Community acquired pneumonia (CAP；pneumonia, organism unspecified) has become highly prevalent in the elderly population which is associated with substantial morbidity and mortality. Several CAP management guidelines have been proposed, and most of the focus has been placed on American Thoracic Society (ATS) CAP guidelines in 1993. The practicality, validity and influence of the guidelines on elderly patients have not been evaluated systemically in Taiwan. Cost-containment handling has been an important goal for hospital administrators and practitioners as well as for health insurance organizations. We have performed a retrospective estimation by assessing the cost under certain aspects linked with the therapeutic intervention of ATS guidelines. This estimation compares the outcomes (such as the patients' length of stay, drug expense, antibiotics expense, number of antibiotics used, total expense, and the daily cost incurred during the hospitalization) of 64 elder inpatients receiving the diagnosis of pneumonia of unknown pathogen (Coded 486 in ICD-9-CM) from one medical center in Taiwan during 1996, whose anti-microbial therapy was either consistent or inconsistent with this very set of guidelines. The results showed, patients whose therapeutic management was consistent with the ATS guidelines had a shorter length of stay (LOS) (13.5 days v.s. 24.1 days, p=.002), cheaper total drug cost (US$823.8 v.s. US$1,901.3, p＜.0001), less antibiotics cost (US$363.10 v.s. US$875.96, p＜.005), and fewer number of parenteral antibiotics (1.19 v.s. 2.56, p=.0001). Notwithstanding, their total hospital expense, and daily cost did not appear to be more favorable (p＞.05; NS). Results suggest that therapeutic intervention of ATS guidelines for treating elder inpatients with pneumonia of unspecified pathogen brings about lower health care expenditure only under certain aspects. In addition to providing the basis for further investigation, this study can also partially offer an important empirical trial for the guidelines as a reasonable and feasible basis in our intervention/treatment for elderly CAP. Moreover, our research findings may become an enlightening reference for clinical practice as well as the reimbursement scheme of National Health Insurance Program in Taiwan.
Abstract The effects of anonymity on utilization review has never been examined in the real world. This study aimed to evaluate the impact of removing anonymity protection for claims reviewers on their review decisions. Using a single-blinded repeated measures design, we randomly selected 1457 claims cases (with 12,237 orders) that had been anonymously reviewed and reimbursed in 2016 and had them re-reviewed in a signed review program in 2017 under the Taiwanese National Health Insurance scheme. The signed review policy significantly decreased the likelihood of a deduction decision at the case and the order level ( P < 0.001). Furthermore, signed reviewers tended to make more “too lenient” decisions, and were less likely to make “too harsh” decisions. Removing anonymity protection dramatically reduced the deduction rate and overturned the tendency of decisions from “too harsh” to “too lenient”. However, whether to maintain the anonymity of utilization reviews is a challenge for health authorities around the globe.
With the promising outcomes of the pre-ESRD (end-stage renal disease) pay-for-performance (P4P) program, the National Health Insurance Administration (NHIA) of Taiwan launched a P4P program for patients with early chronic kidney disease (CKD) in 2011, targeting CKD patients at stages 1, 2, and 3a. This study aimed to examine the long-term effect of the early-CKD P4P program on CKD progression.We conducted a matched cohort study using electronic medical records from a large healthcare delivery system in Taiwan. The outcome of interest was CKD progression to estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2 between P4P program enrolees and non-enrolees. The difference in the cumulative incidence of CKD progression between the P4P and non-P4P groups was tested using Gray's test. We adopted a cause-specific (CS) hazard model to estimate the hazard in the P4P group as compared to non-P4P group, adjusting for age, sex, baseline renal function, and comorbidities. A subgroup analysis was further performed in CKD patients with diabetes to evaluate the interactive effects between the early-CKD P4P and diabetes P4P programs.The incidence per 100 person-months of disease progression was significantly lower in the P4P group than in the non-P4P group (0.44 vs. 0.69, P<.0001), and the CS hazard ratio (CS-HR) for P4P program enrolees compared with non-enrolees was 0.61 (95% CI: 0.58-0.64, P<.0001). The results of the subgroup analysis further revealed an additive effect of the diabetes P4P program on CKD progression; compared to none of both P4P enrolees, the CS-HR for CKD disease progression was 0.60 (95% CI: 0.54-0.67, P<.0001) for patients who were enrolled in both early-CKD P4P and diabetes P4P programs.The present study results suggest that the early-CKD P4P program is superior to usual care to decelerate CKD progression in patients with early-stage CKD.
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.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.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.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.
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