Article Analysis 2

Search the GCU Library and find two new health care articles that use quantitative research. Do not use articles from a previous assignment, or articles that appear in the Topic Materials or textbook. (two articles attached 1. lung cancer stats and 2. ckd stats )

Complete an article analysis for each using the “Article Analysis: Part 2” template (attachment article analysis2).

Don't use plagiarized sources. Get Your Custom Essay on

Article Analysis 2

Just from $13/Page

Order Essay

Refer to the “Patient Preference and Satisfaction in Hospital-at-Home and Usual Hospital Care for COPD Exacerbations: Results of a Randomized Controlled Trial,” (attachment copd stats ) in conjunction with the “Article Analysis Example 2,”(attachment HLT-362V) for an example of an article analysis.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Refer to the

LopesWrite Technical Support articles

for assistance.

Rubic_Print_Format

N/A

10.0%

Course Code

Class Code

Assignment Title

Total Points

HLT-362V

HLT-362V-O501

Article Analysis 2

130.0

Criteria

Percentage

1: Unsatisfactory (0.00%)

2: Less Than Satisfactory (65.00%)

3: Satisfactory (75.00%)

4: Good (85.00%)

5: Excellent (100.00%)

Comments

Points Earned

Content

100.0%

Two Quantitative Articles

10.0%

Fewer than two articles are presented. None of the articles presented use quantitative research.

N/A

Two articles are presented. Of the articles presented, only one articles are based on quantitative research

Two articles are presented. Both articles are based on quantitative research.

Article Citation and Permalink

Article citation and permalink are omitted.

Article citation and permalink are presented. There are significant errors. Page numbers are not indicated to cite information, or the page numbers are incorrect.

Article citation and permalink are presented. Article citation is presented in APA format, but there are errors. Page numbers to cite information are missing, or incorrect, in some areas.

Article citation and permalink are presented. Article citation is presented in APA format. Page numbers are used in to cite information. There are minor errors.

Article citation and permalink are presented. Article citation is accurately presented in APA format. Page numbers are accurate and used in all areas when citing information.

Broad Topic Area/Title

Broad topic area and title are omitted.

Broad topic area and title are referenced but are incomplete.

Broad topic area and title are summarized. There are some minor inaccuracies.

Broad topic area and title are presented. There are some minor errors, but the content overall is accurate.

Broad topic area and title are fully presented and accurate.

Hypothesis

Definition of hypothesis is omitted. The definition of the hypothesis is incorrect.

Hypothesis is summarized. There are major inaccuracies or omissions.

Hypothesis is generally defined. There are some minor inaccuracies.

Hypothesis is defined. Hypothesis is generally defined. There are some minor inaccuracies.

Hypothesis is accurate and clearly defined.

Independent and Dependent Variable Type and Data for Variable

Variable types and data for variables are omitted.

Variable types and data for variables are presented. There are major inaccuracies or omissions.

Variable types and data for variables are presented. There are inaccuracies.

Variable types and data for variables are presented. Minor detail is needed for accuracy.

Variable types and data for variables are presented and accurate.

Population of Interest for the Study

Population of interest for the study is omitted.

Population of interest for the study is presented. There are major inaccuracies or omissions.

Population of interest for the study is presented. There are inaccuracies.

Population of interest for the study is presented. Minor detail is needed for accuracy.

Population of interest for the study is presented and accurate.

Sample

Sample is omitted.

Sample is presented. There are major inaccuracies or omissions.

Sample is presented. There are inaccuracies.

Sample is presented. Minor detail is needed for accuracy. Page citation for sample information is provided.

Sample is presented and accurate. Page citation for sample information is provided.

Sampling Method

Sampling method is omitted.

Sampling is presented. There are major inaccuracies or omissions.

Sampling is presented. There are inaccuracies. Page citation for sample information is omitted.

Sampling is presented. Minor detail is needed for accuracy.

Sampling method is presented and accurate.

How Was Data Collected

The means of data collection are omitted.

The means of data collection are presented. There are major inaccuracies or omissions.

The means of data collection are presented. There are inaccuracies. Page citation for sample information is omitted.

The means of data collection are presented. Minor detail is needed for accuracy. Page citation for sample information is provided.

The means of data collection are presented and accurate. Page citation for sample information is provided.

Mechanics of Writing (includes spelling, punctuation, grammar, and language use)

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is employed.

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.

Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.

Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.

The writer is clearly in command of standard, written, academic English.

Total Weightage

100%

ArticleAnalysis: Example

Article Citation and Permalink	Utens, C. M. A., Goossens, L. M. A., van Schayck, O. C. P., Rutten-van Mölken, M. P. M. H., van Litsenburg, W., Janssen, A., … Smeenk, F. W. J. M. (2013). Patient preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: Results of a randomised controlled trial. International Journal of Nursing Studies, 50, 1537–1549. doi.org/10.1016/j.ijnurstu.2013.03.006 Link: https://www.ncbi.nlm.nih.gov/pubmed/23582671 (Include permalink for articles from GCU Library.)
Point	Description
Broad Topic Area/Title	The differences in preference and satisfaction based upon hospital care location for COPD exacerbations.
Define Hypotheses	Hypothesis not stated. Below is an example from the study: H0: There is no difference in satisfaction levels based upon treatment location. H1: There is a difference in satisfaction levels based upon treatment locations.
Define Variables and Types of Data for Variables	Treatment Location – categorical – “home treatment” and “hospital treatment” Satisfaction – Ordinal Scale (1-5) Preference – categorical “home treatment” and “hospital treatment”
Population of Interest for the Study	COPD exacerbation patients from five hospitals and three home care organizations
Sample	139 patients 69 from the usual hospital care group 70 from the early assisted discharge care group
Sampling Method	Mixed methods; quantitative was randomized sampling
How Were Data Collected?	A questionnaire with both open-ended questions and questions with a scale of 1-5 (p. 1539)

Pa
us
ra

Ce
Ma
An
a De
b De
c Ins
d De

International Journal of Nursing Studies 50 (2013) 1537–1549

A R

Artic

Rece

Acce

Keyw

Hos

Earl

Chro

Pati

dist
§§

Cath

002

http

tient preference and satisfaction in hospital-at-home

and

ual hospital care for COPD exacerbations: Results of a
ndomised controlled trial§,§§

cile M.A. Utens a,b,*, Lucas M.A. Goossens c, Onno C.P. van Schayck b,
ureen P.M.H. Rutten-van Mölken c, Walter van Litsenburg a, Annet Janssen a,
ouschka van der Pouw d, Frank W.J.M. Smeenk a

partment of Respiratory Medicine, Catharina Hospital, Eindhoven, The Netherlands

partment of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands

titute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands

partment of Respiratory Medicine, Rijnstate Hospital, Arnhem, The Netherlands

What is already known about the topic?

� Patient satisfaction with hospital-at-home schemes is
high, but most schemes admit patients with various
conditions.
� Effectiveness and cost-effectiveness of hos

pital-at-home

and usual hospital care for COPD patients are not

T I C L E I N F O

le history:

ived 27 September 2012

ived in revised form 15 March 2013

pted 15 March 2013

ords:

pital-at-home

y assisted

discharge

nic Obstructive Pulmonary Disease

ent preference

ent satisfac

tion

A B S T R A C T

Background: In the absence of clear differences in effectiveness and cost-effectiveness

between hospital-at-home schemes and usual hospital care, patient preference plays an

important role. This study investigates patient preference for treatment place, associated

factors and patient satisfaction with a community-based hospital-at-home scheme for

COPD exacerbations.

Methods: The study is part of a larger randomised controlled trial. Patients were

randomised to usual hospital care or early assisted discharge which incorporated

discharge at day 4 and visits by a home care nurse until day 7 of treatment (T + 4 days). The

hospital care group received care as usual and was discharged from hospital at day 7.

Patients were followed for 90 days (T + 90 days). Patient preference for treatment place

and patient satisfaction (overall and per item) were assessed quantitatively and

qualitatively using questionnaires at T + 4 days and T + 90 days. Factors associated with

patient preference were analysed in the early assisted discharge group.

Results: 139 patients were randomised. No difference was found in overall satisfaction. At

T + 4 days, patients in the early assisted discharge group were less satisfied with care at

night and were less able to resume normal daily activities. At T + 90 days there were no

differences for the separate items. Patient preference for home treatment at T + 4 days was

42% in the hospital care group and 86% in the early assisted discharge group and 35% and

59% at T + 90 days. Patients’ mental state was associated with preference.

Conclusion: Results support the wider implementation of early assisted discharge for

COPD exacerbations and this treatment option should be offered to selected patients that

prefer home treatment.

We thank Kitty van der Meer, research assistant, for her work in

the

ribution and management of the questionnaires and data.

Trial registration: NetherlandsTrialRegister NTR 1129.
Corresponding author at: Department of Respiratory Medicine,

arina Hospital, Eindhoven, The Netherlands. Tel.: +31 612796688.

E-mail address: cecileutens@gmail.com (Cecile M.A. Utens).

Contents lists available at SciVerse ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

0-7489/$ – see front matter � 2013 Elsevier Ltd. All rights reserved.
://dx.doi.org/10.1016/j.ijnurstu.2013.03.006

http://crossmark.crossref.org/dialog/?doi=10.1016/j.ijnurstu.2013.03.006&domain=pdf

http://dx.doi.org/10.1016/j.ijnurstu.2013.03.006

mailto:cecileutens@gmail.

com

http://www.sciencedirect.com/science/journal/00207489

http://dx.doi.org/10.1016/j.ijnurstu.2013.03.006

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491538

different, therefore the choice between the two should
be based on patient preference.

What this paper adds

� This paper is the first to demonstrate patient

satisfaction

with hospital-at-home and usual hospital care and
preference for treatment place in only patients with a
COPD exacerbation.
� This paper demonstrates that patients are satisfied with

hospital-at-home.
� The majority of patients prefers home treatment if they

could choose.

1. Introduction

Internationally, there are trends to deliver care in the
community and more closely to the patients’ home.
Combined with a pressure on hospital beds and a
continuous need to constrain health care costs, this has
led to the development of alternatives for hospital care.
Schemes aimed at avoiding hospital admission or reduce
length of stay by treating and supervising patients at home,
instead of the hospital, are called hospital-at-home
schemes (Shepperd et al., 2008, 2009). Studies have proved
that these schemes are safe and have no negative effects on
patient outcomes (Shepperd et al., 2008, 2009; Ram et al.,
2003). Chronic Obstructive Pulmonary Disease (COPD)
exacerbations are responsible for a great number of annual
hospital admissions, and accompanying health care costs
(Toy et al., 2010). To reduce the pressure on hospital beds
hospital-at-home schemes have been designed. Forty-four
percent of British hospitals runs a hospital-at-home
scheme for COPD exacerbations (Quantrill et al., 2007).
Patient satisfaction with hospital-at-home schemes is
high, but results are mainly derived from studies evaluat-
ing general, non-specialised schemes, meaning that they
admit patients with various conditions and treatments
(Montalto, 1996; Dubois and Santos-Eggimann, 2001;
Wilson et al., 2002; Leff et al., 2006). Three British studies
evaluated patient satisfaction with hospital-at-home
schemes admitting only patients with COPD exacerbations
(Ojoo et al., 2002; Schofield et al., 2006; Clarke et al., 2010).
All studies reported high patient satisfaction. However, the
schemes were hospital-based outreach schemes, with
specialised respiratory nurses performing visits at home.
Recently we have reported the results of a randomised
controlled trial studying the effectiveness of community-
based early assisted discharge for patients admitted to the
hospital with a COPD exacerbation (Utens et al., 2012). The
community-based hospital-at-home scheme for COPD
exacerbations, with community nurses performing home
visits, had similar patient outcomes as usual hospital care
(Utens et al., 2012). The economic evaluation, that was
performed as part of this clinical trial, also did not show a
large cost difference between the two treatments. From
the health care perspective savings of early assisted
discharge were s244 and from a societal perspective,
incorporating costs of informal caregiving and productivity
loss in addition to health care costs, savings of early
assisted discharge were s65 (Goosens et al., 2013).

Therefore, the choice between the two treatments should
be largely based on patient preference. Preference is the
desirability of a treatment, process or treatment choice
(Krahn and Naglie, 2008). Little is known about the
preference for treatment place and which factors influence
this preference. Therefore, in this study we investigate
patient preference for treatment place and associated
factors. Preference for treatment and satisfaction with
treatment are associated. Satisfaction reflects the degree to
which a patients’ perceived experience matches prefer-
ences regarding this experience (Brennan, 1995). In this
study we compared satisfaction with the community-
based hospital-at-home scheme and usual hospital care.
Satisfaction is determined by the ratio between patients’
expectations of care and their perceptions of the actual
care received, influenced by previous experiences and
personal values (Carr-Hill, 1992).

2. Methods

2.1. Design and patients

The current study was part of a randomised controlled
trial, investigating the effectiveness of community-based
early assisted discharge for patients admitted to the
hospital with a COPD exacerbation (Utens et al., 2010). The
study was conducted between November 2007 and March
2011 in five hospitals and three home care organisations.
Patients that were considered eligible according to the
inclusion and exclusion criteria at admission (Table 1), and
those meeting the criteria of clinical stability (see Table 1)
on day three of admission, were randomised to usual
hospital care or early assisted discharge. Clinical stability
was assessed by the reviewing physician of the hospital
ward. Randomisation was performed on a 1:1 scale using a
computer-generated allocation list that was placed in
sealed envelopes. Randomisation was performed per
participating hospital location and a block-size of 6. Due
to the nature of the intervention, patients and health care
staff involved could not be blinded to treatment allocation.
Those randomised to early assisted discharge, were
discharged home on the fourth day of admission and
visited at home by community nurses that same day and
the next 3 days. In addition, during the 4 days of home
treatment a 24-h telephone access with the hospital ward
was installed. After a total of 7 days of hospital followed by
home treatment, patients were discharged from the
scheme. Patients randomised to usual hospital care
continued the hospital treatment for another 4 days,
making the total length of hospital treatment 7 days, and
were then discharged home. Patients were followed-up for
three months. A detailed description of the trial and the
early assisted discharge intervention has been published
elsewhere (Utens et al., 2010). The trial was approved by
the Medical Ethics Committee of the Catharina Hospital
Eindhoven, the Netherlands.

2.2. Measurements

Baseline characteristics were collected at admission.
Characteristics that were obtained are age, gender, living

situ
adm
inc
List
CO
me
me
bid
and
for
(20
con
ope
rec
and
15
var
The
dur
the
que
(co
ans
the
que
par
que
if th
ent
at
trea
(T +
ass
que
eva
ove

Tab

Incl

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1539

ation, presence of informal care, care at home prior to
ission, number of years diagnosed with COPD,

ome, education, coping style with the Utrecht Coping
(Schreurs et al., 1993), health status with the Clinical

PD Questionnaire (van der Molen et al., 2003),
asuring 3 domains: symptoms, functional state and
ntal state, and comorbidity with the Charlson comor-
ity index (Charlson et al., 1987). Patients’ satisfaction

preference for treatment place was measured with a,
this study translated, questionnaire by Ojoo et al.

02). The questionnaire for both treatment groups
sisted of three parts. The first qualitative part was two
n-end questions asking for three things of the

eived treatment that patients were most satisfied
most dissatisfied about. The second part consisted of
quantitative questions, with five response options
ying from a very positive to a very negative response.

questions discuss topics of medication, concerns
ing treatment and nursing care among others. Each of

answer options of the second part of the satisfaction
stionnaire was assigned as score between 1

mpletely negative answer) and 5 (completely positive
wer) and an overall score was calculated by dividing

total sum score by the total number of valid
stions. Six missing values were allowed. The final
t was a quantitative, dichotomous, hypothetical
stion on where patients would want to be treated
ey could choose: in the hospital and partly at home or

irely in the hospital. The questionnaire was completed
two moments; at the end of the home or hospital
tment (T + 4 days) and after three months follow-up

90 days). At the end of the home treatment, the early
isted discharge group received an additional, separate,
stionnaire with six quantitative questions for the
luation of the home care. This questionnaire covered
rall satisfaction, satisfaction with the total number of

days that home care was provided, the number of visits
each day and the duration of the daily visits. A from
Dutch to English translated version of the questionnaires
can be found in Appendix

The sample size calculation for the randomised
controlled trial was performed for the primary outcome
measure, which was effectiveness expressed in change in
the clinical COPD questionnaire. Patient preference and
satisfaction were secondary outcomes in the randomised
controlled trial. The required sample size for the primary
outcome was 165 patients.

2.3. Analysis

Patient satisfaction with the care they receive has been
the subject of many quantitative and qualitative studies. In
order to be more specific in the evaluation of hospital-at-
home in comparison to usual hospital care we used
deductive content analysis for the responses to the first
part of the questionnaire which contained the two open-end
questions (Graneheim and Lundman, 2004; Elo and Kyngas,
2008). Deductive content analysis is based on previous
theories or models and therefore allows to go beyond general
findings which would have been the focus of an inductive
analysis. Sofaer and Firminger (2005) have identified seven
categories on which patients base the definition of quality of
health care on. These categories are namely patient-centred
care; access; communication and information; courtesy and
emotional support; technical quality; efficiency of care/
organisation; and structure and facilities. Responses to the
two open-end questions were reviewed and then coded
according to these seven categories. CU performed the first
coding and CPvS checked these codings. Discrepancies were
discussed between the two coders. For each of the categories
the most named aspects are described and illustrated with
authentic citations.

le 1

usion and exclusion criteria (applied at admission) and randomisation criteria (applied at day 3 of admission).

clusion criteria (checked on day 1 Exclusion criteria (checked on day 1)

e �40 years Major uncontrolled comorbidity, including pneumonia that
is prominent, heart failure that is prominent, acute changes on

ECG and (suspected) underlying malignancy

mpetent to give written informed consent Mental disability, including dementia, impaired level of consciousness and

acute confusion

agnosed with COPD. COPD was defined

as at least GOLD stage I and 10 pack

years of smoking

Living outside care region of the home care organisation

spitalisation for COPD exacerbation Inability to understand the program

Indication for admission to intensive care unit of for non invasive ventilation

Insufficient availability of informal care at home

ndomisation criteria (checked on day 3)

mpleted informed consent of day 3 of admission

ceptable general health:

– Decrease of physical complaints

– Non-dependency of therapies that cannot be

given at home (intravenous therapy and

newly prescribed oxygen treatment)

– Being able to visit toilet independently,

or as

prior to admission

rmal or moderately increased blood sugar levels, defined as �15 mmol/L of �15 mmol/L but capable to regulate independently
spiratory complaints of dyspnoea, wheezing and rhonchi must have been decreased in comparison with day of admission

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491540

For the second part of the questionnaire differences in
the overall satisfaction score and differences on the
different items were tested using Mann–Whitney tests.

The third part of the questionnaire – the preference of
treatment place – was analysed in two steps. First, the
comparison of the percentage of patients in both groups
preferring home treatment in the hypothetical situation
that they could choose between treatments, was analysed
using Chi-square test. Second, we wanted to study which
factors are associated with treatment place. Therefore, for
early assisted discharge group (N = 70), that experienced
both hospital treatment and home treatment, a two-step
logistic regression was performed. First, bivariate logistic
regression analysis was conducted to determine the factors
associated with patients’ preference for treatment place.
The following factors were investigated for their associa-
tion with preference for treatment place: age, gender,
living situation (alone vs. with someone), presence of
informal caregiver, presence of home care prior to
admission, long term oxygen treatment (yes vs. no), oral
corticosteroid maintenance treatment (yes vs. no) coping
styles (active, avoidant and passive style), income, educa-
tion, number of years diagnosed with COPD, clinical COPD
questionnaire scores (symptoms, functional state and
mental state) at randomisation, and comorbidity (COPD
vs. COPD and one/multiple comorbidities). Next, factors
with p � 0.1 in the bivariate analyses were included in a
multivariate logistic regression. Four factors (long-term
oxygen treatment, income, living situation and clinical
COPD questionnaire – mental state) were included in the
multivariate regression. This requires a sample size of at
least 40 cases, a requirement that was met (Rothman et al.,
2008). Dependent variable in the logistic regressions was
either preference at T + 4 days or T + 90 days.

The additional six questions for the evaluation of the
home care from the early assisted discharge group are
reported as percentage of total responses.

3. Findings

In total 139 patients were randomised, 69 to usual
hospital care and 70 to early assisted discharge care. Table
2 provides an overview of the patient characteristics. Both
groups appeared to be comparable on baseline character-
istics. Immediately after randomisation seven patients in
the usual hospital care group and three patients in the
early assisted discharge group withdrew consent, because
they were not satisfied with the allocated place of
treatment. These seven patients were not different from
the other patients in the usual hospital care group, but the
three patients in the early assisted discharge group that
withdrew consent immediately after randomisation had a
worse comorbidity score than other patients in this
treatment group.

3.1. Findings – first part: qualitative questions on satisfaction

In total, 105 patients (49 of the usual hospital care group
and 56 of the early assisted discharge group) provided 200
comments on aspects they were most satisfied about and 87

Table 2

Patient characteristics. Scores represent number (%), unless stated

otherwise.

Characteristic Usual hospital

care (N = 69)

Early assisted

discharge (N = 70)

Age (years), mean (SD) 67.8 (11.30) 68.31 (10.34)

Sex: male 38 (55.1) 48 (68.6)

Charlson comorbidity scorea

Patients with score = 1 42 (60.0) 38 (54.0)

Patients with score > 1 27 (39.0) 32 (46.0)

Clinical COPD Questionnaireb

Symptoms (range 0–6),

mean (SD)

2.25 (1.05) 2.50 (1.05)

Fnctional state

(range 0–6), mean (SD)

2.61 (1.33) 3.33 (1.42)

Mental state

(range 0–6), mean (SD)

1.38 (1.28) 1.49 (1.45)

Long term oxygen treatment

prior to admission

Yes 4 (5.8) 5 (7.1)

No 65 (94.2) 65 (92.2)

Oral corticosteroid maintenance treatment prior to admission

Yes 5 (7.2) 10 (14.3)

No 64 (92.8) 60 (85.7)

Coping Utrecht coping list�
Active coping style

(range 7–28), mean (SD)

16.72 (3.26) 17.98 (4.14)

Passive coping style

(range 7–28), mean (SD)

12.30 (3.04) 12.25 (3.99)

Avoidant coping style

(range 8–32), mean (SD)

17.24 (3.94) 17.67 (3.62)

Living situation

Living alone 21 (30.4) 22 (31.4)

Living with partner 44 (63.8) 42 (60.0)

Living with child(ren) 1 (1.4) 2 (2.8)

Living with partner

and child(ren)

3 (4.3) 4 (5.7)

Presence of informal care

Yes 62 (89.9) 62 (88.6)

No 7 (10.1) 8 (11.4)

Care at home before admission

None 54 (78.3) 53 (75.7)

Nursing care or help with

activities of daily living

2 (2.9) 7 (10.0)

Domestic help 10 (14.5) 7 (10.0)

Both 3 (4.3) 3 (4.3)

Number of years

diagnosed with

COPD, mean (SD)

8.32 (7.69) 8.16 (7.96)

Incomec

Low 17 (40.5) 18 (40.9)

Medium 12 (28.6) 11 (25.0)

High 13 (31.0) 15 (34.1)

Education leveld

Low 20 (33.9) 21 (35.0)

Medium 26 (44.1) 27 (45.0)

High 15 (22.0) 12 (20.0)
a Score of 1 means COPD only, score >1 means COPD and other

comorbidities.
b 0 represents best possible score and 6 worst possible score; �higher

scores mean higher level of trait.
c Low refers to monthly family income � s1249, medium refers to

monthly family income between s1250 and s1749, high refers to
monthly family income � s1750. Data are missing or patient did not want
to specify in 27 cases.

d Low refers to (parts) of primary school only, medium refers to lower

vocational education or intermediate general education, high refers to

intermediate vocational education or higher general education or higher

vocational training or university.

aspects they were most dissatisfied about.

3.1.

asp
Pat
car
the

sati
car

bot
abo
eve
pul

3.1.

by
the
and
car
of
mu
and
clea

the

we
nur
diss

3.1.
tion

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1541

1. Patient-centred care

Most responses in this category were on satisfying
ects. Only 5 comments were on dissatisfying aspects.
ients in both groups were satisfied with the (nursing)
e and counselling they received, which is illustrated by

following comments:

‘‘The care I received, problems were solved and the
assistance of the staff.’’ (Patient in usual hospital care
group)
‘‘The care was personal.’’ (Patient in early assisted
discharge group)

Patients in the early assisted discharge group were
sfied with how they were received at home and the
e at home by the home care nurses.
At the end of the follow-up period, patients from
h groups commented that they were dissatisfied
ut the fact that they saw different nurses and doctors
ry time, or that they did not see their own
monologist.

