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This study aimed to examine the associations between adoption of an advanced medication alert system and decreases in hospital-based outpatient duplicated medication rates in Taiwan.The unit of analysis was the hospital. We merged the hospital medication alert system adoption survey data and Taiwan National Health Insurance outpatient claims data. The observation time was 1998 to 2011, divided into 5 periods (T1-T5). The analysis included 216 hospitals, and outcome variable was hospital-based outpatient duplicated medication rates. The system adoption time frame, hospital accreditation level, and number of drugs per prescription were defined as predicted variables. A generalized estimating equation regression model was used.Adoption of the advanced medication alert system gradually increased, such that 100% of medical centers and 84% of regional hospitals, but less than 50% of district hospitals, had systems by T5. The hospital-based outpatient duplicated medication rate continually decreased, from 29.8% to 11.2%. The generalized estimating equation model showed rates of duplicated medications of b = -8.44 at T2 and b = -17.88 at T5 (P0.001) compared with T1. Medical centers and regional hospitals demonstrated much lower duplication rates (b = -13.71, b = -6.82; P0.001) compared with district hospitals. Hospitals with more medications per prescription had higher duplication rates than did hospitals with fewer items.Hospitals accredited at higher levels tended to have advanced medication alert systems. Hospitals that implemented advanced systems decreased hospital-based outpatient duplicated medications, avoiding a potential risk due to inappropriate medication use.

Objectives To examine the association between service volume and guideline adherence via multiyear observations. Study design Repeated cross-sectional study. Methods This study employed nationwide claims data from Taiwan's National Health Insurance scheme and identified patients with newly diagnosed type 2 diabetes from 2001, 2005, and 2009; a new prescription guideline for diabetes care was introduced in 2006. Physician service volume was measured by the number of total outpatients with diabetes. The outcome variable indicated whether a patient was receiving metformin, the guideline-recommended antihyperglycemic agent, at the index date. Results Patients visiting physicians who had high or medium volumes of patients with diabetes were more likely to receive metformin than patients visiting physicians who had low volumes; the odds ratios (ORs) were 2.48 (95% CI, 2.03-3.04) and 1.76 (95% CI, 1.45-2.13), respectively. Patients with newly diagnosed diabetes in 2009 and 2005 were more likely to receive metformin than their counterparts in 2001, with ORs of 12.00 (95% CI, 11.19-12.86) and 2.44 (95% CI, 2.30-2.59), respectively. We also found that patients who visited younger physicians, physicians with fewer practice years, physicians practicing in large-scale hospitals, or physicians practicing in urban areas were more likely to receive metformin than their counterparts. Conclusions In the process of implementing a new practice guideline for treating patients with diabetes, physicians with higher patient volumes are more likely to adhere to the guideline recommendation.

Objectives Drug price reduction is one of the major policies to restrain pharmaceutical expenses worldwide. This study explores whether there is a relationship between drug price and clinical quality using real-world data. Methods Patients with newly-diagnosed type 2 diabetes receiving metformin or sulfonylureas during 2001 and 2010 were identified using the claim database of the Taiwan universal health insurance system. Propensity score matching was performed to obtain comparable subjects for analysis. Pharmaceutical products were categorized as brand-name agents (BD), highpriced generics (HP) or low-priced generics (LP). Indicators of clinical quality were defined as the dosage of cumulative oral hypoglycemic agents (OHA), exposure to other pharmacological classes of OHA, hospitalization or urgent visit for hypoglycemia or hyperglycemia, insulin utilization and diagnosis of diabetic complications within 1 year after diagnosis. Results A total of 40,152 study subjects were identified. A generalized linear mix model showed that HP and BD users received similar OHA dosages with comparable clinical outcomes. By contrast, LP users had similar outcomes to BD users but received a 39% greater OHA dosage. A marginally higher risk of poor glycemic control in LP users was also observed. Conclusions Drug price is related to indicators of clinical quality. Clinicians and health authorities should monitor the utilization, effectiveness and clinical safety indicators of generic drugs, especially those with remarkably low prices.

OBJECTIVE This study aimed to evaluate the impact of the PharmaCloud program, a health information exchange program implemented in 2013, on medication duplication under a single-payer, universal health insurance program in Taiwan. STUDY DESIGN This study employed a retrospective pre-post study design and used nationwide health insurance claim data from 2013 to 2015. A difference-in-difference analysis was conducted to evaluate the effects of inquiry rate on the probability of receiving duplicate medications and on the number of days of overlapping medication prescriptions after implementation of the PharmaCloud program. RESULTS The study subjects included patients receiving medications in 7 categories: antihypertension drugs, 217,200; antihyperlipidemic drugs, 69,086; hypoglycemic agents, 103,962; antipsychotic drugs, 15,479; antidepressant drugs, 12,057; sedative and hypnotic drugs, 56,048; and antigout drugs, 18,250. Up to 2015, the overall PharmaCloud inquiry rate has increased to 55.36%-69.16%. Compared with subjects in 2013, subjects in 2014 and 2015 had a significantly lower likelihood of receiving duplicate medication in all 7 medication groups; for instance, for antihypertension drug users, the odds ratio (OR) was 0.91 with 95% confidence interval (CI)=0.90-0.92 in 2014, and the OR was 0.81 with 95% confidence interval=0.81-0.82 in 2015. However, a higher inquiry rate led to a lower likelihood of receiving duplicate medication and shorter periods of overlapping medications only in some of the medication groups. CONCLUSIONS The health information exchange program has reduced medication duplication, yet the reduction was not entirely associated with record inquiries. The hospitals have responded to the challenge of medication duplication by enhancing internal prescription control via a prescription alert system, which may have contributed to the reduction in duplicate medications and is a positive, unintended consequence of the intervention.

