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Yang YH, Lin KH, Chang-Lee SN, Wang JY. Effectiveness of diabetes shared care program on metabolic indicators of people with type 2 diabetes: A systematic review and meta-analysis. Prim Care Diabetes 2024; 18:257-267. [PMID: 38490914 DOI: 10.1016/j.pcd.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/29/2024] [Accepted: 03/10/2024] [Indexed: 03/17/2024]
Abstract
AIMS To explore the effectiveness of the Taiwanese Diabetes Shared Care Program (DSCP) on improving the metabolic indicators of people with type 2 diabetes. METHODS Relevant studies published between January 2002 and August 2021 were retrieved from Chinese- and English-language electronic databases, including PubMed, MEDLINE, CINAHL, ProQuest, Cochrane Library, Airiti Library, and Taiwan Periodical Literature System. After screening, studies that met inclusion criteria were included in the literature review. RevMan 5.4 was employed for a meta-analysis. RESULTS Ten studies published between 2007 and 2021 were included in the systematic review, with nine of them contributing to the meta-analysis. In total, 1506 and 1388 participants were classified into DSCP and non-DSCP groups, respectively, for the meta-analysis. The results revealed that the DSCP significantly improved glycated hemoglobin levels (mean difference [MD]: -0.50, 95% Confidence Interval [CI]: -0.83 to -0.17) and body weights (MD: -0.83, 95% CI: -1.29 to -0.38) within 1-year follow-up. However, it did not show significant improvement in other metabolic indicators. CONCLUSIONS Taiwanese DSCP led to improvements in glycated hemoglobin levels and body weights among people with type 2 diabetes. This study suggests that people with diabetes and health-care institutions should consider participating in the DSCP.
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Affiliation(s)
- Ya-Hui Yang
- Department of Healthcare Administration, Asia University, Taichung 413305, Taiwan; Wuchi District Public Health Center, Taichung 435051, Taiwan
| | - Kuan-Han Lin
- Department of Healthcare Administration, Asia University, Taichung 413305, Taiwan
| | - Shu-Nu Chang-Lee
- Department of Long Term Care, National Quemoy University, Kinmen 892, Taiwan
| | - Jiun-Yi Wang
- Department of Healthcare Administration, Asia University, Taichung 413305, Taiwan; Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 404333, Taiwan.
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Wang J, Tan F, Wang Z, Yu Y, Yang J, Wang Y, Shao R, Yin X. Understanding Gaps in the Hypertension and Diabetes Care Cascade: Systematic Scoping Review. JMIR Public Health Surveill 2024; 10:e51802. [PMID: 38149840 PMCID: PMC10907944 DOI: 10.2196/51802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/22/2023] [Accepted: 12/27/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND Hypertension and diabetes are global health challenges requiring effective management to mitigate their considerable burden. The successful management of hypertension and diabetes requires the completion of a sequence of stages, which are collectively termed the care cascade. OBJECTIVE This scoping review aimed to describe the characteristics of studies on the hypertension and diabetes care cascade and identify potential interventions as well as factors that impact each stage of the care cascade. METHODS The method of this scoping review has been guided by the framework by Arksey and O'Malley. We systematically searched MEDLINE, Embase, and Web of Science using terms pertinent to hypertension, diabetes, and specific stages of the care cascade. Articles published after 2011 were considered, and we included all studies that described the completion of at least one stage of the care cascade of hypertension and diabetes. Study selection was independently performed by 2 paired authors. Descriptive statistics were used to elucidate key patterns and trends. Inductive content analysis was performed to generate themes regarding the barriers and facilitators for improving the care cascade in hypertension and diabetes management. RESULTS A total of 128 studies were included, with 42.2% (54/128) conducted in high-income countries. Of them, 47 (36.7%) focused on hypertension care, 63 (49.2%) focused on diabetes care, and only 18 (14.1%) reported on the care of both diseases. The majority (96/128, 75.0%) were observational in design. Cascade stages documented in the literature were awareness, screening, diagnosis, linkage to care, treatment, adherence to medication, and control. Most studies focused on the stages of treatment and control, while a relative paucity of studies examined the stages before treatment initiation (76/128, 59.4% vs 52/128, 40.6%). There was a wide spectrum of interventions aimed at enhancing the hypertension and diabetes care cascade. The analysis unveiled a multitude of individual-level and system-level factors influencing the successful completion of cascade sequences in both high-income and low- and middle-income settings. CONCLUSIONS This review offers a comprehensive understanding of hypertension and diabetes management, emphasizing the pivotal factors that impact each stage of care. Future research should focus on upstream cascade stages and context-specific interventions to optimize patient retention and care outcomes.
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Affiliation(s)
- Jie Wang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fangqin Tan
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhenzhong Wang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yiwen Yu
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jingsong Yang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yueqing Wang
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ruitai Shao
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xuejun Yin
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Kuo WY, Tsai WC, Kung PT. Participation and Outcomes among Disabled and Non-Disabled People in the Diabetes Pay-for-Performance Program. Healthcare (Basel) 2023; 11:2742. [PMID: 37893816 PMCID: PMC10606631 DOI: 10.3390/healthcare11202742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/25/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
OBJECTIVES This study's objectives were to compare the participation rates of people with and without disabilities who had type 2 diabetes in a diabetes pay-for-performance (DM P4P) program, as well as their care outcomes after participation. METHODS This was a retrospective cohort study. The data came from the disability registry file, cause of death file, and national health insurance research database of Taiwan. The subjects included patients newly diagnosed with type 2 diabetes between 2001 and 2013 who were followed up with until 2014 and categorized as disabled and non-disabled patients. The propensity score matching method was used to match the disabled with the non-disabled patients at a 1:1 ratio. Conditional logistic regression analysis was used to determine the odds ratio between the disabled and non-disabled patients who joined the P4P program. The Cox hazard model was used to compare the risk of dialysis and death between the disabled and non-disabled patients participating in the P4P program. RESULTS There were 110,645 disabled and 110,645 non-disabled individuals after matching. After controlling for confounding factors, it was found that the disabled individuals were significantly less likely (odds ratio = 0.89) to be enrolled in the P4P program than the non-disabled individuals. The risk of dialysis was 1.08 times higher for people with disabilities than those without, regardless of their participation in the P4P program. After enrollment in the P4P program, the risk of death for people with disabilities decreased from 1.32 to 1.16 times that of persons without disabilities. Among the people with disabilities, the risk of death for those enrolled in the P4P program was 0.41 times higher than that of those not enrolled. The risk of death was reduced to a greater extent for people with disabilities than for those without disabilities upon enrollment in the DM P4P program. CONCLUSION People with disabilities are less likely to be enrolled in the P4P program in Taiwan and have unequal access to care. However, the P4P program was more effective at reducing mortality among people with disabilities than among those without.
