Impact of dialysis reimbursement policies on care outcomes in peritoneal dialysis patients in Taiwan.

The number of treated end stage renal disease (ESRD) patients worldwide has rapidly grown. To prolong their lives ESRD patients require transplantation or dialysis treatment. Limited donor availability has caused most of the ESRD patients to rely on either hemodialysis (HD) or peritoneal dialysis (PD). Taiwan had the highest prevalence rate worldwide and sought to increase the PD utilization through a series of reimbursement incentives. This study evaluated the effect of those policy initiatives. A retrospective longitudinal study using a before-and-after analysis was conducted. ESRD patients initiating either PD or HD were identified from the entire population of Taiwan NHI's beneficiaries. PD patients, before and after the PD-encouraging initiatives, were matched through a propensity score technique, and the change in PD technical failure was analyzed. HD patients were also matched as the control group to assess the impact on PD mortality. The competing risk regression approach for survival analysis was adopted. The results indicate the increase in PD utilization during this period was also accompanied by increases in both technique failure and mortality. Since PD shifts more burden of care to patients, efforts to increase its utilization may require an increase in the education of providers and patients to benefit more effectively. It may also require an increase in staff to provide ongoing training and support as the policy unfolds.

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

BACKGROUND: Long work hours for physicians not only harm the health of physicians, but also endanger patient safety. Compared with resident physicians, attending physicians-especially hospital-employed attending physicians-assume more responsibilities but has not gotten enough attention. The purpose of this study was to explore whether a hospital's geographic location and emergency care responsibility might influence the number of hours worked. METHODS: The respondents of 2365 attending physicians from 152 hospitals in the 2018 survey of Taiwan physician work hours were used as the data source. The total work hour per week and its components, the regular scheduled shift and three types of on-call shifts, were used as outcome variables. Hospital geographic location and emergency care responsibility were the independent variables. The multilevel random effect model was employed to examine the study objective after adjusting for clinical specialty, hospital teaching status, and ownership. RESULTS: The average number of total working hours was 69.09 hours per week; the regular scheduled shift was account for 75% of total work hours. The results showed the total work hours were only varied by the level of hospital's emergency care responsibility. However, the results also demonstrated the hours of duty shifts were varied by hospital's geographic location and emergency care responsibility. The results of the multilevel random effect model revealed that the hospital's emergency care responsibility was the factor consistently associated with attending physician's work hour, no matter the total work hours or its composition. CONCLUSION: In this study, we explored how a hospital's location and its level of emergency care responsibility were associated with physicians' work hours for each type of shift. Our findings offer an opportunity to review the rationality of physician workforce allocation, and financial incentives and administrative measures could be the next steps for balancing the work hours of attending physicians.

Prevalence of sleep disorders in children with chronic kidney disease: a meta-analysis.

