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Downloaded from the Website of Taiwan's National Health Insurance Administration (TNHIA) from the Third Quarter of 2010 to the Third Quarter of 2016 JMIR MEDICAL INFORMATICS Kan et al Original Paper Therapeutic Duplication in Taiwan Hospitals for Patients With High Blood Pressure, Sugar, and Lipids: Evaluation With a Mobile Health Mapping Tool Wei-Chih Kan1,2, MD; Shu-Chun Kuo3,4*, MD; Tsair-Wei Chien5*, MBA; Jui-Chung John Lin6, DC; Yu-Tsen Yeh7, BSc; Willy Chou8,9*, MD; Po-Hsin Chou10,11*, MD 1Department of Nephrology, Chi Mei Medical Center, Tainan, Taiwan 2Department of Biological Science and Technology, Chung Hwa University of Medical Technology, Tainan, Taiwan 3Department of Ophthalmology, Chi Mei Medical Center, Tainan, Taiwan 4Department of Optometry, Chung Hwa University of Medical Technology, Tainan, Taiwan 5Medical Research, Chi Mei Medical Center, Tainan, Taiwan 6USA Sports Medicine, Sherman Oaks, CA, United States 7Medical School, St George's, University of London, London, United Kingdom 8Department of Physical Medicine and Rehabilitation, Chiali Chi Mei Hospital, Tainan, Taiwan 9Department of Physical Medicine and Rehabilitation, Chung Shan Medical University, Taichung, Taiwan 10Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan 11School of Medicine, National Yang-Ming University, Taipei, Taiwan *these authors contributed equally Corresponding Author: Po-Hsin Chou, MD Department of Orthopedics and Traumatology Taipei Veterans General Hospital 18F, 201, Section 2, Shipai Road, Beitou District Taipei, 112 Taiwan Phone: 886 228757557 Email: [email protected] Abstract Background: Cardiovascular disease causes approximately half of all deaths in patients with type 2 diabetes. Duplicative prescriptions of medication in patients with high blood pressure (hypertension), high blood sugar (hyperglycemia), and high blood lipids (hyperlipidemia) have attracted substantial attention regarding the abuse of health care resources and to implement preventive measures for such abuse. Duplicative prescriptions may occur by patients receiving redundant medications for the same condition from two or more sources such as doctors, hospitals, and multiple providers, or as a result of the patient's wandering among hospitals. Objective: We evaluated the degree of duplicative prescriptions in Taiwanese hospitals for outpatients with three types of medications (antihypertension, antihyperglycemia, and antihyperlipidemia), and then used an online dashboard based on mobile health (mHealth) on a map to determine whether the situation has improved in the recent 25 fiscal quarters. Methods: Data on duplicate prescription rates of drugs for the three conditions were downloaded from the website of Taiwan's National Health Insurance Administration (TNHIA) from the third quarter of 2010 to the third quarter of 2016. Complete data on antihypertension, antihyperglycemia, and antihyperlipidemia prescriptions were obtained from 408, 414, and 359 hospitals, respectively. We used scale quality indicators to assess the attributes of the study data, created a dashboard that can be traced using mHealth, and selected the hospital type with the best performance regarding improvement on duplicate prescriptions for the three types of drugs using the weighted scores on an online dashboard. Kendall coefficient of concordance (W) was used to evaluate whether the performance rankings were unanimous. Results: The data quality was found to be acceptable and showed good reliability and construct validity. The online dashboard using mHealth on Google Maps allowed for easy and clear interpretation of duplicative prescriptions regarding hospital performance https://medinform.jmir.org/2020/7/e11627 JMIR Med Inform 2020 | vol. 8 | iss. 7 | e11627 | p. 1 (page number not for citation purposes) XSL·FO RenderX JMIR MEDICAL INFORMATICS Kan et al using multidisciplinary functionalities, and showed significant improvement in the reduction of duplicative prescriptions among all types of hospitals. Medical centers and regional hospitals showed better performance with improvement in the three types of duplicative prescriptions compared with the district hospitals. Kendall W was 0.78, indicating that the performance rankings were not unanimous (Chi square2=4.67, P=.10). Conclusions: This demonstration of a dashboard using mHealth on a map can inspire using the 42 other quality indicators of the TNHIA by hospitals in the future. (JMIR Med Inform 2020;8(7):e11627) doi: 10.2196/11627 KEYWORDS duplicate medication; mHealth; hypertension; high blood sugar; high blood lipid in a specific period) [14]. A total of 12 indicators of duplicative Introduction prescriptions (ie, types of drugs used in the treatment of Cardiovascular disease causes approximately half of all deaths diseases) have been included and announced quarterly