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Background Vaccine is supposed to be the most effective means to prevent COVID-19 as it may not only save lives but also reduce productivity loss due to resuming pre-pandemic activities. Providing the results of economic evaluation for mass vaccination is paramount important for all stakeholders worldwide. Methods We developed a Markov decision tree for the economic evaluation of mass vaccination against COVID-19. The effectiveness of reducing outcomes after the administration of three COVID-19 vaccines (BNT162b2 (Pfizer-BioNTech), mRNA-1273 (Moderna), and AZD1222 (Oxford-AstraZeneca)) were modelled with empirical parameters obtained from literatures. The direct cost of vaccine and COVID-19 related medical cost, the indirect cost of productivity loss due to vaccine jabs and hospitalization, and the productivity loss were accumulated given different vaccination scenarios. We reported the incremental cost-utility ratio and benefit/cost (B/C) ratio of three vaccines compared to no vaccination with a probabilistic approach. Results Moderna and Pfizer vaccines won the greatest effectiveness among the three vaccines under consideration. After taking both direct and indirect costs into account, all of the three vaccines dominated no vaccination strategy. The results of B/C ratio show that one dollar invested in vaccine would have USD $13, USD $23, and USD $28 in return for Moderna, Pfizer, and AstraZeneca, respectively when health and education loss are considered. The corresponding figures taking value of the statistical life into account were USD $176, USD $300, and USD $443. Conclusion Mass vaccination against COVID-19 with three current available vaccines is cost-saving for gaining more lives and less cost incurred.

Background The surge of COVID-19 pandemic has caused severe respiratory conditions and a large number of deaths due to the shortage of intensive care unit (ICU) in many countries. Methods We developed a compartment queue model to describe the process from case confirmation, home-based isolation, hospitalization, ICU, recovery, and death. By using public assessed data in Lombardy, Italy, we estimated two congestion indices for isolation wards and ICU. The excess ICU needs were estimated in Lombardy, Italy, and other countries when data were available, including France, Spain, Belgium, New York State in the USA, South Korea, and Japan. Results In Lombardy, Italy, the congestion of isolation beds had increased from 2.2 to the peak of 6.0 in March and started to decline to 3.9 as of 9th May, whereas the demand for ICU during the same period has not decreased yet with an increasing trend from 2.9 to 8.0. The results showed the unmet ICU need from the second week in March as of 9th May. The same situation was shown in France, Spain, Belgium, and New York State, USA but not for South Korea and Japan. The results with data until December 2020 for Lombardy, Italy were also estimated to reflect the demand for hospitalization and ICU after the occurrence of viral variants. Conclusion Two congestion indices for isolation wards and ICU beds using open assessed tabulated data with a compartment queue model underpinning were developed to monitor the clinical capacity in hospitals in response to the COVID-19 pandemic.

The reported prevalence of sleep disorders in children with chronic kidney disease (CKD) varies greatly. A quantitative meta-analysis to estimate the prevalence of sleep disorders among pediatric CKD patients may provide further information.The objective of this study is to estimate the prevalence of sleep disorders in children with CKD. The study protocol was registered on PROSPERO (registration number CRD42021268378).Two authors independently searched the PubMed, MEDLINE, EMBASE, and Cochrane review databases up to June 2021.Eligible studies include data of prevalence of sleep disorders in children with CKD.The prevalence of restless legs syndrome, sleep-disordered breathing, pediatric obstructive sleep apnea (i.e., apnea-hypopnea index gt; 1 event/h in polysomnography), excessive daytime sleepiness, and insomnia/insufficient sleep was estimated using a random-effects model. Subgroup analyses were conducted to compare the prevalence of sleep disorders between children on dialysis and not on dialysis. This meta-analysis included 12 studies with 595 children (mean age: 12.9 years; gender ratio: 55.6% boys; mean sample size: 49.6 patients).The prevalence of restless legs syndrome in children with CKD was 21% (95% confidence interval [CI], 14-30%). The prevalence of sleep-disordered breathing, pediatric obstructive sleep apnea, excessive daytime sleepiness, and insomnia/insufficient sleep was 22% (95% CI, 12-36%), 34% (95% CI, 19-53%), 27% (95% CI, 17-41%), and 14% (95% CI, 7-27%), respectively. Subgroup analysis revealed the pooled prevalence of excessive daytime sleepiness was significantly higher in children on dialysis than in children not on dialysis (43.3% vs. 11.2%; P = 0.018). Children on dialysis also had a high prevalence of other sleeping disorders, although the differences did not reach statistical significance. Children with CKD exhibited a 3.9-fold (95% CI, 1.37 to 10.93) increased risk of restless legs syndrome and a 9.6-fold (95% CI, 3.57 to 25.76) increased risk of excessive daytime sleepiness compared with controls.The selected papers are of small sample size, lack of a control group, and exhibit substantial heterogeneity.Sleep disorders are common in children with CKD. Our results indicate that while the prevalence rates of various sleep disorders were higher in children on dialysis than in children not on dialysis, the prevalence of excessive daytime sleepiness was statistically significant in children on dialysis. A higher resolution version of the Graphical abstract is available as Supplementary information.