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Affiliation(s)
- Wei-Yin Kuo
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung 406040, Taiwan; (W.-Y.K.); (W.-C.T.)
| | - Wen-Chen Tsai
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung 406040, Taiwan; (W.-Y.K.); (W.-C.T.)
- Department of Medical Research, China Medical University Hospital, Taichung 404332, Taiwan
| | - Pei-Tseng Kung
- Department of Medical Research, China Medical University Hospital, Taichung 404332, Taiwan
- Department of Healthcare Administration, Asia University, Taichung 413305, Taiwan
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Sung MC, Chung KP, Cheng SH. Impact of a diabetes pay-for-performance program on nonincentivized mental disorders: a panel study based on claims database analysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:41. [PMID: 37415154 DOI: 10.1186/s12962-023-00450-y] [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: 03/19/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Diabetes is one of the most prevalent chronic diseases with subsequent complications. The positive effects of diabetes pay-for-performance (P4P) programs on treatment outcomes have been reported. The program provides financial incentives based on physiological care indicators, but common mental disorder complications such as depression are not covered. METHODS This study employed a natural experimental design to examine the spillover effects of diabetes P4P program on patients with nonincentivized depressive symptoms. The intervention group consisted of diabetes patients enrolled in the DM P4P program from 2010 to 2015. Unenrolled patients were selected by propensity score matching to form the comparison group. Difference-in-differences analyses were conducted to evaluate the effects of P4P programs. We employed generalized estimating equation (GEE) models, difference-in-differences analyses and difference-in-difference-in-differences analyses to evaluate the net effect of diabetes P4P programs. Changes in medical expenses (outpatient and total health care costs) over time were analysed for the treatment and comparison groups. RESULTS The results showed that enrolled patients had a higher incidence of depressive symptoms than unenrolled patients. The outpatient and total care expenses of diabetes patients with depressive symptoms were lower in the intervention group than in the comparison group. Diabetes patients with depressive symptoms enrolled in the DM P4P program had lower expenses for depression-related care than those not enrolled in the program. CONCLUSIONS The DM P4P program benefits diabetes patients by screening for depressive symptoms and lowering accompanying health care expenses. These positive spillover effects may be an important aspect of physical and mental health in patients with chronic disease enrolled in disease management programs while contributing to the control of health care expenses for chronic diseases.
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Affiliation(s)
- Ming-Chan Sung
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Kuo-Piao Chung
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan.
| | - Shou-Hsia Cheng
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan.
- Population Health Research Center, National Taiwan University, 17, Xu-Zhou Road, Taipei, 100, Taiwan.
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Jin Y, Tian W, Yu Y, Pan W, Yuan B. Incentives Promoting Contracted Family Doctor Service Policy to Improve Continuity and Coordination in Diabetes Patient Management Care in China. Front Public Health 2022; 10:843217. [PMID: 35910878 PMCID: PMC9334846 DOI: 10.3389/fpubh.2022.843217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 05/17/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAs the first step toward building a gatekeeping system in China, the governments have introduced a contracted family doctor service (CFDS) policy in primary healthcare (PHC) facilities. This study was to examine the association between apply of incentive to improve the implementation of CFDS and the performance on diabetes management care.MethodsWe conducted a cross-sectional study in 72 PHC facilities in 6 cities that piloted the CFDS. Multivariate regression models were applied, based on a sample of 827 PHC providers and 420 diabetic patients.ResultsPHC providers who reported the performance being linked with increased income were 168.1 and 78.0% more likely to have good continuity and coordination of diabetes patient management care, respectively. Additional one-point percentage of PHC providers whose performance on CFDS was assessed was associated with 7.192 times higher probability of patients with control of blood glucose.DiscussionInclusion of incentives rewarding better performance on CFDS were associated with better delivery process and outcome performance on diabetes management care.ConclusionDesign and implementation of the incentive should be accompanied with the policy of CFDS, in order to increase the proportion of performance-related income of PHC providers, thereby improving the quality of diabetes management care.
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Affiliation(s)
- Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, Beijing, China
| | - Wenya Tian
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Yahang Yu
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, United States
| | - Wen Pan
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, United States
| | - Beibei Yuan
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, United States
- *Correspondence: Beibei Yuan
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Chen YC, Liao YH, Ku LJE, Wang JD. Pay-for-performance and continuity of care synergistically reduced amputation of lower extremity in patients with diabetes: a population-based cohort study. BMC Health Serv Res 2022; 22:748. [PMID: 35659668 PMCID: PMC9167521 DOI: 10.1186/s12913-022-08075-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 05/11/2022] [Indexed: 12/14/2022] Open
Abstract
Abstracts
Background
Diabetic foot is a common and costly complication of diabetes. No existing study has looked at the effect of continuity of care on amputations of diabetes (DM) patients while considering pay-for-performance (P4P) participation. We investigated the impact of the P4P program and the continuity of care index (COCI) on the incidence of lower extremity amputations (LEA) among diabetics in Taiwan.
