Impact of care coordination on 30-day readmission, mortality, and costs for heart failure.

OBJECTIVES: Although coordination of care has become the main focus of health care reform efforts to improve outcomes and decrease costs, limited information is available concerning the impact of care coordination on 30-day outcomes and costs. We used nationwide, population-based data to examine the influence of care coordination on 30-day readmission, mortality, and costs for heart failure (HF). STUDY DESIGN: We analyzed 20,713 patients with HF 18 years or older discharged from hospitals in 2016 using Taiwan's National Health Insurance Research Database. The coordination of care among a patient's outpatient physicians was measured with care density. METHODS: Multilevel regression models were used after adjustment for patient and hospital characteristics to explore the impact of care density on 30-day readmission, mortality, and costs. RESULTS: Patients with high care coordination had lower odds of 30-day readmission (OR, 0.90; 95% CI, 0.82-0.98) and mortality (OR, 0.83; 95% CI, 0.70-0.99) and lower costs (cost ratio [CR], 0.84; 95% CI, 0.79-0.90) compared with those with low care coordination. Patients with medium care coordination had lower costs (CR, 0.92; 95% CI, 0.86-0.98) than those with low care coordination. CONCLUSIONS: High care coordination is associated with decreased 30-day readmission, mortality, and costs for HF. Enhancing coordination of care has the potential to increase the value of care. It is important to monitor coordination of care and develop strategies to maintain high levels of care coordination for HF.

Associations of continuity and coordination of care with outcomes and costs after discharge among patients with heart failure: A nationwide population-based study.

BACKGROUND: Although continuity and coordination of care have received increased attention as important ways to improve outcomes and decrease costs, limited information is available concerning the effects of "care continuity" and "care coordination" on mortality and costs. We used nationwide population-based data from Taiwan to explore the effects of care continuity and coordination on mortality and costs for heart failure. METHODS: We analyzed all 18,991 heart failure patients 18 years of age or older and discharged from hospitals in 2016 using Taiwan's National Health Insurance claims data. Cox proportional hazard and multiple linear regression models were used, after adjustment for patient characteristics, to explore the relative impacts of the continuity of care (COC) index and care density on 1-year mortality and costs. RESULTS: Higher COC index was associated with lower mortality (low vs. medium: hazard ratio [HR], 1.59; 95% confidence interval [CI], 1.47-1.71; high vs. medium: HR, 0.66; 95% CI, 0.61-0.72) and costs (low vs. medium: cost ratio [CR], 1.11; 95% CI, 1.07-1.16; high vs. medium: CR, 0.84; 95% CI, 0.81-0.88). Low care density was associated with higher mortality (low vs. medium: HR, 1.12; 95% CI, 1.04-1.20). Higher care density was associated with lower costs (low vs. medium: CR, 1.14; 95% CI, 1.10-1.18; high vs. medium: CR, 0.76; 95% CI, 0.73-0.79). CONCLUSIONS: Low care continuity and coordination are associated with higher 1-year post-discharge mortality and costs. Facilitating care continuity and coordination may be an important strategy for improving value-based care for heart failure.

Association of antidiabetic therapies with lower extremity amputation, mortality and healthcare cost from a nationwide retrospective cohort study in Taiwan.

We compared risks of clinical outcomes, mortality and healthcare costs among new users of different classes of anti-diabetic medications. This is a population-based, retrospective, new-user design cohort study using the Taiwan National Health Insurance Database between May 2, 2015 and September 30, 2017. An individual was assigned to a medication group based on the first anti-diabetic prescription on or after May 1, 2016: SGLT-2 inhibitors, DPP-4 inhibitors, GLP-1 agonists or older agents (metformin, etc.). Clinical outcomes included lower extremity amputation, peripheral vascular disease, critical limb ischemia, osteomyelitis, and ulcer. We built three Cox proportional hazards models for clinical outcomes and mortality, and three regression models with a log-link function and gamma distribution for healthcare costs, all with propensity-score weighting and covariates. We identified 1,222,436 eligible individuals. After adjustment, new users of SGLT-2 inhibitors were associated with 73% lower mortality compared to those of DPP-4 inhibitors or users of older agents, while 36% lower total costs against those of GLP-1 agonists. However, there was no statistically significant difference in the risk of lower extremity amputation across medication groups. Our study suggested that SGLT-2 inhibitors is associated with lower mortality compared to DPP 4 inhibitors and lower costs compared to GLP-1 agonists.