by the in patients with type 2 diabetes [1,2]. At the population level, TNHIA [19] to help health care providers facilitate management an increasing proportion of all cardiovascular events can be so as to reduce the rate of duplicative prescriptions. attributed to the presence of diabetes [3]. Many epidemiological Furthermore, increasing the transparency of hospitals is a studies have shown a direct relationship between the levels of requirement to improve administration with regard to patient blood pressure, glycemia, low-density lipoprotein-cholesterol, safety [20-22]; therefore, disclosing the performance of hospitals and complications of diabetes [4-7]. However, the therapeutic in effectively controlling duplicative prescriptions to the public duplication of medication in patients with high blood pressure, is required. If a hospital wants to achieve improvement in patient high blood sugar, and high blood lipids has attracted substantial safety, inspection of a publicly available quality reporting system attention to prevent the abuse of health care resources. is essential. Indeed, transparency has been demonstrated as the Duplicative prescriptions refer to situations in which patients most powerful driver of health care improvement [23]. receive redundant medications for the same condition from two By searching for the key words ªduplicative prescriptionsº on or more sources [8] such as doctors, hospitals [9,10], multiple PubMed on April 22, 2020, only one paper [13] was retrieved providers [11], or as a result of the patient's wandering, in which that reported duplicative prescriptions using social network they move from hospital to hospital for the same condition [12]. analysis (SNA). We did not find any study proposing an Doctor (or hospital) shopping (ie, seeking care from multiple appropriate method to decrease the number of duplicative doctors without professional referral for the same or similar prescriptions. That is, when using SNA for interpreting conditions) is common in Asia [9,13]. According to Takahashi duplicative prescriptions [6], the management perspective is et al [13], approximately 5.8% of outpatients in Japan limited in identifying key viewpoints that should be considered self-reported that they visited multiple medical facilities for in dealing with the duplicative prescription issue. treatment of the same conditions. The SNA approach [24-27] is used to define facilities as the The prevalence of duplicative prescriptions is estimated at 7.4% ªnodesº of a prescribing network connected to another node in Japan [13], which is higher than the rate of 0.43% in Taiwan (eg, a square box) with a patient duplicative prescription [14] due to the use of different definitions regarding the represented as an edge (eg, a connecting arrow). For example, Anatomical Therapeutic Chemical (ATC) classification in which a string of ª4 3 1º denotes that node 4 prescribed a duplicative the first three five digits are used in Japan and Taiwan, medication via a patient (with a weight of 1) to node 3 using respectively. The management criteria (or tolerance thresholds) the displayed graphical presentation in which node 4 is of duplicative prescriptions in Taiwan are set at 0.5805%, connected to node 3 with an arrow. 0.4273%, 0.5934%, 1.2866%, and 0.9214% for a medical center, regional hospital, local hospital, clinic, and pharmacy, The objectives of the present study were to (1) assess the respectively [15], leading the Taiwan National Health Insurance attributes of the study data using scale quality indicators, (2) Administration (TNHIA), which operates under the Ministry create a dashboard (ie, a control panel on a webpage that collates of Health and Welfare, to strongly express concern about the visual information about an issue or a topic that can be practice of duplicative prescriptions. manipulated by readers themselves [28] and can be traced using mobile health [mHealth]), and (3) select the hospital type that From the perspective of therapeutic safety and excess shows the best performance in improving duplicate prescriptions expenditures, patients who receive medical care from different of three types of medications (antihypertension, medical facilities are more likely to receive duplicative antihyperglycemia, and antihyperlipidemia) using the weighted prescriptions and suffer adverse drug reactions [9,16-18]. The scores across the types of hospital and performance percentages prevalence of duplicative prescriptions was defined by the on an online dashboard. Finally, the Kendall coefficient of TNHIA as the practice of a patient who receives identical concordance (W) [29,30] was used to evaluate the unanimity of medications (based on the first five digits of the ATC) from an the performance rankings. identical facility (eg, hospital or clinic) for a period
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