Trend and Factors Associated With Healthcare Use and Costs in Type 2 Diabetes Mellitus: A Decade Experience of a Universal Health Insurance Program

Participation and Outcomes among Disabled and Non-Disabled People in the Diabetes Pay-for-Performance Program

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.

The effect of pay-for-performance program on infection events and mortality rate in diabetic patients: a nationwide population-based cohort study

Background

Diabetes mellitus is a known risk factor for infection. Pay for Performance (P4P) program is designed to enhance the comprehensive patient care. The aim of this study is to evaluate the effect of the P4P program on infection incidence in type 2 diabetic patients.

Methods

This is a retrospective longitudinal cohort study using data from the National Health Insurance Research Database in Taiwan. Diabetic patients between 1 January 2002 and 31 December 2013 were included. Primary outcomes analyzed were patient emergency room (ER) infection events and deaths.

Results

After propensity score matching, there were 337,184 patients in both the P4P and non-P4P cohort. The results showed that patients’ completing one-year P4P program was associated with a decreased risk of any ER infection event (27.2% vs. 29%; subdistribution hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.86–0.88). While the number needed to treat was 58 for the non-P4P group, it dropped to 28 in the P4P group. The risk of infection-related death was significantly lower in the P4P group than in the non-P4P group (4.1% vs. 7.6%; HR 0.46, 95% CI 0.45–0.47). The effect of P4P on ER infection incidence and infection-related death was more apparent in the subgroups of patients who were female, had diabetes duration ≥5 years, chronic kidney disease, higher Charlson’s Comorbidity Index scores and infection-related hospitalization in the previous 3 years.

Conclusions

The P4P program might reduce risk of ER infection events and infection-related deaths in type 2 diabetic patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06091-2.

The Early Impact of the Centers for Medicare & Medicaid Services State Innovation Models Initiative on 30-Day Hospital Readmissions Among Adults With Diabetes

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) State Innovation Models (SIM) Initiative funds states to accelerate delivery system and payment reforms. All SIM states focus on improving diabetes care, but SIM's effect on 30-day readmissions among adults with diabetes remains unclear.

METHODS

A quasi-experimental research design estimated the impact of SIM on 30-day hospital readmissions among adults with diabetes in 3 round 1 SIM states (N=671,996) and 3 comparison states (N=2,719,603) from 2010 to 2015. Difference-in-differences multivariable logistic regression models that incorporated 4-group propensity score weighting were estimated. Heterogeneity of SIM effects by grantee state and for CMS populations were assessed.

RESULTS

In adjusted difference-in-difference analyses, SIM was associated with an increase in odds of 30-day hospital readmission among patients in SIM states in the post-SIM versus pre-SIM period relative to the ratio in odds of readmission among patients in the comparison states post-SIM versus pre-SIM (ratio of adjusted odds ratio=1.057, P=0.01). Restricting the analyses to CMS populations (Medicare and Medicaid beneficiaries), resulted in consistent findings (ratio of adjusted odds ratio=1.057, P=0.034). SIM did not have different effects on 30-day readmissions by state.

CONCLUSIONS

We found no evidence that SIM reduced 30-day readmission rates among adults with diabetes during the first 2 years of round 1 implementation, even among CMS beneficiaries. It may be difficult to reduce readmissions statewide without greater investment in health information exchange and more intensive use of payment models that promote interorganizational coordination.

Forecasting the amount and cost of medicine to treat type 2 diabetes mellitus in Nepal using knowledge on medicine usage from a developed country

Objectives

This research was aimed to forecast the amount and cost of medicines required to treat people with type 2 diabetes mellitus (T2DM) in Nepal over 30 years.

Methods

We modelled the financial burden of T2DM medicines by estimating the cost of medicines to treat all cases of T2DM in Nepal over three decades based on the prevalence of T2DM in Nepal, the Nepalese costs of medicine and the T2DM medicine use profile of Australia.

Key findings

With the current T2DM prevalence trend, it would cost US$63–95 million in 2013 to purchase T2DM medicines for Nepal, if Nepalese receive the same mix of T2DM medicines as used in Australia. This cost is almost one-quarter of the total health budget of Nepal (US$308 million). The cost of medicines to treat T2DM is projected to triple between 2013 and 2043.

Conclusions

With the medicines for only T2DM projected to cost about 25% of the entire health budget, the planned health insurance seems unaffordable if patients are treated with the same medicines as those in one of the best healthcare systems in the world. The government needs to stimulate rational prescribing and secure additional funding through taxation, health insurance or health levy to provide such medicines and services.

