The impacts of the scope of benefits expansion on hospice care among adult decedents: a nationwide longitudinal observational study.

OBJECTIVES: Compared to aggressive treatment for patients at the end stage of life, hospice care might be more likely to satisfy such patients' need and benefits and improve their dignity and quality of life. Whether the reimbursement policy expansion affect the use of hospice care among various demographics characteristics and health status was unknown. Therefore, the purpose of this study was to explore the impacts of reimbursement policy expansion on hospice care use, and to investigate the effects on people with various demographics characteristics and health status. METHODS: We used the 2001-2017 Taiwan NHI claims data, Death Registry, and Cancer Registry in this study, and we included people who died between 2002 and 2017. The study period was divided into 4 sub-periods. hospice care use and the initiation time of 1st hospice care use were used as dependent variables; demographic characteristics and health status were also collected. RESULTS: There were 2,445,781 people who died in Taiwan during the study period. The results show that the trend of hospice care use increased over time, going steeply upward after the scope of benefits expansion, but the initiation time of 1st hospice care use did not increase after the scope of benefits expansion. The results also show that the effects of expansion varied among patients by demographic characteristics. CONCLUSION: The scope of benefits expansion might induce people's needs in hospice care, but the effects varied by demographic characteristics. Understanding the reasons for the variations in all populations would be the next step for Taiwan's health authorities.

Pediatric palliative care utilization by decedent children: A nationwide population-based study, 2002-2017.

PURPOSE: This study aimed (1) to describe how trends in pediatric palliative care (PPC) utilization changed from 2002 to 2017, and (2) to examine factors predicting PPC utilization among decedent children in Taiwan. DESIGN: This retrospective, correlational study retrieved 2002-2017 data from three national claims databases in Taiwan. METHODS: Children aged 1 through 18 years who died between January 2002 and December 2017 were included. Pediatric palliative care utilization was defined as PPC enrollment and PPC duration, with enrollment described by frequency (n) and percentage (%) and duration described by mean and standard deviation (SD). Logistic regression was used to examine the associations of various demographic characteristics with PPC enrollment; generalized linear regression was used to examine associations of the demographic characteristics with PPC duration. FINDINGS: Across the 16-year study period, PPC enrollment increased sharply (15.49 times), while PPC duration decreased smoothly (by 29.41%). Cause of death was a continuous predictor of both PPC enrollment and PPC duration. The children less likely to be enrolled in PPC services were those aged 1 to 6 years, boys, living in poverty, living in rural areas, and diagnosed with life-threatening noncancer diseases. CONCLUSION: This study used nationwide databases to investigate PPC enrollment and PPC duration among a large sample of deceased children from 2002 to 2017. The findings not only delineate trends and predictors of PPC enrollment and PPC duration but also highlight great progress in PPC as well as the areas still understudied and underserved. This information could help the pediatric healthcare system achieve the core value of family-centered care for children with life-threatening diseases and their families. CLINICAL RELEVANCE: Pediatric palliative care should be widely and continuously implemented in routine pediatric clinical practice to enhance quality of life for children and their families at the end of life.

Do Hospital and Physician Volume Thresholds for the Volume-Outcome Relationship in Heart Failure Exist?

BACKGROUND: Although volume-outcome relationships have been explored for various procedures and interventions, limited information is available concerning the effect of hospital and physician volume on heart failure mortality. Most importantly, little is known about whether there are optimal hospital and physician volume thresholds to reduce heart failure mortality. OBJECTIVES: We used nationwide population-based data to identify the optimal hospital and physician volume thresholds to achieve optimum mortality and to examine the relative and combined effects of the volume thresholds on heart failure mortality. METHODS: We analyzed all 20,178 heart failure patients admitted in 2012 through Taiwan's National Health Insurance Research Database. Restricted cubic splines and multilevel logistic regression were used to identify whether there are optimal hospital and physician volume thresholds and to assess the relative and combined relationships of the volume thresholds to 30-day mortality, adjusted for patient, physician, and hospital characteristics. RESULTS: Hospital and physician volume thresholds of 40 cases and 15 cases a year, respectively, were identified, under which there was an increased risk of 30-day mortality. Patients treated by physicians with previous annual volumes <15 cases had higher 30-day mortality compared with those with previous annual volumes ≥15 cases, and the relationship was stronger in hospitals with previous annual volumes <40 cases. CONCLUSIONS: This is the first study to identify both the hospital and physician volume thresholds that lead to decreases in heart failure mortality. Identifying the hospital and physician volume thresholds could be applied to quality improvement and physician training.

