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Accepted Manuscript

Title: A Cross-Hospital Cost and Quality Assessment System by Extracting Frequent Physician Order Set from a Nationwide Health Insurance Research Database

Author: Kuo-Hsin Chen Jin-Ming Wu Te-Wei Ho Hwan-Jeu Yu Feipei Lai

Kuo-Hsin Chen Jin-Ming Wu Te-Wei Ho Hwan-Jeu Yu Feipei Lai PII: S0169-2607(15)00093-0 DOI:

PII:

S0169-2607(15)00093-0

DOI:

http://dx.doi.org/doi:10.1016/j.cmpb.2015.04.007

Reference:

COMM 3915

To appear in:

Computer Methods and Programs in Biomedicine

Received date:

26-10-2014

Revised date:

12-4-2015

Accepted date:

13-4-2015

Please cite this article as: K.-H. Chen, J.-M. Wu, T.-W. Ho, H.-J. Yu, F. Lai, A Cross- Hospital Cost and Quality Assessment System by Extracting Frequent Physician Order Set from a Nationwide Health Insurance Research Database, Computer Methods and Programs in Biomedicine (2015), http://dx.doi.org/10.1016/j.cmpb.2015.04.007

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A Cross-Hospital Cost and Quality Assessment System by Extracting Frequent Physician Order Set from a

A Cross-Hospital Cost and Quality Assessment System by Extracting Frequent

Physician Order Set from a Nationwide Health Insurance Research Database

Kuo-Hsin Chen 5,# , MD; Jin-Ming Wu 1,4,# , MD; Te-Wei Ho , MS; Hwan-Jeu Yu

1

PhD; and Feipei Lai 1,2,3 , PhD

2,*

,

1 Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan

University, Taiwan

2 Department of Computer Science and Information Engineering, National Taiwan

University, Taiwan

3 Department of Electrical Engineering, National Taiwan University, Taiwan

4 Department of Surgery, National Taiwan University Hospital, Taiwan

5 Department of Surgery, Far-Eastern Memorial Hospital, New Taipei City, Taiwan

# Equally contributing to this work

*Corresponding author

Tel: +886- 910126148;

Postal address: #1 Roosevelt Rd., Sec. 4, Taipei, Taiwan 106

E-mail: ecpro@seed.net.tw; d95028@csie.ntu.edu.tw

Running title: A Cross-Hospital Cost and Quality Assessment System

Word count of text: 3499

Fax: +886-2-23123456

Highlights

A system that provides a convenient way for physicians to retrieve and compare

clinical pathways among health care providers about herniorrhaphy.

The frequent physician order sets were derived from the National Health

Database.

1

 A higher consistency index leads to lower recurrence rates. Abstract Purpose Clinical pathways fall

A higher consistency index leads to lower recurrence rates.

Abstract

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 3,262 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

2

threshold of 2% was established to separate low and high quality of herniorrhaphy at each

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.

Keywords

Clinical Pathways, Physician order, Quality of Health Care, Database, Hernia

3

Introduction Health Service Quality and Clinical Pathways Health service quality is critical for both health

Introduction

Health Service Quality and Clinical Pathways

Health service quality is critical for both health care providers and receivers. In the

1980’s, Donabedian proposed a conceptual model for studying and evaluating health

care

service

quality

[1].

This

model

classified the

quality

of

care

into

three

perspectives: structure, process, and outcome. The structure perspective focused on

"the material, facilities, equipment, human resources, and organization of the health

care providers". The process perspective focused on "what is actually done in giving

and receiving care", including the activities involved in making a diagnosis and

recommending or implementing treatment. The outcome perspective focused on the

"effects of care based on the patients' health conditions". There are many issues

associated with the three health service delivery perspectives noted above. There are

many concerns associated with implementing these three health service delivery

perspectives, such as providing allocation of resources, providing evidence-based care,

and reducing variability in outcomes [2]. Clinical pathways provide one approach to

addressing these; they comprise "structured, multidisciplinary care plans (identify

patient group; set pathway parameters; agree goals; map multidisciplinary care; track

variances; feedback and review; upgrade pathway) that detail essential steps in the

care of patients with a specific clinical problem [3, 4]. They fall under the process

perspective and are important components of health service quality.

