) to identify the accreditation levels and locations of the hos-pitals with hospice wards, and the registry for contracted beds (BED2003.DAT) to compute the number of beds in each hospice ward.

Study design

To begin with, we extracted the admission records for hos-pice wards according to the type of benefit. Twenty-five hospitals had participated in the NHI hospice program: from 12 hospitals in July 2000 to 21 in December 2003, during which time 4 hospitals dropped out. After comput-ing the utilization of hospice beds for each day, we found that there were indeed cyclic fluctuations around the year. Because data were only available for a few years and the numbers of hospice wards and beds had increased over time, it did not seem appropriate to deploy a conven-tional time series analysis, e.g. the autoregressive inte-grated moving average method [3,4,17]. Instead, we performed a before-and-after comparison of monthly uti-lizations between 2002 and 2003 and plotted daily utili-zation. The analysis was limited to those hospitals that offered hospice inpatient services throughout the whole of 2002 and 2003. Because insurance claims were nor-mally submitted after the patients' discharge, the claims for the final month of the available datasets contained no data for patients who were still hospitalised at the end of that month. Thus, the data for December 2003 were not analysed.

We extended the before-and-after comparison to the total-ity of hospital beds within the National Health Insurance to contrast with the utilization of hospice wards. To indi-cate the situation in individual hospice wards, we com-puted the changes of utilization in each hospice ward separately during and after the SARS epidemic. These data were further stratified by the accreditation levels and loca-tions of the hospice wards. We also analysed the patients who were admitted to hospice wards during the peak period of the SARS epidemic (i.e. May/June 2003) and compared them with the patients admitted during the same months of the previous year. This latter analysis

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included age, sex, and primary diagnosis at discharge and was also stratified by ward accreditation level and loca-tion.

Data processing and statistical analysis

The Perl programming language (version 5.8.7) was used for the extraction and computation of data [18]. The unit of hospice/hospital ward utilization was the patient-day, i.e. each claimed day of hospitalisation. Conventionally, the discharge day is not counted as a hospitalisation day in insurance claims. For example, if a patient was hospi-talised from 1 January to 7 January, the per-diem fees for physician and room services were payable only from 1 January to 6 January. We used two-sample t-tests to com-pare the age distributions of those admitted in May/June 2003 with those admitted in May/June 2002, and Pear-son's chi-square test to compare the sex and diagnosis dis-tributions. We also used one-way analysis of variance to compare the age distributions of those admitted in May/ June 2003 to hospice wards of different accreditation lev-els and locations. A P-value < 0.05 was regarded as statis-tically significant. The statistical analyses were performed using SPSS software (Release 13.0 for Windows, 2004, SPSS Inc., Chicago).

Results

Only 15 hospitals in Taiwan offered hospice inpatient services throughout the whole of 2002 and 2003. The numbers of patients in these wards on each day of 2002 and 2003 are shown in Figure 1. In 2002, the maximal capacity was 214 patients per day (on 11 July) and the reg-ular utilization was between 150 and 200 patients per day. Two noticeable troughs in February 2002 and Janu-ary 2003 corresponded with the Chinese New Year holi-days, which are based on the lunar calendar. In 2003, hospice utilization began to decrease in the middle of April, reached a minimum on 25 May (69 patients), and gradually recovered to the level of the previous Novem-ber. The trend in utilization over 15 hospice wards during 2003 was parallel to that in all hospitals, except that the hospice wards showed a more marked reduction in utili-zation during the peak period of the SARS epidemic (-52.5% vs. -19.9% in May 2003) and a slower recovery with a three-month lag (Figure 2).

The influence of the SARS epidemic on hospice utilization varied widely among the 15 wards studied (Table 1). Even during the peak period of the epidemic, three wards showed growth in utilization and one was unchanged,

Number of patients per day in 15 hospice wards during 2002 (non-SARS year) and 2003 (SARS year) Figure 1

Number of patients per day in 15 hospice wards during 2002 (non-SARS year) and 2003 (SARS year).

0 50 100 150 200 250 1 Ja n 15 J an 29 J an 12 F eb 26 F eb

12 Mar26 Mar 9 Apr 23 Ap r 7 May21 May 4 Ju n 18 J un 2 Ju l 16 J ul 30 J ul 13 Au g 27 Au g 10 Se p 24 Se p 8 Oc t 22 O ct

5 Nov19 Nov 3 Dec17 Dec31 Dec

No of hospice inpatients per

day

2002 2003

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while two seemed temporarily to cease operating. The recovery also varied from ward to ward: two months after the epidemic, four wards still showed a reduction in utili-zation of more than 20%.

In total, 566 patients were admitted to hospice wards in May/June 2003, in contrast to 818 admissions in May/ June 2002. The gender, age and diagnosis distributions did not differ between patient groups in these two years (Table 2).