Physical activity self-efficacy mediates the effect of symptom distress on exercise involvement among adolescents undergoing cancer treatment.

The objective of this study was to examine whether physical activity self-efficacy mediated the adverse effect of symptom distress on exercise involvement among adolescents undergoing cancer treatment. A secondary data analysis approach was used to analyse a pooled sample of 97 adolescents who were undergoing cancer treatment in paediatric oncology/haematology wards and ambulatory settings in northern Taiwan. Mediation analysis was performed to examine the mediation relationship among physical activity self-efficacy, symptom distress and exercise involvement. The total effect (path c) (p < 0.001), the indirect effect (paths a and b) (p < 0.05 and p < 0.01) and the direct effect (path c') (p < 0.001) were significant. The bootstrapping test was significant (95% CI: -0.356 to -0.016), indicating that physical activity self-efficacy partially mediated the adverse effect of symptom distress on exercise involvement after adjusting for age, gender and cancer diagnosis. Physical activity self-efficacy partially mediates the relationship between symptom distress and exercise involvement for adolescents undergoing cancer treatment. There is an imperative need for healthcare professionals to design interventions to enhance these adolescents' physical activity self-efficacy, increase their exercise involvement and thus improve their quality of life.

Using medication utilization information to develop an asthma severity classification model.

BACKGROUND: Claims data are currently widely used as source data in asthma studies. However, the insufficient information in claims data related to level of asthma severity may negatively impact study findings. The present study develops and validates an asthma severity classification model that uses medication utilization in Taiwan National Health Insurance claims data. METHODS: The National Health Insurance Research Database was used for the years 2006-2012 and included a total of 7221 patients newly diagnosed with asthma in 2007 for model development and in 2008 for model validation. The medication utilization of patients during the first year after the index date was used to classify level of severity, and the acute exacerbation of asthma during the second through fourth years after the index date was used as the outcome variable. Three models were developed, with subjects classified into four, three, and two groups, respectively. The area under the receiver operating characteristic curve (AUC) and the Kaplan-Meier survival curve were used to compare the performances of the classification models. RESULTS: In development data, the distribution of subjects and acute exacerbation rate among the stage 1 to stage 4 were: 62.71%, 5.54%, 22.79%, and 8.96%, and 8.17%, 9.55%, 11.97%, and 14.91%, respectively. The results also showed the higher severity groups to be more prone to being prescribed oral corticosteroids for asthma control, while lower severity groups were more likely to be prescribed short-acting medication and inhaled corticosteroid treatment. Furthermore, the results of survival analysis showed two-group classification was recommended and yield moderate performance (AUC = 0.671). In validation data, the distribution of subjects, acute exacerbation rates, and medication uses among stages were similar to those in development data, and the results of survival analysis were also the same. CONCLUSIONS: Understanding asthma severity is critical to conducting effective, scholarly research on asthma, which currently uses claims data as a primary data source. The model developed in the present study not only overcomes a gap in the current literature but also provides an opportunity to improve the validity and quality of claims-data-based asthma studies.

Do relationships exist between the scope and intensity of quality improvement activities and hospital operation performance? A 10-year observation in Taiwan.

BACKGROUND: The relationship between the scope and intensity of quality improvement (QI) activities and hospital performance remains unclear. This study investigated the relationship between performance, external environment, and the scope and intensity of QI activities in hospitals. METHODS: The study used a longitudinal observation. Data regarding the scope and intensity of QI activities were collected using a questionnaire survey among the administrative deputy superintendents / directors of quality management center in 139 hospitals. Hospital performance indicators were abstracted from the 2000-2009 national hospitals profiles. We adopted year 2000 as the baseline, and divided the study period into three 3-year periods. The Generalized Estimating Equations (GEE) model was used for the statistical analysis. RESULTS: Seventy-two hospitals responded to the survey, giving a response rate of 52%. The results showed a significant increase in the scope and intensity of QI activities between 2000 and 2009. The results also showed that the scope and intensity of a hospital's QI activities were associated with the scope and intensity of its competitors' QI activities in the previous period and its own prior performance. The scope of QI activities in the previous period was not significantly related to the selected hospital performance measures. However, the intensity of QI activities in the previous period showed a significant and positive relationship with the number of inpatients and the turnover of beds. CONCLUSION: The study demonstrates that the intensity of QI activities is associated with the external environment and the hospital's own performance in the previous period. Furthermore, some performance measures are associated with the intensity of the QI activities in the previous period.