Purpose of Clinical Pathways

One of the main issues in clinical practice is the variability in care delivery among

health care providers. That is, patients with similar clinical conditions may receive

4

different care, particularly regarding surgical procedures. This situation can result in differences in elements such

different care, particularly regarding surgical procedures. This situation can result in

differences in elements such as hospital stays, laboratory tests, the use of medication

and blood products, outpatient treatment, complications, readmissions, total cost,

outcomes, and patient satisfaction. All of these issues are of concern to patients, health

professionals, and health care management [5]. The application of clinical pathways is

one way to address the quality-of-care challenge, as they provide guidance for

common

diagnostic

and

therapeutic

procedures

in

clinical

practice

[6].

The

application of clinical pathways can reduce re-admission [7] and medical cost [8] for

hernia surgery, pulmonary complications and hospital stays for head and neck

reconstruction [9] or minimize hospital costs and hospital stays for both hepatectomy

[10] and kidney surgery [11]. Thus, clinical pathways have been developed and

applied in many hospitals.

Clinical pathways have taken many forms. A typical clinical pathway contains a set of

physician order activities to be executed during a defined time period for a specific

clinical care objective (e.g., exam, anesthesia, drug prescription). The pathway can be

used to coordinate the clinical care team, standardize practices, and reduce the

variance in health care delivery. The benefits of clinical pathways include achieving

expected outcomes, promoting effectiveness and efficiency of clinical care, and

optimizing resource utilization. Taken together, these benefits lead to a higher quality

of care [12].

The Problems

Best practice clinical pathways come from two sources: creation of clinical pathways

and adherence to clinical pathways. The creation of clinical pathways is usually based

on existing evidence and medical rules discussed in a professional committee. This

process can ensure that the clinical pathways are as objective as possible. However, a

5

group of professionals under the same health care institution may still overlook or exclude an

group of professionals under the same health care institution may still overlook or

exclude an important factor or activity. Day-to-day usage of the clinical pathways

may also identify areas of improvement. In addition, hospitals could possibly find

ways to improve their own clinical pathways by reviewing those of other hospitals.

Though comparing clinical pathways in use at other institutions could be helpful, it

can be difficult to obtain this information. Even when details of the clinical pathways

of another hospital are obtained, the resulting outcome of these clinical pathways can

be difficult to determine. Moreover, it is never known whether the other hospital

precisely follows the clinical pathways. Thus, it is difficult to make a comparison with

another hospital. In summary, we need a practical and convenient method for

overcoming the above issues and realizing an effective comparison of clinical

pathways.

Objectives

Among the diverse components of the clinical pathway, sets of physician orders are a

main component, which can be extracted and validated by reimbursement database.

The National Health Insurance Research Database (NHIRD) of Taiwan can be utilized

to achieve this purpose. In 1995, Taiwan launched a single-payer National Health

Insurance program. More than 99 percent of the population, about 2.3 million people,

were enrolled [13]. A portion of the data from this database was systematically

sampled and de-identified to form a database suitable for research purposes. From this

database, it is possible to extract frequent physician order sets by examining physician

orders that applied to patients from different hospitals. In addition, herniorrhaphy is

an outpatient operation, which includes simple clinical pathway. Thus, one part of the

clinical

pathways

for

herniorrhaphy

can

be

effectively

realized

through

the

comparison

of

physician

order

sets.

This

proposed

system

can

provide

the

6

decision-making information needed by health care management to improve the quality of their services. The

decision-making information needed by health care management to improve the

quality of their services. The objective of this study was to design a system that will

provide an easy process for health care providers to compare sets of physician orders

across all hospitals.

In the remaining sections of this paper, we present the methods, data source,

computation algorithm, and overall system architecture of our study. A sample hernia

surgical operation procedure and its results are shown in Section 3. In Section 4, we

discuss the results of the sample comparison and address the contribution and

potential of our approach.

Materials and Methods

Data Source

The data used in our analysis were drawn from the NHIRD. The dataset used a

representative sample (N=1,000,000) selected from the entire database of beneficiary

information [14]. Data extracted included registration files and original data for

reimbursement

claims.