BACKGROUND: The reported prevalence of sleep disorders in children with chronic kidney disease (CKD) varies greatly. A quantitative meta-analysis to estimate the prevalence of sleep disorders among pediatric CKD patients may provide further information. OBJECTIVES: The objective of this study is to estimate the prevalence of sleep disorders in children with CKD. The study protocol was registered on PROSPERO (registration number CRD42021268378). DATA SOURCES: Two authors independently searched the PubMed, MEDLINE, EMBASE, and Cochrane review databases up to June 2021. STUDY ELIGIBILITY CRITERIA: Eligible studies include data of prevalence of sleep disorders in children with CKD. STUDY APPRAISAL AND SYNTHESIS METHODS: The prevalence of restless legs syndrome, sleep-disordered breathing, pediatric obstructive sleep apnea (i.e., apnea-hypopnea index > 1 event/h in polysomnography), excessive daytime sleepiness, and insomnia/insufficient sleep was estimated using a random-effects model. Subgroup analyses were conducted to compare the prevalence of sleep disorders between children on dialysis and not on dialysis. This meta-analysis included 12 studies with 595 children (mean age: 12.9 years; gender ratio: 55.6% boys; mean sample size: 49.6 patients). RESULTS: The prevalence of restless legs syndrome in children with CKD was 21% (95% confidence interval [CI], 14-30%). The prevalence of sleep-disordered breathing, pediatric obstructive sleep apnea, excessive daytime sleepiness, and insomnia/insufficient sleep was 22% (95% CI, 12-36%), 34% (95% CI, 19-53%), 27% (95% CI, 17-41%), and 14% (95% CI, 7-27%), respectively. Subgroup analysis revealed the pooled prevalence of excessive daytime sleepiness was significantly higher in children on dialysis than in children not on dialysis (43.3% vs. 11.2%; P = 0.018). Children on dialysis also had a high prevalence of other sleeping disorders, although the differences did not reach statistical significance. Children with CKD exhibited a 3.9-fold (95% CI, 1.37 to 10.93) increased risk of restless legs syndrome and a 9.6-fold (95% CI, 3.57 to 25.76) increased risk of excessive daytime sleepiness compared with controls. LIMITATIONS: The selected papers are of small sample size, lack of a control group, and exhibit substantial heterogeneity. CONCLUSIONS: Sleep disorders are common in children with CKD. Our results indicate that while the prevalence rates of various sleep disorders were higher in children on dialysis than in children not on dialysis, the prevalence of excessive daytime sleepiness was statistically significant in children on dialysis. A higher resolution version of the Graphical abstract is available as Supplementary information.

Economic evaluation for mass vaccination against COVID-19.

BACKGROUND: Vaccine is supposed to be the most effective means to prevent COVID-19 as it may not only save lives but also reduce productivity loss due to resuming pre-pandemic activities. Providing the results of economic evaluation for mass vaccination is of paramount importance for all stakeholders worldwide. METHODS: We developed a Markov decision tree for the economic evaluation of mass vaccination against COVID-19. The effectiveness of reducing outcomes after the administration of three COVID-19 vaccines (BNT162b2 (Pfizer-BioNTech), mRNA-1273 (Moderna), and AZD1222 (Oxford-AstraZeneca)) were modelled with empirical parameters obtained from literatures. The direct cost of vaccine and COVID-19 related medical cost, the indirect cost of productivity loss due to vaccine jabs and hospitalization, and the productivity loss were accumulated given different vaccination scenarios. We reported the incremental cost-utility ratio and benefit/cost (B/C) ratio of three vaccines compared to no vaccination with a probabilistic approach. RESULTS: Moderna and Pfizer vaccines won the greatest effectiveness among the three vaccines under consideration. After taking both direct and indirect costs into account, all of the three vaccines dominated no vaccination strategy. The results of B/C ratio show that one dollar invested in vaccine would have USD $13, USD $23, and USD $28 in return for Moderna, Pfizer, and AstraZeneca, respectively when health and education loss are considered. The corresponding figures taking value of the statistical life into account were USD $176, USD $300, and USD $443. CONCLUSION: Mass vaccination against COVID-19 with three current available vaccines is cost-saving for gaining more lives and less cost incurred.

Review of epidemic, containment strategies, clinical management, and economic evaluation of COVID-19 pandemic.

The spread of the emerging pathogen, named as SARS-CoV-2, has led to an unprecedented COVID-19 pandemic since 1918 influenza pandemic. This review first sheds light on the similarity on global transmission, surges of pandemics, and the disparity of prevention between two pandemics. Such a brief comparison also provides an insight into the potential sequelae of COVID-19 based on the inference drawn from the fact that a cascade of successive influenza pandemic occurred after 1918 and also the previous experience on the epidemic of SARS and MERS occurring in 2003 and 2015, respectively. We then propose a systematic framework for elucidating emerging infectious disease (EID) such as COVID-19 with a panorama viewpoint from natural infection and disease process, public health interventions (non-pharmaceutical interventions (NPIs) and vaccine), clinical treatments and therapies (antivirals), until global aspects of health and economic loss, and economic evaluation of interventions with emphasis on mass vaccination. This review not only concisely delves for evidence-based scientific literatures from the origin of outbreak, the spread of SARS-CoV-2 to three surges of pandemic, and NPIs and vaccine uptakes but also provides a new insight into how to apply big data analytics to identify unprecedented discoveries through COVID-19 pandemic scenario embracing from biomedical to economic viewpoints.