Of the 15 wards, eight were located in academic medical centres, six in metropolitan hospitals, and one in a local community hospital. As to geographic location, six were located in northern Taiwan, two in the middle of the country, six in the south and one in the east (Table 3). During the peak period of the SARS epidemic, hospice wards in academic medical centres were affected more severely than those in metropolitan hospitals (-60.4% vs. -38.4% in May 2003), whereas the one in a local

commu-nity hospital was only slightly affected (-3.2% in May 2003) (Figure 3). Hospice wards in northern and middle Taiwan were affected more severely than those in south-ern Taiwan (-66.0% and -71.8% vs. -36.8% in May 2003), whereas the one in eastern Taiwan showed increased uti-lization (+15.4% in May 2003) (Figure 4).

Among the 566 patients admitted to hospice wards during the peak of the epidemic, the gender and age distributions did not differ among patient groups in academic medical centres, metropolitan hospitals or the local community hospital (Table 4). The gender distribution did not differ among patient groups in different locations, but the age distribution did (Table 5).

Discussion

Most studies of the impact of SARS on health service utili-zation have been confined to a single facility. Our study, based on nationwide data, gave a complete and exact pic-ture of hospice utilization. The hospice, also known as palliative care, has usually been considered as conserva-Differences between aggregate patient-days of hospice beds and all kinds of hospital beds in 15 hospitals during each month of 2003 compared with the corresponding months of 2002

Figure 2

Differences between aggregate patient-days of hospice beds and all kinds of hospital beds in 15 hospitals during each month of 2003 compared with the corresponding months of 2002. Difference = ((patient-days in a month of 2003) – (patient-days in a month of 2002))/(patient-days in a month of 2002).

-60% -50% -40% -30% -20% -10% 0% 10% 20%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Hospital Hospice

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tive and non-acute. One could well imagine that the use of hospice services would be compromised because of fears during uncertain times. Our findings support this view. Hospice inpatient utilization in Taiwan was indeed more sensitive to the emerging epidemic than general inpatient utilization. Not only was the reduction sharper, but also recovery to the previous level took longer. Although it cannot be classed as acute care, hospice care is unlike elective surgery, which can put patients on a long waiting list. Hospice care is provided to terminally ill

patients whose life expectancy is limited. During the SARS epidemic in Taiwan, many terminally ill patients might have been suspended or deterred from professional hos-pice care because well-organized patient transfers did not exist. Health consequences might not be a big issue among hospice patients. Instead, quality of care and humanity are the major concerns.

During the peak period of the SARS epidemic, i.e. May/ June 2003, the number of admissions to the 15 hospice wards in our study decreased to 69% of those in the pre-vious year, and the utilization in patient-day units to 54%. This meant that some patients might have been dis-charged earlier. It remains unknown whether the decrease of utilization was due to patients' voluntary decisions or to manoeuvring by the hospitals. According to our per-sonal experiences, both patients' decisions and hospital policies could have played a role. On the patient's side, the family might have a major part in the decision about hospice care, because weak terminally ill patients are usu-ally dependent on their families. The fear of SARS might have come from the family rather than the patient. Only interviews with the patients and their caregivers could give a satisfactory answer.

The aggregate utilization of the 15 hospice wards during the peak period of the SARS epidemic in Taiwan was lower than that during the Chinese New Year holidays (Figure 1). Like Christmas to Christians, the Chinese New Year holidays are important to most Chinese as occasions of family reunion. Usually hospital activities are kept to a minimum on these days. The daily curve of hospice utili-zation vividly illustrated the impact of the SARS epidemic.

Table 2: Characteristics of hospice patients admitted during the peak period of the severe acute respiratory syndrome and one year earlier Admission in May/June 2002 (N = 818), n (%) Admission in May/June 2003 (N = 566), n (%) P value Gender 0.669* Female 352 (43.0) 249 (44.0) Male 465 (56.8) 317 (56.0) Unknown 1 (0.1) Age in years 64.6 (SD 14.6) 64.6 (SD 15.0) 0.946** Primary diagnosis 0.981*

Ca of trachea, bronchus, & lung 147 (18.0) 98 (17.3) Ca of liver & intrahepatic bile ducts 140 (17.1) 93 (16.4)

Ca of colon 56 (6.8) 37 (6.5)

Ca of female breast 48 (5.9) 40 (7.1)

Ca of stomach 51 (6.2) 30 (5.3)

Ca of pancreas 37 (4.5) 24 (4.2)

Ca of rectum, rectosigmoid junction, & anus 32 (3.9) 21 (3.7)

Ca of cervix uteri 29 (3.5) 19 (3.4)

Others 278 (34.0) 204 (36.0)

*Pearson's chi-square test, two-sided. **Two-sample t-test, two-tailed.

