The severe acute respiratory syndrome (SARS) epidemic threw the world into turmoil during the first half of 2003 [1, 2]. Since then, thousands of papers had been devoted to this novel virus, many have addressed its impact on health service utilization [3–8], but few have focused on hospice palliative care [9]. When the fears declined and utilization data became available, we were able retrospectively to review the broad hospice situation during the SARS epidemic in Taiwan, one of the most heavily affected countries.

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

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

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

Most studies of the impact of SARS on health service utilization have been confined to a single facility. Our study, based on nationwide data, gave a complete and exact picture of hospice utilization. The hospice, also known as palliative care, has usually been considered as conservative and non-acute. One could well imagine that the use of hospice services would be compromised because of fears during uncertain times. Our findings support this view. Hospice inpatient utilization in Taiwan was indeed more sensitive to the emerging epidemic than general inpatient utilization. Not only was the reduction sharper, but also recovery to the previous level took longer.

Although it cannot be classed as acute care, hospice care is unlike elective surgery, which can put patients on a long waiting list. Hospice care is provided to terminally ill patients whose life expectancy is limited. During the SARS epidemic in Taiwan, many terminally ill patients might have been suspended or deterred from professional hospice care because well-organized patient transfers did not exist. Health consequences might not be a big issue among hospice patients. Instead, quality of care and humanity are the major concerns.

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

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

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

Although Taiwan had been declared a SARS-affected country, not every hospice ward was equally influenced by this epidemic. The impact was related to the locations and accreditation levels of the hospitals with hospice wards: the bigger the hospital, the stronger the SARS impact. Other features, e.g. the admission policy and mission of each hospital during the SARS epidemic, might have played a role. Hospices in middle Taiwan were most severely affected; only the hospice in eastern Taiwan was negligibly affected. The main island of Taiwan has 22 cities and counties. The probable cases of SARS appeared mainly in Taipei city (in northern Taiwan), Taipei county (northern), Taoyuan county (northern), Kaohsiung city (southern) and Kaohsiung county (southern) [13]. On 26 March 2003, a resident of Hong Kong's Amoy Gardens flew to Taiwan and travelled to Taichung (in middle Taiwan). That man's brother in Taiwan became Taiwan's first SARS fatality [15]. This might partly explain the impact of SARS in middle Taiwan (Figure 4).

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

A striking feature of the SARS epidemic in Taiwan was that 56.3% of SARS patients were hospital-related [15]. In retrospect, it was reasonable and preferable to reduce hospitalisations. A similar phenomenon was observed simultaneously in childbirth in Taiwan [7]. Many deliveries were shifted from secondary and tertiary care hospitals to primary clinics. The question remains whether continuity and quality of care could be ensured. It is unlikely that patients shifted from the 15 hospices in the current study to the other six (unanalysed) hospices, which either quitted or joined the hospice program after the SARS epidemic. However, the possibility of patient flow to other non-hospice wards cannot be excluded. Our claims-based study could not determine whether the needs of patients with terminal illnesses were met during the epidemic, and threw no light on the psychological impact on patients and healthcare workers [20].

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