The impact of global budget on the diffusion of innovations: the example of positron emission tomography in Taiwan.

BACKGROUND: The essence of global budget is to set a cap on the total national health insurance expenditure for a year, which is one form of prospective payment systems. It has always been argued that prospective payment, such as global budgeting, will deter the development of high-tech services in the healthcare industry. The objectives of this study are to explore the impact of global budgeting on the diffusion of high tech equipment in terms of utilization by using Positron Emission Tomography (PET) as an example. METHODS: The study population is the hospitals in Taiwan. We tried to compare the diffusion patterns of Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and PET scanners among these hospitals by analyzing the National Health Insurance (NHI) Database from 1997 to 2010. RESULTS: From 2004 to 2010, 79,380 PET scans in total were performed under the NHI scheme. By the year 2010, the annual reimbursed scans have reached 19,700. The volume curve of cumulative PET services resembles an S diffusion curve with the R2 at 0.95. The results indicated the growth of cumulative PET service volume does correspond with the innovation diffusion model. The cumulative utilizations of CT, MRI and PET demonstrate good correlation with no significant difference in their growth rates. CONCLUSIONS: Therefore, we can infer that even though PET was reimbursed after the implementation of global budgeting, its diffusion was not deterred by this cost containment measure when compared with CT and MRI in the same time span after the inauguration of the NHI.

Comparison of total hip and knee joint replacement in patients with rheumatoid arthritis and osteoarthritis: a nationwide, population-based study.

INTRODUCTION: Patients with rheumatoid arthritis (RA) and osteoarthritis (OA) may require total hip replacement (THR) or total knee replacement (TKR). The present study aimed to compare the demographic characteristics and medical costs of RA and OA patients from Taiwan who underwent either THR or TKR. METHODS: The medical records of patients who had undergone THR or TKR from 1 January 1996 to 31 December 2010 were obtained from the Taiwan National Health Insurance Research Database (NHIRD). In all, we found 49 and 146 RA patients who received THR and TKR, respectively, and 1,191 and 6,574 OA patients who received THR and TKR, respectively. The gender, age, Charlson comorbidity index (CCI), hospital grade, age at registration in the catastrophic illness dataset, and medical utilisation costs of the different groups were compared. RESULTS: There were statistically significant differences in age, CCI score, drug costs and surgery costs between RA and OA patients. Joint replacement incidence was lower in RA patients than in OA patients, and among patients who underwent THR, total medical costs incurred were higher for RA patients than OA patients. RA patients who underwent THR incurred a significantly greater total medical utilisation cost in the outpatient department (3 months before surgery and 12 months after surgery) than OA patients who underwent THR. CONCLUSION: Analysis of Taiwan NHIRD with regard to patients who had undergone either THR or TKR indicated that RA patients were younger than OA patients, and that significantly more medical resources were used for RA patients before, during and after hospitalisation for these procedures.

Costs of staged versus simultaneous bilateral total knee arthroplasty: a population-based study of the Taiwanese National Health Insurance Database.

BACKGROUND: Bilateral total knee arthroplasty (TKA) is required for many patients. There are few studies comparing the overall costs of staged and simultaneous bilateral TKA. METHODS: The Taiwan National Health Insurance Research Database (NHIRD) was searched, and the total medical costs of 452 patients who received simultaneous bilateral TKAs were compared with those of 690 who received staged bilateral TKAs. RESULTS: All categories of medical costs were lower in the simultaneous TKA group, with the exception of therapeutic procedure fees which were higher in the simultaneous bilateral TKA group. The 10-year prosthesis survival rates for simultaneous and staged bilateral TKA were 90.9% and 87.5% (p > 0.05), respectively. CONCLUSIONS: These results indicate that simultaneous bilateral TKA is more cost effective than staged bilateral TKA. Prosthesis survival is not affected by the choice for staged or simultaneous bilateral TKA.

How risky is caring for emergency patients at risk of malpractice litigation: a population based epidemiological study of Taiwan's experiences.

