Effects of health-information-based diabetes shared care program participation on preventable hospitalizations in Taiwan.

BACKGROUND: Taiwan's Diabetes Shared Care Program has been implemented since 2012, and the health information system plays a vital role in supporting most services of this program. However, little is known regarding the effectiveness of this information-based program. Therefore, this study investigated the effects of the participation of the Diabetes Shared Care Program on preventable hospitalizations. METHODS: This longitudinal study examined the data of health-care claims from 2011 to 2014 obtained from the diabetes mellitus health database. Patients with diabetes aged ≥18 years were included. Preventable hospitalizations were identified on the basis of prevention quality indicators developed for administrative data by the US Agency for Healthcare Research and Quality. A multilevel logistic regression was performed to examine the effects of the participation of the Diabetes Shared Care Program on preventable hospitalizations after adjustment for other variables. Analyses were conducted in late 2018. RESULTS: A medium level of participation (p = 0.05), age between 40 and 64 years(p < 0.0001), and absence of a catastrophic illness(p < 0.0001) were associated with a lower probability of having a preventable hospitalization. Male sex(p < 0.0001), age ≥ 65 years(p = 0.0203), low income level(p < 0.0001), living in the Southern division(p = 0.0106), and presence of many comorbidities(p < 0.0001) were associated with a higher probability of having a preventable hospitalization after adjustment for characteristics at the individual and county levels. CONCLUSIONS: The health information system records patients' medical history, monitors quality of care, schedules patient follow-ups, and reminds case managers to provide timely health education. This health-information-based Diabetes Shared Care Program is associated with better quality care of ambulatory, so it should be promoted on a broader scale.

The effectiveness of a participatory program on fall prevention in oncology patients.

Falls are known to be one of the most common in patient adverse events. A high incidence of falls was reported on patients with cancer. The purpose of this study was to explore the effect of a participatory program on patient's knowledge and self-efficacy of fall prevention and fall incidence in an oncology ward. In this quasi-experimental study, 68 participants were recruited at a medical centre in Taiwan. A 20-min fall prevention program was given to patients. A questionnaire was used to evaluate the effectiveness of program after on day 3 of intervention. The data of fall incidence rates were collected from hospital record. Fall incidences with and without the program were used to compare the effectiveness of intervention. The patients' knowledge and self-efficacy of fall prevention are better than after intervention. A statistically significant difference in fall incidence rate was observed with (0.0%) and without (19.3%) the program. Our findings suggest that the fact of the bedside is that the most risk for falling in hospital must be communicated to the hospitalized patients. Educating patients about fall prevention and activities associated with falling increases their awareness of the potential of falling and promoting patient safety.

The impact of job stressors on health-related quality of life of nursing assistants in long-term care settings.

This study aimed to investigate the relationship between various job stressors and health-related quality of life among female nursing assistants working in long-term care facilities. A cross-sectional study was conducted in Taiwan. Data were collected using a structured, well-designed, pre-tested questionnaire with background questions and questions about job stressors and health-related quality of life as measured by SF-12. Our empirical results show that nursing assistants with higher scores for job control and work-related social support tend to enjoy better mental health, as indicated by higher mental component summary scores. Additionally, nursing assistants with higher psychological demand scores tend to have worse overall health, as indicated by lower physical component summary and mental component summary scores. We suggest reducing selected job stressors and enhancing job control to improve nursing assistants' health-related quality of life.

Nurse staffing, direct nursing care hours and patient mortality in Taiwan: the longitudinal analysis of hospital nurse staffing and patient outcome study.

BACKGROUND: Studies over the past decades have shown an association between nurse staffing and patient outcomes, however, most of these studies were conducted in the West. Accordingly, the purpose of this study aimed to provide an overview of the research/evidence base which has clarified the relationship between nurse staffing and patient mortality of acute care hospital wards under a universal health insurance system and attempted to provide explanations for some of the phenomena that are unique in Taiwan. METHODS: Through stratified random sampling, a total of 108 wards selected from 32 hospitals in Taiwan were collected over a consecutive seven month period. The mixed effect logit model was used to explore the relationship between nurse staffing and patient mortality. RESULTS: The medians of direct-nursing-care-hour, and nurse manpower were 2.52 h, and 378 persons, respectively. The OR for death between the long direct-nursing-care-hour (> median) group and the short direct-nursing-care-hour (≦median) group was 0.393 (95% CI = [0.245, 0.617]). The OR for death between the high (> median) and the low (≦median) nurse manpower groups was 0.589 (95% CI = [0.381, 0.911]). CONCLUSIONS: Findings from this study demonstrate an association of nurse staffing and patient mortality and are consistent with findings from similar studies. These findings have policy implications for strengthening the nursing profession, nurse staffing, and the hospital quality associated with nursing. Additional research is necessary to demonstrate adequate nurse staffing ratios of different wards in Taiwan.