Background: Long work hours for physicians not only harm the health of physicians, but also endanger patient safety. Compared with resident physicians, attending physicians—especially hospital-employed attending physicians—assume more responsibilities but has not gotten enough attention. The purpose of this study was to explore whether a hospital’s geographic location and emergency care responsibility might influence the number of hours worked. Methods: The respondents of 2365 attending physicians from 152 hospitals in the 2018 survey of Taiwan physician work hours were used as the data source. The total work hour per week and its components, the regular scheduled shift and three types of on-call shifts, were used as outcome variables. Hospital geographic location and emergency care responsibility were the independent variables. The multilevel random effect model was employed to examine the study objective after adjusting for clinical specialty, hospital teaching status, and ownership. Results: The average number of total working hours was 69.09 hours per week; the regular scheduled shift was account for 75% of total work hours. The results showed the total work hours were only varied by the level of hospital’s emergency care responsibility. However, the results also demonstrated the hours of duty shifts were varied by hospital’s geographic location and emergency care responsibility. The results of the multilevel random effect model revealed that the hospital’s emergency care responsibility was the factor consistently associated with attending physician’s work hour, no matter the total work hours or its composition. Conclusion: In this study, we explored how a hospital’s location and its level of emergency care responsibility were associated with physicians’ work hours for each type of shift. Our findings offer an opportunity to review the rationality of physician workforce allocation, and financial incentives and administrative measures could be the next steps for balancing the work hours of attending physicians.

Long work hours among physicians is a worldwide issue in the healthcare arena. Previous studies have largely focused on the work hours of resident physicians rather than those of attending physicians. The purpose of this study was to investigate total work hours and the composition of those work hours for attending physicians across different hospital settings and across different medical specialties through a nationwide survey. This included examining differences in physician workload and its composition with respect to different hospital characteristics, and grouping medical specialties according to the work similarities. A cross-sectional self-reported nationwide survey was conducted from June to September of 2018, and the two questionnaires were distributed to all accredited hospitals in Taiwan. The number of physician work hours in different types of duty shifts were answered by medical specialty in each surveyed hospital. Each medical specialty in a hospital filled only one response for its attending physicians. The findings reveal that the average total work hours per week of an attending physician is around 69.1 h, but the total work hours and their composition of different duty shifts varied among hospital accreditation levels, geographic locations, emergency care responsibilities, and medical specialties. Because of the variance in the number and composition of attending physicians’ work hours, adjusting physician work hours to a reasonable level will be a major challenge for health authority and hospital managers.

Background: Except for renal transplantation, peritoneal dialysis (PD) is considered to be relatively cost-effective option for end-stage renal disease (ESRD) patients. Less than 7% of ESRD patients receiving PD in Taiwan, and the promising benefits of PD treatment influenced health policy makers to seek ways to encourage PD utilization. The purpose of this study is to evaluate the effect of their policy initiatives.Methods: An observational longitudinal study using a before-and-after analysis was conducted. The propensity score matching technique was employed to match PD patients before and after the introduction of Taiwan’s efforts to encourage PD utilization in ESRD patients, and the change in PD technical failure was analyzed. HD patients were also matched as the control group to assess the impact of Taiwan’s PD utilization encouraging policies on mortality in PD patients. The competing risk regression approach for survival analysis was adopted in our study.Results: The results showed that while the PD encouraging policies had increased the PD utilization, the increase in PD utilization was accompanied by an increase in technique failure and an increase in mortality.Conclusions: The adoption of new treatments which may benefit patients and incentives to change physician practice behaviors require more disciplined and carefully managed implementation efforts. Care providers need to be equipped by adequate training and sufficient manpower as part of the policy package.

Background and Purposes The change in reimbursement policy of erythropoietin application to peritoneal dialysis (PD) patients by Taiwan National Health Insurance (NHI) system provided a natural experimental venue to examine whether cardiovascular risk differs while keeping hematocrit (Hct) below 30% or over 30%. This study intended to analyze the impact of loosening erythropoietin payment criteria for PD patients on their cardiovascular outcomes. Methods Two cohorts of incident PD patients before and after the relaxation of NHI’s erythropoietin payment criteria were identified as Cohort 1 and Cohort 2, respectively, and further matched by propensity scores and then followed up for cardiovascular events. There were 1,759 patients in Cohort 1 and 2,981 patients in Cohort 2. After propensity score matching, 1,754 subjects were selected from each cohort. The outcome measures were cardiovascular events and were analyzed through Cox regressions. Findings and Conclusion For the composite cardiovascular endpoint, Cohort 2 patients had significantly lower risk than Cohort 1. The risk reduction was observed only in diabetic patients. After loosening erythropoietin payment criteria, less cardiovascular risks were observed, particularly for diabetic patients. It is concluded that for diabetic PD patients, maintaining a Hct level higher than 30% is crucial for reducing the cardiovascular risk.

BACKGROUND The change in the reimbursement policy of erythropoietin administration to patients receiving peritoneal dialysis by the Taiwan National Health Insurance (NHI) system provided a natural experimental venue to examine whether cardiovascular risk differs when maintaining the hematocrit (Hct) level below or above 30%. OBJECTIVE The aim of this study was to analyze the impact of loosening the erythropoietin payment criteria for peritoneal dialysis patients on their cardiovascular outcomes. METHODS Two cohorts of incident peritoneal dialysis patients were identified according to the time before and after relaxation of the NHI’s erythropoietin payment criteria, designated cohort 1 (n=1759) and cohort 2 (n=2981), respectively. The cohorts were matched according to propensity scores (1754 patients in each cohort) and then followed up for cardiovascular events, which were analyzed with Cox regressions. RESULTS For the composite cardiovascular endpoint, patients in cohort 2 had a significantly lower risk than those in cohort 1. However, subgroup analysis showed that this risk reduction was observed only in patients with diabetes. CONCLUSIONS After loosening erythropoietin payment criteria, reduced cardiovascular risks were observed, particularly for patients with diabetes. These results indicate that it is crucial to maintain an Hct level above 30% to reduce the cardiovascular risk in patients with diabetes undergoing peritoneal dialysis.