The

registration

files

included

information

on

patients,

physicians, and care providers. The identification data for each file was scrambled to

ensure confidentiality. Based on the hospital registration file, we categorized the

hospitals into three types: medical center, regional hospital, and district hospital. The

inpatient

expenditures

file

contained

patient

admission

claim

data,

including

admission date, discharge date, and up to five ICD9 operation procedure codes for

this hospitalization as well as the patient's gender, date of birth, hospital ID, and

physician ID. The inpatient orders file contained the physician orders related to the

above inpatient expenditures admission record. The physician orders were divided

into

different

categories

including

medication

7

description

and

amount,

special

materials, anesthesia, surgery, treatment of disposal, injection, radiation treatment, inspection, case payment (Diagnosis

materials, anesthesia, surgery, treatment of disposal, injection, radiation treatment,

inspection, case payment (Diagnosis Related Group, DRG), and others. From the

inpatient orders file, we obtained the actual physician orders that applied to the

patients.

Subjects Selection

To demonstrate the usability of the system, we selected and compared results from a

hernia repair operation. "Hernias are associated with reduced quality of life and high

socioeconomic cost" [15, 16]. Hernia repair is classified as a digestive system

procedure. The claim records of inpatients over 18 years of age who underwent a

unilateral inguinal hernia repair for the first time between 2003 and 2007 were

retrieved from the NHIRD, and included ICD9 procedure codes 53.00, 53.01, 53.02,

53.03, 53.04, and 53.05. The selection process is depicted in Figure 1.

Data Preparation and Aggregation

The original NHIRD data comprise detailed records, but our study required us to

aggregate information. Therefore, we prepared the data in order to meet the aggregate

query requirements. This operation was similar to the transition from a transaction

database to a data warehouse. Transaction databases are used for daily operations, and

data warehouses for business decision making. First, ETL (extract, transform, and

load) must be performed on the transaction database to construct the warehouse

database. Then, the normalized transaction database must usually be de-normalized to

accelerate and fulfill the aggregate query requirements of the data warehouse. The

tasks to be performed in advance are as follows: extract the target detailed medical

records that meet the desired procedure codes, apply exclusion criteria, calculate the

number of cases grouped by hospital ID and then sort them by the number of cases,

8

calculate the average number of physician orders per hospital, and calculate the average amount of

calculate the average number of physician orders per hospital, and calculate the

average amount of cost per hospital. Once complete, this process yields a population

and number overview regarding the target surgical operation. Subsequently, we can

decide whether to drill down to the individual data records.

Frequent Physician Order Sets

The clinical pathway for a surgical operation at a specific hospital can be derived

from the physician orders claimed in the insurance records. Our approach was to

compute the frequency of physician orders that applied to patients. We established

five frequency thresholds (80%, 85%, 90%, 95%, and 100%) and determined the

physician orders that reached the respective thresholds. For example, a physician

order that reaches 80% frequency indicate that this physician order occurred in more

than 80% of the claim cases. Similarly, if a physician order reaches 100% frequency,

it means that it occurred in all claim cases. In theory, higher frequency of physician

order sets will result in fewer physician orders that qualify. Physician order sets that

reached one of the thresholds were considered frequent physician order sets. For

example, the frequent physician order sets for some surgical procedure of a care

provider could look like Table 1. The meaning of most of the order codes are found in

Table 6. The concept of the extraction and comparison process is shown in Figure 2.

Consistency Index

Table 1 demonstrates that orders 1–18 occurred in more than 80% of the hospital's

total cases. If the hospital's average number of physician orders applied per case is 20,

then we can say that 18/20 (90%) of physician orders per case reach the 80%

frequency threshold. On the other hand, if the hospital's average number of physician

orders per case is 40, we can say that only 18/40 (45%) of physician orders per case

9

reach the 80% frequency threshold; the former situation is more consistent than the latter. To

reach the 80% frequency threshold; the former situation is more consistent than the

latter. To understand the consistency of each hospital, we defined a consistency index

as follows:

Consistency Index =

Where

a consistency index as follows: Consistency Index = Where FrequencyPercentage k = 80%, 85%, 90%, 95%,

FrequencyPercentage k = 80%, 85%, 90%, 95%, 100% for k=1,2,3,4,5

FrequencyOrderCount k : number of physician orders reaching

FrequencyPercentage k

AverageOrderCount: average count of physician orders per case

Let us use Table 1 as an example. For a surgical procedure, if the hospital's average

number of physician orders per case is 20, the consistency index of this hospital can

be calculated as follows:

Consistency Index = (18×80% + 17×85% + 16×90% + 12×95% + 3×100%) /

(20×80% + 20×85% + 20×90% + 20×95% + 20×100%)

 

= 64.11%

In

an

extreme

condition,

if

all

of

the

FrequencyOrderCount k

=

20,

then

the

consistency index would be 100%. The concept of various frequency thresholds of

physician order sets is shown is Figure 3.