‘‘I was not treated and seen by my own pulmonologist.’’
(Patient in usual hospital care group)
‘‘I saw different specialists’’ and ‘‘I had to tell the same
story over and over again.’’ (Patient in early assisted
discharge group)
‘‘At home there were different nurses every time.’’
(Patient in early assisted discharge group)

2. Access

The aspect which was satisfying and most mentioned
patients in the early assisted discharge group was

possibility to go home by early assisted discharge
receive follow-up care from nurses of the home

e organisation. The regular check-ups, receiving
nursing care and medication at home were very
ch appreciated. One patient described the advantages

disadvantages of early assisted discharge very
rly:

Advantages were: ‘‘Privacy’’ and ‘‘able to follow own
daily rhythm’’ while disadvantages were: ‘‘being alone
at night when I am breathless’’ and ‘‘it is easier to cross
my own limits [in physical context].’’ (Patient in early
assisted discharge group)

Patients in the usual hospital care group appreciated
hospital care that they received.
Due to bed shortages, several patients in both groups
re not treated at the respiratory nursing ward but the
sing ward of another specialty. This was subject of
atisfying comments:

‘‘The first days I stayed not on the respiratory ward.’’
(Patient in usual hospital care group)
‘‘I was not admitted to the respiratory ward, where
I belong.’’ (Patient in early assisted discharge
group)

3. Communication and information

Patients in both groups were satisfied on the informa-
and clear explanation they received of staff which

focussed on the disease COPD, the treatment and the
project, illustrated by the following comments:

‘‘The good explanation on the project.’’ (Patient in early
assisted discharge group)
‘‘The clear explanation about what they [staff] are going
to do.’’ (Patient in usual hospital care group)

However, some patients, especially in the early assisted
discharge group, experienced that they received little
information on medication, the disease and what the
upcoming days would happen. This is illustrated by the
following comments:

‘‘I am surprised that after 12 years having a lung
disease I get breathing exercises for the first time’’ and
‘‘I am surprised to have learned the diagnosis COPD
now and not earlier.’’ (Patient in early assisted
discharge group)
‘‘They [hospital staff] promised more in the hospital.’’
(Patient in early assisted discharge group)
‘‘Insufficient preparation for going home. I expected
more care at home with regard to medication and
making coffee.’’ (Patient in early assisted discharge
group)

3.1.4. Courtesy and emotional support

Patients from both groups were satisfied with the
contact they had with the medical and nursing staff.
Patients were satisfied with the kindness of the staff, the
attention staff had for them and the understanding. The
following comments illustrate this:

‘‘Kindness, which makes me feel calm.’’ (Patient in usual
hospital care group)
‘‘I really appreciated the attention of the student nurse.’’
(Patient early assisted discharge group)
‘‘The guidance at home gave me confidence.’’ (Patient
early assisted discharge group)

At the end of the follow-up period, several patients in
both groups provided satisfying comments on the respira-
tory nurses in the hospital and at home.

Only 2 patients provided comments on where they
were dissatisfied about. Both comments concerned the
attention staff had for them. For example:

‘‘They [staff] have little time and therefore little
attention.’’ (Patient in usual hospital care)

3.1.5. Efficiency of care and organisation

Patients in both groups commented that treatment
(medication, examination and help) took place on time
and/or fast. However, others commented that they had
to wait long for help, medication and examinations.
Patients also commented on the busy hospital staff.

‘‘There is a shortage for staff. There is no time for the
patient.’’ (Patient in usual hospital care group)
‘‘when you press the nursing alarm, you sometimes
have to wait long for a response.’’ (Patient in usual
hospital care group’’

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491542

Patients in both groups had comments on aspects of
coordination of care and transfer of information, which are
illustrated by the following comments:

‘‘The mutual coordination was lacking. This bothers
me.’’ (Patient in the usual hospital care group)
‘‘On the ward it was unstructured and disorganised.’’
(Patient in the usual hospital care group)

‘‘The nurse of the home care organisation did not come.
This should be better organised, especially during
weekends’’ and ‘‘care should be tuned because of the
medication and inhalations.’’ (Patient in early assisted
discharge group)
‘‘There was no clear information transfer to the
respiratory nurse.’’ (Patient in early assisted dischar-
gegroup)

3.1.6. Technical quality

Patients from both groups reported to be satisfied with
the treatment and observation they received in the
hospital and at home that was performed by medical
and nursing staff. Patients were satisfied with the recovery
of their condition.

‘‘Treatment in the hospital was good and the treatment
at home was good as well.’’ (Patient in early assisted
discharge group)

However, many comments on what patients from both
groups were most dissatisfied about concerned medica-
tion in the hospital: the type of medication, errors that
were made with prescribing, distribution and adminis-
tration of medication. The following comments illustrate
this:

‘‘The distribution of medicines was better last time
[previous admission].’’ (Patient in usual hospital care
group)
‘‘There was indistinctness concerning the medicines.’’
(Patient in usual hospital care group)
‘‘In the hospital the mouth piece of my inhaler was not
cleaned.’’ (Patient in early assisted discharge group)
‘‘Mistakes were made with the medicines.’’ (Patient in
early assisted discharge group)

3.1.7. Structure and facilities

Patients in both groups were most satisfied about
the quality of the food in the hospital. On the other
hand, patients in both groups were most dissatisfied
about the busy, crowded rooms in the hospital that
provided little privacy. In addition, one patient com-
mented that the rooms and toilets were dirty. Two
patients in the early assisted discharge group commen-
ted that at home they appreciated the quiet environment
with privacy.

3.2. Findings – second part: quantitative questions on

satisfaction

Table 3 shows the results on the second, quantitative
part of the questionnaire on patient satisfaction. For 34
(49%) patients in the usual hospital care group and 29

(41%) patients in the early assisted discharge group, an
overall satisfaction score could be calculated. Overall
satisfaction was 70% in the usual hospital care group and
71% in the early assisted discharge group (Table 3). Two
differences in satisfaction items between groups were
found (Table 3). During nights, patients in the early
assisted discharge group felt significantly more unsafe in
comparison to patients that received usual hospital care.
Significantly more patients in the early assisted discharge
group felt unable to resume normal daily activities.

More than 60% of patients in both groups were very or
completely satisfied with the received intravenous and
oral medication treatment, inhaled medication treatment
and oxygen treatment. The majority of patients was (very)
satisfied with the medical and nursing treatment, and care
they received in the hospital and/or at home.

At T + 90 days, overall satisfaction was 72% and 70% for
usual hospital care patients (29 valid scores) and early
assisted discharge patients (33 valid scores), respectively.
No differences between groups were found for the separate
questions (data not shown).

3.3. Findings – third part: preference for place of treatment

Fig. 1a shows that at T + 4 days, 42% (N = 25) of patients
allocated to hospital treatment and 86% (N = 56) of patients
allocated to home treatment preferred to be treated at
home, if they could choose. Table 4 shows the results of the
multivariate logistic regression analysis on associated
factors for preference in the early assisted discharge group.
Only clinical COPD questionnaire – mental state was
significantly associated with preference for home treat-
ment. Patients with worse scores were less likely to choose
home treatment. The trend for income was inconsistent. At
T + 90 days the percentage of patients preferring home
treatment had decreased to 35% (N = 17) and 59% (N = 33)
in the hospital treatment and home treatment group,
respectively (Fig. 1b). At T + 90 days, none of the
investigated variables were associated with preference
in the multivariate logistic regression analysis.

3.4. Findings – additional part: evaluation of early assisted

discharge

Results from the additional questionnaire for patients
that received home care showed that 85% (N = 34) of
patients that received home care was (very) satisfied. The
average number of home visits per day was one. The total
number of days that patients received home visits and the
number of visits per day was valued as sufficient by 83%
(N = 29) and 97% (N = 34) of patients. The far majority
valued the duration of the home visits as sufficient.

4. Discussion

The quantitative and qualitative evaluation among
patients in this study showed that patients are satisfied
with the hospital and home care they received. The overall
satisfaction scores in both groups were 70%. Evaluation on
separate items of the satisfaction questionnaire showed
only differences in feelings of safety at night and ability to

Table 3

Patient satisfaction. Numbers represent number of respondents and percentage, unless stated otherwise.

HC N = 34 EAD N = 29

p-Valuea

Overall satisfaction score,

range 0–100, mean (SD)

70 (12.7) 71 (12.5) 0.863

Completely/very satisfied Satisfied (Very) unsatisfied p-Valuea

Satisfaction with HC EAD HC EAD HC EAD

Administration of intravenous therapy

and tablets

44 (72.1) 37 (56.1) 14 (23) 23 (34.8) 3 (4.9) 6 (9.1) 0.068

Administration of nebulised/metered

dose inhalations

41 (69.5) 39 (60.9) 17 (28.8) 19 (29.7) 1 (1.7) 6 (9.4) 0.133

Oxygen treatmentb 30 (73.2) 34 (73.9) 10 (24.4) 12 (26.1) 1 (2.4) 0 (0) 0.755

Improvement of symptoms 37 (60.7) 30 (49.2) 20 (32.8) 21 (34.4) 4 (6.6) 10 (16.4) 0.089

Nursing care during daytime 44 (72.1) 38 (57.6) 15 (24.6) 24 (36.4) 2 (3.3) 4 (6.1) 0.093

Nursing care at night 40 (65.6) 31 (59.6) 17 (27.9) 18 (34.6) 4 (6.6) 3 (5.8) 0.654

Involvement in treatment 33 (55.0) 33 (50.8) 22 (36.7) 28 (43.1) 5 (8.3) 4 (6.2) 0.855

Amount of time spent by

nurses with patient

31 (52.5) 34 (51.5) 25 (42.4) 25 (37.9) 3 (5.1) 7 (10.6) 0.568

Information received on illness 32 (54.2) 32 (49.2) 18 (30.5) 29 (44.6) 9 (15.3) 4 (6.2) 0.736

Length of treatment 28 (46.7) 31 (47.7) 32 (53.3) 29 (44.6) 0 (0) 5 (7.7) 0.516

Extremely/very worried Worried Little or not worried p-Valuea

How worried were you

during treatment?

13 (21.7) 13 (19.7) 18 (30.0) 13 (19.7) 29 (48.3) 40 (60.6) 0.319

Complete/very well

addressed

Adequately addressed Poorly/not at all

addressed
p-Valuea

How was the attention

for worries?

24 (43.6) 28 (45.9) 21 (38.2) 27 (44.3) 10 (18.2) 6 (9.8) 0.417

Extremely/very safe Safe (Most) unsafe p-Valuea

Feeling safe during daytime 42 (68.9) 35 (53.0) 17 (27.9) 30 (45.5) 2 (3.3) 1 (1.5) 0.143

Feeling safe during nights 35 (58.3) 24 (37.5) 20 (33.3) 31 (48.4) 5 (8.3) 9 (14) 0.029

Completely/

very capable

Capable (Very) incapable p-Value*

At end of hospital or home treatment capable to resume normal daily activities 5 (8.5) 4 (6.3) 36 (61) 25 (39.1) 18 (30.5) 35 (54.7) 0.018

HC, usual hospital care; EAD, early assisted discharge; n.a., not applicable.
a Linear-by-linear association.
b Only for those who had oxygen.

Fig. 1. Number of patients preferring hospital and home treatment (A) T + 4 days and (B) T + 90 days.

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1543

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491544

resume activities. Safety at night and ability to resume
activities was valued significantly worse by patients in the
early assisted discharge group. The separate evaluation in
patients that received home care showed that 85% of
patients was satisfied with early assisted discharge. The
number and duration of home visits was sufficient. Forty-
two percent hospital-treated patients and 86% of home-
treated patients preferred home treatment if they could
have chosen. In home-treated patients, this preference was
influenced by their mental state.

Home-treated patients did not, like hospital-treated
patients, have access to nursing care during nights. This
may have caused them feeling unsafe during nights.
Previous studies showed that help at night is important
and an advantage of hospital treatment (Fried et al., 1998).
When designing and implementing hospital-at-home
schemes, nights should be appropriately addressed. Only
1 study reported to have nursing night cover by district
nurses (Davies et al., 2000). In accordance with Ojoo et al.
(2002) and Diaz et al. (2005) a 24-h telephone access to the
hospital was installed in our study. However, no patient
used this possibility during the nights. Nonetheless, we
believe that patients should be instructed on what
problems they might experience at home at night, how
to avoid these problems and how to act upon.

At the end of the 7-day treatment, patients that
experienced hospital-at-home reported significantly more
often not being capable to resume their normal daily
activities in comparison to patients from the usual hospital
care group. Median time to symptomatic recovery of
exacerbations is 7 days (Seemungal et al., 2000). However,
complete recovery of health status may take up to 90 days
(Seemungal et al., 1998, 2000) and many patients
experience difficulties with their daily activities after
hospital admission (Clarke et al., 2010). At the end of the 7-
day treatment patients from the usual hospital care group
had not been confronted yet with possible difficulties at
home when they completed the questionnaire, whereas
patients in the early assisted discharge group had been
confronted with daily activities since day four of the
treatment. Possibly, at the end of the 7-day treatment,
patients from the usual hospital care group have over-
estimated their capabilities to resume normal daily

activities. At the end of the 90 days follow up, the
difference between the groups regarding this item had
disappeared, supporting this explanation.

Despite feeling unsafe during nights and being less able
to resume activities, most patients in the early assisted
discharge still prefer to be treated at home. It is likely that
the benefits and advantages patients experience from
being treated at home outweigh these disadvantages.

Overall satisfaction with hospital and home care was
high, and not different between groups. Many negative
responses in both groups were related to medication. Most
of these comments could be linked to the hospital, as most
comments concerned the distribution and administration
of medicines which in the hospital is the under the
hospitals’ responsibility (prescribing doctors, hospital
pharmacy, distributing nurses) but at home under the
patients’ own responsibility. The comments did not
concern aspects that were the result of the introduction
of early assisted discharge and most likely have been
present before.

Overall, patients were very satisfied with the early
assisted discharge care. Advantages that patients experi-
enced from being treated at home were that the
environment at home was familiar, quiet, clean and
provided privacy. Furthermore, being at home made
patients able to stick to their own daily routines and
rules. However, patients’ comments revealed aspects that
could be improved. Coordination of the logistics of the
community nursing hampered in several cases. Within the
home care organisation separate teams are responsible for
defined geographic areas. Teams should be timely in-
formed about the patients’ discharge, and visiting arrange-
ments should be confirmed before the patient is
discharged. While some patients commented that care
at home was not necessary and nurses only came to check
upon them, others experienced difficulties at home alone
and expected more care, especially in the domestic field.
This wide difference in opinion was also found in the study
by Taylor et al. (2007). Patients should be explicitly
informed about the purpose and objectives of early
assisted discharge and home treatment and which care
can be expected at home. If this is insufficient, the patient
should not be early assisted discharged or additional

Table 4

Odds ratios and 95% confidence intervals for factors associated with preferred place of treatment at day 7 of treatment.

Preference at day 7a N OR 95% CI p-Value

Long term oxygen treatment

Nob 37 1

Yes 3 0.030 0.001–1.302 0.068

Income

Lowb 17 1

Medium 9 0.032 0.001–0.785 0.035
High 14 3.737 0.057–244.181 0.536

Living situation

With somebodyb 23 1

Alone 17 0.348 0.022–5.411 0.451

Clinical COPD Questionniare – mental state 40 0.349 0.135–0.904 0.030
a Results from multivariate logistic regression performed in early assisted discharge group. Variables from the bivariate logistic regression with p < 0.1

were included in the multivariate logistic regression.
b Reference category.

ser
com
hos
sho
sec
et a
prim
ma

no
pat
the
of O
wh
com
ofte
sim
199
exp

pat
the
hom
pat
Sch
tow
skil
an
pas
tho
abl
are
disc
in t
diffi

and
pre
pre
num
hav

we
200
lon
San
alo
the
pre
net
sup
to m
cho

eva
Pat
disc
pat
pos
the
effe

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1545

vices should be arranged. Patients from both groups
mented on the hampering information transfer from

pital to home or between hospital staff. It has been
wn that this is an important issue in transfers from
ondary to primary care (Berendsen et al., 2009; Preston
l., 1999). Health care professionals from secondary and

ary care should pay attention to this topic, in order to
ke flawless transitions from hospital to home possible.
Although patients that were treated in the hospital had
experience with home treatment, over half of all

ients preferred home treatment, if they would have had
opportunity to choose. This confirms previous results
joo et al. (2002) and Schofield et al. (2006). Patients

o were treated at home, and were able to make a true
parison, preferred home treatment significantly more
n. Patients find it difficult to imagine that at home
ilar treatment is possible as in the hospital (Fried et al.,
8), but often adjust their opinion once they have
erienced home treatment (Schofield et al., 2006).
In the group of home-treated patients we found that
ients with worse scores on the mental state domain of
clinical COPD questionnaire were less likely to prefer

e treatment. Home treatment appeals on the ability of
ients to manage with the disease more independently.
ofield et al. (2006) found a correlation between attitude
ards home care and emotional functioning and coping
ls. We found no such association. However, we did find
association between worse emotional functioning and
sive coping style. Patients with more negative or anxious
ughts and feelings are less confident that they will be
e to manage at home when problems occur. Patients who

better able to ration the purpose of early assisted
harge in relation to hospital care and have better insight

heir own role in the scheme, are better able to cope with
culties at home (Schofield et al., 2006).

We found an inconsistent association between income
preference. Medium income was associated with
ference for home treatment, high and low income and
ference were not associated. However, the patient

bers in the three groups were unequal which may
e caused inconsistent association.
Previous studies revealed that patients living alone
re treated more often in the hospital (Schofield et al.,
6) and that patients choose to be treated at home as

g as informal care giving was present (Dubois and
tos-Eggimann, 2001). In our study 30% of patients lived

ne, which did not withhold them from participation to
trial. Fried et al. (1998) stated that in patients that
fer home treatment and live alone, without support
work, strong self-reliance is an important factor. This
ports the conclusion that patients who are better able
anage their symptoms and difficulties will more often

ose home treatment.
This study has some limitations. Firstly, the current
luation was part of a randomised controlled trial.
ients with strong resistance against early assisted
harge and home treatment did not consent to partici-

e, which may have caused selection of patient with
itive attitudes towards home treatment. Furthermore,

design of the study was for the comparison of the
ctiveness, and therefore not optimal for the comparison

of preference. Therefore, the analysis of factors influencing
preference was only performed in patients that experienced
both treatments. Secondly, the number of patients in which
the preference analysis was performed was small, which
might have influenced results. However, this was a
pragmatic study reflecting the real situation enhancing
validity of results. Thirdly, because a validated question-
naire for measuring satisfaction with hospital-at-home was
not available, we had to develop one ourselves. The
questionnaire we developed contained questions on specific
items of the hospital care and hospital-at-home care
patients received, and therefore provided a clear view on
how patients value specific aspects of usual hospital care
hospital-at-home care. However, like in many patient
satisfaction evaluations, we found high satisfaction scores
among patients, which may mask real opinions on certain
subjects (Fitzpatrick, 1991). Finally, the satisfaction and
preference measures were performed at the end of the 7-day
treatment and the end of the 90-day follow-up period. In the
time frame between these time points events and challenges
may have occurred that have not been captured in the study
measurements, but may have influenced patient satisfac-
tion and/or preference. Further research is needed to
evaluate hospital-at-home on specific items and to gain
more insight in what and how patient satisfaction and
preference are influenced.

In conclusion, we found no large differences between
patients’ evaluation of home- and hospital care, but
attention should be paid to ensure patients feel safe at
night whilst receiving home treatment. Forty-two percent
of hospital-treated patients over 86% of home-treated
patients preferred home treatment, suggesting an overall
preference for home treatment. Mental state is associated
with preference for home treatment which is most likely to
be associated with being better able to manage the disease
independently. In the absence of clear differences in
outcomes between hospital-at-home and usual hospital
care, patient preference plays an important role in the
decision to implement hospital-at-home. Results from this
study support the wider implementation of hospital-at-
home for COPD exacerbations and this treatment option
should be offered to selected patients that prefer home
treatment over hospital treatment.

Conflict of interest: No conflict of interest.
Funding: The study was funded by the Netherlands

Organisation for Health Research and Development
(ZonMw), grant application number 945-50-7730. The
funder had no role in the design of the study; the collection
analysis and interpretation of the data; or the writing of the
article and the decision to submit the article for publication.
All researchers were independent from the funder.

Ethical approval: The trial was approved by the Medical
Ethics Committee of the Catharina Hospital Eindhoven, the
Netherlands.

Appendix 1. Patient satisfaction questionnaire

Day 7 of treatment
The questions in this questionnaire apply to the treatment

you received for your lung disease in the past 7 days in the
hospital or partly in the hospital and partly at home.

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491546

For each question we ask you to mark the answer that
applies most to your situation. Some questions require a
written reply from you.

Where would you have preferred to be treated?
& Hospital

& Home

2. What 3 things were you most satisfied with the care
you received?
2.1 ___________________________________________
2.2 ___________________________________________
2.3 ___________________________________________

3. What 3 things were you most dissatisfied with in the
care you received?
3.1 ______________________________________
3.2 ______________________________________
3.3 ______________________________________

4. How satisfied were you with the administration of
your infusion and tablets?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

5. How satisfied were you with your inhalations and
nebulised inhalations?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

6. How satisfied were you with the oxygen treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

7. How satisfied were you with the improvement of your
symptoms?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

8. How worried were you during the treatment period?
& Extremely worried
& Very worried
& Worried
& A little bit worried
& Not at all worried

9. How much attention was there for your worries
addressed by the health care staff?
& Fully attention
& Very good attention
& Adequate attention
& Little attention
& No attention at all

10. How safe did you feel during the days in the treatment
period?
& Extremely safe

& Very safe

& Safe
& Unsafe
& Very unsafe

11. How safe did you feel during the nights in the
treatment period?
& Extremely safe

& Very safe
& Safe
& Unsafe
& Very unsafe

12. How satisfied were you with the nursing care during
the day?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

13. How satisfied were you with the nursing care during
the nights?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

14. How satisfied are you with the amount of time spent to
you by health care staff?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

15. How satisfied were you with the way you were
involved in the treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

16. How satisfied were you with the information you
received concerning your illness?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

17. How satisfied were you with the length of the
treatment period?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

18. To what extent did you feel capable to resume your
usual daily activities?
& Completely capable
& Very capable
& Adequately capable
& Incapable
& Very incapable

Add
For

com
and

Tot

1. T
v

&
&
&

w
h

2. H
c
a
b
c
d

3. T
o
&
&
&

Len
4. T

&
&
&

5. T
w
&
&
&
&

Pat
End

you
ago
hom

app
wri

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1547

This is the end of the questionnaire.
Thank you for completing the questionnaire.

itional questions
early discharge patients only!
The following questions apply to the home visits by the
munity nurses you received.

With these questions we try to optimise the frequency
duration of the home visits.

al number of days with home care

he total number of days of home treatment with home
isits (4 days) is:

Sufficient number of days
Too many days
Too few days

mber of home visits per day

During the home treatment, 3 home visits per day
ere possible. It is possible that you have not used all 3

ome visits.
ow many home visits did you receive each day? Please

ircle the correct number
. Day 1 (day of discharge): 1/2/3 home visits
. Day 2: 1/2/3 home visits
. Day 3: 1/2/3 home visits
. Day 4: 1/2/3 home visits
he number of days that the nurse of the home care
rganisation performed was:

Sufficient number of visits per days
Too many visits per days
Too few visits per days

gth of home visits
he length of the first home visit each day was:

Sufficiently long
Too long
Too short

he length of the second and third home visit each day
as:

Sufficiently long
Too long
Too short
not applicable, I only received 1 home visit per day

ient satisfaction questionnaire
of follow-up

The questions in this questionnaire apply to the treatment
received for your lung disease approximately 3 months

in the hospital or partly in the hospital and partly at
e.

For each question we ask you to mark the answer that
lies most to your situation. Some questions require a
tten reply from you.

Where would you have preferred to be treated?
& Hospital

2. What 3 things were you most satisfied with the care
you received?
2.1 ______________________________________
2.2 ______________________________________
2.3 ______________________________________

3. What 3 things were you most dissatisfied with in the
care you received?
3.1 __________________________________
3.2 __________________________________
3.3 __________________________________

4. How satisfied were you with the administration of
your infusion and tablets?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
5. How satisfied were you with your inhalations and
nebulised inhalations?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
6. How satisfied were you with the oxygen treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
7. How satisfied were you with the improvement of your
symptoms?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
8. How worried were you during the treatment period?
& Extremely worried
& Very worried
& Worried
& A little bit worried
& Not at all worried
9. How much attention was there for your worries
addressed by the health care staff?
& Fully attention
& Very good attention
& Adequate attention
& Little attention
& No attention at all

10. How safe did you feel during the days in the treatment
period?
& Extremely safe
& Very safe
& Safe
& Unsafe
& Very unsafe

11. How safe did you feel during the nights in the
treatment period?
& Extremely safe
& Home
& Very safe

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–15491548

& Safe
& Unsafe
& Very unsafe

12. How satisfied were you with the nursing care during
the day?
? Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

13. How satisfied were you with the nursing care during
the nights?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
14. How satisfied are you with the amount of time spent to
you by health care staff?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
15. How satisfied were you with the way you were
involved in the treatment?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
16. How satisfied were you with the information you
received concerning your illness?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied
17. How satisfied were you with the length of the
treatment period?
& Completely satisfied
& Very satisfied
& Satisfied
& Dissatisfied
& Most dissatisfied

18. To what extent did you feel capable to resume your
usual daily activities?
& Completely capable
& Very capable
& Adequately capable
& Incapable
& Very incapable

This is the end of the questionnaire.
Thank you for completing the questionnaire.

