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Trauma Care in Taiwan -- an Epidemiological Analysis of Trauma Hospitalization and Transfer

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Trauma Care in Taiwan -- an Epidemiological Analysis of Trauma Hospitalization and Transfer Trauma Care in Taiwan -- An Epidemiological Analysis of Trauma Hospitalization and Transfer by Li-Chien Chien, MD, MBA A thesis submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Public Health Baltimore, Maryland May, 2014 © 2014 Li-Chien Chien All Rights Reserved ABSTRACT Background Traumatic injury is still a serious public health problem in Taiwan and often causes catastrophic consequences to the victims, their families and society. However, little is known about the treatment locations, hospitalization rate, interhospital transfer, and relationships among mortality, various demographics, preexisting conditions, injury severity, and socioeconomic factors at the population level in Taiwan. Methods Using the 2007-2008 total admission claims dataset from Taiwan’s National Health Insurance (NHI) system and a longitudinal NHI cohort dataset with a randomized population of one million, total trauma admissions and cases that involved transferring were selected for further analysis. The obtained data included patient demographics, trauma hospitalization rate, the percentage of interhospital emergency transfer (IHET) and the in-hospital mortality rate. We also aimed to analyze the factors that affect these dependent variables, such as gender, age, residency, pre-existing conditions (PECs), mechanisms of injury, associated injuries and severity. Results Medical centers (MC) definitively received only 25% of the injured patients, and regional hospitals (RH) admitted 45.6%. National trauma hospitalization rate found here is higher than that reported in other studies. Males had a higher probability of being admitted to MCs, being transferred to MCs and death. Elderly patients with severe injuries had a slightly lower probability of being admitted to an MC, a lower probability of being transferred to an MC and a higher in-hospital mortality rate. Rural residents had a lower probability of being admitted to an ii MC, a higher probability of being transferred to an MC and a higher risk of death. After proper propensity matching for patient characteristics, being treated at MCs is not associated with a lower risk of death. Patients who were rural residents, male, older than 64 years of age, or associated with severe anatomic injuries had a higher probability of experiencing an inter-hospital emergency transfer (IHET). However, having an IHET was not associated with a higher probability of death. Conclusion The inequality in accessibility to MCs and the effect of MCs on injured patients’ outcomes leave room for improvement. A policy that facilitates a regionalized trauma system to provide rural residents, the elderly and other vulnerable populations with optimal trauma care is mandatory. DISSERTATION COMMITTEE MEMBERS: Ellen J. MacKenzie, PhD, (Advisor) Meicheng Wang, PhD (Chair) Leiyu Shi, PhD Marie Nolan, PhD Matthew HueiMIng Ma, PhD (Public Health Practitioner) DISSERTATION COMMITTEE MEMBER ALTERNATES: Laura Morlock, PhD, Sukon Kanchanerak, PhD iii ACKNOWLEDGEMENTS First, I extend my sincerest gratitude to my advisor, Dr. Ellen J. MacKenzie, for all of her guidance, encouragement, tireless support and endless patience. To Dr. Leiyu Shi, I am bearing many thanks for all of his kind advice and guidance over the past eight years. I also deeply appreciate Dr. Mei-Cheng Wang, for her warm support and encouragement while serving my chair last two years. I also thank Dr. Marie Nolan and Dr Matthew Ma, for their guidance and mentoring in the dissertation process. I especially want to thank my colleague in MBA, Shih-Yu Yeh, her assistance on the data management is crucial and unforgettable. Many thanks are from my heart to Mary Sewell for her friendship and kindest support for these two years in the HPM department. I also want to thank the superintendent of my hospital, Dr. Su-Shun Lo and the ex-superintendent, Dr. Gau-Jun Tang, for generously allowing me for research. Appreciation was also extended to all the teachers, friends and classmates, Kenneth, Sharlene, Kevin, Allen, Alex Chen, Alex Chou, Angel, Simon, Amy, Irene, Esther, Johnny, Civvy, Keng-Han Lin, Dr. Ming-Che Weng, Dr. Jeremy C. Ying, Dr. Yandih Cheu, Dr. Yu-Chun Chen and Dr. Yea-Jen Hsu without whom I would not have fulfilled my dream that I had since 15 years ago when I worked in the emergency room dealing with the transferred, severely injured patients. Appreciations were also extended to Dr. Ann-Michelle Gundlack, Dr. Laura Morlock, Dr. Jenna Tsai, Judith Holzer, Dr. Adil Haider, Dr. Steve Bowmen, Ricky Fine, Rhonda H. McCray, Michelle Ward for their patience, kindness and endless help. Last, thanks to my family, Jean, Alan and Ann, and my parents and my elder brother, Dr. Li-Hsien Chien, and for all your unconditional love and support. And thank you, Jesus. iv TABLE OF CONTENTS ABSTRACT………………………………………………………………………….