Table 1: Differences between bimonthly patient-days in individual hospice wards during 2003 and those at the same periods in 2002

Hospice March/April May/June July/August September/October

A -5% -98% -59% -31% B -8% -94% -39% -7% C 19% -64% -20% -21% D -22% -57% -21% -27% E -8% -50% -9% 3% F 20% -45% 2% 8% G -3% -44% -25% -9% H 0% -44% 0% -2% I -11% -41% -39% -37% J 7% -15% 20% -13% K 2% -5% 5% 27% L -18% 0% -4% 1% M -11% 5% -1% 9% N -10% 6% 7% -4% O 32% 15% 51% 32% Total -3% -46% -13% -4%

*Difference = ((patient-days in two months of 2003) – (patient-days in two months of 2002))/(patient-days in two months of 2002).

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Table 4: Characteristics of hospice patients admitted during the peak period (May/June 2003) of the severe acute respiratory syndrome, stratified by accreditation level

Academic medical centres (N = 372), n (%)

Metropolitan hospitals (N = 165), n (%)

Local community hospitals (N = 29), n (%) P value Gender 0.582* Female 159 (42.7) 75 (45.5) 15 (51.7) Male 213 (57.3) 95 (54.5) 14 (48.3) Age in years 65.2 (SD 15.2) 64.3 (SD 14.3) 59.0 (SD 15.2) 0.091** Primary diagnosis Ca of trachea, bronchus, & lung 63 (16.9) 30 (18.2) 5 (17.2) Ca of liver & intrahepatic bile ducts

58 (15.6) 31 (18.8) 4 (13.8) Ca of colon 26 (7.0) 10 (6.1) 1 (3.4) Ca of female breast 23 (6.2) 13 (7.9) 4 (13.8) Ca of stomach 21 (5.6) 8 (4.8) 1 (3.4) Ca of pancreas 17 (4.6) 6 (3.6) 1 (3.4) Ca of rectum, rectosigmoid junction, & anus

16 (4.3) 4 (2.4) 1 (3.4)

Ca of cervix uteri 10 (2.7) 7 (4.2) 2 (6.9)

Others 138 (37.1) 56 (33.9) 10 (34.5)

*Pearson's chi-square test, two-sided.

**One-way analysis of variance, F (df) = 2.403 (2, 563).

parentheses)

Academic medical centre Metropolitan hospital Local community hospital Total

Northern Taiwan 4 (110) 2 (27) 6 (137)

Middle Taiwan 1 (12) 1 (10) 2 (22)

Southern Taiwan 2 (29) 3 (38) 1 (13) 6 (80)

Eastern Taiwan 1 (15) 1 (15)

Total 8 (166) 6 (75) 1 (13) 15 (254)

Table 5: Characteristics of hospice patients admitted during the peak period (May/June 2003) of the severe acute respiratory syndrome, stratified by location

Northern Taiwan (N = 225), n (%) Middle Taiwan (N = 35), n (%) Southern Taiwan (N = 248), n (%) Eastern Taiwan (N = 58), n (%) P value Gender 0.311* Female 106 (47.1) 11 (31.4) 109 (44.0) 23 (39.7) Male 119 (52.9) 24 (68.6) 139 (56.8) 25 (60.3) Age in years 66.6 (SD 14.7) 61.6 (SD 16.7) 62.5 (SD 14.8) 67.9 (SD 14.3) 0.005** Primary diagnosis

Ca of trachea, bronchus, & lung 42 (18.7) 5 (14.3) 43 (17.3) 8 (13.8) Ca of liver & intrahepatic bile

ducts 38 (16.9) 4 (11.4) 42 (16.9) 9 (15.5) Ca of colon 12 (5.3) 1 (2.9) 18 (7.3) 6 (10.3) Ca of female breast 17 (7.6) 20 (8.1) 3 (5.2) Ca of stomach 13 (5.8) 1 (2.9) 15 (6.0) 1 (1.7) Ca of pancreas 7 (3.1) 4 (11.4) 10 (4.0) 3 (5.2) Ca of rectum, rectosigmoid junction, & anus

9 (4.0) 1 (2.9) 8 (3.2) 3 (5.2)

Ca of cervix uteri 3 (1.3) 14 (5.6) 2 (3.4)

Others 84 (37.3) 19 (54.3) 78 (31.5) 23 (39.7)

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As for the patients admitted to hospice wards during the SARS epidemic, the insurance claims used in our study could only offer three reliable variables (gender, sex and discharge diagnoses), which showed no differences. Because about 60% of cancer patients in Taiwan die at home [19], we could not calculate the survival time of every hospice patient as a proxy of disease severity from our closed datasets.