Evaluating medical capacity for hospitalization and intensive care unit of COVID-19: A queue model approach.

BACKGROUND: The surge of COVID-19 pandemic has caused severe respiratory conditions and a large number of deaths due to the shortage of intensive care unit (ICU) in many countries. METHODS: We developed a compartment queue model to describe the process from case confirmation, home-based isolation, hospitalization, ICU, recovery, and death. By using public assessed data in Lombardy, Italy, we estimated two congestion indices for isolation wards and ICU. The excess ICU needs were estimated in Lombardy, Italy, and other countries when data were available, including France, Spain, Belgium, New York State in the USA, South Korea, and Japan. RESULTS: In Lombardy, Italy, the congestion of isolation beds had increased from 2.2 to the peak of 6.0 in March and started to decline to 3.9 as of 9th May, whereas the demand for ICU during the same period has not decreased yet with an increasing trend from 2.9 to 8.0. The results showed the unmet ICU need from the second week in March as of 9th May. The same situation was shown in France, Spain, Belgium, and New York State, USA but not for South Korea and Japan. The results with data until December 2020 for Lombardy, Italy were also estimated to reflect the demand for hospitalization and ICU after the occurrence of viral variants. CONCLUSION: Two congestion indices for isolation wards and ICU beds using open assessed tabulated data with a compartment queue model underpinning were developed to monitor the clinical capacity in hospitals in response to the COVID-19 pandemic.

Effects of Erythropoietin Payment Policy on Cardiovascular Outcomes of Peritoneal Dialysis Patients: Observational Study.

BACKGROUND: The change in the reimbursement policy of erythropoietin administration to patients receiving peritoneal dialysis by the Taiwan National Health Insurance (NHI) system provided a natural experimental venue to examine whether cardiovascular risk differs when maintaining the hematocrit (Hct) level below or above 30%. OBJECTIVE: The aim of this study was to analyze the impact of loosening the erythropoietin payment criteria for peritoneal dialysis patients on their cardiovascular outcomes. METHODS: Two cohorts of incident peritoneal dialysis patients were identified according to the time before and after relaxation of the NHI's erythropoietin payment criteria, designated cohort 1 (n=1759) and cohort 2 (n=2981), respectively. The cohorts were matched according to propensity scores (1754 patients in each cohort) and then followed up for cardiovascular events, which were analyzed with Cox regressions. RESULTS: For the composite cardiovascular endpoint, patients in cohort 2 had a significantly lower risk than those in cohort 1. However, subgroup analysis showed that this risk reduction was observed only in patients with diabetes. CONCLUSIONS: After loosening erythropoietin payment criteria, reduced cardiovascular risks were observed, particularly for patients with diabetes. These results indicate that it is crucial to maintain an Hct level above 30% to reduce the cardiovascular risk in patients with diabetes undergoing peritoneal dialysis.

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

Long work hours among physicians is a worldwide issue in the healthcare arena. Previous studies have largely focused on the work hours of resident physicians rather than those of attending physicians. The purpose of this study was to investigate total work hours and the composition of those work hours for attending physicians across different hospital settings and across different medical specialties through a nationwide survey. This included examining differences in physician workload and its composition with respect to different hospital characteristics, and grouping medical specialties according to the work similarities. A cross-sectional self-reported nationwide survey was conducted from June to September of 2018, and the two questionnaires were distributed to all accredited hospitals in Taiwan. The number of physician work hours in different types of duty shifts were answered by medical specialty in each surveyed hospital. Each medical specialty in a hospital filled only one response for its attending physicians. The findings reveal that the average total work hours per week of an attending physician is around 69.1 h, but the total work hours and their composition of different duty shifts varied among hospital accreditation levels, geographic locations, emergency care responsibilities, and medical specialties. Because of the variance in the number and composition of attending physicians' work hours, adjusting physician work hours to a reasonable level will be a major challenge for health authority and hospital managers.

