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Yang CT, Chong KS, Wang CC, Ou HT, Kuo S. Adaptation of risk prediction equations for cardiovascular outcomes among patients with type 2 diabetes in real-world settings: a cross-institutional study using common data model approach. Cardiovasc Diabetol 2024; 23:244. [PMID: 38987773 PMCID: PMC11238483 DOI: 10.1186/s12933-024-02320-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/16/2024] [Indexed: 07/12/2024] Open
Abstract
OBJECTIVE To adapt risk prediction equations for myocardial infarction (MI), stroke, and heart failure (HF) among patients with type 2 diabetes in real-world settings using cross-institutional electronic health records (EHRs) in Taiwan. METHODS The EHRs from two medical centers, National Cheng Kung University Hospital (NCKUH; 11,740 patients) and National Taiwan University Hospital (NTUH; 20,313 patients), were analyzed using the common data model approach. Risk equations for MI, stroke, and HF from UKPDS-OM2, RECODe, and CHIME models were adapted for external validation and recalibration. External validation was assessed by (1) discrimination, evaluated by the area under the receiver operating characteristic curve (AUROC) and (2) calibration, evaluated by calibration slopes and intercepts and the Greenwood-Nam-D'Agostino (GND) test. Recalibration was conducted for unsatisfactory calibration (p-value of GND test < 0.05) by adjusting the baseline hazards of original equations to address variations in patients' cardiovascular risks across institutions. RESULTS The CHIME risk equations had acceptable discrimination (AUROC: 0.71-0.79) and better calibration than that for UKPDS-OM2 and RECODe, although the calibration remained unsatisfactory. After recalibration, the calibration slopes/intercepts of the CHIME-MI, CHIME-stroke, and CHIME-HF risk equations were 0.9848/- 0.0008, 1.1003/- 0.0046, and 0.9436/0.0063 in the NCKUH population and 1.1060/- 0.0011, 0.8714/0.0030, and 1.0476/- 0.0016 in the NTUH population, respectively. All the recalibrated risk equations showed satisfactory calibration (p-values of GND tests ≥ 0.05). CONCLUSIONS We provide valid risk prediction equations for MI, stroke, and HF outcomes in Taiwanese type 2 diabetes populations. A framework for adapting risk equations across institutions is also proposed.
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Affiliation(s)
- Chun-Ting Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kah Suan Chong
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Chuan Wang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
- Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Shihchen Kuo
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Liao YS, Tsai WC, Chiu LT, Kung PT. Educational attainment affects the diagnostic time in type 2 diabetes mellitus and the mortality risk of those enrolled in the diabetes pay-for-performance program. Health Policy 2023; 138:104917. [PMID: 37776765 DOI: 10.1016/j.healthpol.2023.104917] [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: 02/05/2023] [Revised: 09/17/2023] [Accepted: 09/19/2023] [Indexed: 10/02/2023]
Abstract
Most patients are diagnosed as having diabetes only after experiencing diabetes complications. Educational attainment might have a positive relationship with diabetes prognosis. The diabetes pay-for-performance (P4P) program-providing comprehensive, continuous medical care-has improved diabetes prognosis in Taiwan. This retrospective cohort study investigated how educational attainment affects the presence of diabetes complications at diabetes diagnosis and mortality risk in patients with diabetes enrolled in the P4P program. From the National Health Insurance Research Database, we identified patients aged >45 years who had received a new diagnosis of type 2 diabetes during 2002-2015; they were followed up until the end of 2017. We next used logistic regression analysis to explore whether the patients with different educational attainments had varied diabetic complication risks at diabetes diagnosis. The Cox proportional hazard model was employed to examine the association of different educational attainments in people with diabetes with mortality risk after their enrollment in the P4P program. The results indicated that as educational attainment increased, the risk of diabetes complications at type 2 diabetes diagnosis decreased gradually. When type 2 diabetes with different educational attainments joined the P4P program, high school education had the highest effect on reducing mortality risk; however, those with ≤ 6th grade education had the lowest impact.
