Perceptions of Chinese hospital leaders on joint commission international accreditation: a qualitative study.

Background: Joint Commission International (JCI) accreditation plays a significant role in improving the quality of care and patient safety worldwide. Hospital leadership is critical in making international accreditation happen with successful implementation. Little is known about how Chinese hospital leaders experienced and perceived the impact of JCI accreditation. This paper is the first study to explore the perceptions of hospital leaders toward JCI accreditation in China. Methods: Qualitative semi-structured interviews were used to explore the perceptions of the chief operating officers, the chief medical officers, and the chief quality officers in five JCI-accredited hospitals in China. Thematic analysis was used to analyze the interview transcripts and identify the main themes. Results: Fifteen hospital leaders participated in the interviews. Three themes emerged from the analysis, namely the motivations, challenges, and benefits related to pursuing and implementing JCI accreditation. The qualitative study found that eight factors influenced hospital leadership to pursue JCI accreditation, five challenges were identified with implementing JCI standards, and eight benefits emerged from the leadership perspective. Conclusion: Pursuing JCI accreditation is a discretionary decision by the hospital leadership. Participants were motivated by prevalent perceptions that JCI requirements would be used as a management tool to improve the quality of care and patient safety in their hospitals. These same organizational leaders identified challenges associated with implementing and sustaining JCI accreditation. The significant challenges were a clear understanding of the foreign accreditation standards, making staff actively participate in JCI processes, and changing staff behaviors accordingly. The top 5 perceived benefits to JCI accreditation from the leaders' perspective were improved leadership and hospital safety, improvements in the care processes, and the quality of care and the learning culture improved. Other perceived benefits include enhanced reputation, better cost containment, and a sense of pride in the staff in JCI-accredited hospitals.

Organisational Culture Research in Healthcare: A Big Data Bibliometric Study.

Across international healthcare, organisational culture and work environment have become central to all patient safety. However, there is a lack of comprehensive overview to assess and track the evolution of the literature on organisational culture in healthcare. This study aims to describe the current situation and global trends in organisational culture research in healthcare. The methodology is based on bibliometric mapping using scientific visualisation software (CiteSpace and VOSviewer). The big data were collected from the Web of Science core citation database. After applying the search criteria, we retrieved 1559 publications, which have steadily increased over the last two decades. In addition, 92 countries and regions have published studies on organisational culture in healthcare. The United States has made significant contributions to this field. In particular, organisational culture occupies an important position in the quality management of different types of care and caregiving. At the same time, organisational culture in healthcare may be inadequately researched in terms of theoretical underpinnings, which in turn leads to a lack of widespread dissemination of practice, and research on organisational culture in healthcare through evidence-based medicine may remain a significant focus and hot topic throughout the research field in the coming years.

Exploring human resource management in the top five global hospitals: a comparative study.

Background: The pivotal role of Human Resource Management (HRM) in hospital administration has been acknowledged in research, yet the examination of HRM practices in the world's premier hospitals has been scant. Objective: This study explored how the world's leading hospitals attain operational efficiency by optimizing human resource allocation and melding development strategies into their HRM frameworks. A comparative analysis of the HRM frameworks in the top five global hospitals was undertaken to offer a reference model for other hospitals. Methods: This research offers a comparative exploration of the HRM frameworks utilized by the top five hospitals globally, underscoring both shared and distinct elements. Using a multi-case study methodology, the research scrutinized each hospital's HRM framework across six modules, drawing literature from publicly accessible sources, including websites, annual reports, and pertinent English-language scholarly literature from platforms such as Google Scholar, PubMed, Medline, and Web of Science. Results: The analyzed hospitals exhibited inconsistent HRM frameworks, yet all manifested potent organizational cultural attributes and maintained robust employee training and welfare policies. The design of the HR systems was strategically aligned with the hospitals' objectives, and the study established that maintaining a sustainable talent system is pivotal to achieving hospital excellence. Conclusion: The HRM frameworks of the five analyzed hospitals align with their developmental strategies and exhibit unique organizational cultural attributes. All five hospitals heavily prioritize aligning employee development with overall hospital growth and place a spotlight on fostering a healthy working environment and nurturing employees' sense of achievement. While compensation is a notable performance influencer, it is not rigorously tied to workload in these hospitals, with employees receiving mid-to-upper industry-range compensation. Performance assessment criteria focus on job quality and aligning employee actions with organizational values. Comprehensive welfare and protection are afforded to employees across all five hospitals.