Validity of a Short Food Frequency Questionnaire Assessing Macronutrient and Fiber Intakes in Patients of Han Chinese Descent with Type 2 Diabetes

Few food frequency questionnaires (FFQs) have been developed to assess diet in diabetes patients. This cross-sectional study examined the validity of a 45-item FFQ assessing the intake of macronutrients against three 24-h dietary recalls (24-HDRs) in Taiwan, and compared vegetable and fruit intakes with carotenoid biomarkers. We recruited 126 adults with type 2 diabetes who completed the FFQ and three 24-HDRs administered by a registered dietitian. We measured plasma carotenoids (α-carotene, β-carotene and lutein) in 71 subjects. Partial Pearson correlation coefficients derived from the FFQs and three 24-HDRs and adjusted for energy were of 0.651, 0.587, 0.639 and 0.664 for protein, fat, carbohydrate and fiber, respectively. Cross-classification analysis revealed that 71.5⁻81% of the macronutrients and fiber were categorized into the same or adjacent quartiles by the FFQ and 24-HDRs. Bland⁻Altman plots revealed good agreement for energy/macronutrients/fiber across the range of intakes. Multiple linear regression of backward elimination revealed that tertile levels of dark- or light-colored vegetables obtained by the FFQ were significantly associated with plasma α-carotene and β-carotene, but not lutein. Fruit consumption did not correlate with carotenoid biomarkers. In conclusion, this short FFQ provided a valid assessment of macronutrients and fiber intake in type 2 diabetes patients. Vegetable consumption estimated by the FFQ corresponded to plasma α-carotene and β-carotene concentrations.

Vegetarian diet, change in dietary patterns, and diabetes risk: a prospective study

Background/objectives

Vegetarian diets are inversely associated with diabetes in Westerners but their impact on Asians—whose pathophysiology differ from Westerners—is unknown. We aim to investigate the association between a vegetarian diet, change in dietary patterns and diabetes risk in a Taiwanese Buddhist population.

Methods

We prospectively followed 2918 non-smoking, non-alcohol drinking Buddhists free of diabetes, cancer, and cardiovascular diseases at baseline, for a median of 5 years, with 183 incident diabetes cases confirmed. Diet was assessed through a validated food frequency questionnaire at baseline and a simple questionnaire during follow-ups. Incident cases of diabetes were ascertained through follow-up questionnaires, fasting glucose and HbA1C. Stratified Cox Proportional Hazards Regression was used to assess the effect of diets on risk of diabetes.

Results

Consistent vegetarian diet was associated with 35% lower hazards (HR: 0.65, 95% CI: 0.46, 0.92), while converting from a nonvegetarian to a vegetarian pattern was associated with 53% lower hazards (HR: 0.47, 95% CI: 0.30, 0.71) for diabetes, comparing with nonvegetarians while adjusting for age, gender, education, physical activity, family history of diabetes, follow-up methods, use of lipid-lowering medications, and baseline BMI.

Conclusion

Vegetarian diet and converting to vegetarian diet may protect against diabetes independent of BMI among Taiwanese.

Influencing Pathways to Quality of Life and HbA1c in Patients With Diabetes: A Longitudinal Study That Inform Evidence-Based Practice

BACKGROUND

Determining possible associated factors and the influencing pathways to hemoglobin A1C (HbA1C) levels and quality of life (QoL) will facilitate the development of effective interventions to improve the physical and psychosocial health of patients with type 2 diabetes mellitus (T2DM).

OBJECTIVES

To test a hypothesized model that addressed the pathways among personal characteristics, social support, diabetes distress, and self-care behaviors to HbA1C and QoL.

METHODS

A total of 382 adults with T2DM were recruited. Self-reported questionnaires and medical records were used to collect data regarding personal characteristics, diabetes distress, and social support at baseline. The self-care behaviors characters were collected 6 months later, as well as QoL and HbA1C levels 1 year later.

RESULTS

The 12-month QoL directly affected 12-month HbA1C levels. The 6-month self-care behaviors directly affected 12-month QoL, and indirectly affected 12-month HbA1C levels through 12-month QoL. Baseline diabetes distress directly affected 12-month QoL. Moreover, baseline diabetes distress indirectly affected 12-month HbA1C levels through 12-month QoL. Baseline social support directly affected baseline diabetes distress and 6-month self-care behaviors. In addition, baseline social support indirectly affected 12-month QoL through baseline diabetes distress. Baseline social support also indirectly affected 12-month QoL through 6-month self-care behaviors.

