Policy Spotlight Effects on Critical Time-Sensitive Diseases: Nationwide Retrospective Cohort Study on Taiwan’s Hospital Emergency Capability Categorization Policy

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BACKGROUND: Taiwan's categorization of hospital emergency capability (CHEC) policy is designed to regionalize and dispatch critical patients. The policy was designed in 2009 to improve the quality of emergency care for critical time-sensitive diseases (CTSDs). The CHEC policy primarily uses time-based quality surveillance indicators. OBJECTIVE: We aimed to investigate the impact of Taiwan's CHEC policy on CTSDs. METHODS: Using Taiwan's 2005 Longitudinal Health Insurance Database, this nationwide retrospective cohort study examined the CHEC policy's impact from 2005 to 2011. Propensity score matching and difference-in-differences analysis within a generalized estimating equation framework were used to compare pre- and postimplementation periods. The study focused on acute ischemic stroke (AIS), ST-segment elevation myocardial infarction (STEMI), septic shock, and major trauma. AIS and STEMI cases, monitored with time-based indicators, were evaluated for adherence to diagnostic and treatment guidelines as process quality measures. Mortality and medical use served as outcome indicators. Major trauma, with evolving guidelines and no time-based monitoring, acted as a control to test for policy spotlight effects. RESULTS: In our cohort of 9923 patients, refined through 1:1 propensity score matching, 5566 (56.09%) were male and were mostly older adults. Our analysis revealed that the CHEC policy effectively improved system efficiency and patient outcomes, resulting in significant reductions in medical orders (-7.29 items, 95% CI -10.09 to -4.48; P<.001), short-term mortality rates (-0.09%, 95% CI -0.17% to -0.02%; P=.01) and long-term mortality rates (-0.09%, 95% CI -0.15% to -0.04%; P=.001), and total medical expenses (-5328.35 points per case, 95% CI -10,387.10 to -269.60; P=.04), despite a modest increase in diagnostic fees (376.37 points, 95% CI 92.42-660.33; P=.01). The CHEC policy led to notable increases in diagnostic fees, major treatments, and medical orders for AIS and STEMI cases. For AIS cases, significant increases were observed in major treatments (β=0.77; 95% CI 0.21-1.33; P=.007) and medical orders (β=15.20; 95% CI 5.28-25.11; P=.003) compared to major trauma. In STEMI cases, diagnostic fees significantly increased (β=1983.75; 95% CI 84.28-3883.21; P=.04), while upward transfer rates significantly decreased (β=-0.59; 95% CI -1.18 to -0.001; P=.049). There were also trends toward increased major treatments (β=0.30; 95% CI -0.03 to 0.62, P=.07), medical orders (β=11.92; 95% CI -0.90 to 24.73; P=.07), and medical expenses (β=24,275.54; 95% CI -640.71 to 4,991,991.78; P=.06), although these were not statistically significant. In contrast, no significant changes were identified in process or outcome quality indicators for septic shock. These findings suggest policy spotlight effects, reflecting a greater emphasis on diseases directly prioritized under the CHEC policy. CONCLUSIONS: The CHEC policy demonstrated the dual benefits of reducing costs and improving patient outcomes. We observed unintended consequences of policy spotlight effects, which led to a disproportionate improvement in guideline adherence and process quality for CTSDs with time-based surveillance indicators.

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