Methods
This was a population-based cohort study using insurance claims data from 1997 to 2013. We selected 15,650 DM patients in the P4P program along with age- and sex-matched non-P4P participants at a 1:4 ratio. Time-weighted average (TWA) of the COCI was calculated and included in the time-dependent Cox proportional hazard models to examine the impact of P4P and COCI on the risk of LEA, while controlling for individual and area level characteristics.
Results
During four-year follow-up, 1816 subjects experienced LEA. The cumulative LEA hazard rate of the P4P group (n = 153) was significantly lower than that of the non-P4P group (n = 1663) (hazard ratio = 0.37, 95% CI = 0.31–0.43, p < 0.0001, by log-rank test). In the time-dependent Cox proportional hazard model, the adjusted hazard ratios (aHR) for the P4P group was 0.35, (p < 0.0001). With the low COCI (< 0.360) group as the reference, the aHR of LEA was 0.49 (p < 0.0001) for the middle COCI group, (p < 0.0001), and the aHR of LEA for the high COCI (≥0.643) group was 0.23 (p < 0.0001).
Conclusions
Participating in the P4P program and increasing COCI might reduce the risk of amputation for DM patients, independently and synergistically.
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Wieczorek E, Kocot E, Evers S, Sowada C, Pavlova M. Do financial aspects affect care transitions in long-term care systems? A systematic review. Arch Public Health 2022; 80:90. [PMID: 35321727 PMCID: PMC8941782 DOI: 10.1186/s13690-022-00829-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 02/13/2022] [Indexed: 11/19/2022] Open
Abstract
Background Suboptimal care transitions of older adults may ultimately lead to worse quality of care and increased costs for the health and social care systems. Currently, policies and financing often focus on care in specific settings only, and neglect quality of care during transitions between these settings. Therefore, appropriate financing mechanisms and improved care coordination are necessary for effective care transitions. This study aims to review all available evidence on financial aspects that may have an impact on care transitions in LTC among older adults. Methods This systematic review was performed as part of the European TRANS-SENIOR project. The databases Medline, EMBASE (Excerpta Medica Database) and CINAHL (Cumulated Index to Nursing and Allied Health Literature) were searched. Studies were included if they reported on organizational and financial aspects that affect care transitions in long-term care systems. Results All publications included in this review (19 studies) focused specifically on financial incentives. We identified three types of financial incentives that may play a significant role in care transition, namely: reimbursement mechanism, reward, and penalty. The majority of the studies discussed the role of rewards, specifically pay for performance programs and their impact on care coordination. Furthermore, we found that the highest interest in financial incentives was in primary care settings. Conclusions Overall, our results suggest that financial incentives are potentially powerful tools to improve care transition among older adults in long-term care systems and should be taken into consideration by policy-makers. Trial registration A review protocol was developed and registered in the International Prospective Register of Systematic Reviews (PROSPERO) under identification number CRD42020162566. Supplementary Information The online version contains supplementary material available at 10.1186/s13690-022-00829-y.
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Affiliation(s)
- Estera Wieczorek
- Department of Health Economics and Social Security, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Collegium Medicum, Krakow, Poland. .,Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Ewa Kocot
- Department of Health Economics and Social Security, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Silvia Evers
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Christoph Sowada
- Department of Health Economics and Social Security, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Milena Pavlova
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Lu CW, Wu YF, Chen TH, Chung CM, Lin CL, Lin YS, Chen MY, Yang YH, Lin MS. A nationwide cohort investigation on pay-for-performance and major adverse limb events in patients with diabetes. Prev Med 2021; 153:106787. [PMID: 34506818 DOI: 10.1016/j.ypmed.2021.106787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 07/18/2021] [Accepted: 09/04/2021] [Indexed: 11/19/2022]
Abstract
A retrospective cohort study was conducted using claims data from Taiwan's National Health Insurance program to assess the effect of diabetic pay-for-performance (P4P) program on major adverse limb events (MALE) and major adverse cardiovascular events (MACE) in patients with type 2 diabetes mellitus (T2DM). This study included patients with T2DM who had completed or not completed a 1-year P4P program from 2002 to 2013. Propensity-score matching was used to balance the baseline characteristics between groups. The Cox proportional-hazard model and Fine and Gray subdistribution hazard model were used to examine the association between P4P and the risks of MALE, MACE, systemic thromboembolism (ST), heart failure (HF) hospitalization, and all-cause mortality. Patients who underwent the P4P program had a significantly decreased incidence of MALE (2.0% vs. 2.6%, subdistribution hazard ratio [SHR] 0.73, 95% CI 0.71-0.76). Regarding the individual components, the P4P group demonstrated lower risks for foot ulcer (1.1% vs 1.3%, SHR 0.80, 95% CI 0.77-0.84), gangrene (0.57% vs 0.93%, SHR 0.59, 95% CI 0.56-0.63), percutaneous transluminal angioplasty (0.61% vs 0.79%, SHR 0.72, 95% CI 0.68-0.77), and amputation (0.46% vs 0.75%, SHR 0.58, 95% CI 0.55-0.62). In addition, the risks of MACE, ST, HF hospitalization, and all-cause mortality were remarkably lower in the P4P group. The P4P program might significantly reduce critical events of MALE, MACE, ST, HF, and mortality in the diabetic population.
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Affiliation(s)
- Cheng-Wei Lu
- Department of Family Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yi-Fang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Tien-Hsing Chen
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chang-Min Chung
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chun-Liang Lin
- Department of Nephrology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yu-Sheng Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Mei-Yen Chen
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan; Department of Nursing, Chang Gung University, Taoyuan, Taiwan
| | - Yao-Hsu Yang
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan; Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan; School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Shyan Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan.