Despite a growing understanding of health-related quality of life (HRQOL) and its determinants in hemodialysis (HD) patients, little is known about the effects and interrelationships concerning the perception of autonomy support and basic need satisfaction of HD patients on their HRQOL. Based on self-determination theory (SDT), this study examines whether HD patients' perceived autonomy support from health care practitioners (physicians and nurses) relates to the satisfaction of HD patients' basic needs and in turn influences their HRQOL.A questionnaire was administered to 250 Taiwanese HD patients recruited from multiclinical centers and regional hospitals in northern Taiwan. Structural equation modeling (SEM) analysis was conducted to examine the causal relationships between patient perceptions of autonomy support and HRQOL through basic need satisfaction.The empirical results of SEM indicated that the HD patients' perceived autonomy support increased the satisfaction of their basic needs (autonomy, competency, and relatedness), as expected. The higher degree of basic need satisfaction led to higher HRQOL, as measured by physical and mental component scores.Autonomy support from physicians and nurses contributes to improving HD patients' HRQOL through basic need satisfaction. This indicates that staff caring for patients with severe chronic diseases should offer considerable support for patient autonomy.

The current volume of information accumulated in hospitals has exceeded the capacity of their medical information systems.Some hospitals employ business intelligence systems (BIS) to extract correct, timely, and useful information for hospital decision-makers.Medical information quality was significantly influenced by BIS maturity.Medical information quality exerted a significant effect on medical decision quality, BIS usage, and user satisfaction.The positive influence of user satisfaction on medical decision quality is also noted. Executives of information officers polled agree that rapid and accurate decision-making are essential to organizational agility and data plays an important role in decision making process. With Advanced information technologies, collecting data can be ubiquitously. However, the current volume of data accumulated in hospitals has exceeded the capacity of their medical information systems, not to mention using the data to make decisions. Hospitals started to employ business intelligence systems (BIS) to extract correct, timely, and useful information for hospital decision-makers. Most studies in the area focus on the establishment and related benefits of BIS. This research aims to evaluate the BIS maturity and its influences on decision quality to reveal the BIS impacts on hospital agility. To test the research model, opinions were collected by distributing questionnaires to clinical and administrative decision-makers who had experiences of using BIS in hospitals. The results showed that medical information quality was significantly influenced by BIS maturity. Furthermore, medical information quality exerted a significant effect on medical decision quality, BIS usage, and user satisfaction. The positive influence of user satisfaction on medical decision quality is also verified.

BACKGROUND Stage 5 chronic kidney disease (CKD) presents a high risk for dialysis initiation and for complications such as uremic encephalopathy, uremic symptoms, gastrointestinal bleeding, and infection. One of the most common barriers to health care for patients with stage 5 CKD is poor continuity of care due to unresolved communication gaps. OBJECTIVE Our aim was to establish a powerful care model that includes the use of a social networking service (SNS) to improve care quality for patients with CKD and safely delay dialysis initiation. METHODS We used a retrospective cohort of CKD patients aged 20-85 years who received care between 2007 and 2017 to evaluate the efficacy of incorporating an SNS into the health care system. In 2014, author F-JY, a nephrologist at the National Taiwan University Hospital Yunlin Branch, started to use an SNS app to connect with stage 5 CKD patients and their families. In cases of emergency, patients and families could quickly report any condition to F-JY. Using this app, F-JY helped facilitate productive interactions between these patients and the health care system. The intention was to safely delay the initiation of dialysis therapy. We divided patients into four groups: group 1 (G1) included patients at the study hospital during the 2007-2014 period who had contact only with nephrologists other than F-JY; group 2 (G2) included patients who visited F-JY during the 2007-2014 period before he began using the SNS app; group 3 (G3) included patients who visited nephrologists other than F-JY during the 2014-2017 period and had no interactions using the SNS; and group 4 (G4) included patients who visited F-JY during the 2014-2017 period and interacted with him using the SNS app. RESULTS We recruited 209 patients with stage 5 CKD who had been enrolled in the study hospital’s CKD program between 2007 and 2017. Each of the four groups initiated dialysis at different times. Before adjusting for baseline estimated glomerular filtration rate (eGFR), the G4 patients had a longer time to dialysis (mean 761.7 days, SD 616.2 days) than the other groups (G1: mean 403.6 days, SD 409.4 days, P=.011 for G4 vs G1; G2: 394.8 days, SD 318.8 days, P=.04; G3: 369.1 days, SD 330.8 days, P=.049). After adjusting for baseline eGFR, G4 had a longer duration for each eGFR drop (mean 84.8 days, SD 65.1 days) than the other groups (G1: mean 43.5 days, SD 45.4 days, P=.005; G2: mean 42.5 days, SD 26.5 days, P=.03; G3: mean 3.8.7 days, SD 33.5 days, P=.002). CONCLUSIONS The use of an SNS app between patients with stage 5 CKD and their physicians can reduce the communication gap between them and create benefits such as prolonging time-to-dialysis initiation. The role of SNSs and associated care models should be further investigated in a larger population.

