Chen Yu-Ching, Lee Charles Tzu-Chi, Lin Boniface J, Chang Yong-Yuan, Shi Hon-Yi
Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung Department of Health Promotion and Health Education, National Taiwan Normal University, Taipei College of Medicine, Fu Jen Catholic University, New Taipei College of Medicine, National Taiwan University, Taipei, Taiwan.
Medicine (Baltimore). 2016 Jul;95(27):e4197. doi: 10.1097/MD.0000000000004197.
The impact of pay-for-performance (P4P) programs on long-term mortality for chronic illnesses, especially diabetes mellitus, has been rarely reported. Several studies described the favorable impact of P4P for diabetes mellitus on medical utilizations or intermediate outcomes. Therefore, this study aimed to investigate the impact of a P4P program on mortality in patients with type 2 diabetes.
The P4P group in this population-based cohort study was 2090 individuals with a primary diagnosis of type 2 diabetes who had been newly enrolled in the P4P program of Taiwan between January 1, 2004 and December 31, 2004. Matched by 1:1 ratio, patients in the non-P4P group were selected by propensity score matching (PSM) for sex, age, the first year of diagnosis as diabetes, and 32 other potential confounding factors. Mean (SD) age was 60.91 (12.04) years when diabetes was first diagnosed and mean (SD) duration of diabetes was 4.3 (1.9) years at baseline. The time-dependent Cox regression model was used to explore the impact of P4P on all-cause mortality.
During a mean of 5.13 years (SD = 1.07 years) of follow-up, 206 and 263 subjects died in the P4P group and the non-P4P group, respectively. After adjusting for the potential confounding factors at baseline, survival was significantly longer in the P4P group than in the non-P4P group (hazard ratio, 0.76 [95% confidence interval, 0.64-0.92], P = 0.004, by log-rank test). This decrease in mortality is equivalent to one less death for every 37 patients who were treated in the P4P program for 5.13 years. In this study, the P4P program significantly increased the medical utilization of physician visits and diabetes-related examinations, improved the adherence of oral hypoglycemic drugs during the first 3 years and that of insulin during the second 3 years, and was negatively associated with risk of cancer and chronic kidney disease. In annual health expense, there was no significant difference between P4P and non-P4P groups, P = 0.430.
As compared with control, pay-for-performance program significantly improved survival in patients with diabetes without increasing the medical cost. The P4P group had significantly lower risk of cancer and chronic kidney disease.
绩效薪酬(P4P)计划对慢性病尤其是糖尿病患者长期死亡率的影响鲜有报道。多项研究描述了P4P对糖尿病患者医疗利用或中间结局的有利影响。因此,本研究旨在探讨P4P计划对2型糖尿病患者死亡率的影响。
在这项基于人群的队列研究中,P4P组为2090例初诊为2型糖尿病且于2004年1月1日至2004年12月31日新加入台湾P4P计划的个体。非P4P组患者按1:1比例通过倾向得分匹配(PSM)法选取,匹配因素包括性别、年龄、糖尿病诊断的第一年以及其他32个潜在混杂因素。首次诊断糖尿病时的平均(标准差)年龄为60.91(12.04)岁,基线时糖尿病的平均(标准差)病程为4.3(1.9)年。采用时间依赖性Cox回归模型探讨P4P对全因死亡率的影响。
在平均5.13年(标准差 = 1.07年)的随访期间,P4P组和非P4P组分别有206例和263例受试者死亡。在对基线潜在混杂因素进行调整后,P4P组的生存期显著长于非P4P组(风险比,0.76 [95%置信区间,0.64 - 0.92],经对数秩检验,P = 0.004)。这种死亡率的降低相当于在P4P计划中接受治疗5.13年的每37例患者中少发生1例死亡。在本研究中,P4P计划显著提高了门诊就诊和糖尿病相关检查的医疗利用率,在前3年提高了口服降糖药的依从性,在后3年提高了胰岛素的依从性,并且与癌症和慢性肾脏病风险呈负相关。在年度医疗费用方面,P4P组和非P4P组之间无显著差异,P = 0.430。
与对照组相比,绩效薪酬计划显著提高了糖尿病患者的生存率且未增加医疗成本。P4P组的癌症和慢性肾脏病风险显著较低。