References

Berendsen, A.J., de Jong, G.M., Meyboom-de, J.B., Dekker, J.H., Schuling, J.,
2009. Transition of care: experiences and preferences of patients
across the primary/secondary interface—a qualitative study. BMC
Health Services Research 9, 62.

Brennan, P.F., 1995. Patient satisfaction and normative decision theory.
Journal of the American Medical Informatics Association 2 (4)
250–259.

Carr-Hill, R.A., 1992. The measurement of patient satisfaction. Journal of
Public Health Medicine 14 (3) 236–249.

Charlson, M.E., Pompei, P., Ales, K.L., MacKenzie, C.R., 1987. A new method
of classifying prognostic comorbidity in longitudinal studies: devel-
opment and validation. Journal of Chronic Diseases 40 (5) 373–383.

Clarke, A., Sohanpal, R., Wilson, G., Taylor, S., 2010. Patients’ perceptions of
early supported discharge for chronic obstructive pulmonary disease: a
qualitative study. Quality & Safety in Health Care 19 (2) 95–98.

Davies, L., Wilkinson, M., Bonner, S., Calverley, P.M., Angus, R.M., 2000.
‘‘Hospital at home’’ versus hospital care in patients with exacerba-
tions of chronic obstructive pulmonary disease: prospective
randomised controlled trial. British Medical Journal 321 (7271)
1265–1268.

Diaz, L.S., Gonzalez, L.F., Gomez Mendieta, M.A., Mayoralas, A.S., Martin,
A., Villasante Fernandez-Montes, I.C., 2005. Evaluation of a home
hospitalization program in patients with exacerbations of chronic
obstructive pulmonary disease. Archivos de Bronconeumologia 41 (1)
5–10.

Dubois, A., Santos-Eggimann, B., 2001. Evaluation of patients’ satisfaction
with hospital-at-home care. Evaluation and the Health Professions 24
(1) 84–98.

Elo, S., Kyngas, H., 2008. The qualitative content analysis process. Journal
of Advanced Nursing 62 (1) 107–115.

Fitzpatrick, R., 1991. Surveys of patients satisfaction: I—Important general
considerations. British Medical Journal 302 (6781) 887–889.

Fried, T.R., van, D.C., Tinetti, M.E., Drickamer, M.A., 1998. Older persons’
preferences for site of treatment in acute illness. Journal of General
Internal Medicine 13 (8) 522–527.

Goosens, L.M.A., Utens, C.M.A., Smeenk, F.W.J.M., van Schayck, C.P., van
Vliet, M., Seezink, W., van Litsenburg, W., Braken, M., Rutten-van
Mölken, M.P.H.M., 2013. Cost-effectiveness of early assisted discharge
for COPD exacerbations in the Netherlands, accepted for publication.

Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in
nursing research: concepts, procedures and measures to achieve
trustworthiness. Nurse Education Today 24 (2) 105–112.

Krahn, M., Naglie, G., 2008. The next step in guideline development:
incorporating patient preferences. Journal of the American Medical
Association 300 (4) 436–438.

Leff, B., Burton, L., Mader, S., Naughton, B., Burl, J., Clark, R., Greenough III,
W.B., Guido, S., Steinwachs, D., Burton, J.R., 2006. Satisfaction with
hospital at home care. Journal of the American Geriatrics Society 54
(9) 1355–1363.

Montalto, M., 1996. Patients’ and carers’ satisfaction with hospital-in-the-
home care. International Journal for Quality in Health Care 8 (3) 243–
251.

Ojoo, J.C., Moon, T., McGlone, S., Martin, K., Gardiner, E.D., Greenstone,
M.A., Morice, A.H., 2002. Patients’ and carers’ preferences in two
models of care for acute exacerbations of COPD: results of a random-
ised controlled trial. Thorax 57 (2) 167–169.

Preston, C., Cheater, F., Baker, R., Hearnshaw, H., 1999. Left in limbo:
patients’ views on care across the primary/secondary interface. Qual-
ity in Health Care 8 (1) 16–21.

Quantrill, S.J., Lowe, D., Hosker, H.S., Anstey, K., Pearson, M.G., Michael,
R.C., 2007. Survey of early discharge schemes from the 2003 UK
National COPD Audit. Respiratory Medicine 101 (5) 1026–1031.

Ram, F.S., Wedzicha, J.A., Wright, J., Greenstone, M., 2003. Hospital at
home for acute exacerbations of chronic obstructive pulmonary
disease. Cochrane Database of Systematic Reviews (4) CD003573.

Rothman, K.J., Greenland, S., Lash, T.L., 2008. Modern Epidemiology, 3rd
ed. Lippincott Williams & Wilkins, Philidelphia.

Schofield, I., Knussen, C., Tolson, D., 2006. A mixed method study to
compare use and experience of hospital care and a nurse-led acute
respiratory assessment service offering home care to people with an
acute exacerbation of chronic obstructive pulmonary disease. Inter-
national Journal of Nursing Studies 43 (4) 465–476.

Schreurs, P.J.G., van de Willige, G., Brosschot, J.F., Tellegen, B., Graus,
G.M.H., 1993. De Utrechtse Coping Lijst: UCL; Omgaan met proble-
men en gebeurtenissen. Swets en Zeitlinger B.V, Lisse.

Seemungal, T.A., Donaldson, G.C., Bhowmik, A., Jeffries, D.J., Wedzicha,
J.A., 2000. Time course and recovery of exacerbations in patients with
chronic obstructive pulmonary disease. American Journal of Respira-
tory and Critical Care Medicine 161 (5) 1608–1613.

Seemungal, T.A., Donaldson, G.C., Paul, E.A., Bestall, J.C., Jeffries, D.J.,
Wedzicha, J.A., 1998. Effect of exacerbation on quality of life in
patients with chronic obstructive pulmonary disease. American
Journal of Respiratory and Critical Care Medicine 157 (5 Pt 1)
1418–1422.

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0005

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0010

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0015

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0020

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0025

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0030

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0035

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0040

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0045

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0050

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0055

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0065

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0070

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0075

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0080

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0085

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0090

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0095

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0100

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0105

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0110

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0115

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0120

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0125

Shep

Sofa

Tayl

Toy

Uten

C.M.A. Utens et al. / International Journal of Nursing Studies 50 (2013) 1537–1549 1549

perd, S., Doll, H., Angus, R.M., Clarke, M.J., Iliffe, S., Kalra, L., Ricauda,
N.A., Wilson, A.D., 2008. Admission avoidance hospital at home.
Cochrane Database of Systematic Reviews (4) CD007491.
perd, S., Doll, H., Broad, J., Gladman, J., Iliffe, S., Langhorne, P.,

Richards, S., Martin, F., Harris, R., 2009. Early discharge hospital at
home. Cochrane Database of Systematic Reviews (1) CD000356.
er, S., Firminger, K., 2005. Patient perceptions of the quality of health
services. Annual Review of Public Health 26, 513–559.
or, S., Eldridge, S., Chang, Y.M., Sohanpal, R., Clarke, A., 2007. Evalu-
ating hospital at home and early discharge schemes for patients with
an acute exacerbation of COPD. Chronic Respiratory Disease 4 (1)
33–43.
, E.L., Gallagher, K.F., Stanley, E.L., Swensen, A.R., Duh, M.S., 2010.
The economic impact of exacerbations of chronic obstructive pul-
monary disease and exacerbation definition: a review. COPD 7 (3)
214–228.
s, C.M., Goossens, L.M., Smeenk, F.W., Rutten-van Molken, M.P., van,

V.M., Braken, M.W., van Eijsden, L.M., van Schayck, O.C., 2012. Early

assisted discharge with generic community nursing for chronic ob-
structive pulmonary disease exacerbations: results of a randomised
controlled trial. BMJ Open 2 (5) .

Utens, C.M., Goossens, L.M., Smeenk, F.W., van Schayck, O.C., van, L.W.,
Janssen, A., van, V.M., Seezink, W., Demunck, D.R., van de Pas, B., de
Bruijn, P.J., van der Pouw, A., Retera, J.M., de Laat-Bierings, P., van, E.L.,
Braken, M., Eijsermans, R., Rutten-van Molken, M.P., 2010. Effective-
ness and cost-effectiveness of early assisted discharge for chronic
obstructive pulmonary disease exacerbations: the design of a ran-
domised controlled trial. BMC Public Health 10 (1) 618.

van der Molen, T., Willemse, B.W., Schokker, S., ten Hacken, N.H., Postma,
D.S., Juniper, E.F., 2003. Development, validity and responsiveness of
the Clinical COPD Questionnaire. Health and Quality of Life Outcomes
1, 13.

Wilson, A., Wynn, A., Parker, H., 2002. Patient and carer satisfaction with
‘hospital at home’: quantitative and qualitative results from a ran-
domised controlled trial. British Journal of General Practice 52 (474)
9–13.

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0130

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0135

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0140

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0145

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0150

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0155

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0160

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0165

http://refhub.elsevier.com/S0020-7489(13)00094-1/sbref0170

Patient preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: Results of a randomised controlled trial

Introduction
Methods
Design and patients
Measurements
Analysis
Findings
Findings – first part: qualitative questions on satisfaction
Patient-centred care
Access
Communication and information
Courtesy and emotional support
Efficiency of care and organisation
Technical quality
Structure and facilities
Findings – second part: quantitative questions on satisfaction
Findings – third part: preference for place of treatment
Findings – additional part: evaluation of early assisted discharge
Discussion
Patient satisfaction questionnaire
References

Systematic Review

IntroductIon
Quality of life is an important criterion that illustrates the
effectiveness of health care, health level, and well-being. It
is a multidimensional concept that includes ability, function,
health, well-being, and psychological state, which is defined by
the World Health Organization as values, goals, standards, and
individual interests.[1-4] There is a relationship between diseases
and quality of life. Quality of life can have a direct impact
on physical performance, emotional, and physical problems,
fatigue, mental health, social performance, physical pain,
and general health.[5-10] Therefore, knowledge about chronic
diseases, especially chronic kidney diseases (CKD) is very
important in the evolution of patients’ health problems.[11-14]

CKD is one of the major public health problems worldwide.[15-17]
The incidence of chronic renal failure in the world is 242 cases
per a million people, and 8% is added to this population each
year.[18,19] The population of patients with renal failure in Iran

is 320,000.[20,21] One of the ways to improve the condition
of patients with chronic renal failure is hemodialysis.[18,22]
In addition to hemodialysis, peritoneal dialysis and kidney
transplantation are the common alternative treatments.[23] The
patients undergoing dialysis have to spend several hours of their
lives in dialysis sessions (2–3 sessions each week), and these
constraints affect the living conditions of these patients.[18,24]
In general, patients with CKD are affected by a wide range of
physical, psychological, economic, and social problems[11,25-29]
which ultimately influence their quality of lives.[30]

Considering the contradictory results of previous studies
and the importance of “quality of life” and its effects on the

Abstract

Introduction: Renal diseases are among the major health problems around the world that cause major changes in patients’ lifestyle and affect
their quality of lives. The aim of this study was to evaluate the quality of life of patients with chronic kidney disease (CKD) in Iran through
a meta-analysis. Materials and Methods: This study was conducted using authentic Persian and English keywords in the national and
international databases including IranMedex, SID, Magiran, IranDoc, Medlib, Science Direct, Pubmed, Scopus, Cochrane, Embase, Web of
Science, and Medline. The data were analyzed using meta-analysis (random effects model). Heterogeneity of studies was assessed using I2 index.
In this study, SF-36: 36-Item Short Form health-related quality of life (HRQOL), kidney disease quality of life-SF (KDQOL-SF), KDQOL
and KDQOL-SFTM questionnaires were used. Data were analyzed using STATA Version 11 software. Results: A total of 17200 individuals
participated in 45 reviewed studies, and the mean score of CKD patients’ quality of life was estimated by SF-36 (60.31), HRQOL (60.51), and
KDQOL-SF (50.37) questionnaires. In addition, meta-regression showed that the mean score of CKD patients’ quality of life did not significantly
decrease during the past years. Conclusion: The mean score of quality of life of patients with CKD was lower in different dimensions in comparison
with that of normal people. Therefore, interventional measures should be taken to improve the quality of life of these patients in all dimensions

Keywords: Iran, kidney patients, meta-analysis, quality of life, renal patients

Address for correspondence: Dr. Mohammad Hossein Heydari,
Proteomics Research Center, Shahid Beheshti University of Medical

Sciences, Tehran, Iran.
E‑mail: mhheidari@sbmu.ac.ir

Quality of Life of patients with chronic kidney disease in Iran:
Systematic Review and Meta-analysis

Bahareh Ghiasi, Diana Sarokhani1, Ali Hasanpour Dehkordi2,3, Kourosh Sayehmiri4, Mohammad Hossein Heidari5

Department of Nephrology, Faculty of Medicine, 1Psychosocial Injuries Research Center, Ilam University of Medical Science, Ilam, 2Social Determinants of Health
Research Center, Shahrekord University of Medical Sciences, Shahrekord, 3Department of Medical‑Surgical ,Faculty of Nursing and Midwifery, Shahrekord University

of Medical Sciences, Shahrekord, Iran, 4Department of Biostatistics, Psychosocial Injuries Research Center, Ilam University of Medical Science, Ilam, 5Proteomics
Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Access this article online

Quick Response Code:
Website:
www.jpalliativecare.com

DOI:
10.4103/IJPC.IJPC_146_17

This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non‑commercially, as long as the author is credited and the
new creations are licensed under the identical terms.

For reprints contact: reprints@medknow.com

How to cite this article: Ghiasi B, Sarokhani D, Dehkordi AH, Sayehmiri K,
Heidari MH. Quality of life of patients with chronic kidney disease in Iran:
Systematic Review and Meta-analysis. Indian J Palliat Care 2018;24:104-11.

[Downloaded free from http://www.jpalliativecare.com on Wednesday, January 17, 2018, IP: 202.177.173.189]

Ghiasi, et al.: Quality of Life in Kidney Patients

Indian Journal of Palliative Care ¦ Volume 24 ¦ Issue 1 ¦ January-March 2018 105

personal and social life in patients with CKD, the present study
was carried out through meta-analysis to provide a general
assessment of the quality of life of CKD patients in Iran.

MaterIals and Methods
Search strategy
In this study, the quality of life in patients with CKD in Iran
was examined using a systematic review and meta-analysis. To
access the relevant Persian and English articles, national and
international databases including IranMedex, SID, Magiran,
IranDoc, Medlib, ScienceDirect, Pubmed, Scopus, Cochrane,
Embase, Web of Science, and Medline were searched using
related Persian keywords and their English equivalent
(“Iran,” “CKD Patients,” “CKD,” “Quality of Life”) along
with the logical combinations of these keywords. The Google
Scholar search engine was also used to find relevant articles.
References of related articles were searched to come up with
an exhaustive search.[11,25-29] The search was done on databases
from 2005 to May 2017.

Inclusion and exclusion criteria
The inclusion criteria referred to the quality of life in patients
with CKD in Persian and English from 2000 to 2017. The
exclusion criteria included nonrandom sampling, insufficient
data, and statistical population other than in patients with CKD.

In the first stage, 231 articles on the quality of life in patients
with CKD were found. After reviewing the titles, 113 articles
were excluded due to the problem of duplication. The abstracts
of all remaining articles were reviewed, and 39 irrelevant
articles were omitted. The full texts of the remaining articles
were reviewed, and 34 articles were excluded in conformity
with the exclusion criteria. In the end, 45 articles entered the
qualitative assessment process [Chart 1].

Qualitative assessment of studies
To assess the quality of studies, the preferred reporting items

for systematic review and meta-analysis,[31] which is a checklist
specifically designed for meta-analyses and systematic
reviews, were used.

Data extraction
Two researchers independently extracted the data from the
sources to minimize the errors in data reporting, and thereby
increase the accuracy of the gleaned data. The researchers
designed a checklist for extracting data from the sources
(the items of researcher-made checklist were the name of the
first author, the purpose of the study, the number of samples,
the year and place of research, the type of kidney disease, the
type of quality of life questionnaire, the average age of the
individuals, and mean and standard deviation (SD) of different
dimensions of the quality of life in in patients with CKD).
Questionnaires used in the studies included the following:

SF-36 standard questionnaire
This is a short 36-item form consisting of two parts; the first
part comprises demographic information, and the second
part contains 11 questions that examine different aspects of
health pertaining to quality of life. In fact, the second part of
theSF-36 questionnaire is the same as health-related quality
of life (HRQOL). These aspects include social function,
limitations in the role due to physical problems, pain, mental
health, limitations in the role due to emotional problems, and
overall understanding of general health. Questions were rated
by Likert Scale and ranged from 0 to 100, where higher points
indicate a more favorable situation.[32-35]

The kidney disease quality of life-short form (KDQOL-SF)
questionnaire, which is a multidimensional questionnaire
that includes SF-36 questions and questions on CKD. The
questionnaire assesses 12 factors of health and quality of life,
including physical function, general health, the effects of CKD
on life, imposed conditions, pain, sleep, social function, social
support, energy, emotional roles, sexual function, and patient’s
satisfaction. Questions were rated from 0 to 100, where higher
points indicate more favorable conditions.[36,37]

Kidney disease quality of life-short form TM questionnaire
This questionnaire is a specific tool for assessing the quality
of life in hemodialysis patients and includes two general and
specific scales on the quality of life. The general quality of
life scale consists of two subscales of physical conditions and
emotional conditions. The physical subscale contains four areas
of general health (with 6 items), physical function (10 items),
playing physical role (including 4 items), and physical
pain (including 3 items). The subscale comprised emotional
conditions comprising three areas of playing emotional
role (3 items), social function (including 2 items), and mental
health (including 8 items). The specific dimension of the
research tool consisted of nine areas including CKD-related
constraints (11 items), health-related mental problems
(6 items), health-related physical function (12 items), general
health (3 items), health-related family satisfaction (4 items),
sleep status (score from 0 to 100), health-related occupational
status (3 items), sexual issues (2 items), and satisfaction with

230 records identified through
database searching

One additional record identifi

through other sources

113 duplicate records removed

118 records screened
39 records excluded

79 full-text articles
assessed for eligibility

45studies entered
in qualitative synthesis

34 full-text articles
excluded

45 studies included in
quantitative synthesis

(meta-analysis)

Id
en

tif
ic

at
io

n
S

cr
ee

ni
ng

E
lig

ib
ili

ty
In

cl
ud

Chart 1: Flowchar t of steps involved in entering the studies into the
systematic review and meta‑analysis process

[Downloaded free from http://www.jpalliativecare.com on Wednesday, January 17, 2018, IP: 202.177.173.189]

Ghiasi, et al.: Quality of Life in Kidney Patients

Indian Journal of Palliative Care ¦ Volume 24 ¦ Issue 1 ¦ January-March 2018106

care and ward staff (3 items). Each area has 100 points. This
questionnaire is a multidimensional, valid, and reliable tool
that addresses all aspects of the SF-36 questionnaire.[38]

Statistical analysis
The reviewed studies were combined based on the number of
samples, mean, and SD. The standard error of the mean was
calculated using SD/sqrt (n) equation according to the normal
distribution. To evaluate the heterogeneity of the studies, Q test
and I2 index were used. Due to the heterogeneity in the studies,
the random-effects model was used to combine the results of
the studies. The significance level of the test was considered
P < 0.05. Data were analyzed using Stata is a general-purpose statistical software package created in 1985 by StataCorp. Most of its users work in research, especially in the fields of economics, sociology, political science, biomedicine and epidemiology

results
In 45 studies with a sample size of 17,200 people, the mean
score of “quality of life” in CKD patients based on SF-36
questionnaire was 60.31% (95% confidence interval [CI]:
69.00%–51.62%), it was 51.60% (95% CI: 53.45%–49.75%)
according to HRQOL questionnaire and 50.37% (95% CI:

54.77%–45.96%) based on KDQOL-SF questionnaire.
Considering the heterogeneity of the studies in focus, the CI
for each study based on the random effects model is presented
in Figure 1 and Tables 1,2.

dIscussIon
In 45 studies with a sample size of 17,200 people, the mean
score of the quality of life in patients with CKD based on
SF-36, HRQOL, and KDQOL-SF questionnaires was 60.31,
51.60, and 50.37%, respectively. However, the mean score
of the “quality of life” based on KDQOL-SFTM and KDQOL
questionnaires was not calculated since each of them was only
used in a single study

According to meta-regression diagram, there is no significant
relationship between the quality of life in patients with CKD
and the number of research samples, that is, with an increase in
the number of research samples, the mean score of the quality
of life in patients with CKD decreased, but this reduction is
not statistically significant (P = 0.502). In the above diagram,
the size of the circle shows the magnitude of the sample
size [Figure 2]. In Figure 3, meta-regression model showed
that there is no significant relationship between the quality of
life in patients with CKD and the year of study. In other words,

NOTE: Weights are from random effects analysis

.
.
.

Overall (I-squared = 99.6%, p = 0.000)

Moeinnezhad (2016)

Noohi (.)

Dashti-Khavidaki (.)

Soleimanian (2012)

Parvan (2012)

Fardinfar (2011)

Baghaee (2011)

Subtotal (I-squared = 70.6%, p = 0.009)

Taheri (2011)

Subtotal (I-squared = 95.2%, p = 0.000)

Noorbala (2006)

SF-36

Zamanzadeh (2005)

Noohi (2005)

Tayyebi (2012)

Aghakhani (2007)

Kachuee (2006)

HRQOL

Malek-Ahmadi (2006)

Raeisifar (2009)

KDQOL-SF

Heydarzadeh (2008)
Abbaszadeh (.)

Zeraati (2009)

Subtotal (I-squared = 99.7%, p = 0.000)

Hemati-Maslakpak (2013)

Moghareb (2012)

Shahgholian (2014)

Kavyani (2012)

Shakoor (2015)

Namdar (2010)

Emami-Naeini (2012)

Fouladi (2012)

Edalat-Nezhad (2013)

Rostami (.)

