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Factors influencing transitional care from adolescents to young adults with cancer in Taiwan: A population-based study
© The Author(s). 2016
Received: 21 October 2015
Accepted: 26 July 2016
Published: 2 August 2016
To investigate the progress of transition from paediatric to adult health care for patients with cancer in Taiwan’s medical system.
The data were retrieved from the Longitudinal Health Insurance Database (LHID), which contains the original inpatient and outpatient medical claims data for 1,000,000 enrollees randomly sampled from the NHIRD between 1997 and 2010.
Among the 1,411 cancer patients selected for this study, 98.09 % received adult-oriented therapy before the age of 18. In addition, only 1.91 % of the patients received paediatric-oriented therapy during adolescence. The primary factors that determine whether these patients would receive paediatric-oriented therapy or adult-oriented therapy at an early age were as follows: the age of the patient at the first visit and the performance-level of the hospital (p < 0.001).
Previous studies conducted in developed countries have demonstrated that the unwillingness of patients to switch from paediatric-oriented therapy to adult-oriented therapy being the major obstacle that hinders the transition process. However, this study revealed a different result: the implementation of the National Health Insurance system in Taiwan makes healthcare affordable for the adolescent patients who may not possess adequate knowledge about paediatric health care and may not appreciate paediatric-oriented therapy, thereby hindering the transition process.
In recent years, with the significant advances in medical science and technology, more children with chronic diseases can survive into adulthood [1–3]. Childhood cancer in particular exhibits a high survival rate of approximately 80 % . Consequently, when transitioning from paediatric to adult healthcare services, these children, their families, and healthcare providers may encounter numerous potential problems, such as adult health insurance, adaptation to adult life, and financial conditions that create specific healthcare needs [5–9], because the healthcare environment for children must be changed from dependent to independent [10–12].
Transitional care is widely defined as “the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from child- centered to adult-oriented healthcare systems” . An effective transition process can provide appropriate, high-quality, and uninterrupted medical care services for the patient, as well as a communication platform for the main participants in the patient’s treatment, including the patient, family members, paediatricians, nurses, adult-healthcare providers, and other healthcare professionals [14–22], to enhance the patient’s health, life outcomes, self-management and autonomy [23, 24].
In developed western countries such as the United Kingdom and Australia, the transitional medicine is supported by the government and has been implemented for years . In United States, some individual states and health services have recognised the importance of transition and the need for formal approaches to transition planning . Numerous researchers have demonstrated that the bond formed among the patients, their families, and adult-healthcare providers during transitional care provides excellent results, including reduced length of stay , reduced medical costs , and increased medical usage satisfaction of adolescent patients with chronic illnesses and their families [29, 30].
The goals of this study are to identify the characteristics of childhood cancer patients, and to investigate the progress of transition from paediatric to adult health care for these patients in Taiwan’s medical system. The Taiwanese government initiated a single-payer National Health Insurance programme approximately 20 years ago; Taiwan’s National Health Insurance system covers most forms of treatment, including general diagnoses and treatment, medical consultations and operations, and other related procedures such as examinations, laboratory tests, anaesthesia, prescription medications, supplies, nursing care, hospital admissions, and certain over-the-counter drugs. A family of four pays a premium of roughly United States Dollar (USD) $100 per month, accounting for about 2 % of the average household income. In addition, over 23 million people were enrolled in the National Health Insurance Research Database (NHIRD) after implementing the programme, thus granting researchers access to a large amount of samples for analysis. Compared with most previous studies on transitional care, which used questionnaire methods to determine the needs of a small number of patients, families, medical professionals, and adult-healthcare providers by interviewing them , the analytic results derived from a larger sample from the NHIRD are more reliable and more representative.
Data source and sample
In this study, the data were retrieved from the Longitudinal Health Insurance Database (LHID) 2005, which contains the original inpatient and outpatient medical claims data for 1,000,000 enrollees randomly sampled from the NHIRD between 1997 and 2010. We selected patients diagnosed with neoplasms before the age of 18 years based on the International Classification of Diseases, Ninth Revision (ICD-9) codes 140–239 and maintained an adult electronic medical record in the LHID 2005.
