The LACE index and risk factors of 14-day versus 30-day readmissions in children.

Risk factors for readmissions in children differ from those in adults, yet little is known about whether the LACE index (Length of stay, Acute admission, Charlson comorbidity index, Emergency department visits in the previous 6 months) developed for adults retains its validity when applied to the prediction of readmissions in children or within shorter intervals of time after discharge. In this retrospective cohort analysis of 4256 patients aged ≤18 years hospitalized at one academic medical center in Taiwan in 2019, we first evaluated the performance of a LACE index model and the three other multivariate logistic regression models in their predictions of hospital readmissions in children using the same time interval of 30 days. We then used multinomial logistic regression to analyze the characteristics and risk factors for readmissions that occur in the first 14 days with those that occur between 15 and 30 days after discharge. The optimal cut-off of the LACE index score for children in the current study was 7, which is less than the optimal score of 10 in the original derivation for adults. The predictive model with the least discriminatory power was based on the LACE score alone, whereas our model that included only two variables (length of stay and the number of admissions in the past 1 year) was found to outperform the LACE index. Multinomial logistic regression results revealed that children who had supplemental private health insurance had lower readmission rates than those insured by the National Health Insurance program only, suggesting a disparity by insurance status. Some risk factors of readmission within 14 days such as acute admissions and supplemental private health insurance were not found to be relevant for longer-term predictions, while age, which was a valid predictor of readmission within 15-30 days, did not affect the prediction of shorter-term readmissions. Prior health care utilization and a higher illness burden were found to be greater contributors to readmissions beyond 14 days. Our simpler model outperformed the more complex LACE tool in identifying children at risk of readmission. Shorter-term readmissions can be attributed to different causes than 30-day readmissions, suggesting a need for different screening tools, interventions, and care support. There remains some socioeconomic disparity associated with readmission rates in the current health care system.

Early prediction of 30- and 14-day all-cause unplanned readmissions.

BACKGROUND: An unplanned readmission is a dual metric for both the cost and quality of medical care. METHODS: We employed the random forest (RF) method to build a prediction model using a large dataset from patients' electronic health records (EHRs) from a medical center in Taiwan. The discrimination abilities between the RF and regression-based models were compared using the areas under the ROC curves (AUROC). RESULTS: When compared with standardized risk prediction tools, the RF constructed using data readily available at admission had a marginally yet significantly better ability to identify high-risk readmissions within 30 and 14 days without compromising sensitivity and specificity. The most important predictor for 30-day readmissions was directly related to the representing factors of index hospitalization, whereas for 14-day readmissions the most important predictor was associated with a higher chronic illness burden. CONCLUSIONS: Identifying dominant risk factors based on index admission and different readmission time intervals is crucial for healthcare planning.

Comparison of Back-Propagation Neural Network, LACE Index and HOSPITAL Score in Predicting All-Cause Risk of 30-Day Readmission.

BACKGROUND: The main purpose of this study is to predict the all-cause risk of 30-day readmission by employing the back-propagation neural network (BPNN) in comparison with traditional risk assessment tools of LACE index and HOSPITAL scores. METHODS: This was a retrospective cohort study from January 1st, 2018 to December 31st, 2019. A total of 55,688 hospitalizations from a medical center in Taiwan were examined. The LACE index (length of stay, acute admission, Charlson comorbidity index score, emergency department visits in previous 6 months) and HOSPITAL score (hemoglobin level at discharge, discharge from an Oncology service, sodium level at discharge, procedure during hospital stay, Index admission type, number of hospital admissions during the previous year, length of stay) are calculated. We employed variables from LACE index and HOSPITAL score as the input vector of BPNN for comparison purposes. RESULTS: The BPNN constructed in the current study has a considerably better ability with a C statistics achieved 0.74 (95% CI 0.73 to 0.75), which is statistically significant larger than that of the other two models using DeLong's test. Also, it was possible to achieve higher sensitivity (70.32%) without penalizing the specificity (71.76%) and accuracy (71.68%) at its optimal threshold, which is at the 20% of patients with the highest predicted risk. Moreover, it is much more informative than the other two methods because of a considerably higher LR+ and a lower LR-. CONCLUSION: Our findings suggest that more attention should be paid to methods based on non-linear classification systems, as they lead to substantial differences in risk-scores.

Factors that infertile couples from mainland China may take into consideration for cross-border reproductive care - A cross-sectional questionnaire study.