ID
Study

56.74 (52.09, 61.38)

55.50 (51.49, 59.51)

52.37 (50.26, 54.48)

53.20 (49.07, 57.33)

49.81 (48.05, 51.57)

48.40 (46.91, 49.89)

54.70 (48.66, 60.74)

54.00 (52.32, 55.68)

51.60 (49.75, 53.45)

47.22 (45.27, 49.17)

50.37 (45.96, 54.77)

52.50 (51.00, 54.00)

139.50 (135.76, 143.24)

53.32 (51.79, 54.85)

60.60 (58.13, 63.07)

60.21 (57.44, 62.98)

54.04 (52.28, 55.80)

65.39 (61.66, 69.12)

60.60 (58.12, 63.08)

131.30 (127.44, 135.16)
89.54 (79.13, 99.95)

53.56 (49.34, 57.78)

60.31 (51.62, 69.00)

54.70 (51.72, 57.68)

54.30 (51.61, 56.99)

48.10 (43.94, 52.26)

46.85 (43.09, 50.61)

-1.28 (-3.87, 1.31)

50.38 (46.09, 54.67)

46.65 (41.41, 51.89)

39.70 (35.37, 44.03)

44.70 (42.11, 47.29)
44.29 (43.87, 44.71)

43.69 (43.17, 44.21)

ES (95% CI)

100.00

3.32

3.38

3.31

3.39

3.22

3.39

16.74

3.38

19.98

3.39

3.33

3.39

3.37

3.36

3.39
3.33
3.37

3.32
2.91

3.31

63.28

3.36
3.36
3.31
3.33
3.37
3.31

3.26

3.30

3.37

3.40

Weight
%

56.74 (52.09, 61.38)
55.50 (51.49, 59.51)
52.37 (50.26, 54.48)
53.20 (49.07, 57.33)
49.81 (48.05, 51.57)
48.40 (46.91, 49.89)
54.70 (48.66, 60.74)
54.00 (52.32, 55.68)
51.60 (49.75, 53.45)
47.22 (45.27, 49.17)
50.37 (45.96, 54.77)
52.50 (51.00, 54.00)
139.50 (135.76, 143.24)
53.32 (51.79, 54.85)
60.60 (58.13, 63.07)
60.21 (57.44, 62.98)
54.04 (52.28, 55.80)
65.39 (61.66, 69.12)
60.60 (58.12, 63.08)
131.30 (127.44, 135.16)
89.54 (79.13, 99.95)
53.56 (49.34, 57.78)
60.31 (51.62, 69.00)
54.70 (51.72, 57.68)
54.30 (51.61, 56.99)
48.10 (43.94, 52.26)
46.85 (43.09, 50.61)
-1.28 (-3.87, 1.31)
50.38 (46.09, 54.67)
46.65 (41.41, 51.89)
39.70 (35.37, 44.03)
44.70 (42.11, 47.29)
44.29 (43.87, 44.71)
43.69 (43.17, 44.21)
ES (95% CI)
100.00
3.32
3.38
3.31
3.39
3.39
3.22
3.39
16.74
3.38
19.98
3.39
3.33
3.39
3.37
3.36
3.39
3.33
3.37
3.32
2.91
3.31
63.28
3.36
3.36
3.31
3.33
3.37
3.31
3.26
3.30

3.37
3.40

3.40
Weight
%

0-143 0 143

Figure 1: Average quality of life in patients with chronic kidney disease in Iran (95% confidence interval) based on questionnaire according to random
effects model. The middle point of each segment shows the quality of life score in chronic kidney disease patients in each study

[Downloaded free from http://www.jpalliativecare.com on Wednesday, January 17, 2018, IP: 202.177.173.189]

Ghiasi, et al.: Quality of Life in Kidney Patients

Indian Journal of Palliative Care ¦ Volume 24 ¦ Issue 1 ¦ January-March 2018 107

Table 1: Specifications of the articles reviewed on quality of life in chronic kidney diseases patients in Iran

References Author Year City Age
mean

Type of
questionnaire

Type of disease Sample
size

QOL
mean

QOL
SD

[39] Zargooshi 1989-2000 Kermanshah 33 SF-36 Donors and patients
underwent nephrectomy

400 – –

[40] Nourbala et al. 2006 Tehran 49.53 HRQOL Kidney recipients 164 52.5 9.79
[41] Noohi et al. 2005 Tehran 43.37 HRQOL Kidney transplant 162 53.32 9.95
[42] Kachuee et al. 2006 Tehran 42 SF-36 Kidney transplant 125 54.04 10.05
[43] Noohi et al. 2005-2006 Tehran 42.05 SF-36 Kidney transplant 88 52.37 10.12
[44] Baghaei et al. 2011 Guilan >18 SF-36 Hemodialysis 241 54 13.33
[45] Taheri et al. 2011 Khorramshahr-Abadan 47.43 KDQOL-SF Hemodialysis 80 47.22 8.89
[46] Yekaninejad et al. 2012 Sari-Zanjan-Tehran 57.5 KDQOL-SF Hemodialysis 212 – –
[47] Shakoor and Hassan

Sadeghi
2015 Shiraz 20-50 SF-36 Kidney transplant 44 -1.28 8.78

[48] Kaviani et al. 2012 Ahvaz 56 SF-36 End stage patients and
hemodialysis

122 46.85 21.2

[49] Baljani et al. 2014 Urmia 47.08 KDQOL-SF™ Hemodialysis 82 – –
[50] Hadi et al. 2010 Shiraz – SF-36 CKD under hemodialysis 120 – –
[51] Fardinmehr et al. 2011 Isfahan 52.7 KDQOL-SF End stage renal disease 50 54.7 21.8
[52] Ramezani Badr et al. 2011 Zanjan 51.8 KDQOL Hemodialysis 74 – –
[53] Fallahzadeh et al. 2011 Shiraz 38.35 SF-36 Kidney donors 144 – –
[54] Pakpour et al. 2012 Qazvin-Tehran 57.8 SF-36 Hemodialysis 512 – –
[55] Malekahmadi et al. 2006 Tehran 14.2 SF-36 Kidney recipients 55 65.39 14.11
[56] Raiisifar et al. 2009 Tehran 41 SF-36 Kidney transplant 218 60.6 18.7
[21] Abbaszadeh et al. 2008-2009 Kerman 41.98 SF-36 Kidney transplant and

hemodialysis
120 89.54 58.16

[57] Tayyebi et al. 2008 Tehran 44.88 SF-36 Kidney transplant and
hemodialysis

76 – –

[58] Moeinzadeh et al. 2016 Isfahan 58.05 KDQOL-SF Hemodialysis 52 55.5 14.75
[59] Aghakhani et al. 2007 Urmia 38.72 SF-36 Hemodialysis 166 60.21 18.21
[60] Rostami et al. 2010-2011 – 55 KDQOL-SF Hemodialysis patients

with viral hepatitis
4101 43.69 16.99

[61] Hemmati Maslakpak
and Shams

2013 Urmia 47.03 KDQOL-SF Hemodialysis 120 54.7 16.63

[62] Parvan et al. 2012 Tabriz 58.03 SF-36 Hemodialysis 245 48.4 11.9
[63] Emami Naeini et al. 2012 Isfahan 52.78 HRQOL Hemodialysis 51 46.65 19.08
[64] Rostami et al. 2010-2011 – 54.4 SF-36 Hemodialysis 6930 44.29 17.7
[65] Taheri-Kharameh

et al.
2012-2013 Qom 50.4 SF-36 Hemodialysis 95 – –

[66] Heidarzadeh et al. 2008 Bonab 50.2 SF-36 Hemodialysis 115 131.3 21.1
[67] Aghakhani et al. 2012 Urmia 45.2 SF-36 Hemodialysis 70 – –
[68] Shahgholian et al. 2014 Isfahan 50.4 KDQOL-SF Hemodialysis 25 48.1 10.6
[69] Hajian-Tilaki et al. 2014 Babol 54.2 SF-36 Hemodialysis 154 – –
[70] Pakpour et al. 2008 Tehran 53.63 SF-36 Hemodialysis 250 – –
[71] Tayyebi et al. 2012 Tehran 41.24 SF-36 Kidney transplant 220 60.6 18.7
[72] Arab et al. 2011 Mashhad 18-70 SF-36 Hemodialysis 93 – –
[73] Dashti-Khavidaki

et al.
2010-2011 Tehran 53.6 HRQOL Hemodialysis 92 53.2 20.2

[22] Zamanzadeh et al. 2005 Tabriz 51.9 SF-36 Hemodialysis 164 139.5 24.46
[74] Sharif and Vedad 2007 Shiraz >15 SF-36 Hemodialysis 90 – –
[75] Moghareb et al. 2012 Birjand 18-70 SF-36 Kidney transplant and

hemodialysis
118 54.3 14.89

[76] Edalat Nejad and
Qlich Khani

2013 Arak 63 SF-36 Hemodialysis 115 44.7 14.15

[77] Baraz et al. 2004-2005 Tehran 61.4 SF-36 CKD 85 – –
[10] Soleymanian et al. 2012 Tehran 56 HRQOL Hemodialysis 532 49.81 20.66
[78] Zeraati et al. 2009 Mashhad 47.22 SF-36 Hemodialysis 80 53.56 19.26
[79] Fouladi et al. 2012 Isfahan 54.5 SF-36 Hemodialysis 96 39.7 21.64
[80] Namdar et al. 2010 Jahrom 56.48 SF-36 Dialysis 52 50.38 15.8
SF-36: 36-Item short form, HRQOL: Health-related QOL, KDQOL-SF: Kidney disease QOL-SF, QOL: Quality of life, SD: Standard deviation, CKD: Chronic
kidney diseases

[Downloaded free from http://www.jpalliativecare.com on Wednesday, January 17, 2018, IP: 202.177.173.189]

Ghiasi, et al.: Quality of Life in Kidney Patients

Indian Journal of Palliative Care ¦ Volume 24 ¦ Issue 1 ¦ January-March 2018108

during the studied years, the quality of life in patients with
CKD in Iran has decreased, but this decline is not statistically
significant (P = 0.07).

Different studies show that quality of life in patients undergoing
dialysis in Iran is lower than that of other chronic diseases.[81] In
a study by Vázquez et al. in 2004, there were clear differences
between men and women with CKD compared to the normal
population in terms of quality of life (physical function,
limited role due to mental problems, social function, and
general health), while women had a worse situation.[82] In
another study, among hemodialysis patients in Saudi Arabia
in 2011, AL-Jumaih et al. showed that the majority of patients
had limited physical role, emotional role, job status, and
cognitive function and had poor quality of life.[83] In a study
by Nonoyama et al. in Toronto, Canada, it was found that
the majority of hemodialysis patients had average quality of

Table 2: The mean score of the quality of life in patients with chronic kidney diseases in Iran based on the type of
questionnaire

Type of questionnaire Subgroups Number of study Sample size QOL mean
QOL in CKD patients
based on SF-36

Total 19 9314 60.31 (51.62-69)
Physical 28 11,097 50.59 (45.67-55.51)
Mental-psychological 23 10,543 47.32 (40.84-53.81)
Social and occupational 27 10,585 52.85 (41.57-64.14)
Vitality 23 10,146 46.64 (34.48-58.79)
General health 24 10,236 46.15 (40.48-51.82)
Physical pain 24 10,236 52.35 (42.28-62.42)
Playing a physical role 9 8319 37.14 (25.07-49.20)
Emotional 10 8560 47.68 (42.57-52.79)
Role limitation for physical causes 14 1841 42.99 (28.87-57.11)
Role limitation to emotional causes 12 1577 46.21 (27.14-65.28)
Mental health 4 361 51.38 (43.67-59.10)

QOL in CKD patients
based on HRQOL

Total 5 1001 50.37 (45.96-54.77)
Physical 4 909 57.30 (45.23-69.16)
Mental-psychological 4 909 50.50 (45.98-55.02)
Social and occupational 3 858 49.83 (48.36-51.31)
Vitality 2 694 44.28 (36.76-51.81)
General health 3 784 47.73 (45.71-49.75)
Physical pain 3 784 43.24 (25.32-61.17)
Playing a physical role 1 532 48.61 (46.00-51.22)
Emotional 1 532 56.14 (53.12-59.16)
Role limitation for physical causes 2 326 62.16 (58.26-66.07)
Role limitation to emotional causes 2 326 63.04 (60.19-65.88)
Mental health 2 326 44.34 (43.36-45.33)

QOL in CKD patients
based on KDQOL-SF

Total 6 4428 50.37 (45.96-54.77)
Physical 4 4443 38.28 (32.80-43.75)
Mental-psychological 3 4363 52.52 (47.20-57.84)
Social and occupational 4 4443 55.90 (53.11-58.69)
Vitality 4 4443 44.51 (40.4048.62)
General health 5 4563 43.69 (41.41-45.97)
Physical pain 4 4443 54.61 (48.09-61.13)
Playing a physical role 2 4181 39.48 (12.02-66.95)
Emotional 2 4181 34.30 (33.15-35.44)
Role limitation for physical causes 2 262 23.09 (18.75-27.44)
Role limitation to emotional causes 2 262 37.28 (15.58-58.97)

KDQOL-SF: Kidney disease QOL-SF, CKD: Chronic kidney diseases, HRQOL: Health-related QOL, SF-36: 36-Item short form, QOL: Quality of life

0
50

10
0

15
0

M
ea

n
of

Q
O

L
in

R
en

al
P

at
ie

0 2000 4000 6000 8000
Sample Size

Figure 2: The relationship between quality of life in chronic kidney disease
patients and number of research samples using meta‑regression

[Downloaded free from http://www.jpalliativecare.com on Wednesday, January 17, 2018, IP: 202.177.173.189]

Ghiasi, et al.: Quality of Life in Kidney Patients

Indian Journal of Palliative Care ¦ Volume 24 ¦ Issue 1 ¦ January-March 2018 109

life.[84] In a study by Chow and Wong, dialysis patients had
the lowest quality of life scores in terms of physical health,
social function, and dimensions of CKD including job status
and burden of the disease.[85] In studies conducted by Cleary
and Drennan and Vasilieva, the mean score for physical and
mental health was low and patients had poor quality of life.[86,87]

The mean score of diabetic patients’ quality of life in Iran
estimated by SF-36 was 59.94 (CI 95%: 36.78–83.10).[88]
The mean score of heart patients’ quality of life in Iran was
42.09 (CI 95%: 19.90–64.29).[89] Among 17 accomplished
studies in Iran with the sample size of 1476 from 2003 to 2015,
the average quality of life score for patients with cancer in Iran
was 42 (CI 95%: 34.05–49.96).[90]

In other studies conducted in Iran, people over 50 had
significantly lower scores in physical, psychological, and
renal domains compared with younger people.[91] In the study
of Baraz et al., the highest scores of quality of life before
intervention were related to physical function (60.3%) and social
function (60%). The lowest scores were those of emotional
role (41.9%) and health perception (43.5%).[92] A study by
Namadi and Movahhedpour demonstrated that 52.1% of
hemodialysis patients had a moderate quality of life.[93] In a study
by Raiisifar et al., the quality of life in patients who underwent
kidney transplantation in Tehran in 2009 was assessed; they
found that the mean and SD of quality of life was 60.6%.[56]
Considering the different accessible data for the quality of life
in patients with CKD, we used the meta-analysis method to
obtain an accurate estimate of the quality of life in these patients.

Limitations of the study
Due to the different types of questionnaires used in the
reviewed articles, the difference in scoring the questions of the
respective questionnaires, and the difference in the number of
questions in questionnaires, we could not combine the results
of different questionnaires and report accurate statistics on the
quality of life in patients with CKD in general and for various
dimensions. Because of the variety of questionnaires, we did

not manage to estimate the average score of the quality of life
in patients with CKD in terms of type of disease, age, and
place of research.

conclusIon
The mean score for quality of life of patients with CKD was
estimated by SF-36 (60.31), HRQOL (60.51), and KDQOL-SF
(50.37) questionnaires. In addition, meta-regression showed
that the mean score of these patients’ quality of life has not
significantly decreased during the past few years. The mean
score of quality of life for patients with CKD was lower in
different dimensions in comparison with that of normal people.
The mean score of quality of life of patients with CKD in Iran
was more than those of patients with heart diseases, diabetic
patients, and patients with cancer.[94,95] Therefore, interventional
measures should be taken to improve the quality of life of these
patients in all dimensions.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.

references
1. Unruh ML, Weisbord SD, Kimmel PL. Health-related quality of life in

nephrology research and clinical practice. Semin Dial 2005;18:82-90.
2. Isikhan V, Güner P, Kömürcü S, Ozet A, Arpaci F, Oztürk B, et al. The

relationship between disease features and quality of life in patients with
cancer – I. Cancer Nurs 2001;24:490-5.

3. The World Health Organization quality of life assessment (WHOQOL):
Position paper from the World Health Organization. Soc Sci Med
1995;41:1403-9.

4. Forouhari S, Safari Rad M, Moattari M, Mohit M, Ghaem H. The of
education on quality of life in menopausal women referring to Shiraz
Motahhari clinic in 2004. J Birjand Univ Med Sci 2009;16:39-45.

5. Hasanpour-Dehkordi A, Dehghani A, Solati K. A comparison of the
effects of pilates and McKenzie training on pain and general health in
men with chronic low back pain: A Randomized trial. Indian J Palliat
Care 2017;23:36-40.

6. Hasanpour-Dehkordi A, Khaledi-Far A, Khaledi-Far B, Salehi-Tali S.
The effect of family training and support on the quality of life and cost
of hospital readmissions in congestive heart failure patients in Iran. Appl
Nurs Res 2016;31:165-9.

7. Hassanpour-Dehkordi A, Jalali A. Effect of progressive muscle
relaxation on the fatigue and quality of life among Iranian aging persons.
Acta Med Iran 2016;54:430-6.

8. Asadi Noghabi AA, Zandi M, Mehran A, Alavian SM, Dehkordi AH.
The effect of education on quality of life in patients under interferon
therapy. Hepat Mon 2010;10:218-22.

9. Noghani F, Seyedfatemi N, Karimirad MR, Akbarzadeh A,
Hasanpour-Dehkordi A. Health related quality of life in family
caregivers of patients suffering from mental disorders. J Clin Diagn Res
2016;10:VC05-9.

10. Soleymanian T, Kokabeh Z, Ramaghi R, Mahjoub AR, Argani H.
Clinical outcomes and quality of life in hemodialysis diabetic patients
versus non diabetics. J Nephropathol 2017;6:81-9.

11. Amiri M. Aggravation of chronic kidney disease by inflammatory factors;
a narrative review on current concepts. J Renal Endocrinol 2016;2:e05.

12. Dehkordi AH, Heydarnejad MS. Effect of booklet and combined method
on parents’ awareness of children with beta-thalassemia major disorder.
J Pak Med Assoc 2008;58:485-7.

13. Kari J. Epidemiology of chronic kidney disease in children.

0
50
10
0
15
0
M
ea
n
of
Q
O
L
in
R
en
al
P
at
ie
nt

2005 2010 2015
Year

Figure 3: The relationship between quality of life in patients with chronic
kidney disease and years of research using meta‑regression

[Downloaded free from http://www.jpalliativecare.com on Wednesday, January 17, 2018, IP: 202.177.173.189]

Ghiasi, et al.: Quality of Life in Kidney Patients

Indian Journal of Palliative Care ¦ Volume 24 ¦ Issue 1 ¦ January-March 2018110

J Nephropathol 2012;1:162-3.
14. Nasri H. Ischemic nephropathy; new concepts on its pathophysiology.

Angiol Persica Acta. 2016;1:e03
15. Johnson CA, Levey AS, Coresh J, Levin A, Lau J, Eknoyan G, et al.

Clinical practice guidelines for chronic kidney disease in adults: Part I.
Definition, disease stages, evaluation, treatment, and risk factors. Am
Fam Physician 2004;70:869-76.

16. Vafaei AA, Nobahar M. The care preferences of patients under
hemodialysis. J Renal Inj Prev. 2017; 6:210-215.

17. Tamadon MR, Zahmatkesh M. World kidney day 2015. J Parathyr Dis
2015;3:34-6.

18. Xue JL, Ma JZ, Louis TA, Collins AJ. Forecast of the number of patients
with end-stage renal disease in the United States to the year 2010. J Am
Soc Nephrol 2001;12:2753-8.

19. Snyder JJ, Foley RN, Collins AJ. Prevalence of CKD in the United
States: A sensitivity analysis using the National Health and Nutrition
Examination Survey (NHANES) 1999-2004. Am J Kidney Dis
2009;53:218-28.

20. Ghaffari A. Seminar of kidney transplantation report. Mohandesi
Pezeshki 2008;6:73.

21. Abbaszadeh A, Javanbakhtian R, Salehee S, Motvaseliyan M.
Comparative assessment of quality of life in hemodialysis and kidney
transplant patients. J Shahid Sadoughi Univ Med Sci 2010;18:461-8.

22. Zamanzadeh V, Heydarzadeh M, Eeshvandi KH, Lakdizaji S.
Relationship between quality of life and social support in hemodialysis
patients in Imam Khomeini and sina educational hospitals of Tabriz
university of medical science. Med J Tabriz Univ Med Sci 2007;29:49-54.

23. Monfared A, Orang Pour R, Kohani M. Evaluation of hemodialysis A
dequacy on patients undergoing hemodialysis in Razi hospital in Rasht.
J Guilan Univ Med Sci 2007;17:44-9.

24. Lindqvist R, Carlsson M, Sjödén PO. Coping strategies and
health-related quality of life among spouses of continuous ambulatory
peritoneal dialysis, haemodialysis, and transplant patients. J Adv Nurs
2000;31:1398-408.

25. Baradaran A. Administration of herbal drugs in geriatric
individuals;trends on its helps and hazards. Geriatr Persia. 2017; 1:e01.

26. Assadi F. The epidemic of pediatric chronic kidney disease: The danger
of skepticism. J Nephropathol 2012;1:61-4.

27. Assadi F. Psychological impact of chronic kidney disease among
children and adolescents: Not rare and not benign. J Nephropathol
2013;2:1.

28. Nasri H. World lupus day 2016. Immunopathol Persa. 2015; 1(1):e06.
29. Gheissari A, Hemmatzadeh S, Merrikhi A, Fadaei Tehrani S, Madihi Y.

Chronic kidney disease in children: A report from a tertiary care center
over 11 years. J Nephropathol 2012;1:177-82.

30. Tavallaii SA, Einollahi B, Azizabadi Farahani M, Namdari M.
Socioeconomic links to health-related quality of life, anxiety,
and depression in kidney transplant recipients. Iran J Kidney Dis
2009;3:40-4.

31. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M,
et al. Preferred reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4:1.

32. Sayin A, Mutluay R, Sindel S. Quality of life in hemodialysis, peritoneal
dialysis, and transplantation patients. Transplant Proc 2007;39:3047-53.

33. Safi Zadeh H, Garoosi B, Afsharpoor S. Quality of life in hemodialysis
patients. Payesh 2005;5:29-35.

34. Fujisawa M, Ichikawa Y, Yoshiya K, Isotani S, Higuchi A, Nagano S,
et al. Assessment of health-related quality of life in renal transplant
and hemodialysis patients using the SF-36 health survey. Urology
2000;56:201-6.

35. Virzì A, Signorelli MS, Veroux M, Giammarresi G, Maugeri S,
Nicoletti A, et al. Depression and quality of life in living related renal
transplantation. Transplant Proc 2007;39:1791-3.

36. Rahimi A, Ahmadi F, Gholyaf M. Effects of applying continuous
care model on quality of life in hemodialysis patients. Razi J Med Sci
2006;13:123-34.

37. Korevaar JC, Merkus MP, Jansen MA, Dekker FW, Boeschoten EW,
Krediet RT, et al. Validation of the KDQOL-SF: A dialysis-targeted
health measure. Qual Life Res 2002;11:437-47.

38. Hays RD, Kallich JD, Mapes DL, Coons SJ, Carter WB. Development

of the kidney disease quality of life (KDQOL) instrument. Qual Life Res
1994;3:329-38.

39. Zargooshi J. Quality of life of iranian kidney “donors”. J Urol
2001;166:1790-9.

40. Nourbala MH, Hollisaaz MT, Nasiri M, Bahaeloo-Horeh S, Najafi M,
Araghizadeh H, et al. Pain affects health-related quality of life in kidney
transplant recipients. Transplant Proc 2007;39:1126-9.

41. Noohi S, Khaghani-Zadeh M, Javadipour M, Assari S, Najafi M,
Ebrahiminia M, et al. Anxiety and depression are correlated with higher
morbidity after kidney transplantation. Transplant Proc 2007;39:1074-8.

42. Kachuee H, Ameli J, Taheri S, Assari S, Riahipour F, Khedmat H, et al.
Sleep quality and its correlates in renal transplant patients. Transplant
Proc 2007;39:1095-7.

43. Noohi S, Karami GR, Lorgard-Dezfuli-Nejad M, Najafi M, Saadat SH.
Are all domains of quality of life poor among elderly kidney recipients?
Transplant Proc 2007;39:1079-81.

44. Baghaei M, Rahimi S, Adib M, Kazemnejad Leili E, Monfared A.
Redictive personal factors of quality of life in hemodialysis patient.
J Holist Nurs Midwifery 2015;24:9-19.

45. Taheri N, Kamangar S, Cheraghian B, Mousavi S, Solaimanzadeh M.
Quality of life hemodialysis patients. Knowl Health 2013;8:119-24.

46. Yekaninejad MS, Mohammadi Zeidi I, Akaberi A, Golshan A,
Pakpour A. Validity and reliability of the kidney disease quality of
life-short form (KDQOL-SF™ 1.3) in Iranian patients. J North Khorasan
Univ Med Sci 2012;4:261-73.

47. Shakoor E, Hassan Sadeghi EK. The effects of 10 weeks concurrent
aerobic and strength exercise on quality of life and resilience of kidney
transplant patients. Int J Appl Exerc Physiol 2015;4:1-8.

48. Kaviani K, Khalafi A, Ghorbanibirgani A, Haghighat M. Life quality
and health status correlation in hemodialysis patients with end-stage
renal disease from Ahvaz university of medical sciences affiliated
hospitals, 2012. Jundishapur J Chronic Dis Care 2013;2:39-47.

49. Baljani E, Rahimi Z, Sasan A. The effect of self management programs
on the quality of life in patients under going hemodialysis. J Urmia Nurs
Midwifery Fac 2014;12:815-24.

50. Hadi N, Rahmani Z, Montazeri A. Health-related quality of life in chronic
renal failure patients receiving hemodialysis. Payesh 2010;9:349-54.

51. Fardinmehr O, Farajzadegan Z, Naini A, Mortazavi M, Gholamrezaei A.
The validity and reliability of the persian version of kidney disease
quality of life questionnaire-short form (KDQOL-SF) in Iranian
patients. J Isfahan Med Sch 2012;29:1-10.

52. 52-Ramezani Badr F, Moien V, Nematikhah M, Shiri Gheydari
P,Akhlaghi M, Tahrekhani, MQuality of life and related factors in
hemodialysisPatients referred to teaching hospitals in Zanjan. J
Neyshabur Univ Med Sci 2016; 4:57-64.