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Liao K, Lin KC, Chiou SJ. Self-efficacy remains a vital factor in reducing the risk of dialysis in type 2 diabetes care. Medicine (Baltimore) 2021; 100:e26644. [PMID: 34260563 PMCID: PMC8284740 DOI: 10.1097/md.0000000000026644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/25/2021] [Indexed: 01/04/2023] Open
Abstract
Studies have provided promising outcomes of the pay-for-performance (P4P) program or with good continuity of care levels in diabetes control.We investigate the different exposures in continuity of care (COC) with their providers and those who participate in the P4P program and its effects on the risk of diabetes diabetic nephropathy in the future.We obtained COC and P4P information from the annual database, to which we applied a hierarchical linear modeling (HLM) in 3 levels adjusted to account for other covariates as well as the effects of hospital clustering and accumulating time.Newly diagnosed type 2 diabetes in 2003At the individual level, those with a higher Diabetes Complications Severity Index (DCSI) score have a higher likelihood of diabetic nephropathy than those with a lower DCSI (OR, 1.46), whereas contrasting results were obtained for the Charlson Comorbidity Index (CCI) (odds ratio[OR], 0.88). Patients who visited family physicians, endocrinologists, and gastroenterologists showed a lower likelihood of diabetic nephropathy (OR, 0.664, 0.683, and 0.641, respectively), whereas those who continued to visit neurologists showed an increased risk of diabetic nephropathy by 4 folds. At the hospital level, patients with diabetes visiting primary care clinics had a lower risk of diabetic nephropathy with an OR of 0.584 than those visiting hospitals of other higher levels. Regarding the repeat time level, the patients who had a higher COC score and participated in the P4P program had a reduced diabetic nephropathy risk with an OR of 0.339 and 0.775, respectively.Diabetes control necessitates long-term care involving the patients' healthcare providers for the management of their conditions to reduce the risk of diabetic nephropathy. Indeed, most contributing factors are related to patients, but we cannot eliminate the optimal outcomes related to good relationships with healthcare providers and participation in the P4P program.
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Affiliation(s)
- Kuomeng Liao
- Department of endocrinology and metabolism, Zhongxiao Branch, Taipei City Hospital, Taipei, Taiwan
| | - Kuan-Chia Lin
- Preventive Medicine Center, National Yang Ming University, Taipei, Taiwan, R.O.C
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan, R.O.C
| | - Shang-Jyh Chiou
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, R.O.C
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Tung YJ, Huang CT, Lin WC, Cheng HH, Chow JC, Ho CH, Chou W. Longer length of post-acute care stay causes greater functional improvements in poststroke patients. Medicine (Baltimore) 2021; 100:e26564. [PMID: 34190196 PMCID: PMC8257905 DOI: 10.1097/md.0000000000026564] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 06/11/2021] [Indexed: 01/04/2023] Open
Abstract
Post-acute care (PAC) is a type of transitional care for poststroke patients after the acute medical stage; it offers a relatively intensive rehabilitative program. Under Taiwan's National Health Insurance guidelines, the only patients who can transfer to PAC institutions are those who have had an acute stroke in the previous month, are in a relatively stable medical condition, and have the potential for improvement after aggressive rehabilitation. Poststroke patients receive physical, occupational, and speech therapy in PAC facility. However, few studies have evaluated the effects of PAC in poststroke patients since PAC's initiation in Taiwan. Thus, this study aims to investigate whether the length of stay in a PAC institution correlates with patients' improvements.This retrospective and single-center study in Taiwan enrolled 193 poststroke patients who had received acute care at Chi-Mei Medical Center, Taiwan, at any period between 2014 and 2017. Data on their length of stay in the PAC institution were collected. Poststroke patients' functional ability-such as activities of daily living (ADL) function and swallowing ability-as well as their corresponding scales were assessed on the first and last day of PAC stay. Statistical analysis was conducted by SPSS version 21.0 .The average duration of PAC stay was 35.01 ± 16.373 days. Duration of PAC stay was significantly positively correlated with the Barthel index (P < .001), Berg balance test score (P < .001), gait speed (P = .002), and upper sensory function and upper motor function within the Fugl-Meyer Assessment (both P < .001).Poststroke patients with longer stay in a PAC institution had superior ADL function, balance and coordination, walking speed, and upper-limb dexterity and sensory function.
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Affiliation(s)
- Yu-Ju Tung
- Department of Physical Medicine and Rehabilitation, Chi Mei Medical Center, Tainan, Taiwan
| | - Chin-Tsan Huang
- Department of Physical Medicine and Rehabilitation, Chi Mei Medical Center, Tainan, Taiwan
| | - Wen-Chih Lin
- Department of Physical Medicine and Rehabilitation Department, Chi Mei Hospital, Chiali Branch
| | - Hsin-Han Cheng
- Department of Physical Medicine and Rehabilitation Department, Chi Mei Hospital, Chiali Branch
| | - Julie Chi Chow
- Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei
| | - Chung-Han Ho
- Department of Medical Research, Chi-Mei Medical Center, Tainan
| | - Willy Chou
- Department of Physical Medicine and Rehabilitation, Chi Mei Medical Center, Tainan, Taiwan
- Department of Physical Medicine and Rehabilitation Department, Chi Mei Hospital, Chiali Branch
- Department of Physical Medicine and Rehabilitation, Chung Shan Medical University Hospital, Taichung, Taiwan
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Chen TT, Oldenburg B, Hsueh YS. Chronic care model in the diabetes pay-for-performance program in Taiwan: Benefits, challenges and future directions. World J Diabetes 2021; 12:578-589. [PMID: 33995846 PMCID: PMC8107979 DOI: 10.4239/wjd.v12.i5.578] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/08/2021] [Accepted: 04/05/2021] [Indexed: 02/06/2023] Open
Abstract
In this review, we discuss the chronic care model (CCM) in relation to the diabetes pay-for-performance (P4P) program in Taiwan. We first introduce the 6 components of the CCM and provide a detailed description of each of the activities in the P4P program implemented in Taiwan, mapping them onto the 6 components of the CCM. For each CCM component, the following three topics are described: the definition of the CCM component, the general activities implemented related to this component, and practical and empirical practices based on hospital or local government cases. We then conclude by describing the possible successful features of this P4P program and its challenges and future directions. We conclude that the successful characteristics of this P4P program in Taiwan include its focus on extrinsic and intrinsic incentives (i.e., shared care network), physician-led P4P and the implementation of activities based on the CCM components. However, due to the low rate of P4P program coverage, approximately 50% of patients with diabetes cannot enjoy the benefits of CCM-related activities or receive necessary examinations. In addition, most of these CCM-related activities are not allotted an adequate amount of incentives, and these activities are mainly implemented in hospitals, which compared with primary care providers, are unable to execute these activities flexibly. All of these issues, as well as insufficient implementation of the e-CCM model, could hinder the advanced improvement of diabetes care in Taiwan.