Time trends and associated factors of global burden due to drug use disorders in 204 countries and territories, 1990-2019.

BACKGROUND: Drug use disorders (DUDs) have been a public health crisis which strongly impacted community health and socio-economic development. However, there are few studies based on the latest global data to show changes in the disease burden due to DUDs, specifically investigating associations between the country-level socio-economic factors and the burden of DUDs. METHODS: Data of DUDs were extracted from the Global Burden of Disease Study 2019 database to explore the trends of the disease burden due to DUDs from 1990 to 2019. Univariate linear regression and stepwise multiple linear regression analysis were performed to analyze the correlations between burden due to DUDs and country-level socio-economic factors. RESULTS: Globally, the number of disability-adjusted life-years (DALYs) caused by DUDs approximately increased by 2.6% yearly from 1990 to 2019, though the age-standardized DALY rate has not changed significantly in the past 30 years. The age-standardized DALY rate of opioid use disorders showed an upward trend during the past 30 years and was highest among 5 types of DUDs in 2019. Inequality-adjusted human development index (ß = 15.9, 95% confidence interval [CI]: 12.9-18.9, P < 0.001) was identified as the key risk factor associated with square-root transformed age-standardized DALY rate of DUDs. CONCLUSIONS: Global burden due to DUDs has increased significantly over the past 30 years. More effective targeted public health policies should be formulated to manage the public health challenge of DUDs, especially in developed countries and territories.

Study of Hospitalization Costs in Patients with Cerebral Ischemia Based on E-CHAID Algorithm.

Background: The aging of the population has led to a rapid increase in the prevalence of most neurological diseases between 1990 and 2016, with a growth rate of up to 117%, which has put enormous pressure on medical insurance funds. As one of the core diseases of disease diagnosis grouping, the hospitalization cost composition and grouping research of patients with cerebral ischemic disease can help to determine scientific payment standards and reduce the economic burden of patients. Aim: We aimed to understand the cost composition and influencing factors of hospitalized patients with cerebral ischemic diseases and to identify a reasonable cost grouping scheme. Methods: The data come from the homepage of medical records of inpatients with cerebral ischemia in a tertiary hospital in Sichuan Province from 2018 to 2020. After cleaning the data, a total of 5,204 pieces of data were obtained. Nonparametric tests and gamma regression models were used to explore the influencing factors of hospitalization costs. Taking the influencing factors as the predictor variables and the hospitalization cost as the target variable, the exhaustive Chi-squared automatic interaction detector (E-CHAID) algorithm was used to form the costs grouping, and the payment standard of the hospitalization cost for each group was determined. The rationality of cost grouping was evaluated by coefficient of variation (CV) and Kruskal-Wallis H test. Results: From 2018 to 2020, the average hospital stay of 5,204 inpatients with cerebral ischemic disease was 10.70 days, and the average hospitalization cost was 17,206.09 RMB yuan. Among the hospitalization costs, diagnosis costs and drug costs accounted for the highest proportion, accounting for 41.18% and 22.38%, respectively, in 2020. Gender, age, admission route, comorbidities and complications, super length of stay (>30 days), and discharge mode had significant effects on hospitalization costs (P < 0.05). Patients were divided into 10 cost groups, and the grouping nodes included comorbidities and complications, discharge mode, age, gender, and admission route. The CV of 9 of the 10 cost groups is less than or equal to 1. The Kruskal-Wallis H test showed that the difference between groups was statistically significant (P < 0.05). Conclusion: The cost grouping of patients with cerebral ischemic diseases based on the E-CHAID algorithm is reasonable. This study examined the effects of super length of stay (>30 days), comorbidities and complications, and age on hospitalization cost in patients with cerebral ischemic disease. This study can provide a theoretical basis for advancing the China Healthcare Security Diagnosis Related Groups (CHS-DRG) grouping program and medical expense payment, thereby reducing the disease burden of patients.