53. Fallahzadeh MK, Jafari L, Roozbeh J, Singh N, Shokouh-Amiri H,
Behzadi S, et al. Comparison of health status and quality of life of
related versus paid unrelated living kidney donors. Am J Transplant
2013;13:3210-4.

54. Pakpour AH, Kumar S, Fridlund B, Zimmer S. A case-control study on
oral health-related quality of life in kidney disease patients undergoing
haemodialysis. Clin Oral Investig 2015;19:1235-43.

55. Malekahmadi MR, Rahimzadeh S, Dezfuli Nejad ML, Lankarani MM,
Einollahi B, Assari S, et al. Importance of socioeconomic, clinical, and
psychological factors on health-related quality of life in adolescents
after kidney transplant. Exp Clin Transplant 2011;9:50-5.

56. Raiisifar A, Tayyebi A, Ebadi A, Najafi S, Hashemi S, Asiyabi M. An
investigation of quality of life in kidney transplant patients. Iran J Crit
Care Nurs 2011;4:149-52.

57. Tayyebi A, Salimi S, Mahmoudi H, Tadrisi S. Comparison of quality of
life in hemodialysis and renal transplantation patients. Iran J Crit Care
Nurs 2010;3:7-8.

58. Moeinzadeh F, Shahidi S, Mortazavi M, Dolatkhah S, Kajbaf M,
Haghjooy Javanmard S, et al. Effects of omega-3 fatty acid
supplementation on serum biomarkers, inflammatory agents, and quality
of life of patients on hemodialysis. Iran J Kidney Dis 2016;10:381-7.

59. Aghakhani N, Sharif Nia H, Samad Zadeh S, Toupchi V, Toupchi S,
Rahbar N, et al. Quality of life during hemodialysis and study dialysis
treatment in patients referred to teaching hospitals in Urmia-Iran in
2007. Caspian J Intern Med 2011;2:183-8.

[Downloaded free from http://www.jpalliativecare.com on Wednesday, January 17, 2018, IP: 202.177.173.189]

Ghiasi, et al.: Quality of Life in Kidney Patients

Indian Journal of Palliative Care ¦ Volume 24 ¦ Issue 1 ¦ January-March 2018 111

60. Rostami Z, Lessan Pezeshki M, Soleimani Najaf Abadi A, Einollahi B.
Health related quality of life in Iranian hemodialysis patients with viral
hepatitis: Changing epidemiology. Hepat Mon 2013;13:e9611.

61. Hemmati Maslakpak M, Shams S. A comparison of face to face and
video-based self care education on quality of life of hemodialysis
patients. Int J Community Based Nurs Midwifery 2015;3:234-43.

62. Parvan K, Lakdizaji S, Roshangar F, Mostofi M. Assessment of quality
of life in patients undergoing continuous hemodialysis in four hospitals
of East Azarbayjan, in 2012. Razi J Med Sci 2014;21:19-28.

63. Emami Naini A, Moradi M, Mortazavi M, Amini Harandi A,
Hadizadeh M, Shirani F, et al. Effects of oral L-carnitine supplementation
on lipid profile, anemia, and quality of life in chronic renal disease
patients under hemodialysis: A Randomized, double-blinded,
placebo-controlled trial. J Nutr Metab 2012;2012:510483.

64. Rostami Z, Einollahi B, Lessan-Pezeshki M, Soleimani Najaf Abadi A,
Mohammadi Kebar S, Shahbazian H, et al. Health-related quality of
life in hemodialysis patients: An Iranian multi-center study. Nephrourol
Mon 2013;5:901-12.

65. Taheri-Kharameh Z, Zamanian H, Montazeri A, Asgarian A, Esbiri R.
Negative religious coping, positive religious coping, and quality of life
among hemodialysis patients. Nephrourol Mon 2016;8:e38009.

66. Heidarzadeh M, Atashpeikar S, Jalilazar T. Relationship between
quality of life and self-care ability in patients receiving hemodialysis.
Iran J Nurs Midwifery Res 2010;15:71-6.

67. Aghakhani N, Samadzadeh S, Mafi TM, Rahbar N. The impact of
education on nutrition on the quality of life in patients on hemodialysis:
A comparative study from teaching hospitals. Saudi J Kidney Dis
Transpl 2012;23:26-30.

68. Shahgholian N, Eshghinezhad A, Mortazavi M. The effect of tai
chi exercise on quality of life in hemodialysis patients. Iran J Nurs
Midwifery Res 2014;19:152-8.

69. Hajian-Tilaki K, Heidari B, Hajian-Tilaki A. A comparison of health-related
quality of life in patients with renal failure under hemodialysis and healthy
participants. Saudi J Kidney Dis Transpl 2017;28:133-40.

70. Pakpour AH, Saffari M, Yekaninejad MS, Panahi D, Harrison AP,
Molsted S, et al. Health-related quality of life in a sample of Iranian
patients on hemodialysis. Iran J Kidney Dis 2010;4:50-9.

71. Tayyebi A, Raiesifar A, Najafi Mehri S, Ebadi A, Einolahi B, Pashandi S,
et al. Measuring health related quality of life (hrqol) in renal transplant
patients: Psychometric properties and cross-cultural adaptation of
kidney transplant questionnaire (ktq-25) in persian. Nephrourol Mon
2012;4:617-21.

72. Arab Z, Shariati AR, Asayesh H, Vakili MA, Bahrami-Taghanaki H,
Azizi H, et al. A sham-controlled trial of acupressure on the quality of
sleep and life in haemodialysis patients. Acupunct Med 2016;34:2-6.

73. Dashti-Khavidaki S, Sharif Z, Khalili H, Badri S, Alimadadi A, Ahmadi F,
et al. The use of pharmaceutical care to improve health-related quality
of life in hemodialysis patients in iran. Int J Clin Pharm 2013;35:260-7.

74. Sharif F, Vedad F. The relationship between mental health and quality
of life of hemodialysis patients referred to hospitals affiliated to Shiraz
university of medical sciences. IJN 2007;20:61-9.

75. Moghareb M, Sharifzadeh GH, Moghareb M, Sorouri M. Quality of life
in hemodialysis and kidney transplantation patients in Birjand, 2012.
Mod Care J 2014;11:127-35.

76. Edalat Nejad M, Qlich Khani M. Quality of life and sleep in hemodialysis
patients. Saudi J Kidney Dis Transpl 2013;24:514-8.

77. Baraz S, Mohammadi E, Broumand B. Correlation of quality of sleep
or quality of life and some of blood factors in hemodialysis patients.
J Shahrekord Univ Med Sci 2008;9:67-74.

78. Zeraati AA, Naghibi M, Mojahedi MJ, Ahmadzade SH,
Hassan Zamani B. Comparison of quality of life between hemodialysis
and peritoneal dialysis patients in Imam Reza and Ghaem hospital
dialysis centers in Mashhad. Med J Mashhad Univ Med Sci
2010;53:169-76.

79. Fouladi Z, Ebrahimi A, Manshaei G, Afshar H, Fouladi M. Investigation
of relationship betweenpositive psychological variables (spirituality
and hope) psychopathology (depression, stress, anxiety) and quality
of life inhemodialysis patients Isfahan – 2012. J Res Behav Sci
2014;11:567-77.

80. Namdar A, Beigizadeh SH, Najafipour S. Health related quality of life in
dialysis patients. J Jahrom Univ Med Sci 2013;10:19-27.

81. Zamanzadeh V, Heidarzadeh M, Oshvandi KH, Argani H, Abedi Azar S.
Effect of physical exercises on quality of life in hemodialysis patients.
Med J Tabriz Univ Med Sci 2008;30:51-5.

82. Vázquez I, Valderrábano F, Fort I, Jofré R, López-Gómez JM, Moreno F,
et al. Differences in health-related quality of life between male and
female hemodialysis patients. Nefrologia 2004;24:167-78.

83. AL-Jumaih A, Al-Onazi K, Binsalih S, Hejaili F, Al-Sayyari A. A study
of quality of life and its determinants among hemodialysis patients
using the KDQOL-SF instrument in one center in Saudi Arabia. Arab J
Nephrol Transplant 2011;4:125-30.

84. Nonoyama M, Brooks D, Ponikvar A, Vanita Jassal S, kontos P,
Devins G, et al. Exercise program to inhance physical performance and
quality of life of older hemodialysis patients: A feasibility study. Int Urol
Nephrol 2010;42:1125-30.

85. Chow SK, Wong FK. Health-related quality of life in patients undergoing
peritoneal dialysis: Effects of a nurse-led case management programme.
J Adv Nurs 2010;66:1780-92.

86. Cleary J, Drennan J. Quality of life of patients on haemodialysis for
end-stage renal disease. J Adv Nurs 2005;51:577-86.

87. Vasilieva IA. Quality of life in chronic hemodialysis patients in Russia.
Hemodial Int 2006;10:274-8.

88. Soleimannejad K, Sarokhani D, Sarokhani M, Sayehmiri K, Ahmadi N.
Quality of life in diabetes patients in Iran: A systematic review and
meta-analysis method. Int J Pharm Technol 2016;8:21608-18.

89. Mohsenzadeh Y, Sarokhani D, Hemmati F, Sarokhani M,
Akbarzadeh Baghban A, Sayehmiri K. Quality of life in heart patients
in Iran: A systematic review and meta-analysis method. Pharma Chem
2016;8:27-34.

90. Saroukhani D, Omidi K, Norouzi R, Zali H, Sayehmiri K, Forozeshfard M.
The quality of life in cancer patients in Iran: A systematic review by
using meta-analysis. Koomesh 2016;18:1-12.

91. Lessan Pezeshki M, Rostami Z. Contributing factors in health-related
quality of life assessment of ESRD patients: A single center study.
Nephrourol Mon 2009;1:129-36.

92. Baraz S, Mohammadi E, Broumand B. The effect of self care educational
program on decreasing the problems and improving the quality of life of
dialysis patients. Hayat 2005;11:51-62.

93. Namadi M, Movahhedpour A. Quality of life in patients after renal
transplantation in comparison with intermittent hemodialysis. J Ardabil
Univ Med Sci 2009;9:171-9.

94. Naderifar M, Zagheri Tafreshi M, Ilkhani M, Kavousi A. The
outcomes of stress exposure in hemodialysis patients. J Renal Inj Prev
2017;6:275-81.

95. Shahdadi H, Balouchi A, JahantighHaghighi M. Comparison of two
interventions of increased blood f low rate and high-f lux filters on
hemodialysis adequacy and complications; a quasi-experimental study.
J Renal Inj Prev 2017;6:247-52.

[Downloaded free from http://www.jpalliativecare.com on Wednesday, January 17, 2018, IP: 202.177.173.189]

Copyright of Indian Journal of Palliative Care is the property of Wolters Kluwer India Pvt Ltd
and its content may not be copied or emailed to multiple sites or posted to a listserv without
the copyright holder’s express written permission. However, users may print, download, or
email articles for individual use.

Research Article
Epidemiology and Survival Outcomes of Lung Cancer: A
Population-Based Study

Huan-Tang Lin ,1,2,3 Fu-Chao Liu ,1,2 Ching-Yang Wu,2,4 Chang-Fu Kuo,5,6

Wen-Ching Lan,7 and Huang-Ping Yu 1,2,8

1Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
2College of Medicine, Chang Gung University, Taoyuan, Taiwan
3Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
4Division of %oracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
5Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
6Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Nottingham, UK
7Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
8Department of Anesthesiology, Xiamen Chang Gung Hospital, Xiamen, China

Correspondence should be addressed to Huang-Ping Yu; yuhp2001@adm.cgmh.org.tw

Received 20 June 2019; Accepted 4 December 2019; Published 30 December 2019

Academic Editor: Joanna Domagala-Kulawik

Copyright © 2019 Huan-Tang Lin et al. -is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose. Lung cancer has been the top-ranking cause of cancer deaths in Taiwan for decades. Limited data were available in global
cancer surveillance regarding lung cancer epidemiology in Taiwan, and previous reports are outdated. Patients and Methods. -is
population-based cohort study extracted data of patients with lung cancer from the Taiwan National Health Insurance database
and determined the lung cancer incidence and prevalence during 2002–2014. Histological subtypes were retrieved from the
Taiwan Cancer Registry database; survival rates were gathered from the National Death Registry. Average annual percentage
changes (APCs) of prevalence, incidence, and overall survival were estimated by joinpoint regression analysis. Results. Age-
standardized incidence of lung cancer increased from 45.04 per 100,000 person-years in 2002 to 49.86 per 100,000 person-years in
2014, with an average APC of 0.7 (95% CI � 0.3–1.1; 0.2 in males, 2.0 in females). Lung cancer was more prevalent in male patients,
but this increase gradually slowed down. Socioeconomic analysis showed that lung cancer has higher prevalence in patients with
higher income level and urban residency. Adenocarcinoma was the most abundant histological subtype in Taiwan (adeno-
carcinoma-to-squamous cell carcinoma ratio � 4.16 in 2014), with a 2.4-fold increase of incident cases during 2002–2014 (from
43.47% to 64.89% of all lung cancer cases). -e 5-year survival rate of lung cancer patients in 2010 was 17.34% (12.60% in male,
25.40% in female), with an average APC of 9.3 (6.3 in male, 11.8 in female) during 2002–2010. Conclusion. Average APCs

prevalence and incidence of lung cancer were 3.1 and 0.7, respectively, during 2002–2014 in Taiwan. -e number of female
patients and number of patients with adenocarcinoma have increased the most, with incident cases doubling in these years. Facing
this fatal malignancy, it is imperative to improve risk stratification, encourage early surveillance, and develop effective therapeutics
for lung cancer patients in Taiwan.

1. Introduction

Lung cancer is the top-ranking cause of cancer deaths
worldwide, and the incidence has risen over the last three
decades. According to the latest GLOBOCAN 2018 esti-
mates, lung cancer is the most often diagnosed malignancy
(2.1 million new cases, equal to 11.6% of the total incident

cancer cases in 2018) with an age-standardized incidence
rate of 22.5 (31.5 in male, 14.6 in female) per 100,000 person-
years worldwide in 2018 [1]. Furthermore, lung cancer
ranked first and accounted for 18.4% of the total cancer
deaths (equal to 1.8 million deaths) in 2018, with an age-
standardized mortality rate of 18.6 (27.1 in males, 11.2 in
females) per 100,000 persons [2]. In 2015, lung cancer

Hindawi
BioMed Research International
Volume 2019, Article ID 8148156, 19 pages
https://doi.org/10.1155/2019/8148156

mailto:yuhp2001@adm.cgmh.org.tw

https://orcid.org/0000-0001-6411-7978

https://orcid.org/0000-0003-1712-4053

https://orcid.org/0000-0002-3030-05

https://creativecommons.org/licenses/by/4.0/

https://doi.org/10.1155/2019/8148156

accounted for 36.4 million (95% uncertainty interval,
35.4–37.6 million) disability-adjusted life-years and ranked
first among all malignancies for absolute years of life lost in
both sexes [3]. Considering absolute cases, lung cancer
accounts for most of the cancer incident cases and deaths in
the majority of developed countries; however, the incidence
and mortality are lower (ranking tenth and seventh, re-
spectively) in countries with a lower sociodemographic
index [3]. In the CONCORD-3 program, a global surveil-
lance of cancer survival in 71 countries, the 5-year survival
for patients diagnosed with lung cancer during 2010–2014
was high in Japan (32.9%), followed by 20–30% in another 12
countries such as Korea (25.1%) and the USA (21.2%); the
range was 10–19% in other countries [4].

Generally, men have a higher chance of developing lung
cancer than women. However, the incidence rates of male
patients have fallen since the mid-1990s in most developed
countries, while the incidence rates of female patients have
continuously increased [5]. -erefore, the incidence rates of
lung cancer in male and female patients have converged in
the USA and several other developed countries, especially
among the younger generation [5, 6]. -e differential in-
cidence based on sex might be contributed by sex-specific
differences in histological subtypes of lung cancer as well as
the change of prevalence in smoking.

Typical risk factors for lung cancer include tobacco
smoking, family history of malignancy, previous lung dis-
eases, and exposure to secondhand smoke, radon, asbestos,
arsenic, air pollutants, or occupational carcinogens [5, 7].
-e different subtypes of lung cancer possess distinct epi-
demiological and prognostic features [8]. Smoking has been
identified as the major risk factor for small cell lung cancer
(SCLC) and squamous cell carcinoma. More than 80% of
lung cancer etiology could be ascribed to smoking in the
Western population. -e occurrence of lung cancer has been
reduced through tobacco control such as increasing tobacco
taxes and prices, health warnings on packages, and advo-
cating smoking cessation, as well as through comprehensive
ban on tobacco advertising [1]. On the other hand, ade-
nocarcinoma is more common in the Asian population,
particularly among females and never-smokers [5, 9]. Ro-
bust data exist regarding the prevalence of EGFR mutations
in adenocarcinoma patients, ranging from the highest EGFR
mutation frequency of 47% in the Asia-Pacific subgroup to
the lowest frequency of 12% in the Oceania subgroup [10].
Studies in China and Hong Kong suggested that the rise of
lung adenocarcinoma in Asian nonsmokers has significant
exposure-response relationships with secondhand smoke
and cooking fumes [11, 12].

Population-based cancer registries are essential for
assessing the current cancer burden of the healthcare sys-
tems, as well as to monitor the efficacy of cancer prevention
and treatment strategies. Regarding lung cancer epidemi-
ology in Taiwan, limited data were available in global cancer
surveillance and information reported in previous studies
has become outdated [13, 14]. In this population-based
epidemiologic study, we managed to update the trends of the
prevalence, incidence, and overall survival of patients with
lung cancer in Taiwan between 2002 and 2014 by combining

information from the National Health Insurance Research
Database (NHIRD), Taiwan Cancer Registry Database
(TCRD), and National Death Registry (NDR).

2. Materials and Methods

2.1. Source Data and Study Population. -e Taiwan NHIRD
has been regularly collecting demographic data on the
diagnoses, prescriptions, and operations of all Taiwan
National Health Insurance (NHI) beneficiaries from pri-
mary care and special care providers since 1995. -e NHI is
a universal health insurance that had an extensive coverage
of over 99.6% of registered beneficiaries in Taiwan at the
end of 2014 [15]. Individual information contained in the
NHI database during 2002–2014 was encrypted utilizing
the International Classification of Diseases, Ninth Revision,
Clinical Modification (ICD-9-CM) code. -e NHIRD is a
large representative health care database, and its validity
and clinical consistency in cancer research have been
proved [16]. -is population-based epidemiologic study
was reviewed and permitted by the Institutional Review
Board of Chang Gung Medical Foundation, Taiwan (ap-
proval number: 201801054B1). As the source data used in
this study were totally deidentified and encrypted, the
requirement for obtaining patient consent was waived.

-is study utilized the crosslinking databases of the
NHIRD, TCRD, and NDR with the approval of the De-
partment of Statistics, Ministry of Health and Welfare of
Taiwan. -e utilized databases of NHIRD, TCRD, and NDR
all belong to subsets of the NHI database. Using a unique
personal encrypted identification number for each benefi-
ciary in Taiwan, we are able to crosslink efficiently among
different subsets of the NHI database. -e internal linkage
between each dataset is robust, and the data quality was
accepted with validity in previous publications [16, 17]. -is
population-based cohort study comprised ethnic Taiwanese
patients with the main diagnosis of lung cancer (ICD-9-CM
code 162.xx) identified via the NHIRD from 2002 to 2014.
-e histological subtypes of lung cancer were retrieved from
the TCRD, while the survival rates were extracted from the
NDR database.

2.2. Estimate of the Prevalence, Incidence, and Overall
Survival. -e crude prevalence rate of lung cancer per
100,000 persons was calculated by dividing the number of
prevalent lung cancer patients by the eligible population in a
specified year. We defined lung cancer patients as indi-
viduals who were diagnosed as lung cancer, ICD-9-CM code
162.xx, before July 1 of that calendar year. -e eligible
population comprised every individual who registered on
July 1 of that calendar year. On the other hand, the crude
incidence rate of lung cancer per 100,000 person-years was
estimated by dividing the number of incident lung cancer
patients by the total person-years in the at-risk population
during a specified year. -e incident lung cancer cases were
defined as patients with a record of lung cancer in a specified
year but without diagnosis of lung cancer prior to January 1
of that year. People with no history of lung cancer during the

2 BioMed Research International

same year were defined as the at-risk population. All eligible
subjects were followed up from January 1 of the year when
the earliest diagnosis of lung cancer was done to the primary
outcome of death or the end of the study period on De-
cember 31, 2014. To diminish the fundamental restriction of
database estimation, the eligible cohorts included patients
with registration period more than one-year prior to January
1 of each year. -e age-standardized prevalence and inci-
dence rate of lung cancer in each year from 2002 to 2014
were calculated with reference to the population structure of
2014. -e prevalence and incidence of lung cancer were
further analyzed by dividing patients into subgroups based
on sex, calendar year, socioeconomic status, and histological
subtypes. -e histological subtype of lung cancer was cat-
egorized according to the classification of lung cancer in
2004 World Health Organization (WHO) criteria with
mainly SCLC and non-small cell lung cancer (NSCLC

)

including adenocarcinoma, squamous cell carcinoma, large
cell carcinoma, and other subtypes [8]. Overall survival rates
of patients with lung cancer were extracted from overall
mortality rates in the National Death Registry of Taiwan and
were relative survival rates by definition. -e relative sur-
vival rate represents the cumulative probability of a cancer
patient who would have survived a given period compared to
the comparable general population after adjusting for age,
sex, and observed calendar year [18]. -e presented 1-year,

3-year, and 5-year survival rates in each calendar year were
estimated using the life table method [19]. -e geographic
variations in the prevalence and incidence of lung cancer in
2002 and in 2014 were also compared by dividing Taiwan
into 21 administrative districts, including Keelung, Taipei
city, New Taipei City, Taoyuan city, Hsinchu, Miaoli, Tai-
chung city, Changhua, Yunlin, Nantou, Chiayi, Tainan city,
Kaohsiung city, Pingtung, Yilan, Hualien, Taitung, Lian-
jiang, and offshore Penghu islets. -e age-standardized
prevalence and incidence of lung cancer for each district
were estimated with reference to the overall population
structure of 2014 to diminish the regional effects of diverse
age and sex. To evaluate the recognized risk factors of lung
cancer, we also obtained air pollution information including
Pollutant Standards Index (PSI) and fine particulate matter
(PM 2.5) concentrations from the Taiwan Air Quality
Monitoring Network and retrieved publications on the
prevalence of smoking from the Adult Smoking Behavior
Surveillance System [20–22].

2.3. Statistical Analysis. -e 95% confidence intervals (95%
CIs) for the prevalence, incidence, and survival rate of lung
cancer were estimated using Poisson regression. -e secular
trends for the prevalence, incidence, and survival rates of
lung cancer were estimated using the joinpoint regression

Table 1: Clinical characteristics of lung cancer patients in Taiwan from 2002 to 2014.

Entire cohort
(n � 124,148)

By gender By calendar year
Female

(n � 45,003)
Male

(n � 79,145)

p value

2002
(n � 7,308)

2014
(n � 11,784)

p value

Age (years) (mean±standard
deviation)

68.53±12.75 66.67±13.35 69.58±12.28 <0.0001∗ 68.13±12.30 67.80±12.90 0.0762

Sex — <0.0001∗ Female 45,003 (36.25) — — — — 2,429 (33.24) 4,840 (41.07) Male 79,145 (63.75) — — — — 4,879 (66.76) 6,944 (58.93)

Place of residence, no. (%) <0.0001∗ <0.0001∗ Urban 62,187 (50.09) 24,468 (54.37) 37,719 (47.66) 3,609 (49.38) 6,597 (55.98) Suburban 36,873 (29.70) 12,670 (28.15) 24,203 (30.58) 2,353 (32.20) 3,744 (31.77) Rural 14,900 (12.00) 4,951 (11.00) 9,949 (12.57) 1,037 (14.19) 1,385 (11.75) Unknown 10,188 (8.21) 2,914 (6.48) 7,274 (9.19) 309 (4.23) 58 (0.49)

Income levels, no. (%) <0.0001∗ <0.0001∗ Quintile 1 16,536 (13.32) 4,747 (10.55) 11,789 (14.90) 1,924 (26.33) 0 (0.00) Quintile 2 31,632 (25.48) 11,466 (25.48) 20,166 (25.48) 3,241 (44.35) 3,141 (26.65) Quintile 3 16,190 (13.04) 5,758 (12.79) 10,432 (13.18) 184 (2.52) 597 (5.07) Quintile 4 26,534 (21.37) 10,586 (23.52) 15,948 (20.15) 485 (6.64) 5,075 (43.07) Quintile 5 23,469 (18.90) 9,682 (21.51) 13,787 (17.42) 1,096 (15.00) 2,931 (24.87) Unknown 9,787 (7.88) 2,764 (6.14) 7,023 (8.87) 378 (5.17) 40 (0.34)

Occupation, no. (%) <0.0001∗ <0.0001∗ Dependents of the insured

individuals
36,796 (29.64) 16,724 (37.16) 20,072 (25.36) 2,050 (28.05) 4,172 (35.40)

Civil servants, teachers,
military personnel, and veterans

5,876 (4.73) 1,617 (3.59) 4,259 (5.38) 160 (2.19) 1,132 (9.61)

Nonmanual workers and
professionals

8,990 (7.24) 3,491 (7.76) 5,499 (6.95) 474 (6.49) 1,213 (10.29)

Manual workers 38,813 (31.26) 14,032 (31.18) 24,781 (31.31) 28,68 (39.24) 3,926 (33.32)
Other 33,673 (27.12) 9,139 (20.31) 24,534 (31.00) 1,756 (24.03) 1,341 (11.38)

Charlson Index (mean±standard
deviation)

3.80±3.09 3.73±3.11 3.83±3.08 <.0001∗ 4.23±3.12 3.48±3.03 <0.0001∗

∗p <0.05.