Background: With the promising outcomes of the pre-ESRD (end-stage renal disease) pay-for-performance (P4P) program, the National Health Insurance Administration (NHIA) of Taiwan launched a P4P program for patients with early chronic kidney disease (CKD) in 2011, targeting CKD patients at stages 1, 2, and 3a. This study aimed to examine the long-term effect of the early-CKD P4P program on CKD progression. Methods: We conducted a matched cohort study using electronic medical records from a large healthcare delivery system in Taiwan. The outcome of interest was CKD progression to estimated glomerular filtration rate (eGFR)

Background Little is known about hip fracture inpatient care in East Asia. This study examined the characteristics of patients, hospitals, and regions associated with delivery of hip fracture surgeries across Japan, Korea, and Taiwan. We also analyzed and compared how the resource use and a short-term outcome of the care in index hospitals varied according to factors in the respective health systems. Methods We developed comparable, nationwide, individual-level health insurance claims datasets linked with hospital- and regional-level statistics across the health systems using common protocols. Generalized linear multi-level analyses were conducted on length of stay (LOS) and total cost of index hospitalization as well as inpatient death. Results The majority of patients were female and aged 75 or older. The standardized LOS of the hospitalization for hip fracture surgery was 32.5 (S.D. = 18.7) days in Japan, 24.7 (S.D. = 12.4) days in Korea, and 7.1 (S.D. = 2.9) days in Taiwan. The total cost per admission also widely varied across the systems. Hospitals with a high volume of hip fracture surgeries had a lower LOS across all three systems, while other factors associated with LOS and total cost varied across countries. Conclusion There were wide variations in resource use for hip fracture surgery in the index hospital within and across the three health systems with similar social health insurance schemes in East Asia. Further investigations into the large variations are necessary, along with efforts to overcome the methodological challenges of international comparisons of health system performance.

Quality of primary diabetes care is a key health policy concern in many OECD countries with an aging population. This cross-national, population-based study examined the extent and attributes of diabetes-related avoidable hospitalizations (DRAHs) in South Korea and Taiwan, both of which have social health insurance-based health systems with limited gate-keeping for hospitalizations. We analyzed comparable, nationally representative health insurance beneficiary datasets for the two countries (2002-2013), linked with community health resource data. The age- and sex-standardized DRAH rates were calculated, and multivariate, multi-level longitudinal modeling approaches were adopted. The DRAH rate decreased in Taiwan consistently during 2002-2013 and in Korea after 2011 only. Under the universal health coverage, people enjoyed high accessibility to care. A higher number of physician visits reduced DRAHs in Korea but not in Taiwan. Socio-economic disparities in DRAHs still existed in both countries, especially in Taiwan. We found a different trajectory in two similar health systems for the selected health system performance indicator for primary diabetes care. This can be partly explained by different policy approaches to diabetes management in the two countries over the years. Necessary are policy efforts to improve the quality and equality of primary diabetes care and better control of hospital admissions in these two health systems that provide generous access to care at a low cost in East Asia.

Objective The adoption of medication alert systems in the health care sector varies among regions. In Taiwan, the health authority introduced policies in 2005 to encourage the adoption of medication alert systems in hospitals. This study aimed to understand the adoption of medication alert systems in the outpatient departments of hospitals in Taiwan using a nationwide survey. Methods A questionnaire was developed and mailed to 380 accredited general hospitals in Taiwan in 2013. The information collected from the questionnaire concerning the outpatient department included (1) the time of adoption of a medication alert system; (2) the operation of individual alert functions: availability, management, and stability; and (3) hospital characteristics: accreditation level, teaching status, ownership, and number of beds. Results A total of 216 hospitals completed and returned the questionnaire, corresponding to a response rate of 56.8%. The adoption rate of medication alert systems in hospital outpatient departments increased from less than 10% in 1997–95.83% in 2012. Approximately two-thirds of the hospitals developed and maintained the alert systems independently or collaboratively with vendors. Teaching and large hospitals tended to develop more advanced alert functions such as drug–drug interaction functions. Improving the safety and quality of pharmaceutical services and meeting the policy requirements are reasons for hospitals to establish medication alert systems. Conclusion The adoption rate of medication alert systems reached 95% in accredited general hospitals in Taiwan. Government policy and available health information professionals and vendors may somewhat contribute to the high adoption rate.

Purpose Generic medications used for chronic diseases are beneficial in containing healthcare costs and improving drug accessibility. However, the effects of generic drugs in acute and severe illness remain controversial. This study aims to investigate treatment costs and outcomes of generic antibiotics prescribed for adults with a urinary tract infection in outpatient settings. Methods The data source was the Longitudinal Health Insurance Database of Taiwan. We included outpatients aged 20 years and above with a urinary tract infection who required one oral antibiotic for which brand-name and generic products were simultaneously available. Drug cost and overall healthcare expense of the index consultation, healthcare cost during a 42-day follow-up period, and treatment failure rates were the main dependent variables. Data were compared between brand-name and generic users from the entire cohort and a propensity score-matched samples. Results Results from the entire cohort and propensity score-matched samples were similar. Daily antibiotic cost was significantly lower among generic users than brand-name users. Significant lower total drug claims of the index consultation only existed in patients receiving the investigated antibiotics, while the drug price between brand-name and generic versions were relatively large (e.g., >50%). The overall healthcare cost of the index consultation, healthcare expenditure during a 42-day follow-up period, and treatment failure rates were similar between the two groups. Conclusions Compared with those treated with brand-name antibiotics, outpatients who received generic antibiotics had equivalent treatment outcomes with lower drug costs. Generic antibiotics are effective and worthy of adoption among outpatients with simple infections indicating oral antibiotic treatment. Copyright © 2016 John Wiley & Sons, Ltd.

