A cross-hospital cost and quality assessment system by extracting frequent physician order set from a nationwide Health Insurance Research Database.

PURPOSE: Clinical pathways fall under the process perspective of health care quality. For care providers, clinical pathways can be compared to improve health care quality. The objective of this study was to design a convenient physician order set comparison system based on claim records from the National Health Insurance Research Database (NHIRD) of Taiwan. METHODS: Data were retrieved from the NHIRD for the period of 2003-2007 for frequent physician order sets found in hospital surgical hernia repair inpatient claim records. The derived frequent physician order sets were divided into five frequency thresholds: 80%, 85%, 90%, 95% and 100%. A consistency index was defined and calculated to understand each care providers' adherence to clinical pathways. In addition, the average count of physician orders, average amount of cost, Charlson comorbidity index, and recurrence rate were calculated; these variables were considered in frequent physician order sets comparison. RESULTS: Records for 3262 patients from 257 hospitals were retrieved. The frequent physician order sets of various frequency thresholds, Charlson comorbidities, and recurrence rates were extracted and computed for comparison among hospitals. A recurrence rate threshold of 2% was established to separate low and high quality of herniorrhaphy at each hospital. Univariable analysis showed that low recurrence rate was associated with high consistency index (70.99±23.88 vs. 52.60±20.30; P<.001), few surgeons at each hospital (3.50±4.41 vs. 7.09±6.57; P<.001), and non-medical center facility type (P=.042). A multivariable Cox regression analysis indicated an association of low recurrence rates with consistency index only (one percentage increased: OR=0.973; CI: 0.957-0.990; P=.002). CONCLUSIONS: The proposed system leveraged the claim records to generate frequent physician order sets at hospitals, thus solving the difficulty in obtaining clinical pathway data. This allows medical professionals and management to conveniently and effectively compare and query similarities and differences in clinical pathways among hospitals.

Tablet PC-enabled application intervention for patients with gastric cancer undergoing gastrectomy.

BACKGROUND: Gastric cancer is among the most common gastrointestinal cancers worldwide. Patients who have undergone surgery for gastric cancer may suffer from malnutrition and potential consequences such as gastrointestinal complications, surgical stress, and cancer cachexia. A tablet PC-based intervention via a mobile application might enhance the early recovery of postgastrectomy patients. OBJECTIVE: The aim of this study was to develop and test a tablet personal computer (PC)-assisted intervention to hasten the recovery of postgastrectomy cancer patients with respect to nutritional status. METHODS: This single-arm pilot study investigated a tablet PC application developed to serve the functions of nutritional monitoring, medical information management, drainage follow-up, and wound care. All services were delivered by medical professionals. RESULTS: Twenty consecutive gastrectomy patients at the National Taiwan University Hospital received perioperative care via this application (App group). During the study period, we retrospectively collected an additional 20 demographically matched gastrectomy cases as a control group. The App group had a lower body weight loss percentage relative to the control group during a 6-month follow-up period (4.8±1.2% vs. 8.7±2.4%; p<0.01). However, the patients in the App group had more outpatient clinic (OPC) visits than did those in the control group (9.8±0.9 vs. 5.6±0.8; p<0.01). CONCLUSIONS: This study supported the feasibility of a tablet PC-based application for the perioperative care of gastric cancer subjects to promote a lower body weight loss and the collection of comprehensive surgical records.

Improvement of heart rate variability after decreased insulin resistance after sleeve gastrectomy for morbidly obesity patients.

