Hsieh Hui-Min, Lin Tsung-Hsien, Lee I-Chen, Huang Chun-Jen, Shin Shyi-Jang, Chiu Herng-Chia
Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan.
Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Taiwan.
Prev Med. 2016 Apr;85:53-59. doi: 10.1016/j.ypmed.2015.12.013. Epub 2015 Dec 29.
Diabetes and diabetes-related complications are major causes of morbidity and mortality worldwide and contribute substantially to health care costs. Proper care can prevent or delay vascular complications in people with type 2 diabetes. We sought to examine whether a diabetes pay-for-performance (P4P) program under Taiwan's National Health Insurance program decreased risk of macrovascular complications in type 2 diabetes patients, and associated risk factors.
We conducted a longitudinal observational case and control cohort study using two nationwide population-based databases in Taiwan, 2007-2012. Type 2 diabetes patients with a primary diabetes diagnosis in year 2007 and 2008 were included. We excluded patients with any diabetes complications within 2years before the index date. A propensity score matching approach was used to determine comparable P4P and non-P4P groups. We followed each P4P and non-P4P patient until December 31, 2012. Complication incidence rates per 1000 person-years for each complication were calculated.
Overall, our results indicated that P4P patients had lower risk of macrovascular complications than non-P4P patients. Specifically, hazard ratios (95% confidence intervals) were 0.84 (0.80-0.88) for stroke, 0.83 (0.75-0.92) for myocardial infarction, 0.72 (0.60-0.85) for atrial fibrillation, 0.93 (0.87-0.98) for heart failure, 0.61 (0.50-0.73) for gangrene, and 0.83 (0.74-0.93) for ulcer of lower limbs.
Compared with patients not enrolled in the P4P program, P4P patients had lower risk of developing serious vascular complications. Our empirical findings provide evidence for the potential long-term benefit of P4P programs in reducing risks of macrovascular complications.
糖尿病及糖尿病相关并发症是全球发病和死亡的主要原因，且极大地增加了医疗成本。恰当的护理可预防或延缓2型糖尿病患者的血管并发症。我们试图研究台湾国民健康保险计划下的糖尿病绩效付费（P4P）项目是否降低了2型糖尿病患者大血管并发症的风险及相关危险因素。
我们利用台湾两个基于全国人口的数据库，于2007年至2012年进行了一项纵向观察性病例对照队列研究。纳入2007年和2008年初次诊断为糖尿病的2型糖尿病患者。我们排除了索引日期前2年内有任何糖尿病并发症的患者。采用倾向得分匹配方法确定可比的P4P组和非P4P组。我们对每位P4P和非P4P患者随访至2012年12月31日。计算每种并发症每1000人年的并发症发生率。
总体而言，我们的结果表明，P4P患者发生大血管并发症的风险低于非P4P患者。具体而言，中风的风险比（95%置信区间）为0.84（0.80 - 0.88），心肌梗死为0.83（0.75 - 0.92），心房颤动为0.72（0.60 - 0.85），心力衰竭为0.93（0.87 - 0.98），坏疽为0.61（0.50 - 0.73），下肢溃疡为0.83（0.74 - 0.93）。
与未参加P4P项目的患者相比，P4P患者发生严重血管并发症的风险更低。我们的实证研究结果为P4P项目在降低大血管并发症风险方面的潜在长期益处提供了证据。