Objectives To examine the long-term effects of drug reimbursement adjustments on drug-switching decisions and to investigate whether patients with complicated or severe conditions are more affected. Methods A population-based, longitudinal study with a before-and-after design. Analysis of 141,703 patients with type 2 diabetes covered by the universal health insurance program in Taiwan. Observation of five 6-month phases before and after a drug reimbursement adjustment implemented in October 2009. Drug switching was defined as a brand change within the same anatomical therapeutic chemical group between two consecutive physician visits. Generalized estimating equations were employed to control for the random subject effect. Results The drug-switching rates in the five phases were 10.85% and 13.71% before implementation and 31.53%, 28.29% and 15.61% after implementation. Results from the regression model revealed a higher likelihood of receiving switched drugs in phases 3, 4 and 5, with odds ratios of 3.16, 2.72 and 1.44 (with 95% confidence interval 3.04–3.29, 2.61–2.84 and 1.38–1.51), respectively, compared with phase 1. Patients with complicated or severe conditions were more likely to have their drugs switched after the reimbursement adjustment. Conclusions The drug reimbursement adjustment under the health insurance program resulted in an increase in drug-switching decisions, and patients were not exempt from medication switching regardless of the complications or the severity level of their illness.

AIMS The direct cost of operations and health care expenditure for treating pelvic floor dysfunction are substantial. In this study, we evaluate the number of inpatient surgical procedures and direct expenditures for treating pelvic organ prolapse and urinary incontinence under the coverage of National Health Insurance (NHI) in Taiwan. METHODS Thirteen years of population-based NHI inpatient claims were used in this study. The number of surgical procedures and the average direct cost of inpatient fees for treating pelvic floor dysfunction for each patient from 1999 to 2011 were calculated. The patients were stratified based on age into a younger than 65 years group and 65 years or older group for comparisons. RESULTS The number of patients per year increased by 27%, increasing from 5278 patients in 1999 to 6706 patients in 2011. The total direct cost of inpatient (surgical and admission) fees for pelvic floor dysfunction increased by 57.2%, increasing from $6 674 968 USD in 1999 to $10 494 894 USD in 2011. However, while the expenditures for women 65 years or older increased by 102.2% from 1999 to 2011, there was only a 38.3% increase for those younger than 65 years when we stratified the patients by age. CONCLUSION The increasing expenditures for inpatient surgery for pelvic floor dysfunction are mainly due to the escalating utilization of inpatient surgical procedures, especially those for pelvic organ prolapse in women aged 65 or older.

Due to the increasing prevalence of multimorbidity, the percentage of heavy users of health care services increased rapidly. To contain inappropriate outpatient visits and improve better medication management of high utilizers, the National Health Insurance Administration in Taiwan launched a community pharmacist home visit (CPHV) project for high utilizers in 2010. We employed a natural experimental design to evaluate the preliminary effects of the CPHV project. The intervention group consisted of patients enrolled in the CPHV project during 2010 and 2013. Patients in the comparison group were non-enrollees selected via a propensity score matching technique. A difference-in-differences analysis was conducted by using multilevel models to examine the effects of the project. The average number of physician visits decreased from 130.0 to 98.9 visits (23.8%) among the CPHV project enrollees, while the average number decreased from 99.5 to 89.5 visits (10.1%) among the non-enrollees, with a net effect of a 21.0-visit reduction. The CPHV project also led to modest reductions in the number of medication items used per day, the probability of hospital admission and yearly healthcare expenses. The CPHV project seems promising for decreasing health care utilization and costs of the patients with high-needs.

Objective To examine the effects of potentially inappropriate medication (PIM) use on health care outcomes in elderly individuals using an instrumental variable (IV) approach. Data Sources/Study Setting Representative claim data from the universal health insurance program in Taiwan from 2007 to 2010. Study Design We employed a panel study design to examine the relationship between PIM and hospitalization. We applied both the naive generalized estimating equation (GEE) model, which controlled for the observed patient and hospital characteristics, and the two-stage residual inclusion (2SRI) GEE model, which further accounted for the unobserved confounding factors. The PIM prescription rate of the physician most frequently visited by each patient was used as the IV. Principal Findings The naive GEE models indicated that patient PIM use was associated with a higher likelihood of hospitalization (odds ratio [OR], 1.399; 95 percent confidence interval [CI], 1.363–1.435). Using the physician PIM prescribing rate as an IV, we identified a stronger significant association between PIM and hospitalization (OR, 1.990; 95 percent CI, 1.647–2.403). Conclusions PIM use is associated with increased hospitalization in elderly individuals. Adjusting for unobserved confounders is needed to obtain unbiased estimates of the relationship between PIM and health care outcomes.

Introduction: Numerous studies have examined the impact of pay-for-performance (P4P) programmes, yet little is known regarding their effects on continuity of care (COC) and the role of multiple chronic conditions (MCCs). This study aimed to examine the effects of a P4P programme for diabetes care on health care provision, COC and health care outcomes in diabetic patients with and without comorbid hypertension. Methods: This study utilized a large-scale natural experiment with a 4-year follow-up period under a compulsory universal health insurance programme in Taiwan. The intervention groups consisted of patients with diabetes who were enrolled in the P4P programme in 2005. The comparison groups were selected via propensity score matching with patients who were seen by the same group of physicians. A difference-in-differences analysis was conducted using generalized estimating equation models to examine the effects of the P4P programme. Results: Significant impacts were observed after the implementation of the P4P programme for diabetic patients with and without hypertension. The programme increased the number of necessary examinations/tests and improved the COC between patients and their physicians. The programme significantly reduced the likelihood of diabetes-related hospital admissions and emergency department visits [odds ratio (OR): 0.71; 95% confidence interval (CI): 0.63‐0.80 for diabetic patients with hypertension; OR: 0.74; 95% CI: 0.64‐0.86 for patients without hypertension]. However, the effects of the P4P programme diminished to some extent in the second year after its implementation. Conclusion: This study suggests that a financial incentive programme may improve the provision of necessary health care, COC and health care outcomes for diabetic patients both with and without comorbid hypertension. Health authorities could develop policies to increase participation in P4P programmes and encourage continued improvement in health care outcomes.