The Impact of a Social Networking Service-Enhanced Smart Care Model on Stage 5 Chronic Kidney Disease: Quasi-Experimental Study.

BACKGROUND: Stage 5 chronic kidney disease (CKD) presents a high risk for dialysis initiation and for complications such as uremic encephalopathy, uremic symptoms, gastrointestinal bleeding, and infection. One of the most common barriers to health care for patients with stage 5 CKD is poor continuity of care due to unresolved communication gaps. OBJECTIVE: Our aim was to establish a powerful care model that includes the use of a social networking service (SNS) to improve care quality for patients with CKD and safely delay dialysis initiation. METHODS: We used a retrospective cohort of CKD patients aged 20-85 years who received care between 2007 and 2017 to evaluate the efficacy of incorporating an SNS into the health care system. In 2014, author F-JY, a nephrologist at the National Taiwan University Hospital Yunlin Branch, started to use an SNS app to connect with stage 5 CKD patients and their families. In cases of emergency, patients and families could quickly report any condition to F-JY. Using this app, F-JY helped facilitate productive interactions between these patients and the health care system. The intention was to safely delay the initiation of dialysis therapy. We divided patients into four groups: group 1 (G1) included patients at the study hospital during the 2007-2014 period who had contact only with nephrologists other than F-JY; group 2 (G2) included patients who visited F-JY during the 2007-2014 period before he began using the SNS app; group 3 (G3) included patients who visited nephrologists other than F-JY during the 2014-2017 period and had no interactions using the SNS; and group 4 (G4) included patients who visited F-JY during the 2014-2017 period and interacted with him using the SNS app. RESULTS: We recruited 209 patients with stage 5 CKD who had been enrolled in the study hospital's CKD program between 2007 and 2017. Each of the four groups initiated dialysis at different times. Before adjusting for baseline estimated glomerular filtration rate (eGFR), the G4 patients had a longer time to dialysis (mean 761.7 days, SD 616.2 days) than the other groups (G1: mean 403.6 days, SD 409.4 days, P=.011 for G4 vs G1; G2: 394.8 days, SD 318.8 days, P=.04; G3: 369.1 days, SD 330.8 days, P=.049). After adjusting for baseline eGFR, G4 had a longer duration for each eGFR drop (mean 84.8 days, SD 65.1 days) than the other groups (G1: mean 43.5 days, SD 45.4 days, P=.005; G2: mean 42.5 days, SD 26.5 days, P=.03; G3: mean 3.8.7 days, SD 33.5 days, P=.002). CONCLUSIONS: The use of an SNS app between patients with stage 5 CKD and their physicians can reduce the communication gap between them and create benefits such as prolonging time-to-dialysis initiation. The role of SNSs and associated care models should be further investigated in a larger population.

Association of Constipation with risk of end-stage renal disease in patients with chronic kidney disease.

