Trends in proportions of hospitals and operators not meeting minimum percutaneous coronary intervention volume standards in Taiwan, 2001-2013.

OBJECTIVE: To examine trends in proportions of hospitals and operators not meeting the minimum percutaneous coronary intervention (PCI) volume standards in Taiwan during 2001-2013. BACKGROUND: The 2013 Clinical Competence Statement recommends that operators perform a minimum of ≥50 PCIs annually (averaged over a 2-year period) in hospitals conducting ≥200 PCIs annually. METHODS: Taiwan National Health Insurance claims data from 2001 to 2013 are used to determine the annual numbers of PCIs performed by each hospital and operator. RESULTS: The percentage of hospitals conducting annual PCI volumes of <200 decreased from 57% (26/46) in 2001 to 39% (29/74) in 2007 and 33% (33/91) in 2013; the percentage of operators conducting PCI volumes <50 annually remained relatively constant at 60% (146/243) in 2001, 60% (270/452) in 2007, and 58% (354/611) in 2013; and the percentage of operators conducting low volumes (<50) in low-volume hospitals (<200) decreased from 24% (57/243) in 2001 to 15% (66/452) in 2007 and 12% (76/611) in 2013. CONCLUSIONS: Approximately one-third of hospitals and three-fifths of operators in Taiwan failed to meet minimum PCI volume standards. Further research examining patient outcomes from PCIs performed by low-volume hospitals and operators is recommended.

When high-volume PCI operators in high-volume hospitals move to lower volume hospitals-Do they still maintain high volume and quality of outcomes?

OBJECTIVES: The aim of this quasi-experimental study was to examine whether high-volume percutaneous coronary intervention (PCI) operators still maintain high volume and quality of outcomes when they moved to lower volume hospitals. BACKGROUND: Systematic reviews have indicated that high-volume PCI operators and hospitals have higher quality outcomes. However, little is known on whether high PCI volume and high quality outcomes are mainly due to operator characteristics (i.e., skill and experience) and is portable across organizations or whether it is due to hospital characteristics (i.e., equipment, team, and management system) and is less portable. METHODS: We used Taiwan National Health Insurance claims data 2000-2012 to identify 98 high-volume PCI operators, 10 of whom moved from one hospital to another during the study period. We compared the PCI volume, risk-adjusted mortality ratio, and major adverse cardiovascular event (MACE) ratio before and after moving. RESULTS: Of the 10 high-volume operators who moved, 6 moved from high- to moderate- or low-volume hospitals, with median annual PCI volumes (interquartile range) of 130 (117-165) in prior hospitals and 54 (46-84) in subsequent hospitals (the hospital the operator moved to), and the remaining 4 moved from high to high-volume hospitals, with median annual PCI volumes (interquartile range) of 151 (133-162) in prior hospitals and 193 (178-239) in subsequent hospitals. No significant differences were observed in the risk-adjusted mortality ratios and MACE ratios between high-volume operators and matched controls before and after moving. CONCLUSIONS: High-volume operators cannot maintain high volume when they moved from high to moderate or low-volume hospitals; however, the quality of care is maintained. High PCI volume and high-quality outcomes are less portable and more hospital bound.

Ranking regional drowning mortality rates: population-based versus aquatic area-based rate.

Population, the most often used denominator in calculating drowning mortality rate, might not be a good measure of risk exposure. In this study, we sought to compare the rankings of township drowning mortality according to population-based rates with those according to aquatic area-based rates in Taitung County, Taiwan. The township with the highest mortality rate using population as the denominator (deaths per 100 000 persons) was Changbin (32.3) followed by Lanyu (22.4), Donghe (19.6) and Chenggong (18.0). On the other hand, the township with the leading mortality rate using aquatic area as the denominator (deaths per 100 000 km2) was Lanyu (353) followed by Lyudao (307), Chenggong (282) and Taitung City (219). Taitung City ranked 10th according to the population-based rate, but ranked 4th according to the aquatic area-based rate. In conclusion, rankings of regional drowning mortality rates using aquatic area as the denominator differ from those using population as the denominator.

Regional and hospital variations in the extent of decline in the proportion of percutaneous coronary interventions performed for nonacute indications - a nationwide population-based study.