Charlson Comorbidity Index

In order to assess the relationship between a patient's past health status and the current

health outcome, we computed the comorbidity index of every patient and the average

comorbidity index of every hospital. We used Charlson's model [17] to compute

patient comorbidity, and examined the correlation between morbidity and ICD9

disease and procedure codes, as adapted by Deyo [18]. We designed a software

10

module to compute the Charlson score for each patient by using patient ID and index

module to compute the Charlson score for each patient by using patient ID and index

date. After computing each patient's Charlson score, we computed the average

Charlson score for each hospital. We approximated each hospital’s comorbidity status

with the Charlson scores.

Recurrence

One indicator of health care quality is patient recurrence rate. The system retrieved

patients’ recurrence records by identifying the ICD9 code 550.91 (hernia recurrence)

from the index date until the end of 2008. As this database is nationwide, we also

determined whether the patient returned to the same or a different hospital. The

system displayed all recurrence records after the index date. The system also showed

the physician ID associated with each surgical procedure. We then determined if

different physicians had varying favorite physician orders, assessing if they differed

from the frequent physician orders derived from the hospital's frequent physician

order sets.

Comparison Algorithm

The ultimate objective of the proposed system is to provide a method of comparison

among hospitals. Users can select any number of hospitals among which to compare

their frequent physician order sets as well as the Charlson score, recurrence rate, and

categorized amount of cost. The system then shows the similarity and difference of

the selected hospitals, item by item. In the frequent physician order set comparison

procedure, the system retrieves the frequent order sets of the selected hospitals and

calculates the union of these order sets to form a list data structure. Then, the system

traverses each retrieved order set to make a mark in the union order set list if the

current visited order matches between the union order set list and the retrieved order

11

set. Then, the system displays the marked union order set list to the user. The

set. Then, the system displays the marked union order set list to the user. The pseudo

code of the comparison procedure is listed as follows:

Algorithm Comparison

Input: FrequentOrderSetA, FrequentOrderSetB

Output:UnionOrderSet

Set UnionOrderSet = Union of FrequentOrderSetA and FrequentOrderSetB

For each PhysicianOrder t in FrequentOrderSetA

Begin

If t exists in UnionOrderSet

Set a mark in the A field of matched PhysicianOrder of UnionOrderSet

End

For each PhysicianOrder t in FrequentOrderSetB

Begin

If t exists in UnionOrderSet

Set a mark in the B field of matched PhysicianOrder of UnionOrderSet

End

Return UnionOrderSet

System Architecture

To increase the system’s accessibility, it was developed in C# to operate as a web

application based on SQL Server 2008 and running on Microsoft Internet Information

Services. Figure 4 depicts the system architecture, and Figure 5 the hierarchy of

functionalities.

Results

Aggregate by Year and Hospital

The proposed system can display aggregate information regarding the number of

cases that underwent surgical hernia repair by year on one web page, or by hospital on

another web page. Users can view the aggregate information to obtain an overall view

of the target surgical procedure from different perspectives, and then view a list of

12

claim cases in that year or that hospital. The listed fields include patient gender, age,

claim cases in that year or that hospital. The listed fields include patient gender, age,

Charlson score, admission date, discharge date, length of stay, amount of cost, and

average number of physician orders applied. When users are interested in a specific

case, they can further click to view the detailed physician orders applied on the case.

The aggregate record distributions from 2003 to 2007 were 520, 688, 717, 680, and

657, respectively. The ratio of patients receiving hernia repair surgical procedure for

the first time was about 6.52±0.77 per ten thousand (652/1,000,000).

There were 257 hospitals involved, including 19 medical centers, 79 regional

hospitals, and 159 district hospitals. The aggregated count of cases for the top twelve

hospitals is shown in Table 2. Among these twelve hospitals were 9 medical centers, 2

regional hospitals, and 1 district hospital. The average Charlson score was at a normal

level, 1.72±0.39, and the average number of physician orders applied to patients was

34.33±3.98(416/12). The recurrence rate was 3.13±0.04%(32/1,052), and the average

amount of cost per case was 40,068±6,468(480,816/12).

We viewed the average categorized amount of cost for a hospital to understand the

amount of cost for each physician order category. An example is shown in Table 3.