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

OBJECTIVE: This study explores the association between coronary artery bypass surgery (CABG) patients' residence and quality of care in terms of 30-day mortality. DESIGN: A retrospective, multilevel study design was conducted using claims data from Taiwan's Universal Health Insurance Scheme. Hospital and surgeon's 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 Kenny's procedures for mediation effect were conducted. SETTING: Hospitals in Taiwan. PARTICIPANTS: Patients 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. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Thirty-day mortality. RESULTS: There 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 residence's urbanization level and 30-day mortality was partially mediated by patterns of quality of care. CONCLUSIONS: The 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?

BACKGROUND: Equity 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. METHODS: A 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. RESULTS: A 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. CONCLUSIONS: The 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.

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

OBJECTIVE: Quality 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. DESIGN: This is a retrospective questionnaire-based survey. SETTING: All medical centres, regional hospitals and district teaching hospitals in Taiwan. PARTICIPANTS: Directors or persons in charge of implementing QI methods in hospitals. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The breadth and depth of QI method implementation. RESULTS: Seventy-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. CONCLUSIONS: In 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.

Is it possible to identify cases of coronary artery bypass graft postoperative surgical site infection accurately from claims data?

BACKGROUND: Claims data has usually been used in recent studies to identify cases of healthcare-associated infection. However, several studies have indicated that the ICD-9-CM codes might be inappropriate for identifying such cases from claims data; therefore, several researchers developed alternative identification models to correctly identify more cases from claims data. The purpose of this study was to investigate three common approaches to develop alternative models for the identification of cases of coronary artery bypass graft (CABG) surgical site infection, and to compare the performance between these models and the ICD-9-CM model. METHODS: The 2005-2008 National Health Insurance claims data and healthcare-associated infection surveillance data from two medical centers were used in this study for model development and model verification. In addition to the use of ICD-9-CM codes, this study also used classification algorithms, a multivariable regression model, and a decision tree model in the development of alternative identification models. In the classification algorithms, we defined three levels (strict, moderate, and loose) of the criteria in terms of their strictness. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to evaluate the performance of each model. RESULTS: The ICD-9-CM-based model showed good specificity and negative predictive value, but sensitivity and positive predictive value were poor. Performances of the other models were varied, except for negative predictive value. Among the models, the performance of the decision tree model was excellent, especially in terms of positive predictive value. CONCLUSION: The accuracy of identification of cases of CABG surgical site infection is an important issue in claims data. Use of the decision tree model to identify such cases can improve the accuracy of patient-level outcome research. This model should be considered when performing future research using claims data.

Occurrence of perfluorinated compounds in the aquatic environment as found in science park effluent, river water, rainwater, sediments, and biotissues.

The current article maps perfluoroalkyl acids (PFAAs) contamination in the largest Science Park of Taiwan. The occurrence of ten target PFAAs in the effluent of an industrial wastewater treatment plant (IWWTP), its receiving rivers, rainwater, sediment, and the muscles and livers of fish was investigated. All target PFAAs were found in effluent of IWWTP, in which perfluorooctane sulfonate (PFOS) (6,930 ng/L), perfluorohexyl sulfonate (PFHxS) (2,662 ng/L) and perfluorooctanoic acid (PFOA) (3,298 ng/L) were the major constituents. Concentrations of PFBS and PFOS in the IWWTP downstream areas have exceeded safe concentration levels of avian and aquatic life, indicating a potential risk to wildlife in those areas. In sediment samples, predominant contaminants were PFOS (1.5-78 ng/g), PFOA (0.5-5.6 ng/g), and perfluorododecanoic acid (PFDoA) (nd-5.4 ng/g). In biological tissue samples, concentrations as high as 28,933 ng/g of PFOS were detected in tilapia and catfish liver samples. A positive correlation for log (C sediment/C water) and log (C tissue/C water) was found. The concentration and proportion (percentage of all PFAAs) of PFOS found in biotissue samples from the Keya River (which receives industrial wastewater) were found to be much greater (200 times) than those of samples from the Keelung River (which receives mainly domestic wastewater). These findings suggest that the receiving aquatic environments and, in turn, the human food chain can be significantly influenced by industrial discharges.

