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Factors Related to Continuing Care and Interruption of P4P Program Participation in Patients With Diabetes
Suh-May Yen, MD, PhD; Pei-Tseng Kung, ScD; Yi-Jing Sheen, MD, MHA, Li-Ting Chiu, MHA; Xing-Ci Xu, MHA; and Wen-Chen Tsai, DrPH
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Factors Related to Continuing Care and Interruption of P4P Program Participation in Patients With Diabetes

Suh-May Yen, MD, PhD; Pei-Tseng Kung, ScD; Yi-Jing Sheen, MD, MHA, Li-Ting Chiu, MHA; Xing-Ci Xu, MHA; and Wen-Chen Tsai, DrPH
Analyzing factors associated with continuing care participation in patients with diabetes and with interrupted participation by patients enrolled in a diabetes pay-for-performance program.
ABSTRACT

Objectives: To examine factors that influenced continuing care participation in patients with diabetes and factors contributing to interrupted participation for patients with diabetes enrolled in a diabetes pay-for-performance (P4P) program in Taiwan.

Study Design: Retrospective cohort analysis.

Methods: Data were obtained from Taiwan’s National Health Insurance Research Database on patients with a new confirmed diagnosis of type 2 diabetes during 2001 to 2008, selected as 1:1 propensity score-matched P4P program enrollees and nonenrollees (totaling 396,830). Logistic regression was performed to analyze factors associated with continuing care participation and with interrupted P4P program participation after enrollment.

Results: Among the patients with diabetes, P4P program enrollees were 4.27 times (95% CI, 4.19-4.36) more likely to participate in continuing care than nonenrollees. Factors affecting the participation of patients with diabetes in continuing care included P4P program enrollment status, personal characteristics, health status, characteristics of the main physician, and characteristics of the main healthcare organization. Interruption of P4P program participation occurred in 78,759 (44.33%) of the enrolled patients with diabetes and was correlated with male gender, younger age (<35 years), residence in areas of highest urbanization, greater severity of diabetes complications, presence of catastrophic illness/injury, high service volume at the site of the main physician, older age (≥55 years) of the main physician, having a regional or private hospital as the main healthcare organization, and change of physician.

Conclusions: Taiwan’s diabetes P4P program increased continuing care participation in patients with diabetes. The rate of interruption of P4P program participation among enrolled patients with diabetes, at 44.33%, should be a focus of improvement for Taiwan’s health authorities.

Am J Manag Care. 2016;22(1):e18-e30
Take-Away Points
 
This study examined factors associated with continuing care participation in patients with diabetes and with interrupted participation for those patients enrolled in a diabetes pay-for-performance (P4P) program.
  • Taiwan’s P4P program increased the rate of continuing care in patients with diabetes.
  • Factors that correlated with the participation of patients with diabetes in continuing care included the patient’s P4P program enrollment status, personal characteristics, health status, characteristics of the main physician, and characteristics of the main healthcare organization.
  • Factors associated with interrupted participation by patients with diabetes in the P4P program after enrollment included male gender, younger age (<35 years), residence in areas of the highest urbanization level, greater severity of diabetes complications, presence of catastrophic illness or injury, high service volume at the site of the main physician, older age (≥55 years) of the main physician, having a regional or private hospital as the main healthcare organization, and change of physician.
In 2014, an estimated 415 million individuals worldwide had diabetes, and the number of individuals with diabetes is expected to rise to 642 million by 2040.1 Previous studies have shown the challenges of diabetes prevention and management,2,3 but better continuity of care has been associated with improved medication compliance4,5 and reductions in  hospitalizations,6,7 emergency department visits,8 mortality,9 and healthcare expenses for patients with diabetes.8,10

Pay-for-performance (P4P) is a payment scheme that rewards healthcare providers for providing high-quality continuing care services.11,12 In many countries—such as the United States, Australia, Germany, and the United Kingdom—P4P programs are a priority policy for promoting more efficient use of healthcare resources and enhancing the quality of care.13-15