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Affiliation(s)
- Yi-Shu Liao
- Department of Pathology, Taichung Armed Forces General Hospital, National Defense Medical Center, Taiwan; Department of Public Health, China Medical University, Taiwan
| | - Wen-Chen Tsai
- Department of Health Services Administration, China Medical University, Taiwan
| | - Li-Ting Chiu
- Department of Health Services Administration, China Medical University, Taiwan
| | - Pei-Tseng Kung
- Department of Healthcare Administration, Asia University, Taiwan; Department of Medical Research, China Medical University Hospital, Taiwan.
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Lu JFR, Chen YI, Eggleston K, Chen CH, Chen B. Assessing Taiwan's pay-for-performance program for diabetes care: a cost-benefit net value approach. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:717-733. [PMID: 35995886 DOI: 10.1007/s10198-022-01504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 07/26/2022] [Indexed: 05/20/2023]
Abstract
Pay-for-Performance (P4P) to better manage chronic conditions has yielded mixed results. A better understanding of the cost and benefit of P4P is needed to improve program assessment. To this end, we assessed the effect of a P4P program using a quasi-experimental intervention and control design. Two different intervention groups were used, one consisting of newly enrolled P4P patients, and another using P4P patients who have been enrolled since the beginning of the study. Patient-level data on clinical indicators, utilization and expenditures, linked with national death registry, were collected for diabetic patients at a large regional hospital in Taiwan between 2007 and 2013. Net value, defined as the value of life years gained minus the cost of care, is calculated and compared for the intervention group of P4P patients with propensity score-matched non-P4P samples. We found that Taiwan's implementation of the P4P program for diabetic care yielded positive net values, ranging from $40,084 USD to $348,717 USD, with higher net values in the continuous enrollment model. Our results suggest that the health benefits from P4P enrollment may require a sufficient time frame to manifest, so a net value approach incorporating future predicted mortality risks may be especially important for studying chronic disease management. Future research on the mechanisms by which the Taiwan P4P program helped improve outcomes could help translate our findings to other clinical contexts.
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Affiliation(s)
- Jui-Fen Rachel Lu
- Graduate Institute of Business and Management and Department of Health Care Management, College of Management, Chang Gung University, Taoyuan City, Taiwan
- Department of Radiation Oncology, Chang Gung Memorial Hospital in Linkou, Taoyuan City, Taiwan
| | - Ying Isabel Chen
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Karen Eggleston
- Shorenstein Asia-Pacific Research Center, Freeman Spogli Institute for International Studies, Stanford University, and NBER, Stanford, CA, USA
| | - Chih-Hung Chen
- Division of Metabolism, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Brian Chen
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
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Importance of medication adherence in treatment needed diabetic retinopathy. Sci Rep 2021; 11:19100. [PMID: 34580364 PMCID: PMC8476599 DOI: 10.1038/s41598-021-98488-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/09/2021] [Indexed: 11/29/2022] Open
Abstract
We aim to investigate the role of medication adherence history in treatment needed diabetic retinopathy (TNDR). We conducted a retrospective nested case–control study using 3 population-based databases in Taiwan. The major one was the 2-million-sample longitudinal health and welfare population-based database from 1997 to 2017, a nationally representative random sample of National Health Insurance Administration enrolled beneficiaries in 2010 (LHID2010). The national death registry and national cancer registry were also checked to verify the information. The outcome was defined as the TNDR. The Medication possession ratio (MPR) was defined as the ratio of total days of diabetes mellitus (DM) medication supply divided by total observation days. MPR ≥ 80% was proposed as good medication adherence. The association of MPR and the TNDR was analyzed. Other potential confounders and MPR ratio were also evaluated. A total of (n = 44,628) patients were enrolled. Younger aged, male sex and patients with less chronic illness complexity or less diabetes complication severity tend to have poorer medication adherence. Those with severe comorbidity or participating pay-for-performance program (P4P) revealed better adherence. No matter what the characteristics are, patients with good MPR showed a significantly lower likelihood of leading to TNDR after adjustment with other factors. The protection effect was consistent for up to 5 years. Good medication adherence significantly prevents treatment needed diabetic retinopathy. Hence, it is important to promote DM medication adherence to prevent risks of diabetic retinopathy progression, especially those who opt to have low medication adherence.
