Policy-Driven Post-Acute Care Program Lowers Mortality Rate and Medical Expenditures After Hospitalization for Acute Heart Failure: A Nationwide Propensity Score-Matched Study.

OBJECTIVE: The beneficial effects of multidisciplinary disease management programs have been demonstrated. The present study investigated the effects of a policy-driven, health insurance-reimbursed, heart failure (HF) post-acute care (PAC) program on mortality, health care service utilization, and readmission expenses for patients following hospitalization for HF. DESIGN: This was a retrospective propensity score-matched cohort study using the Taiwan National Health Insurance Research Database. SETTING AND PARTICIPANTS: In total, 4346 patients (2173 receiving HF-PAC and 2173 controls) with left ventricular ejection fraction of ≤40% who were discharged following hospitalization for HF were included for analysis. METHODS: All patients were followed up after discharge for all-cause mortality, emergency visits within 30 days, and length of stay and medical expenses for readmission within 180 days after discharge. RESULTS: After propensity score matching, baseline characteristics of the HF-PAC and control groups were similar. During a mean follow-up period of 1.59 ± 0.92 years, according to the Cox multivariable analysis, HF-PAC reduced mortality by 48% compared with the control group, independent of traditional risk factors (hazard ratio = 0.520, 95% CI = 0.452-0.597, P < .001). Kaplan-Meier curves revealed that HF-PAC was associated with a higher cumulative survival rate (log-rank = 96.43, P < .001). HF-PAC also decreased the frequency of emergency visits after discharge by 23% in the 30 days post discharge and decreased length of stay and medical expenses related to readmission by 61% and 63%, respectively, in the 180 days post discharge (all P < .001). CONCLUSIONS AND IMPLICATIONS: HF-PAC reduces short-term all-cause emergency visits, length of stay, and medical expenses for all-cause readmission and all-cause mortality in patients discharged following hospitalization for HF. Our findings suggest that PAC should include care continuity, optimal adaptation of transitional care components, and HF cardiologist engagement with multidisciplinary coordination.

Patient participation in healthcare activities: Nurses' and patients' perspectives in Taiwan.

Patient participation in healthcare activities is key to producing successful patient-centered care. However, little is known about both nurses' and patients' perspectives regarding patient participation in East Asia. This paper compared and contrasted perspectives of patient participation in healthcare activities between nurses and patients, using a qualitative study with a purposive sample of 39 nurses and 15 patients. A semi-structured interview was applied to focus groups for nurses, and to face-to-face interviews for patients. Content analysis was utilized to analyze the data, and common themes and subthemes were identified showing three similarities (authoritative culture, participation behaviors, and obstacles to participation), and two differences (sources of acquiring patient-related health information, and responsible party). Nurses and patients did not entirely view participation in healthcare activities congruently. Relevant clinical practices are also suggested, including respecting patients' autonomy, nurses' using layman's language for explanations, patients' understanding the meaning behind their participation behaviors, recognizing obstacles faced in enhancing patient participation with adjusted nursing workload, actively providing needed health information, and leading patients to realize that they will be responsible for their health behaviors after discharge.

Incentives for physician teams: Effectiveness of performance feedback and payment distribution methods.

Best practices in team-based incentive design remain underexplored. This study examines under group-based pay-for-performance, how managers incentivize physicians for teamwork through internal feedback and payment distribution methods. In collaboration with Taiwan Association of Family Medicine, authors conducted a national survey of physician groups, with a response rate of 48.3%. Multilevel linear regression was applied to 134 groups, collectively consisting of 1,245 physicians in Taiwan. The outcome variables were two manager-rated scores for group performance on achieving (a) comprehensive, coordinated, continuous care, and (b) patient health improvement. The results indicate that providing each physician feedback on peer performance is superior to not providing it; when providing peer information within a group, concealing identities is superior to revealing them. These findings imply that application of the principle of social comparison can be effective; however, caution should be taken when disclosure of identifiable peer performance may intensify peer competition and undermine care coordination in team-based models. Further, groups that distribute payments equally among physicians perform better than groups that distributed payment proportionally to physicians' patient shares. The findings are germane to small teams, where physicians do not have full control over care processes and outcomes, and need to work cooperatively to maximize group-based payment.