Objective Taiwan’s single health insurer introduced a medication record exchange platform, the PharmaCloud program, in 2013. This study aimed to evaluate the effects of the medication record inquiry rate on medication duplication among patients with diabetes. Materials and methods A retrospective pre-post design with a comparison group was conducted using nationwide health insurance claim data of diabetic patients from 2013 to 2014. Patients whose medication record inquiry rate fell within the upper 25th percentile were classified as the high-inquiry group, and the others as the low-inquiry group. The dependent variables were the likelihood of receiving duplicated medication and the overlapped medication days of the study subjects. Generalized estimation equations with difference-in-difference analysis were calculated to examine the net effect of the PharmaCloud inquiry rate for a matched sub-sample. Results In total, 106,508 patients with diabetes were randomly selected. From 2013 to 2014, the medication duplication rate was reduced 7.76 percentile (54.12%–46.36%) for the high-inquiry group and 9.58 percentile (63.72%–54.14%) for the low-inquiry group; the average medication overlap periods were shortened 4.36 days (8.49–4.13) and 6.29 days (11.28–4.99), respectively. The regression models showed patients in the high-inquiry group were more likely to receive duplicated medication (OR = 1.11, 95% C.I. = 1.07–1.16) and with longer overlapped days (7.53%, P = 0.0081) after the program. Conclusion The medication record sharing program has reduced medication duplication among diabetes patients. However, higher inquiry rate did not lead to greater reduction in medication duplication; the overall effect might be due to enhanced internal control via prescription alert system in hospitals rather physician’s review of the records.

Introduction Patients with chronic conditions largely depend on proper medications to maintain health. This study aims to examine, for patients with diabetes and hypertension, whether the appropriateness of the quantity of drug obtained is associated with favorable healthcare outcomes and lower expenses. Methods This study utilized a longitudinal design with a seven-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. The patients under study were those aged 18 years or older and newly diagnosed with type 2 diabetes or hypertension in 2002. Generalized estimating equations were performed to examine the relationship between medication supply and health outcomes as well as expenses. Results The results indicate that while compared with patients with an appropriate medication supply, patients with either an undersupply or an oversupply of medications tended to have poorer healthcare outcomes. The study also found that an excess supply of medications for patients with diabetes or hypertension resulted in higher total healthcare expenses. Conclusion Either an undersupply or an oversupply of medication was associated with unfavorable healthcare outcomes, and that medication oversupply was associated with the increased consumption of health resources. Our findings suggest that improving appropriate medication supply is beneficial for the healthcare system.

BACKGROUND The effects of continuity of care on health care outcomes are well documented. However, little is known about the effect of continuity at the physician or the site level on the process of care for patients with multiple chronic conditions (MCCs). OBJECTIVE The objective of this study was to examine the effects of physician continuity versus site continuity on duplicated medications received by patients with and without MCCs. RESEARCH DESIGN AND SUBJECTS This study utilized a longitudinal design with an 8-year follow-up from 2004 to 2011 of patients aged 65 or older under a universal health insurance program in Taiwan (55,573 subjects and 389,011 subject-years). Generalized estimating equation models with propensity score method were conducted to assess the association between continuity and medication duplication. RESULTS The rates of subjects receiving duplicated medications ranged from 40.38% to 43.50% with 1.45-1.62 duplicated medications during the study period. The findings revealed that better continuity, either at the physician level or the site level, was significantly associated with fewer duplicated medications. This study also indicated that the physician continuity had a stronger effect on medication duplication than did site continuity. Furthermore, the magnitude of the protective effect of continuity against duplicated medications increased when the patients had more chronic conditions [physician continuity: the marginal effect ranged from -10.7% to -52.9% (all P

The effects of continuity of care (COC) on health care outcomes are well established. However, the mechanism of this association is not fully understood.The objective of this study was to examine the relationship between COC and medication adherence, as well as to investigate the mediating effect of medication adherence on the association between COC and health care outcomes, in patients with newly diagnosed type 2 diabetes.This study utilized a longitudinal design and included a 7-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. Patients aged 18 years or older who were first diagnosed with type 2 diabetes in 2002 were included in the study. Random intercept models were conducted to assess the temporal relationship between COC, medication adherence, and health care outcomes.Patients with high or intermediate COC scores were more likely to be adherent to medications than those with low COC scores [odds ratio (OR), 3.37; 95% confidence interval (CI), 3.15-3.60 and OR, 1.84; 95% CI, 1.74-1.94, respectively]. In addition, the association between COC and health care outcomes was partly mediated by better medication adherence in patients with newly diagnosed type 2 diabetes.Improving the COC for patients with type 2 diabetes may result in higher medication adherence and better health care outcomes.

Better continuity of care (COC) is associated with improved health care outcomes, such as decreased hospitalization and emergency department visit. However, little is known about the effect of COC on potentially inappropriate medication.This study aimed to investigate the association between COC and the likelihood of receiving inappropriate medication, and to examine the existence of a mediating effect of inappropriate medication on the relationship between COC and health care outcomes and expenses.A longitudinal analysis was conducted using claim data from 2004 to 2009 under universal health insurance in Taiwan. Participants aged 65 years and older were categorized into 3 equal tertiles by the distribution of COC scores. This study used a propensity score matching approach to assign subjects to 1 of 3 COC groups to increase the comparability among groups. Generalized estimating equations were used to examine the association between COC, potentially inappropriate medication, and health care outcomes and expenses.The results revealed that patients with the best COC were less likely to receive drugs that should be avoided [odd ratios (OR), 0.44; 95% confidence interval (CI), 0.43-0.45) or duplicated medication (OR, 0.22; 95% CI, 0.22-0.23) than those with the worst COC. The findings also indicated that potentially inappropriate medication was a partial mediator in the association between COC and health care outcomes and expenses.Better COC is associated with fewer negative health care outcomes and lower expenses, partially through the reduction of potentially inappropriate medication. Improving COC deserves more attention in future health care reforms.