BackgroundThe change in the reimbursement policy of erythropoietin administration to patients receiving peritoneal dialysis by the Taiwan National Health Insurance (NHI) system provided a natural experimental venue to examine whether cardiovascular risk differs when maintaining the hematocrit (Hct) level below or above 30%.ObjectiveThe aim of this study was to analyze the impact of loosening the erythropoietin payment criteria for peritoneal dialysis patients on their cardiovascular outcomes.MethodsTwo cohorts of incident peritoneal dialysis patients were identified according to the time before and after relaxation of the NHI’s erythropoietin payment criteria, designated cohort 1 (n=1759) and cohort 2 (n=2981), respectively. The cohorts were matched according to propensity scores (1754 patients in each cohort) and then followed up for cardiovascular events, which were analyzed with Cox regressions.ResultsFor the composite cardiovascular endpoint, patients in cohort 2 had a significantly lower risk than those in cohort 1. However, subgroup analysis showed that this risk reduction was observed only in patients with diabetes.ConclusionsAfter loosening erythropoietin payment criteria, reduced cardiovascular risks were observed, particularly for patients with diabetes. These results indicate that it is crucial to maintain an Hct level above 30% to reduce the cardiovascular risk in patients with diabetes undergoing peritoneal dialysis.

Table S1. Diseases and corresponding ICD-9-CM codes. Table S2. Anatomical Therapeutic Chemical codes of drugs used concomitantly by patients during the study period. (DOCX 21 kb)

Objectives The aims of this study were to investigate (1) whether and (2) the extent to which Taiwanese older adults' leisure time activity (LTA) trajectories mediated the potential association between their sociodemographic factors and their functional disability trajectories. Methods Longitudinal data from four waves of the Taiwan Longitudinal Study on Aging (TLSA), collected between 1996 and 2007, were used for analysis (N = 3,429). Parallel-process latent growth curve modeling was adopted to evaluate the process by which LTA mediated between sociodemographic factors (age, gender, education, self-rated health, comorbidities, and depression) and the outcome process of functional disabilities. Results When mediated by baseline level of LTA, five sociodemographic factors-age, gender, education level, self-rated health, and number of comorbidities-had significant and negative mediating effects on baseline or change in functional disability, thus improving disability outcomes. However, four of the sociodemographic factors (age, education level, and number of comorbidities), when mediated through the rate of change in LTA, were found to have significant and positive mediating effects, which increased disability levels. The proportion of effects mediated by the LTA trajectory ranged from 0% to 194%. Discussion The large proportion of effects mediated through the LTA process underlines the importance of LTA to public health policy and health programs for older adults. The study's findings shed light on how to better target populations of older adults to promote an active lifestyle and achieve more successful aging in late life in Asian countries.

Purpose: Few studies have addressed health-related quality of life (QoL) in patients who chose conservative management over dialysis. This systematic review aims to better define the role of conservative management in improving health-related QoL in patients with end-stage renal disease (ESRD). Methods: Medline, Cochrane and EMBASE were searched for prospective or retrospective studies published until June 30, 2016, that examined QoL of ESRD patients. The primary outcome was health-related QoL. Results: Four studies were included (405 patients received dialysis and 332 received conservative management). Two studies that used the Short Form-36 Survey (SF-36) showed that the dialysis group had higher physical component scores, but the conservative management group had similar, or better, mental component scores at the end of intervention. Another study using the SF-36 showed that the physical and mental component scores of the dialysis group did not significantly change after intervention. In the conservative management group, the physical component scores did not change, but the mental component scores increased significantly over time (0.12 ± 0.32, p < 0.05). One study, which used the Kidney Disease Quality of Life-Short Form (KD QoL-SF), found no change after intervention in either physical or mental component scores in the dialysis group; however, the physical component score declined (p = 0.047) and the mental component score increased (p = 0.033) in the conservative management group. Conclusion: Although there are only a limited number of published articles, ESRD patients who receive conservative management may have improved mental health-related QoL when compared with those who receive dialysis.

OBJECTIVES This study examined whether outpatient haemodialysis providers changed their treatment practices with the establishment of an outpatient dialysis global budget (ODGB) through analysing the outpatient visits and medication received by those patients. METHODS A sample of 4668 observations (patient year) of 1350 haemodialysis with hypertension (HH) patients and 4668 observations of 1436 non-HH (NHH) patients were drawn from the National Health Insurance Research Database over the years from 1999 to 2005. The impact of ODGB on hypertension-related outpatient utilization of HH was estimated using the difference in difference (DID) method and examined in three stages: (1) the fee for service stage, the pre-ODGB (2000), (2) the phase-in stage (2001-2002) and (3) the post-ODGB stage (2003-2005). RESULTS ODGB implementation did not affect the number of dialysis visits for HH patients. However, it did lead to a reduction in fees for antihypertension drugs used by haemodialysis facilities. There was an increase of 4.06 visits per patient per year (P < 0.001) in the number of non-dialysis outpatient with antihypertensive drugs visits for HH patients compared with the control group. The total fees for antihypertensive drugs for HH patients increased by New Taiwan Dollars (NT$)13 008 (P < 0.001) per patient per year relative to the control group after the implementation of ODGB. CONCLUSIONS As ODGB was implemented, HH patients received fewer antihypertensive drugs during their dialysis visit. In addition, there was an increase in the number of non-dialysis outpatient visits by HH patients as well as increased payment in the drugs associated with their non-dialysis outpatient visits compared with the control group.