Assessment and determinants of global outcomes among 445 mass-casualty burn survivors: A 2-year retrospective cohort study in Taiwan.

PURPOSE: To study outcomes among survivors of the mass-casualty powder explosion on 27 June 2015, at Formosa Fun Coast Waterpark, New Taipei City, Taiwan. METHODS: Using retrospective data on Taiwanese survivors, we analyzed prehospital management, burns assessment and prognosis, functional recovery, and medical costs, followed-up through 30 June 2017. We related outcomes to burn extent, categorized according to the percentages of total body surface area with second/third-degree burns (%TBSA) or autologous split-thickness skin grafts (%STSG), and an investigational scale: f{SASG} = (%TBSA + %STSG)/2, stratified by %STSG. Analyses included casualty dispersal, comparisons between %TBSA, %STSG and f{SASG}, and their relationships with length of hospitalization, times to rehabilitation and social/school re-entry, physical/mental disability, and medical costs. We also investigated how burn scars restricting joint mobility affected rehabilitation duration. RESULTS: 445 hospitalized casualties (excluding 16 foreigners, 23 with 0% TBSA and 15 fatalities) aged 12-38 years, had mean TBSA of 41.1%. Hospitalization and functional recovery durations correlated with %TBSA, %STSG and f{SASG} - mean length of stay per %TBSA was 1.5 days; more numerous burn scar contractures prolonged rehabilitation. Females had worse burns than males, longer hospitalization and rehabilitation, and later school/social re-entry; at follow-up, 62.3% versus 37.7% had disabilities and 57.7% versus 42.3% suffered mental trauma (all p ≤ 0.001). Disabilities affecting 225/227 people were skin-related; 34 were severely disabled but 193 had mild/moderate impairments. The prevalence of stress-related and mood disorders increased with burn extent. Treatment costs (mean USD-equivalents ∼$48,977/patient, ∼$1192/%TBSA) increased with burn severity; however, the highest %TBSA, %STSG and f{SASG} categories accounted for <10% of total costs, whereas TBSA 41-80% accounted for 73.2%. CONCLUSIONS: Besides %TBSA, skin-graft requirements and burn scar contractures are complementary determinants of medium/long-term outcomes. We recommend further elucidation of factors that influence burn survivors' recovery, long-term physical and mental well-being, and quality of life.

Performance competence of pregraduate nursing students and hospital nurses: A comparison study.

AIMS AND OBJECTIVES: To compare and contrast the competence in clinical performance between pregraduate nursing students and hospital nurses. The study also explored the most difficult technical skills for the participants to perform. BACKGROUND: Assessment, communication and critical thinking are competencies that help in providing safe and appropriate care for patients. Yet, self-perceived competence was mostly measured while performance competence that reflected nurses' performance in real cases has seldom been explored in literature. DESIGN: A cross-sectional design was applied. The study adhered to the STROBE guidelines to improve reporting quality. METHOD: Fifty-two nurses and 50 nursing students completed the Computerized Model of Performance-Based Measurement system, which measures performance competence including the steps of critical thinking, conflict resolutions and common clinical technical problems. Six case scenarios containing 107 test questions were completed. RESULTS: Only 53.85% of nurses and 20.0% of students achieved a satisfactory level of performance competence. They showed low scores on the steps of critical thinking: "collecting data from on-site physical assessment," "processing information," "recognising/prioritising problems" and "arranging a course of action for patient care," as well as solving common technical problems and conflicts. The three most difficult skills to perform were CPR, reading EKGs and venipuncture/starting intravenous lines. CONCLUSIONS: The study captured the participants' weaknesses in the critical thinking process and the nursing skills that were difficult to perform. These skills are imperative to nursing care and need to be strengthened in school and in-service education. The academic curriculum and course design for students as well as training programmes for nurses need to be reviewed to address the challenges to be faced in a clinical setting. RELEVANCE TO CLINICAL PRACTICE: Teaching-learning strategies that focus on enhancing critical thinking and performing difficult skills need to be designed and implemented both in practice and in school.

Dynamic Changes in Prognosis with Elapsed Time on Ventilators among Mechanically Ventilated Patients.