Background The impact of cuts in reimbursement, such as the Balanced Budget Act in the United States or global budgeting, on the quality of patient care is an important issue in health-care reform. Limited information is available regarding whether reimbursement cuts are associated with processes and outcomes of acute myocardial infarction (AMI) care. Objectives We used nationwide longitudinal population-based data to examine how 30-day mortality and percutaneous coronary intervention (PCI) use for AMI patients changed in accordance with the degree of financial strain induced by the implementation of hospital global budgeting since July 2002 in Taiwan. Methods We analyzed all 102,520 AMI patients admitted to general acute care hospitals in Taiwan over the period 1997 to 2008 through Taiwan's National Health Insurance Research Database. Multilevel logistic regression analysis was performed after adjustment for patient, physician, and hospital characteristics to test the association of reimbursement cuts with 30-day mortality and PCI use. Results The mean magnitude of payment reduction on overall hospital revenues was highest (10.02%) during the period 2004 to 2005. Large reimbursement cuts were associated with higher adjusted 30-day mortality. There was no statistically significant correlation between reimbursement cuts and PCI use. Conclusions The mortality of AMI patients increases under increased financial strain from cuts in reimbursement. Nevertheless, the use of PCI is not affected throughout the study period. Reductions in the quantity or quality of services with a negative contribution margin or high cost, such as nurse staffing, may explain the association between reimbursement cuts and AMI outcome.

INTRODUCTION Numerous studies have suggested that better continuity of care (COC) can lead to fewer emergency department (ED) visits and fewer hospital admissions. However, these studies were conducted in countries where patients have their own family physician or in countries with referral systems. This study aimed to determine whether the association between lower COC and increased health care utilization may be apparent in a health care system that lacks a family physician or a referral system. METHODS The study population included a total of 134 422 subjects who made four or more visits to physicians in 2005. Negative binominal regressions were performed to examine the effects of three different COC indices on the numbers of hospital admissions and ED visits in 2005 and in the subsequent year (2006). RESULTS The data suggest that lower COC was associated with increased hospital admissions and ED visits in our study population. Compared with the high COC group, subjects in the low and medium COC groups had 42-82% and 39-46% more hospital admissions, respectively, as well as 75-102% and 41-45% more ED visits, respectively, in 2005. Weaker protective effects of COC were also observed in the subsequent year. CONCLUSIONS This study indicates that lower COC is associated with increased hospital admissions and ED visits, even in a health care system that lacks a referral arrangement framework. This suggests that improving the COC is beneficial both for patients and for the health care system.

Potentially inappropriate medication use among the elderly in an outpatient setting has been widely reported. However, the potential association between inappropriate medication use and adverse outcomes is seldom examined. To identify the prevalence, risk factors for and adverse outcomes of potentially inappropriate medication use in ambulatory elderly patients with chronic diseases. Data for this observational cohort study consisted of computerized claims from a tertiary medical centre in Taiwan to the Bureau of National Health Insurance. Consecutive ambulatory elderly patients aged ≥65 years who received long-term (3-month) prescriptions for treatment of a chronic disease were recruited from 1 to 31 March 2005. The cohort included 5741 elderly patients who received 7538 long-term prescriptions. Patients who required repeat prescriptions were able to be given the same prescription if their conditions were stable. The prevalence of potentially inappropriate medication use and the incidence of adverse outcomes, including emergency visits, hospitalizations and mortality, were documented for up to 6 months after the first day the patient was recruited. Beers’ 2002 criteria were used to determine the potential inappropriateness of prescribed medications. Associations between potentially inappropriate medications and adverse outcomes were examined by multivariate logistic regression analyses controlling for possible confounding factors. The prevalence of potentially inappropriate medication use was 23.7% in the studied hospital. The most frequently prescribed potentially inappropriate medications of high severity (i.e. having a high likelihood of being associated with an adverse effect that was clinically significant) were amiodarone, chlorzoxazone, bisacodyl, nifedipine and amitriptyline. Logistic regression analysis revealed that female sex, advanced age, number of chronic diseases and number of medications taken all significantly increased the likelihood of receiving potentially inappropriate medications. The incidence of adverse outcomes in patients with potentially inappropriate medication use in the studied hospital was 25.1%. Multivariate logistic regression analysis revealed that potentially inappropriate medication use was significantly associated with hospitalization. Potentially inappropriate medication use is not a rare event in elderly patients and is associated with higher risk of hospitalization in this age group. In order to reduce the possibility of prescribing inappropriate medications, and therefore to reduce the consequent risk of hospitalization, more attention should be paid when prescribing drugs to, in particular, older female patients with multiple chronic illnesses that require treatment with multiple medications.

In 2011, a novel capitation program was launched in Taiwan under its universal health insurance plan. This study aimed to assess the short-term impact of the program. Two hospitals in the greater Taipei area, one participating in the “loyal patient” model (13,319 enrollees) and one in the “regional resident” model (13,768 enrollees), were analyzed. Two comparison groups were selected by propensity score matching. Generalized estimating equation models with differences-in-differences analysis were used to examine the net effects of the capitation program on health care utilization, expenses, and outcomes. Enrollees in the loyal patient model had fewer physician visits in the host hospital, but more physician visits outside that hospital during the program year than they had the year before. Compared with non-enrollees, the loyal patient model enrollees incurred fewer physician visits (β = −0.042, p

Objectives. To examine patient satisfaction with and recommendation of a hospital, with a special focus on the correlation of these measures to patient ratings of interpersonal and technical performance of the hospital. Design. Telephone survey of patients with four specific conditions after their discharge from hospitals. Setting. Accredited district teaching hospitals and above, nationwide in Taiwan. Participants. A total of 4945 patients from 126 hospitals diagnosed with or undergoing procedures related to stroke, diabetes mellitus, Caesarean section, or appendectomy were interviewed by telephone. Main outcome measures. Overall patient satisfaction and recommendation were measured by single-item questions. Interpersonal skills were measured by three items: doctors' explanation, attitude, and caring. Technical skills were measured by another three items: hospital equipment, clinical competence, and outcome of treatment. Results. Interpersonal skills were as influential or more influential than clinical competence on patient satisfaction for three of the four disease categories. In contrast, technical competence was a more influential predictor for recommendation for patients in all four disease categories. Conclusion. The preliminary results imply that a hospital with high percentage of patient satisfaction does not necessarily receive a high level of recommendation. This finding provides new insights for researchers and for hospital managers who devote resources exclusively for achieving the highest possible levels of patient satisfaction.

