Tsung-Hsien Yu

Are quality improvement methods a fashion for hospitals in Taiwan

OBJECTIVEnThis study reviews the rise and fall of the quality improvement (QI) methods implemented by hospitals in Taiwan, and examines the factors related to these methods.nnnDESIGNnCross-sectional, questionnaire-based survey.nnnSETTINGnOne hundred and thirty-nine district teaching hospitals, regional hospitals and medical centers.nnnPARTICIPANTSnDirectors or the persons in charge of implementing QI methods.nnnINTERVENTIONns) None.nnnMAIN OUTCOME MEASUREns) Breadth and depth of the 18 QI methods.nnnRESULTSnSeventy-two hospitals responded to the survey, giving a response rate of 52%. In terms of breadth based on the hospitals self-reporting, the average number of QI methods adopted per hospital was 11.78 (range: 7-17). More than 80% of the surveyed hospitals had implemented eight QI methods, and >50% had implemented five QI methods. The QI methods adopted by over 80% of the surveyed hospitals had been implemented for a period of ∼7 years. On the basis of the authors classification, seven of the eight QI methods (except for QI team in total quality management) had an implementation depth of almost 70% or higher in the surveyed hospitals.nnnCONCLUSIONSnThis study provides a snapshot of the QI methods implemented by hospitals in Taiwan. The results show that the average breadth of the QI methods adopted was 11.78; however, only 8.83 were implemented deeply. The hospitals accreditation level was associated with the breadth and depth of QI method implementation.

Why do outcomes of CABG care vary between urban and rural areas in Taiwan? A perspective from quality of care

OBJECTIVEnThis study explores the association between coronary artery bypass surgery (CABG) patients residence and quality of care in terms of 30-day mortality.nnnDESIGNnA retrospective, multilevel study design was conducted using claims data from Taiwans Universal Health Insurance Scheme. Hospital and surgeons CABG operation volume, risk-adjusted surgical site infection rate and risk-adjusted 30-day mortality rate in the previous year were adopted as performance indicators, and the level of quality was evaluated via K-means clustering algorithm. Baron and Kennys procedures for mediation effect were conducted.nnnSETTINGnHospitals in Taiwan.nnnPARTICIPANTSnPatients who underwent CABG surgeries from 1 January 2008 to 30 September 2011 were identified in this study. However, patients who were under the age of 18 years or above the age of 85(n = 164), with missing data for gender (n = 3) or received surgeries from surgeons who never performed any CABG surgeries (n = 27), were excluded.nnnINTERVENTIONSnNone.nnnMAIN OUTCOME MEASURESnThirty-day mortality.nnnRESULTSnThere were 9973 CABG surgeries included in this study. Patients who lived in urban areas received better quality of care (28.90 vs. 21.57%) and enjoyed better outcome (4.33 vs. 6.84%). After the procedure of mediation effect testing, the results showed that the relationship between patient residences urbanization level and 30-day mortality was partially mediated by patterns of quality of care.nnnCONCLUSIONSnThe rural-dwelling CABG patients are less likely to approach the better performing healthcare providers, and this tendency indirectly affects their treatment outcomes. Policymakers still need to develop strategies to ensure better equity in access to quality health care.

Do low-income coronary artery bypass surgery patients have equal opportunity to access excellent quality of care and enjoy good outcome in Taiwan?

