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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
PII:
DOI:
Reference:

S0169-2607(15)00093-0
http://dx.doi.org/doi:10.1016/j.cmpb.2015.04.007
COMM 3915

To appear in:

Computer Methods and Programs in Biomedicine

Received date:
Revised date:
Accepted date:

26-10-2014
12-4-2015
13-4-2015

Please cite this article as: K.-H. Chen, J.-M. Wu, T.-W. Ho, H.-J. Yu, F. Lai, A CrossHospital 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

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Physician Order Set from a Nationwide Health Insurance Research Database

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Kuo-Hsin Chen5,#, MD; Jin-Ming Wu1,4,#, MD; Te-Wei Ho1, MS; Hwan-Jeu Yu2,*,
PhD; and Feipei Lai1,2,3, PhD

Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan

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University, Taiwan
2

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Department of Computer Science and Information Engineering, National Taiwan


University, Taiwan
Department of Electrical Engineering, National Taiwan University, Taiwan

Department of Surgery, National Taiwan University Hospital, Taiwan

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

# Equally contributing to this work

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*Corresponding author

Tel: +886- 910126148; Fax: +886-2-23123456

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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

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.
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A higher consistency index leads to lower recurrence rates.

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Abstract

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Purpose

Clinical pathways fall under the process perspective of health care quality. For care

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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

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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 20032007 for frequent

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physician order sets found in hospital surgical hernia repair inpatient claim records.

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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
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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 (70.9923.88 vs. 52.6020.30; P<.001), few surgeons at

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each hospital (3.504.41 vs. 7.096.57; P<.001), and non-medical center facility type
(P=.042). A multivariable Cox regression analysis indicated an association of low

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recurrence rates with consistency index only (one percentage increased: OR=0.973;

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CI:0.9570.990; P=.002).

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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

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Keywords

compare and query similarities and differences in clinical pathways among hospitals.

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

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Introduction

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Health Service Quality and Clinical Pathways


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

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

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care service quality [1]. This model classified the quality of care into three
perspectives: structure, process, and outcome. The structure perspective focused on

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"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

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associated with the three health service delivery perspectives noted above. There are
many concerns associated with implementing these three health service delivery

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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
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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,

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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

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

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common diagnostic and therapeutic procedures in clinical practice [6]. The


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

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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

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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

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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
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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

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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

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

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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

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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

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Objectives

pathways.

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

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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
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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

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across all hospitals.


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

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

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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

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potential of our approach.

Materials and Methods

Data Source

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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

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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 description and amount, special
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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

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patients.

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Subjects Selection

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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

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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.

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Data Preparation and Aggregation

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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,
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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

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decide whether to drill down to the individual data records.

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Frequent Physician Order Sets

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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

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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,

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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

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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 118 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
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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:

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Consistency Index =
Where

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

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FrequencyOrderCountk: number of physician orders reaching


FrequencyPercentagek

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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 = (1880% + 1785% + 1690% + 1295% + 3100%) /

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(2080% + 2085% + 2090% + 2095% + 20100%)


= 64.11%

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In an extreme condition, if all of the FrequencyOrderCountk = 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
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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 hospitals comorbidity status

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with the Charlson scores.

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Recurrence

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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)

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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

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order sets.

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

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
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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

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System Architecture

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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

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

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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
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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

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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

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

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the first time was about 6.520.77 per ten thousand (652/1,000,000).

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

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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, 1.720.39, and the average number of physician orders applied to patients was

34.333.98(416/12). The recurrence rate was 3.130.04%(32/1,052), and the average

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amount of cost per case was 40,0686,468(480,816/12).


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

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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.
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Comparison of Three Medical Centers


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

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threshold of frequent physician order sets. For convenience, the system displayed the
results of the comparison (including Charlson score, recurrence rate, categorized

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

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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

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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,

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examinations.

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

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 (70.9923.88 vs.
52.6020.30; P<.001), small number of surgeons at each hospital (3.504.41 vs.

7.096.57; 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
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rates (one percentage increased: OR=0.973; CI:0.9570.990; P=.002).

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Discussion

Principal Results and Improvement Actions

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

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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

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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:


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

2.

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frequency threshold.

1.

Compute the consistency index based on the derived frequent physician order

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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
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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

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comparative data to better understand the hospital eco-system, their current practices,
and ways to improve current practices.

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

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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

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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

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operations, such as cancer, are examined.

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

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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].

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Limitations

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Weight of Physician Orders


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

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

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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

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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

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Variance of Physicians

of physician orders and mortality.

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

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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.
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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

data mining association items or sequential items in future work.

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

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

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purpose. In the future, the system can be improved to provide general-purpose queries
for any procedure code operation.

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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

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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

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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
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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

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

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Acknowledgement: nil

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Conflicts of Interest

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None declared.