Background: Survival after an out-of-hospital cardiac arrest (OHCA) depends on the integrity of the community chain of survival, including optimal and high-quality CPR, early defibrillation, and postresuscitation care. Older OHCA patients may have worse outcomes than the younger ones. This study aimed to find out the influence of age and other factors on the outcomes of OHCAs. Methods: We analyzed the original claims data of the National Health Insurance from 2005 to 2007, and identified all patients who were sent to the emergency department with OHCA. Traumatic OHCA patients and patients without codes for intubation and CPR were excluded. Survival rates between the different groups were identified. Factors such as age, sex, pre-existing comorbidities, and different hospital levels were adjusted in a logistic regression model for survival. Results: A total of 1673 OHCA cases were identified. Overall, the 1-month survival rates were similar in each year. However, the survival rates for those who were treated in medical centers improved from 3.4% (2005) to 6.8% (2007) (p

Many countries have implemented pay-for-performance programs to improve the quality of care. The structure of these programs, however, can have perverse consequences beyond improving care for patients. To investigate this possibility, we studied the pattern of enrollment of patients with diabetes in the first five years of a pay-for-performance program in Taiwan's National Health Insurance Program from 2001 through 2005. Taiwan's program did sharply improve quality of care for enrolled patients, producing 100 percent or nearly 100 percent adherence to all process measures. But at the same time, only a minority of the nation's patients with diabetes were enrolled, because the program's design encouraged physicians not to enroll their most complicated patients. By "cherry-picking" the healthiest patients most likely to perform well on selected measures, physicians were able to game the system and potentially reap the rewards of higher pay-for-performance payments without actually improving the care of all of their diabetic patients. Our study provides a cautionary tale, emphasizing the importance of proper program design so that quality is improved on the broadest scale.

Background: Nonalcoholic fatty liver disease (NAFLD), which represents metabolic abnormality and reflects extra visceral fat deposition, has been shown to be a threat to public health and associated with cardiovascular risks. However, data regarding the differences in clinical presentation and related metabolic abnormalities in the aging group population remained scarce in the Taiwanese population. Methods: We subsequently examined 8,658 subjects participating general health evaluation in Mackay Memorial hospital from 2003 to 2007. Baseline characteristics, anthropometrics, medical history, and biochemical markers were all collected. Abdominal ultrasonography was performed in all subjects. Two estimated cardiovascular risk scores were calculated according to criteria of the U.S. National Cholesterol Education Program Adult Treatment Panel III as metabolic score and Framingham risk score. Univariate logistic regression model was used to examine whether the baseline characteristics, anthropometrics, histories, and biochemical markers were independently associated with NAFLD from various age groups (young vs. aging groups) classified by 60 years of age. Respective receiver operating characteristic curves (ROC) with area under the curve were generated to test the capability of both cardiovascular risk scores in NAFLD discrimination from different age groups. Results: Totally 7,204 subjects (mean age: 44.5±11 years, 36% female) were finally enrolled in our study. Subjects with NAFLD were observed to have high body weight, body mass index, and circumferential waist and significantly abnormal biochemical markers accompanying worsening lipid profiles when compared with those without NAFLD in both the young and aging group populations (all p

SUMMARY There is no consistent evidence of the relationship between market competition and hospital efficiency. Some studies indicated that more competition led to a faster patient turnover rate, higher hospital costs, and lower hospital efficiency. Since the 1980s some studies found market competition could increase the efficiency of inpatient services. However, there were few studies testing the market competition during a hospital's earlier stages on its efficiency during later stages, or the dynamic of efficiency. In this study, we examined the effect of early-stage market competition on later-stage hospital efficiency in Taiwan, and we determine the efficiency change using longitudinal study design. The data for the analysis came from the annual national hospital survey of 1996 and 2001 provided by the Department of Health. There were 102 teaching hospital be analysed. The results show that no evidence supports the proposition that higher market competition would improve the efficiency of hospitals in delivering inpatient services in Taiwan. Importantly, neither was the inefficiency score nor the Malmquist productivity index of inpatient services associated with the level of hospital market competition, regardless of the adjustment for hospital characteristics. However, the results may be related with the hospital increasing beds investment behavior. Copyright © 2010 John Wiley & Sons, Ltd.

SUMMARY Background: Stroke and acute myocardial infarction (AMI) are serious diseases for elderly patients in Taiwan. For better outcomes, we prepared guidelines for the transfer of these patients to major medical centers. However, there has been no evidence-based research conducted in Taiwan focusing on the mortality rate of elderly AMI and stroke patients in different levels of hospital. The purpose of our study was to evaluate the outcomes for elderly stroke and AMI patients in different levels of hospitals. Methods: From the original claim data of 1 million beneficiaries enrolled in 2007, all hospitalized patients older than 50 years with the primary diagnosis of AMI, hemorrhagic stroke, or ischemic stroke (ICD-9-CM code 410, 430–432, or 433–438) were identified from the database. In 2007, 338 AMI cases, 293 hemorrhagic stroke cases, and 1,290 ischemic stroke cases were included in our study. Patients who were transferred between hospitals were excluded. All the possible risk factors such as patient age, sex, triage classification, preexisting comorbidities, and different hospital levels were adjusted for in a logistic regression model. Results: In ischemic stroke patients, the odds ratio of mortality for the patients in major medical centers was 0.4 times that for patients in regional hospitals. Thus, major medical centers were safer for ischemic stroke patients after adjusting for patient age, sex, triage classifications and preexisting comorbidities. However, differences in the survival rates of hemorrhagic stroke patients between hospitals were insignificant. In AMI patients, the survival rates were also not significantly different after adjusting for age, sex, triage classification, preexisting comorbidities and hospital level. Conclusions: Our study showed that major medical centers were safer only for ischemic stroke patients after adjusting for patient age, sex, triage classifications and preexisting comorbidities. This finding suggests that all patients with acute onset stroke should be sent to major medical centers for further evaluation and treatment. [International Journal of Gerontology 2010; 4(3): 137–142]

