Kuo-Piao Chung

Vascularized lymph node transfer based on the hilar perforators improves the outcome in upper limb lymphedema.

Background:Maintenance of the blood supply to the lymph nodes is necessary for survival and function. We report the outcome of vascularized lymph node transfer with hilar perforators compared with the conventional technique. Patients:A total of 21 patients affected by early stage II upper limb lymphedema were included in this study. Of them, 11 patients received a free groin flap containing lymph nodes, and 10 patients received vascularized inguinal lymph nodes with hilar perforators. Mean follow-up was 46 and 40 months, respectively. Complications, secondary procedures, circumference of the limb, and subjective symptomatology were registered. The differences were evaluated statistically. Results:The limb circumferences decreased significantly in the new group. The number of secondary procedures was significantly higher in the standard group. There were 2 cases of partial flap loss and donor site lymphorrhea in the standard group. In both the groups, visual analog scale scores improved after the operation. Conclusions:Transfer of vascularized inguinal lymph nodes based on the hilar perforators improves the outcomes in the treatment of early lymphedema of the upper extremity.

The Unintended Consequence of Diabetes Mellitus Pay‐for‐Performance (P4P) Program in Taiwan: Are Patients with More Comorbidities or More Severe Conditions Likely to Be Excluded from the P4P Program?

OBJECTIVE Taiwan has instituted a pay-for-performance (P4P) program for diabetes mellitus (DM) patients that rewards doctors based in part on outcomes for their DM patients. Doctors are permitted to choose which of their DM patients are included in the P4P program. We test whether seriously ill DM patients are disproportionately excluded from the P4P program. DATA SOURCE/STUDY SETTING This study utilizes data from the National Health Insurance (NHI) database in Taiwan for the period of January 2007 to December 2007. Our sample includes 146,481 DM-P4P patients (16.56 percent of the total) and 737,971 non-DM-P4P patients. DATA COLLECTION/EXTRACTION METHODS We use logistic and multilevel models to estimate the effects of patient and hospital characteristics on P4P selection. PRINCIPAL FINDINGS The results show that older patients and patients with more comorbidities or more severe conditions are prone to be excluded from P4P programs. CONCLUSIONS We found that DM patients are disproportionately excluded from P4P programs. Our results point to the importance of mandated participation and risk adjustment measures in P4P programs.

Organization-based performance measures of cancer care quality: core measure development for breast cancer in Taiwan

The purpose of the study was to develop organization-based core performance measures (CPMs) for breast cancer patients treated in hospitals that participated in cancer quality improvement programmes in Taiwan. CPMs were developed in three stages that included a preparation, a consensus building stage, and two stages of stakeholder feedback. Three criteria and seven subcriteria were applied in the development process. Indicators listed in a Delphi questionnaire were based on a literature search, indicators developed by relevant institutions and discussion by authors. Each indicator needed to meet inclusion criteria as a final indicator. Evidence-based guidelines, expert opinions from panel group, 27 hospitals and empirical data were all applied to develop and revise the core measures. Fifteen out of 28 indicators were selected and modified after the three stages. There were two pre-treatment indicators for screening and diagnosis, nine treatment-related indicators, and four monitoring-related indicators. Six indicators were supported by evidence level I, and four indicators by level II evidence. The CPMs for breast cancer can be developed systematically and be applied for internal quality improvement and external surveillance. Our experience can be extended to other cancer sites and adapted to link with pay for performance or certification program in cancer care.

Is quality of colorectal cancer care good enough? Core measures development and its application for comparing hospitals in Taiwan

BackgroundAlthough performance measurement for assessing care quality is an emerging area, a system for measuring the quality of cancer care at the hospital level has not been well developed. The purpose of this study was to develop organization-based core measures for colorectal cancer patient care and apply these measures to compare hospital performance.MethodsThe development of core measures for colorectal cancer has undergone three stages including a modified Delphi method. The study sample originated from 2004 data in the Taiwan Cancer Database, a national cancer data registry. Eighteen hospitals and 5585 newly diagnosed colorectal cancer patients were enrolled in this study. We used indicator-based and case-based approaches to examine adherences simultaneously.ResultsThe final core measure set included seventeen indicators (1 pre-treatment, 11 treatment-related and 5 monitoring-related). There were data available for ten indicators. Indicator-based adherence possesses more meaningful application than case-based adherence for hospital comparisons. Mean adherence was 85.8% (79.8% to 91%) for indicator-based and 82.8% (77.6% to 88.9%) for case-based approaches. Hospitals performed well (>90%) for five out of eleven indicators. Still, the performance across hospitals varied for many indicators. The best and poorest system performance was reflected in indicators T5-negative surgical margin (99.3%, 97.2% - 100.0%) and T7-lymph nodes harvest more than twelve(62.7%, 27.6% - 92.2%), both of which related to surgical specimens.ConclusionsIn this nationwide study, quality of colorectal cancer care still shows room for improvement. These preliminary results indicate that core measures for cancer can be developed systematically and applied for internal quality improvement.