Variables related to healthcare transition
The Childhood Cancer Survivor Study revealed a phenomenon that approximately a third of young adult survivors experiencing difficulty in obtaining health insurance beginning at 18 years of age . In comparison, the siblings of these young adults or those around the same age who are in good health do not share the same experience. In addition, 18 is the legal age of adulthood in Taiwan. Therefore, this study used the following criterion to identify patients who meets a well-timed transition: if a patient received paediatric services before the age of 18 years and adult-healthcare services in adulthood, a successful transfer was achieved; otherwise, no transitional care was received.
In previous studies, patient characteristics and characteristics of medical service providers were common explanatory variables used to identify factors and barriers associated with transition decision. In this study, we used the performance-level of hospitals where patients visited prior to adulthood, and hospital location, the criteria obtained from the registration files of the LHID 2005, as the characteristics of medical service providers. The hospital performance-levels were assigned by a professional Taiwanese medical evaluation institution by performing objective assessments of the quality of medical services provided. Hospitals were categorized into one of the following three categories: academic medical centers (AMCs); superior in hospital accreditation and excellence in teaching hospital (SHET); and others. AMCs and SHET represent hospitals with the highest level of medical service quality according to the old and new evaluation systems, respectively. AMCs takes a more holistic approach in providing care to patients, including medical education and research, development of medical and health technology. In contrast, SHETs are based on patients’ point of view and strive to provide all the relevant information to the patients’ condition prior to giving any medical treatment. In other word, AMCs generally focus on teaching life-saving skills, whereas SHETs not only focus on teaching life-saving skills, but also on teaching the purpose and the quality of the care provided. Hospital locations were divided into six major cities of Taiwan and non-metropolitan regions based on the area classification of Taiwan. These major cities included Taipei, New Taipei, Taoyuan, Taichung, Tainan, and Kaohsiung. Urban regions were defined as areas with a population density of at least 1,500 people per square kilometer, and rural regions were defined as those with 1,499 or fewer people per square kilometer. The following information for patient characteristics was retrieved from the database: gender, average healthcare expenses and yearly clinical visit frequency before 18 years of age, cancer, and the age of first visit. Cancer was divided into single and multiple primary cancer types. Single primary cancer denotes patients with only one type of cancer, whereas multiple primary cancer represents patients with other complications as a result of the cancer(s) and other patients not classified in the single primary cancer category. Average medical expenses and clinical visit frequency both were divided into low and high level based on the average.
Frequency analysis, comprising t tests for continuous data and multivariate logistic regression models for determining the independent contributions of explanatory variable to the appropriateness of transition time, was conducted in this study. A significance level of α = 0.01 was established to determine the significance of the results. Microsoft Access 2010 was used to filter all data and IBM SPSS 20.0 was employed to perform all statistical analyses.
Sample Characteristics of Participants (N = 1,411)
Standard Deviation (SD)
Age (range 18–29 years)
Age at first visit
Clinic visit frequency (mean yearly) before age of 18
Low (≤2 times)
High (> 2 times)
Mean medical expenses per visit before age of 18
Low (≤ USD $ 3)
High (> USD $3)
The medical expenses of adult service ($/time)
Low (≤ USD $ 3.65)
High (> USD $ 3.65)
No receiving adult service
The medical expenses of pediatric service ($/time)
Low (≤ USD $ 2.7)
High (> USD $ 2.7)
No receiving pediatric care
Age at first receiving adult service
No receiving adult service
Factors Associated with Receiving Care at Adult Health Care Clinics Before the Age of 18 Years on Multiple Logistic Regression Analysis
Multivariate logistic regression
Odds Ratio (OR)
95 % CI
Mean medical expenses per visit before age of 18
Low (≤ USD $3)
High (> USD $3)
Clinic visit frequency (mean yearly) before age of 18
Low (≤2 times)
High (>2 times)
The age of first visit
0.000 - .
0.000 - .
0.000 - .
Previous studies have demonstrated that when insurance systems does not cover the medical expenses for adult health care, adolescent patients will prolong the period of paediatric health care . In Taiwan, people can receive medical treatment at a low cost regardless of the type of care and the limitation of age because of National health insurance system. The mean medical expenses per visit is less than USD $3. The financial burden borne by patients with cancer is less severe, and patients are able to switch from paediatric to adult health care without contemplating future medical expenses. Instances of delayed transition to adult care are relatively rare. Thus, the mean medical expense was not a significant barrier in the regression.