Background: Since the fee-for-service reimbursement mechanism has been under the global budget of the National Health Insurance program, physicians’ workloads have been increasing. Attending physicians in medical centers usually have long working hours because of their clinical work as well as teaching, research, and other administrative responsibilities. Many studies regarding reasonable work hours for physicians have been undertaken globally, but few have been conducted in Taiwan. In this study, we focused on the difference in working hours among physicians in different departments. Methods: Using attending physicians from a major teaching hospital as the study population, we adopted self-administered questionnaires to investigate physicians’ time allocations for 4 major categories: clinical work, teaching, research, and administrative work. We distributed 432 questionnaires and received 380 filled-out questionnaires, yielding a response rate of 88%. After eliminating questionnaires with incomplete responses, the valid sample size was 376. We used t test and 1-way ANOVA to analyze the association between physicians’ characteristics and workload and used multiple linear regression to examine factors influencing physicians’ work hours. Results: The average weekly work time among attending physicians was 65.6 hours; physicians under the age of 40 worked an average of 69.8 hours. Males worked an average of 66.2 hours weekly and females an average of 62.7 hours. Total work hours and hours of clinical work, teaching, research, and administrative work all reached significant differences among departments. Physicians who were under 40 years old, those with a doctoral degree, those with a teaching position as associate professor or above, and those working in anesthesiology had longer total work hours. Conclusion: This study found that work hours among departments differed significantly and that physicians in surgical departments spend the longest hours in clinical work. Those in administrative positions are most involved in clinical work. However, work hours do not definitely represent work intensity, and to define the workload by working hours may be inappropriate for some departments. This possible difference between work hours and work intensity merits further consideration. [J Chin Med Assoc 2010;73(8):425–430]

SUMMARY Background: Left ventricular (LV) remodeling has been shown to impart prognostic significance in previous studies. However, the underlying exact mechanisms involved and interactions between LV geometry alterations and age with other clinical and biochemical variables in general population have not been well established. Methods: A total of 406 consecutive subjects were enrolled in a health evaluation center-based population study (mean age, 51.5 ± 10.9 years; 42% women). Data including baseline characteristics, echocardiography, biochemistry and biomarkers were all collected and evaluated. Univariate and multivariate regression analysis was performed to test the relationship between relative wall thickness (RWT) and other variables. We also divided the subjects into older and younger groups, compared RWT between the two groups, and analyzed the distribution of LV geometry in these groups. Results: The prevalence of diabetes and hypertension in our study population was relatively small (11.6% and 16.5%, respectively). The most common type of LV geometry in our study was normal (67.5%) and concentric remodeling (30.3%) compared with a relatively small proportion of concentric LV hypertrophy (1.5%) and eccentric hypertrophy (< 1%). Of all 406 subjects evaluated, age, uric acid, height, systolic blood pressure and serum insulin level were all independent factors associated with RWT in a multivariate regression model. Conclusion: In our study, we revealed that aging, together with baseline blood pressure and serum biochemistries, were associated with LV geometric alterations. These data suggest that the LV remodeling process actually involves dynamic and complex interactions with multiple metabolic factors in an unselected general population in Taiwan. (International Journal of Gerontology 2009; 3(1): 66-74)

Under the global shortage of Registered Nurses (RNs), some hospitals have integrated nursing assistants (NAs) into their teams to help to provide maximum quality care for acute patients, while keeping the hospital's staff-related costs down. However, the RNs may have to shoulder an increased burden of assigning and overseeing NAs. A web-based Nursing Assistants Management System (NAMS) was developed and evaluated for a case hospital in Taiwan to compare the processes of assigning and managing NAs before and after the NAMS intervention. The results showed that NAMS saved 80% of the time needed for manual operation and there were no more complains about NAs being slow in dealing with patients after the system intervention. The satisfaction levels of all NA managers and RNs were acceptable. Based on the research findings, the implication and limitations of this study were discussed.

Continuing professional education is essential for nurses to update their clinical skills and knowledge to meet the complex demands of current patient care. Compared to traditional in-class continuing education, a web-based learning system is efficient for nurses with a three shift-working schedule and is timely to deliver knowledge about newly emerging epidemics such as Severe Acute Respiratory Syndrome. Many studies reveal the advantages of various web-based learning systems but seldom evaluate them from the perspective of quality. This study develops an instrument to assess the quality of a web-based learning system for nurses' continuing education based on the quality dimensions of a mature information systems success model. The research results show that all indicators of the instrument provide a fit to the quality measurement of a web-based learning system and have high reliability and validity. Based on the research findings, implications and limitations are discussed.