In Taiwan, 7% of the population (1,631,599 individuals) had diabetes as of 2012, which accounts for 3.8% of the National Health Insurance program’s total annual healthcare expenditure.16,17 To improve the prevention and treatment of this disease, Taiwan launched a diabetes P4P program in November 2001. As part of this program, a team of care providers, consisting of physicians, nurses, nutritionists, and other healthcare professionals work together to provide examination, testing, health education, and follow-up services in an effort to reduce the occurrence of diabetic complications and comorbidities.18 Healthcare organizations participating in the program must perform specific diagnosis and management tasks, including medical history, physical examination, laboratory evaluation, evaluation of the management plan, and diabetes self-management education. Patients who are enrolled in the diabetes P4P program must undergo a complete annual evaluation of their disease. If healthcare services have been provided as required by the program, the healthcare organization will receive a bonus payment: a value-added physician examination fee and a case management fee. For Taiwan’s diabetes P4P program, the amount of the bonus payment is calculated using a point system, and the case management fee includes: 400 points awarded for the initial physician visit (once per patient), 200 points for each follow-up visit (once every 3 months), and 800 points for the annual evaluation (once per year),19 where 1 point is worth around 1 New Taiwan Dollar (NTD) (30 NTD = US$1). In 2009, 27.56% (214,340) of Taiwan’s patients with diabetes were enrolled in the program.19

Previous assessments of Taiwan’s diabetes P4P program have found it to effectively increase clinical guideline adherence18,20 and patient satisfaction with the quality of care,21 as well as decrease inpatient care utilization.22,23 In this study, we used data from the National Health Insurance database to examine factors that influence continuing care participation in patients with diabetes who either are or are not enrolled in the P4P program, and factors that affect whether interrupted participation in the P4P program occurs in patients with diabetes who are enrolled in the program. Both Taiwan and the United States provide doctors with financial incentives to enhance medical quality, and some payments are based on quality indicators. However, P4P in Taiwan is implemented by a single public insurer (National Health Insurance), whereas P4P in the United States is practiced under multiple medical insurance systems. The study results could be a policy reference for comparisons among different health insurance systems.

Previous studies have adopted variables such as gender, age, monthly salary, comorbidities,24 Diabetes Complications Severity Index (DCSI) score, and hospital accreditation level22 when evaluating diabetes P4P programs. On the basis of logical inference, we searched for possible variables that might account for patients joining or withdrawing from a diabetes P4P program; the topic has rarely been studied.

METHODS
Data Source and Participants

In this retrospective cohort study, analysis was performed with secondary data obtained from the National Health Insurance Research Database maintained by Taiwan’s National Health Research Institutes. The study population consisted of all patients with a confirmed diagnosis of type 2 diabetes from 2001 through 2008. Patients with diabetes were defined as individuals with 1 hospitalization, or 3 or more outpatient visits within 365 days, in which the primary or secondary diagnosis was diabetes (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 250.x or A-code A181).25 Patients with diabetes in pregnancy (ICD-9-CM code 648.0), or diabetes that is gestational (648.8) or neonatal (775.1), or had abnormal glucose tolerance (790.2) were excluded from the study. Patients with diabetes whose outpatient records had ever been designated with the specific treatment code “E4” (for the diabetes P4P program) were defined as P4P program enrollees (N = 198,420). All study subjects were followed until the end of 2009.

Propensity score matching was performed on the basis of personal characteristics (gender, age, monthly salary, and residence urbanization level); health status (comorbidity, severity of diabetes complications, and presence or absence of catastrophic illness or injury); and characteristics of the healthcare organization (level and ownership type) in order to match P4P enrollees 1:1 with nonenrollees among patients with diabetes. This resulted in a sample of 396,830 patients for analysis. For the analysis of factors related to interrupted participation in the diabetes P4P program after enrollment, we excluded enrollees, totaling 20,744, who did not reach the time point for their annual evaluation (29 full weeks after enrollment), leaving 177,676 enrollees for the analysis. To encourage medical teams to improve their monitoring of and continual care for patients, the National Health Insurance Administration in Taiwan has established payment regulations for its diabetes P4P program. Patients with diabetes who have been in the P4P program for 29 weeks can participate in yearly evaluations, and the doctor can receive the annual case management fee for each patient.