Frequent Physician Order Sets and Consistency Index

We viewed the extracted frequent physician orders for hospitals according to different

frequency thresholds: 80%, 85%, 90%, 95%, and 100%. The results were similar to

Table 1. The consistency indices for these twelve hospitals (Table 4) varied from

32.68% to 82.09%.

The ratio of frequent physician order sets to average number of physician orders

applied per case for each hospital at each frequency threshold are depicted in Figure 6.

Higher consistency indices are indicated by higher ratio scales and flatter curves.

13

Comparison of Three Medical Centers We compared three medical centers (denoted by B, G, and

Comparison of Three Medical Centers

We compared three medical centers (denoted by B, G, and J) under the 80% frequency

threshold of frequent physician order sets. For convenience, the system displayed the

results of the comparison (including Charlson score, recurrence rate, categorized

amount of cost, and frequent physician order sets) in one table. We separated the table

into two smaller tables here to aid explanation. Table 5 shows the comparison of the

Charlson score, recurrence rate, and categorized amount of cost. Hospital J had a

group of medium Charlson score patients, medium amount of cost, and an extremely

low recurrence rate.

The comparison results of frequent physician orders are shown in Table 6. The three

medical centers presented common orders such as CBC-I, and general biochemistry

examination - asparate aminotransferase, E.K.G., chest examination, parenteral fluid,

pulse or ear oximetry and so on. Hospital J performed more general biochemistry

examinations.

Consistency Index vs. Recurrence Rate

We are interested in the relationship between consistency index and recurrence rate. A

2% recurrence rate at each hospital is the cutting point to separate low and high

quality

herniorrhaphy.

Univariable

analysis

was

conducted

to

predict

rates

of

recurrence greater than 2% after herniorrhaphy; the results are presented in Table 7.

Results

showed that

a

high proportion

of

consistency

index

(70.99±23.88

vs.

52.60±20.30; P<.001), small number of surgeons at each hospital (3.50±4.41 vs.

7.09±6.57; P<.001), and non-medical center hospital type (P=.042) were associated

with low recurrence rates. Multivariable Cox regression analysis (Table 8) revealed

that only a high proportion of consistency index was associated with low recurrence

14

rates (one percentage increased: OR=0.973; CI:0.957–0.990; P =.002). Discussion Principal Results and Improvement

rates (one percentage increased: OR=0.973; CI:0.957–0.990; P=.002).

Discussion

Principal Results and Improvement Actions

The present analysis of the proposed system indicates that a higher consistency index

leads to a lower recurrence rate. This suggests that efforts to increase consistency

index may be a good solution for hospitals with low consistency and high recurrence

rates; a change in consistency rate may yield improved health care delivery. Based on

the results of our analyses, hospitals should aim to achieve a benchmark consistency

index of 70%.

In addition, hospital administrations can take several steps to improve outcomes:

1. Compute the average orders per case and frequent physician order sets at each

frequency threshold.

2. Compute the consistency index based on the derived frequent physician order

sets.

3. Review the variation between the universal physician order set and the frequent

physician order sets.

4. Compare the frequent order sets with those of other care providers.

5. Adjust clinical pathway physician orders.

6. Adhere to the adjusted clinical pathway.

Our proposed system can easily support the implementation of these improvement

steps. With the annual addition of new NHIRD data, the system can provide insights

on innovative practices and allow continuous updating of the sets of physician orders.

Clinical pathways are germane to the process perspective of health care quality.

Comparing the sets of physician orders across care providers is a good approach to

15

identifying areas for clinical improvement and improving health care service delivery overall. Our system provides

identifying areas for clinical improvement and improving health care service delivery

overall. Our system provides a convenient point of access to this part of the clinical

pathway, because data is often challenging to obtain. Physicians may use the

comparative data to better understand the hospital eco-system, their current practices,

and ways to improve current practices.

We chose hernia repair as a starting point for this system because it can be examined

as a single pure surgical operation more easily than other conditions with a higher

proportion of mixed operational procedures[19]. Furthermore, hernia repair is less

complicated than other conditions, and the operation required is relatively well

established, compared with operations for other conditions. In previous reports,

recurrence after herniorrhaphy may be associated with skills of surgical mesh fixation

[20], characteristics of mesh [21, 22], and types of hernia [23]. We expect that this

system can provide even more benefits for physicians when increasingly complex

operations, such as cancer, are examined.