OBJECTIVE: Cross-border reproductive care (CBRC) has become popular in the world, including mainland China. We designed a questionnaire and aimed to determine the main factors that infertile couples from mainland China may consider for CBRC. MATERIALS AND METHODS: In this cross-sectional questionnaire-based study, we retrospectively analyzed the data from questionnaires collected at the Reproductive Center of Beijing BaoDao Obstetrics and Gynecology Hospital from January 2018 to June 2018. The questionnaire contained 38 items that belonged to six different categories (environment and equipment, service quality, patient safety, medical quality, information acquisition channel and overseas medical services). The item scores for each factor were calculated and then weighted using principal component analysis. RESULTS: A total of 297 infertile couples were identified. Most of the infertile women were aged 31-35 years, were married 1-3 years, and had a bachelor's degree. In the weighted factor analysis, "clean outpatient clinic and medical equipment" had the highest weight in the dimension of environment and equipment. The item with the highest weight in the dimension of service quality was "wait time for examination". In the dimension of patient safety, "health education on medication and surgery by counselors" had the highest weight. The item with the highest weight in the dimension of medical quality was "fee charged for ART treatment". The items with the three highest weights in the dimension of information acquisition channel were "other (seminar, exhibition, dissertation …)", "introduction from friends and relatives", and "telephone inquiry". In the dimension of overseas medical services, the two items with the highest weights were "cultural similarities" and "language similarities". CONCLUSION: For CBRC, infertile couples from mainland China may take following significant factors into consideration: a high success rate and inexpensive treatment, cultural and linguistic familiarity, high-quality service and short wait time.

Factors that influence infertile couples' selection of reproductive medicine centers---A cross-sectional questionnaire study.

OBJECTIVE: The number of infertile women undergoing in vitro fertilization (IVF) cycles has increased annually. Due to this competitive environment, we designed a questionnaire and aimed to investigate factors affecting the choice of reproductive medicine center among infertile couples. MATERIALS AND METHODS: This was a retrospective cross-sectional study that analyzed questionnaires provided by the reproductive medicine center of the Kaohsiung Veterans General Hospital from January 2018 to June 2018. In the questionnaire, there are six categories (environment and equipment, service quality, patient safety, medical quality, information acquisition channel and other) and 36 items. The identified factors were scored and then weighted using principal component analysis. RESULTS: Most of the 100 identified infertile women were aged 31-35 years, were married 1-3 years, and had a university education level. In the weight analysis, "Clean outpatient clinic and medical equipment" had the greatest weight in the dimension of environment and equipment. The item with the greatest weight in the dimension of service quality was "Waiting time for registration, charging, and receiving medicine". In the dimension of patient safety, "Privacy is highly respected by medical personnel" had the highest weight. The item with the greatest weight in the dimension of medical quality was "Success rate of reproductive medicine center". The three items with the highest weights in the dimension of information acquisition channel were "Newspapers and magazines", "TV media", and "Facebook page and website of our hospital". In the other dimensions, the two with the greatest weights were "Reputation of the hospital" and "Reputation of physicians". CONCLUSION: In the infertile couples' view, optimal reproductive medicine centers should have a high success rate and great reputation on the internet and in mass media. Additionally, a short waiting time and high levels of privacy and confidentiality are also imperative.

Constructing "behavioral" comparison groups: A difference-in-difference analysis of the effect of copayment based on the patient's price elasticity.

It is well known that the differences-in-differences (DD) estimator is based on the assumption that in the absence of treatment, the average outcomes for the treated group and the control group will follow a common trend over time. That can be problematic, especially when the selection for the treatment is influenced by the individual's unobserved behavior correlating with the medical utilization. The aim of this study was to develop an index for controlling a patient's unobserved heterogeneous response to reform, in order to improve the comparability of treatment assignment. This study showed that a DD estimator of the reform effects can be decomposed into effects induced by moral hazard and by changes in health risk within the same treated/untreated group. This article also presented evidence that the constructed index of the price elasticity of the adjusted clinical group has good statistical properties for identifying the impact of reform.

Agency problems in hospitals participating in self-management project under global budget system in Taiwan.

OBJECTIVE: The main purposes of this study are to clarify the agency problems in the hospitals participating in self-management project within the context of Global Budgeting Payment System regulated by Taiwan government, and also to provide some suggestions for hospital administrator and health policy maker in reducing the waste of healthcare resources resulting from agency problems. METHOD: For the purposes above, this study examines the relationships between two agency problems (ex ante moral hazard and ex post moral hazard) aroused among the hospitals and Bureau of National Health Insurance in Taiwan's health care sector. This study empirically tested the theoretical model at organization level. RESULTS: The findings suggest that the hospital's ex ante moral hazards before participating the self-management project do have some influence on its ex post moral hazards after participating the self-management project. CONCLUSION: This study concludes that the goal conflict between the agents and the principal certainly exist. The principal tries hard to control the expenditure escalation and keep the financial balance, but the agents have to subsist within limited healthcare resources. Therefore, the agency cost would definitely occur due to the conflicts between both parties. According to the results of the research, some suggestions and related management concepts were proposed at the end of the paper.

Establishment of an integrated management model for the secondary prevention of cervical cancer - an experience in taiwan hospital.

In the present study, secondary data analysis was utilized to evaluate the efficiency of the integrated management model (IMM) on the Pap smear test for screening of women's uterine cervical cancer. The data of female patients receiving a Pap smear test were collected both before (from July to December, 2006) and after (from January to June, 2007) introducing the IMM in a regional hospital in Tainan. The result revealed an increment of participation rate from 5.1% to 15.4% (p < 0.001) among the female patients in the OPD (out-patient department), although the post-IMM participation rate was still much lower than that of general hospital data in Taiwan. Since IMM has proved efficacious for the management of various diseases, improvement in our IMM for the female uterine cervical cancer's prevention and management is conceivable. Studies on influencing factors should be carried out to allow strategies for resolution of problems to be designed, documented and implemented.