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

Tables

80% 85% 90% 95% 100%

05216K

02006K

03001K

57017B

96025B

96026B

32001C

08036B

08011C

an

12 18001C

14 A013718277

15 39004C

16 48011C

17 96007C

18 03026K

te

13 75607C

Ac
ce
p

11 09005C

10 08013C

us

cr

Order Code

ip
t

Table 1. Frequent physician order sets by various frequency thresholds

Table 2. Top twelve case count by hospital


Type

Cases Recurrence

Avg.
Charlson 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

Page 22 of 34

66

2(3.03%)

1.29

40,982

34

Medical Center

66

3(4.55%)

1.59

43,067

37

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

87.67 2.75(3.13%)

1.72

40,068

34.33

Average

ip
t

H Medical Center

Category Name

cr

Table 3. Categorized amount of cost for a hospital

Amount
3,722

us

Basic Medical
Laboratory Examination

1,852

203

Injection
Therapeutic Treatment
Anesthesia

13,517
4,263

Special Material

55

Diagnosis Related Group(DRG)

1,656
38,864

Ac
ce
p

te

Total

13,346

Other

66

184

Operation

an

X-RAY

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%

34

16

15

11

32.68%

32

18

17

17

12

40.66%

33

16

14

13

11

34.92%

31

16

16

16

12

41.00%

40

22

21

18

13

37.78%

33

24

24

22

19

13

59.12%

34

22

20

17

13

45.96%

37

20

19

17

17

13

50.07%

38

23

23

20

17

46.31%

40

19

19

18

14

37.14%

38

22

20

17

14

38.71%

23

Page 23 of 34

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

1.61

2.20

1.62

5.06%

3.03%

0.00%

Basic Medical

3,787

3,826

Laboratory Examination

1,519

1,344

Charlson Score
Recurrence Rate

257

Injection

72

Therapeutic Treatment
Blood Transfusion and Bone Marrow
Transplantation
Anesthesia

Special Material

Diagnosis Related Group(DRG)

77

66

234

177

184

13,615

13,816

13,517

3,369

3,224

4,263

22

67

55

18,390

5,828

13,346

1,019

1,230

1,656

42,417

29,787

38,864

133

te

Total

Other

203

an

Operation

1,852

198

us

X-RAY

3,722

cr

Categorized Amount of Cost

ip
t

Care Provider

Ac
ce
p

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

5 08011C

CBC-I (WBC,RBC,Hb,Hc,platelet
count,MCV,MCH,MCHC )

6 08036B

Activated Partial Thromboplastin Time

7 09002C

General Biochemistry Examination - BUN, blood urea


nitrogen

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

v v
v v v

24

Page 24 of 34

0
General Biochemistry Examination - K(Potassium)

v v

1
09023C
2

General Biochemistry Examination - Cl (Chloride)

1
09025C
3

General Biochemistry Examination - Asparate


Aminotransferase (AST)(GOT)

1
09029C
4

General Biochemistry Examination - Bilirubin total

1
18001C
5

E.K.G. (Electrocardiography)

1
32001C
6

Chest Examination

1
39004C
7

Parenteral Fluid

1
48011C
8

Change Dressing - small(<10cm)

1
57017B
9

Pulse or Ear Oximetry

2
75607C
0

Repair of Inguinal Hernia - without bowel resection

2
96007C
1

Spinal Anesthesia

ip
t

1
09022C
1

v v v

cr

te

an

us

v v v
v v v
v v v
v v
v v v
v v v

Ac
ce
p

v v

2
96025B
2

Anesthesia Recovery Care Fee

v v v

2
96026B
3

Pre-Anesthesia Evaluation

v v v

2
A013382100
4

Cathartics And Laxatives

v v

2
A013718277
5

Replacement Preparations Composite - 5% / 0.45%


Injection

2
A020444100
6

Miscellaneous Analgesics And Antipyretics Acetaminophen

2
A025485209
7

Replacement Preparations Composite - 5% / 0.225%


Injection

2
A033698277
8

Antibiotics Cephalosporins

2 NCS010005NP Special Material - 5 cc Syringe

v
v
v
v

25

Page 25 of 34

9 W
3 NDN041622N
Special Material - IV Catheter(Teflon)
0 BD

3 NDN041622N
Special Material -IV Catheter(Teflon)
1 TM

ip
t

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


Recurrence rate <2%

cr

P value

us

Recurrence rate 2%
70.99 23.88

52.6020.30

Charlson score

1.871.33

1.880.87

.953

Average cases per


surgeon at each
hospital

2.214.28

2.892.82

.133

Number of surgeons
at each hospital

3.504.41

7.096.57

<.001

Regional hospital

12

46

33

128

31

Ac
ce
p

District hospital

te

Medical center

<.001

.042

Hospital type

an

Consistency index(%)

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


herniorrhaphy
Predictor

Consistency index
Hospital type

Number of surgeons
at each hospital
a

P value

OR

95% CI (lowerupper)

.002

0.973

0.9570.990

.475

1.758

0.3738.279

.421

1.036

0.9501.129

Every 1% increased
Considered as categorical variable

26

Page 26 of 34

Figure legends
Figure 1. The selection of study subjects.

Figure 4. System architecture of the comparison system.

cr

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

ip
t

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

us

Figure 5. Hierarchy of functionalities within the comparison system.

an

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

applied at various frequency thresholds.

te

Abbreviations

AST: Aspartate Aminotransferase

Ac
ce
p

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

Page 27 of 34

MCH: Mean Corpuscular Hemoglobin


MCHC: Mean Corpuscular Hemoglobin Concentration
MCV: Mean Corpuscular Volume

ip
t

NHIRD: National Health Insurance Research Database


RBC: Red Blood Cell

cr

WBC: White Blood Cell

Ac
ce
p

te

an

us

28

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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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