Chen Chi-Chen, Cheng Shou-Hsia
Department of Public Health, College of Medicine, Fu Jen Catholic University, Taipei, Taiwan and.
Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
Health Policy Plan. 2016 Feb;31(1):83-90. doi: 10.1093/heapol/czv024. Epub 2015 May 5.
Numerous studies have examined the impact of pay-for-performance (P4P) programmes, yet little is known regarding their effects on continuity of care (COC) and the role of multiple chronic conditions (MCCs). This study aimed to examine the effects of a P4P programme for diabetes care on health care provision, COC and health care outcomes in diabetic patients with and without comorbid hypertension.
This study utilized a large-scale natural experiment with a 4-year follow-up period under a compulsory universal health insurance programme in Taiwan. The intervention groups consisted of patients with diabetes who were enrolled in the P4P programme in 2005. The comparison groups were selected via propensity score matching with patients who were seen by the same group of physicians. A difference-in-differences analysis was conducted using generalized estimating equation models to examine the effects of the P4P programme.
Significant impacts were observed after the implementation of the P4P programme for diabetic patients with and without hypertension. The programme increased the number of necessary examinations/tests and improved the COC between patients and their physicians. The programme significantly reduced the likelihood of diabetes-related hospital admissions and emergency department visits [odds ratio (OR): 0.71; 95% confidence interval (CI): 0.63-0.80 for diabetic patients with hypertension; OR: 0.74; 95% CI: 0.64-0.86 for patients without hypertension]. However, the effects of the P4P programme diminished to some extent in the second year after its implementation.
This study suggests that a financial incentive programme may improve the provision of necessary health care, COC and health care outcomes for diabetic patients both with and without comorbid hypertension. Health authorities could develop policies to increase participation in P4P programmes and encourage continued improvement in health care outcomes.
众多研究探讨了按绩效付费（P4P）项目的影响，但对于其对医疗连续性（COC）的影响以及多重慢性病（MCCs）的作用却知之甚少。本研究旨在探讨糖尿病护理的P4P项目对有或无合并高血压的糖尿病患者的医疗服务提供、COC及医疗结果的影响。
本研究利用台湾强制性全民健康保险项目下为期4年随访期的大规模自然实验。干预组由2005年参加P4P项目的糖尿病患者组成。通过倾向得分匹配法，从由同一组医生诊治的患者中选取对照组。使用广义估计方程模型进行差分分析，以检验P4P项目的效果。
在实施P4P项目后，有或无高血压的糖尿病患者均观察到显著影响。该项目增加了必要检查/测试的次数，并改善了患者与其医生之间的COC。该项目显著降低了糖尿病相关住院和急诊就诊的可能性[比值比（OR）：0.71；95%置信区间（CI）：对于合并高血压的糖尿病患者为0.63 - 0.80；OR：0.74；95% CI：对于无高血压患者为0.64 - 0.86]。然而，P4P项目的效果在实施后的第二年有所减弱。
本研究表明，一项经济激励项目可能改善有或无合并高血压的糖尿病患者必要医疗服务的提供、COC及医疗结果。卫生当局可制定政策，以增加对P4P项目的参与，并鼓励持续改善医疗结果。