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Affiliation(s)
- Tsung-Tai Chen
- Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei 24205, Taiwan
| | - Brian Oldenburg
- Noncommunicable Disease Control Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne 3053, Australia
| | - Ya-Seng Hsueh
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne 3053, Australia
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Chen YC, Weng SF, Hsu YJ, Wei CJ, Chiu CH. Continuity of care: evaluating a multidisciplinary care model for people with early CKD via a nationwide population-based longitudinal study. BMJ Open 2020; 10:e041149. [PMID: 33376170 PMCID: PMC7778764 DOI: 10.1136/bmjopen-2020-041149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To control and prevent the burdens associated with chronic kidney disease (CKD), Taiwan's National Health Insurance Administration (NHIA) launched the 'early-CKD programme' in 2011 to extend care and education to patients with CKD. This study aims to evaluate the effectiveness of the early-CKD programme in terms of continuity of care (COC). DESIGN AND PARTICIPANTS This study used secondary data from 2010 to 2014 provided by the NHIA to identify 86 581 participants each for the intervention and control groups. Patients with CKD who participated in the early-CKD programme between 2011 and 2013 were defined as the intervention group. For the control group, propensity score matching was used to select patients with CKD who did not participate in the programme, but were seen by the same group of physicians. INTERVENTION A multidisciplinary care model for patients with early CKD launched in 2011. PRIMARY OUTCOME MEASURES Outcome variables included the continuity of care index (COCI), which measures a physician's COC; number of essential examinations; and resource utilisation. To better identify the difference between groups, we separated COCI into two groups based on mean: high (above mean) and low (below mean). A generalised estimating equation model was used to examine the effects of the early-CKD programme. RESULTS The programme significantly increased the number of essential examinations/tests administered to patients (β=0.61, p<0.001) and improved COCI between physicians and patients (OR=4.18, p<0.001). Medical expenses (β=1.03, p<0.001) and medication expenses (β=0.23, p<0.001) significantly increased after the programme was implemented, but patients' kidney-related hospitalisations and emergency department visits decreased (β=-0.13, p<0.001). CONCLUSION From the COC viewpoint, the programme in Taiwan showed a positive effect on COCI, number of essential examinations and resource utilisation.
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Affiliation(s)
- Yin-Cheng Chen
- Division of Nephrology, Department of Internal Medicine, Taipei Hospital, Ministry of Health and Welfare, Taipei, Taiwan
| | - Shuen-Fu Weng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Juei Hsu
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Jen Wei
- Department of Public Health, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chiung-Hsuan Chiu
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
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Sun M, Rasooly A, Fan X, Jian W. Assessing the quality of primary healthcare for diabetes in China: multivariate analysis using the China Health and Retirement Longitudinal Study (CHARLS) Database. BMJ Open 2020; 10:e035192. [PMID: 33318105 PMCID: PMC7737069 DOI: 10.1136/bmjopen-2019-035192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To assess the quality of primary healthcare (PHC) for patients with diabetes in China from 2011 to 2015. SETTING This study analysed data on 1006, 1472 and 1771 participants with diabetes who were surveyed in 2011, 2013 and 2015, respectively, in the China Health and Retirement Longitudinal Study, a nationally representative survey conducted in 29 provinces of China. OUTCOME MEASURES The study measured the proportions of patients with diabetes who received diabetes-related health education, examinations and treatments, as well as the hospital admission rate due to diabetes of these patients. Multilevel logistic regression was used to adjust sociodemographic variables. RESULTS According to the multivariate analysis, the proportion of patients who received diabetes-related health education decreased significantly (OR=0.74, 95% CI 0.61 to 0.90), and the proportion of those receiving examinations and treatments remained unchanged from 2011 to 2015. Diabetes-related hospitalisation increased from 4.01% in 2011 to 6.08% in 2013 (OR=1.47, 95% CI 0.97 to 2.22), and recurrent hospitalisations increased from 18.87% in 2011 to 28.45% in 2015 (OR=1.78, 95% CI 1.44 to 2.20). The proportions of patients with diabetes-related and recurrent hospitalisations in western China were higher than those in the east (OR=1.80, 95% CI 1.13 to 2.87; OR=1.92, 95% CI 1.50 to 2.45). CONCLUSIONS Nationally, the analysis of patient-reported process and outcome indicators cannot confirm that the quality of PHC has improved in China during 2011-2015. Regional disparities in primary diabetes care require urgent resource allocation to western China. Establishing a national quality registry for PHC, which transparently reports outcomes by region and social-economic position, is essential for countries sharing the challenge of improving both quality and equity of PHC.
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Affiliation(s)
- Meiping Sun
- Department of Health Policy and Management, Peking University Health Science Centre, Beijing, China
| | - Alon Rasooly
- School of Public Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Xiaoqi Fan
- School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Weiyan Jian
- Department of Health Policy and Management, Peking University Health Science Centre, Beijing, China
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Thavam T, Devlin RA, Thind A, Zaric GS, Sarma S. The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:1279-1293. [PMID: 32676753 DOI: 10.1007/s10198-020-01216-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/25/2020] [Indexed: 06/11/2023]
Abstract
Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.