BACKGROUND: Chronic Kidney Disease (CKD) is a growing public health problem. Many risk factors were identified and interventions were applied accordingly, but the incidence of end-stage renal disease continued increasing. Some other risk factors may be ignored. Gut microbiota has been recognized as an important endogenous organ. The kidney-gut axis would contribute to gut dysbiosis, which might worsen CKD. Constipation, commonly seen in CKD, was one of the clinical presentation of gut dysbiosis. The clinical impact of constipation to CKD remains unknown. Our study aimed at assessing the risk of ESRD between CKD patients with and without constipation in a nationwide database. METHODS: We identified newly diagnosed cases of CKD without constipation history before in 2000-2011 from the Taiwan National Health Insurance database. Subjects who developed constipation later formed constipation group. The others without constipation matched by propensity score formed non-constipation group. The incidence rates and hazards of ESRD in patients with and without constipation by the end of 2013 were compared by using Cox proportional hazard models with a time-dependent variable. RESULTS: The incidences of ESRD per 1000 person-years were 22.9 for constipation group and 12.2 for non-constipation group, respectively. Cox proportional hazard models with a time-dependent variable revealed an adjusted hazard ratio of 1.90 (95% CI, 1.60-2.27). Compared to the CKD patients without constipation, adjusted hazard ratio for the CKD patients with laxatives < 33, 33-197 and ≥ 198 days per year were 0.45 (0.31-0.63), 1.85 (1.47-2.31) and 4.41 (3.61-5.39) respectively. CONCLUSION: In a population of newly-diagnosed CKD patients, we observed that subjects with de novo constipation, as compared with non-constipation, have increased risk of developing ESRD. More severe constipation would increase the risk further.

Leisure time activities as mediating variables in functional disability progression: An application of parallel latent growth curve modeling.

OBJECTIVES: The aims of this study were to investigate (1) whether and (2) the extent to which Taiwanese older adults' leisure time activity (LTA) trajectories mediated the potential association between their sociodemographic factors and their functional disability trajectories. METHODS: Longitudinal data from four waves of the Taiwan Longitudinal Study on Aging (TLSA), collected between 1996 and 2007, were used for analysis (N = 3,429). Parallel-process latent growth curve modeling was adopted to evaluate the process by which LTA mediated between sociodemographic factors (age, gender, education, self-rated health, comorbidities, and depression) and the outcome process of functional disabilities. RESULTS: When mediated by baseline level of LTA, five sociodemographic factors-age, gender, education level, self-rated health, and number of comorbidities-had significant and negative mediating effects on baseline or change in functional disability, thus improving disability outcomes. However, four of the sociodemographic factors (age, education level, and number of comorbidities), when mediated through the rate of change in LTA, were found to have significant and positive mediating effects, which increased disability levels. The proportion of effects mediated by the LTA trajectory ranged from 0% to 194%. DISCUSSION: The large proportion of effects mediated through the LTA process underlines the importance of LTA to public health policy and health programs for older adults. The study's findings shed light on how to better target populations of older adults to promote an active lifestyle and achieve more successful aging in late life in Asian countries.

Effects of perceived autonomy support and basic need satisfaction on quality of life in hemodialysis patients.

PURPOSE: Despite a growing understanding of health-related quality of life (HRQOL) and its determinants in hemodialysis (HD) patients, little is known about the effects and interrelationships concerning the perception of autonomy support and basic need satisfaction of HD patients on their HRQOL. Based on self-determination theory (SDT), this study examines whether HD patients' perceived autonomy support from health care practitioners (physicians and nurses) relates to the satisfaction of HD patients' basic needs and in turn influences their HRQOL. METHODS: A questionnaire was administered to 250 Taiwanese HD patients recruited from multiclinical centers and regional hospitals in northern Taiwan. Structural equation modeling (SEM) analysis was conducted to examine the causal relationships between patient perceptions of autonomy support and HRQOL through basic need satisfaction. RESULTS: The empirical results of SEM indicated that the HD patients' perceived autonomy support increased the satisfaction of their basic needs (autonomy, competency, and relatedness), as expected. The higher degree of basic need satisfaction led to higher HRQOL, as measured by physical and mental component scores. CONCLUSION: Autonomy support from physicians and nurses contributes to improving HD patients' HRQOL through basic need satisfaction. This indicates that staff caring for patients with severe chronic diseases should offer considerable support for patient autonomy.

A nationwide survey of healthcare personnel's attitude, knowledge, and interest toward renal supportive care in Taiwan.