Factors associated with walking performance among adolescents undergoing cancer treatment: A correlational study.

This study aimed to describe and compare the differences in walking performance between adolescent patients in inpatient wards and outpatient units, and to identify factors that influence walking performance among adolescents receiving cancer treatment. The cross-sectional study with correlational research design recruited 32 adolescents with cancer between February 2015 and March 2017 in two teaching hospitals in Taiwan. Descriptive, bivariate, and multivariate regression analyses were used. Participants' age, treatment setting, and symptom distress were significantly associated with number of walking steps. All independent variables in the model together accounted for 82.1% of variance. This study addresses a gap in the existing literature to identify associated factors that affected walking performance among adolescents undergoing cancer treatment. Our findings represent a pathway toward generating knowledge to enhance well-being for this unique population.

Are quality improvement methods a fashion for hospitals in Taiwan?

OBJECTIVE: This 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. DESIGN: Cross-sectional, questionnaire-based survey. SETTING: One hundred and thirty-nine district teaching hospitals, regional hospitals and medical centers. PARTICIPANTS: Directors or the persons in charge of implementing QI methods. INTERVENTION: s) None. MAIN OUTCOME MEASURE: s) Breadth and depth of the 18 QI methods. RESULTS: Seventy-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. CONCLUSIONS: This 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.

Associations Between Fatigue, Sleep Disturbance, Physical Activity, and Quality of Life for Children With Cancer: A Correlational Study.

BACKGROUND: Fatigue, sleep disturbance, and physical inactivity have been increasingly recognized as health issues that negatively affect quality of life (QoL) for children with cancer. Existing studies focus either on children receiving treatment or in survivorship, but not on both populations in a study. This causes difficulty in examining differences of these issues between treatment statuses and identifying associations of these issues with QoL. OBJECTIVE: The aims of this study were to examine differences in fatigue, sleep disturbance, physical activity, and QoL between on- and off-treatment children and to identify their associations with QoL. METHODS: The correlational study was conducted with 100 children with cancer 7 to 12 years old. Descriptive, bivariate, and multivariate regression analyses were used. RESULTS: Participants undergoing treatment had higher degrees of fatigue ( P = .002), physical inactivity ( P = .004), and QoL distress ( P = .001) than those in survivorship. Mean sums (SDs) of sleep disturbance were 47.15 (8.23) and 48.48 (7.13) in the on- and off-treatment groups. Age ( P = .000), sex ( P = .023), fatigue ( P = .000), and sleep disturbance ( P = .004) were significantly associated with QoL distress. CONCLUSIONS: This study is unique in that a frame of reference is addressed to gain insight into the distinct developmental issues of school-aged children undergoing cancer treatment and in survivorship. More studies are needed. IMPLICATIONS FOR PRACTICE: Interventions to increase QoL should target children who are younger, male, and have higher levels of fatigue and sleep disturbance. Diagnosis and treatment of sleep disturbance should be considered as part of routine activities.

Exploring Factors Associated With the Work Hours of Attending Physicians Working in Hospitals.

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.

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

OBJECTIVE: In 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. DESIGN: A cross-sectional questionnaire surveys to measure achievements on Taiwan's national patient safety goals. This survey was also followed up with an onsite audit to ensure accuracy. SETTING: All hospitals in Taiwan. PARTICIPANTS: A total of 361 hospitals in Taiwan respond to questionnaire survey and 80 randomly selected hospitals for onsite audit. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Average scores on achievements of the national patient safety goals. RESULTS: Among 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. CONCLUSION: The 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.