Rationale: Previous outcome studies of mechanical ventilation usually adopted a static timeframe to observe the outcome and reported prognosis from the standpoint of the first ventilator day. However, patients and their families may repeatedly inquire about prognosis over time after the initiation of mechanical ventilation.Objectives: We aimed to describe dynamic changes in prognosis according to the elapsed time on a ventilator among mechanically ventilated patients.Methods: For this cohort study we used the entire population dataset of Taiwan's National Health Insurance database. We enrolled adults who newly received invasive mechanical ventilation for at least two consecutive days between March 1, 2010, and August 31, 2011. For every single ventilator day after the initiation of mechanical ventilation, we estimated the cumulative probabilities of weaning success and death in the subsequent 90 days.Results: A total of 162,200 episodes of respiratory failure requiring invasive mechanical ventilation were included. The median age of the subjects was 72 years (interquartile range 57-81 yr) and the median follow-up time was 250 days (interquartile range 30-463 d). The probability curve of weaning success against the time on ventilation showed a unidirectionally decreasing trend, with a relatively sharp slope in the initial 2 months. The probabilities of weaning success in 90 days after the 2nd, 7th, 21st, and 60th ventilator days were 68.3% (95% confidence interval [CI], 68.1-68.5%), 62.6% (95% CI, 62.2-62.9%), 46.3% (95% CI, 45.8-46.8%), and 21.0% (95% CI, 20.3-21.8%), respectively. In contrast, the death curve showed an initial increase and then a decreasing trend after the 19th ventilator day. We also reported tailored prognosis information according to the age, sex, and ventilator day of a mechanically ventilated patient.Conclusions: This study provides ventilator-day-specific prognosis information obtained from a large cohort of unselected patients on invasive mechanical ventilation. The probability of weaning success decreased with the elapsed time on mechanical ventilation, and the decline was particularly remarkable in the first 2 months of ventilatory support.

Post-acute care regains quality of life among middle-aged and older stroke patients in Taiwan.

OBJECTIVE: This study aims to evaluate health-related quality of life (HRQoL) of middle-aged and older stroke patients receiving the stroke post care (PAC) program and to identify possible predictors. DESIGN, SETTING AND PARTICIPANTS: This is a retrospective cohort study. Demographic characteristics and functional outcomes (modified Rankin Scale, Barthel Index, Mini-Mental State Examination, and the Concise Chinese Aphasia Test) were collected at enrollment. EQ-5D HRQoL questionnaires were administered at the beginning and the end of PAC, and health state utilities were compared. RESULTS: The EQ-5D utilities of stroke patients aged 75-84 years and 85 years or above were estimated to be 0.091 and 0.159 lower than those aged less than 50 years. A decrease of the utility by 0.075 was observed among patients with the prior history of stroke. The EQ-5D utilities of patients having Barthel Index of 21-40, 41-60, and 61-100 were 0.1432, 0.1568, and 0.1387 higher than those having Barthel Index of 0-20, respectively. For patients reporting extreme problems in self-care or any dimension of EQ-5D questionnaires prior to PAC, increases in utilities by 0.0733 and 0.2875 were noted. The EQ-5D utility of PAC service duration rose by 0.0733 per one incremental day. CONCLUSIONS AND IMPLICATIONS: This study provides vital evidence regarding time-varying benefits of PAC services to HRQoL of stroke patients and to identify multiple predictors of HRQoL among stroke patients receiving PAC services. This study thus could serve as good reference to enhance quality of PAC services among stroke patients.

Managing health expenditure inflation under a single-payer system: Taiwan's National Health Insurance.

As nations strive to achieve and sustain universal health coverage (UHC), they seek answers as to what health system structures are more effective in managing health expenditure inflation. A fundamental macro-level choice a nation has to make is whether to adopt a single- or a multiple-payer health system. Using Taiwan's National Health Insurance (NHI) as a case, this paper examines how a single-payer system manages its health expenditure growth and draws lessons for other countries whose socioeconomic development is similar to Taiwan's. Our analyses show that as a single payer, Taiwan's NHI is able to exercise its monopsony power to manage its health expenditure growth. This is achieved primarily through the adoption of a system-wide global budget. The global budget sets a hard aggregate budget cap to limit NHI's total spending to its expected revenue, with the annual budget growth rate established by a process of negotiation among key stakeholders. The global budget system is complemented by comprehensive and continuous monitoring and review of encounter records of all providers and patients, enabled by the NHI's advanced information technology. However, by paying its providers using a point-based fee schedule, Taiwan's NHI suffers from inefficient service provision. In particular, providers have incentives to increase use of services and drugs with positive profit margins. Furthermore, Taiwan demonstrates that its control of NHI expenditure growth might be leading it to inadequately meet the changing needs of the population, resulting in the rapid growth of private insurance to cover services excluded or not fully covered by the NHI. If this trend persists and results in a two-tier system, Taiwan's NHI may risk compromising the equity it has achieved in the past two decades.