BACKGROUND: Renal supportive care (RSC) is an important option for elderly individuals reaching end-stage renal disease; however, the frequency of RSC practice is very low among Asian countries. We evaluated the attitude, the knowledge, and the preference for specific topics concerning RSC among participants who worked in different medical professions in Taiwan. METHODS: A cross-sectional questionnaire-based survey was employed. Healthcare personnel (N = 598) who were involved in caring for end-stage renal disease patients at more than 40 facilities in Taiwan participated in this study. Participants were asked about their motivation for learning about RSC, the topics of RSC they were most and least interested in, their willingness to provide RSC, and to rate their knowledge and perceived importance of different topics. RESULTS: The vast majority of respondents (81.9%) were self-motivated about RSC, among whom nephrologists (96.8%) and care facilitators (administrators/volunteers) (45%) exhibited the highest and the least motivation, respectively (p < 0.01). Overall, respondents indicated that they had adequate knowledge about the five pre-specified RSC topics between medical professions (p = 0.04). Medical professions and institutional size exerted significant influence on the willingness to provide RSC. CONCLUSIONS: Our results facilitate the understanding of the knowledge and attitude toward different RSC topics among varied medical professions, and can guide the design of RSC education content for healthcare personnel.

Conservative management and health-related quality of life in end-stage renal disease: a systematic review.

PURPOSE: Few studies have addressed health-related quality of life (QoL) in patients who chose conservative management over dialysis. This systematic review aims to better define the role of conservative management in improving health-related QoL in patients with end-stage renal disease (ESRD). METHODS: Medline, Cochrane and EMBASE were searched for prospective or retrospective studies published until June 30, 2016, that examined QoL of ESRD patients. The primary outcome was health-related QoL. RESULTS: Four studies were included (405 patients received dialysis and 332 received conservative management). Two studies that used the Short Form-36 Survey (SF-36) showed that the dialysis group had higher physical component scores, but the conservative management group had similar, or better, mental component scores at the end of intervention. Another study using the SF-36 showed that the physical and mental component scores of the dialysis group did not significantly change after intervention. In the conservative management group, the physical component scores did not change, but the mental component scores increased significantly over time (0.12 ± 0.32, p < 0.05). One study, which used the Kidney Disease Quality of Life-Short Form (KD QoL-SF), found no change after intervention in either physical or mental component scores in the dialysis group; however, the physical component score declined (p = 0.047) and the mental component score increased (p = 0.033) in the conservative management group. CONCLUSION: Although there are only a limited number of published articles, ESRD patients who receive conservative management may have improved mental health-related QoL when compared with those who receive dialysis.

Influence of patient and provider factors on the workload of on-call physicians: A general internal medicine cohort observational study.

Factors associated with the physician workload are scarcely reported. The study aims to investigate the associated factors of on-call physician workload based on a published conceptual framework.The study was conducted in a general internal medicine unit of National Taiwan University Hospital. On-call physician workloads were recorded on a shift basis from 1198 hospitalized patients between May 2010 and April 2011. The proxy of on-call workloads included night calls, bedside evaluation/management (E/M), and performing clinical procedures in a shift. Multivariable logistic and negative binomial regression models were used to determine the factors associated with the workloads of on-call physicians.During the study period, 378 (31.6%) of patients had night calls with related workloads. Multivariate analysis showed that the number of patients with unstable conditions in a shift (odds ratio [OR] 1.89 and 1.66, respectively) and the intensive care unit (ICU) training of the nurse leader (OR 2.87 and 3.08, respectively) resulted in higher likelihood of night calls to and bedside E/M visits by the on-call physician. However, ICU training of nurses (OR = 0.37, 95% confidence interval: 0.16-0.86) decreased the demand of performing clinical procedures by the on-call physician. Moreover, number of patients with unstable conditions (risk ratio [RR] 1.52 and 1.55, respectively) had significantly increased the number of night calls and bedside E/M by on-call physicians by around 50%. Nurses with N1 level (RR 2.16 and 2.71, respectively) were more likely to place night calls and facilitate bedside E/M by the on-call physician compared to nurses with N0 level. In addition, the nurse leaders with ICU training (RR 1.72 and 3.07, respectively) had significant increases in night calls and bedside E/M by the on-call physician compared to those without ICU training.On-call physician workload is associated with patient factors and the training of nurses. Number of unstable patients in a shift may be considered in predicting workload. The training of nurses may improve patient safety and decrease demand for clinical procedure.

