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Somé NH, Devlin RA, Mehta N, Sarma S. Primary care payment models and avoidable hospitalizations in Ontario, Canada: A multivalued treatment effects analysis. HEALTH ECONOMICS 2024. [PMID: 38898671 DOI: 10.1002/hec.4872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 03/28/2024] [Accepted: 04/30/2024] [Indexed: 06/21/2024]
Abstract
Improving access to primary care physicians' services may help reduce hospitalizations due to Ambulatory Care Sensitive Conditions (ACSCs). Ontario, Canada's most populous province, introduced blended payment models for primary care physicians in the early- to mid-2000s to increase access to primary care, preventive care, and better chronic disease management. We study the impact of payment models on avoidable hospitalizations due to two incentivized ACSCs (diabetes and congestive heart failure) and two non-incentivized ACSCs (angina and asthma). The data for our study came from health administrative data on practicing primary care physicians in Ontario between 2006 and 2015. We employ a two-stage estimation strategy on a balanced panel of 3710 primary care physicians (1158 blended-fee-for-service (FFS), 1388 blended-capitation models, and 1164 interprofessional team-based practices). First, we account for the differences in physician practices using a generalized propensity score based on a multinomial logit regression model, corresponding to three primary care payment models. Second, we use fractional regression models to estimate the average treatment effects on the treated outcome (i.e., avoidable hospitalizations). The capitation-based model sometimes increases avoidable hospitalizations due to angina (by 7 per 100,000 patients) and congestive heart failure (40 per 100,000) relative to the blended-FFS-based model. Switching capitation physicians into interprofessional teams mitigates this effect, reducing avoidable hospitalizations from congestive heart failure by 30 per 100,000 patients and suggesting better access to primary care and chronic disease management in team-based practices.
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Affiliation(s)
- Nibene Habib Somé
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rose Anne Devlin
- Department of Economics, University of Ottawa, Ottawa, Ontario, Canada
| | - Nirav Mehta
- Department of Economics, Western University, London, Ontario, Canada
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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Tsai WC, Huang KH, Chen PC, Chang YC, Chen MS, Lee CB. Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single-payer health system. Soc Sci Med 2023; 326:115930. [PMID: 37146356 DOI: 10.1016/j.socscimed.2023.115930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 02/14/2023] [Accepted: 04/25/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Enrollment in and adherence to a diabetes pay-for-performance (P4P) program can lead to desirable processes and outcomes of diabetes care. However, knowledge is limited on the potential exclusion of patients with individual or neighborhood social risks or interruption of services in the disease-specific P4P program without mandatory participation under a single-payer health system. OBJECTIVE To investigate the impact of individual and neighborhood social risks on exclusion from and adherence to the diabetes P4P program of patients with type 2 diabetes (T2D) in Taiwan. METHODS This study used data from Taiwan's 2009-2017 population-based National Health Insurance Research Database, 2010 Population and Housing Census, and 2010 Income Tax Statistics. A retrospective cohort study was conducted, and study populations were identified from 2012 to 2014. The first cohort comprised 183,806 patients with newly diagnosed T2D, who had undergone follow up for 1 year; the second cohort consisted of 78,602 P4P patients who had undergone follow up for 2 years after P4P enrollment. Binary logistic regression models were used to examine the associations of social risks with exclusion from and adherence to the diabetes P4P program. RESULTS T2D patients with higher individual social risks were more likely to be excluded from the P4P program, but those with higher neighborhood-level social risks were slightly less likely to be excluded. T2D patients with the higher individual- or neighborhood-level social risks showed less likelihood of adhering to the program, and the person-level coefficient was stronger in magnitude than the neighborhood-level one. CONCLUSIONS Our results indicate the importance of individual social risk adjustment and special financial incentives in disease-specific P4P programs. Strategies for improving program adherence should consider individual and neighborhood social risks.