Risk groups defined by Recursive Partitioning Analysis of patients with colorectal adenocarcinoma treated with colorectal resection

BackgroundTo define different prognostic groups of surgical colorectal adenocarcinoma patients derived from recursive partitioning analysis (RPA).MethodsTen thousand four hundred ninety four patients with colorectal adenocarcinoma underwent colorectal resection from Taiwan Cancer Database during 2003 to 2005 were included in this study. Exclusion criteria included those patients with stage IV disease or without number information of lymph nodes. For the definition of risk groups, the method of classification and regression tree was performed. Main primary outcome was 5-year cancer-specific survival.ResultsWe identified six prognostic factors for cancer-specific survival, resulting in seven terminal nodes. Four risk groups were defined as following: Group 1 (mild risk, 1,698 patients), Group 2 (moderate risk, 3,129 patients), Group 3 (high risk, 4,605 patients) and Group 4 (very high risk, 1,062 patients). The 5-year cancer-specific survival for Group 1, 2, 3, and 4 was 86.6%, 62.7%, 55.9%, and 36.6%, respectively (p < 0.001). Hazard ratio of death was 2.13, 5.52 and 10.56 (95% confidence interval 1.74-2.60, 4.58-6.66 and 8.66-12.9, respectively) times for Group 2, 3, and 4 as compared to Group 1. The predictive capability of these grouping was also similar in terms of overall and progression-free survival.ConclusionThe use of RPA offered an alternative grouping method that could predict the survival of patients who underwent surgery for colorectal adenocarcinoma.

The laparoscopic right gastroepiploic lymph node flap transfer for upper and lower limb lymphedema: Technique and outcomes

Lymph node flap transfer popularity for treatment of extremity lymphedema is increasing quickly. Multiple flap donor sites were described in search of the optimal one. We describe the technique and outcomes of a laparoscopically harvested right gastroepiploic lymph node flap for treatment of extremity lymphedema.

The use of statistical process control (risk-adjusted CUSUM, risk-adjusted RSPRT and CRAM with prediction limits) for monitoring the outcomes of out-of-hospital cardiac arrest patients rescued by the EMS system

OBJECTIVE Based on previous experience from surgical surveillance, risk-adjusted cumulative sum (CUSUM)-type charts were applied to monitor out-of-hospital cardiac arrest (OHCA) patient mortality. MATERIALS AND METHODS Data from 2356 OHCA patients were collected by the Taipei County Fire Bureau from June 2006 to November 2007. Logistic regression analysis was applied to create a risk-adjusted model. Next, a risk-adjusted CUSUM chart, a risk-adjusted resetting sequential probability ratio test chart and a cumulative risk-adjusted mortality with prediction limits chart were used to detect excess deaths of the OHCA patients rescued by the emergency medical service (EMS) system. RESULTS The overall mortality rate, defined as having no return of spontaneous circulation, was 79.3%. These three charts signalled an increase in the death rate at similar sites, and also suggested a small process shift. CONCLUSION A visual approach to EMS systems monitoring that combines the risk-adjusted cumulative sum, Risk-adjusted resetting sequential probability ratio test and cumulative risk-adjusted mortality with prediction limits charts was established. It was found that this approach can be effectively used by the EMS community to monitor OHCA outcomes in real time.