BackgroundEquity is an important issue in the healthcare research field. Many studies have focused on the relationship between patient characteristics and outcomes of care. These studies, however, have seldom examined whether patients´ characteristics affected their access to quality healthcare, which further affected the care outcome. The purposes of this study were to determine whether low-income coronary artery bypass surgery (CABG) patients receive healthcare services with poorer quality, and if such differences in treatment result in different outcomes.MethodsA retrospective multilevel study design was conducted using claims data from Taiwan´s universal health insurance scheme for 2005-2008. Patients who underwent their CABG surgery between 2006 and 2008 were included in this study. CABG patients who were under 18´years of age or had unknown gender or insured classifications were excluded. Hospital and surgeon´s performance indicators in the previous one year were used to evaluate the level of quality via k-means clustering algorithm. Baron and Kenny´s procedures for mediation effect were conducted to explore the relationship among patient´s income, quality of CABG care, and inpatient mortality.ResultsA total of 10,320 patients were included in the study. The results showed that 5.65% of the low-income patients received excellent quality of care, which was lower than that of patients not in the low-income group (5.65% vs.11.48%). The mortality rate of low-income patients (12.10%) was also higher than patients not in the low-income group (5.25%). Also, the mortality of patients who received excellent care was half as low as patients receiving non-excellent care (2.63% vs. 5.68%). Finally, after the procedure of mediation effect testing, the results showed that the relationship between patient income level and CABG mortality was partially mediated by patterns of quality of care.ConclusionsThe results of the current study implied that worse outcome in low-income CABG patients might be associated with poorer quality of received services. Health authorities should pay attention to this issue, and propose appropriate solutions.

Which Kind of Provider’s Operation Volumes Matters? Associations between CABG Surgical Site Infection Risk and Hospital and Surgeon Operation Volumes among Medical Centers in Taiwan

Background Volume-infection relationships have been examined for high-risk surgical procedures, but the conclusions remain controversial. The inconsistency might be due to inaccurate identification of cases of infection and different methods of categorizing service volumes. This study takes coronary artery bypass graft (CABG) surgical site infections (SSIs) as an example to examine whether a relationship exists between operation volumes and SSIs, when different SSIs case identification, definitions and categorization methods of operation volumes were implemented. Methods A population-based cross-sectional multilevel study was conducted. A total of 7,007 patients who received CABG surgery between 2006 and 2008 from19 medical centers in Taiwan were recruited. SSIs associated with CABG surgery were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) codes and a Classification and Regression Trees (CART) model. Two definitions of surgeon and hospital operation volumes were used: (1) the cumulative CABG operation volumes within the study period; and (2) the cumulative CABG operation volumes in the previous one year before each CABG surgery. Operation volumes were further treated in three different ways: (1) a continuous variable; (2) a categorical variable based on the quartile; and (3) a data-driven categorical variable based on k-means clustering algorithm. Furthermore, subgroup analysis for comorbidities was also conducted. Results This study showed that hospital volumes were not significantly associated with SSIs, no matter which definitions or categorization methods of operation volume, or SSIs case identification approaches were used. On the contrary, the relationships between surgeon’s volumes varied. Most of the models demonstrated that the low-volume surgeons had higher risk than high-volume surgeons. Conclusion Surgeon volumes were more important than hospital volumes in exploring the relationship between CABG operation volumes and SSIs in Taiwan. However, the relationships were not robust. Definitions and categorization methods of operation volume and correct identification of SSIs are important issues for future research.

Is it enough to set national patient safety goals? An empirical evaluation in Taiwan

OBJECTIVEnIn 2004, the Taiwan Department of Health set the national patient safety goals. To date, however, there has been no evaluation of these goals. This study aimed to develop a method to evaluate the status of the national patient safety goals in Taiwan.nnnDESIGNnA cross-sectional questionnaire surveys to measure achievements on Taiwans national patient safety goals. This survey was also followed up with an onsite audit to ensure accuracy.nnnSETTINGnAll hospitals in Taiwan.nnnPARTICIPANTSnA total of 361 hospitals in Taiwan respond to questionnaire survey and 80 randomly selected hospitals for onsite audit.nnnINTERVENTIONSnNone.nnnMAIN OUTCOME MEASURESnAverage scores on achievements of the national patient safety goals.nnnRESULTSnAmong the 516 hospitals to which the questionnaire was sent, 361 (70%) responded. A total of 80 hospitals were randomly selected according to geographic location and size for onsite audit. The results show that the longer the period of implementation, the higher the average scores on achievements of the goals. After stratified analysis by hospital size, the large hospitals were found to have a higher average score in every goal, especially in the new goals. Furthermore, in terms of the difference between self-report results and the onsite audit, the score in the self-report was higher than the score given by experts upon onsite audit; however, they were similar. Most items were approximately the same in the self-report score and the onsite judgment, and those that differed were merely either one rank higher or lower.nnnCONCLUSIONnThe self-report questionnaire combined with an onsite audit appears to be a promising approach for measuring scores on achievements of the national patient safety goals. The Department of Health could conduct this program annually to evaluate the progress and propose coping strategies.