Impact of bundled payments on hip fracture outcomes: a nationwide population-based study.

OBJECTIVE: Establishing one price for all bundled services for a particular illness, which has become the key to healthcare reform efforts, is designed to encourage health professionals to coordinate their care for patients. Limited information is available, however, concerning whether bundled payments are associated with changes in patient outcomes. Nationwide longitudinal population-based data were used to examine the effect of bundled payments on hip fracture outcomes. DESIGN: An interrupted time series design with a comparison group. SETTING: General acute care hospitals throughout Taiwan. PARTICIPANTS: A total of 178 586 hip fracture patients admitted over the period 2007-12 identified from the Taiwan's National Health Insurance Research Database. INTERVENTION: Bundled payments for hip fractures were implemented in Taiwan in January 2010. MAIN OUTCOME MEASURES: The 30-day unplanned readmission and postdischarge mortality. Segmented generalized estimating equation regression models were used after adjustment for trends, patient, physician and hospital characteristics to assess the effect of bundled payments on 30-day outcomes for hip fracture compared with a reference condition. RESULTS: The 30-day unplanned readmission rate for hip fracture showed a relative decreasing trend after the implementation of bundled payments compared with the trend before the implementation relative to that of the reference condition. CONCLUSIONS: This finding might imply that the implementation of bundled payments encourages health professionals to coordinate their care, leading to reduced readmission for hip fracture.

Relationship between Early Physician Follow-Up and 30-Day Readmission after Acute Myocardial Infarction and Heart Failure.

BACKGROUND: Thirty-day readmission rates after acute myocardial infarction (AMI) and heart failure are important patient outcome metrics. Early post-discharge physician follow-up has been promoted as a method of reducing 30-day readmission rates. However, the relationships between early post-discharge follow-up and 30-day readmission for AMI and heart failure are inconclusive. We used nationwide population-based data to examine associations between 7-day physician follow-up and 30-day readmission, and further associations of 7-day same physician (during the index hospitalization and at follow-up) and cardiologist follow-up with 30-day readmission for non-ST-segment-elevation myocardial infarction (NSTEMI) or heart failure. METHODS: We analyzed all patients 18 years or older with NSTEMI and heart failure and discharged from hospitals in 2010 in Taiwan through Taiwan's National Health Insurance Research Database. Cox proportional hazard models with robust sandwich variance estimates and propensity score weighting were performed after adjustment for patient and hospital characteristics to test associations between 7-day physician follow-up and 30-day readmission. RESULTS: The study population for NSTEMI and heart failure included 5,008 and 13,577 patients, respectively. Early physician follow-up was associated with a lower hazard ratio of readmission compared with no early physician follow-up for patients with NSTEMI (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.39-0.57), and for patients with heart failure (HR, 0.54; 95% CI, 0.48-0.60). Same physician follow-up was associated with a reduced hazard ratio of readmission compared with different physician follow-up for patients with NSTEMI (HR, 0.56; 95% CI, 0.48-0.65), and for patients with heart failure (HR, 0.69; 95% CI, 0.62-0.76). CONCLUSIONS: For each condition, patients who have an outpatient visit with a physician within 7 days of discharge have a lower risk of 30-day readmission. Moreover, patients who have an outpatient visit with the same physician within 7 days of discharge have a much lower risk of 30-day readmission.

The Relationships Among Regionalization, Processes, and Outcomes for Stroke Care: A Nationwide Population-based Study.