Differential Acceptance of Advance Directives Between Millennials and Baby Boomer Generations: A Cross-Sectional Survey Study Among College Students and Their Relatives.

Objectives: This study aims to explore the differentials of knowledge and attitude of advance directives (ADs) between millennials and baby boomer generations, and the effects of the intention to sign the advance directives. Methods: This is a cross-sectional study using a self-administered questionnaire to collect data from 325 students in a health-related college of a University of Science and Technology in Taiwan, and their parents, as total of 226, who are baby boomers. The statistical methods include descriptive statistics and inferential statistics. Results: Only 10 people from the 2 generations signed an AD. The multivariate logistic regression showed that baby boomer generation, AD knowledge, and AD attitude were significant positive associate of willingness to sign AD in the future. Conclusions: The government may enhance promotion of ADs among millennials and improve the connection between millennials' knowledge of and attitude toward ADs, and their AD signing behavior.

Utilization of emergency department in patients with non-urgent medical problems: patient preference and emergency department convenience.

BACKGROUND/PURPOSE: We investigated the factors associated with emergency department (ED) use among patients with non-urgent medical problems, with a focus on convenience and preference to use the ED instead of primary care clinics. METHODS: A five-level triage system was adopted by research nurses to decide each patient's triage level and the maximum time to physician interview. Patients who had a maximum time to physician interview of more than 60 minutes were assumed to be non-urgent in this study. RESULTS: More than half of ED visits were considered to be non-urgent. Non-urgent patients were more likely to be unmarried, government employees, visit the ED due to trauma, have a history of chronic illness, and present in the day time or at the weekend. ED visits were also more likely to occur in patients who took less than 15 minutes to reach the ED, chose the ED for its convenience, agreed that they could have chosen another facility for their visit, did not agree that the ED was convenient for receiving medical care. Multivariate logistic regression showed that marital status, time of presentation, time needed to get to the ED, and occupation were associated with non-urgent ED visits. CONCLUSION: Preference for using EDs for medical care and their convenience might contribute to non-urgent ED visits. A five-level triage system reliably stratified patients with different admission rates and utilization of medical resources, and could be helpful for reserving limited medical resources for more urgent patients.

[A comparison of long-term care insurance in Germany and the Netherlands].

This paper reports on results of a comparative study of the long-term care systems and relevant laws in Germany and the Netherlands. Information and data used was obtained through articles in the literature. The character of long-term care systems and the major elements of such in both countries are described in detail, including system development, organizational structures, insurance coverage, payment systems, services, delivery systems, and financial mechanisms. Findings-based recommendations are then offered related to Taiwan's long-term care and emerging long-term care insurance systems. Based on the long-term care insurance implementation experiences of these two nations, the authors propose several policy recommendations, including the following: Premiums, taxes, and government subsidies should provide the major sources of funding for the system in order to minimize risk and achieve equity in service. Co-payments should apply to all provided services in order to reduce abuse of the system. Various financial control mechanisms, including controlling benefit levels and ceilings and applying appropriate care management and financial adjustment mechanisms, are also suggested. As national insurance benefits all insured individuals, premium sharing must consider the equity of relevant stakeholders. Developed service delivery systems should be both highly accessible and use a unified evaluation tool to define the needs of the insured. In addition, the long-term care administration organization should coordinate all current long-term care related services.

[Effect of nurse staffing on patient outcomes: a review of the literature].

Staff shortages present nurses with ever increasing levels of stress and working hours. This has resulted in a corresponding increase in talent flight away from the nursing profession. Responding to financial constraints imposed by the Bureau of National Health Insurance (NHI), Taiwan hospitals have reduced nursing staff numbers and recruited nurses at lower levels of competencies and experience. However, few studies have explored the impact of nurse staffing on patient outcomes in Taiwan. Accordingly, we review relevant literature on nurse classifications, the current status of Taiwan nursing manpower, Taiwan and other national regulations on nursing staffing, and the impact of nursing staffing on patient outcomes in an effort to facilitate future study. Our literature review demonstrated that insufficient nursing staffing relates significantly to rates of nosocomial infections, patient mortality, patient falls, pressure ulcers, and rates of patient and family satisfaction. Insufficient nurse staffing leads to increases in adverse patient events, prolonged average hospital stay lengths, and total healthcare expenditures. Evidence shows that nurse staffing is closely linked to patient outcomes.

[Exploring the current state and progress of the skill-mixed model in Taiwan].