Do the Preferences of Healthcare Provider Selection Vary among Rural and Urban Patients with Different Income and Cause Different Outcome

Background Equal access to healthcare facilities and high-level quality of care are important strategies to eliminate the disparity in outcome of care. However, the existing literature regarding how urban or rural dwelling patients with different income level select healthcare providers is insufficient. The purposes of this study were to examine whether differences of healthcare provider selection exist among urban and rural coronary artery bypass surgery (CABG) patients with different income level. If so, we further investigated the associated impact on mortality. Methods A retrospective, multilevel study design was conducted using claims data from 2007–2011 Taiwan’s Universal Health Insurance Scheme. Healthcare providers’ performance and patients’ travelling distance to hospitals were used to define the patterns of healthcare provider selection. Baron and Kenny’s procedures for mediation effect were conducted. Results There were 10,108 CABG surgeries included in this study. The results showed that urban dwelling and higher income patients were prone to receive care from better-performance providers. The travelling distances of urban dwelling patients was 15 KM shorter, especially when they received better-performance provider’s care. The results also showed that the difference of healthcare provider selection and mortality rate existed between rural and urban dwelling patients with different income levels. After the procedure of mediation effect testing, the results showed that the healthcare provider selection partially mediated the relationships between patients’ residential areas with different income levels and 30-day mortality. Conclusion Preferences of healthcare provider selection vary among rural and urban patients with different income, and such differences partially mediated the outcome of care. Health authorities should pay attention to this issue, and propose appropriate solutions to eliminate the disparity in outcome of CABG care.

Is the implementation of quality improvement methods in hospitals subject to the neighbourhood effect

OBJECTIVEnQuality improvement (QI) methods have been fashionable in hospitals for decades. Previous studies have discussed the relationships between the implementation of QI methods and various external and internal factors, but there has been no examination to date of whether the neighbourhood effect influences such implementation. The aim of this study was to use a multilevel model to investigate whether and how the neighbourhood effect influences the implementation of QI methods in the hospital setting in Taiwan.nnnDESIGNnThis is a retrospective questionnaire-based survey.nnnSETTINGnAll medical centres, regional hospitals and district teaching hospitals in Taiwan.nnnPARTICIPANTSnDirectors or persons in charge of implementing QI methods in hospitals.nnnINTERVENTIONSnNone.nnnMAIN OUTCOME MEASURESnThe breadth and depth of QI method implementation.nnnRESULTSnSeventy-two of the 139 hospitals contacted returned the questionnaire, yielding a 52% response rate. The breadth and depth of QI method implementation increased over the 10-year study period, particularly between 2004 and 2006. The breadth and depth of the QI methods implemented in the participating hospitals were significantly associated with the average breadth and depth of those implemented by their competitors in the same medical area during the previous period. In addition, time was positively associated with the breadth and depth of QI method implementation.nnnCONCLUSIONSnIn summary, the findings of this study show that hospitals QI implementation status is influenced by that of their neighbours. Hence, the neighbourhood effect is an important factor in understanding hospital behaviour.

