Lin Min-Ting, Hsu Chien-Ning, Lee Chien-Te, Cheng Shou-Hsia
Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan.
Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
Int J Health Policy Manag. 2022 Aug 1;11(8):1307-1315. doi: 10.34172/ijhpm.2021.27. Epub 2021 Apr 13.
With the promising outcomes of the pre-ESRD (end-stage renal disease) pay-for-performance (P4P) program, the National Health Insurance Administration (NHIA) of Taiwan launched a P4P program for patients with early chronic kidney disease (CKD) in 2011, targeting CKD patients at stages 1, 2, and 3a. This study aimed to examine the long-term effect of the early-CKD P4P program on CKD progression.
We conducted a matched cohort study using electronic medical records from a large healthcare delivery system in Taiwan. The outcome of interest was CKD progression to estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m between P4P program enrolees and non-enrolees. The difference in the cumulative incidence of CKD progression between the P4P and non-P4P groups was tested using Gray's test. We adopted a cause-specific (CS) hazard model to estimate the hazard in the P4P group as compared to non-P4P group, adjusting for age, sex, baseline renal function, and comorbidities. A subgroup analysis was further performed in CKD patients with diabetes to evaluate the interactive effects between the early-CKD P4P and diabetes P4P programs.
The incidence per 100 person-months of disease progression was significantly lower in the P4P group than in the non-P4P group (0.44 vs. 0.69, <.0001), and the CS hazard ratio (CS-HR) for P4P program enrolees compared with non-enrolees was 0.61 (95% CI: 0.58-0.64, <.0001). The results of the subgroup analysis further revealed an additive effect of the diabetes P4P program on CKD progression; compared to none of both P4P enrolees, the CS-HR for CKD disease progression was 0.60 (95% CI: 0.54-0.67, <.0001) for patients who were enrolled in both early-CKD P4P and diabetes P4P programs.
The present study results suggest that the early-CKD P4P program is superior to usual care to decelerate CKD progression in patients with early-stage CKD.
鉴于终末期肾病（ESRD）前绩效付费（P4P）项目取得了令人满意的成果，台湾地区国民健康保险署（NHIA）于2011年针对早期慢性肾脏病（CKD）患者推出了一项P4P项目，目标人群为1、2和3a期的CKD患者。本研究旨在探讨早期CKD的P4P项目对CKD进展的长期影响。
我们利用台湾一个大型医疗服务系统的电子病历进行了一项匹配队列研究。感兴趣的结局是P4P项目参与者和非参与者中CKD进展为估计肾小球滤过率（eGFR）<45 mL/min/1.73 m²的情况。使用Gray检验来检验P4P组和非P4P组之间CKD进展累积发生率的差异。我们采用特定病因（CS）风险模型来估计P4P组与非P4P组相比的风险，并对年龄、性别、基线肾功能和合并症进行了调整。对患有糖尿病的CKD患者进一步进行亚组分析，以评估早期CKD的P4P项目与糖尿病P4P项目之间的交互作用。
P4P组每100人月的疾病进展发生率显著低于非P4P组（0.44对0.69，P<0.0001），P4P项目参与者与非参与者相比的CS风险比（CS-HR）为0.61（95%CI：0.58-0.64，P<0.0001）。亚组分析结果进一步揭示了糖尿病P4P项目对CKD进展的叠加效应；与两个P4P项目都未参与的患者相比，同时参与早期CKD的P4P项目和糖尿病P4P项目的患者发生CKD疾病进展的CS-HR为0.60（95%CI：0.54-0.67，P<0.0001）。
本研究结果表明，早期CKD的P4P项目在减缓早期CKD患者的CKD进展方面优于常规治疗。