Advanced Medication Alert System Decreased Hospital-Based Outpatient Duplicated Medications: A Longitudinal Hospital Cohort Study.

OBJECTIVES: This study aimed to examine the associations between adoption of an advanced medication alert system and decreases in hospital-based outpatient duplicated medication rates in Taiwan. METHODS: The unit of analysis was the hospital. We merged the hospital medication alert system adoption survey data and Taiwan National Health Insurance outpatient claims data. The observation time was 1998 to 2011, divided into 5 periods (T1-T5). The analysis included 216 hospitals, and outcome variable was hospital-based outpatient duplicated medication rates. The system adoption time frame, hospital accreditation level, and number of drugs per prescription were defined as predicted variables. A generalized estimating equation regression model was used. RESULTS: Adoption of the advanced medication alert system gradually increased, such that 100% of medical centers and 84% of regional hospitals, but less than 50% of district hospitals, had systems by T5. The hospital-based outpatient duplicated medication rate continually decreased, from 29.8% to 11.2%. The generalized estimating equation model showed rates of duplicated medications of b = -8.44 at T2 and b = -17.88 at T5 (P < 0.001) compared with T1. Medical centers and regional hospitals demonstrated much lower duplication rates (b = -13.71, b = -6.82; P < 0.001) compared with district hospitals. Hospitals with more medications per prescription had higher duplication rates than did hospitals with fewer items. CONCLUSIONS: Hospitals accredited at higher levels tended to have advanced medication alert systems. Hospitals that implemented advanced systems decreased hospital-based outpatient duplicated medications, avoiding a potential risk due to inappropriate medication use.

Disease Burden of Chronic Kidney Disease Due to Hypertension From 1990 to 2019: A Global Analysis.

Background: Although it is widely known that hypertension is an important cause of chronic kidney disease (CKD), little detailed quantitative research exists on the burden of CKD due to hypertension. Objective: The objective of the study is to estimate the global disease burden of CKD due to hypertension and to evaluate the association between the socioeconomic factors and country-level disease burden of CKD due to hypertension. Methods: We extracted the disability-adjusted life-year (DALY) numbers, rates, and age-standardized rates of CKD due to hypertension from the Global Burden of Disease Study 2019 database to investigate the time trends of the burden of CKD due to hypertension from 1990 to 2019. Stepwise multiple linear regression analysis was performed to evaluate the correlations between the age-standardized DALY rate and socioeconomic factors and other related factors obtained from open databases. Results: Globally, from 1990 to 2019, DALY numbers caused by CKD due to hypertension increased by 125.2% [95% confidential interval (CI), 124.6 to 125.7%]. The DALY rate increased by 55.7% (55.3 to 56.0%) to 128.8 (110.9 to 149.2) per 100,000 population, while the age-standardized DALYs per 100,000 population increased by 10.9% (10.3 to 11.5%). In general, males and elderly people tended to have a higher disease burden. The distribution disparity in the burden of CKD due to hypertension varies greatly among countries. In the stepwise multiple linear regression model, inequality-adjusted human development index (IHDI) [ß = -161.1 (95% CI -238.1 to -84.2), P < 0.001] and number of physicians per 10,000 people [ß = -2.91 (95% CI -4.02 to -1.80), P < 0.001] were significantly negatively correlated with age-standardized DALY rate when adjusted for IHDI, health access and quality (HAQ), number of physicians per 10,000 people, and population with at least some secondary education. Conclusion: Improving the average achievements and equality of distribution in health, education, and income, as well as increasing the number of physicians per 10,000 people could help to reduce the burden of CKD due to hypertension. These findings may provide relevant information toward efforts to optimize health policies aimed at reducing the burden of CKD due to hypertension.

Impact of Multidisciplinary Stroke Post-Acute Care on Cost and Functional Status: A Prospective Study Based on Propensity Score Matching.