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Affiliation(s)
- Thaksha Thavam
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Rose Anne Devlin
- Department of Economics, University of Ottawa, Ottawa, ON, Canada
| | - Amardeep Thind
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Gregory S Zaric
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
- Ivey School of Business, University of Western Ontario, London, ON, Canada
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada.
- ICES, Toronto, ON, Canada.
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Liang LL. Impact of integrated healthcare: Taiwan’s Family Doctor Plan. Health Policy Plan 2019; 34:ii56-ii66. [DOI: 10.1093/heapol/czz111] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Integration of health services has been pursued worldwide. Diversity in integration approaches and in the contexts in which integrated programmes operate, however, hinders comparative analysis of care integration in both high-income countries (HICs) and low- and middle-income countries (LMICs). This study evaluates an HIC programme implemented in a delivery system resembling those of LMICs, especially its weak primary care system. The programme, Taiwan’s Family Doctor Plan (FDP), targets high-cost and chronic patients, incorporating key elements of integrated care, viz., case management, multidisciplinary teams and care pathways. This study estimates the effects of shifting from usual to integrated care and locates contextual factors that may distort programme implementation. To estimate programme effects, difference-in-differences analysis is applied to a balanced panel comprising >160 000 patients over 2009–13. Because physician participation is voluntary, a propensity score matching method is used to match providers. The research findings reveal that introduction of the FDP has not reoriented the model of care from fragmented towards integrated health services. It reduces continuity of care and has no effect on co-ordination of care. Regarding quality of care, the FDP is shown to have no effect on avoidable admissions and increases drug injections and emergency department visits. Several contextual factors may serve as barriers that impede elements of FDP from generating desirable outcomes. These include absence of registration and gatekeeping systems; limited capacities of clinics; and preponderance of fee-for-service remuneration. These findings suggest that HIC design elements may not be directly transferrable to settings with weak primary care systems, as is typical of LMIC healthcare. Changes at the system level, such as establishing regular sources of care, may be necessary before elements of integrated care are introduced to a weaker primary care system.
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Affiliation(s)
- Li-Lin Liang
- Department of Business Management, National Sun Yat-sen University, 70 Lienhai Road, Kaohsiung, Taiwan
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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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Multidiscipline Stroke Post-Acute Care Transfer System: Propensity-Score-Based Comparison of Functional Status. J Clin Med 2019; 8:jcm8081233. [PMID: 31426354 PMCID: PMC6724215 DOI: 10.3390/jcm8081233] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/15/2019] [Accepted: 08/15/2019] [Indexed: 12/19/2022] Open
Abstract
Few studies have investigated the characteristics of stroke inpatients after post-acute care (PAC) rehabilitation, and few studies have applied propensity score matching (PSM) in a natural experimental design to examine the longitudinal impacts of a medical referral system on functional status. This study coupled a natural experimental design with PSM to assess the impact of a medical referral system in stroke patients and to examine the longitudinal effects of the system on functional status. The intervention was a hospital-based, function oriented, 12-week to 1-year rehabilitative PAC intervention for patients with cerebrovascular diseases. The average duration of PAC in the intra-hospital transfer group (31.52 days) was significantly shorter than that in the inter-hospital transfer group (37.1 days) (p < 0.001). The intra-hospital transfer group also had better functional outcomes. The training effect was larger in patients with moderate disability (Modified Rankin Scale, MRS = 3) and moderately severe disability (MRS = 4) compared to patients with slight disability (MRS = 2). Intensive post-stroke rehabilitative care delivered by per-diem payment is effective in terms of improving functional status. To construct a vertically integrated medical system, strengthening the qualified local hospitals with PAC wards, accelerating the inter-hospital transfer, and offering sufficient intensive rehabilitative PAC days are the most essential requirements.
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The effectiveness of financial intervention strategies for reducing caesarean section rates: a systematic review. BMC Public Health 2019; 19:1080. [PMID: 31399068 PMCID: PMC6688325 DOI: 10.1186/s12889-019-7265-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 06/30/2019] [Indexed: 01/08/2023] Open
Abstract
Background The increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge. Previous studies have proposed financial intervention strategies for reducing CS rates by limiting caesarean delivery on maternal request (CDMR). This study synthesizes such strategies while evaluating their effectiveness. Methods The sources of data for this study are Cochrane Library, PubMed, EMBASE, and CINAHL. The publication period included in this study is from January 1991 to November 2018. The financial intervention strategies are divide into two categories: healthcare provider interventions and patient interventions. Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) was employed to assess the risk of bias of included studies. The outcome of each study was evaluated with Grades of Recommendation, Assessment, Development and Evaluation (GRADE) through the GRADEpro Guideline Development Tool software. Results Nine studies were included in this systematic review: five with high certainty evidence (HCE), three with moderate certainty evidence (MCE), and one with low certainty evidence (LCE). Of the nine studies, seven are centered on the effect of provider-side interventions. Three of the HCE studies found that the diagnosis-related group payment system, risk-adjusted capitation, and equalizing fee for both facilities and physicians were effective intervention strategies. One HCE and one MCE study showed that only equalizing facility fees between vaginal and CS deliveries in healthcare service settings had no significant effect on reducing the CS rate. The MCE study showed that case payment had a negative effect on reducing the CS rates. One LCE study revealed that the effect of a global budget system was uncertain, and one HCE and one MCE study focused on combining both provider and patient-side interventions. However, equalizing fees for vaginal and CS deliveries and a co-payment policy for CDMRs failed to reduce the CS rate. Conclusions The effectiveness of risk-adjusted payment methods appears promising and should be the subject of further research. Financial interventions should consider stakeholders’ characteristics, especially the personal interests of doctors. Finally, high-quality randomized control trials and comparative studies on different financial intervention methods are needed to confirm or refute previous studies’ outcomes. Electronic supplementary material The online version of this article (10.1186/s12889-019-7265-4) contains supplementary material, which is available to authorized users.