Taboo in the Workplace: A Qualitative Study of Taiwanese Nurses' "Not-Eating Pineapple" in Clinical Practice.

There has been an increased emphasis on nurses' mental health and well-being in the workplace. Psychologists have established a correlative link between individual's beliefs on luck and mental health. The pineapple taboo has been observed among Taiwanese hospital nurses as a prevalent superstitious belief for bringing luck or warding off increased clinical workloads, but how and why the ritual persists in the hospital workplace remains unknown. This article aims to explore the latent meaning of observance of the taboo and how it is related to nurses' clinical practice and possibly affects their mental health at work. A qualitative research was designed in line with the hermeneutic phenomenological method. Through purposive sampling, 18 nurse participants were recruited for in-depth semistructured interviews. Resulting from the ensuing analysis, 3 modalities were identified as constituting the spectrum of observance of the taboo: (a) "strictly not eating pineapple"; (b) "not eating pineapple at work"; and (c) "eating pineapple without admitting to doing so." Each reflects the position of nurses revealed in relation to the pineapple taboo in clinical settings. Based on the subjective narratives of nurses, it may be understood as an active moral attempt at "being right" rather than a passive avoidance of bad luck in the taboo observation. The findings facilitate an appropriate understanding of the embedded meaning of nurses' workplace-related belief and its seminal function of empowerment for nurses in holistic nursing practice.

Functional Outcomes, Subsequent Healthcare Utilization, and Mortality of Stroke Postacute Care Patients in Taiwan: A Nationwide Propensity Score-matched Study.

OBJECTIVE: To evaluate the benefits of the national stroke postacute care (PAC) program on clinical outcomes and subsequent healthcare utilization. DESIGN: Propensity score-matched case-control study using the National Health Insurance data. PARTICIPANTS: A total of 1480 stroke cases receiving PAC services and 3159 matched controls with similar stroke severity but without PAC services. MEASUREMENTS: Demographic characteristics, functional outcomes (modified Rankin Scale, Barthel Index, Lawton-Brody Instrumental Activities of Daily Living, Functional Oral Intake Scale, Mini-Nutritional Assessment, Berg Balance Test, Usual Gait Speed Test, 6-Minute Walk Test, Fugl-Meyer Assessment (modified sensation and motor), Mini-Mental State Examination, Motor Activity Log, and the Concise Chinese Aphasia Test), subsequent healthcare utilization (90-day stroke re-admission and emergency department visits), and 90-day mortality. RESULTS: After propensity score matching, baseline characteristics, stroke severity, and status of healthcare utilization before index stroke admission were similar between cases and controls. After PAC services, the case group obtained significant improvement in all functional domains and may have reduced subsequent disability. Among all functional assessments, balance was the most significantly improved domain and was suggestive for the reduction of subsequent falls risk and related injuries. Compared with controls, patients receiving PAC services had significantly lower 90-day hospital re-admissions [11.1% vs 21.0%, adjusted odds ratio (aOR) 0.47 with 95% confidence interval (CI) 0.34-0.64], stroke-related re-admissions (2.1% vs 8.8%, aOR 0.22, 95% CI 0.12-0.41), and emergency department visits (13.5% vs 24.0%, aOR 0.49, 95% CI 0.37-0.65), but the 90-day mortality rate remained similar between groups (1.4% case group vs 2.0% control group, aOR 0.68, 95% CI 0.29-1.62). CONCLUSIONS: PAC significantly improved the recovery of stroke patients in all functional domains through the program, with universal interorganizational staff training, periodic functional assessment, and high-intensity rehabilitation. Further longitudinal research is needed to evaluate the long-term survival benefits and healthcare utilization.

Half-Managed Care: A Preliminary Assessment of a Capitation Program in a Health Care System Without Gatekeepers.