Description of Variables

The dependent variables examined in this study included whether participation in the diabetes P4P program was interrupted and whether continuing care participation was maintained. The independent variables analyzed included personal characteristics, health status, characteristics of the main physician seen (age and annual service volume), and characteristics of the main healthcare organization utilized. The National Health Insurance Administration in Taiwan has identified 30 types of severe illness or injury as catastrophic illnesses or injuries (eg, malignant neoplasm, type 1 diabetes, chronic renal failure, cerebrovascular disease, rare disease).

Further details on the variables are as follows: 1) continuing care participation was defined as having at least 1 diabetes-related physician visit every 3 months and at least 4 such visits per year following a confirmed diabetes diagnosis for patients not enrolled in the P4P program, or following P4P program enrollment for enrollees. Otherwise, patients were considered to lack continuing care participation. 2) Uninterrupted diabetes P4P program participation was defined as having regular diabetes visits during the year following P4P program enrollment, and then undergoing the annual evaluation of diabetes disease (prescription code P1409C). Enrolled patients who failed to complete the first annual diabetes evaluation were considered to have interrupted participation in the diabetes P4P program. 3) Monthly salaries were taken to be the monthly salary amounts used in the determination of National Health Insurance premiums. 4) The urbanization level of the residence area was designated as 1 of 7 levels, with level 1 corresponding to the highest level of urbanization and level 7 to the lowest. 5) Comorbidity was assessed using the Deyo modification of the Charlson comorbidity score. Each patient’s ICD-9-CM primary and secondary diagnosis codes were converted to weighted numerical scores, which were then summed to give the patient’s Charlson comorbidity index (CCI).26 6) The severity of diabetes complications was assessed using the categories of diabetes complications described by Young et al (retinopathy, nephropathy, neuropathy, stroke, cardiovascular disease, peripheral vascular disease, and metabolic complications). Each patient’s ICD-9-CM primary and secondary diagnosis codes were converted to weighted numerical scores, which were then summed to give the patient’s DCSI.27 7) Physician service volume was computed as the annual service volume of the patient’s main physician, categorized by the quartile method as high (≥75%), medium (≥25% and <75%), or low (<25%). 8) The characteristics of the main healthcare organization utilized were classified in terms of its level and ownership type. 9) Low-income household status was defined as belonging to a household in which the average monthly income per person falls below the lowest living index, which is 60% of the living expenditure per person in the previous year in the household’s local area.28

This study was approved by the Institutional Review Board of China Medical University and Hospital (IRB No. 20130326C).

Statistical Analysis

First, descriptive statistics were used to examine the distribution of different variables—personal characteristics, health status, characteristics of the main physician, characteristics of the main healthcare organization, and continuing care participation—in the study participants, who were distinguished by whether they were enrolled in the P4P program and whether interruption occurred in their participation in the P4P program after enrollment. The distributions were expressed as percentages and means.

Next, the χ2 test and t test were used to examine each variable’s association with continuing care participation in diabetes P4P program enrollees and nonenrollees, as well as association with interrupted P4P program participation in the enrollees. Logistic regression analysis was performed to examine factors that influenced continuing care participation in patients with diabetes.

Finally, logistic regression was employed to examine factors that influenced whether interruption occurred in the participation of patients with diabetes in the P4P program after enrollment. In this study, all statistical analyses were performed using SAS 9.3 software (SAS Institute, Cary, North Carolina) for Windows. A P value less than .05 was considered statistically significant.

 
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