Effects of health intervention program on cardiometabolic risk profiles from health evaluation center in Asian population: a longitudinal study and propensity analysis.

BACKGROUND: Health intervention program (HIP) based on diet and lifestyle modifications had been shown to improve cardiovascular risks. The effects of such program on a variety of cardiometabolic outcome measures conducted in a strict analysis remained relatively unexplored. MATERIALS AND METHODS: A total of 2,660 participants (mean age: 43.3 ± 10 years, 63.6% male) underwent annual health survey from our health evaluation department. We implemented health intervention program (HIP) in which diet and lifestyle modifications including smoking cessation and advised physical activities were introduced. We further studied the effects of HIP on several cardiometabolic outcome measures including Framingham, metabolic scores and renal function in terms of Egfr with a mean follow-up period of 38.5 months. Propensity score (PS) matching (HIP vs non-HIP group) was used to avoid effects of case selection bias. RESULTS: Totally 1,004 (502 subjects for each group) left after PS matching protocol (both HIP and non-HIP group). The HIP group showed significant decline of waist circumference (-1.46 ± 0.61, p = 0.016), post-prandial glucose (-6.77 ± 2.06, p = 0.001), and total cholesterol level (-4.42 ± 2.15, p = 0.04), with borderline increase in eGFR (1.72 ± 0.94, p = 0.068) after an average of 1.91 ± 1.14 year follow up period. Exercise behavior significantly increased for those who received HIP when compared to the non-HIP group (44.6 vs 52.4 %, p = 0.014). PS matching and difference-in-difference (DID) analysis further confirmed the beneficial effects of ATP III reduction by HIP (-0.36 ± 0.06, p < 0.05). CONCLUSION: We demonstrated in our study that several cardiometabolic profiles can be substantially improved after health intervention introduction at the health evaluation center, supporting the beneficial evidence of such health intervention programs implementation based on primary prevention view points.

Assessing the impact of budget controls on the prescribing behaviours of physicians treating dialysis-dependent patients.

OBJECTIVES: This study examined whether outpatient haemodialysis providers changed their treatment practices with the establishment of an outpatient dialysis global budget (ODGB) through analysing the outpatient visits and medication received by those patients. METHODS: A sample of 4668 observations (patient year) of 1350 haemodialysis with hypertension (HH) patients and 4668 observations of 1436 non-HH (NHH) patients were drawn from the National Health Insurance Research Database over the years from 1999 to 2005. The impact of ODGB on hypertension-related outpatient utilization of HH was estimated using the difference in difference (DID) method and examined in three stages: (1) the fee for service stage, the pre-ODGB (2000), (2) the phase-in stage (2001-2002) and (3) the post-ODGB stage (2003-2005). RESULTS: ODGB implementation did not affect the number of dialysis visits for HH patients. However, it did lead to a reduction in fees for antihypertension drugs used by haemodialysis facilities. There was an increase of 4.06 visits per patient per year (P < 0.001) in the number of non-dialysis outpatient with antihypertensive drugs visits for HH patients compared with the control group. The total fees for antihypertensive drugs for HH patients increased by New Taiwan Dollars (NT$)13 008 (P < 0.001) per patient per year relative to the control group after the implementation of ODGB. CONCLUSIONS: As ODGB was implemented, HH patients received fewer antihypertensive drugs during their dialysis visit. In addition, there was an increase in the number of non-dialysis outpatient visits by HH patients as well as increased payment in the drugs associated with their non-dialysis outpatient visits compared with the control group.

Patient severity matters for night-shift workload for internal medicine residents in Taiwan.