The Charlson score is a general evaluation of the severity of comorbidities of the

patient. In this study, there is no statistically significant difference between low and

high recurrence rate in terms of the Charlson score (Table 7). It means that the

Charlson score has no association with recurrence after herniorrhaphy. Our study has

similar findings compared to one meta-analysis study, which reports that female

gender, direct inguinal hernias at the primary procedure, operation for a recurrent

inguinal hernia, and smoking history are significant risk factors for recurrence after

inguinal hernia surgery [24].

16

Limitations Weight of Physician Orders We calculated the consistency index by tabulating the number of

Limitations

Weight of Physician Orders

We calculated the consistency index by tabulating the number of physician orders. We

only assessed quantity and did not consider the physical influence of the physician

orders. For example, a surgical method may be considered more influential than a lab

test method. This circumstance may be improved by controlling for the weight of

physician orders in future studies. Moreover, herniorrhaphy is not a major operation,

which has very low surgical mortality (less than 0.1%). In terms of patient outcomes

(28-day mortality), there is no statistically significant difference between frequent sets

of physician orders and mortality.

Variance of Physicians

The purpose of this system is to compare hospitals, not individual physicians.

However, physician orders or decision making of method of operations that apply to

patients may differ from those issued physician-to-physician. This situation may

influence overall hospital consistency. In the previously mentioned consistency index

analysis, we considered the number of surgeons at each hospital that performed this

operation. In order to provide more cross-reference information for users, this system

can also display the de-identified physician ID to better signal when two operations

were performed by the same physician.

Frequent Association Patterns and Sequential Patterns

The frequent physician order set we calculated was based on the hospital viewpoint.

17

In contrast, analyses computed from the individual patient base might yield another order set, a

In contrast, analyses computed from the individual patient base might yield another

order set, a frequent association physician order set. If we further considered the

sequence of these physician orders during a hospital stay, it will lead to a frequent

sequential physician order set. These results may be obtained from data models by

data mining association items or sequential items in future work.

Currently the system is a project-based application for a specific surgical operation

purpose. In the future, the system can be improved to provide general-purpose queries

for any procedure code operation.

Deviation of clinical pathway

Herniorrhaphy is a well-developed and matured procedure with few deviations during

general practice. Nonetheless, deviations from original clinical pathways may happen,

and are enrolled on the variance record. Most important of all, some deviations may

be beneficial for specific patients in specific situations. However, such variance

records are not available on our database, and our system does not support this

function. In the future, our system may do regular mining for individual hospital to

find the serial change of uncommon physician orders, which may become standard

afterward.

Conclusions

In conclusion, we developed a system that provides a convenient way for physicians

to retrieve and compare one part of the clinical pathways among health care providers.

The sets of physician orders were derived from the NHIRD, an evidence-based

database. Thus, the data can provide a means for actual practice other than just a

document description or workflow. The claim records of the NHIRD, the related

Charlson score, days of hospitalization, and recurrence rate were also calculated and

18

displayed for comparison to evaluate the related potential quality. Results suggest that a higher consistency

displayed for comparison to evaluate the related potential quality. Results suggest that

a

higher

consistency

index

leads

to

lower

recurrence

rates.

Care-provider

administrators can use a consistency index of 70% as a reference benchmark when

taking steps to continuously adjust and adhere to their clinical pathways.

Acknowledgement: nil

Conflicts of Interest

None declared.

19

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21

Meta-Analysis of Observational Studies, Surgical innovation, (2014). Tables T a b l e 1 .

Meta-Analysis of Observational Studies, Surgical innovation, (2014).

Tables

Table 1. Frequent physician order sets by various frequency thresholds

   

Order Code

 

80%

85%

90%

95%

100%

 
 

1 05216K

 

v

v

v

v

v

 

2 02006K

 

v

v

v

v

v

 

3 03001K

 

v

v

v

v

v

 

4 57017B

 

v

v

v

v

 
 

5 96025B

 

v

v

v

v

 
 

6 96026B

 

v

v

v

v

 
 

7 32001C

 

v

v

v

v

 
 

8 08036B

 

v

v

v

v

 
 

9 08011C

 

v

v

v

v

 
 

10 08013C

 

v

v

v

v

 
 

11 09005C

 

v

v

v

v

 
 

12 18001C

 

v

v

v

v

 
 

13 75607C

 

v

v

v

   
 

14 A013718277

 

v

v

v

   
 

15 39004C

 

v

v

v

   
 

16 48011C

 

v

v

v

   
 

17 96007C

 

v

v

     
 

18 03026K

 

v

       

Table 2. Top twelve case count by hospital

 
   

Type

Cases

Recurrence

Charlson

Avg.