BACKGROUND: Emergency medicine has generally been considered a high risk specialty. The purpose of this study is to assess the risk of being sued in the district courts for caring emergency room (ER) patients from the perspective of epidemiology. METHODS: This research was designed to be a retrospective population based cohort study. We intended to find out the incidence of litigations arising from ER patients and that of birth inpatients in Taiwan, and computed their relative risks. The inclusion criterion was set to be incidents transpired in the time period of 1998 to 2002. The study materials included the reimbursement claim dataset of the National Health Insurance from 1998 to 2002, and the district court decision database of the Judicial Yuan from 1999 to 2006. RESULTS: The average annual incidence rate of becoming a plaintiff for ER patients is 0.86 per million, and for birth patients is 33.5 per million. There is a statistically significant difference between birth patients and ER patients. The relative risk comparing ER patients against birth inpatients is 0.03. CONCLUSION: The findings of this population based study indicate that the patient population emergency physicians are facing in Taiwan have relatively lower risks of developing litigation in comparison with the patients that come to give birth. Due to the large volume of ER patients, malpractice still pose a major threat in the emergency department, and misdiagnosis remains the major complaint of plaintiffs in subsequent litigations.

Development and implementation of a nationwide health care quality indicator system in Taiwan.

UNLABELLED: QUALITY ISSUES: Quality is an increasingly important issue to the health care sector. The Taiwanese government also recognizes the need to implement a nationwide health care quality indicator system to strengthen quality surveillance. CHOICE OF SOLUTION: In 1999, the Department of Health funded a 2-year project led by the Taiwan Healthcare Executive College to develop a comprehensive performance assessment system, subsequently named as Taiwan Healthcare Indicator Series (THIS). The series includes four categories of indicators, namely outpatient, in-patient, emergency care, and intensive care, and has 139 items in total. IMPLEMENTATION: The system was officially launched in 2001. Participation is voluntary. The Taiwan Healthcare Executive College processes the data and provides feedback to the participating hospitals. The information is for the participating hospitals' own use and is not released to the public. EVALUATION: Participating hospitals have increased from 45 in 2001 to 227 in 2006 and now constitute approximately 50% of the total hospital population in Taiwan. The reporting rate averaged 77.7% in 2004. The first five most reported indicators are the percentage of first-visit outpatients to outpatient clinics, the average length of in-patient stay, the nosocomial infection rate, the occupancy rate, and the crude mortality rate. LESSONS LEARNED: How the data are interpreted and how data interpretation can lead to quality improvement are the principal concerns of participating hospitals. In light of the success of the indicator series, the Bureau of National Health Insurance (BNHI) of Taiwan has proposed participation in the series as being one of the criteria to be reimbursed for quality.

Tumoral calcinosis-like metastatic calcification in a patient on renal dialysis.

Tumoral calcinosis-like metastatic calcification in a patient with uremia on dialysis has rarely been reported in the radiological literatures. This report describes the radiographic, scintigraphic, ultrasound, and CT findings of this condition in a 54-year-old man who had a clinical history of renal dialysis for 6 years. Elevation of serum phosphate and parathyroid hormone levels was noted. Physical examination revealed a hard, movable, and tender mass over his left arm. Plain radiographs of the left shoulder showed an amorphous massive calcification in the upper arm. Scintigraphy showed increased tracer accumulation in the soft tissue of the proximal portion of the left arm and both thighs, where CT scan revealed multilocular, amorphous, calcified masses in these areas. Scintigraphy can help in screening multiple lesions, and CT scan may further help in identifying the extent of a localized lesion such as joint involvement. Ultrasound showed localized multiloculated fluid accumulation within hyperechoic masses and perifocal interstitial fluid collection, which can help to determine the activity of the lesion. Ultrasound findings of tumoral calcinosis have not been reported before.

Intense uptake of [F-18]-fluoro-2 deoxy-D-glucose in active pulmonary tuberculosis.

FDG PET is well recognized for its utility in cancer workup. Nonetheless, the differentiation between malignant and benign pulmonary lesions by FDG PET is challenging. The authors report three proved cases of pulmonary tuberculosis in acute active and open stages. The activities and extents of infection were demonstrable in FDG PET, which could not be observed in either chest radiograph or computed tomography.