Few papers discuss how the economic burden of patients with stroke receiving rehabilitation courses is related to post-acute care (PAC) programs. This is the first study to explore the economic burden of stroke patients receiving PAC rehabilitation and to evaluate the impact of multidisciplinary PAC programs on cost and functional status simultaneously. A total of 910 patients with stroke between March 2014 and October 2018 were separated into a PAC group (at two medical centers) and a non-PAC group (at three regional hospitals and one district hospital) by using propensity score matching (1:1). A cost-illness approach was employed to identify the cost categories for analysis in this study according to various perspectives. Total direct medical cost in the per-diem-based PAC cohort was statistically lower than that in the fee-for-service-based non-PAC cohort (p < 0.001) and annual per-patient economic burden of stroke patients receiving PAC rehabilitation is approximately US $354.3 million (in 2019, NT $30.5 = US $1). Additionally, the PAC cohort had statistical improvement in functional status vis-à-vis the non-PAC cohort and total score of each functional status before rehabilitation and was also statistically significant with its total score after one-year rehabilitation training (p < 0.001). Early stroke rehabilitation is important for restoring health, confidence, and safe-care abilities in these patients. Compared to the current stroke rehabilitation system, PAC rehabilitation shortened the waiting time for transfer to the rehabilitation ward and it was indicated as an efficient policy for treatment of stroke in saving medical cost and improving functional status.

Development and validation of an instrument in job evaluation factors of physicians in public hospitals in Beijing, China.

BACKGROUND: Job evaluation has been widely used to establish a foundation for internal equity and other human resource functions. The United Kingdom adopts the National Health Service (NHS) Job Evaluation scheme to determine the pay bands for most NHS staff and ensure equal pay for work of equal value. The challenges of recruiting and retaining physicians in Chinese public hospitals have heightened the need for a reliable job evaluation system to ensure the equality of physician compensation. The aim of this study was to construct job evaluation factors of physicians in Chinese public hospitals based on the NHS Job Evaluation scheme and to examine the reliability and validity of the established system. METHODS: Questionnaire surveys and statistical analyses were used to determine the job evaluation factors for physicians. The preliminary screening of the evaluation factors was based on a literature review, focused interviews with physicians and the Delphi method. Based on the results of preliminary screening, a questionnaire with 25 factors was designed to survey physicians regarding the importance of each factor in physician job evaluation. After the pretest, final questionnaire data were collected from 900 physicians by adopting a stratified sampling from 6 tertiary public hospitals in Beijing. A principal component analysis was used for factor extraction and structural validity analysis. The reliability was determined using Cronbach's alpha. RESULTS: The results of the principal component analysis showed that the 25 physician job evaluation factors were grouped into the 5 dimensions of Task Characteristics, Knowledge, Responsibility, Effort/Environment, and Skills. The Cronbach's alpha coefficients of the five dimensions ranged from 0.841 to 0.909, which indicated a high level of reliability. The result of the factor analysis indicated fair structural validity. The content validity was established by building onto the NHS Job Evaluation scheme and other well-established job evaluation systems. CONCLUSIONS: Our study indicates that the Chinese version of physician job evaluation is an instrument with fair reliability and validity, which fully reflects the characteristics of physicians in Chinese public hospitals. This system can provide an important basis for developing a physician compensation plan and ensuring internal equity in healthcare organizations.

Cost-effectiveness of stereotactic vacuum-assisted biopsy for nonpalpable breast lesions.