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Abstract
BACKGROUND Pay-for-Performance (P4P) is a payment model that rewards health care providers for meeting pre-defined targets for quality indicators or efficacy parameters to increase the quality or efficacy of care. OBJECTIVES Our objective was to assess the impact of P4P for in-hospital delivered health care on the quality of care, resource use and equity. Our objective was not only to answer the question whether P4P works in general (simple perspective) but to provide a comprehensive and detailed overview of P4P with a focus on analyzing the intervention components, the context factors and their interrelation (more complex perspective). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers on 27 June 2018. In addition, we searched conference proceedings, gray literature and web pages of relevant health care institutions, contacted experts in the field, conducted cited reference searches and performed cross-checks of included references and systematic reviews on the same topic. SELECTION CRITERIA We included randomized trials, cluster randomized trials, non-randomized clustered trials, controlled before-after studies, interrupted time series and repeated measures studies that analyzed hospitals, hospital units or groups of hospitals and that compared any kind of P4P to a basic payment scheme (e.g. capitation) without P4P. Studies had to analyze at least one of the following outcomes to be eligible: patient outcomes; quality of care; utilization, coverage or access; resource use, costs and cost shifting; healthcare provider outcomes; equity; adverse effects or harms. DATA COLLECTION AND ANALYSIS Two review authors independently screened all citations for inclusion, extracted study data and assessed risk of bias for each included study. Study characteristics were extracted by one reviewer and verified by a second.We did not perform meta-analysis because the included studies were too heterogenous regarding hospital characteristics, the design of the P4P programs and study design. Instead we present a structured narrative synthesis considering the complexity as well as the context/setting of the intervention. We assessed the certainty of evidence using the GRADE approach and present the results narratively in 'Summary of findings' tables. MAIN RESULTS We included 27 studies (20 CBA, 7 ITS) on six different P4P programs. Studies analyzed between 10 and 4267 centers. All P4P programs targeted acute or emergency physical conditions and compared a capitation-based payment scheme without P4P to the same capitation-based payment scheme combined with a P4P add-on. Two P4P program used rewards or penalties; one used first rewards and than penalties; two used penalties only and one used rewards only. Four P4P programs were established and evaluated in the USA, one in England and one in France.Most studies showed no difference or a very small effect in favor of the P4P program. The impact of each P4P program was as follows.Premier Hospital Quality Incentive Demonstration Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events, quality of care, equity or resource use as the certainty of the evidence was very low.Value-Based Purchasing Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events or quality of care as the certainty of the evidence was very low. Equity and resource use outcomes were not reported in the studies, which evaluated this program.Non-payment for Hospital-Acquired Conditions Program: It is uncertain whether this penalty-based program has an impact on adverse clinical events as the certainty of the evidence was very low. Mortality, quality of care, equity and resource use outcomes were not reported in the studies, which evaluated this program.Hospital Readmissions Reduction Program: None of the studies that examined this penalty-based program reported mortality, adverse clinical events, quality of care (process quality score), equity or resource use outcomes.Advancing Quality Program: It is uncertain whether this reward-/penalty-based program has an impact on mortality as the certainty of the evidence was very low. Adverse clinical events, quality of care, equity and resource use outcomes were not reported in any study.Financial Incentive to Quality Improvement Program: It is uncertain whether this reward-based program has an impact on quality of care, as the certainty of the evidence was very low. Mortality, adverse clinical events, equity and resource use outcomes were not reported in any study.Subgroup analysis (analysis of modifying design and context factors)Analysis of P4P design factors provides some hints that non-payments compared to additional payments and payments for quality attainment (e.g. falling below specified mortality threshold) compared to quality improvement (e.g. reduction of mortality by specified percent points within one year) may have a stronger impact on performance. AUTHORS' CONCLUSIONS It is uncertain whether P4P, compared to capitation-based payments without P4P for hospitals, has an impact on patient outcomes, quality of care, equity or resource use as the certainty of the evidence was very low (or we found no studies on the outcome) for all P4P programs. The effects on patient outcomes of P4P in hospitals were at most small, regardless of design factors and context/setting. It seems that with additional payments only small short-term but non-sustainable effects can be achieved. Non-payments seem to be slightly more effective than bonuses and payments for quality attainment seem to be slightly more effective than payments for quality improvement.
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Affiliation(s)
- Tim Mathes
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Dawid Pieper
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Johannes Morche
- Federal Joint CommitteeMedical Consultancy DepartmentWegelystraße 8BerlinGermany
| | - Stephanie Polus
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Thomas Jaschinski
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Michaela Eikermann
- Medical advisory service of social health insurance (MDS)Department of Evidence‐based medicineTheodor‐Althoff‐Straße 47EssenNorth Rhine WestphaliaGermany51109
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Kao YH, Tseng TS, Ng YY, Wu SC. Association between continuity of care and emergency department visits and hospitalization in senior adults with asthma-COPD overlap. Health Policy 2018; 123:222-228. [PMID: 30466799 PMCID: PMC7114593 DOI: 10.1016/j.healthpol.2018.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/25/2018] [Accepted: 11/04/2018] [Indexed: 12/26/2022]
Abstract
COC enables healthcare more effectively and improves clinical outcomes. COC is also important for elderly ACO patients. Increasing COC is beneficial for elderly patients with ACO in disease management.