However, the vast majority of the patients begin receiving adult health care well before the age of 18 and few adolescent patients with cancer are provided a complete transition mechanism. In fact, the expenses of adult-oriented health care are higher than those of pediatric health care (p = 0.01). But, patients’ families are likely to favor adult-oriented therapy when choosing the medical facilities for their adolescent children. This would jeopardize the mental and physical development of children with cancer. Moreover, transition planning requires long-term preparation. Premature transition to adult-oriented therapy may lead to insufficient preparation, resulting in transition failure7.
Taiwan Pediatrics Association has completed a survey of 14,730 parents in Taiwan via a web questionnaire. The results show that 83 % of parents don’t know their children should receive pediatric-oriented therapy before age of 18 and 58.5 % of parents don’t know which department their children should visit. In other words, the fact that patients and their families lack the knowledge related to pediatric health care could be the reason why patients did not receive any pediatric-oriented therapy or accepted adult-oriented therapy early. In Taiwan, most hospitals have a paediatric specialist that can treat those patients and hold a consultation with other specialists if necessary. But, hospitals accredited with the SHET have more complete healthcare systems and provide more comprehensive health education than do hospitals of other performance-levels. Patients receiving health care in these hospitals are more favourably positioned to learn about paediatric health care. The ratio of patients prematurely receiving adult health care at hospitals accredited with the SHET was significantly lower than that of patients receiving care at hospitals of other performance-levels, which again well demonstrated that transition failure is due to patients’ lack of understanding of the influence of paediatric health care on adolescent patients, the lack of a transition mechanism in hospitals, and hospitals failing to provide related information to patients and their families. Therefore, patients and their family members choose their health care based solely on the department’s specialty (e.g., patients with cancer choosing the department of oncology), resulting in transition failure. In Taiwan, adolescent survivors and their family should be informed about the paediatric healthcare and the supporting groups that can assist in transitioning care.
In this study, the physicians’/pediatricians’ views on transition care were not explored because the LHID contains only the circumstantial factors, such as medical expenses, hospital location and hospital performance-level. However, the scope of the investigation has provided a relevant depiction of the effect of a low-cost health insurance system have on transitional care. A starting point has been provided by this study for factors to transitional care in areas that have implemented national health insurance.
As the survival rate of adolescent patients with cancer continues to rise, transition mechanisms also become increasingly vital. Transition mechanisms provide patients with appropriate health care as their demands change when transitioning from adolescence to adulthood. These mechanisms enhance their quality of life and reduce medical expenses. While researchers in numerous developed western countries have looked into various topics surrounding transitional care in recent years, in Asia, only researchers in Japan and Hong Kong have conducted similar research. These studies indicated that health insurance and unwillingness to leave familiar medical professionals and environments were the two common factors contributing to transition failure.
However, factors influencing the transition care differ between cultures and health policies. In this study, we conducted investigations to explore the situation of transition care for Taiwan, where the National Health Insurance system has been implemented. The major transition obstacles hindering the transition from paediatric to adult health care in Taiwan differ substantially from those suggested by previous studies. In Taiwan, the adolescents with cancer have a very short period of paediatric treatment or have never receive paediatric treatment. Lack of appropriate paediatric treatment is the very obstacle for successful transitional care.
AMCs, Academic Medical Centers; LHID, longitudinal national health insurance research database; NHIRD, National Health Insurance Research Database; OR, odds ratio; SD, standard deviation; SHET, Superior in Hospital accreditation and Excellence in Teaching hospital; USD, United States Dollar.
This study is based in part on data from the National Health Insurance Research Database provided by the National Health Insurance Administration, the Ministry of Health and Welfare and maintained by the National Health Research Institute. The interpretations and conclusions contained herein do not necessarily represent those of the National Health Insurance Administration or the National Health Research Institute.
No funding to declare.
Availability of data and material
All relevant raw data are obtained from the NHIRD and cannot be shared freely without permission of the National Health Research Institutes in Taiwan.
YTJ conceived the study. YTJ and WCC completed all statistical analyses. YTJ and CMC drafted the manuscript. YTJ, CMC and WCC contributed to the discussion. YTJ revised the manuscript. All authors have read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
This research is a secondary data analysis. The data have been reviewed and approved by NHIRD’s Professional Peer Reviewer Committee. The patients’ personal data have been encrypted and their privacy is protected in this research, thereby conforming to the Declaration of Helsinki.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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