Objectives. To investigate Taiwanese patients’ ability to judge hospital quality and to examine their knowledge of commonly used quality indicators. Design. Survey of patients during their stay in hospital. Setting. Internal medicine, surgery, and gynecology wards in seven hospitals in northern Taiwan. Participants. Sample of 661 patients who voluntarily completed a questionnaire. Main outcome measures. (1) Patients’ ability to judge hospital quality in relation to medical equipment, technical competence, and medication; (2) patients’ knowledge of seven quality indicators: patient satisfaction, hospital-acquired infection, accreditation level, percent specialists, malpractice claims, unscheduled readmission, and mortality rate 48 hours after surgery. Results. A total of 31–50% of the participants claimed that they could judge a hospital’s quality on the basis of medical equipment, technical competence, or medication. The most frequently mentioned reasons on which their judgments were based were related to their own experiences and to the hospital’s reputation. The percentage of participants reporting that they understood the quality indicators was 6.7–42.1%. Conclusion. In general, patients lack the ability to judge hospital quality and are unfamiliar with the commonly used quality indicators. Public education should be enhanced, or more understandable indicators should be developed in the future.

Immunisation registry systems have been shown to be important for finding pockets of under-immunised individuals and for increasing vaccination coverage. The National Immunisation Information System (NIIS) was established in 2003 in Taiwan. In this perspective, we present the construction of the NIIS and two innovative applications, which were implemented in 2009, which link the NIIS with other databases for better control of measles. Firstly, by linking the NIIS with hospital administrative records, we are able to follow up contacts of measles cases in a timely manner to provide the necessary prophylaxis, such as immunoglobulin or vaccines. Since 2009, there have been no measles outbreaks in hospitals in Taiwan. Secondly, by linking the NIIS with an immigration database, we are able to ensure that young citizens under the age of five years entering Taiwan from abroad become fully vaccinated. Since 2009, the measles-mumps-rubella vaccine coverage rate at two years of age has increased from 96% to 98%. We consider these applications of the NIIS to be effective mechanisms for improving the performance of infectious disease control in Taiwan. The experience gained could provide a valuable example for other countries.

Background— As healthcare spending continues to increase, reimbursement cuts have become 1 type of healthcare reform to contain costs. Little is known about the long-term impact of cuts in reimbursement, especially under a global budget cap with fee-for-service (FFS) reimbursement, on processes and outcomes of care. The FFS-based reimbursement cuts have been implemented since July 2002 in Taiwan. We examined the long-term association of FFS-based reimbursement cuts with trends in processes and outcomes of care for stroke. Methods and Results— We analyzed all 411 487 patients with stroke admitted to general acute care hospitals in Taiwan during the period 1997 to 2010 through Taiwan’s National Health Insurance Research Database. We used a quasi-experimental design with quarterly measures of healthcare utilization and outcomes and used segmented autoregressive integrated moving average models for the analysis. After accounting for secular trends and other confounders, the implementation of the FFS-based reimbursement cuts was associated with trend changes in computed tomography/magnetic resonance imaging scanning (0.31% per quarter; P =0.013), antiplatelet/anticoagulant use (−0.20% per quarter; P P =0.027), physiotherapy/occupational therapy assessment (0.25% per quarter; P P Conclusions— There are improvement trends in processes and outcomes of care over time. However, the reimbursement cuts from the FFS-based global budget cap are associated with trend changes in processes and outcomes of care for stroke. The FFS-based reimbursement cuts may have long-term positive and negative associations with stroke care.

Objective. To analyze the disparity in hospital care among people of various socio-economic status (SES) under a universal health insurance scheme. Design. A survey questionnaire was mailed to discharged patients in October 2010. Setting. This study included 183 large-scale hospitals in Taiwan. Participants. A total of 3015 patients/caregivers completed the questionnaires, which yielded a response rate of 58%. Main Outcome Measures. Three variables were included. The two access-to-care variables were admission route and accreditation level of the hospital in which the patient stayed. A structured questionnaire, the patient-reported hospital quality (PRHQ), was included to characterize patient’s experience of hospital stay. Results. Patients with lower education were less likely to be admitted to a hospital according to a planned schedule, or to choose an Medical Center Hospital. However, SES was not associated with the PRHQ scores. Furthermore, patients with unplanned admission were associated with lower PRHQ scores than those with planned admission to the hospital. Conclusions. Under the universal health insurance system in Taiwan, lower education is associated with unplanned admission to a hospital, which might result in poorer perceived quality of care. Reducing unplanned admission is a challenge for health authorities in the future.

Numerous studies have examined the impacts of pay-for-performance programs, yet little is known about their long-term effects on health care expenses.This study aimed to examine the long-term effects of a pay-for-performance program for diabetes care on health care utilization and expenses.This study represents a nationwide population-based natural experiment with a 4-year follow-up period under a compulsory universal health insurance program in Taiwan. The intervention groups consisted of 20,934 patients enrolled in the program in 2005, and 9694 patients continuously participated in the program for 4 years. Two comparison groups were selected by propensity score matching from patients seen by the same group of physicians. Generalized estimating equations were used to estimate differences-in-differences models to examine the effects of the pay-for-performance program.Patients enrolled in the pay-for-performance program underwent significantly more diabetes specific examinations and tests after enrollment; the differences between the intervention and comparison groups declined gradually over time but remained significant. Patients in the intervention groups had a significantly higher number of diabetes-related physician visits in only the first year after enrollment and had fewer diabetes-related hospitalizations in the follow-up period. Concerning overall health care expenses, patients in the intervention groups spent more than the comparison group in the first year; however, the continual enrollees spent significantly less than their counterparts in the subsequent years.The program seemed to achieve its primary goal in improving health care and providing long-term cost benefits.