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Airhihenbuwa CO, Tseng TS, Sutton VD, Price L. Global Perspectives on Improving Chronic Disease Prevention and Management in Diverse Settings. Prev Chronic Dis 2021; 18:E33. [PMID: 33830913 PMCID: PMC8051856 DOI: 10.5888/pcd18.210055] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The Centers for Disease Control and Prevention (CDC) define chronic diseases as conditions that last 1 year or more and that require ongoing medical attention or limit activities of daily living, or both (1). Chronic diseases may be influenced by a combination of genetics, lifestyle and social behaviors, health care system factors, community influences, and environmental determinants of health (2). These risk factors often coexist and interact with each other. Therefore, a better understanding of determinants of chronic diseases such as tobacco use, unhealthy eating, and physical inactivity stands to benefit from effective strategies for improving primary, secondary, and tertiary disease prevention and management in diverse global settings (3). Strategies to prevent and manage chronic disease outcomes such as diabetes and cardiovascular diseases (CVDs) have global commonalities (4-7). The impact of chronic diseases is disproportionately evident in Black and Brown communities (8,9). Chronic disease prevention and management typically focus on behavioral interventions such as healthy eating, increased physical activity, and cessation of unhealthy practices such as tobacco and alcohol use (10-15). In 2020, the COVID-19 pandemic added to the fact that chronic diseases disproportionately affect low-resource communities, where many Black and Brown populations live (16,17). COVID-19 demonstrated that chronic disease disparities actually present as preexisting conditions in Black and Brown communities, who are disproportionately affected by COVID-19 outcomes. Although most of the articles in this Preventing Chronic Disease (PCD) collection were published before the pandemic, the insights they present, combined with the racial and ethnic data on the burden of COVID-19 thus far, support this reality. Many researchers and public health practitioners often consider the need to sufficiently address the relationships between chronic diseases and social, behavioral, and community factors (18). Global lessons in the prevention and management of chronic diseases, therefore, can help researchers and practitioners benefit from the shared lessons and experience derived from research and interventions conducted in different parts of the world. There are more than 7 billion people worldwide, who speak diverse languages and who have different nationalities, identities, and health systems. Yet, if we share challenges and opportunities for chronic disease prevention and management, many of the global adversities to improving health and well-being can be ameliorated, which is the purpose of this collection. The authors in this collection share lessons that represent experiences in diverse contexts across countries and regions of the world.
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Affiliation(s)
- Collins O Airhihenbuwa
- Health Policy and Behavioral Sciences, School of Public Health, Georgia State University, 140 Decatur St, Atlanta, GA 30303.
| | - Tung-Sung Tseng
- Behavioral and Community Health Sciences Department, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Victor D Sutton
- Office of Preventive Health and Health Equity, Mississippi State Department of Health, Jackson, Mississippi
| | - LeShawndra Price
- Office of Research Training and Special Programs, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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Kung FP, Tsai CF, Lu CL, Huang LC, Lu CH. Diabetes pay-for-performance program can reduce all-cause mortality in patients with newly diagnosed type 2 diabetes mellitus. Medicine (Baltimore) 2020; 99:e19139. [PMID: 32049836 PMCID: PMC7035087 DOI: 10.1097/md.0000000000019139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
This study aimed to examine the effect of a diabetes pay-for-performance (P4P) program on all-cause mortality in patients with newly diagnosed type 2 diabetes mellitus. Using a Taiwanese representative nationwide cohort, we recruited 5478 patients with newly diagnosed type 2 diabetes enrolled in the P4P program within 5 years after a diagnosis of diabetes between January 1, 2002 and December 31, 2010 and individuals not enrolled in the P4P program were recruited as the control group matched 1:1 with the study group. We used multivariate Cox proportional hazard models analysis to investigate the effect of the P4P program and adherence on all-cause mortality. A total of 250 patients died in the P4P group compared to 395 in the control group (mortality rate 104 vs 169 per 10,000 person-years, respectively, P < .0001). The control group also had more comorbidities. Patients enrolled in the P4P program demonstrated significant long-term survival benefits, of which the adjusted hazard ratio (aHR) for all-cause mortality was 0.58 [95% CI (0.48-0.69)]. In the study group, better adherence to the P4P program resulted in a greater reduction in mortality, with aHRs [95% CI] of 0.48 [0.38-0.62] and 0.36 [0.26-0.49] in subjects with a minimum 1-year and 2-year good P4P adherence, respectively. Participating in the P4P program within 5 years after the diagnosis of diabetes resulted in a significant reduction in all-cause mortality, and this effect was particularly pronounced in the patients with better adherence to the P4P program.