Objective To investigate associations between continuity of care (COC) and emergency department (ED) visits and hospitalization for chronic obstructive pulmonary disease (COPD) or asthma among elderly adults with asthma-COPD overlap (ACO). Methods A retrospective cohort study was performed using the Taiwan National Health Insurance research database. A total of 1141 ACO patients aged ≥65 years during 2005–2011 were observed and followed for 2 years. The Bice and Boxerman COC index (COCI) was used to evaluate COC by considering ambulatory care visits duo to COPD or asthma in the first year; ED visits and hospitalization for COPD or asthma were identified in the subsequent year, respectively. The COCI was divided into three levels (COCI < 0.3= low, 0.3 ≤ COCI<1=medium, COCI = 1=high). The Cox model was used to estimate the hazard ratio (HR) for ED visits and hospital admissions due to COPD or asthma. Results The average COCI was 0.55. 21.3% patients received outpatient care from a single physician. Compared to patients with high COC, those with low and medium COC had a higher risk of ED visits (aHR = 2.80 and 2.69, P < .01) and admissions (aHR = 1.80 and 1.72, P < .05). Conclusion Increasing COC is beneficial for elderly patients with ACO in disease management. Policymakers could create effective pay-for-performance programs for the elderly ACO population to enhance COC and improve care outcomes.
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Affiliation(s)
- Yu-Hsiang Kao
- Behavioral and Community Health Sciences, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, United States.
| | - Tung-Sung Tseng
- Behavioral and Community Health Sciences, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA, United States.
| | - Yee-Yung Ng
- Department of Medicine, Fu Jen Catholic University Hospital, and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan.
| | - Shiao-Chi Wu
- Institute of Health and Welfare Policy, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Wang CY, Chen YR, Hong JP, Chan CC, Chang LC, Shi HY. Rehabilitative post-acute care for stroke patients delivered by per-diem payment system in different hospitalization paths: A Taiwan pilot study. Int J Qual Health Care 2018; 29:779-784. [PMID: 29025039 DOI: 10.1093/intqhc/mzx102] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 08/01/2017] [Indexed: 11/14/2022] Open
Abstract
Objective To explore how post-acute care (PAC) for stroke patients delivered by per-diem payment system in varying hospitalization paths affects medical care utilization and functional status. Design, setting and patients A longitudinal prospective cohort study of 181 acute stroke patients in a southern Taiwan hospital and patients were separated into two groups: patients transferred from regional hospitals (group 1) and patients referred from medical centers (group 2). Intervention The intervention was a hospital based, function oriented, 3- to 12-weeks rehabilitative PAC intervention for patients with cerebrovascular diseases. Measurements Barthal Index, Functional Oral Intake Scale, Instrumental Activities of Daily Living Scale, EuroQoL Quality of Life Scale, and Berg Balance Scale. Results The average duration between day of stroke onset and day of admission to PAC ward was significantly (P < 0.001) shorter in group 1 (9.88 days) compared to group 2 (17.11 days). The average duration of PAC was also significantly (P < 0.01) shorter in group 1 (25.51 days) compared to group 2 (34.11 days). Finally, the average cost of PAC under per-diem payment was significantly lower (P < 0.01) in group 1 (US$2637) compared to group 2 (US$3450). Functional status significantly (P < 0.05) improved in patients who had received rehabilitative PAC. However, functional status did not significantly differ between the two groups. Conclusions The most effective way to reduce the costs of PAC for stroke patients is to minimize the duration of their hospital stay before transfer to rehabilitative PAC. Because it substantially reduces medical costs, rehabilitative PAC should be considered standard care for stroke patients.
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Affiliation(s)
- Chung-Yuan Wang
- Department of Physical Medicine and Rehabilitation, Pingtung Christian Hospital, Taiwan
| | - Yu-Ren Chen
- Department of Physical Medicine and Rehabilitation, Pingtung Christian Hospital, Taiwan
| | - Jia-Pei Hong
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, Taiwan
| | - Chih-Chun Chan
- Department of Neurology, Pingtung Christian Hospital, Taiwan
| | | | - Hon-Yi Shi
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Taiwan.,Department of Business Management, National Sun Yat-sen University, Taiwan
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22
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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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23
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Yang YW, Liu HH, Lin TH, Chuang HY, Hsieh T. Association between different anticholinergic drugs and subsequent dementia risk in patients with diabetes mellitus. PLoS One 2017; 12:e0175335. [PMID: 28384267 PMCID: PMC5383287 DOI: 10.1371/journal.pone.0175335] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/24/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The effects of oxybutynin, solifenacin and tolterodine on dementia risk in patients with diabetes mellitus (DM) remain unknown. We investigated the effects of oxybutynin, solifenacin and tolterodine on dementia risk in patients with DM. METHODS We conducted a cohort study by using the diabetes dataset of the Taiwan National Health Insurance Research Database from 1 January, 2002 to 31 December, 2013. We included 10,938 patients received one type of oxybutynin, solifenacin, or tolterodine, while 564,733 had not. We included a comparable number of patients not receiving oxybutynin, solifenacin, or tolterodine as controls through systematic random sampling matching by age, gender, and the year of the index date with 1 to 1 ratio. The dementia risk was estimated through multivariate Cox proportional hazard regression after adjustment for several confounding factors. RESULTS The dementia event rates were 3.9% in the oxybutynin group, 4.3% in the solifenacin group, 2.2% in the tolterodine group and 1.2% in the control group (P<0.001). The adjusted HRs compared to nonusers of anticholinergic drugs were 2.35 (95% CI, 1.96 to 2.81), 2.16 (95% CI, 1.81 to 2.58), and 2.24 (95% CI, 1.85 to 2.73), respectively, for patients receiving oxybutynin, solifenacin, or tolterodine. CONCLUSION Our study indicates an association between taking oxybutynin, solifenacin and tolterodine and the subsequent diagnosis of dementia in DM patients. Moreover, the patients using oxybutynin had highest risk. The impact of these three drugs on risk of dementia in non-diabetic populations is warrant.
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Affiliation(s)
- Yu-Wan Yang
- Department of Neurology, China Medical University Hospital Taichung, Taiwan
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Hsin-Ho Liu
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Tien-Huang Lin
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Hsun-Yang Chuang
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
| | - Tengfu Hsieh
- Department of Urology, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualian, Taiwan
- Department of Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- * E-mail:
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