In 2011, a novel capitation program was launched in Taiwan under its universal health insurance plan. This study aimed to assess the short-term impact of the program. Two hospitals in the greater Taipei area, one participating in the "loyal patient" model (13,319 enrollees) and one in the "regional resident" model (13,768 enrollees), were analyzed. Two comparison groups were selected by propensity score matching. Generalized estimating equation models with differences-in-differences analysis were used to examine the net effects of the capitation program on health care utilization, expenses, and outcomes. Enrollees in the loyal patient model had fewer physician visits in the host hospital, but more physician visits outside that hospital during the program year than they had the year before. Compared with non-enrollees, the loyal patient model enrollees incurred fewer physician visits (ß = -0.042, p < .001), fewer emergency department visits, (ß = -0.140, p < .001), and similar total expenses and outcome. For the regional resident model, no differences were found in the number of physician visits, expenses, or outcomes between enrollees and non-enrollees. The novel capitation models in Taiwan had minimal impact on health care utilization after 1 year of implementation and the health care outcome was not compromised.

On My Own: A Qualitative Phenomenological Study of Mothers of Young Children with Autism Spectrum Disorder in Taiwan.

BACKGROUND: There has been a dramatic increase in autism around the world. However, little is known about the impact of the Taiwanese primogeniture system on mothers of children with ASD. Greater knowledge is needed to understand the life experiences of Taiwanese mothers with ASD children when a healthy male descendent is expected. MATERIALS AND METHODS: Research follows the hermeneutic phenomenological approach with in-depth interviews and participant observation (Agar, Speaking of Ethnography. Sage, California, 1986). The researchers collected and analysed stories from seven mothers who are the major caregivers of their school-aged autistic children. RESULTS: The data revealed the following themes that represented the mothers' experiences: taking the blame, my world was turned upside down, a child-centred life and two lives as one. CONCLUSIONS: The findings provide a deeper understanding of common expectations of, and behaviours directed towards, Taiwanese mothers of children with autism. This offers healthcare professionals ways of reconceptualizing therapeutic practice, thus benefitting these mothers.

What Is the Addiction World Like? Understanding the Lived Experience of the Individuals' Illicit Drug Addiction in Taiwan.

PURPOSE: This study focuses on the participants' lived experience of addiction. DESIGN AND METHODS: The study presents a qualitative method. The use of the fieldwork-based participant observation and in-depth interviews guided the data collection and analysis. FINDINGS: Three major themes of addiction emerge from the analysis: incorrigible conduct, inexcusable compromise, and inevitable corruption. PRACTICE IMPLICATIONS: This study provides a better understanding of what the world is like for people struggling with addiction and also enhances the healthcare professionals' knowledge of the individual's experience of addiction. This knowledge is essential for clinicians to understand this experience as a framework for planning and implementing appropriate treatment.

Association of a Bundled-Payment Program With Cost and Outcomes in Full-Cycle Breast Cancer Care.

IMPORTANCE: Value-driven payment system reform is a potential tool for aligning economic incentives with the improvement of quality and efficiency of health care and containment of cost. Such a payment system has not been researched satisfactorily in full-cycle cancer care. OBJECTIVE: To examine the association of outcomes and medical expenditures with a bundled-payment pay-for-performance program for breast cancer in Taiwan compared with a fee-for-service (FFS) program. DESIGN, SETTING, AND PARTICIPANTS: Data were obtained from the Taiwan Cancer Database, National Health Insurance Claims Data, the National Death Registry, and the bundled-payment enrollment file. Women with newly diagnosed breast cancer and a documented first cancer treatment from January 1, 2004, to December 31, 2008, were selected from the Taiwan Cancer Database and followed up for 5 years, with the last follow-up data available on December 31, 2013. Patients in the bundled-payment program were matched at a ratio of 1:3 with control individuals in an FFS program using a propensity score method. The final sample of 17 940 patients included 4485 (25%) in the bundled-payment group and 13 455 (75%) in the FFS group. MAIN OUTCOMES AND MEASURES: Rates of adherence to quality indicators, survival rates, and medical payments (excluding bonuses paid in the bundled-payment group). The Kaplan-Meier method was used to calculate 5-year overall and event-free survival rates by cancer stage, and the Cox proportional hazards regression model was used to examine the effect of the bundled-payment program on overall and event-free survival. Sensitivity analysis for bonus payments in the bundled-payment group was also performed. RESULTS: The study population included 17 940 women (mean [SD] age, 52.2 [10.3] years). In the bundled-payment group, 1473 of 4215 patients (34.9%) with applicable quality indicators had full (100%) adherence to quality indicators compared with 3438 of 12 506 patients (27.5%) with applicable quality indicators in the FFS group (P < .001). The 5-year event-free survival rates for patients with stages 0 to III breast cancer were 84.48% for the bundled-payment group and 80.88% for the FFS group (P < .01). Although the 5-year medical payments of the bundled-payment group remained stable, the cumulative medical payments for the FFS group steadily increased from $16 000 to $19 230 and exceeded pay-for-performance bundled payments starting in 2008. CONCLUSIONS AND RELEVANCE: In Taiwan, compared with the regular FFS program, bundled payment may lead to better adherence to quality indicators, better outcomes, and more effective cost-control over time.