Fate of selected pharmaceuticals and personal care products after secondary wastewater treatment processes in Taiwan.

Pharmaceuticals and personal care products (PPCPs) constitute a class of chemicals of emerging concern due to the potential risks they pose to organisms and the environment, even at low concentrations (ng/L). Recent studies have found that PPCPs are not efficiently removed in secondary wastewater treatment plants (WWTPs). This study has: (1) simultaneously investigated the occurrence of sixty-one PPCPs using solid phase extraction and high-performance liquid chromatography-tandem mass spectrometry, (2) evaluated removal efficiencies of target PPCPs in six WWTPs that discharge effluents into major Taiwanese rivers, and lastly (3) examined matrix interference during analysis of target PPCPs in water samples. The twenty target PPCPs were chosen for their high detection frequencies, high influent concentrations, and stability during wastewater treatment processes. Caffeine and acetaminophen were detected at the highest concentrations (as high as 24,467 and 33,400 ng/L) and were effectively removed (both >96%); other PPCPs were detected in the high ng/L range but were not effectively removed. Matrix interference (by ion suppression or enhancement) during the analysis resulted in underestimation of the removal efficiencies of erythromycin-H(2)O, cefazolin, clarithromycin, ibuprofen, diclofenac, clofibric acid and gemfibrozil.

The number and composition of work hours for attending physicians in Taiwan.

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.

Should we pay attention to surgeon or hospital volume in total knee arthroplasty? Evidence from a nationwide population-based study.

BACKGROUND: Although prior research into the relationship between volume and outcome indicates that this relationship is not linear and that an optimal volume should be specified, consensus is lacking regarding the ideal value of this optimal volume. The purposes of this study were to use a visual method to identify surgeon- and hospital-volume thresholds and to examine the relationships of surgeon and hospital volume thresholds to 30-day readmission. METHODS: A retrospective nationwide population-based study design was adopted. Patients who received total knee replacement surgery between 2007 and 2008 in any hospital in Taiwan were included. After adjusting for patient, physician, and hospital characteristics, a restricted cubic spline regression model was used to identify optimal surgeon- and hospital-volume thresholds. Further, a patient-level mixed effect model was conducted to test the respective relationships between these thresholds and 30-day readmission. RESULTS: A total of 30,828 patients who had received their surgeries from 1,468 surgeons in 437 hospitals were included in this study. Thresholds of 50 cases a year for surgeons and 75 cases a year for hospitals were identified using a restricted cubic spline regression model. However, only the surgeon volume threshold was associated with 30-day readmission using a patient-level mixed effect model after adjusting for patient-, surgeon- and hospital-level covariates. CONCLUSIONS: According to the results of the restricted cubic spline models, the optimal volume thresholds for surgeons and hospitals are 50 cases and 75 cases a year, respectively. However, only the surgeon volume threshold is associated with 30-day readmission.

Quasi-dynamic leaching characteristics of polychlorinated dibenzo-p-dioxins and dibenzofurans from raw and solidified waste incineration residues.

Quasi-dynamic leaching characteristics of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) from raw and solidified air pollution control (APC) residues were examined via a nine-time multiple leaching test. The effect of injected activated carbon in the APC residues on the PCDD/F leachability was also evaluated. When humic acid solution was used as a leachant, the leaching concentrations of PCDD/Fs fluctuated between the first and the fifth leaching, followed by a gradual increase and then suddenly reached maximum values at the leaching sequences around seventh and eighth. This significant enhancement in PCDD/F leachability was mainly due to an increase in the release of highly chlorinated PCDD/Fs. Leaching of PCDD/Fs with n-hexane was, in contrast, primarily caused by the partitioning of hydrophobic PCDD/Fs between the APC residue surface and the liquid phase of n-hexane. Consequently, the largest leaching concentrations for n-hexane tests achieved at the first leaching, followed by a decrease and reached plateaus. Solidification/stabilization (S/S) decreased the PCDD/F leachability up to the fifth leaching by the use of humic acid solution. However, S/S increased the PCDD/F leaching concentrations and rates with n-hexane. The activated carbon in APC residues significantly inhibited the release of PCDD/F with n-hexane. The inhibiting effect provided by activated carbon was, however, less significant by the use of humic acid solution.