Regionalization for stroke care, including stroke center designation, is being implemented in the United States, Canada, or other countries. Limited information is available, however, concerning the relationships among regionalization, processes, and outcomes for stroke care. We examined the association of regionalization with processes and outcomes, and the mediating effect of processes of care on the association between regionalization and mortality for acute stroke in Taiwan. We analyzed all 229,568 admissions with acute ischemic stroke from January 2004 to September 2012 through Taiwan's National Health Insurance Research Database. Regionalized care for acute stroke has been implemented since July 2009 in Taiwan. Rates of thrombolytic therapy within 3 hours after onset of ischemic stroke, average numbers of processes of care, and 30-day mortality rates at monthly intervals for baseline (66 months) and 39 months after the implementation of regionalization. After accounting for secular trends and other confounders, changes in rates of thrombolytic therapy (level change 0.269% per month, P = 0.017 and trend change 0.010% per month, P = 0.048), average numbers of processes of care (trend change 0.001 per month, P = 0.030), and 30-day mortality rates (level change -0.442% per month, P = 0.007 and trend change -0.021% per month, P = 0.015) were attributable to regionalization. The processes of care were mediators of the association between regionalization and 30-day mortality after stroke. Regionalization for stroke care may improve timeliness and processes of stroke care, including access to timely thrombolytic therapy from emergency medical services to hospital care, which may in turn enhance stroke outcomes.

The Effect of Anesthetic Type on Outcomes of Hip Fracture Surgery: A Nationwide Population-Based Study.

Hip fractures are a global public health problem. During surgery following hip fractures, both general and regional anesthesia are used, but which type of anesthesia offers a better outcome remains controversial. There has been little research evaluating different anesthetic types on mortality and readmission rates for hip fracture surgery using nationwide population-based data.We used nationwide population-based data to examine the effect of anesthetic type on mortality and readmission rates for hip fracture surgery.Retrospective observational study.General acute care hospitals throughout Taiwan.A total of 17,189 patients hospitalized for hip fracture surgery in 2011.Generalized estimating equation models with propensity score weighting were performed after adjustment for patient, surgeon, and hospital characteristics to examine the associations of anesthesia type with 30-day all-cause mortality, 30-day all-cause readmission, and 30-day specific-cause readmission (including surgical site infection, sepsis, acute respiratory failure, acute stroke, acute myocardial infarction, acute renal failure, deep vein thrombosis, pneumonia, and urinary tract infection).Of 17,189 patients, 11,153 (64.9%) received regional anesthesia and 6036 (35.1%) received general anesthesia. Overall, the 30-day mortality rate was 1.7%, and the 30-day readmission rate was 12.3%. Regional anesthesia was not associated with decreased 30-day all-cause mortality (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.67-1.18, P = 0.409), but associated with decreased 30-day all-cause readmission and surgical site infection readmission relative to general anesthesia (OR 0.83, 95% CI 0.75-0.93, P = 0.001 and OR 0.69, 95% CI 0.49-0.97, P = 0.031).Regional anesthesia is not associated with 30-day mortality, but is associated with lower 30-day all-cause and surgical site infection readmission compared with general anesthesia for hip fracture surgery.

Processes and outcomes of ischemic stroke care: the influence of hospital level of care.