For many years assistant personnel have been an integral part of Taiwan's healthcare system, assisting nurses to take care of patients and helping out with various aspects of unit work. The skill-mixed model was discussed during the period of greatest SARS risk in Taiwan, when the tradition of family accompaniment in hospitals presented a real and present risk of nosocomial cross-infection. Since 2003, health care authorities have continued to attempt to implement an appropriate nursing model to improve overall delivery of healthcare. The nursing model implementation in Taiwan is similar to the skill-mixed model deployed in Western countries. Therefore, this article introduces the origin, definition, purpose and categories of the skill-mixed model, as well as related studies on the impact of the skill-mixed model on nursing and patient care outcomes. The article will further explore the current situation and difficulties of applying the skill-mixed model in Taiwan. This article can serve as a reference for health policy makers and be used to help improve Taiwan's healthcare delivery system.

Is the United States in the middle of a healthcare bubble?

OBJECTIVES: This study investigates the possibility of multiple healthcare bubbles in the US healthcare market. METHODS: We first applied the newly developed Generalized Sup ADF test to locate multiple healthcare bubble episodes and then estimated the switching regression model specifying multiple healthcare bubble periods to evaluate to what extent macroeconomic variables (such as the interest rate, public debt, and fiscal deficit) and public financing healthcare programs influence the magnitude of healthcare bubbles in terms of the deviation of the medical care price inflation from either the overall price inflation or the money wage growth. RESULTS: Our results show that expansionary monetary and fiscal policies play important roles in determining the deviation of the medical care price inflation from the overall price inflation and that the net government debt has a positive impact on the deviation of the medical care price inflation from the money wage growth. The US healthcare market is now in the middle of a healthcare bubble, and this healthcare bubble has developed slowly and has lasted for approximately 3 decades, mirroring an increased societal preference for healthcare. CONCLUSIONS: Policymakers in the US should cautiously consider the fact that healthcare bubbles must imply a misallocation of resources into healthcare, leading to negative consequences on the sustainability of the healthcare system.

Factors affecting adequate prenatal care and the prenatal care visits of immigrant women to Taiwan.

This paper investigates prenatal care utilization, identifies factors affecting the adequacy of prenatal care, and explores the effect of adequate initial timing of prenatal care on total prenatal care visits among Taiwan new immigrant females. Data was obtained from the 2008 Prenatal Care Utilization among Taiwan New Immigrant Females Survey on women who either had at least one preschool-aged child or had delivered their infants but were still hospitalized (N = 476). The Adequacy of Prenatal Care Utilization Index was applied to rate the prenatal care adequacy. The logistic regression model was used to investigate factors associated with the adequacy of prenatal care utilization, and the linear regression model was estimated to identify the impact of influential factors on the prenatal care usage. Females' nationality, employment, and transportation convenience increased the likelihood of receiving adequate prenatal care. Having adequate initial timing of prenatal care was found to be positively related to the frequency of prenatal care visits. Prenatal care utilization can be affected by factors within the health care system and by characteristics of the population; therefore, a measure of prenatal care utilization cannot distinguish these factors but reflects the result of all of them in varying combinations.

Effects of nurse staffing ratios on patient mortality in Taiwan acute care hospitals: a longitudinal study.

BACKGROUND: The nurse workload in Taiwan averages two to seven times more than that in the United States and other developed countries. Previous studies have indicated heavy nursing workload as an underlying cause of preventable patient death. No studies have yet explored the relationship between nurse staffing ratio and patient mortality in Taiwan. PURPOSE: This study explored the effect of nurse staffing ratios on patient mortality in acute care hospitals in Taiwan and considered the implications in terms of policy. METHODS: Using stratified random sampling, 108 hospital nursing units in 32 of Taiwan's 441 accredited Western medicine district/regional hospitals and medical centers were included in the study. Variables were retrospectively measured from 108 wards by using monthly data during a 7-month period. A generalized estimating equation logistic model was used to obtain more precise estimates of the nurse staffing effect by controlling for hospital characteristic and patient acuity variables. RESULTS: The population-averaged odds ratio for the incidence of death between the low and high patient-nurse ratio groups was 3.617 (95% CI = [1.930, 6.776]). The risk of death in the high patient-nurse ratio group was significantly higher than in the low patient-nurse ratio group. CONCLUSIONS: Nurse staffing levels affect patient outcomes. Faced with the problem of inadequate nurses for hospital healthcare needs, Taiwanese policymakers should work to implement a legislatively mandated minimum patient-nurse ratio on a shift-by-shift basis to regulate nurse staffing. In setting guidelines for nurse staffing, policymakers must consider nursing staff characteristics in addition to the number of nurses.

Nonemergent emergency department visits under the National Health Insurance in Taiwan.