BACKGROUND: The volume and percentage of percutaneous coronary interventions (PCIs) performed for nonacute indications have declined in the United States since 2007. However, little is known if similar trends occurred in Taiwan. METHODS: We used data from Taiwan National Health Insurance inpatient claims to examine the regional and hospital variations in the extent of decline in the percentage of nonacute indication PCIs from 2007 to 2012. RESULTS: The volume of total PCIs persistently increased from 29,032 in 2007 to 35,811 in 2010 and 37,426 in 2012. However, the volume of nonacute indication PCIs first increased from 7916 in 2007 to 9143 in 2009 and then decreased to 8666 in 2012. The percentage of nonacute indication PCIs steadily decreased from 27% in 2007 to 26% in 2009 and then to 23% in 2012, a - 15% change. The extent of decline was largest in the North region (from 27% to 21%, a - 22% change) and least in Kaopin region (from 20% to 18%, a - 13% change). Of the 71 hospitals studied, 14 did not show a decreasing trend. Five of the 14 hospitals even showed an increasing trend, with a percentage change >10% between 2007 and 2012. In 2012, 6 hospitals had a nonacute indication PCI percentage >35%. CONCLUSIONS: In Taiwan, four-fifths of the hospitals showed a decline in the percentage of nonacute indication PCIs from 2007 to 2012. It is plausible that Taiwanese cardiologists would have been influenced by the recommendations of crucial US trials and guidelines.

The temporal trends of incidence, treatment, and in-hospital mortality of acute myocardial infarction over 15years in a Taiwanese population.

BACKGROUND: The study was conducted to examine the nationwide temporal trends of incidence, treatment, and short-term outcomes for acute myocardial infarction (AMI) over a 15-year period in Taiwan. METHODS: We identified patients who were hospitalized for incident AMI between 1997 and 2011 from the inpatient medical claim dataset of the National Health Insurance Research Database. Age- and sex-adjusted incidence and in-hospital mortality rates were calculated for AMI, and separately for ST-segment elevation and non-ST-segment elevation myocardial infarction (STEMI and NSTEMI). RESULTS: A total of 144,634 patients were identified. The incidence rates (per 100,000 population) of AMI increased from 30 in 1997 to 42 in 2011, which was mainly driven by the increase of NSTEMI. The in-hospital mortality rate after AMI decreased from 9.1% in 1997 to 6.5% in 2011, which was also driven by the case mortality rate for NSTEMI. Although the in-hospital mortality rates significantly decreased from 7.3% to 5.1% between 1997 and 2003 for STEMI, it did not change significantly from 2004 to 2011. Moreover, AMI patients undergoing revascularization treatment, particularly PCI, was the most important independent predictor for improved in-hospital survival. CONCLUSION: The results of this study demonstrated a recent dramatic increase in the incidence rates and a decrease in short-term mortality in patients with NSTEMI; while the incidence and in-hospital morality of STEMI only modestly changed over time in Taiwan. Further quality improvement approaches for AMI prevention and treatment to favorably affect the incidence and outcomes from both major types of AMI are highly recommended.

Characteristics of Early and Late Adopting Hospitals Providing Percutaneous Coronary Intervention in Taiwan.

BACKGROUND: Studies in the United States suggested that the characteristics of hospitals providing percutaneous coronary intervention (PCI) differed from those not providing PCI. However, little is known on the differences between the characteristics of early-adopting hospitals and those of late-adopting hospitals, and on their potential impacts on PCI volume and access. METHODS AND RESULTS: We used inpatient claims data from 1997 to 2012 from the Taiwan National Health Insurance program to identify the hospitals offering PCI. Geographic information systems (GIS) were used to determine the population access to PCI hospital. As of 2012, 88 hospitals were capable of providing PCI. On the basis of the year that the hospitals started providing PCI, 32 hospitals were designated as early adopters (before 1998), 23 as early majority (1998-2002), 24 as late majority (2003-2007), and 16 as laggards (2008-2012). Hospitals that adopted PCI later were smaller in size and closer to an existing PCI hospital and had lower PCI volumes performed and less bypass surgery support. The median PCI volumes in 2012 were n=706, 330, 138, and 81 in early adopters, early majority, late majority, and laggards, respectively. Despite the low volume of PCI performed in laggard hospitals, the percentage with ST-elevation myocardial infarction and acute myocardial infarction as principal discharge diagnosis was higher than their early-adopting hospital counterparts. The percentage of the Taiwanese population living within 40 km of PCI hospitals (appropriate access defined in this study) was 95.7% in 1997 and 98.0% in 2002, and this has remained unchanged since 2002. CONCLUSIONS: The characteristics of early-adopting hospitals differed from those of late-adopting hospitals. Despite lower PCI volume performed in late-adopting hospitals, many of them are in remote areas and provide needed and timely services for patients with acute myocardial infarction.