This study proposes a multi-level model of institutional innovation in the healthcare sector-in other words, field-level institutional change pressures that start as network-level institutional innovation by hospitals and government for their organizational performance, with an emphasis on the effect of organizational-level construct-knowledge creation capabilities. A case study using in-depth interviews and a historical inquiry approach has been used to qualitatively analyze our cases during the development of Taiwan\'s National Health Insurance (NHI). Our results propose a multi-level explanation of institutional innovation by showing how field-level institutional change pressures can stimulate the government\'s institutional innovation at the network level. Moreover, knowledge creation capabilities may positively influence the government hospitals\' ongoing institutional change pressures induced institutional innovation activity for their performance at the organizational level in an institutional setting. This study contributes to health organization management researchers and administrators by developing explanations of institutional innovation and creating a much-needed multi-level insight into hospital behavior in the highly institutionalized healthcare sector.

Background and Objectives: Direct-acting antiviral agents (DAA) are a safe and highly effective treatment for hepatitis C virus (HCV) infection. However, the uptake of DAA treatment remains a challenge. This study aims to examine the reasons for DAA refusal among HCV patients covered by the Taiwan National Health Insurance system. Materials and Methods: This retrospective observational study covered the period from January 2009 to December 2019 and was conducted at a single hepatitis treatment center in Taiwan. This study involved chart reviews and phone-based surveys to confirm treatment status and refusal causes. To confirm treatment status, subjects with HCV without treatment records were phone-contacted to confirm treatment status. Patients who did not receive treatment were invited back for treatment. If the patient refused, the reason for refusal was discussed. Results: A total of 3566 patients were confirmed with DAA treatment; 418 patients (179 patients who were lost to contact or refused the survey and 239 patients who completed the survey of DAA refusal) were included in the no-DAA-therapy group. Factors associated with receiving DAAs were hemoglobin levels, hepatitis B virus co-infection, and regular gastroenterology visits. Meanwhile, male sex, platelet levels, and primary care physician visits were associated with DAA refusal. The leading causes of treatment refusal were multiple comorbidities, low health literacy, restricted access to hospitals, nursing home residence, and old age. The rate of DAA refusal remains high (10%). Conclusions: The reasons for treatment refusal are multifactorial, and addressing them requires complex interventions.