OBJECTIVES: To explore the magnitude of nonemergent emergency department visits under the Taiwan National Health Insurance program and to identify significant factors associated with these visits. METHODS: A cross-sectional analysis of the 2002 Taiwan National Health Insurance Research Database was used to identify nonemergent emergency department conditions according to the New York University algorithm. The data contained 43,384 visits, of which 83.89% could be classified. Multivariate logistic regression identified individual and contextual factors associated with nonemergent emergency department visits. RESULTS: Nearly 15% of all emergency department visits were nonemergent; an additional 20% were emergent-preventable with primary care. Patients likely to make nonemergent emergency department visits were older, female, categorized as a Taiwan National Health Insurance Category IV beneficiary, and without major illness. Hospital accreditation level, teaching status, and location were associated with an increased likelihood of nonemergent emergency department visits. CONCLUSION: Understanding the factors leading to nonemergent emergency department visits can assist in evaluating the overall quality of a health care system and help reduce the use of the emergency department for nonemergent conditions. Policy makers desiring cost-effective care should assess emergency department visit rates in light of available resources for specific populations.

The skill mix model: a preliminary study of changing nurse role functions in Taiwan.

BACKGROUND: : Nursing shortage is a critical problem worldwide. Using nurse aides (NAs) within a skill mix model has been applied in the healthcare delivery system as a strategy to improve nursing workforce shortages. PURPOSE: : The purpose of this study was to investigate changes in nurse perceptions of their role functions under the skill mix model in Taiwan. METHODS: : This was a cross-sectional designed study that employed a structured questionnaire. Participants included 38 registered nurses from three medical wards in three hospitals that had implemented the skill mix model for 6 months. The questionnaire gathered data on participant demographics, perceptions on the role functions, role and job satisfaction of nurses, and patient care quality. Nurses' role functions were grouped into independent, dependent, and interdependent categories. RESULTS: : Results demonstrate that nurses' perceptions of independent and interdependent role function have changed since the implementation of the skill mix model. The most significant role changes in the independent function category included the nurse as educator of NAs, supervisor for patient care, and evaluator for nursing care outcomes. The most significant role changes in the interdependent function category included the nurse as integrator of nursing work and coordinator of the healthcare team. Nurses' perceived changes increase in repetitive confirmation of patient conditions and patient care quality. CONCLUSIONS: : This study revealed that nurses working in skill mix model environments need more authority to delegate and educate NAs and to supervise and integrate nursing care. Study results may serve as a reference for hospital nursing practice in Taiwan.

Pricing-out effect from possible user-fee policies under Taiwan's National Health Insurance.

This article simulates the pricing-out effect due to various user-fee policies under Taiwan's National Health Insurance. Our simulation results indicate that the lower income group is more likely to be priced out of the healthcare system than the higher income group. On average, pricing-out effects are 0.04, 0.21, 0.52 and 0.73% of total beneficiaries with respect to the new co-payment policy, the catastrophic insurance policy, the under insurance policy, and the case of no National Health Insurance, respectively. We caution that a reduction of healthcare utilization due to higher user fees could result in some patients being left behind without professional care because the pricing-out effects could be higher than the substitution effects diverting demand to other professional care alternatives.

Relationships between serious psychological distress and the use of health services in the United States: findings from the Behavioral Risk Factor Surveillance System.

OBJECTIVE: To determine rates of access to and use of health services among adults with Serious Psychological Distress (SPD). METHODS: Adults > or = 18 years in the 2007 BRFSS were stratified based on the presence of SPD, assessed by scores > or = 13 using the Kessler-6 tool (N = 199,209). Access to and use of general and mental health services were compared for those with scores < 13 and those > or = 13 using Chi-square analyses and logistic regression models. RESULTS: Less than half of all adults with SPD indicated receiving mental health treatment. Persons < 65 years and having SPD were significantly less likely to have access to any type of health insurance (0.59 O.R., 0.51-0.68 95% C.I.) compared to persons <65 years without SPD. CONCLUSIONS: These results present a situation which could potentially lead to increased use of emergency departments for possible non-emergent services. Less than half of adults with SPD were receiving mental health treatment and most, regardless of their SPD score, were receiving routine health checkups; presenting an opportunity to identify and treat many mental health issues in the primary care setting.

Valuing healthcare under Taiwan's national health insurance.

This paper provides a new assessment of the most recent premium policy - the second-generation National Health Insurance (NHI) policy under Taiwan's NHI system. The willingness to pay (WTP) value for a universal coverage NHI plan is NT$201 per month and NT$940 per month for an individual level and for a household level, respectively. We find that the WTP rate is approximately 3.89% of monthly household income, consistent with the range of the new premium rate (2.5-4% of monthly household income) proposed by Taiwan's government. However, the regressive effect of the new premium policy is significant, suggesting that policy makers may consider other policy alternatives such as subsidy to the lower income for healthcare to eliminate the possible regressive effect of the second-generation-NHI premium policy.