BioMed Research International 3

analysis program (version 4.4.0.0) to generate different
“joinpoints” for the secular change and calculate the average
annual percentage change (APC) for each linear segment.
-e Charlson Comorbidity Index (CCI) score was utilized to
estimate the medical burden and mortality risk of lung
cancer patients. Statistically, continuous variables such as
age and CCI score were compared with the t-test, while
categorical variables such as sex and income level were
compared with χ2 analysis. -e statistical significance level in

this study was set at α<0.05. All statistical analyses in this study were calculated using the SAS software (version 9.4; SAS Institute, Cary, NC, the United States).

3. Results

3.1. Demographic Characteristics and Geographic Variations.
-e total eligible population in our study consisted of
23,850,842 registered NHI beneficiaries (50.02% male,

26.0–29.

29.5–33.0
33.0–36.5

36.5–40.0
40.0–43.5

Incidence

(a)

42–

50–58
58–66

66–74
74–82

Prevalence

(b)

42–46
46–50
50–54

54–58
58–62

Incidence

(c)

94–107
107–1

120–132

132–1

145–158

Prevalence

(d)

Figure 1: Geographic variation in the prevalence and incidence of lung cancer in Taiwan in 2002 and 2014. (a) Prevalence in 2002. (b)
Incidence in 2002. (c) Prevalence in 2014. (d) Incidence in 2014.

4 BioMed Research International

49.98% female) in 2014. Among these, we identified 124,148
patients with a diagnosis of lung cancer (79,145 males and
45,003 females) during 2002–2014. -e demographic
characteristics of these lung cancer patients are listed in
Table 1. Although the majority of lung cancer patients were
male, the percentage of female patients increased from
33.24% in 2002 to 41.07% in 2014. On average, male patients
with lung cancer were older (69.58±12.28 years in male
versus 66.67±13.35 years in female) and had a lower so-
cioeconomic status (lower income level, urban residency,
and professional occupation). -e incident cases of lung
cancer increased from 7,308 in 2002 to 11,784 in 2014, and
the average CCI score at lung cancer diagnosis decreased
from 4.23±3.12 to 3.48±3.03. Most lung cancer patients in
Taiwan lived in the high-income urban areas during this
period. -e socioeconomic analyses implied that there was a
growing trend towards a higher socioeconomic status
among the lung cancer patients in 2014 in comparison with
the distribution in 2002.

-e geographic distribution of the prevalence and in-
cidence of lung cancer in 2002 and 2014 is shown in Figure 1.

We also demonstrated the change of available air pollution
indicators (PSI in 2002 and 2014; PM2.5 in 2005, 2014, and
2018) in every district of Taiwan for possible exposure-
disease relationship (PSI in Figure 2; PM2.5 in Figure 3)
[20, 21]. Eastern areas of Taiwan showed lower air pollution
level in comparison with higher PM2.5 concentrations in
southwestern areas. However, this distribution of air pol-
lution indicators could not fully explain the geographic
variation of the prevalence and incidence of lung cancer.

3.2. Prevalence and Incidence of Lung Cancer. Tables 2 and 3
show the prevalence and incidence of lung cancer in Taiwan
during 2002–2014. Generally, a higher prevalence and in-
cidence was observed among the male than female patients
with lung cancer during 2003–2014; however, the prevalence
and incidence in female patients increased more quickly
while the increase in male patients slowed down. -e age-
standardized prevalence of lung cancer was 93.38 (95%
CI = 91.84–94.92) per 100,000 persons in 2002 and 132.

(95% CI = 130.94–133.86) per 100,000 persons in 2014. -e

PSI (μg/m3)

32–39
39–46
46–53

53–

60–67

(a)
PSI (μg/m3)
32–39
39–46
46–53
53–60
60–67
(b)

Figure 2: Annual average of Pollutant Standards Index (PSI, μg/m3) in Taiwan by county in 2002 and 2014. Data were obtained from the
Taiwan Air Quality Monitoring Network. PSI is calculated by averaging air pollutant concentration collected for the past 24 hours including
particulate matter (PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO) and ozone (O3). PSI>100 is considered to
impair health.

BioMed Research International 5

joinpoint analysis of lung cancer prevalence showed that the
average APC was 3.1 (95% CI = 2.7–3.4) during 2002–2014,
with faster accumulation in the female (average APC, 5.0
(95% CI = 4.8–5.1)) than male patients (average APC, 1.7
(95% CI = 1.3–2.0)) (Table 4). -e standardized incidence of
lung cancer was 45.04 (95% CI = 43.95–46.13) per 100,000
person-years in 2002 and 49.86 (95% CI = 48.96–50.76) per
100,000 person-years in 2014, with increasing female-to-
male incidence ratio from 0.56 in 2002 to 0.69 in 2014. -e
joinpoint analysis of lung cancer incidence showed the
average APC during 2002–2014 was 0.7 (Table 5). Notably,

the trend of incidence changes in the male patients dem-
onstrated a diverse direction with upward segment during
2002–2006 (average APC, 2.2 (0.5–4.0)) and downward
segment during 2006–2014 (average APC, − 0.8 (− 1.3 to
− 0.3)). Overall, the age-standardized prevalence of lung
cancer was 1.42-fold higher in 2014 than in 2002; similarly,
the age-standardized incidence of lung cancer was 1.11-fold
higher in 2014 than in 2002. -e age-specific prevalence and
incidence of lung cancer in 2014 is shown in Figure 4. -e
majority of lung cancer patients (95.22%) were diagnosed at
an age≥45 years. Interestingly, the age-specific prevalence of

PM2.5 (µg/m3)
0-

15-20
20-

25-

30-

35-40
40-45
45-50
50-

(a)
PM2.5 (µg/m3)
0-15
15-20
20-25
25-30
30-35
35-40
40-45
45-50
50-55
(b)
PM2.5 (µg/m3)
0-15
15-20
20-25
25-30
30-35
35-40
40-45
45-50
50-55
(c)

Figure 3: Annual average of fine particulate matter exposure (PM2.5, μg/m3) in Taiwan by county in 2005, 2014, and 2018. Data were
obtained from the Taiwan Air Quality Monitoring Network. -e first nationwide PM2.5 concentration in Taiwan was released since 2005.
For counties with several monitoring stations, we selected the monitoring station with the representative county level of air pollution.

6 BioMed Research International

T
a

b
le

C
ru
de

an
d
ag
e-
st
an
da
rd
iz
ed

ev
al

en
ce

(p
er

0,
00
0

pe
rs
on

s)
of

lu
ng

ca
nc
er

in
Ta
iw
an

fr
om

20
02

20
14

Y
ea
r

To
ta
l

al
e

Fe
m
al
e

N
C
ru
de

St
an
da
rd
iz
ed

N
C
ru
de
St
an
da
rd
iz
ed
N
C
ru
de
St
an
da
rd
iz
ed
20
02

22
,4
58
,0
27

69
.1
2

(6
8.
03
–7
0.
21
)

93
.3
8

(9
1.
84
–9
4.
92
)

11
,3
81
,7
56

87
.6
1

(8
5.
89
–8
9.
32
)

11
4.
95

(1
12
.5
6–
11
7.
35
)

11
,0
76
,2
71

50
.1
3

(4
8.
81
–5
1.
44
)

71
.7
9

(6
9.
85
–7
3.
74
)

20
03

22
,6
66
,9
86

.5
7

(6
9.
48
–7
1.
67
)

93
.4
4

(9
1.
93
–9
4.
95
)

11
,4
88
,5

88
.9
0

(8
7.
17
–9
0.
62
)

11
4.
74

(1
12
.4
0–
11
7.
09
)

11
,1
78
,4
21

51
.7
4

(5
0.
41
–5
3.
08
)

72
.1
2

(7
0.
21
–7
4.
03
)

20
04

22
,8
23
,8
02

75
.8
4

(7
4.
71
–7
6.
97
)

98
.1
9

(9
6.
67
–9
9.
71
)

11
,5
60
,1
32

94
.6
9

(9
2.
91
–9
6.
46
)

11
9.
73

(1
17
.3
9–
12
2.
08
)

11
,2
63
,6
70

56
.4
9

(5
5.
10
–5
7.
88
)

76
.6
2

(7
4.
69
–7
8.
55
)

20
05

22
,9
55
,3
92

81
.1
0

(7
9.
93
–8
2.
26
)

10
2.
78

(1
01
.2
5–
10
4.
30
)

11
,6
13
,6
52

10
0.
56

(9
8.
74
–1
02
.4
)

12
4.
69

(1
22
.3
3–
12
7.
05
)

11
,3
41
,7
40

61
.1
6

(5
9.
72
–6
2.
60
)

.8
5

(7
8.
90
–8
2.
79
)

20
06

23
,0
86
,3
19

85
.7
4

(8
4.
54
–8
6.
93
)

10
6.
15

(1
04
.6
3–
10
7.
68
)

11
,6
65
,4
82

10
4.
08

(1
02
.2
–1
05
.9
)

12
6.
76

(1
24
.4
2–
12
9.
09
)

11
,4
20
,8
37

67
.0
0

(6
5.
50
–6
8.
50
)

85
.5
3

(8
3.
58
–8
7.
49
)

20
07

23
,2
02
,3
10

90
.7
5

(8
9.
53
–9
1.
98
)

10
9.
46

(1
07
.9
4–
11
0.
97
)

11
,7
08
,2
20

10
9.
14

(1
07
.2
–1
11
.0
)

12
9.
63

(1
27
.3
2–
13
1.
95
)

11
,4
94
,0
90

72
.0
3

(7
0.
48
–7
3.
58
)

89
.2
7

(8
7.
31
–9
1.
22
)

20
08

23
,3
09
,0
90

96
.9
7

(9
5.
70
–9
8.
23
)

11
4.
03

(1
12
.5
2–
11
5.
55
)

11
,7
45
,7
23

11
4.
54

(1
12
.6
–1
16
.5
)

13
2.
96

(1
30
.6
6–
13
5.
26
)

11
,5
63
,3
67

79
.1
1

(7
7.
49
–8
0.
73
)

95
.1
0

(9
3.
12
–9
7.
07
)

20
09

23
,4
10
,3
04

10
2.
72

(1
01
.4
–1
04
.0
)

11
7.
73

(1
16
.2
2–
11
9.
24
)

11
,7
78
,3
94

11
9.
86

(1
17
.9
–1
21
.8
)

13
5.
94

(1
33
.6
6–
13
8.
22
)

11
,6
31
,9
10

85
.3
6

(8
3.
68
–8
7.
04
)

99
.5
1

(9
7.
53
–1
01
.5
)

20
10

23
,5
09
,7
64

10
7.
08

(1
05
.8
–1
08
.4
)

11
9.
55

(1
18
.0
6–
12
1.
04
)

11
,8
10
,5
06

12
1.
80

(1
19
.8
–1
23
.8
)

13
4.
56

(1
32
.3
4–
13
6.
78
)

11
,6
99
,2
58

92
.2
2

(9
0.
48
–9
3.
96
)

10
4.
53

(1
02
.5
–1
06
.5
)

20
11

23
,6
63
,0
66

11
1.
56

(1
10
.2
–1
12
.9
)

12
1.
47

(1
20
.0
0–
12
2.
95
)

11
,8
73
,7
18

12
4.
77

(1
22
.8
–1
26
.8
)

13
4.
83

(1
32
.6
5–
13
7.
01
)

11
,7
89
,3
48

98
.2
6

(9
6.
47
–1
00
.0
)

10
8.
11

(1
06
.1
–1
10
.1
)

20
12

23
,7
51
,2
97

11
8.
24

(1
16
.9
–1
19
.6
)

12
5.
23

(1
23
.7
6–
12
6.
70
)

11
,9
05
,4
97

12
9.
39

(1
27
.3
–1
31
.4
)

13
6.
30

(1
34
.1
4–
13
8.
45
)

11
,8
45
,8
00

10
7.
04

(1
05
.2
–1
08
.9
)

11
4.
15

(1
12
.2
–1
16
.1
)

20
13

23
,7
97
,4
77

12
4.
89

(1
23
.5
–1
26
.3
)

12
8.
46

(1
27
.0
0–
12
9.
92
)

11
,9
16
,4
06

13
4.
22

(1
32
.1
–1
36
.3
)

13
7.
71

(1
35
.5
8–
13
9.
85
)

11
,8
81
,0
71

11
5.
53

(1
13
.6
–1
17
.5
)

11
9.
21

(1
17
.2
–1
21
.2
)

20
14

23
,8
50
,8
42

13
2.
40

(1
30
.9
–1
33
.9
)

13
2.
40

(1
30
.9
4–
13
3.
86
)

11
,9
30
,1
81

13
9.
29

(1
37
.2
–1
41
.4
)

13
9.
29

(1
37
.1
7–
14
1.
40
)

11
,9
20
,6
61

12
5.
50

(1
23
.5
–1
27
.5
)

12
5.
50
(1
23
.5
–1
27
.5
)

BioMed Research International 7

T
a
b
le

3:
C
ru
de

an
d
ag
e-
st
an
da
rd
iz
ed

ci
de

nc
e
(p
er

10
0,
00
0
pe
rs
on

-y
ea
rs

)
of

lu
ng
ca
nc
er
in
Ta
iw
an
fr
om
20
02

to
20
14
.

Y
ea
r
To
ta
l

M
al
e

Fe
m
al
e

Pe
rs
on

-y
ea
rs
C
ru
de
St
an
da
rd
iz
ed
Pe
rs
on
-y
ea
rs
C
ru
de
St
an
da
rd
iz
ed
Pe
rs
on
-y
ea
rs
C
ru
de
St
an
da
rd
iz
ed
20
02

22
,0
13
,2
02

33
.2
0

(3
2.
44
–3
3.
96
)

45
.0
4

(4
3.
95
–4
6.
13
)

11
,1
17
,3
09

43
.8
9

(4
2.
66
–4
5.
12
)

57
.5
0

(5
5.
77
–5
9.
22
)

10
,8
95
,8
93

22
.2
9

(2
1.
41
–2
3.
18
)

32
.5
7

(3
1.
24
–3
3.
91
)

20
03

22
,3
32
,5
02

32
.9
1

(3
2.
16
–3
3.
66
)

43
.8
0

(4
2.
75
–4
4.
85
)

11
,3
03
,6
61

43
.9
2

(4
2.
70
–4
5.
15
)

56
.8
4

(5
5.
16
–5
8.
51
)

11
,0
28
,8
41

21
.6
3

(2
0.
76
–2
2.
49
)

30
.7
6

(2
9.
49
–3
2.
03
)

20
04

22
,5
45
,3
06

36
.4
8

(3
5.
69
–3
7.
27
)

47
.1
8

(4
6.
12
–4
8.
25
)

11
,4
12
,6
85

48
.8
1

(4
7.
52
–5
0.
09
)

61
.6
1

(5
9.
91
–6
3.
31
)

11
,1
32
,6
21

23
.8
5

(2
2.
94
–2
4.
76
)

32
.7
5

(3
1.
48
–3
4.
03
)

20
05

22
,6
93
,1
44

37
.6
9

(3
6.
89
–3
8.
48
)

47
.7
0

(4
6.
65
–4
8.
75
)

11
,4
77
,8
94

49
.7
7

(4
8.
47
–5
1.
06
)

61
.3
6

(5
9.
70
–6
3.
02
)

11
,2
15
,2
51

25
.3
2

(2
4.
39
–2
6.
25
)

34
.0
3

(3
2.
75
–3
5.
31
)

20
06

22
,8
26
,8
48

39
.0
3

(3
8.
22
–3
9.
84
)

48
.1
1

(4
7.
08
–4
9.
14
)

11
,5
32
,3
38

50
.7
3

(4
9.
43
–5
2.
03
)

61
.3
6

(5
9.
72
–6
2.
99
)

11
,2
94
,5
10

27
.0
8

(2
6.
12
–2
8.
04
)

34
.8
7

(3
3.
61
–3
6.
12
)

20
07

22
,9
56
,2
17

41
.2
2

(4
0.
39
–4
2.
05
)

49
.4
4

(4
8.
42
–5
0.
46
)

11
,5
83
,7
71

53
.0
5

(5
1.
72
–5
4.
37
)

62
.5
2

(6
0.
91
–6
4.
13
)

11
,3
72
,4
46

29
.1
8

(2
8.
18
–3
0.
17
)

36
.3
6

(3
5.
10
–3
7.
62
)

20
08

23
,0
69
,3
98

41
.6
4

(4
0.
80
–4
2.
47
)

48
.5
9

(4
7.
60
–4
9.
58
)

11
,6
25
,1
47

53
.7
6

(5
2.
43
–5
5.
10
)

61
.7
8

(6
0.
22
–6
3.
35
)

11
,4
44
,2
51

29
.3
2

(2
8.
32
–3
0.
31
)

35
.3
9

(3
4.
17
–3
6.
60
)

20
09

23
,1
74
,4
74

43
.5
7

(4
2.
72
–4
4.
41
)

49
.7
3

(4
8.
75
–5
0.
72
)

11
,6
61
,9
44

54
.7
4

(5
3.
40
–5
6.
08
)

61
.7
6

(6
0.
22
–6
3.
30
)

11
,5
12
,5
30

32
.2
4

(3
1.
21
–3
3.
28
)

37
.7
0

(3
6.
48
–3
8.
93
)

20
10

23
,2
73
,6
18

43
.1
3

(4
2.
28
–4
3.
97
)

47
.8
5

(4
6.
91
–4
8.
80
)

11
,6
93
,7
29

54
.2
3

(5
2.
90
–5
5.
57
)

59
.4
7

(5
7.
99
–6
0.
95
)

11
,5
79
,8
89

31
.9
1

(3
0.
88
–3
2.
94
)

36
.2
4

(3
5.
06
–3
7.
41
)

20
11

23
,3
61
,6
90

44
.9
9

(4
4.
13
–4
5.
85
)

48
.5
9

(4
7.
66
–4
9.
53
)

11
,7
19
,3
56

56
.2
8

(5
4.
92
–5
7.
64
)

60
.3
3

(5
8.
87
–6
1.
79
)

11
,6
42
,3
34

33
.6
2

(3
2.
57
–3
4.
67
)

36
.8
6

(3
5.
70
–3
8.
01
)

20
12

23
,5
09
,9
00

47
.1
4

(4
6.
26
–4
8.
02
)

49
.7
8

(4
8.
85
–5
0.
71
)

11
,7
80
,4
25

56
.8
5

(5
5.
49
–5
8.
21
)

59
.7
2

(5
8.
28
–6
1.
15
)

11
,7
29
,4
75

37
.3
9

(3
6.
29
–3
8.
50
)

39
.8
4

(3
8.
66
–4
1.
02
)

20
13

23
,5
95
,3
08

47
.5
8

(4
6.
70
–4
8.
46
)

48
.8
6

(4
7.
96
–4
9.
77
)

11
,8
11
,2
25

57
.6
7

(5
6.
30
–5
9.
03
)

59
.0
7

(5
7.
66
–6
0.
47
)

11
,7
84
,0
83

37
.4
7

(3
6.
36
–3
8.
57
)

38
.6
6

(3
7.
52
–3
9.
80
)

20
14

23
,6
33
,1
48

49
.8
6

(4
8.
96
–5
0.
76
)

49
.8
6
(4
8.
96
–5
0.
76
)

11
,8
17
,5
77

58
.7
6

(5
7.
38
–6
0.
14
)

58
.7
6
(5
7.
38
–6
0.
14
)

11
,8
15
,5
71

40
.9
6

(3
9.
81
–4
2.
12
)

40
.9
6
(3
9.
81
–4
2.
12
)

8 BioMed Research International

lung cancer was slightly higher in the female than male pa-
tients aged ≤60 years, whereas the age-specific incidence of
lung cancer was predominant in male patients, except those
aged 25–35 years. Figure 5 shows the sex-specific differences
in the prevalence of smoking among adults in Taiwan during

2004–2017 [22]. -e overall prevalence of smoking among
adults decreased gradually from 24.1% in 2004 to 14.5% in
2017 as a result of a concurrent 38.5% decrease in prevalence
of smoking among men; the prevalence of smoking among
women, however, persisted at around 4% during these years.

Table 4: Joinpoint analysis of lung cancer prevalence by sex in Taiwan from 2002 to 2014.

Lung cancer prevalence (per 100,000 peopl

Average APC

Trend 1 Trend 2

2002 2014 Years APC (95% CI) Years APC (95% CI)

Prevalence
Total 93.38 (91.84–94.92) 132.40 (130.94–133.86) 3.1 (2.7–3.4)∗ 2002 to 2008 3.6 (3.1–4.2)∗ 2008 to 2014 2.5 (2.0–2.9)∗
Male 114.95 (112.56–117.35) 139.29 (137.17–141.40) 1.7 (1.3–2.0)∗ 2002 to 2008 2.7 (2.1–3.3)∗ 2008 to 2014 0.6 (0.1–1.1)∗
Female 71.79 (69.85–73.74) 125.50 (123.50–127.50) 5.0 (4.8–5.1)∗ 2002 to 2014 5.0 (4.8–5.1)∗

APC, annual percent change; ∗p<0.05.

85
90
95

100
105
110
115
120
125
130
135

140

A
ge

-a
dj

us
te

d
pr

ev
al
en
ce

Year

(a) (b) (c)

0 : 1 joinpoint

Observed
2002–2008 APC = 3.65∗

2008–2014 APC = 2.47∗

∗The annual percent change (APC) is
significantly different from zero at alpha = 0.05
final selected model: 1 joinpoint

20
01

20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14

20
15

A
ge
-a
dj
us
te
d
pr
ev
al
en
ce
Observed
2002–2008 APC = 3.65∗
2008–2014 APC = 2.47∗

105
110
115
120
125
130
135
140
145
150

1 : 1 joinpoint

Year
∗The annual percent change (APC) is
significantly different from zero at alpha = 0.05
final selected model: 1 joinpoint
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
A
ge
-a
dj
us
te
d
pr
ev
al
en
ce

60
65
70
75
80
85
90
95

100
105
110
115
120
125
130
135

2 : 0 joinpoints

∗The annual percent change (APC) is
significantly different from zero at alpha = 0.05
final selected model: 0 joinpoint

Year
Observed
2002–2008 APC = 4.96∗

20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15

Table 5: Joinpoint analysis of lung cancer incidence by sex in Taiwan from 2002 to 2014.