BACKGROUND: Morbidly obese patients display both an autonomic nervous imbalance and impaired glucose metabolism, and both of these conditions can be partially reversed after bariatric surgery. The aim of the present study was to investigate changes in heart rate variability (HRV) and glucose metabolism in patients after laparoscopic sleeve gastrectomy (SG). METHODS: Eighteen morbidly obese patients who underwent SG were examined before surgery and at 7, 30, 90, and 180 days after surgery. Indices of HRV included time-domain, frequency-domain, and nonlinear parameters. Glucose metabolism was evaluated by the measuring levels of insulin resistance, glycated hemoglobin (HbA(1c)), and gut hormones. RESULTS: The study included 9 men and 9 women with a mean age of 34 years. In the HRV study, the average R-R interval, median R-R interval, standard deviation of the R-R intervals, root mean squared successive difference of the R-R intervals (RMSSD), and the number of pairs of successive normal-to-normal beat intervals that differed by>50 ms significantly increased at 180 days after surgery. Regarding the frequency-domain indices, the low frequency (LF)/high frequency (HF) ratio was more balanced at 90 days after SG compared with baseline, and increases in the total power, LF band, and HF band were observed at 180 days. The assessments of insulin resistance, glucose metabolism, and gut hormones revealed not only improvements in the homeostasis model assessment of insulin resistance and HbA1c levels but also increases in the levels of glucagon-like peptide-1 at 90 and 180 days after surgery compared with baseline. A multivariable regression model revealed significantly negative associations between the perioperative changes in HOMA-IR and changes in both the RMSSD and HF band. CONCLUSIONS: SG leads to early improvements in insulin resistance and glucose metabolism that are followed by improvements in HRV indices. Improvements in insulin resistance were associated with increases in the RMSSD and HF band index, but the mechanism of these changes require further study.

A sharable cloud-based pancreaticoduodenectomy collaborative database for physicians: emphasis on security and clinical rule supporting.

BACKGROUND: Pancreaticoduodenectomy (PD) is a major operation with high complication rate. Thereafter, patients may develop morbidity because of the complex reconstruction and loss of pancreatic parenchyma. A well-designed database is very important to address both the short-term and long-term outcomes after PD. OBJECTIVE: The objective of this research was to build an international PD database implemented with security and clinical rule supporting functions, which made the data-sharing easier and improve the accuracy of data. METHODS: The proposed system is a cloud-based application. To fulfill its requirements, the system comprises four subsystems: a data management subsystem, a clinical rule supporting subsystem, a short message notification subsystem, and an information security subsystem. After completing the surgery, the physicians input the data retrospectively, which are analyzed to study factors associated with post-PD common complications (delayed gastric emptying and pancreatic fistula) to validate the clinical value of this system. RESULTS: Currently, this database contains data from nearly 500 subjects. Five medical centers in Taiwan and two cancer centers in Mongolia are participating in this study. A data mining model of the decision tree analysis showed that elderly patients (>76 years) with pylorus-preserving PD (PPPD) have higher proportion of delayed gastric emptying. About the pancreatic fistula, the data mining model of the decision tree analysis revealed that cases with non-pancreaticogastrostomy (PG) reconstruction - body mass index (BMI)>29.65 or PG reconstruction - BMI>23.7 - non-classic PD have higher proportion of pancreatic fistula after PD. CONCLUSIONS: The proposed system allows medical staff to collect and store clinical data in a cloud, sharing the data with other physicians in a secure manner to achieve collaboration in research.

A physician order category-based clinical guideline comparison system.

Today, in order to provide high-quality medical services and to extend resources and reduce costs, many large hospitals have adopted clinical guidelines as a structured way to manage medical activities. However, customization of clinical guidelines in order to treat a large number of patients is a major challenge. In this paper, we present a physician order category-based clinical guideline comparison system. The system uses a preprocessor software to convert the clinical guidelines from a Microsoft Word document into XML format, and it can also compare clinical guidelines over the conceptual view such as the physician order category. The system has already been used to compare the HCC surgical clinical guidelines of Taiwan and Mongolia-resulting in some differences being found, for which possible causes were discussed. Therefore, it can be seen that our research provides a practical and convenient way in which to compare clinical guidelines based on physician order category-thereby saving time and enabling physicians to quickly resolve discrepancies and make necessary adjustments to clinical guidelines.