……………ii ACKNOWLEDGEMENTS..……………………………………………………….…...………iv LIST OF TABLES……………………………………………………………………….………vii LIST OF FIGURES………………………………………………………….……...…..……...viii CHAPTER ONE INTRODUCTION AND BACKGROUND 1.1 Overview and Historical Background……………………...……………….….…..…..1 1.2 Study Aims and Hypotheses…………………………….……………………….……..3 1.3 Significance………………….…………………………….………....……...…………5 CHAPTER TWO LITERATURE REVIEW 2.1 The Public Health Burden of Trauma in the USA and Taiwan……..….……………....7 2.2 Development and Benefits of a Regionalized Approach to Trauma Care in the United Sates and Taiwan. …………….………....…………………………………..……...….9 2.3 The System of Hospital Care in Taiwan, Specifically the Distribution and Classification of Hospitals …….………………….……….……………..………...…20 2.4 Development and Use of the National Health Insurance Research Database in Trauma Research in Taiwan……….……………………….………………..……....……....…28 2.5 Behavioral Model of Health Service Use……………….……...…….....…………….30 CHAPTER THREE MATERIALS AND METHODS 3.1 Study Aims and Hypotheses……………………………….………………………….34 3.2 Study Rationale and Conceptual Framework .…………….………………………….36 3.3 Data Resource………………………….…………….………….…………………….38 3.4 Variables………………………….…………….………….………………………….40 3.5 Statistical Analysis …………………………………….…….….…………………….44 CHAPTER FOUR AN EPIDEMIOLOGICAL ANALYSIS OF PATIENT DEMOGRAPHICS, TRAUMA HOSPITALIZATION RATE, AND THE EFFECT OF PATIENTS’ DEMOGRAPHICS, PREEXISTING CONDITIONS, AND INJURY SEVERITY ON THE PROBABILITY OF BEING DEFINITIVELY TREATED IN MEDICAL CENTERS 4.1 RESULTS ………………………… .…………….…………………………………..49 v 4.2 DISCUSSION …………………… .…………….………………………………..…..55 CHAPTER FIVE AN EPIDEMIOLOGICAL ANALYSIS OF THE EFFECT OF PATIENTS’ DEMOGRAPHICS, PREEXISTING CONDITIONS, INJURY SEVERITY, AND TREATMENT LOCATION ON THE IN-HOSPITAL MORTALITY RATE 5.1 RESULTS ….…………………….…….……….………………………………..…..73 5.2 DISCUSSION…….……………….…….……….…………………………………..78 CHAPTER SIX AN EPIDEMIOLOGICAL ANALYSIS OF THE INTER-HOSPITAL EMERGENCY TRANSFER RATE AMONG PATIENTS WHO WERE DEFINITIVELY TREATED AT MEDICAL CENTERS AND THE EFFECT OF PATIENTS’ DEMOGRAPHICS, PREEXISTING CONDITIONS, INJURY SEVERITY AND THE STATUS OF BEING TRANSFERRED ON THE IN-HOSPITAL MORTALITY RATE 6.1 RESULTS ……………………….…….……….………………………………...…..92 6.2 DISCUSSION…………………….…….……….……………………………….…..97 CHAPTER SEVEN POLICY IMPLICATIONS AND CONCLUSION 7.1 Summary of Findings…..………….…….……………………………….................111 7.2 Policy Implications of Findings………….…….……………………………….......112 7.3 Future Research ……………….…….……….……………………………….….....124 7.4 Conclusion…...……………….…….……….……………………………….…..... 126 REFERENCES…………………………………………………………………………………126 CURRICULUM VITAE……………………………………………………………………….142 vi LIST OF TABLES Table 3-1 Definitions of Preexisting Conditions………………………………………………..48 Table 4-1 Trauma Hospitalizations rate by Age Groups in Taiwan…………………………….66 Table 4-2 Patients Characteristics by Place of Treatment………………………………………67 Table 4-3 Injury Characteristics by Place of Treatment………………………………………...69 Table 4-4 Regression Results: Adjusted Odds of Being Treated at a Medical Center, All Patients……………………………………………………………………………………71 Table 4-5 Regression Results: Adjusted Odds of Being Treated at a Medical Center, the Patients with ICD/ISS >15…………………………………………………………………………72 Table 5-1 Distribution of Hospital Mortality by Level of Hospital and ICD/ISS Score………………………………………………………………………………………85 Table 5-2 Distribution of Hospital Mortality by Age and ICD/ISS Score……………………...86 Table 5-3 Distribution of Mortality by Mechanisms of Injury…………………………………87 Table 5-4 Relative Odds of Risk Factors for In-hospital Mortality due to Injuries…………………………………………………………………………………….88 Table 5-5 Relative Odds of Risk Factors for In-hospital Mortality due to Severe Injuries (ISS >15) ………………………………………………………………………………………89 Table 5-6 Results of Propensity Score Matching ………………………………………………90 Table 5-7 Relative Odds of In-hospital Mortality due to Injuries Associated with Risk Factors After Propensity Score Matching ………………………………………………………...91 Table 6-1 Patients Demographics: Comparison of Direct Admission (DA) to Medical Centers and Interhospital Emergency Transfer (IHET) ……………………………………….…104 Table 6-2 Characteristics of Mechanisms of Injury: Comparison of DA and IHET……………………………………………………………………………………..106 Table 6-3 Mortality Rate in Different ICD/ISS Strata: Comparison of DA and IHET…………………………………………………………………………………..…107 Table 6-4 Regression results: Adjusted Odds of Being Treated at a RH or LH Initially Then Transferred to a MC (IHET) ……………………………………………………………108 Table 6-5 Regression results: Adjusted Odds of Being an IHET to a MC (for ISS > 15) ……………………………………………………………………………………….109 Table
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