Effectiveness of Pay-for-Performance Incentive Designs on Diabetes Care.

BACKGROUND: Taiwan's National Health Insurance program implemented a pay-for-performance (P4P) program based on process measures in 2001. In late 2006, the P4P was revised to also include achievement of outcome measures. OBJECTIVES: This study examined whether a change in P4P incentive design structure affected diabetes outcomes. RESEARCH DESIGN AND METHOD: We used a longitudinal cohort study design using 2 population-based databases. Newly enrolled P4P patients with diabetes in 2002-2003 (phase 1) and 2007-2008 (phase 2) made up the study cohorts. Propensity score matching was used to match comparable cohorts in each phase. In total, 46,286 matched cohorts in phase 1 and 2 were analyzed. Process measures were defined as the provision of tests of glycosylated hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol, and blood pressure, and outcome measures as changes in those values between baseline and last follow-up within 3 years. Patient-level generalized linear regression models were used and patient characteristics, physician characteristics, and health care facility characteristics were adjusted for. RESULTS: Our results indicated that the process measures of HbA1c and low-density lipoprotein cholesterol tests did not differ significantly between the 2 phases. In addition, better improvements were noted in outcome measures for the phase 2 patients (ie, HbA1c level and lipid profiles), whereas nonincentivized intermediate measures (eg, blood pressure) showed no negative unintended consequences. CONCLUSIONS: Quality of care tended to be better when both process and targeted outcome measures were combined as quality metrics in the P4P program in Taiwan.

Development of the Computerized Model of Performance-Based Measurement System to Measure Nurses' Clinical Competence.

Critical thinking skills and clinical competence are for providing quality patient care. The purpose of this study is to develop the Computerized Model of Performance-Based Measurement system based on the Clinical Reasoning Model. The system can evaluate and identify learning needs for clinical competency and be used as a learning tool to increase clinical competency by using computers. The system includes 10 high-risk, high-volume clinical case scenarios coupled with questions testing clinical reasoning, interpersonal, and technical skills. Questions were sequenced to reflect patients' changing condition and arranged by following the process of collecting and managing information, diagnosing and differentiating urgency of problems, and solving problems. The content validity and known-groups validity was established. The Kuder-Richardson Formula 20 was 0.90 and test-retest reliability was supported (r = 0.78). Nursing educators can use the system to understand students' needs for achieving clinical competence, and therefore, educational plans can be made to better prepare students and facilitate their smooth transition to a future clinical environment. Clinical nurses can use the system to evaluate their performance-based abilities and weakness in clinical reasoning. Appropriate training programs can be designed and implemented to practically promote nurses' clinical competence and quality of patient care.

Effects of Changes in Diabetes Pay-for-Performance Incentive Designs on Patient Risk Selection.