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Affiliation(s)
- Wen-Chen Tsai
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Kuang-Hua Huang
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Pei-Chun Chen
- International Master Program for Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Yu-Chia Chang
- Department of Long Term Care, National Quemoy University, 1 University Rd., Jinning Township, Kinmen County, 892009, Kinmen, Taiwan; Department of Healthcare Administration, Asia University, 500, Lioufeng Rd., Wufeng, Taichung City, 41354, Taiwan
| | - Michael S Chen
- Department of Social Welfare, National Chung Cheng University, 168 Section 1, University Rd., Minhsiung, Chiayi, 621301, Taiwan
| | - Chiachi Bonnie Lee
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan.
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The Effectiveness of Pay-for-Performance Program of Diabetes Care for Psychiatric Patients: A Regional Psychiatric Hospital Experience. Healthcare (Basel) 2021; 9:healthcare9111565. [PMID: 34828611 PMCID: PMC8624475 DOI: 10.3390/healthcare9111565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/13/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The Pay-for-performance (P4P) program of diabetes care has demonstrated successful outcomes in patients with type 2 diabetes. However, the effectiveness of this multidisciplinary care model for psychiatric patients has never been evaluated. The objective of this study is to examine the effectiveness of P4P program of diabetes for psychiatric patients with diabetes. METHODS This study utilized a retrospective cohort design to examine the effectiveness of P4P program of diabetes care for psychiatric patients with diabetes. The participants' HbA1c (hemoglobin A1c) data of the fourth quarter in 2018 were used as baseline value, while P4P program was not applied yet. HbA1c data of every quarter in 2019 were collected. Generalized estimating equations (GEE) was used to analyze the change of HbA1c level. RESULTS The HbA1c level increased slightly in the first quarter, and then decreased gradually since the second quarter. The HbA1c level was significantly lower in the fourth quarter after P4P program intervention (p < 0.05). CONCLUSION P4P program of diabetes care is also effective on psychiatric patients with diabetes, and this multidisciplinary care model could be encouraged and promoted for psychiatric patients with diabetes.
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Lee IT, Hsu CC, Sheu WHH, Su SL, Wu YL, Lin SY. Pay-for-performance for shared care of diabetes in Taiwan. J Formos Med Assoc 2019; 118 Suppl 2:S122-S129. [PMID: 31471222 DOI: 10.1016/j.jfma.2019.08.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/04/2019] [Accepted: 08/12/2019] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND/PURPOSE Comprehensive and continuous care is crucial for patients with diabetes. The diabetes pay-for-performance (P4P) program launched by the National Health Insurance (NHI) administration in Taiwan provides a financial incentive to facilitate this goal. In this study, we explored the characteristics of patients in the P4P program between 2005 and 2014. METHODS Data of patients with diabetes enrolled in the NHI program between 2005 and 2014 were extracted from the NHI research database. Patients were classed as having diabetes if they had three or more outpatient visits within 365 calendar days with an International Classification of Diseases, 9th Revision, Clinical Modification diagnostic code of 250 or hospitalization one or more times with such a diagnosis. The trends of participating in the P4P program were analyzed. RESULTS Participation rate of the P4P program increased from 12.1% to 19% between 2005 and 2014. Participants were younger and more likely to be female than those not participating in the program. Lower risks of cancer-related mortality, annual mortality and heart failure were seen in patients participating in the P4P program than in those not participating. CONCLUSION Older, male patients with a high disease severity may be less likely to enroll in the P4P program. Although participation rate is increasing, a broad enrollment is expected.
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Affiliation(s)
- I-Te Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; College of Science, Tunghai University, Taichung, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Shih-Li Su
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yi-Ling Wu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Shih-Yi Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Center for Geriatrics and Gerontology, Taichung Veterans General Hospital, Taichung, Taiwan.