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Affiliation(s)
- Fang-Ping Kung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Ditmanson Chia-Yi Christian Hospital
| | - Ching-Fang Tsai
- Department of Medical Research, Ditmanson Chia-Yi Christian Hospital, Chia-Yi City
| | - Chin-Li Lu
- Department of Medical Research, Ditmanson Chia-Yi Christian Hospital, Chia-Yi City
- Graduate Institute of Food Safety, College of Agriculture and Natural Resources, National Chung-Hsing University, Taichung
| | - Li-Chung Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Ditmanson Chia-Yi Christian Hospital
- Division of Psychiatry, Ditmanson Chia-Yi Christian Hospital, Chia-Yi City
| | - Chieh-Hsiang Lu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Ditmanson Chia-Yi Christian Hospital
- Kaohsiung Christian Hospital, Kaohsiung City, Taiwan
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Gupta N, Ayles HM. Effects of pay-for-performance for primary care physicians on diabetes outcomes in single-payer health systems: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:1303-1315. [PMID: 31401699 DOI: 10.1007/s10198-019-01097-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/31/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Although pay-for-performance (P4P) for diabetes care is increasingly common, evidence of its effectiveness in improving population health and health system sustainability is deficient. This information gap is attributable in part to the heterogeneity of healthcare financing, covered medical conditions, care settings, and provider remuneration arrangements within and across countries. We systematically reviewed the literature concentrating on whether P4P for physicians in primary and community care leads to better diabetes outcomes in single-payer national health insurance systems. METHODS Studies were identified by searching ten databases (01/2000-04/2018) and scanning the reference lists of review articles and other global health literature. We included primary studies evaluating the effects of introducing P4P for diabetes care among primary care physicians in countries of universal health coverage. Outcomes of interest included patient morbidity, avoidable hospitalization, premature death, and healthcare costs. RESULTS We identified 2218 reports; after exclusions, 10 articles covering 8 P4P interventions in 7 countries were eligible for analysis. Five studies, capturing records from 717,166 patients with diabetes, were graded as high-quality evaluations of P4P on health outcomes. Based on three quality studies, P4P can result in reduced risk of mortality over the longer term-when linked to performance metrics. However, studies from other jurisdictions, where P4P was not linked to specific patient-oriented objectives, yielded little or mixed evidence of positive health impacts. CONCLUSION Evidence of the effectiveness of P4P depends on whether physicians' incentive payments are explicitly tied to performance metrics. However, the most appropriate indicators for performance monitoring remain in question. More research with rigorous evaluation in different settings is needed.
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Affiliation(s)
- Neeru Gupta
- University of New Brunswick, PO Box 4400, Fredericton, NB, E3B 5A3, Canada.