BACKGROUND: Although work hour is an important factors for resident workload, other contributing factors, such as patient severity, with regards to resident workload have been scarcely studied. METHODS: A prospective observational cohort study was conducted in a general medicine unit in an academic medical center in Taiwan. Every event for which the nurses needed to call the on-call residents was recorded. To quantify the workload, the responses of on-duty residents to calls were analyzed. To allow comparisons of patient factors to be made, we classified all patients by assigning them stable, unstable, or do-not-resuscitate (DNR) codes. The reasons for the calls were categorized to facilitate the comparisons across these three groups. RESULTS: From October 2009 to September 2011, a total of 2,518 patients were admitted to the general medicine unit. The nurses recorded a total of 847 calls from 730 call nights, ranging from 0 to 7 per night. Two peaks of calls, at 0-2 am and 6-7 am, were noted. Calls from stable, unstable, and DNR patients were 442 (52.2%), 95 (11.2%), and 298 (35.2%), respectively. For both unstable and DNR patients, the leading reason was abnormal vital signs (62.1% and 67.1%, respectively), while only 36.2% for stable patients. Both unstable and DNR patients required more bedside evaluation and management compared to stable patients. CONCLUSION: Beyond work hours and patient census, patients with different clinical severity and palliative goal produce different workload for on-call residents.

After-hours physician care for patients with do-not-resuscitate orders: an observational cohort study.

BACKGROUND: Medical care at night for patients with do-not-resuscitate orders and the practice patterns of the on-call residents have rarely been reported. AIM: To evaluate the after-hours physician care for patients with do-not-resuscitate orders in the general medicine ward. DESIGN: Observational study. SETTING/PARTICIPANTS: This study was conducted at an urban, university-affiliated academic medical center in Taiwan. The night shift nurses consecutively recorded every event that required calling the duty residents. Patients with and without a do-not-resuscitate order were compared in demographics, reasons for calling, residents' response, and nurses' satisfaction. A standard report form was established for the nurses to record events. RESULTS: From October 2009 to September 2010, 1379 inpatients contributed to 456 after-hours calls. do-not-resuscitate patients accounted for 256 (18.7%) of all inpatients, and 160 (35.1%) of all after-hours calls. The leading reason for calls was abnormal vital signs, which was significantly higher for patients with do-not-resuscitate orders compared to patients without a do-not-resuscitate order (64.4% vs 36.1%, p < 0.001). The pattern of residents' responses showed a significant difference with more bedside visits for patients with do-not-resuscitate orders (p < 0.001). The nurses were usually satisfied with the residents' management of both groups. CONCLUSION: Abnormal vital sign, rather than symptom, was the leading reason for after-hours calls. The existence of do-not-resuscitate order produced different medical needs and physician workload. Patients with do-not-resuscitate orders accounted for one-third of night calls and nearly half of bedside visits by on-call residents and may require a different care approach.

Application of the balanced scorecard to an academic medical center in Taiwan: the effect of warning systems on improvement of hospital performance.

BACKGROUND: The balanced scorecard (BSC) is considered to be a useful tool for management in a variety of business environments. The purpose of this article is to utilize the experimental data produced by the incorporation and implementation of the BSC in hospitals and to investigate the effects of the BSC red light tracking warning system on performance improvement. METHODS: This research was designed to be a retrospective follow-up study. The linear mixed model was applied for correcting the correlated errors. The data used in this study were secondary data collected by repeated measurements taken between 2004 and 2010 by 67 first-line medical departments of a public academic medical center in Taipei, Taiwan. The linear mixed model of analysis was applied for multilevel analysis. RESULTS: Improvements were observed with various time lags, from the subsequent month to three months after red light warning. During follow-up, the red light warning system more effectively improved controllable costs, infection rates, and the medical records completion rate. This further suggests that follow-up management promotes an enhancing and supportive effect to the red light warning. CONCLUSION: The red light follow-up management of BSC is an effective and efficient tool where improvement depends on ongoing and consistent attention in a continuing effort to better administer medical care and control costs.