Lung cancer incidence (per 100,000 person-
years) Average APC

Trend 1 Trend 2

2002 2014 Years APC (95% CI) Years APC (95% CI)
Incidence
Total 45.04 (43.95–46.13) 49.86 (48.96–50.76) 0.7 (0.3–1.1)∗ 2002 to 2014 0.7 (0.3–1.1)∗
Male 57.50 (55.77–59.22) 58.76 (57.38–60.14) 0.2 (− 0.4–0.8) 2002 to 2006 2.2 (0.5–4.0)∗ 2006 to 2014 − 0.8 (− 1.3 to − 0.3)∗
Female 32.57 (31.24–33.91) 40.96 (39.81–42.12) 2.0 (1.5–2.5)∗ 2002 to 2014 2.0 (1.5–2.5)∗

APC, annual percent change; ∗p<0.05. (a) (b) (c) 35 40 45 50 55

60
0 : 0 joinpoint

∗The annual percent change (APC) is
significantly different from zero at alpha = 0.05
final selected model: 0 joinpoint

Year
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
A
ge
-a
dj
us
te
d
pr
ev
al
en
ce

Observed
2002–2014 APC = 0.71∗

∗The annual percent change (APC) is
significantly different from zero at alpha = 0.05
final selected model: 1 joinpoint

50
55
60
65

70
1 : 1 joinpoint

Year
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
A
ge
-a
dj
us
te
d
pr
ev
al
en
ce

Observed
2002–2014 APC = 2.24∗

2008–2014 APC = 0.79∗ ∗The annual percent change (APC) is
significantly different from zero at alpha = 0.05
final selected model: 0 joinpoint

25
30
35
40
45

50
2 : 0 joinpoints

Year
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
A
ge
-a
dj
us
te
d
pr
ev
al
en
ce

Observed
2002–2014 APC = 2.01∗

BioMed Research International 9

3.3. Analysis of Lung Cancer Overall Survival Rates.
Joinpoint analysis of overall lung cancer survival trends by sex
and CCI in Taiwan are shown in Table 6. -e 1-, 3-, and 5-year
survival rates of lung cancer in Taiwan improved significantly
in either sex, especially in the female patients with an average
APC of 11.8 (95% CI � 10.5–13.0) for the 5-year survival rate
during 2002–2010 (also see Figure 6). Despite these im-
provements, the 5-year survival rate in 2010 was merely
17.34% (12.60% in males, 25.40% in females). -e male lung
cancer patients had a relatively poor prognosis with 1-, 3-, and
5-year survival rates of 48.20% in 2014, 22.00% in 2012, and
12.60% in 2010, respectively, compared with 1-, 3-, and 5-year
survival rates of 70.60%, 41.10%, and 25.40%, respectively, in
the females. To evaluate the influence of comorbidities on the
overall survival rates, we stratified patients into two groups
according to the calculated CCI score at lung cancer diag-
nosis. Lung cancer patients with a CCI score ≤1 (28.7% of
total lung cancer patients) had much better prognosis with a

5-year survival rate of 24.5% in 2010 compared with a mere
14.2% in patients with a CCI score ≥2 (71.3% of total lung
cancer patients).

3.4. Analysis Based on the Histological Subtypes of Lung
Cancer. Table 7 shows the demographic characteristics of
patients with different histological subtypes of lung cancer.
Patients with lung adenocarcinoma comprised 54.49% of total
lung cancer patients during 2002–2014 and the highest
proportion of female patients (49.64%); moreover, these
patients had a higher socioeconomic status (urban residency,
higher income level, and professional occupation) compared
with patients with other subtypes of lung cancer. On the other
hand, patients with squamous cell carcinoma and SCLC were
presented at an older age (70.89±11.13 and 69.90±11.00
years); had more comorbidities at diagnosis (CCI: 3.58±2.86
and 4.02±3.14); were less likely to be a female (12.81% and

0~
5

6~
10

11
~1

16
~2

21
~2

26
~3

31
~3

36
~4

41
~4

46
~5

51
~5

56
~6

61
~6

66
~7

71
~7

76
~8

81
~8

86
~9

>9
1

Age

400

200

1000

800

600

400
200
0

Pr
ev

al
en

ce
(p

er
1

00
,0

00
p

eo
pl

Men
Women

(a)
0~
5
6~
10
11
~1
5
16
~2
0
21
~2
5
26
~3
0
31
~3
5
36
~4
0
41
~4
5
46
~5
0
51
~5
5
56
~6
0
61
~6
5
66
~7
0
71
~7
5
76
~8
0
81
~8
5
86
~9
0
>9
1
Age
Men
Women

500
450
400
350
300
250
200
150
100

50
0In

ci
de

nc
ec

(p
er

1
00

,0
00

p
er

so
n-

ye
ar

)
(b)

Figure 4: Age-specific (a) prevalence and (b) incidence of lung cancer in Taiwan in 2014 (blue: men; red: women).

10 BioMed Research International

Table 6: Joinpoint analysis of lung cancer overall survivala by sex and Charlson Comorbidity Index (CCI) in Taiwan from 2002 to 2014.

Lung cancer survival rate
Average APC

Trend 1 Trend 2

2002 Endb Years APC (95% CI) Years
APC

(95% CI)
Total
1-year survival

rate
37.81 (36.70–38.92) 57.39 (56.49–58.28)

3.60
(3.20–4.10)∗

2002 to
2014

3.60
(3.20–4.10)∗

3-year survival
rate

14.66 (13.86–15.48) 29.55 (28.70–30.40)
7.50

(6.50–8.60)∗
2002 to
2012

7.50
(6.50–8.60)∗

5-year survival
rate

9.37 (8.72–10.06) 17.34 (16.61–18.09)
9.30

(7.60–11.10)∗

2002 to
2010

9.30
(7.60–11.10)∗

Sex
Male
1-year

survival rate
34.90 (33.55–36.22) 48.20 (47.01–49.36)

3.10
(2.70–3.50)∗

2002 to
2014
3.10
(2.70–3.50)∗

3-year
survival rate

13.10 (12.13–14.02) 22.00 (20.99–22.97)
5.90

(4.60–7.30)∗
2002 to
2012

5.90
(4.60–7.30)∗

5-year
survival rate

8.40 (7.67–9.22) 12.60 (11.82–13.46)
6.30

(4.00–8.60)∗
2002 to
2010

6.30
(4.00–8.60)∗

Female
1-year

survival rate
43.70 (41.70–45.64) 70.60 (69.29–71.86)

4.10
(3.00–5.30)∗

2002 to
2007

6.30
(3.30–9.40)∗

2007 to
2014

2.60
(1.60–3.60)∗

3-year
survival rate

17.90 (16.37–19.42) 41.10 (39.66–42.57)
8.10

(7.00–9.30)∗
2002 to
2012

8.10
(7.00–9.30)∗

5-year
survival rate

11.30 (10.06–12.58) 25.40 (24.04–26.85)
11.80

(10.50–13.00)∗
2002 to
2010

11.80
(10.50–13.00)∗

CCI
CCI≤1
1-year

survival rate
42.40 (39.98–44.82) 69.80 (68.33–71.20)

4.00
(3.50–4.50)∗

2002 to
2014
4.00
(3.50–4.50)∗
3-year
survival rate

17.70 (15.85–19.59) 39.20 (37.58–40.79)
8.60

(6.90–10.20)∗
2002 to
2012

8.60
(6.90–10.20)∗

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Calendar year

80
70
60
50
40
30
20
10
0

Sm
ok

in
g

pr
ev

al
en

ce
(%

)

42.9
40 39.6 39 38.6

35.4 35 33.5 32.7 32.5
29.2 29.9 28.6 26.4

24.1 22.7 22.1 22.3 21.9 20 19.8 19.1 18.7 18 16.4 17.1 15.3 14.5

4.6 4.8 4.1 5.1 4.8 4.2 4.1 4.4 4.3 3.3 3.5 4.2 3.8 2.3

In Feb 2006, NT$ 10 surcharge was
added to each pack of cigarettes

In Jan 2009, the tobacco hazard prevention and control law started,
and in june, NT$ 20 surcharge was addes to each pack of cigarettes

Total
Male
Female

Figure 5: Sex-specific prevalence of smoking among adults (over 18 years of age) in Taiwan during 2004–2017 (green: total population; blue:
male; red: female). (1) Data based on adult smoking behavior survey provided by the Taiwan health promotion administration. (2) Current
smokers were defined as those who had smoked more than 100 cigarettes (5 packs) and had smoked within the past 30 days. (3) -e adult
smoking rate was weighted and standardized according to sex, age, educational level, and geographic region in year 2000.

BioMed Research International 11

Table 6: Continued.

Lung cancer survival rate
Average APC
Trend 1 Trend 2
2002 Endb Years APC (95% CI) Years
APC

(95% CI)
5-year

survival rate
11.40 (9.93–13.05) 24.50 (22.98–26.04)

11.30
(9.00–13.80)∗

2002 to
2010
11.30
(9.00–13.80)∗

CCI≥2
1-year

survival rate
36.50 (35.27–37.77) 51.20 (50.08–52.29)

3.10
(2.60–3.60)∗

2002 to
2014
3.10
(2.60–3.60)∗
3-year
survival rate

13.80 (12.93–14.72) 25.00 (24.05–26.00)
6.40

(5.60–7.20)∗
2002 to
2012

6.40
(5.60–7.20)∗

5-year
survival rate

8.80 (8.08–9.55) 14.30 (13.44–15.08)
7.40

(5.80–9.00)∗
2002 to
2010

7.40
(5.80–9.00)∗

APC, annual percent change; CCI, Charlson Comorbidity Index;∗p<0.05. aOverall survival of patients with lung cancer was extracted from overall mortality rates in the National Death Registry of Taiwan, and the relative survival rates were estimated using the life table method. b-e end year in one-year survival is 2014, the end year in three-year survival is 2012, and the end year in five-year survival is 2010.

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Calender year

80
70
60
50
40
30
20
10
0

Su
rv

iv
al

ra
te

(%
)

1-yr survival rate in men
3-yr survival rate in men
5-yr survival rate in men

(a)

Figure 6: Continued.

12 BioMed Research International

10.87%); and were less likely to be categorized into high
socioeconomic status among these subtypes.

Figure 7 illustrates the incident percentage of different
subtypes of lung cancer in Taiwan in 2002 and 2014. Ade-
nocarcinoma was the most abundant subtype of lung cancer,
growing from 43.47% of the total cases in 2002 (3,177 incident
cases) to 64.89% in 2014 (7,647 incident cases). Meanwhile,
the percentage of squamous cell carcinoma and SCLC de-
creased substantially during 2002–2014 (squamous cell car-
cinoma, 22.15% in 2002 to 15.61% in 2014; SCLC, 8.85% in
2002 to 7.26% in 2014). Table 8 shows the variation in overall
survival rates in different subtypes of lung cancer. In a
joinpoint analysis, the 5-year survival rate in 2010 for large cell
carcinoma, adenocarcinoma, squamous cell carcinoma, other
subtypes, and small cell carcinoma was 30.2%, 22.0%, 12.9%,
11.6%, and 4.4%, respectively. Among these subtypes, the
survival rates of adenocarcinoma improved most with an
average APC of 10.6 (95% CI � 8.4–12.9) for a 5-year survival
rate during 2002–2010. -e secular trends of 3-year overall
survival for patients with different subtypes (Figure 8)
revealed that large cell carcinoma had a relative better survival
rate, adenocarcinoma improved the most, and SCLC had a
relatively poor prognosis.

4. Discussion

In this population-based cohort study, which is mainly based
on the NHIRD, the temporal change of lung cancer epi-
demiology in Taiwan during 2002–2014 was evaluated
thoroughly by correlating with the histological subtypes and
overall survival rates. -e age-standardized incidence rate of
lung cancer in Taiwan was 49.86 per 100,000 person-years in
2014, which is lower than the reported incidence rate in

Europe and North America, but the trend of incidence kept
rising with an average APC of 0.7 (95% CI 0.3–1.1) during
2002–2014 [5]. A higher incidence of lung cancer was ob-
served in the males; however, the incidence in the females
increased more rapidly than that in the males, with the
female-to-male incidence ratio increasing from 0.56 in 2002
to 0.69 in 2014. Besides, we also observed that lung cancer
developed more frequently in patients with a higher income
level and urban residency. -e urban-rural disparity might
be correlated with a higher air pollution and environmental
smoke exposure in the urban areas. Adenocarcinoma
comprised almost two-thirds of lung cancer patients in 2014,
and the survival rates of patients with adenocarcinoma
improved the most during 2002–2014. Because of the
accelerated incidence and improved overall survival, ade-
nocarcinoma is becoming the increasingly predominant
histological subtype of lung cancer in Taiwan. Following the
one-third decrease in the prevalence of smoking among
adults in this period, the percentage of smoking-correlated
subtypes (squamous cell carcinoma and SCLC) also declined
substantially. -e 5-year survival rate of lung cancer was
17.34% in 2010, but it improved a lot with an average APC of
9.30 during 2002–2010, especially in the female patients and
patients with the adenocarcinoma subtype.

SCLC is strongly associated with cigarette smoking and,
consequently, it is deemed as highly preventable. -e de-
creased incidence of SCLC in the United States over the past
30 years could be explained by the decrease in the prevalence
of smoking, particularly among men, and by the decrease in
the percentage of tar and nicotine in cigarettes [23]. Based on
the increasing health and economic burden of tobacco use,
the Taiwan Ministry of Health and Welfare implemented the
Tobacco Hazards Prevention Act in 1997 and has put

80
70
60
50
40
30
20
10
0
Su
rv
iv
al
ra
te
(%
)
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Calender year

1-yr survival rate in women
3-yr survival rate in women
5-yr survival rate in women

(b)

Figure 6: Secular trends of 1-year, 3-year, and 5-year survival rates of lung cancer in (a) men and (b) women in Taiwan from 2002 to 2014
(blue: 1-year survival rate; red: 3-year survival rate; green: 5-year survival rate).

BioMed Research International 13

T
a
b
le

7:
C
lin

ic
al

ch
ar
ac
te
ri
st
ic
s
of

lu
ng
ca
nc
er

pa
tie
nt
s
w
ith

di
ffe
re
nt

hi
st
ol
og
ic
al

su
bt
yp
es

in
Ta
iw
an
fr
om
20
02
to
20
14
.

La
rg
e
ce
ll

ca
rc
in
om

a
(N

�
1,
31
9)

Sm
al
l
ce
ll

ca
rc
in
om
a
(N

�
10
,5
82
)

A
de
no

ca
rc
in
om
a
(N

�
67
,6
49
)

Sq
ua
m
ou

s
ce
ll

ca
rc
in
om
a
(N

�
22
,9
51
)

O
th
er

ty
pe
s
of

lu
ng
ca
nc
er

(N
�
21
,6
47
)

A
ge

(y
ea
rs
)
(m

ea
n
±
st
an
da
rd

de
vi
at
io
n)

65
.6
6
±
12
.9
1

69
.9
0
±
11
.0
0

66
.4
3
±
12
.9
6

70
.8
9
±
11
.1
3

72
.0
7
±
13
.1
7

Se
x F
em

al
e

39
3

29
.8

1,
15
0

10
.8
7

33
,5
84

49
.6
4

2,
94
0

12
.8
1

6,
93
6

32
.0
4

M
al
e

92
6

70
.2

9,
43
2

89
.1
3

34
,0
65

50
.3
6

20
,0
11

87
.1
9

14
,7
11

67
.9
6

Pl
ac
e
of

re
si
de
nc
e,
no

.(
%
)

rb
an

66
0

(5
0.
04
)

4,
95
3

(4
6.
81
)

36
,7
65

(5
4.
35
)

10
,0
20

(4
3.
66
)

9,
78
9

(4
5.
22
)

Su
bu

rb
an

39
4

(2
9.
87
)

3,
17
0

(2
9.
96
)

19
,5
60

(2
8.
91
)

42
4

(3
2.
35
)

6,
32
5

(2
9.
22
)

R
ur
al

14
7

(1
1.
14
)

1,
35
6

(1
2.
81
)

7,
28
4

(1
0.
77
)

3,
45
6

(1
5.
06
)

2,
65
7

(1
2.
27
)

U
nk

no
w
n

11
8

(8
.9
5)

1,
10
3

(1
0.
42
)

4,
04
0

(5
.9
7)

2,
05
1

(8
.9
4)

2,
87
6

(1
3.
29
)

In
co
m
e
le
ve
ls
,n

o.
(%

)

Q
ui
nt
ile

1
17
6

(1
3.
34
)

1,
66
8

(1
5.
76
)

7,
81
7

(1
1.
56
)

3,
38
8

(1
4.
76
)

3,
48
7

(1
6.
11
)

Q
ui
nt
ile

2
31
1

(2
3.
58
)

2,
67
3

(2
5.
26
)

16
,7
52

(2
4.
76
)

6,
19
6

(2
7.
0)

5,
70
0

(2
6.
33
)

Q
ui
nt
ile

3
15
7

(1
1.
9)

1,
45
8

(1
3.
78
)

8,
35
4

(1
2.
35
)

3,
40
6

(1
4.
84
)

2,
81
5

(1
3.
0)

Q
ui
nt
ile

4
30
9

(2
3.
43
)

2,
12
7

(2
0.
1)

15
,6
74

(2
3.
17
)

4,
86
1

(2
1.
18
)

3,
56
3

(1
6.
46
)

Q
ui
nt
ile

5
25
3

(1
9.
18
)

1,
56
8

(1
4.
82
)

15
,2
77

(2
2.
58
)

3,
12
0

(1
3.
59
)

3,
25
1

(1
5.
02
)

U
nk
no
w
n

11
3

(8
.5
7)

1,
08
8

(1
0.
28
)

3,
77
5

(5
.5
8)

1,
98
0

(8
.6
3)

2,
83
1

(1
3.
08
)

O
cc
up

at
io
n,

no
.(
%
)

D
ep
en
de
nt
s
of

th
e
in
su
re
d
in
di
vi
du

al
s

36
9

(2
7.
98
)

2,
93
8

(2
7.
76
)

21
,2
25

(3
1.
38
)

6,
21
0

(2
7.
06
)

6,
05
4

(2
7.
97
)

C
iv
il
se
rv
an
ts
,t
ea
ch
er
s,
m
ili
ta
ry

pe
rs
on

ne
l,
an
d

ve
te
ra
ns

50
(3
.7
9)

44
6

(4
.2
1)

3,
37
9

(4
.9
9)

1,
05
0

(4
.5
7)

95
1

(4
.3
9)

N
on

m
an
ua
l
w
or
ke
rs

an
d
pr
of
es
si
on

al
s

10
0

(7
.5
8)

45
0

(4
.2
5)

6,
46
8

(9
.5
6)

93
9

(4
.0
9)

1,
03
3

(4
.7
7)

M
an
ua
l
w
or
ke
rs

42
4

(3
2.
15
)

3,
33
5

(3
1.
52
)

20
,4
48

(3
0.
23
)

8,
18
4

(3
5.
66
)

6,
42
2

(2
9.
67
)

O
th
er

37
6

(2
8.
51
)

3,
41
3

(3
2.
25
)

16
,1
29

(2
3.
84
)

6,
56
8

(2
8.
62
)

7,
18
7

(3
3.
2)

C
ha
rl
so
n
In
de
x
(m

ea
n
±
st
an
da
rd
de
vi
at
io
n)

3.
58
±
3.
01

4.
02
±
3.
14

3.
68
±
3.
09

3.
58
±
2.
86

4.
29
±
3.
22

14 BioMed Research International

Squamous cell carcinoma
Other types of lung cancer

Large cell carcinoma
Small cell carcinoma
Adenocarcinoma

0.88

8.85

43.47

22.15

24.64

(a)
Squamous cell carcinoma
Other types of lung cancer
Large cell carcinoma
Small cell carcinoma
Adenocarcinoma

1.05

7.26

64.89

11.18

15.61

(b)

Figure 7: Percentage of different histological subtypes of lung cancer in Taiwan in (a) 2002 and (b) 2014 (red: adenocarcinoma; gray:
squamous cell carcinoma; blue: other types of lung cancer; yellow: small cell carcinoma; green: large cell carcinoma).

Table 8: Joinpoint analysis of overall survivala for lung cancer patients with different histological subtypes in Taiwan during 2002–2014.

Lung cancer survival rate
Average APC

Trend 1 Trend 2
2002 Endb Years APC (95% CI) Years APC (95% CI)

Large cell carcinoma
1-year survival

rate
40.60 (28.61–52.29) 58.10 (48.88–66.18)

2.60
(1.00–4.10)∗

2002 to
2014
2.60
(1.00–4.10)∗
3-year survival
rate

21.90 (12.73–32.61) 36.80 (28.42–45.18)
4.70

(2.30–7.20)∗
2002 to
2012

4.70
(2.30–7.20)∗

5-year survival
rate

20.30 (11.52–30.86) 30.20 (21.76–39.04)
5.80

(0.20–11.70)∗
2002 to
2010

5.80
(0.20–11.70)∗

Small cell carcinoma
1-year survival

rate
27.40 (23.98–30.83) 29.10 (26.08–32.16)

1.70
(0.60–2.70)∗

2002 to
2014
1.70
(0.60–2.70)∗
3-year survival
rate

5.60 (3.98–7.52) 5.30 (3.90–6.94)
2.20

(− 0.30–4.70)
2002 to
2012

2.20
(− 0.30–4.70)

5-year survival
rate

3.10 (1.95–4.64) 4.40 (3.12–5.91)
5.40

(2.10–8.80)∗
2002 to
2010

5.40
(2.10–8.80)∗

Adenocarcinoma
1-year survival

rate
44.70 (42.96–46.42) 67.90 (66.81–68.90)

3.70
(2.80–4.70)∗

2002 to
2007

5.50
(3.10–7.90)∗

2007 to
2014

2.50
(1.70–3.30)∗

3-year survival
rate

17.70 (16.41–19.07) 38.30 (37.15–39.45)
7.60

(6.20–8.90)∗
2002 to
2012

7.60
(6.20–8.90)∗

5-year survival
rate

11.10 (10.08–12.27) 22.00 (20.93–23.07)
10.60

(8.40–12.90)∗
2002 to
2010

10.60
(8.40–12.90)∗

Squamous cell carcinoma
1-year survival

rate
38.50 (36.11–40.85) 43.00 (40.72–45.24)

1.20
(0.70–1.60)∗

2002 to
2014
1.20
(0.70–1.60)∗

BioMed Research International 15

forward a sequential Health and Welfare Surcharge since 2002
[24]. -e Taiwan government also joined the global fight against
tobacco by participating in the Framework Convention for
Tobacco Control under the auspices of the WHO in 2005 and
endeavored to implement the MPOWER package [24]. To
monitor the effects of the tobacco control legislations, the
Taiwan Health Promotion Administration has been conducting
an annual national telephone survey on smoking behavior since
2004 [22]. Ever since, a significant decrease in the prevalence of
smoking has been observed in Taiwan, mainly among the
middle-aged men; we have also observed a significant decrease
in smoking-correlated subtypes of lung cancer in our study.
Although initial success has been achieved in reducing the
prevalence of cigarette smoking, efforts to promote smoking
prevention, encourage smoking cessation, and reduce sec-
ondhand smoke exposure remain our top priority [25].

Most women with lung cancer are nonsmokers, how-
ever, and the incidence of lung adenocarcinoma became

increasingly predominant, especially in the Asian population
[9]. Indoor and outdoor air pollution has been deemed as a
significant contributor for lung cancer, especially for lung
adenocarcinoma and female patients; additionally, it might
play a role in the observed urban-rural disparity of lung
cancer in Taiwan [26]. -e exposure-response relationship
was demonstrated by several large cohorts where each 10 μg/
m3 increase in the ambient PM 2.5 concentration was
correlated with an increased risk of lung adenocarcinoma
(hazard ratio 1.31; 95% CI � 0.87–1.97) in nonsmokers and
an additional 15–27% risk of lung cancer mortality in
lifelong never-smokers [26–28]. Former smokers had an
additional risk of lung cancer in association with outdoor
particular matter exposure compared with never-smokers
[29]. -erefore, the International Agency for Research on
Cancer announced in 2013 that outdoor air pollution ex-
posure, especially particulate matter, as a Group 1 carcin-
ogen to human, especially for lung cancer [26]. -e

Table 8: Continued.

Lung cancer survival rate
Average APC
Trend 1 Trend 2
2002 Endb Years APC (95% CI) Years APC (95% CI)
3-year survival
rate

15.60 (13.85–17.38) 17.40 (15.65–19.14)
2.10

(0.80–3.50)∗
2002 to
2012

2.10
(0.80–3.50)∗

5-year survival
rate

10.60 (9.18–12.18) 12.90 (11.37–14.46)
3.10

(− 0.40–6.80)
2002 to
2008

0.30
(− 2.80–3.60)

2008 to
2010

12.00
(− 5.60–33.00)

Other subtypes of lung cancer
1-year survival

rate
28.70 (26.63–30.81) 35.00 (32.43–37.58)

1.40
(0.70–2.10)∗

2002 to
2014
1.40
(0.70–2.10)∗
3-year survival
rate

11.40 (10.02–12.96) 16.40 (14.53–18.36)
4.10

(2.50–5.80)∗
2002 to
2012

4.10
(2.50–5.80)∗

5-year survival
rate

7.00 (5.88–8.24) 11.60 (10.07–13.21)
5.00

(2.00–8.20)∗
2002 to
2010

5.00
(2.00–8.20)∗

APC, annual percent change; ∗p<0.05. aOverall survival of patients with lung cancer were extracted from overall mortality rates in the National Death Registry of Taiwan, and the relative survival rates were estimated using the life table method. b-e end year in one-year survival is 2014, the end year in three-year survival is 2012, and the end year in five-year survival is 2010.

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Calender year

50
45
40
35
30
25
20
15
10
5
0
Su
rv
iv
al
ra
te
(%
)

Large cell carcinoma
Squamous cell carcinoma
Small cell carcinoma

Adenocarcinoma
Other types of lung cancer

Figure 8: Secular trends of 3-year survival rate in patients with different subtypes of lung cancer (orange: large cell carcinoma; red: adenocarcinoma;
blue: squamous cell carcinoma; green: other types of lung cancer; gray: small cell carcinoma).