OBJECTIVE: Processes of stroke care play an increasingly important role in comparing hospital performance. The relationship between processes of care and outcomes for stroke is unclear. Moreover, in terms of stroke care regionalization, little information is available with regard to the relationships among hospital level of care, processes and outcomes of stroke care. We used nationwide population-based data to examine the relationship between processes of care and mortality and the relationships among hospital level of care, processes and mortality for ischemic stroke. DESIGN: Cross-sectional study. SETTING: General acute care hospitals throughout Taiwan. PARTICIPANTS: A total of 31 274 ischemic stroke patients admitted in 2010 through Taiwan's National Health Insurance Research Database. MAIN OUTCOME MEASURES: Processes of care and 30-day mortality. Multilevel models were used after adjustment for patient and hospital characteristics to test the relationship between processes of care and 30-day mortality and the relationships among hospital level of care, processes and 30-day mortality. RESULTS: The use of thrombolytic therapy, antithrombotic therapy, statin treatment and rehabilitation assessment was associated with lower mortality. Hospital level of care was associated with the use of thrombolytic therapy, antithrombotic therapy, statin treatment and rehabilitation assessment, and mortality. These processes of care were mediators of the relationship between hospital level of care and mortality. CONCLUSIONS: Outcomes among patients with ischemic stroke can be improved by thrombolytic therapy, antithrombotic therapy, statin treatment and rehabilitation assessment. Among patients with ischemic stroke, admission to designated stroke center hospitals may be associated with lower mortality through better processes of care.

Long-term effect of fee-for-service-based reimbursement cuts on processes and outcomes of care for stroke: interrupted time-series study from Taiwan.

BACKGROUND: As healthcare spending continues to increase, reimbursement cuts have become 1 type of healthcare reform to contain costs. Little is known about the long-term impact of cuts in reimbursement, especially under a global budget cap with fee-for-service (FFS) reimbursement, on processes and outcomes of care. The FFS-based reimbursement cuts have been implemented since July 2002 in Taiwan. We examined the long-term association of FFS-based reimbursement cuts with trends in processes and outcomes of care for stroke. METHODS AND RESULTS: We analyzed all 411,487 patients with stroke admitted to general acute care hospitals in Taiwan during the period 1997 to 2010 through Taiwan's National Health Insurance Research Database. We used a quasi-experimental design with quarterly measures of healthcare utilization and outcomes and used segmented autoregressive integrated moving average models for the analysis. After accounting for secular trends and other confounders, the implementation of the FFS-based reimbursement cuts was associated with trend changes in computed tomography/magnetic resonance imaging scanning (0.31% per quarter; P=0.013), antiplatelet/anticoagulant use (-0.20% per quarter; P<0.001), statin use (0.18% per quarter; P=0.027), physiotherapy/occupational therapy assessment (0.25% per quarter; P<0.001), and 30-day mortality (0.06% per quarter; P<0.001). CONCLUSIONS: There are improvement trends in processes and outcomes of care over time. However, the reimbursement cuts from the FFS-based global budget cap are associated with trend changes in processes and outcomes of care for stroke. The FFS-based reimbursement cuts may have long-term positive and negative associations with stroke care.

The relationships among physician and hospital volume, processes, and outcomes of care for acute myocardial infarction.

BACKGROUND: A volume-outcome relationship has been found for acute myocardial infarction (AMI); however, the mechanisms underlying the relationship remain unclear. In particular, it is not known whether processes of care are mediators of the volume-outcome relationship, that is, whether the mechanisms underlying the relationship are through processes of care. OBJECTIVE: We used nationwide population-based data to examine the mediating effects of processes of care on the relationships of physician and hospital volume with AMI mortality. METHODS: We analyzed all 6838 ST-elevation myocardial infarction (STEMI) patients admitted in 2008, treated by 740 physicians in 142 hospitals through Taiwan's National Health Insurance Research Database. Multilevel meditational models were performed after adjustment for patient, physician, and hospital characteristics to test the relationships among physician and hospital volume, processes of care, and 30-day STEMI mortality. RESULTS: Physicians with higher volume had higher use of percutaneous coronary intervention and aspirin, and lower mortality in the following year, and the processes of care were mediators of the relationship between physician volume and mortality. Low-volume hospitals had higher mortality in the following year than medium-volume hospitals. In stratified analyses the relationships only existed in nonlarge hospitals. CONCLUSIONS: Physicians with high volume perform better on certain processes of care than those with medium and low volume, and have better outcomes for patients with AMI. The processes of care could partly explain the relationship between physician volume and AMI mortality. However, the relationships existed in nonlarge hospitals but not in large hospitals.