Avg.

Score

Amount

Orders

A

District Hospital

170

 

3(1.76%)

 

1.32

45,535

26

B

Medical Center

158

 

8(5.06%)

 

1.61

42,422

34

C

Medical Center

120

 

1(0.83%)

 

2.40

38,021

32

D

Medical Center

100

 

0(0.00%)

 

1.28

32,433

33

E

Medical Center

79

 

12(15.19%)

 

1.85

46,171

31

F

Regional Hospital

68

 

0(0.00%)

 

2.21

51,266

40

G

Medical Center

66

 

2(3.03%)

 

2.20

29,791

33

22

  H Medical Center 66 2(3.03%)   1.29 40,982 34 I Medical Center 66 3(4.55%)
 

H

Medical Center

66

2(3.03%)

 

1.29

40,982

34

I

Medical Center

66

3(4.55%)

 

1.59

43,067

37

J

Medical Center

55

0(0.00%)

 

1.62

38,867

38

K

Regional Hospital

55

1(1.82%)

 

1.87

41,220

40

L

Medical Center

49

1(2.04%)

 

1.43

31,041

38

 

Average

87.67

2.75(3.13%)

 

1.72

40,068

34.33

Table 3. Categorized amount of cost for a hospital

 
 

Category Name

 

Amount

 

Basic Medical

 

3,722

Laboratory Examination

 

1,852

X-RAY

 

203

Injection

   

66

Therapeutic Treatment

 

184

Operation

 

13,517

Anesthesia

 

4,263

Special Material

   

55

Diagnosis Related Group(DRG)

13,346

Other

1,656

Total

38,864

Table 4. The consistency index

Hospital

Average Number of Orders

80%

85%

90%

95%

100%

Consistency Index

 

A 26

22

22

22

21

20

82.09%

 

B 34

16

15

11

9

6

32.68%

 

C 32

18

17

17

12

3

40.66%

 

D 33

16

14

13

11

5

34.92%

 

E 31

16

16

16

12

5

41.00%

 

F 40

22

21

18

13

4

37.78%

 

G 33

24

24

22

19

13

59.12%

 

H 34

22

20

17

13

6

45.96%

 

I 37

20

19

17

17

13

50.07%

 

J 38

23

23

20

17

5

46.31%

 

K 40

19

19

18

14

6

37.14%

 

L 38

22

20

17

14

3

38.71%

23

T a b l e 5 . The comparison of Charlson score, recurrence rate, and

Table 5. The comparison of Charlson score, recurrence rate, and categorized amount

 

Care Provider

B

G

 

J

 

Charlson Score

1.61

2.20

1.62

Recurrence Rate

5.06%

3.03%

0.00%

Categorized Amount of Cost

     

Basic Medical

3,787

3,826

3,722

Laboratory Examination

1,519

1,344

1,852

X-RAY

257

198

203

Injection

72

77

 

66

Therapeutic Treatment

234

177

 

184

Operation

13,615

13,816

13,517

Blood Transfusion and Bone Marrow

     

Transplantation

133

Anesthesia

3,369

3,224

4,263

Special Material

22

67

 

55

Diagnosis Related Group(DRG)

18,390

5,828

13,346

Other

1,019

1,230

1,656

Total

42,417

29,787

38,864

Table 6. The comparison of frequent physician orders

 
 

Order Code

Order Name

B

G

J

 

1 02006K

General Beds Hospitalization Diagnosis Fee

 

v

v

v

 

2 03001K

Acute General Beds - Ward Fee

v

v

v

 

3 03026K

Acute General Beds - Nursing Fee

 

v

v

v

 

4 05216K

Drug Service Fee

 

v

v

   

CBC-I (WBC,RBC,Hb,Hc,platelet

       

5 08011C

count,MCV,MCH,MCHC )

v

v

v

 

6 08036B

Activated Partial Thromboplastin Time

     

v

 

7 09002C

General Biochemistry Examination - BUN, blood urea nitrogen

   

v

 

8 09005C

General Biochemistry Examination - Glucose

   

v

v

 

9 09015C

General Biochemistry Examination - Creatinine (B) CRTN

   

v

v

 