16 BioMed Research International

deteriorating air pollution in the Asian countries after de-
cades of rapid industrialization and urbanization has been
recognized as the worst region among the world [30]. -e
potential health impacts of air pollution are multisystemic,
and several studies had established the causal link of PM2.5
with lung cancer, ischemic heart disease, stroke, and pul-
monary diseases [31]. Taiwan has established a nationwide
air quality monitoring system and has been releasing a
monthly report of PM2.5 concentration since 2005 [21]. -e
PM2.5 distribution was generally higher in central and
southwestern Taiwan possibly due to widespread coal-fired
power plants and heavy industries. Although the PM2.5
concentration in most areas of Taiwan has shown decreasing
trends in recent years along with other air pollutants, the
estimated national average of annual PM2.5 concentration
in 2017 (20.7 μg/m3) was still far above the optimal level
recommended by WHO air quality guideline (10 μg/m3)
[21, 32]. Since the consequence of air pollution is far-
reaching and long-lasting, our government should set more
stringent air pollution regulations and enforce environ-
mental protection for benefit of the next generation.

Delayed diagnosis is the major reason behind poor long-
term survival of lung cancer patients, as most patients were
at an advanced stage at first diagnosis which made early
interventions almost impossible. Regarding surveillance of
lung cancer, low-dose computed tomography (CT) was
effective in identifying lung cancer at early stage. -e Na-
tional Lung Screening Trial conducted in the US deduced
that screening with the use of low-dose CTreduced 20.0% of
lung cancer-specific mortality compared with chest radi-
ography in high-risk smokers (aged 55–75 years with
smoking intensity≥30 pack-years) [33]. -erefore, low-dose
CT has already been included under insurance coverage for
screening of lung cancer by the Centers for Medicare and
Medicaid Services in the US since 2015 [34]. In Taiwan, the
majority of lung cancer cases identified by the use of low-
dose CTscreening were adenocarcinoma at early stage. -us,
implementation of CT screening in Taiwan would be more
cost-effective than in the Western countries where adeno-
carcinoma is less prevalent [35, 36]. Radiation exposure and
risk of malignancy arising from the use of low-dose CT
screening for lung cancer might be a major concern, but
many screening trials showed that these related risks can be
considered acceptable and even negligible considering the
associated substantial mortality reduction [37]. With ac-
cessible health checkup services and an appropriate
screening program for the high-risk population, the use of
low-dose CT screening might identify more patients with
early stage, potentially curable lung cancer for timely
treatment and thereby improve the overall prognosis [38].

Strengths of this study include an extended 13-year follow-
up period (2002–2014) with a total of 124,148 observed lung
cancer patients; representative data extracted from the na-
tionwide database of the NHIRD, the TCRD, and NDR; de-
tailed analyses of socioeconomic status, comorbidities,
histological subtypes, and geographic variations; and the
availability of ecologic measures of plausible risk factors in-
cluding air pollution concentration and smoking prevalence.
-erefore, our updated reports on lung cancer epidemiology

are comprehensive and trustworthy for the Taiwanese pop-
ulation. -e epidemiological results presented here provide
valuable information for the development of future healthcare
policies in order to reduce the huge burden of lung cancer.

-ere were several limitations and uncertainties in our
study. First, clinical information on stages, treatment, and
molecular profiling of lung cancer were not presented in this
study due to the limitations of the available databases.
-erefore, it became inaccessible to evaluate the possible im-
pact of early surveillance, novel therapies, and other prognostic
factors on overall survival of lung cancer. Nevertheless, we have
managed to include the latest available evidences to present a
comprehensive lung cancer epidemiology in Taiwan. Second,
the associations between known carcinogens and the incidence
or mortality rate of lung cancer are difficult to evaluate based on
available information. For example, our presented air pollution
indicators (PSI, PM 2.5) might provide partially explanation for
the higher prevalence and incidence of lung cancer in the
southwestern Taiwan. But the other geographic variation of
lung cancer distribution requires further investigation on other
causative factors such as smoking, environmental carcinogens,
or subpopulation susceptibility. -ird, coding errors might
occur in large national databases despite routine checkup, thus
leading to possible underestimation of the incidence and
survival rates of lung cancer.

5. Conclusion

-is nationwide cohort study of lung cancer in Taiwan found
that the incidence and prevalence of lung cancer increased
1.11-fold and 1.42-fold, respectively, with almost two-thirds of
patients with lung cancer belonging to subtype of adenocar-
cinoma in 2014. -e slowing down of the incidence of lung
cancer in male patients and decrease of smoking-correlated
subtypes (SCLC and squamous cell carcinoma) might be at-
tributed to the dramatic decrease in the prevalence of smoking
in adults, especially among the middle-aged males. -e overall
survival rates of lung cancer were relatively poor, but it im-
proved a lot in these years, especially in female patients and
patients with adenocarcinoma. -e Taiwan government has
implemented sequential strategies to alleviate the health and
economic burden of lung cancer, including tobacco control
regulations, reduction of air pollution, application of so-
phisticated therapeutics, and early surveillance with low-dose
CT screening. Despite these efforts, the incidence of lung
cancer in Taiwan was still on the rise and the attributable
cancer deaths were the highest among all malignancies.
-erefore, we should dedicate more resources to improve the
prevention strategies, encourage early surveillance, and de-
velop effective therapeutics for lung cancer patients in Taiwan.

Data Availability

-e data used to support the findings of this study are
available from the corresponding author upon request.

Conflicts of Interest

-e authors declare no conflicts of interest in this work.

BioMed Research International 17

Authors’ Contributions

Dr. H-P Yu had full access to all the data in the study and
takes responsibility for the integrity of the data and the
accuracy of the data analysis. F-C Liu, H-T Lin, and H-P Yu
conceived and designed the study. C-F Kuo and H-P Yu
were involved in data acquisition. H-T Lin, F-C Liu, C-Y
Wu, C-F Kuo, and W-C Lan were responsible for data
analysis and interpretation. F-C Liu, C-F Kuo, and H-P Yu
carried out funding acquisition. H-T Lin, F-C Liu, C-Y Wu,
W-C Lan, and H-P Yu wrote the draft and revised the
manuscript. All authors approved the final manuscript. Dr.
Huan-Tang Lin and Dr. Fu-Chao Liu contributed equally in
this study.

Acknowledgments

-is work was partially supported by grants from the Na-
tional Science Council of Taiwan (105-2314-B-182A-137-
MY3 and 105-2314-B-182A-012-MY3) and the Chang Gung
Memorial Hospital (CORP3E0132, CORP3E0152,
CMRPG3F1011-3, and CMRPG3D1671). -e analyzed data
were partially obtained via Applied Health Research Data
Integration Service from the National Health Insurance
Administration. -e work also received support from the
Maintenance Project of the Center for Big Data Analytics
and Statistics (Grant CLRPG3D0045) at Chang Gung Me-
morial Hospital. -e authors thank the statistical assistance
from the Center for Big Data Analytics and Statistics at
Chang Gung Memorial Hospital for study design and
monitoring, data analysis, and interpretation. -is study was
partially based on data from the NHI research database
provided by the National Health Insurance Administration,
Ministry of Health and Welfare, and managed by the Na-
tional Health Research Institutes.

References

[1] F. Bray, J. Ferlay, I. Soerjomataram, R. L. Siegel, L. A. Torre,
and A. Jemal, “Global cancer statistics 2018: GLOBOCAN
estimates of incidence and mortality worldwide for 36 cancers
in 185 countries,” CA: A Cancer Journal for Clinicians, vol. 68,
no. 6, pp. 394–424, 2018.

[2] J. Ferlay, M. Colombet, I. Soerjomataram et al., “Estimating
the global cancer incidence and mortality in 2018: GLO-
BOCAN sources and methods,” International

Journal of

Cancer, vol. 144, no. 8, pp. 1941–1953, 2019.

[3] C. Global Burden of Disease Cancer, C. Fitzmaurice,
C. Allen et al., “Global, regional, and national cancer in-
cidence, mortality, years of life lost, years lived with dis-
ability, and disability-adjusted life-years for 32 cancer
groups, 1990 to 2015: a systematic analysis for the global
burden of disease study,” JAMA Oncology, vol. 3, no. 4,
pp. 524–548, 2017.

[4] C. Allemani, T. Matsuda, V. Di Carlo et al., “Global sur-
veillance of trends in cancer survival 2000–2014 (CONCORD-
3): analysis of individual records for 37,513,025 patients di-
agnosed with one of 18 cancers from 322 population-based
registries in 71 countries,” %e Lancet, vol. 391, no. 10125,
pp. 1023–1075, 2018.

[5] T.-Y. D. Cheng, S. M. Cramb, P. D. Baade, D. R. Youlden,
C. Nwogu, and M. E. Reid, “-e international epidemiology of
lung cancer: latest trends, disparities, and tumor character-
istics,” Journal of %oracic Oncology, vol. 11, no. 10,
pp. 1653–1671, 2016.

[6] A. Jemal, K. D. Miller, J. Ma et al., “Higher lung cancer in-
cidence in young women than young men in the United
States,” New England Journal of Medicine, vol. 378, no. 21,
pp. 1999–2009, 2018.

[7] J. M. Samet, E. Avila-Tang, P. Boffetta et al., “Lung cancer in
never smokers: clinical epidemiology and environmental risk
factors,” Clinical Cancer Research, vol. 15, no. 18,
pp. 5626–5645, 2009.

[8] W. D. Travis, E. Brambilla, H. K. Müller-Hermelink, and
C. C. Harris, Pathology and Genetics: Tumours of the Lung,
Pleura, %ymus and Heart. Lyon: International Agency for
Research on Cancer, World Health Organization Press, Ge-
neva, Switzerland, 2004.

[9] J. Y. Huang, Z. H. Jian, O. N. Nfor et al., “-e effects of
pulmonary diseases on histologic types of lung cancer in both
sexes: a population-based study in Taiwan,” BMC Cancer,
vol. 15, no. 1, p. 834, 2015.

[10] A. Midha, S. Dearden, and R. McCormack, “EGFR mutation
incidence in non-small-cell lung cancer of adenocarcinoma
histology: a systematic review and global map by ethnicity
(mutMapII),” American Journal of Cancer Research, vol. 5,
no. 9, pp. 2892–2911, 2015.

[11] L. A. Tse, I. T. Yu, J. S. Au et al., “Environmental tobacco
smoke and lung cancer among Chinese nonsmoking males:
might adenocarcinoma be the culprit?,” American Journal of
Epidemiology, vol. 169, no. 5, pp. 533–541, 2009.

[12] X.-R. Wang, Y.-L. Chiu, H. Qiu, J. S. K. Au, and I. T.-S. Yu,
“-e roles of smoking and cooking emissions in lung cancer
risk among Chinese women in Hong Kong,” Annals of On-
cology, vol. 20, no. 4, pp. 746–751, 2009.

[13] B.-Y. Wang, J.-Y. Huang, C.-Y. Cheng, C.-H. Lin, J. L. Ko, and
Y.-P. Liaw, “Lung cancer and prognosis in taiwan: a pop-
ulation-based cancer registry,” Journal of %oracic Oncology,
vol. 8, no. 9, pp. 1128–1135, 2013.

[14] J. S. Chang, L.-T. Chen, Y.-S. Shan et al., “Comprehensive
analysis of the incidence and survival patterns of lung cancer
by histologies, including rare subtypes, in the era of molecular
medicine and targeted therapy,” Medicine, vol. 94, no. 24,
p. e969, 2015.

[15] National Health Insurance Administration and Ministry of
Health and Welfare, Executive Yuan, 2015-2016 National Health
Insurance Annual Report, National Health Insurance Adminis-
tration, MOHW, Taipei, Taiwan, 2015, https://www.nhi.gov.tw/
Resource/webdata/30285_1_National%20Health%20Insurance%
20in%20Taiwan%202015-2016%20(bilingual) .

[16] W.-H. Kao, J.-H. Hong, L.-C. See et al., “Validity of cancer
diagnosis in the national health insurance database compared
with the linked national cancer registry in taiwan,” Phar-
macoepidemiology and Drug Safety, vol. 27, no. 10,
pp. 1060–1066, 2018.

[17] C.-J. Chiang, S.-L. You, C.-J. Chen, Y.-W. Yang, W.-C. Lo,
and M.-S. Lai, “Quality assessment and improvement of
nationwide cancer registration system in Taiwan: a review,”
Japanese Journal of Clinical Oncology, vol. 45, no. 3,
pp. 291–296, 2015.

[18] C.-J. Chiang, W.-C. Lo, Y.-W. Yang, S.-L. You, C.-J. Chen,
and M.-S. Lai, “Incidence and survival of adult cancer patients
in Taiwan, 2002–2012,” Journal of the Formosan Medical
Association, vol. 115, no. 12, pp. 1076–1088, 2016.

18 BioMed Research International

https://www.nhi.gov.tw/Resource/webdata/30285_1_National%20Health%20Insurance%20in%20Taiwan%202015-2016%20(bilingual)

[19] G. Forjaz de Lacerda, N. Howlader, and A. B. Mariotto,
“Differences in cancer survival with relative versus cause-
specific approaches: an update using more accurate life ta-
bles,” Cancer Epidemiology Biomarkers & Prevention, vol. 28,
no. 9, pp. 1544–1551, 2019.

[20] TWEPA, “Taiwan air quality monitoring Network,” February
2019, https://taqm.epa.gov.tw/taqm/en/YearlyDataDownload.
aspx.

[21] “Air quality information, environment resource database,”
February 2019, https://erdb.epa.gov.tw/ENG/DataRepository/
EnvMonitor/AirQualityMonitorMonData.aspx?topic1�Air&
topic2�Environmental+and+Biological+Monitoring&subject�
Air+Quality.

[22] “Adult smoking behavior surveillance system (ASBS), health
promotion administration, Ministry of health and Welfare,”
February 2019, https://www.hpa.gov.tw/Pages/List.aspx?
nodeid�1710.

[23] R. Mao, T. Chen, F. Zhou et al., “-e burdens of lung cancer
involved multiple primary cancers and its occurring patterns-
SEER Analysis between 1973 and 2006,” Scientific Reports,
vol. 7, no. 1, p. 6451, 2017.

[24] “Health education and tobacco control, health promotion ad-
ministration, Ministry of health and Welfare,” February 2019,
https://www.hpa.gov.tw/EngPages/List.aspx?nodeid�1078.

[25] M. Sanna, W. Gao, Y. W. Chiu et al., “Tobacco control within
and beyond WHO MPOWER: outcomes from Taiwan
SimSmoke,” Tobacco Control, vol. 29, no. 1, pp. 36–42, 2018.

[26] L. Gharibvand, W. Lawrence Beeson, D. Shavlik et al., “-e
association between ambient fine particulate matter and in-
cident adenocarcinoma subtype of lung cancer,” Environ-
mental Health, vol. 16, no. 1, p. 71, 2017.

[27] M. C. Turner, D. Krewski, C. A. Pope 3rd, Y. Chen,
S. M. Gapstur, and M. J. -un, “Long-term ambient fine par-
ticulate matter air pollution and lung cancer in a large cohort of
never-smokers,” American Journal of Respiratory and Critical
Care Medicine, vol. 184, no. 12, pp. 1374–1381, 2011.

[28] S. Cakmak, C. Hebbern, L. Pinault et al., “Associations be-
tween long-term PM2.5 and ozone exposure and mortality in
the Canadian Census Health and Environment Cohort
(CANCHEC), by spatial synoptic classification zone,” Envi-
ronment International, vol. 111, pp. 200–211, 2018.

[29] G. B. Hamra, N. Guha, A. Cohen et al., “Outdoor particulate
matter exposure and lung cancer: a systematic review and
meta-analysis,” Environmental Health Perspectives, vol. 122,
no. 9, pp. 906–911, 2014.

[30] T.-C. Su, S.-Y. Chen, and C.-C. Chan, “Progress of ambient air
pollution and cardiovascular disease research in Asia,”
Progress in Cardiovascular Diseases, vol. 53, no. 5, pp. 369–
378, 2011.

[31] W.-C. Lo, R.-H. Shie, C.-C. Chan, and H.-H. Lin, “Burden of
disease attributable to ambient fine particulate matter ex-
posure in Taiwan,” Journal of the Formosan Medical Associ-
ation, vol. 116, no. 1, pp. 32–40, 2017.

[32] World Health Organization, WHO Air Quality Guidelines for
Particulate Matter, Ozone, Nitrogen Dioxide and Sulfur
Dioxide–Global Update 2005, World Health Organization,
Geneva, Switzerland, 2018, https://www.who.int/airpollution/
publications/aqg2005/en/.

[33] National Lung Screening Trial Research Team, D. R. Aberle,
A. M. Adams et al., “National Lung Screening Trial Research
Team. Reduced lung-cancer mortality with low-dose com-
puted tomographic screening,” %e New England Journal of
Medicine, vol. 365, no. 5, pp. 395–409, 2011.

[34] Centers for Medicare & Medicaid Services, Decision Memo for
Screening for Lung Cancer with Low Dose Computed To-
mography (LDCT). (CAG-00439N), Centers for Medicare &
Medicaid Services, Baltimore, MA, USA, 2015, https://www.
cms.gov/medicare-coverage-database/details/nca-decision-
memo.aspx?NCAId�274.

[35] C.-Y. Chen, C.-H. Chen, T.-C. Shen et al., “Lung cancer
screening with low-dose computed tomography: experiences
from a tertiary hospital in Taiwan,” Journal of the Formosan
Medical Association, vol. 115, no. 3, pp. 163–170, 2016.

[36] S.-C. Yang, W.-W. Lai, C.-C. Lin et al., “Cost-effectiveness of
implementing computed tomography screening for lung
cancer in Taiwan,” Lung Cancer, vol. 108, pp. 183–191, 2017.

[37] C. Rampinelli, P. De Marco, D. Origgi et al., “Exposure to low
dose computed tomography for lung cancer screening and
risk of cancer: secondary analysis of trial data and risk-benefit
analysis,” BMJ, vol. 356, p. j347, 2017.

[38] M. C. Tammemagi, H. Schmidt, S. Martel et al., “Participant
selection for lung cancer screening by risk modelling (the
Pan-Canadian Early Detection of Lung Cancer [PanCan]
study): a single-arm, prospective study,” %e Lancet Oncology,
vol. 18, no. 11, pp. 1523–1531, 2017.

BioMed Research International 19

https://taqm.epa.gov.tw/taqm/en/YearlyDataDownload.aspx

https://erdb.epa.gov.tw/ENG/DataRepository/EnvMonitor/AirQualityMonitorMonData.aspx?topic1=Air&topic2=Environmental+and+Biological+Monitoring&subject=Air+Quality

https://www.hpa.gov.tw/Pages/List.aspx?nodeid=1710

https://www.hpa.gov.tw/EngPages/List.aspx?nodeid=1078

https://www.who.int/airpollution/publications/aqg2005/en/

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274

Stem Cells
International

Hindawi
www.hindawi.com

Volume 2018

Hindawi
www.hindawi.com Volume 2018

MEDIATORS
INFLAMMATION

Endocrinology
International Journal of

Hindawi
www.hindawi.com Volume 2018
Hindawi
www.hindawi.com Volume 2018

Disease Markers

Hindawi
www.hindawi.com Volume 2018

BioMed
Research International

Oncology
Journal of

Hindawi
www.hindawi.com Volume 2013

Hindawi
www.hindawi.com Volume 2018

Oxidative Medicine and
Cellular Longevity

Hindawi
www.hindawi.com Volume 2018

PPAR Research

Hindawi Publishing Corporation
http://www.hindawi.com Volume 2013
Hindawi
www.hindawi.com

The Scientific
World Journal

Volume 2018

Immunology Research
Hindawi
www.hindawi.com Volume 2018

Journal of

Obesity
Journal of

Hindawi
www.hindawi.com Volume 2018
Hindawi
www.hindawi.com Volume 2018

Computational and
Mathematical Methods
in Medicine

Hindawi
www.hindawi.com Volume 2018

Behavioural
Neurology

Ophthalmology
Journal of

Hindawi
www.hindawi.com Volume 2018

Diabetes Research
Journal of

Hindawi
www.hindawi.com Volume 2018
Hindawi
www.hindawi.com Volume 2018

Research and Treatment
AIDS

Hindawi
www.hindawi.com Volume 2018

Gastroenterology
Research and Practice

Hindawi
www.hindawi.com Volume 2018

Parkinson’s
Disease

Evidence-Based
Complementary and
Alternative Medicine

Volume 2018
Hindawi
www.hindawi.com

Submit your manuscripts at
www.hindawi.com

https://www.hindawi.com/journals/sci/

https://www.hindawi.com/journals/mi/

https://www.hindawi.com/journals/ije/

https://www.hindawi.com/journals/dm/

https://www.hindawi.com/journals/bmri/

https://www.hindawi.com/journals/jo/

https://www.hindawi.com/journals/omcl/

https://www.hindawi.com/journals/ppar/

https://www.hindawi.com/journals/tswj/

https://www.hindawi.com/journals/jir/

https://www.hindawi.com/journals/jobe/

https://www.hindawi.com/journals/cmmm/

https://www.hindawi.com/journals/bn/

https://www.hindawi.com/journals/joph/

https://www.hindawi.com/journals/jdr/

https://www.hindawi.com/journals/art/

https://www.hindawi.com/journals/grp/

https://www.hindawi.com/journals/pd/

https://www.hindawi.com/journals/ecam/

https://www.hindawi.com/

Copyright of BioMed Research International is the property of Hindawi Limited and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.

Article Analysis

Article Citation

and Permalink
(APA format)

Article 1

Article 2

Point

Description

Broad Topic Area/Title

Define Hypotheses

Define Independent and Dependent Variables and Types of Data for Variables

Population of Interest for the Study

Sample

Sampling Method

How Were Data Collected?

What Will You Get?

We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.

Premium Quality

Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.

Experienced Writers

Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.

On-Time Delivery

Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.

24/7 Customer Support

Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.

Complete Confidentiality

Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.

Authentic Sources

We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.

Moneyback Guarantee

Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.

Order Tracking

You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.

Order Now Talk to Us

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Trusted Partner of 9650+ Students for Writing

From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.

Preferred Writer

Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.

Grammar Check Report

Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.

One Page Summary

You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.

Plagiarism Report

You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.

Free Features $66FREE

Most Qualified Writer $10FREE
Plagiarism Scan Report $10FREE
Unlimited Revisions $08FREE
Paper Formatting $05FREE
Cover Page $05FREE
Referencing & Bibliography $10FREE
Dedicated User Area $08FREE
24/7 Order Tracking $05FREE
Periodic Email Alerts $05FREE

Our Services

Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.

On-time Delivery
24/7 Order Tracking
Access to Authentic Sources

Academic Writing

We create perfect papers according to the guidelines.

Professional Editing

We seamlessly edit out errors from your papers.

Thorough Proofreading

We thoroughly read your final draft to identify errors.

Thorough Proofreading

We thoroughly read your final draft to identify errors.

Delegate Your Challenging Writing Tasks to Experienced Professionals

Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!

Check Out Our Sample Work

Dedication. Quality. Commitment. Punctuality

It May Not Be Much, but It’s Honest Work!

Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.

0+

Happy Clients

0+

Words Written This Week

0+

Ongoing Orders

0%

Customer Satisfaction Rate

Process as Fine as Brewed Coffee

We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.

Call Us +1 (877) 657-8180 Discuss Order Details Now

See How We Helped 9000+ Students Achieve Success

We Analyze Your Problem and Offer Customized Writing

We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.

Clear elicitation of your requirements.
Customized writing as per your needs.

We Mirror Your Guidelines to Deliver Quality Services

We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

Proactive analysis of your writing.
Active communication to understand requirements.

We Handle Your Writing Tasks to Ensure Excellent Grades

We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.

Thorough research and analysis for every order.
Deliverance of reliable writing service to improve your grades.

Place an Order Start Chat Now

Article Analysis 2

Rubic_Print_Format

What Will You Get?

Premium Quality

Experienced Writers

On-Time Delivery

24/7 Customer Support

Complete Confidentiality

Authentic Sources

Moneyback Guarantee

Order Tracking

Areas of Expertise

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Areas of Expertise

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Trusted Partner of 9650+ Students for Writing

Preferred Writer

Grammar Check Report

One Page Summary

Plagiarism Report

Free Features $66FREE

Our Services

Academic Writing

Professional Editing

Thorough Proofreading

Thorough Proofreading

Delegate Your Challenging Writing Tasks to Experienced Professionals

Check Out Our Sample Work

It May Not Be Much, but It’s Honest Work!

0+

Happy Clients

0+

Words Written This Week

0+

Ongoing Orders

0%

Customer Satisfaction Rate

Process as Fine as Brewed Coffee

Share Your Requirements

Place Order & Deposit Funds

Release Payment to Your Writer

See How We Helped 9000+ Students Achieve Success

We Analyze Your Problem and Offer Customized Writing

We Mirror Your Guidelines to Deliver Quality Services

We Handle Your Writing Tasks to Ensure Excellent Grades