Sheen Yi-Jing, Kung Pei-Tseng, Kuo Wei-Yin, Chiu Li-Ting, Tsai Wen-Chen
Department of Health Services Administration.
Department of Public Health, China Medical University.
Medicine (Baltimore). 2018 Oct;97(41):e12759. doi: 10.1097/MD.0000000000012759.
Patients with diabetes are at a high risk of lower extremity amputations and may have a reduced life expectancy. Taiwan has implemented a diabetes pay-for-performance (P4P) program providing team care to improve the control of disease and avoid subsequent complications. Few studies investigated the effects of adopting a nationalized policy to decrease amputation risk in diabetes previously. Our study aimed to analyze the impact of the P4P programs on the incidence of lower extremity amputations in Taiwanese patients with diabetes.This was a population-based cohort study using the Taiwan National Health Insurance Research Database (which provided coverage for 98% of the total population in Taiwan) from 1998 to 2007. Patients with diabetes were identified based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes. We linked procedure codes to inpatient claims to identify patients hospitalized for nontraumatic lower extremity amputations.A total of 9738 patients with diabetes with amputations were enrolled (mean age ± standard deviation: 64.4 ± 14.5 years; men: 63.9%). The incidence of nontraumatic diabetic lower extremity amputations decreased over the time period studied (3.79-2.27 per 1000 persons with diabetes). Based on the Cox proportional hazard regression model, male sex (hazard ratio: 1.83, 95% confidence interval [CI] 1.76-1.92), older age, and low socioeconomic status significantly interact with diabetes with respect to the risks of amputation. Patients who did not join the P4P program for diabetes care had a 3.46-fold higher risk of amputation compared with those who joined (95% CI 3.19-3.76).The amputation rate in Taiwanese diabetic patients decreased over the time period observed. Diabetes in patients with low socioeconomic status is associated with an increased risk of amputations. Our findings suggested that in addition to medical interventions and self-management educations, formulate and implement of medical policies, such as P4P program, might have a significant effect on decreasing the diabetes-related amputation rate.
糖尿病患者下肢截肢风险高，预期寿命可能缩短。台湾实施了糖尿病绩效付费（P4P）计划，提供团队护理以改善疾病控制并避免后续并发症。此前很少有研究调查采用国家化政策降低糖尿病截肢风险的效果。我们的研究旨在分析P4P计划对台湾糖尿病患者下肢截肢发生率的影响。
这是一项基于人群的队列研究，使用了1998年至2007年的台湾国民健康保险研究数据库（该数据库覆盖了台湾总人口的98%）。根据国际疾病分类第9版临床修订本（ICD-9-CM）诊断代码确定糖尿病患者。我们将手术代码与住院索赔相关联，以识别因非创伤性下肢截肢住院的患者。
总共纳入了9738例截肢的糖尿病患者（平均年龄±标准差：64.4±14.5岁；男性：63.9%）。在研究期间，非创伤性糖尿病下肢截肢的发生率有所下降（每1000例糖尿病患者中从3.79例降至2.27例）。基于Cox比例风险回归模型，男性（风险比：1.83，95%置信区间[CI] 1.76 - 1.92）、年龄较大以及社会经济地位较低在截肢风险方面与糖尿病存在显著交互作用。未参加糖尿病护理P4P计划的患者截肢风险比参加者高3.46倍（95% CI 3.19 - 3.76）。
在观察期内台湾糖尿病患者的截肢率有所下降。社会经济地位较低的患者患糖尿病后截肢风险增加。我们的研究结果表明，除了医疗干预和自我管理教育外，制定和实施P4P计划等医疗政策可能对降低糖尿病相关截肢率有显著效果。