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Chen TT, Hsueh YSA, Ko CH, Shih LN, Yang SS. The effect of a hepatitis pay-for-performance program on outcomes of patients undergoing antiviral therapy. Eur J Public Health 2018; 27:955-960. [PMID: 29020377 DOI: 10.1093/eurpub/ckx114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background To examine the effect of a participatory pay-for-performance (P4P) program in Taiwan on health outcomes for patients with severe hepatitis B or C. Methods This study adopted 4-year panel data from the databases of the National Health Insurance Administration (NHIA) in Taiwan. Using the caliper matching method to match patients in the P4P (experimental) group with those in the potential comparison group on a one-to-one basis for the year 2010, we tracked patients up to the year 2013 and employed Cox proportional-hazards regression models to evaluate the effect on patient outcomes. Results The P4P group did not have a lower risk (HR = 0.44, P = 0.05) of hospital admission for severe hepatitis patients (i.e. need antiviral therapy). The risk of developing liver cirrhosis was also lower, but the reduction was not statistically significant (HR = 0.92, P = 0.77). Conclusions This study found that participatory-type P4P has not resulted in reduced hospital admission of hepatitis B or C patients who need antiviral therapy. The means by which the participatory P4P program could strengthen patient-centered care to achieve better patient health outcomes is discussed in detail.
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Affiliation(s)
- Tsung-Tai Chen
- Department of Public Health, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Ya-Seng Arthur Hsueh
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Chun-Hsiung Ko
- Department of Public Health, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Ling-Na Shih
- Department of Hepatogastroenterology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
| | - Sien-Sing Yang
- Liver Unit, Cathay General Hospital Medical Center, Taipei, Taiwan.,School of Medicine, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
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Lu CL, Chang HH, Chen HF, Ku LJE, Chang YH, Shen HN, Li CY. Inverse relationship between ambient temperature and admissions for diabetic ketoacidosis and hyperglycemic hyperosmolar state: A 14-year time-series analysis. ENVIRONMENT INTERNATIONAL 2016; 94:642-648. [PMID: 27395337 DOI: 10.1016/j.envint.2016.06.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/14/2016] [Accepted: 06/30/2016] [Indexed: 06/06/2023]
Abstract
This study aimed to investigate the association of admissions for diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) with ambient temperature and season, respectively in patients with diabetes mellitus (DM), after excluding known co-morbidities that predispose onset of acute hyperglycemia events. This was a time series correlation analysis based on medical claims of 40,084 and 33,947 episodes of admission for DKA and HHS, respectively over a 14-year period in Taiwan. These episodes were not accompanied by co-morbidities known to trigger incidence of DKA and HHS. Monthly temperature averaged from 19 meteorological stations across Taiwan was correlated with monthly rate of admission for DKA or HHS, respectively, using the 'seasonal Autoregressive Integrated Moving Average' (seasonal ARIMA) regression method. There was an inverse relationship between ambient temperature and rates of admission for DKA (β=-0.035, p<0.001) and HHS (β=-0.016, p<0.001), despite a clear decline in rates of DKA/HHS admission in the second half of the study period. We also noted that winter was significantly associated with increased rates of both DKA (β=0.364, p<0.001) and HHS (β=0.129, p<0.05) admissions, as compared with summer. On the other hand, fall was associated with a significantly lower rate of HHS admission (β=-0.016, p<0.05). Further stratified analyses according to sex and age yield essentially similar results. It is suggested that meteorological data can be used to raise the awareness of acute hyperglycemic complication risk for both patients with diabetes and clinicians to further avoid the occurrence of DKA and HHS.
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Affiliation(s)
- Chin-Li Lu
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsin-Hui Chang
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hua-Fen Chen
- Department of Endocrinology, Far Eastern Memorial Hospital, New Taipei City, Taiwan; School of Medicine, Fujen Catholic University, New Taipei City, Taiwan
| | - Li-Jung Elizabeth Ku
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ya-Hui Chang
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsiu-Nien Shen
- Department of Intensive Care Medicine, Chi Mei Medical Center, Yong-Kang District, Tainan, Taiwan.
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
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