LINKING EVIDENCE TO ACTION

Enhancing QoL is important to improve HbA1C levels. Enhancing self-care behaviors is essential to improve subsequent HbA1C control and QoL. Reducing diabetes distress is crucial to improve subsequent QoL. Improving social support is suggested a favorable strategy to reduce diabetes distress and enhance subsequent self-care behaviors in patients with T2DM.

Assessment of hospital length of stay and direct costs of type 2 diabetes in Hubei Province, China

BACKGROUND

The incidence of type 2 diabetes is increasing, creating a huge burden for China's social healthcare system. This study aimed to evaluate hospital length of stay (LOS) based on admission characteristics and direct costs correlated with various types of complications for type 2 diabetic inpatients in Hubei Province, China.

METHODS

A total of 1528 inpatients diagnosed with type 2 diabetes discharged between April 1, 2013, and March 31, 2014, were included in this study. Information regarding patients' admission and hospitalization were obtained from the hospital information system. The relationship between admission characteristics and LOS, distribution of total costs, and types of complications were described and analysed.

RESULTS

(1) The mean LOS was 11.65 days (median: 10 days). Multiple linear regression analysis demonstrated that inpatients with New Cooperative Medical Scheme (NCMS), aged 80 and above, had longer LOS than the reference group, and inpatients with chronic or acute + chronic complications had shorter LOS than those without. (2) Mean total costs per patient were US$159.72 ± 130.83 (median: US$135.33), US$240.60 ± 166.58 (median: US$192.09), and US$247.98 ± 166.22 (median: US$200.99) for inpatients with no complications, chronic complications, and acute + chronic complications, respectively. Total and individual costs were significantly less for patients without complications than for those with the two types of complications (p < 0.001). (3) Mean total costs per patient were US$225.40 ± 115.32 (median: US$200.34), US$221.25 ± 177.64 (median: US$170.05), and US$275.18 ± 193.14 (median: US$217.91) for inpatients with microvascular complications, macrovascular complications, and microvascular + macrovascular complications, respectively. Total costs were significantly higher for patients with microvascular + macrovascular complications than for those with other types of chronic complications (p < 0.001). (4) Drugs were the greatest expense for patients, and the least expensive treatment was nursing care.

CONCLUSIONS

Medical insurance status, age, and type of complication may help to predict LOS for patients with type 2 diabetes in Hubei Province, China. The total and individual costs for patients with complications were higher than for those without, and hospitalization expenses posed a heavy burden. Efforts should be made to reduce the financial impact on patients by integrating the medical insurance system of urban and rural areas, and by reducing the risk of complications, especially microvascular complications.

Recent trends in the use of antidiabetic medications from 2008 to 2013: A nation-wide population-based study from Taiwan

BACKGROUND

Studies from other countries indicate that utilization patterns of antidiabetic drugs change significantly after the introduction of newer classes of antidiabetic drugs (e.g. dipeptidyl peptidase-4 inhibitors [DPP-4i]). Evidence on recent trends regarding antidiabetic drug use in Taiwan is lacking, especially for times after the introduction of newer classes of drugs (e.g. DPP-4i). Therefore, the aim of the present study was to assess: (i) recent trends in the use and spending on antidiabetic drugs; (ii) changes in utilization patterns after introduction of newer classes of antidiabetic drugs; and (iii) factors associated with the choice of newer versus older classes of antidiabetic drugs.

METHODS

Cases of type 2 diabetes were derived from Taiwan's National Health Insurance Research Database. Antidiabetic drug use was measured in terms of total quantity of drug exposure and healthcare spending in each calendar year from 2008 to 2103. Multiple logistic regression analysis was used to assess factors associated with drug choice.

RESULTS

The use of and healthcare spending on DPP-4i increased significantly from 2008 to 2013, whereas healthcare spending on sulfonylureas decreased. For monotherapy, sulfonylureas were the most common alternatives to metformin, whereas in dual and triple antidiabetic therapies, a DPP-4i was the most common alternative to initial regimens. The use of a DPP-4i was positively associated with the use of beta-blockers, angiotensin II-converting enzyme inhibitors and/or angiotensin receptor blockers, and lipid-lowering agents, but negatively correlated with age, hypertension, severity of diabetes complications, and the use of diuretics and calcium channel blockers.

CONCLUSIONS

With growing spending on newer antidiabetic drugs, future research on the comparative cost-effectiveness and safety of antidiabetic drugs is anticipated.