To examine the impacts of diagnosis-related group (DRG) payments on health care provider's behavior under a universal coverage system in Taiwan.This study employed a population-based natural experiment study design. Patients who underwent coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty, which were incorporated in the Taiwan version of DRG payments in 2010, were defined as the intervention group. The comparison group consisted of patients who underwent cardiovascular procedures which were paid for by fee-for-services schemes and were selected by propensity score matching from patients treated by the same group of surgeons. The generalized estimating equations model and difference-in-difference analysis was used in this study.The introduction of DRG payment resulted in a 10% decrease (p0.001) in patient's length of stay in the intervention group in relation to the comparison group. The intensity of care slightly declined with p0.001. No significant changes were found concerning health care outcomes measured by emergency department visits, readmissions, and mortality after discharge.The DRG-based payment resulted in reduced intensity of care and shortened length of stay. The findings might be valuable to other countries that are developing or reforming their payment system under a universal coverage system.

Background Few studies have examined the effect of continuity of care on avoidable hospitalization, and the results have been inconclusive. This study aimed to examine the effects of continuity of care on avoidable hospitalization and hospital admission for any condition in a health care system with a high level of access to care. Methods We used a longitudinal design to examine claims data that captured health care utilization between January 1, 2000, and December 31, 2006, under a universal coverage health insurance program in Taiwan. In total, 30 830 randomly selected subjects with 3 or more physician visits per year between 2000 and 2006 were analyzed in 3 age groups. The main outcome was avoidable hospitalization and hospital admission for any condition. A random intercept logistic regression model was used to control for age, sex, low-income status, health status, time effect, and random subject effect. Results Higher continuity of care was significantly associated with lower likelihood of avoidable hospitalization in all 3 age groups. Similar associations were found for hospital admission for any condition in the 3 age groups. Conclusions Better continuity of care is associated with fewer avoidable hospitalizations and fewer hospital admissions for any condition in a health care system with easy access to care. Therefore, improvement of continuity of care is an appropriate path to follow in a universal coverage health care system.

To examine the effects of market competition on patient-perceived quality of care under a single-payer system in Taiwan.Data came from two nationwide surveys conducted on discharged patients and National Health Insurance (NHI) hospital claim datasets in 2002 and 2004. Competition was measured by the Herfindahl-Hirschman Index (HHI). Quality of care was measured by patient-rated hospital performance including interpersonal skills and clinical competence domains. We used the instrumental variable approach to address the endogeneity between competition and patient-perceived quality of care.The results showed that HHI was significantly associated with a decrease in the perceived interpersonal skills (coefficient of -0.460; p0.001), indicating that the interpersonal skill level increases in competition. A similar association was found for the perceived clinical competence (coefficient of -0.457; p=0.001).Quality of care from the patients' perspective is sensitive to the degree of competition. By using patient-reported data, this study provides new evidence concerning competition and quality of care.

This study reports the prevalence of hypertension, proportions of awareness, treatment, and control in the 2002 Taiwanese Survey on Hypertension, Hyperglycemia, and Hyperlipidemia (TwSHHH), and compared the changes of hypertension prevalence, awareness, treatment, and control in two recent nationwide surveys.TwSHHH is the second nationwide survey designed to assess the prevalence, awareness, treatment, and control of hyperglycemia, hyperlipidemia, and hypertension. The TwSHHH survey applied a multistage, stratified, and random sampling during 2002 with a total of 7566 participants. Among them, 3088 male and 3391 female participants were 19 years old and over and were selected from households throughout Taiwan. The data of Nutrition and Health Survey in Taiwan (NAHSIT), the first nationwide survey to assess disease and nutrition status during 1993-1996, was also applied to compare changes of the prevalence, awareness, treatment, and control of hypertension between the two surveys.Compared with the NAHSIT, the prevalence of hypertension on TwSHHH decreased significantly in female adults, between 1993-1996 and 2002. In both males and females of all age groups, the awareness, treatment, and control of hypertension significantly and substantially improved between NAHSIT and TwSHHH. These results also correlated in time with the implementation of National Health Insurance since 1995. The favorable changes in education and availability of care may account for improved control of hypertension and, possibly, its prevention.There was a significant improvement of hypertension awareness, treatment, and control in the TwSHHH survey compared with the NAHSIT survey in Taiwan.

Objectives The use of mechanic ventilators (MVs) is increasing in many countries. Taiwan's Bureau of National Health Insurance (NHI) launched a new payment program in 2000 to encourage integrated care for mechanically ventilated patients and to reduce the heavy utilization of high-cost intensive care unit. This study examines the trend in MV usage in Taiwan. Methods This study used nationally representative NHI claim data from 1997 to 2004 to examine the MV usage. Total inpatient days and MV usage days were analyzed by piece-wise regression model. We also analyzed the major diagnoses related to MV dependence. Results While the total hospital inpatient days increased only 49.41%, MV usage rose 181.75% over the 8-year study period. The increase in number of MV patient-days in ICUs has not been curbed, besides there was an increase in respiratory care center/wards. Acute respiratory failure (ARF), pneumonia and diabetes mellitus were the leading diagnoses for mechanically ventilated patients. Conclusions The new NHI insurance payment program may have helped spark the increased trend in MV usage in Taiwan. The significant impact of insurance incentive on healthcare utilization is a critical issue for policymakers in developing healthcare programs.

Quality of care rather than price is the main concern in health care. However, does price notmatter at all? To investigatewhat quality and cost factors influence whether patients perceive health care services as expensive and will recommend a hospital to other patients, the authors analyzed data from a national survey of patients in Taiwan in 2002. A total of 6725 subjects returned questionnaires. Results from logistic regression models showed that (1) a patient's perception of expensiveness was determined simultaneously with the perceived quality and the outofpocket price of care, (2) a patient's perception of hospital quality appeared to be themost important determinant for recommending ahospital, and(3) while the out-of-pocket price did not affect a patient's recommendation, the perceived expensiveness of the services did. The perceived value rather than the price itself-is the essence of quality competition in Taiwan's health care market.