| | - Holly M Ayles
- University of New Brunswick, PO Box 4400, Fredericton, NB, E3B 5A3, Canada
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Liang YW, Chang HF, Lin YH. Effects of health-information-based diabetes shared care program participation on preventable hospitalizations in Taiwan. BMC Health Serv Res 2019; 19:890. [PMID: 31771584 PMCID: PMC6880543 DOI: 10.1186/s12913-019-4738-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Taiwan's Diabetes Shared Care Program has been implemented since 2012, and the health information system plays a vital role in supporting most services of this program. However, little is known regarding the effectiveness of this information-based program. Therefore, this study investigated the effects of the participation of the Diabetes Shared Care Program on preventable hospitalizations. METHODS This longitudinal study examined the data of health-care claims from 2011 to 2014 obtained from the diabetes mellitus health database. Patients with diabetes aged ≥18 years were included. Preventable hospitalizations were identified on the basis of prevention quality indicators developed for administrative data by the US Agency for Healthcare Research and Quality. A multilevel logistic regression was performed to examine the effects of the participation of the Diabetes Shared Care Program on preventable hospitalizations after adjustment for other variables. Analyses were conducted in late 2018. RESULTS A medium level of participation (p = 0.05), age between 40 and 64 years(p < 0.0001), and absence of a catastrophic illness(p < 0.0001) were associated with a lower probability of having a preventable hospitalization. Male sex(p < 0.0001), age ≥ 65 years(p = 0.0203), low income level(p < 0.0001), living in the Southern division(p = 0.0106), and presence of many comorbidities(p < 0.0001) were associated with a higher probability of having a preventable hospitalization after adjustment for characteristics at the individual and county levels. CONCLUSIONS The health information system records patients' medical history, monitors quality of care, schedules patient follow-ups, and reminds case managers to provide timely health education. This health-information-based Diabetes Shared Care Program is associated with better quality care of ambulatory, so it should be promoted on a broader scale.
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Affiliation(s)
- Yia-Wun Liang
- Department of Senior Citizen Services Management, National Taichung University of Science and Technology, Taichung, Taiwan, Republic of China
| | - Hsiao-Feng Chang
- Department of Nursing, Chung-Kang Branch, Cheng Ching Hospital, Taichung, Taiwan, Republic of China
| | - Yu-Hsiu Lin
- Graduate Institute and Department of Information Management/Graduate Institute of Healthcare Information Management, Center for Innovative Research on Aging Society (CIRAS), 168, Sec. 1, University Road, Min-Hsiung, Chiayi, 62102, Taiwan, Republic of China.
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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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Lee MC, Lee CH, Chang LY, Chang CH, Zhang JF, Lee MR, Wang JY, Chen SM. Association of Metformin Use With End-Stage Renal Disease in Patients With Type 2 Diabetes Mellitus: A Nationwide Cohort Study Under the Pay-for-Performance Program. J Clin Pharmacol 2019; 59:1443-1452. [PMID: 31163098 DOI: 10.1002/jcph.1452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/16/2019] [Indexed: 12/25/2022]
Abstract
Animal studies have demonstrated that metformin exerts a renoprotective effect. Human studies of patients with diabetes mellitus (DM) regarding the association of metformin use with end-stage renal disease (ESRD) are lacking. Patients with type 2 DM and without a history of kidney disease who were enrolled under the pay-for-performance program of the National Health Insurance in Taiwan were identified. Those who received ≥90 cumulative defined daily doses of metformin within 1 year were selected (metformin users) and compared with a 1:1 propensity score-matched metformin nonuser cohort. Primary and secondary outcomes were development of ESRD and chronic kidney disease (CKD), respectively. Independent predictors were investigated using Cox regression analysis. A total of 24 158 pairs of metformin users and nonusers were enrolled, with an incidence of ESRD of 1908 and 1723 and CKD of 1095 and 1056 cases per 100 000 person-years, respectively. Metformin use was independently associated with increased risks of ESRD (adjusted hazard ratio, 1.22; 95% confidence interval, 1.12-1.32) and CKD (adjusted hazard ratio, 1.25; 95% confidence interval, 1.12-1.40) in a dose-response relationship. Patients with hypertension plus nonuse of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers potentiated kidney damage by metformin. In patients with DM, use of metformin may increase the risk of ESRD and CKD. Health care professionals should be alert and closely monitor renal function when prescribing metformin.
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Affiliation(s)
- Ming-Chia Lee
- Department of Pharmacy, New Taipei City Hospital, New Taipei City, Taiwan.,School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Chih-Hsin Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Lih-Yu Chang
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Chia-Hao Chang
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jun-Fu Zhang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Rui Lee
- Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Ming Chen
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
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