Factors associated with pneumonia outcomes: a nationwide population-based study over the 1997-2008 period.

BACKGROUND: Pneumonia is the most common infectious cause of death worldwide. Over the last decade, patient characteristics and health care factors have changed. However, little information is available regarding systematically and simultaneously exploring effects of these changes on pneumonia outcomes. OBJECTIVES: We used nationwide longitudinal population-based data to examine which patient characteristics and health care factors were associated with changes in 30-day mortality rates for pneumonia patients. DESIGN: Trend analysis using multilevel techniques. SETTING: General acute care hospitals throughout Taiwan. PARTICIPANTS: A total of 788,011 pneumonia admissions. MEASUREMENTS: Thirty-day mortality rates. Taiwan's National Health Insurance claims data from 1997 to 2008 were used to identify the effects of patient characteristics and health care factors on 30-day mortality rates. RESULTS: Male, older, or severely ill patients, patients with more comorbidities, weekend admissions, larger reimbursement cuts and lower physician volume were associated with increased 30-day mortality rates. Moreover, there were interactions between patient age and trend on mortality. CONCLUSIONS: Male, older or severely ill patients with pneumonia have higher 30-day mortality rates. However, mortality gaps between elderly and young patients narrowed over time; namely, the decline rate of mortality among elderly patients was faster than that among young patients. Pneumonia patients admitted on weekends also have higher mortality rates than those admitted on weekdays. The mortality of pneumonia patients rises under increased financial strain from cuts in reimbursement such as the Balanced Budget Act in the United States or global budgeting. Higher physician volume is associated with lower mortality rates.

Impact of cuts in reimbursement on outcome of acute myocardial infarction and use of percutaneous coronary intervention: a nationwide population-based study over the period 1997 to 2008.

BACKGROUND: The impact of cuts in reimbursement, such as the Balanced Budget Act in the United States or global budgeting, on the quality of patient care is an important issue in health-care reform. Limited information is available regarding whether reimbursement cuts are associated with processes and outcomes of acute myocardial infarction (AMI) care. OBJECTIVES: We used nationwide longitudinal population-based data to examine how 30-day mortality and percutaneous coronary intervention (PCI) use for AMI patients changed in accordance with the degree of financial strain induced by the implementation of hospital global budgeting since July 2002 in Taiwan. METHODS: We analyzed all 102,520 AMI patients admitted to general acute care hospitals in Taiwan over the period 1997 to 2008 through Taiwan's National Health Insurance Research Database. Multilevel logistic regression analysis was performed after adjustment for patient, physician, and hospital characteristics to test the association of reimbursement cuts with 30-day mortality and PCI use. RESULTS: The mean magnitude of payment reduction on overall hospital revenues was highest (10.02%) during the period 2004 to 2005. Large reimbursement cuts were associated with higher adjusted 30-day mortality. There was no statistically significant correlation between reimbursement cuts and PCI use. CONCLUSIONS: The mortality of AMI patients increases under increased financial strain from cuts in reimbursement. Nevertheless, the use of PCI is not affected throughout the study period. Reductions in the quantity or quality of services with a negative contribution margin or high cost, such as nurse staffing, may explain the association between reimbursement cuts and AMI outcome.

The effect of cuts in reimbursement on stroke outcome: a nationwide population-based study during the period 1998 to 2007.