Potential excess use of health care services caused by insurance has been a major concern for almost every industrialized county. Moral hazard problems and fee-for-service payment methods are considered to be important factors for higher medical care utilization among those insured. Health care availability is another feature reportedly associated with health care use. Using the data from a National Health Interview Survey in Taiwan in 1990, this study examined differences in medical care utilization by beneficiaries under three major social insurance plans (i.e. Labor Insurance-LI, Government Employees' Insurance-GEI, and Farmers' Insurance-FI) which covered about half the population at that time. Logistic and Poisson regression models were applied to examine the effects of relevant factors on the probability and volume of physician visits. Results from the analyses revealed that (1) persons with different insurance plans had a similar higher probability of seeing a doctor than the uninsured, with the odds ratios ranged from 1.8 to 2.0. Also (2) the LI/FI participants consumed 60 73% more physician services than the uninsured, while the GEI enrollees utilized only 30% more physician services. Findings from our study concerning the access and use of physician services in different insurance plans provide some useful information for reforming a health care delivery system.

The government of Taiwan introduced universal health insurance to cover all citizens in 1995. This national health insurance program was proposed to assure the accessibility to health care at reasonable cost. Evaluation of the consequences, including health care utilization and expenditure, is crucial for policy adjustment.To evaluate the effect of Taiwan's national health insurance on health care utilization.Cohort survey conducted before and after the implementation of the national health insurance program.A total of 1021 randomly selected Taiwanese adults.Physician visits in the 2 weeks prior to the survey and hospital admissions and emergency department visits in the immediate past year.After the introduction of universal health insurance, the newly insured consumed more than twice the amount of outpatient physician visits (0.21 vs 0.48, P.05) and hospital admissions (0.04 vs 0.11, P.05) than before universal health insurance was implemented, bringing them to the same amount of health care contacts as the previously insured group. The newly insured also experienced an insignificant increase in emergency department visits. In contrast, the previously insured group had a small but statistically significant increase in outpatient visits (0.48 vs 0.59, P.05) and insignificant changes in hospital admissions and emergency department visits.The universal health insurance removed some barriers to health care for those newly insured. The copayment design in the insurance scheme seemed to have an insignificant effect on curbing medical care utilization. Taiwanese health policy analysts should seriously consider the growth of health care expenditures since the implementation of universal health insurance.

Objective: To examine the association between stroke and migraine in an epidemiological study. Data Sources and Design: The National Health and Nutrition Examination Survey baseline and first follow-up data were used to investigate cross-sectional and longitudinal associations between headache/migraine and stroke. Setting: Study participants from a national probability sample of the civilian noninstitutionalized population of the United States. Main Outcome Measure: Self-reported physician diagnosis of stroke. Results: After controlling for established risk factors for stroke (hypertension, diabetes, heart disease, and gender), both migraine and severe nonspecific headache were associated with a significantly increased risk for stroke reported at follow-up. The risk for stroke associated with migraine decreased as the age at stroke increased. Conclusions: Our results strengthen previous evidence regarding a nonrandom association of both headache and migraine with stroke, particularly among young women. To our knowledge, this is the first systematic examination in a large-scale prospective epidemiological study of men and women with sufficient statistical power to test the association between migraine and stroke in women. Severe headache and migraine should be considered as risk factors for the development of stroke, particularly in the absence of other well-established stroke risk factors. Further investigation is required to identify the putative mechanisms underlying comorbidity of migraine and stroke.

The objective of this study was to examine multiple risk factors and correlated malignant neoplasms of blackfoot disease (BFD), a unique peripheral vascular disease related to continuous exposure to high-arsenic artesian well water. A total of 241 BFD cases, including 169 with spontaneous or surgical amputations of affected extremities, and 759 age-sex-residence-matched healthy community controls were studied to explore the risk factors of BFD. Multiple logistic regression analysis showed that artesian well water consumption, arsenic poisoning, familial history of BFD, and undernourishment were significantly associated with the development of BFD. The life-table method used to analyze cancer mortality of 789 BFD patients followed for 15 years showed a significantly higher mortality from cardiovascular diseases, peripheral vascular diseases, and cancers of bladder, skin, lung, and liver among BFD patients as compared with the general population in Taiwan or residents in the BFD-endemic area. The results imply the atherogenicity and carcinogenicity of the artesian well water in the BFD-endemic area.

To evaluate the efficacy of the mass hepatitis B vaccination program in Taiwan in interrupting perinatal hepatitis B virus transmission, 3464 randomly selected 18-month-old infant vaccinees born to hepatitis B surface antigen—carrier mothers were recruited from 9697 eligible infants during a six-month period of the program. They were divided into ten groups according to maternal infectivity and compliance with the vaccination schedule. Serum samples were tested for hepatitis B surface antigen, antibody to hepatitis B surface antigen, and antibody to hepatitis B core antigen. In 786 infants who had highly infectious mothers and who received hepatitis B immune globulin and vaccine on schedule, the protective efficacy was about 85%. The efficacy seemed to be slightly lower in those immunized off schedule. Overall, 11% of infants still carried hepatitis B surface antigen, and 81% of the infants had antibody to hepatitis B surface antigen that exceeded 10 mlU/mL in more than 90% of them. The geometric mean titers of antibody to hepatitis B surface antigen were more than 200 mlU/mL in every group of infants. We conclude that the mass vaccination program is efficacious in preventing perinatal hepatitis B virus transmission and the chronic carrier state; most infant vaccinees have adequate levels of protective antibody at 18 months of age. This program is extremely significant in the control of hepatitis B virus infection in Taiwan. ( JAMA 1988;260:2231-2235)