PURPOSE: To examine the potential cost-savings of stereotactic vacuum-assisted biopsy (SVAB) over open surgical biopsy (OSB) in diagnosis of nonpalpable lesions on mammography and to estimate the cost-saving effect on lesions at different levels of malignant probability. METHODS: This retrospective study was approved by our Institutional Review Board. We retrospectively reviewed 276 (33.8 %) SVAB and 541 (66.2 %) OSB medical records at a medical center. Direct costs included patients' self-paid and national health insurance claim charges. Indirect costs were calculated using sick days, average salary, and age-adjusted employment rate. One-way and two-way sensitivity analyses were conducted. Lesion classification was determined by the assessment categories of Breast Imaging Reporting and Data System (BI-RADS), 4th or 5th editions. RESULTS: SVAB decreased the direct cost by $90.3 (10.1 %) per diagnosis. The indirect cost was decreased by $560.2 (96.0 %). Overall, SVAB saved 43.9 % of resource utilization for each biopsy. Taking the cost of the subsequent malignant surgery into account, from the healthcare providers' perspective, SVAB was cost-effective if a lesion had less than 19 % likelihood of malignancy. From the societal perspective, SVAB reduced productivity loss for all the lesions. Based on the positive predictive value of the BI-RADS categories, SVAB was more suitable for the lesions of category 4A and category 3, resulting in greater savings in both medical and societal resources. CONCLUSIONS: SVAB is a cost-effective diagnostic option for nonpalpable breast lesions. The cost-saving effect is greater for the lesions of category 4A and category 3.

Frailty is Associated with an Increased Risk of Major Adverse Outcomes in Elderly Patients Following Surgical Treatment of Hip Fracture.

We intended to explore the effect of level of frailty on, and relationship with, 1-, 3-, and 6-month postoperative emergency department visits, readmissions, and mortality. This is a prospective multicenter observational cohort study design. Patients aged 50 years or older treated for hip fracture (n = 245) were taken from Orthopedic wards in one medical center (n = 131) and one district hospital (n = 114) in Changhua County, Taiwan. Frailty was defined as measured by the validated Clinical Frailty Scale and categorized as robust, pre-frail, and frail. We used Kaplan-Meier analysis to estimate survival rates and Cox regression to estimate the risk of frailty associated with adverse outcomes. To examine the longitudinal associations between frailty and adverse outcome, the cross-lagged models were explored. Of the 245 patients, 55 (22.4%) were classified as frail, 113 (46.1%) as pre-frail, and 77 (31.4%) as robust. More cumulative events occurred for frail than for robust patients for each adverse outcome. Frailty has long-term effect on each adverse outcome after discharge, rather than the effect simultaneously. Targeting pre-frailty and frailty is essential for prevent adverse outcomes and improving the overall health of older adults after discharge for hip fracture.

Impact of orthogeriatric care, comorbidity, and complication on 1-year mortality in surgical hip fracture patients: An observational study.

After acute hip surgery, the 1-year mortality rate is high. Therefore, this study evaluated the risk factors for 1-year mortality. The purposes of this study was first to examine the effect of integrated care on 1-year mortality in surgical patients and secondly to explore magnitude of comorbidity and complication on mortality.This retrospective cohort study included 313 patients received surgery for hip fragility fracture. Patients with multiple fractures or combined trauma were excluded. The patients were grouping into integrated (n = 106) and non-integrated care group (n = 207) models. Univariate and multiple Cox regression were used to examine effect of care model, comorbidity, and complication event.One-year mortality in integrated and non-integrated patients was 4.7% and 14.0% respectively. After adjustments, patients in non-integrated care, have 2.89 times (95% confidence interval [CI] 1.07-7.81) likely to die 1-year after discharged.Patients had elevated comorbidity or postoperative complications contributed to the mortality. Our study found the effect of patients treated by integrated care models, compared with usual model, significantly reduced 1-year mortality rate. Appropriated treatment of comorbidities during hospitalization and after discharge is critical to post-surgical survival. The findings imply that the co-care for hip fracture of hip surgical patients with orthogeriatricians is strongly recommended, particularly for those with >3 comorbidities.

Accuracy and outcomes of stereotactic vacuum-assisted breast biopsy for diagnosis and management of nonpalpable breast lesions.

