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Study Finds Diabetes Pay-for-Performance Program Reduces All-Cause Mortality


Diabetes pay-for-performance programs may reduce all-cause mortality in patients with type 2 diabetes (T2D).

Diabetes pay-for-performance (P4P) programs may reduce all-cause mortality in patients with type 2 diabetes (T2D), according to a recent study.

The study, published by Medicine, assessed the effect of a diabetes P4P program on all-cause mortality in patients with newly diagnosed T2D. The researchers recruited 5478 patients with T2D enrolled in the P4P program within 5 years after a diagnosis of diabetes between January 1, 2002 and December 31, 2010. Patients not enrolled in the P4P program were also recruited as the control group.

In P4P payment models, providers, care organizations, and other healthcare stakeholders are given incentives for achieving performance objectives. Programs within the model, also known as value-based purchasing, are supported by leading insurance providers in Medicare and Medicaid as it promotes a culture that rewards providers for efficiency and penalizes high costs, poor patient outcomes, and medical errors.

“Previous studies have reported that patients enrolled in P4P programs had better adherence to the guideline-recommended examinations, had better clinical processes of care (e.g. HbA1c) and intermediate outcomes, decreased diabetes-related hospitalizations and inpatient costs, but increased rates of severe hypoglycemia requiring emergency medical care and increased outpatient expenses due to more regular follow-up visits,” the authors said. “Patients with type 2 diabetes are associated with a two-fold increase in mortality and a reduction in life expectancy by about 6 years compared with individuals without diabetes.”

The effect of the P4P program and adherence on all-cause mortality was evaluated using multivariate Cox proportional hazard models analysis, showing that a total of 250 patients had died in the P4P program group, compared with 395 in the control group (mortality rate 104 vs 169 per 10,000 person-years, respectively, P < .0001). Additionally, the control group had more comorbidities.

Of those in the P4P program, the researchers observed better adherence and a greater reduction in mortality. Also, participating in the P4P program within 5 years after the diagnosis of diabetes resulted in a significant reduction in all-cause mortality; this effect was particularly pronounced in the patients with better adherence to the P4P program.

Adjusted hazard ratio (aHR) for all-cause mortality was 0.58 (95% CI, 0.48-0.69). In those with a minimum 1-year and 2-year good P4P adherence, there was a greater reduction in mortality, with aHRs (95% CI) of 0.48 (0.38-0.62) and 0.36 (0.26-0.49), respectively.

“The positive effects of the P4P program existed across age- and disease-specific groups except for those with stroke, cancer and psychosis, which may be explained by high competing mortality of these diseases and poor compliance due to the underlying diseases and conditions that can lead to a diminished P4P effect,” the authors stated. “In the subgroup analysis, the patients with a longer regular adherence to the P4P program had a greater reduction in mortality rate. Hence, both participating in and adhering to the P4P program played an important role in contributing to the reduction of mortality in the patients with newly diagnosed type 2 diabetes.”

The authors suggested that future efforts should focus on promoting P4P programs in patients with newly diagnosed T2D for long-term survival benefits.


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(7):e19139. doi: 10.1097/MD.0000000000019139.

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