Effect of the Pay-for-Performance Program for Breast Cancer Care in Taiwan

OBJECTIVE To evaluate the impact of the nationwide pay-for-performance (P4P) program for breast cancer care (BC-P4P) in Taiwan on care quality, patient survival, and recurrence. STUDY DESIGN A population-based observational study with cross-sectional design. METHODS Retrospective analysis of population based cancer registration and claims data was used in this study. A total of 4528 patients with stage I or II breast cancer diagnosed in 2002 or 2003 who received curative surgery were observed until the end of 2008. This study applied multivariate linear regression to explore the association between BC-P4P enrollment and quality of care. Cox regression was applied to examine the effect of BC-P4P enrollment on 5-year recurrence and overall survival among patients with breast cancer. RESULTS After controlling for age, stage, type of surgery, and other factors, BC-P4P enrollees were found to have received better quality care than nonenrollees (P = .001). Cox regression models also indicated that after controlling for patient characteristics, quality of care was related to better 5-year overall survival (odds ratio [OR], 0.212; P = .001) and recurrence (OR, 0.289; P <.001). Even when controlled by quality of care provided to patients and its interaction with status of BC-P4P enrollment, BC-P4P enrollment remained statistically significant regarding 5-year overall survival (OR, 0.167; P <.001) and recurrence (OR, 0.370; P = .002). CONCLUSION Patients with breast cancer enrolled in the BC-P4P program received better quality care and had better outcome than nonenrolled patients. Evidence from this study indicates that financial incentives in the payment design had a positive impact on outcome of breast cancer care.PURPOSE To evaluate the impact of the nationwide pay-for-performance (P4P) program for breast cancer care (BC-P4P) in Taiwan on care quality, patient survival, and recurrence. STUDY DESIGN A population-based observational study with cross-sectional design. METHODS Retrospective analysis of population-based cancer registration and claims data was used in this study. A total of 4,528 patients with stage I or II breast cancer diagnosed in 2002 or 2003 who received curative surgery were observed until the end of 2008. This study applied multivariate linear regression to explore the association between BC-P4P enrollment and quality of care. Cox regression was applied to examine the effect of BC-P4P enrollment on 5-year recurrence and overall survival among patients with breast cancer. RESULTS After controlling for age, stage, type of surgery, and other factors, BC-P4P enrollees were found to have received better quality care than nonenrollees (P = .001). Cox regression models also indicated that after controlling for patient characteristics, quality of care was related to better 5-year overall survival (odds ratio [OR], 0.212; P = .001) and recurrence (OR, 0.289; P < .001). Even when controlled by quality of care provided to patients and its interaction with status of BC-P4P enrollment, BC-P4P enrollment remained statistically significant regarding 5-year overall survival (OR, 0.167; P < .001) and recurrence (OR, 0.370; P = .002). CONCLUSION Patients with breast cancer enrolled in the BC-P4P program received better quality care and had better outcome than nonenrolled patients. Evidence from this study indicates that financial incentives in the payment design had a positive impact on outcome of breast cancer care.

Development of Service Quality Scale for Surgical Hospitalization

BACKGROUND/PURPOSE Findings from literature showed inconsistent results for applying service quality scale in hospitals. Moreover, hospitalization services are provided by diversified departments and a scale designed to measure the overall hospitalization quality is difficult and capturing special characteristics of different departments is also not an easy task. This study attempted to develop a service quality scale for surgical hospitalization (SQSH). METHODS Forty-two items were designed via literature review, interviews with patients, health professionals and experienced care givers. A cross-sectional survey was conducted in one hospital. A total of 271 patients in surgical wards were chosen using stratified random sampling; 57.7% of the sampled patients were aged below 55, and 52.2% were male. RESULTS The response rate was 93.4%. Twenty-nine items were retained through the scale development process and six factors were formed: needs management, assurance, sanitation, customization, convenience and quiet, and attention. Six factors explained 57.3% of total variance. Five experts assessed the content validity; content validity index was 0.964. Furthermore, all Cronbachs alpha exceeded 0.642 and all factor loadings exceeded 0.5. The concurrent validity correlation was 0.583, which had a p value below 0.01. CONCLUSION The SQSH has sufficient usefulness, reliability and validity. Future research on service quality can apply the SQSH scale to link with utilization intention and patient loyalty and attempt to develop a hospitalization quality scale for other departments.

Processes and outcomes of ischemic stroke care: the influence of hospital level of care

OBJECTIVE Processes of stroke care play an increasingly important role in comparing hospital performance. The relationship between processes of care and outcomes for stroke is unclear. Moreover, in terms of stroke care regionalization, little information is available with regard to the relationships among hospital level of care, processes and outcomes of stroke care. We used nationwide population-based data to examine the relationship between processes of care and mortality and the relationships among hospital level of care, processes and mortality for ischemic stroke. DESIGN Cross-sectional study. SETTING General acute care hospitals throughout Taiwan. PARTICIPANTS A total of 31 274 ischemic stroke patients admitted in 2010 through Taiwans National Health Insurance Research Database. MAIN OUTCOME MEASURES Processes of care and 30-day mortality. Multilevel models were used after adjustment for patient and hospital characteristics to test the relationship between processes of care and 30-day mortality and the relationships among hospital level of care, processes and 30-day mortality. RESULTS The use of thrombolytic therapy, antithrombotic therapy, statin treatment and rehabilitation assessment was associated with lower mortality. Hospital level of care was associated with the use of thrombolytic therapy, antithrombotic therapy, statin treatment and rehabilitation assessment, and mortality. These processes of care were mediators of the relationship between hospital level of care and mortality. CONCLUSIONS Outcomes among patients with ischemic stroke can be improved by thrombolytic therapy, antithrombotic therapy, statin treatment and rehabilitation assessment. Among patients with ischemic stroke, admission to designated stroke center hospitals may be associated with lower mortality through better processes of care.