Impact of pay-for-performance on mortality in diabetes patients in Taiwan: A population-based study

BACKGROUND

The impact of pay-for-performance (P4P) programs on long-term mortality for chronic illnesses, especially diabetes mellitus, has been rarely reported. Several studies described the favorable impact of P4P for diabetes mellitus on medical utilizations or intermediate outcomes. Therefore, this study aimed to investigate the impact of a P4P program on mortality in patients with type 2 diabetes.

METHODS

The P4P group in this population-based cohort study was 2090 individuals with a primary diagnosis of type 2 diabetes who had been newly enrolled in the P4P program of Taiwan between January 1, 2004 and December 31, 2004. Matched by 1:1 ratio, patients in the non-P4P group were selected by propensity score matching (PSM) for sex, age, the first year of diagnosis as diabetes, and 32 other potential confounding factors. Mean (SD) age was 60.91 (12.04) years when diabetes was first diagnosed and mean (SD) duration of diabetes was 4.3 (1.9) years at baseline. The time-dependent Cox regression model was used to explore the impact of P4P on all-cause mortality.

RESULTS

During a mean of 5.13 years (SD = 1.07 years) of follow-up, 206 and 263 subjects died in the P4P group and the non-P4P group, respectively. After adjusting for the potential confounding factors at baseline, survival was significantly longer in the P4P group than in the non-P4P group (hazard ratio, 0.76 [95% confidence interval, 0.64-0.92], P = 0.004, by log-rank test). This decrease in mortality is equivalent to one less death for every 37 patients who were treated in the P4P program for 5.13 years. In this study, the P4P program significantly increased the medical utilization of physician visits and diabetes-related examinations, improved the adherence of oral hypoglycemic drugs during the first 3 years and that of insulin during the second 3 years, and was negatively associated with risk of cancer and chronic kidney disease. In annual health expense, there was no significant difference between P4P and non-P4P groups, P = 0.430.

CONCLUSIONS

As compared with control, pay-for-performance program significantly improved survival in patients with diabetes without increasing the medical cost. The P4P group had significantly lower risk of cancer and chronic kidney disease.

Comparative cost-effectiveness of metformin-based dual therapies associated with risk of cardiovascular diseases among Chinese patients with type 2 diabetes: Evidence from a population-based national cohort in Taiwan

OBJECTIVE

To assess the cost-effectiveness of metformin-based dual therapies associated with cardiovascular disease (CVD) risk in a Chinese population with type 2 diabetes.

METHODS

We utilized Taiwan's National Health Insurance Research Database (NHIRD) 1997-2011, which is derived from the claims of National Health Insurance, a mandatory-enrollment single-payer system that covers over 99% of Taiwan's population. Four metformin-based dual therapy cohorts were used, namely a reference group of metformin plus sulfonylureas (Metformin-SU) and metformin plus acarbose, metformin plus thiazolidinediones (Metformin-TZD), and metformin plus glinides (Metformin-glinides). Using propensity scores, each subject in a comparison cohort was 1:1 matched to a referent. The effectiveness outcome was CVD risk. Only direct medical costs were included. The Markov chain model was applied to project lifetime outcomes, discounted at 3% per annum. The bootstrapping technique was performed to assess uncertainty in analysis.

RESULTS

Metformin-glinides was most cost-effective in the base-case analysis; Metformin-glinides saved $194 USD for one percentage point of reduction in CVD risk, as compared to Metformin-SU. However, for the elderly or those with severe diabetic complications, Metformin-TZD, especially pioglitazone, was more suitable; as compared to Metformin-SU, Metformin-TZD saved $840.1 USD per percentage point of reduction in CVD risk. Among TZDs, Metformin-pioglitazone saved $1831.5 USD per percentage point of associated CVD risk reduction, as compared to Metformin-rosiglitazone.

CONCLUSIONS

When CVD is considered an important clinical outcome, Metformin-pioglitazone is cost-effective, in particular for the elderly and those with severe diabetic complications.

The association between participation in a pay-for-performance program and macrovascular complications in patients with type 2 diabetes in Taiwan: A nationwide population-based cohort study

OBJECTIVE

Diabetes and diabetes-related complications are major causes of morbidity and mortality worldwide and contribute substantially to health care costs. Proper care can prevent or delay vascular complications in people with type 2 diabetes. We sought to examine whether a diabetes pay-for-performance (P4P) program under Taiwan's National Health Insurance program decreased risk of macrovascular complications in type 2 diabetes patients, and associated risk factors.