OBJECTIVE: Taiwan's National Health Insurance (NHI) Program implemented a Diabetes Pay-for-Performance Program (P4P) based on process-of-care measures in 2001. In late 2006, that P4P program was reformed to also include achievement of intermediate health outcomes. This study examined how the change in design affected patient risk selection. DESIGNS/STUDY POPULATIONS: Study populations were identified from a 2002 to 2003 period (Phase 1) and a 2007 to 2008 period (Phase 2), spanning pre- and postimplementation of reforms in the P4P incentive design. Phase 1 had 74,529 newly enrolled P4P patients and 215,572 non-P4P patients, and Phase 2 had 76,901 newly enrolled P4P patients and 299,573 non-P4P patients. Logistic regression models were used to estimate the effect of changes in design on P4P patient selection. PRINCIPAL FINDINGS: Patients with greater disease severity and comorbidity were more likely to be excluded from the P4P program in both phases. Furthermore, the additional financial incentive for patients' intermediate outcomes moderately worsened patient risk selection. CONCLUSIONS: Policy makers need to carefully monitor the care of the diabetes patients with more severe and complex disease statuses after the changes of P4P financial incentive design.

The secular trends in the incidence rate and outcomes of out-of-hospital cardiac arrest in Taiwan--a nationwide population-based study.

OBJECTIVE: This study investigated the trends in incidence and mortality of out-of-hospital cardiac arrest (OHCA), as well as factors associated with OHCA outcomes in Taiwan. METHODS: Our study included OHCA patients requiring cardiopulmonary resuscitation (CPR) upon arrival at the hospital. We used national time-series data on annual OHCA incidence rates and mortality rates from 2000 to 2012, and individual demographic and clinical data for all OHCA patients requiring mechanical ventilation (MV) care from March of 2010 to September of 2011. Analytic techniques included the time-series regression and the logistic regression. RESULTS: There were 117,787 OHCAs in total. The overall incidence rate during the 13 years was 51.1 per 100,000 persons, and the secular trend indicates a sharp increase in the early 2000s and a decrease afterwards. The trend in mortality was also curvilinear, revealing a substantial increase in the early 2000s, a subsequent steep decline and finally a modest increase. Both the 30-day and 180-day mortality rates had a long-term decreasing trend over the period (p<0.01). For both incidence and mortality rates, a significant second-order autoregressive effect emerged. Among OHCA patients with MV, 1-day, 30-day and 180-day mortality rates were 31.3%, 75.8%, and 86.0%, respectively. In this cohort, older age, the female gender, and a Charlson comorbidity index score ≥ 2 were associated with higher 180-day mortality; patients delivered to regional hospitals and those residing in non-metropolitan areas had higher death risk. CONCLUSIONS: Overall, both the 30-day and the 180-day mortality rates after OHCA had a long-term decreasing trend, while the 1-day mortality had no long-term decline. Among OHCA patients requiring MV, those delivered to regional hospitals and those residing in non-metropolitan areas tended to have higher mortality, suggesting a need for effort to further standardize and improve in-hospital care across hospitals and to advance pre-hospital care in non-metropolitan areas.

Cost-effectiveness of diabetes pay-for-performance incentive designs.

BACKGROUND: Taiwan's National Health Insurance (NHI) Program implemented a diabetes pay-for-performance program (P4P) based on process-of-care measures in 2001. In late 2006, that P4P program was revised to also include achievement of intermediate health outcomes. OBJECTIVES: This study examined to what extent these 2 P4P incentive designs have been cost-effective and what the difference in effect may have been. RESEARCH DESIGN AND METHOD: Analyzing data using 3 population-based longitudinal databases (NHI's P4P dataset, NHI's claims database, and Taiwan's death registry), we compared costs and effectiveness between P4P and non-P4P diabetes patient groups in each phase. Propensity score matching was used to match comparable control groups for intervention groups. Outcomes included life-years, quality-adjusted life-years (QALYs), program intervention costs, cost-savings, and incremental cost-effectiveness ratios. RESULTS: QALYs for P4P patients and non-P4P patients were 2.08 and 1.99 in phase 1 and 2.08 and 2.02 in phase 2. The average incremental intervention costs per QALYs was TWD$335,546 in phase 1 and TWD$298,606 in phase 2. The average incremental all-cause medical costs saved by the P4P program per QALYs were TWD$602,167 in phase 1 and TWD$661,163 in phase 2. The findings indicated that both P4P programs were cost-effective and the resulting return on investment was 1.8:1 in phase 1 and 2.0:1 in phase 2. CONCLUSIONS: We conclude that the diabetes P4P program in both phases enabled the long-term cost-effective use of resources and cost-savings regardless of whether a bonus for intermediate outcome improvement was added to a process-based P4P incentive design.