Background Health intervention program (HIP) based on diet and lifestyle modifications had been shown to improve cardiovascular risks. The effects of such program on a variety of cardiometabolic outcome measures conducted in a strict analysis remained relatively unexplored. Materials and methods A total of 2,660 participants (mean age: 43.3 ± 10 years, 63.6 % male) underwent annual health survey from our health evaluation department. We implemented health intervention program (HIP) in which diet and lifestyle modifications including smoking cessation and advised physical activities were introduced. We further studied the effects of HIP on several cardiometabolic outcome measures including Framingham, metabolic scores and renal function in terms of Egfr with a mean follow-up period of 38.5 months. Propensity score (PS) matching (HIP vs non-HIP group) was used to avoid effects of case selection bias. Results Totally 1,004 (502 subjects for each group) left after PS matching protocol (both HIP and non-HIP group). The HIP group showed significant decline of waist circumference (−1.46 ± 0.61, p = 0.016), post-prandial glucose (−6.77 ± 2.06, p = 0.001), and total cholesterol level (−4.42 ± 2.15, p = 0.04), with borderline increase in eGFR (1.72 ± 0.94, p = 0.068) after an average of 1.91 ± 1.14 year follow up period. Exercise behavior significantly increased for those who received HIP when compared to the non-HIP group (44.6 vs 52.4 %, p = 0.014). PS matching and difference-in-difference (DID) analysis further confirmed the beneficial effects of ATP III reduction by HIP (−0.36 ± 0.06, p

Current debates in the insurance and public policy literatures over health care financing and cost control measures continue to focus on managed care and HMOs. The lower utilization rates found in HMOs (compared to tradi- tional fee-for-service indemnity plans) have generally been attributed to the organization's incentive to eliminate all unnecessary medical services. As a consequence HMOs are often considered to be a more efficient arrangement for delivering health care. However, it is important to make a distinction between utilization and efficiency (the ratio of outcomes to resources). Few studies have investigated the effect that HMO arrangements would have on the actual efficiency of health care delivery. Because greater control over provider autonomy appears to be a recurrent theme in the literature on re- form, it is important to investigate the effects these restrictions have already had within the HMO market. In this article, the efficiencies of two major classes of HMO arrangements are compared using "game-theoretic" data envelopment analysis (DEA) models. While other studies confirm that abso- lute costs to insurance firms and sponsoring companies are lowered using HMOs, our empirical findings suggest that, within this framework, efficiency generally becomes worse when provider autonomy is restricted. This should give new fuel to the insurance companies providing fee-for-service (FFS) indemnification plans in their marketplace contentions.

The major components, content of examinations, measurements and intervention programs in Health Intervention Program (HIP) in our center. Figure S1. As shown in Figure S1, the age and sex distribution of all 3,057 individuals in this health screen program before the final enrollment criteria. Figure S2. Among 2,660 individuals who fit the enrollment criteria before propensity matching, 1,691 (63.6Â %) were male and 969 (36.4Â %) were female, resulting in a total of 922 and 1,738 subjects in the intervention and non-intervention groups, respectively. (DOC 232 kb)

Background: Although work hour is an important factors for resident workload, other contributing factors, such as patient severity, with regards to resident workload have been scarcely studied. Methods: A prospective observational cohort study was conducted in a general medicine unit in an academic medical center in Taiwan. Every event for which the nurses needed to call the on-call residents was recorded. To quantify the workload, the responses of on-duty residents to calls were analyzed. To allow comparisons of patient factors to be made, we classified all patients by assigning them stable, unstable, or do-not-resuscitate (DNR) codes. The reasons for the calls were categorized to facilitate the comparisons across these three groups. Results: From October 2009 to September 2011, a total of 2,518 patients were admitted to the general medicine unit. The nurses recorded a total of 847 calls from 730 call nights, ranging from 0 to 7 per night. Two peaks of calls, at 0-2 am and 6-7 am, were noted. Calls from stable, unstable, and DNR patients were 442 (52.2%), 95 (11.2%), and 298 (35.2%), respectively. For both unstable and DNR patients, the leading reason was abnormal vital signs (62.1% and 67.1%, respectively), while only 36.2% for stable patients. Both unstable and DNR patients required more bedside evaluation and management compared to stable patients. Conclusion: Beyond work hours and patient census, patients with different clinical severity and palliative goal produce different workload for on-call residents.

Background: Some articles proved indirect-transfer the major trauma patients to the trauma centers had non-significant different outcomes with the patients direct-transfer to the centers. But the outcomes for the major trauma patients in the counties without trauma centers still can be worse. So we did a population based research by using the NHIRD data for the results. Methods: From the claim data of one million beneficiaries of Taiwan National Health Insurance during the year of 2006 to 2008, all of the trauma patients were identified from the database by the ICD-9-CM system. ICDMAP-90 was used for calculating the Injury Severity Score (ISS) as the variable controlling the disease severity. The patients of major trauma were defined as ISS more than fifteen. We used the diagnosis one year before the trauma admission for calculating Charlson Comorbidity Index (CCI). The first hospitals and the second transferred hospitals that the major trauma patients admitted, and the areas of the first hospitals were recognized in our data bank. The condition of transfer, age, genders, intubation, ICU admission, ISS, CCI, and the triage classifications were adjusted in a logistic regression model for further analysis. Results: There were 2497 major trauma patients (ISS more then 15). The total mortality rate was 12.49%. The variables like age, intubation, ICU admission, ISS and CCI were significant for mortality, but the condition of transfer was not significant in our model. After controlling all the factors, the major trauma patients that first admitted in the areas with no trauma centers have a significant higher risk of mortality (OR=1.73, P=0.005). Conclusions: Our results hint that, although indirect-transfer for the major trauma patients have insignificant difference in mortality with the direct transfer patients, the counties with no trauma centers have significant higher mortality rates in major trauma patients. Further researches are needed for investigating the possible reasons.