Insight into Patients’ Experiences of Cancer Care in Taiwan: An Instrument Translation and Cross-Cultural Adaptation Study

Background: Since Taiwan launched the Cancer Prevention Act in 2003, several prevention strategies and early detection programs have been implemented to reduce the incidence, morbidity and mortality rates of cancer. However, most of the programs have concentrated on healthcare providers. Evaluations from the patient’s perspective have been lacking. Thus, in this study a cancer patient experience questionnaire was developed in the Taiwanese context and a preliminary nationwide investigation was conducted on the status of cancer care from the patient’s perspective. Methods: An extensive literature review was first conducted to collect information on the existing instruments used to measure the cancer patient’s experience. Thereafter, a multidisciplinary expert panel was convened to select an optimal instrument based on the IOM’s six domains for evaluating patient-centered care. The European Organisation for Research and Treatment of Cancer (EORTC) translation procedure was applied to the questionnaire for cross-cultural adaptation. A nationwide field test was then implemented at certificated cancer care hospitals. Results: Fifteen questionnaires were collected for the literature review. The expert panel selected the National Cancer Patient Experience Survey based on the IOM’s recommendations. After cross-cultural translation of the questionnaire, a total of 4000 questionnaires were administered in 19 certificated cancer care hospitals and two major cancer patient associations, with 1010 being returned (25.25% response rate). Most of the respondents were middle-aged, and 70% were female. The respondents reported they had a good experience with cancer care, except for “Home care and support” and “Finding out what was wrong with you”. Stratified analysis was conducted, with the results showing that the cancer patients’ experiences varied depending on their sociodemographic and cancer-related characteristics. Conclusions: A Taiwanese version of the cancer patient experience survey questionnaire was developed. Its results showed that the cancer patient’s experiences varied, depending on the patient’s age, cancer type, and cancer history. This study can be used as a basis to establish a patient-centered care model for cancer care in Taiwan.

Are PCI Service Volumes Associated with 30-Day Mortality? A Population-Based Study from Taiwan

The volume-outcome relationship has been discussed for over 30 years; however, the findings are inconsistent. This might be due to the heterogeneity of service volume definitions and categorization methods. This study takes percutaneous coronary intervention (PCI) as an example to examine whether the service volume was associated with PCI 30-day mortality, given different service volume definitions and categorization methods. A population-based, cross-sectional multilevel study was conducted. Two definitions of physician and hospital volume were used: (1) the cumulative PCI volume in a previous year before each PCI; (2) the cumulative PCI volume within the study period. The volume was further treated in three ways: (1) a categorical variable based on the American Heart Association’s recommendation; (2) a semi-data-driven categorical variable based on k-means clustering algorithm; and (3) a data-driven categorical variable based on the Generalized Additive Model. The results showed that, after adjusting the patient-, physician-, and hospital-level covariates, physician volume was associated inversely with PCI 30-day mortality, but hospital volume was not, no matter which definitions and categorization methods of service volume were applied. Physician volume is negatively associated with PCI 30-day mortality, but the results might vary because of definition and categorization method.

Can Hospital Competition Really Affect Hospital Behavior or Not? an Empirical Study of Different Competition Measures Comparison in Taiwan

Different approaches to measure the hospital competition index might lead to inconsistent results of the effects of hospital competition on innovation adoption. The purpose of this study is to adopt a different approach to define market area and measure the level of competition to examine whether hospital competition has a positive effect on hospital behavior, taking quality indicator projects participation as an example. A total of 238 hospitals located in Taipei, Taichung, and Kaohsiung were recruited in this study. Competition index was used as the independent variable, and participation lists of Taiwan Clinical Performance Indicator and Taiwan Healthcare Indicator Series in 2012 were used as dependent variables. All data used in this study were retrieved from the 2012 national hospital profiles and the participation list of the 2 quality indicator projects in 2012; these profiles are issued by the Taiwan Ministry of Health and Welfare annually. Geopolitical boundaries and 4 kinds of fixed radiuses were used to define market area. Herfindahl-Hirschman Index and hospital density were used to measure the level of competition. A total of 12 competition indices were produced in this study by employing the geographic information system, while max-rescaled R2 was used to evaluate and compare the models on goodness of fit. The results show that the effects of hospital competition on quality indicator projects participation were varied, which mean different indicators for market competition might reveal different conclusions. Furthermore, this study also found the Herfindahl-Hirschman Index at 5-km radius was the optimum competition index.