Although Taiwan had been declared a SARS-affected country, not every hospice ward was equally influenced by this epidemic. The impact was related to the locations and accreditation levels of the hospitals with hospice wards: the bigger the hospital, the stronger the SARS impact. Other features, e.g. the admission policy and mission of each hospital during the SARS epidemic, might have played a role. Hospices in middle Taiwan were most severely affected; only the hospice in eastern Taiwan was negligibly affected. The main island of Taiwan has 22 cit-ies and countcit-ies. The probable cases of SARS appeared mainly in Taipei city (in northern Taiwan), Taipei county (northern), Taoyuan county (northern), Kaohsiung city (southern) and Kaohsiung county (southern) [13]. On 26

March 2003, a resident of Hong Kong's Amoy Gardens flew to Taiwan and travelled to Taichung (in middle Tai-wan). That man's brother in Taiwan became Taiwan's first SARS fatality [15]. This might partly explain the impact of SARS in middle Taiwan (Figure 4).

Because the NHIRD prohibited any break of confidential-ity, we did not continue the analysis hierarchically from geographic location to accreditation level. Instead, we dis-played the aggregate data in location and level separately. However, hierarchical modelling could be used to exam-ine the factors associated with reduced utilization and would help construct a real-time and on-line analytical processing system for nationwide surveillance during an outbreak of an infectious disease.

A striking feature of the SARS epidemic in Taiwan was that 56.3% of SARS patients were hospital-related [15]. In ret-rospect, it was reasonable and preferable to reduce hospi-talisations. A similar phenomenon was observed simultaneously in childbirth in Taiwan [7]. Many deliver-ies were shifted from secondary and tertiary care hospitals to primary clinics. The question remains whether continu-Differences between aggregate patient-days in hospice wards during each month of 2003 and those of the corresponding months of 2002, stratified by accreditation level

Figure 3

Differences between aggregate patient-days in hospice wards during each month of 2003 and those of the corresponding months of 2002, stratified by accreditation level. Difference = ((patient-days in a month of 2003) – (patient-days in a month of 2002))/(patient-days in a month of 2002). -70.0% -60.0% -50.0% -40.0% -30.0% -20.0% -10.0% 0.0% 10.0% 20.0% 30.0% 40.0%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Academic medical centre Metropolitan hospital Local community hospital

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ity and quality of care could be ensured. It is unlikely that patients shifted from the 15 hospices in the current study to the other six (unanalysed) hospices, which either quit-ted or joined the hospice program after the SARS epi-demic. However, the possibility of patient flow to other non-hospice wards cannot be excluded. Our claims-based study could not determine whether the needs of patients with terminal illnesses were met during the epidemic, and threw no light on the psychological impact on patients and healthcare workers [20].

Conclusion

The SARS epidemic will not be the last to affect human-kind. The lessons for the hospice society in Taiwan and for the world might be to distribute services into well-bal-anced networks, e.g. hospice care at home (through visits by physicians and nurses), shared hospice care in hospi-tals (i.e. providing hospice care in non-hospice wards), and hospice care at independent hospices in the commu-nity. A seamless continuity of care between facilities should be ensured at all times.

Abbreviations

NHI: National Health Insurance

NHIRD: National Health Insurance Research Database SARS: severe acute respiratory syndrome

Competing interests

The author(s) declare that they have no competing inter-ests.

Authors' contributions

TJC conceived and carried out the study, performed the statistical analysis and drafted the manuscript. MHL and LFC participated in the design of the study and helped to perform the statistical analysis as well as to interpret find-ings. SJH participated in the design and coordination of the study and helped to draft the manuscript. All authors read and approved the final manuscript.

Acknowledgements

This study is based in part on data from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health and managed by National Health Research Institutes Differences between aggregate patient-days in hospice wards during each month of 2003 and those of the corresponding months of 2002, stratified by geographic location

Figure 4

Differences between aggregate patient-days in hospice wards during each month of 2003 and those of the corresponding months of 2002, stratified by geographic location. Difference = ((patient-days in a month of 2003) – (patient-days in a month of 2002))/(patient-days in a month of 2002). -80.0% -70.0% -60.0% -50.0% -40.0% -30.0% -20.0% -10.0% 0.0% 10.0% 20.0% 30.0%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Northern Taiwan Middle Taiwan Southern Taiwan Eastern Taiwan

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Pre-publication history

The pre-publication history for this paper can be accessed here:

數據

Table 1: Differences between bimonthly patient-days in individual  hospice wards during 2003 and those at the same periods in 2002
Table 5: Characteristics of hospice patients admitted during the peak period (May/June 2003) of the severe acute respiratory  syndrome, stratified by location

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