BACKGROUND AND PURPOSE: As healthcare costs keep rising, cuts in reimbursement such as the Balanced Budget Act in the United States or global budgeting have become the key to healthcare reform efforts. Limited information is available, however, concerning whether reimbursement cuts are associated with changes in stroke outcomes. The objective of this study is to determine whether 30-day mortality rates for patients with ischemic stroke changed under increased financial strain from global budgeting in Taiwan. METHODS: We analyzed all 258 167 patients with ischemic stroke admitted to general acute care hospitals in Taiwan over the period 1998 to 2007 through Taiwan's National Health Insurance Research Database. Multilevel logistic regression analysis was used to examine whether 30-day stroke mortality rates varied after the implementation of hospital global budgeting since July 2002 adjusted for patient, physician, and hospital characteristics. RESULTS: The magnitude of payment reduction on overall hospital net revenues was between 4.3% and 10.0%. The 30-day mortality rates for patients with ischemic stroke in Taiwan increased after the implementation of hospital global budgeting after adjustment for patient gender and age, comorbidities, surgery, physician age and volume, specialty, hospital volume, ownership, accreditation level, bed size, geographic location, competition, and trend. CONCLUSIONS: The mortality rate of patients with stroke rose under increased financial strain from cuts in reimbursement. Therefore, stroke outcomes are more likely to be affected by hospital financial pressures. It is imperative to monitor stroke outcomes and develop strategies to maintain levels of stroke care as cuts in reimbursement are adopted.

Associations of physician volume and weekend admissions with ischemic stroke outcome in Taiwan: a nationwide population-based study.

BACKGROUND: Although volume-outcome and weekend-outcome relationships have been explored for various procedures and interventions, limited information is available concerning "physician volume" and the "weekend effect" on stroke mortality. Moreover, little is known about the relative and combined influence of physician and hospital volume on stroke mortality. OBJECTIVES: We used nationwide population-based data to explore the influences of physician volume and weekend admissions on stroke mortality. METHODS: We analyzed all 34,347 ischemic stroke patients admitted in 2005, treated by 2424 physicians practicing in 245 hospitals in Taiwan through Taiwan's National Health Insurance Research Database. Multilevel logistic regression analysis was performed after adjustment for patient, physician, and hospital characteristics to explore the individual and combined impact of annual physician volume and annual hospital volume, as well as the impact of weekend admissions, on 30-day mortality. RESULTS: Higher physician volume, simultaneous contribution of higher physician and higher hospital volume, and weekday admissions were associated with decreased 30-day mortality, after adjusting for patient gender and age, comorbidities, surgery, physician age and specialty, hospital ownership, accreditation level, teaching status, geographic location, regional resources, and competition. CONCLUSIONS: Higher physician volume, rather than higher hospital volume is associated with lower 30-day ischemic stroke mortality, but the relationship has become stronger in higher-volume hospitals. Stroke patients admitted on weekends also have a higher mortality than those admitted on weekdays.

Patient satisfaction with and recommendation of a primary care provider: associations of perceived quality and patient education.

OBJECTIVE: To identify whether attributes of perceived clinic quality and patient education are associated with patient satisfaction and recommendation of a primary care provider. DESIGN: Data used in this study were obtained through a national telephone survey by random sampling. SETTING: Clinics throughout Taiwan. PARTICIPANTS: A total of 1910 patients. MAIN OUTCOME MEASURES: Overall patient satisfaction and recommendation were measured by single item questions. Attributes of clinic quality were measured using 11 items: doctor's technical skill (four items), doctor's interpersonal skill (three items), staff care and access (four items). Patient education was measured on the basis of education provided on disease prevention and control during the visit. RESULTS: With regard to clinic quality, doctor's technical skill was most related to overall satisfaction and recommendation, followed by doctor's interpersonal skill. Staff care and access were associated with overall satisfaction but were not associated with recommendation. Patient education was related to both overall satisfaction and recommendation. CONCLUSION: Doctor's technical skill is the most critical attribute of primary care quality for both overall satisfaction and recommendation, followed by doctor's interpersonal skill. Staff care and access are associated with improved overall satisfaction but not related to increasing the likelihood of recommending a clinic to relatives and friends. Doctor's technical and interpersonal skills rather than staff care and access can be the essence of quality competition in the primary care market. Providing patient education during the visit on how to prevent or control diseases may also relate to improved patient satisfaction and recommendation.