Stereotactic vacuum-assisted biopsy (SVAB) is an alternative method of breast biopsy for nonpalpable lesions detected by mammography. Considering the diagnostic effectiveness, a direct comparison of SVAB and open surgical biopsy (OSB) is lacking. We performed a retrospective review of 276 (33.8%) SVAB and 541 (66.2%) OSB to compare the diagnostic accuracy and the total number of procedures the patients underwent. The negative predictive values of OSB and SVAB were 99.77% and 99.61%, and their false-negative rates were 0.96% and 4.76%, respectively. SVAB, as the first-line biopsy method, obviated 92.3% of operations. All malignancies diagnosed using SVAB could be treated with single therapeutic surgery. By contrast, 48% of malignancies of OSB group received two operations. Breast Imaging Reporting and Data System (BI-RADS) category used at the study correlated well with the percentage of malignancy and can thus be used to predict biopsy results. Our study concluded that SVAB is reliable for diagnosing nonpalpable breast lesions and is the better biopsy method for categories 3 and 4A lesions, which reduces the benign surgery rate. For lesions with a higher likelihood of malignancy, BI-RADS 4B, 4C and 5, SVAB has an advantage over OSB, which lowers the total number of operations for malignancy treatment.

Cost-effectiveness of mini-laparotomy in patients with colorectal cancers: A propensity scoring matching approach.

OBJECTIVE: Surgical technique process innovations are expected to generally incur no additional cost but gain better quality. Whether a mini-laparotomy surgery (MLS) in the treatment of colorectal cancer (CRC) is more cost effective than conventional open surgery had not been well examined. The objective of this study was to apply cost-effectiveness approaches to investigate the cost effectiveness of adopting MLS compared with open surgery 1 year following resection in CRC patients. RESEARCH DESIGN: A prospective non-randomized cohort study design. SETTING: An academic medical center. PARTICIPANTS: A total of 224 patients who received elective MLS and 339 who received conventional surgery; after propensity score matching, 212 pairs were included for analysis. INTERVENTION: None. MAIN OUTCOME MEASURES: Cost measures were hospital-index cost and outpatient and inpatient costs within 1 year after discharge. Effectiveness measures were life-years (LYs) gained and quality-adjusted life-year (QALYs) gained. STATISTICAL METHODS: We calculated incremental costs and effectiveness by differences in these values between MLS and conventional surgery using adjusted predicted estimates. RESULTS: MLS patients had lower rates of blood transfusions, less complication, and shorter post-surgical lengths of stay and more medical cost savings. One-year overall medical costs for MLS patients were TWD 748,269 (USD 24,942) per QALY gained, significant lower than for the comparison group (p-value = 0.045). CONCLUSION: Our findings supported that the less invasive surgical process through MLS not only saved medical costs, but also increased QALYs for surgical treatment in CRC patients.

Dose-Dependent Relationship Between Metformin and Colorectal Cancer Occurrence Among Patients with Type 2 Diabetes-A Nationwide Cohort Study.

BACKGROUND: Increasing bodies of evidence suggest that metformin may be beneficial in the primary prevention of colorectal cancer (CRC), and a dose-response relationship has been reported. However, long-term epidemiological observations between the treatment period, cumulative dose, and intensity of metformin and CRC are rarely reported. The aim of this study was to identify the association between the effect of metformin and CRC development in a nationwide cohort study. METHODS: This nationwide population-based study examined a cohort of 1,000,000 patients randomly sampled from individuals enrolled in the Taiwan National Health Insurance system. Patients with newly diagnosed type 2 diabetes mellitus (DM) between 1997 and 2007 were enrolled. A statistical variables, including the demographic data, treatment period, cumulative dose, and intensity of metformin use, was compared between patients developing CRC and those without CRC. RESULTS: This study included 47,597 patients. The mean follow-time was 7.17 ± 3.21 years. After adjustment, metformin use was an independent protective factor against CRC development (P < .001). Although the protective ability of metformin against CRC development was reduced during long-term therapy, the risk of CRC decreased progressively with a higher cumulative dose or higher intensity of metformin use (both P < .001). CONCLUSION: This study revealed that metformin use significantly reduced the risk of CRC in a dose-dependent manner in patients with type 2 DM in the Taiwanese population. However, a gradual decline in medication adherence may reduce the protective ability of metformin against CRC development during long-term therapy.

Impact of non-apnea sleep disorders on diabetic control and metabolic outcome - A population-based cohort study.