Background: Medical care at night for patients with do-not-resuscitate orders and the practice patterns of the on-call residents have rarely been reported. Aim: To evaluate the after-hours physician care for patients with do-not-resuscitate orders in the general medicine ward. Design: Observational study. Setting/participants: This study was conducted at an urban, university-affiliated academic medical center in Taiwan. The night shift nurses consecutively recorded every event that required calling the duty residents. Patients with and without a do-not-resuscitate order were compared in demographics, reasons for calling, residents’ response, and nurses’ satisfaction. A standard report form was established for the nurses to record events. Results: From October 2009 to September 2010, 1379 inpatients contributed to 456 after-hours calls. do-not-resuscitate patients accounted for 256 (18.7%) of all inpatients, and 160 (35.1%) of all after-hours calls. The leading reason for calls was abnormal vital signs, which was significantly higher for patients with do-not-resuscitate orders compared to patients without a do-not-resuscitate order (64.4% vs 36.1%, p < 0.001). The pattern of residents’ responses showed a significant difference with more bedside visits for patients with do-not-resuscitate orders ( p < 0.001). The nurses were usually satisfied with the residents’ management of both groups. Conclusion: Abnormal vital sign, rather than symptom, was the leading reason for after-hours calls. The existence of do-not-resuscitate order produced different medical needs and physician workload. Patients with do-not-resuscitate orders accounted for one-third of night calls and nearly half of bedside visits by on-call residents and may require a different care approach.

Factors associated with the physician workload are scarcely reported. The study aims to investigate the associated factors of on-call physician workload based on a published conceptual framework. The study was conducted in a general internal medicine unit of National Taiwan University Hospital. On-call physician workloads were recorded on a shift basis from 1198 hospitalized patients between May 2010 and April 2011. The proxy of on-call workloads included night calls, bedside evaluation/management (E/M), and performing clinical procedures in a shift. Multivariable logistic and negative binomial regression models were used to determine the factors associated with the workloads of on-call physicians. During the study period, 378 (31.6%) of patients had night calls with related workloads. Multivariate analysis showed that the number of patients with unstable conditions in a shift (odds ratio [OR] 1.89 and 1.66, respectively) and the intensive care unit (ICU) training of the nurse leader (OR 2.87 and 3.08, respectively) resulted in higher likelihood of night calls to and bedside E/M visits by the on-call physician. However, ICU training of nurses (OR = 0.37, 95% confidence interval: 0.16–0.86) decreased the demand of performing clinical procedures by the on-call physician. Moreover, number of patients with unstable conditions (risk ratio [RR] 1.52 and 1.55, respectively) had significantly increased the number of night calls and bedside E/M by on-call physicians by around 50%. Nurses with N1 level (RR 2.16 and 2.71, respectively) were more likely to place night calls and facilitate bedside E/M by the on-call physician compared to nurses with N0 level. In addition, the nurse leaders with ICU training (RR 1.72 and 3.07, respectively) had significant increases in night calls and bedside E/M by the on-call physician compared to those without ICU training. On-call physician workload is associated with patient factors and the training of nurses. Number of unstable patients in a shift may be considered in predicting workload. The training of nurses may improve patient safety and decrease demand for clinical procedure.

Background The balanced scorecard (BSC) is considered to be a useful tool for management in a variety of business environments. The purpose of this article is to utilize the experimental data produced by the incorporation and implementation of the BSC in hospitals and to investigate the effects of the BSC red light tracking warning system on performance improvement. Methods This research was designed to be a retrospective follow-up study. The linear mixed model was applied for correcting the correlated errors. The data used in this study were secondary data collected by repeated measurements taken between 2004 and 2010 by 67 first-line medical departments of a public academic medical center in Taipei, Taiwan. The linear mixed model of analysis was applied for multilevel analysis. Results Improvements were observed with various time lags, from the subsequent month to three months after red light warning. During follow-up, the red light warning system more effectively improved controllable costs, infection rates, and the medical records completion rate. This further suggests that follow-up management promotes an enhancing and supportive effect to the red light warning. Conclusion The red light follow-up management of BSC is an effective and efficient tool where improvement depends on ongoing and consistent attention in a continuing effort to better administer medical care and control costs.

Hypertension-associated intracerebral hemorrhage, when compared with cerebral infarction and subarachnoid hemorrhage, is associated with worse clinical outcomes or major disability. Worse clinical outcomes have been observed in the elderly population though age as a factor influencing physicians' final treatment decision is not well determined.We studied 199 patients diagnosed with intracerebral hemorrhage (ICD code: ICD-9-CM-431) who visited a tertiary medical center from January 2003 to March 2006. Baseline characteristics, major medical histories (including co-morbidities), vital signs, neurological assessment (evaluated by the Glasgow Coma Scale), location of the hemorrhage, and the amount of hemorrhaging were all included as variables. A multivariate logistic regression model was chosen to evaluate the significant independent factors that could influence the physician's choice of treatment approach.There were totally 110 patients meeting the inclusion criteria for enrollment. We observed that worse neurological function on-arrival (chi2 = 8.57, p = .01) and larger amount of bleeding (chi2 = 9.29, p = .01) were more likely to receive surgery. Multivariate logistic regression revealed that age, neurological function on-arrival, and the amount of hemorrhage were significant independent factors influencing the physicians' treatment decision (all p.05).Age, after adjustment for clinical variables representative of clinical severity, was an important factor in the final therapeutic decision. Our data suggest that a comprehensive evaluation of the patients' on-arrival status may be made and that advanced age should not be a determining factor in the choice of final treatment methods.