RESEARCH DESIGN AND METHOD

We conducted a longitudinal observational case and control cohort study using two nationwide population-based databases in Taiwan, 2007-2012. Type 2 diabetes patients with a primary diabetes diagnosis in year 2007 and 2008 were included. We excluded patients with any diabetes complications within 2years before the index date. A propensity score matching approach was used to determine comparable P4P and non-P4P groups. We followed each P4P and non-P4P patient until December 31, 2012. Complication incidence rates per 1000 person-years for each complication were calculated.

RESULTS

Overall, our results indicated that P4P patients had lower risk of macrovascular complications than non-P4P patients. Specifically, hazard ratios (95% confidence intervals) were 0.84 (0.80-0.88) for stroke, 0.83 (0.75-0.92) for myocardial infarction, 0.72 (0.60-0.85) for atrial fibrillation, 0.93 (0.87-0.98) for heart failure, 0.61 (0.50-0.73) for gangrene, and 0.83 (0.74-0.93) for ulcer of lower limbs.

CONCLUSIONS

Compared with patients not enrolled in the P4P program, P4P patients had lower risk of developing serious vascular complications. Our empirical findings provide evidence for the potential long-term benefit of P4P programs in reducing risks of macrovascular complications.

Effect of coexisting diabetes mellitus and chronic kidney disease on mortality of cirrhotic patients with esophageal variceal bleeding

BACKGROUND

Esophageal variceal bleeding (EVB) is a serious and common complication of cirrhosis. Diabetes mellitus (DM) and chronic kidney disease (CKD) increase mortality in patients with cirrhosis. However, whether coexisting DM and CKD increase mortality in cirrhotic patients with EVB remains unclear.

METHODS

We enrolled cirrhotic patients hospitalized with the first presentation of EVB from 2005 through 2010 using Longitudinal Health Insurance Database 2005. The hazard ratios (HRs) of 42-day and one-year EVB mortality were calculated using Cox regression model.

RESULTS

We identified 888 patients hospitalized with the first presentation of EVB. Among the cirrhotic patients with EVB, all-cause mortality at 42-day and one-year were 21.3 and 45.0 %, respectively. The respective HRs for the 42-day and one-year mortality were 1.80 (95 % confidence interval [CI], 1.10-2.97) and 1.52 (95 % CI, 1.06-2.17) for patients with CKD and 0.79 (95 % CI, 0.57-1.10) and 0.88 (95 % CI, 0.71-1.09) for patients with DM. Specifically, coexisting CKD and DM increased the 42-day and one-year mortality with respective HRs of 1.99 (95%CI, 1.03-3.84) and 1.84 (95%CI, 1.14-2.98) compared with those without CKD and DM. The HRs for 42-day and 1-year mortality in female patients with DM and CKD were 4.03 (95%CI, 1.40-11.59) and 2.84 (95%CI, 1.31-6.14) respectively, and were 2.93 (95%CI, 1.14-7.57) and 2.42 (95%CI, 1.28-4.57) in male patients with DM and CKD.

CONCLUSION

We identified that coexisting DM and CKD increased risk of mortality at 42 days and 1 year following EVB.

Medication Adherence With Diabetes Medication: A Systematic Review of the Literature

PURPOSE

The primary purpose of this systematic review is to synthesize the evidence regarding risk factors associated with nonadherence to prescribed glucose-lowering agents, the impact of nonadherence on glycemic control and the economics of diabetes care, and the interventions designed to improve adherence.

METHODS

Medline, EMBASE, the Cochrane Collaborative, BIOSIS, and the Health and Psychosocial Instruments databases were searched for studies of medication adherence for the period from May 2007 to December 2014. Inclusion criteria were study design and primary outcome measuring or characterizing adherence. Published evidence was graded according to the American Association of Clinical Endocrinologists protocol for standardized production of clinical practice guidelines.

RESULTS

One hundred ninety-six published articles were reviewed; 98 met inclusion criteria. Factors including age, race, health beliefs, medication cost, co-pays, Medicare Part D coverage gap, insulin use, health literacy, primary nonadherence, and early nonpersistence significantly affect adherence. Higher adherence was associated with improved glycemic control, fewer emergency department visits, decreased hospitalizations, and lower medical costs. Adherence was lower when medications were not tolerated or were taken more than twice daily, with concomitant depression, and with skepticism about the importance of medication. Intervention trials show the use of phone interventions, integrative health coaching, case managers, pharmacists, education, and point-of-care testing improve adherence.

CONCLUSION

Medication adherence remains an important consideration in diabetes care. Health professionals working with individuals with diabetes (eg, diabetes educators) are in a key position to assess risks for nonadherence, to develop strategies to facilitate medication taking, and to provide ongoing support and assessment of adherence at each visit.