OBJECTIVE: There has been a growing recognition that obstructive sleep apnea (OSA) could increase the propensity for type 2 diabetes the metabolic syndrome. However, studies concerning about the impact of non-apnea sleep disorders (NSD) on diabetes control and metabolic outcomes are relatively scarce. Our aim is to investigate the impact of non-apnea sleep disorders (NSD) on diabetic control and associated metabolic outcomes in patients with type 2 diabetes. METHODS: The data were obtained from two nationwide population-based databases for a period 2007 to 2012. A total 66,992 patients with type 2 diabetes were enrolled and divided into two cohorts based on comorbidity with or without a NSD diagnosis, and were followed up four years. The primary outcomes were to compare rate of change in HbA1c and associated metabolic outcomes during follow-up visits between patients with or without NSD. The secondary outcome is to examine whether NSD were associated with poor glycemic control of the last clinical records while controlling for the baseline HbA1c value. RESULTS: Of the 66,992 patients with type 2 diabetes, 14.82% had comorbidity with a NSD. HbA1C decreases were significantly lower by 0.04% in the NSD group (P < 0.05), and triglyceride (TG) decreases remained significantly lower by 2.53% in the NSD group (P < 0.05). Furthermore, patients in the NSD group had an 8% higher risk of poor glycemic control (HbA1C >9) (OR = 1.08; 95%CI, 1.01-1.16). CONCLUSION: Our findings indicated patients with type 2 diabetes comorbid with NSD had a slower improvement in HbA1c compared with the comparison cohort. It may because there may exist potential floor effect given those with NSD having significantly lower HbA1c values at baseline. On the other hand, the poor diabetic control among those with NSD may be also affected by other confounders such as medical treatment or interventions. Nevertheless, given the rapidly increasing prevalence of metabolic diseases and subsequent complications, the results may highlight the importance of sleep in the clinical management of type 2 diabetes.

Short- and long-term outcomes of laparoscopic-assisted surgery, mini-laparotomy and conventional laparotomy in patients with Stage I-III colorectal cancer.

BACKGROUND: Three operative techniques have been used for colorectal cancer (CRC) resection: Conventional laparotomy (CL) and the mini-invasive techniques (MITs)- laparoscopic-assisted surgery (LAS) and mini-laparotomy (ML). The aim of the study was to compare the short- and long-term outcomes of patients undergoing the three surgical approaches for Stage I-III CRC resection. PATIENTS AND METHODS: This study enrolled 688 patients with Stage I-III CRC undergoing curative resection. The primary endpoints were perioperative quality and outcomes. The secondary endpoints were oncological outcomes including disease-free survival (DFS), overall survival (OS) and local recurrence (LR). RESULTS: Patients undergoing LAS had significantly less blood loss (P < 0.001), earlier first flatus (P = 0.002) and earlier resumption of normal diet (P = 0.025). Although post-operative complication rates were remarkably higher in patients undergoing CL than in those undergoing MITs (P = 0.002), no difference was observed in the post-operative mortality rate (P = 0.099) or 60-day re-intervention rate (P = 0.062). The quality of operation as assessed by the number of lymph nodes harvested and rates of R0 resection did not differ among the groups (all P > 0.05). During a median follow-up of 5.42 years, no significant difference was observed among the treatment groups in the rates of 3-year late morbidity, 3-year LR, 5-year LR, 5-year OS or 5-year DFS (all P > 0.05). CONCLUSIONS: Patients undergoing CL had higher post-operative morbidities. Moreover, the study findings confirm the favourable short-term and comparable long-term outcomes of LAS and ML for curative CRC resection. Therefore, both MITs may be feasible and safe alternatives to CL for Stage I-III CRC resection.

Health Care Utilization and Expenditures of Patients with Diabetes Comorbid with Depression Disorder: A National Population-Based Cohort Study.