1 09021C

General Biochemistry Examination - Na (Sodium)

   

v

v

24

0           1           1 09022C General

0

         

1

         

1

09022C

General Biochemistry Examination - K(Potassium)

v

v

1

         

2

09023C

General Biochemistry Examination - Cl (Chloride)

v

1

09025C

General Biochemistry Examination - Asparate

v

v

v

3

Aminotransferase (AST)(GOT)

1

         

4

09029C

General Biochemistry Examination - Bilirubin total

v

1

         

5

18001C

E.K.G. (Electrocardiography)

v

v

v

1

         

6

32001C

Chest Examination

v

v

v

1

         

7

39004C

Parenteral Fluid

v

v

v

1

         

8

48011C

Change Dressing - small(<10cm)

v

v

1

         

9

57017B

Pulse or Ear Oximetry

v

v

v

2

         

0

75607C

Repair of Inguinal Hernia - without bowel resection

v

v

v

2

         

1

96007C

Spinal Anesthesia

v

v

2

         

2

96025B

Anesthesia Recovery Care Fee

v

v

v

2

         

3

96026B

Pre-Anesthesia Evaluation

v

v

v

2

         

4

A013382100

Cathartics And Laxatives

v

v

2

A013718277

Replacement Preparations Composite - 5% / 0.45%

 

v

 

5

Injection

2

A020444100

Miscellaneous Analgesics And Antipyretics -

   

v

6

Acetaminophen

2

A025485209

Replacement Preparations Composite - 5% / 0.225%

v

   

7

Injection

2

         

8

A033698277

Antibiotics – Cephalosporins

v

2

NCS010005NP

Special Material - 5 cc Syringe

 

v

 

25

9 W       3 NDN041622N       0 BD Special Material -

9

W

     

3

NDN041622N

     

0

BD

Special Material - IV Catheter(Teflon)

v

3

NDN041622N

     

1

TM

Special Material -IV Catheter(Teflon)

v

Table 7. Univariable analysis for prediction of recurrent hernia after herniorrhaphy

 

Recurrence rate <2%

Recurrence rate 2%

P value

Consistency index(%)

70.99 ± 23.88

52.60±20.30

<.001

Charlson score

1.87±1.33

1.88±0.87

.953

Average cases per

2.21±4.28

2.89±2.82

.133

surgeon at each

hospital

Number of surgeons

3.50±4.41

7.09±6.57

<.001

at each hospital

Hospital type

   

.042

Medical center

7

12

 

Regional hospital

46

33

 

District hospital

128

31

 

Table 8. Multivariable regression model for prediction of recurrent hernia after

herniorrhaphy

Predictor

 

P value

OR

95% CI (lower–upper)

Consistency index

a

.002

0.973

0.957–0.990

Hospital type

b

.475

1.758

0.373–8.279

Number of surgeons

.421

1.036

0.950–1.129

at each hospital

 

a Every 1% increased b Considered as categorical variable

26

Figure legends Figure 1. The selection of study subjects. Figure 2. The extraction and comparison

Figure legends

Figure 1. The selection of study subjects.

Figure 2. The extraction and comparison of frequent order sets.

Figure 3. The various frequency thresholds of physician order sets.

Figure 4. System architecture of the comparison system.

Figure 5. Hierarchy of functionalities within the comparison system.

Figure 6. The ratio of frequent physician order sets to average number of orders

applied at various frequency thresholds.

Abbreviations

AST: Aspartate Aminotransferase

BUN: Blood Urea Nitrogen

CBC: Complete Blood Count

CRTN: Creatinine

DRG: Diagnosis Related Group

EKG: Electrocardiography

ETL: Extract Transform Load

GOT: Glutamate Oxaloacetate Transaminase

Hb: Hemoglobin

Hct: Hematocrit

ICD9: The International Classification of Diseases, 9th Revision

ID: identification

27

MCH: Mean Corpuscular Hemoglobin MCHC: Mean Corpuscular Hemoglobin Concentration MCV: Mean Corpuscular Volume NHIRD:

MCH: Mean Corpuscular Hemoglobin

MCHC: Mean Corpuscular Hemoglobin Concentration

MCV: Mean Corpuscular Volume

NHIRD: National Health Insurance Research Database

RBC: Red Blood Cell

WBC: White Blood Cell

a

28

Figure 1

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Figure 2

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Figure 3

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Figure 4

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Figure 5

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Figure 6

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