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The Relationship between Strategy and Hemodialysis Performance: The Moderating Role of Competitive
Intensity

to economies of scale and can preclude the transactional costs of outsourcing, thereby
enhancing efficiency and health-care quality. However, outsourcing helps minimize a
hospital’s specific investments that can also promote efficiency. In the management of
hemodialysis-related operations, hospitals’ outsourcing partners are usually hemodialysis

equipment suppliers. Hospitals that adopt the outsourcing strategy may also experience
hemodialysis-related efficiency gains attributable to the nature of economies of scale. Our
findings have practical implications for the selection of hospital management strategies in

regions with various degrees of competitive intensity.
This study has some limitations that should be addressed in future research. First, the
results of this study suggest that competitive intensity moderates the relationship between
hospital management strategy and performance. However, a hospital’s competitors may
initiate competitive actions in response to strategies adopted by the hospital. This study

did not account for competitive actions. Future studies can explore the effect of competi-
tive actions on the strategy-performance relationship. Second, various indices can be used
to evaluate the quality of hemodialysis, including urea clearance rate (Kt/V), albumin, he-

moglobin (Hb), hematocrit (Hct), arteriovenous fistula reconstruction rate, renal transplan-
tation rate, hepatitis B surface antigen (HBsAg) conversion rate, and anti-HCV conversion
rate. Statistics related to each index are announced by the National Health Insurance Ad-
ministration at different intervals. For example, hemoglobin (Hb) statistics are announced
quarterly; Kt/V statistics, arteriovenous fistula reconstruction rates, and renal transplan-

tation rates are announced every six months; and HBsAg and anti-HCV conversion rates
are announced annually; and in 2013, hematocrit statistics are not announced but replaced
by hemoglobin statistics. As a result, to address concerns regarding completeness of data

and consistency of intervals, this study uses hemoglobin as a proxy for health-care quality
instead. Future studies can adopt multiple indices to evaluate the effects of different strat-
egies on different aspects of health-care quality. Third, this study excludes medical centers
and clinics, in which patients can also receive hemodialysis services. However, the glob-
al clinic budget allocated by the National Health Insurance Administration is one of the

funding sources for hemodialysis. Future research can combine hemodialysis data from
different levels of hospitals and clinics to further investigate the strategy-performance re-
lationship and the effects of regional factors. Finally, this study conducts a cross-sectional

analysis of data collected only over a two-year period. Additional data collection for longi-

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