OBJECTIVE: The study investigated to compare health care utilization and expenditures between diabetic patients with and without depression in Taiwan. METHODS: Health care utilization and expenditure among diabetic patients with and without depression disorder during 2000 and 2004 were examined using Taiwan's population-based National Health Insurance claims database. Health care utilization included outpatient visits and the use of inpatient services, and health expenditures were outpatient, inpatient, and total medical expenditures. Moreover, general estimation equation models were used for analyzing the factors associated with outpatient visits and expenditures. Multiple logistic regression analysis was applied for identifying the factors associated with hospitalization. RESULTS: The average annual outpatient visits and annual total medical expenditures in the study period were 44.23-52.20; NT$87,496-133,077 and 30.75-32.92; NT$64,411-80,955 for diabetic patients with and without depression. After adjustment for covariates, our results revealed that gender and complication were associated with out-patient visits. Moreover, the time factor was associated with the total medical expenditure, and residential urbanization and complication factors were associated with hospitalization. CONCLUSION: Health care utilization and expenditures for diabetic patients with depression were significantly higher than those without depression. Sex, complications, time, and urbanization are the factors associated with health care utilization and expenditures.

A Diabetes Pay-for-Performance Program and Risks of Cancer Incidence and Death in Patients With Type 2 Diabetes in Taiwan.

INTRODUCTION: We sought to evaluate the effects of diabetes disease management through a diabetes pay-for-performance (P4P) program in Taiwan on risks of incident cancer and mortality among patients with type 2 diabetes. METHODS: We conducted a longitudinal observational cohort study using 3 population-based databases in Taiwan. Using propensity score matching, we compared patients with type 2 diabetes who enrolled in a P4P program with a similar group of patients who did not enroll in the in P4P program (non-P4P). Primary end points of interest were risks of incident cancer and all-cause, cancer-specific, and diabetes-related mortality. Total person-years and incidence and mortality rates per 1,000 person-years were calculated. Multivariable Cox proportional hazard models and competing risk regression were used in the analysis. RESULTS: Overall, our findings indicated that the diabetes P4P program was not significantly associated with lower risks of cancer incidence, but it was associated with lower risks of all-cause mortality (adjusted subdistribution hazard ratio [aSHR], 0.59; 95% confidence interval [CI], 0.55-0.63), cancer-specific mortality (aSHR, 0.85; 95% CI, 0.73-1.00), and diabetes-related mortality (aSHR, 0.54: 95% CI, 0.49-0.60). Metformin, thiazolidinediones, and α glucosidase inhibitors were associated with lower risks of cancer incidence and cancer-specific mortality. CONCLUSION: Our findings provide evidence of the potential benefit of diabetes P4P programs in reducing risks of all-cause mortality and competing causes of death attributable to cancer-specific and diabetes-related mortality among type 2 diabetes patients.

A diabetes pay-for-performance program and the competing causes of death among cancer survivors with type 2 diabetes in Taiwan.

OBJECTIVE: To examine associations between a diabetes pay-for-performance (P4P) program in Taiwan and all-cause of mortality and competing causes of death in cancer survivors with type 2 diabetes. DESIGN: A longitudinal observational intervention and comparison group study design. SETTING AND PARTICIPANTS: Cancer survivors with type 2 diabetes who enrolled in the P4P program compared with survivors who did not participate (non-P4P) under the Taiwan National Health Insurance program. INTERVENTION(S): A nationwide diabetes P4P program. MAIN OUTCOME MEASURES: The main outcome was a comparison of all-cause, diabetes-related and cancer mortality in P4P and non-P4P patients during a 5-year follow-up period. Total person-years and mortality rates per 1000 person-years for causes of death were calculated. Multivariate Cox proportional hazard models and competing risk regression were used in the analysis. RESULTS: Overall, our results indicate that P4P cancer survivors had lower risk of all-cause mortality and diabetes-related mortality than non-P4P survivors. Specifically, the hazard ratio (95% confidence interval) was 0.581 (0.447-0.756) for all-cause mortality; SHRs were 0.451 (0.266-0.765) for diabetes-related mortality and 0.791 (0.558-1.121) for cancer mortality. CONCLUSIONS: Our empirical findings provide evidence of potential benefits of diabetes P4P programs in reducing risks of deaths due to diabetes or cardiovascular diseases among cancer survivors, compared with survivors who did not enroll in the P4P program. In consideration of recommended care for long-term survival, the diabetes P4P program can serve as a care model for cancer survivors for reducing mortality due to diabetes or cardiovascular diseases.