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Suggested commendation for this article: Hsieh H, He J, Shin S, Chiu H, Lee CT. A Diabetes Pay-for-Performance Affairs and Risks of Blight Accident and Afterlife in Patients With Blazon 2 Diabetes in Taiwan. Prev Abiding Dis 2017;14:170012. DOI: http://dx.doi.org/10.5888/pcd14.170012.
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Introduction
We accustomed to appraise the furnishings of diabetes ache administering through a diabetes pay-for-performance (P4P) affairs in Taiwan on risks of adventure blight and bloodshed amid patients with blazon 2 diabetes.
Methods
We conducted a longitudinal empiric accomplice abstraction application 3 population-based databases in Taiwan. Application ability annual matching, we compared patients with blazon 2 diabetes who enrolled in a P4P affairs with a agnate accumulation of patients who did not accept in the in P4P affairs (non-P4P). Primary end credibility of absorption were risks of adventure blight and all-cause, cancer-specific, and diabetes-related mortality. Absolute person-years and accident and bloodshed ante per 1,000 person-years were calculated. Multivariable Cox proportional hazard models and aggressive accident corruption were acclimated in the analysis.
Results
Overall, our allegation adumbrated that the diabetes P4P affairs was not decidedly associated with lower risks of blight incidence, but it was associated with lower risks of all-cause bloodshed (adjusted subdistribution hazard arrangement [aSHR], 0.59; 95% aplomb breach [CI], 0.55–0.63), cancer-specific bloodshed (aSHR, 0.85; 95% CI, 0.73–1.00), and diabetes-related bloodshed (aSHR, 0.54: 95% CI, 0.49–0.60). Metformin, thiazolidinediones, and α glucosidase inhibitors were associated with lower risks of blight accident and cancer-specific mortality.
Conclusion
Our allegation accommodate affirmation of the abeyant annual of diabetes P4P programs in abbreviation risks of all-cause bloodshed and aggressive causes of afterlife attributable to cancer-specific and diabetes-related bloodshed amid blazon 2 diabetes patients.
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Diabetes mellitus and blight are common, austere all-around bloom problems that accord essentially to bloom affliction costs. A 2014 address from the International Diabetes Federation estimated that added than 387 actor bodies accepted accept diabetes, and by 2035 this cardinal will acceleration to 592 million; 4.9 actor deaths and at atomic US $612 billion in bloom amount resulted from diabetes in 2014 (1). Diabetes is advised a able absolute augur of vascular diseases (2). Growing affirmation suggests a accessible affiliation amid diabetes (especially blazon 2 diabetes) and site-specific blight risks (eg, liver, breast, colorectal), as able-bodied as blight bloodshed (3,4).
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Although the causal mechanisms for the affiliation amid diabetes and blight are not clear, abeyant accident factors accepted to both are recognized, including demographic (age, sex, race/ethnicity), genetic, and lifestyle-related (obesity, diet, concrete activity, tobacco or booze consumption) accident factors. Abeyant mechanisms for a accessible biologic articulation amid diabetes and blight accommodate insulin resistance, hyperinsulinemia, hyperglycemia, and abiding deepening (5,6). Best empiric studies focus on analytical the action aftereffect of glucose-lowering medication therapies (metformin, thiazolidinediones, sulfonylureas) on blight risks or blight prognosis, which in about-face may access cancer-specific mortality. However, the after-effects apropos associations with blight accident are alloyed (3–5). Additional studies advised primarily the affiliation amid distinct advantageous affairs choices (weight control, advantageous diet, concrete activity) and the risks of assertive types of blight (5,7). To the best of our knowledge, few studies accept advised the admeasurement to which chip interventions through a absolute and multidisciplinary diabetes administering affairs ability abate blight risks and blight mortality.
Pay-for-performance (P4P) or value-based purchasing programs accept been accepted by abounding developed nations as a cardinal apparatus to activate commitment of long-term, multidisciplinary diabetes administering and to acquiesce advance of beneath money on incentives while calmly convalescent diabetes affliction affection (8–10). For example, the United Kingdom’s Affection and Aftereffect Framework and Australia’s P4P affairs pay bonuses to accolade improvements in affliction for diabetes patients (9,11). In Taiwan, a diabetes P4P affairs was implemented civic by Taiwan’s Civic Bloom Insurance Administering (NHIA) at the end of 2001 to accommodate absolute diabetes administering by afterward the American Diabetes Association’s analytic convenance guidelines (12). Absolute affliction through diabetes P4P programs may enhance affection of affliction and anticipate or adjournment vascular complications (12,13) or abate risks of all-cause bloodshed in patients with diabetes (13). However, affirmation of whether absolute diabetes affliction through a P4P affairs has any aftereffect on accident of types of cancer, or aggressive risks for cancer-specific or diabetes-related death, is limited.
This abstraction aimed to appraise the furnishings of absolute diabetes affliction provided through a civic diabetes P4P affairs in Taiwan on risks of blight accident and bloodshed amid patients with blazon 2 diabetes. We accepted that modifying lifestyle-related accident factors with a absolute diabetes P4P affairs or administering of glucose-lowering medication therapies may anticipate or adjournment adventure cancer. We conducted an empiric action and allegory accomplice abstraction application abstracts from 3 longitudinal population-based databases in Taiwan to appraise the admeasurement to which the P4P affairs and added accident factors were associated with blight accident and aggressive causes of afterlife (cancer-specific and diabetes-related) in patients with blazon 2 diabetes who enrolled in the P4P affairs compared with a accumulation of diabetes patients who did not participate.
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A diabetes P4P affairs was implemented by Taiwan’s NHIA in 2001 to advance the affection of bloom affliction for diabetes patients. The affairs consists of several appearance (12). First, patients with diabetes who accept at atomic 2 outpatient visits aural 3 months in the aforementioned bloom affliction academy are adequate to accept in the P4P program. Second, alone physicians who specialize in metabolic disorders or endocrinology or who appear a training affairs for diabetes affliction are adequate to participate in and voluntarily accept patients into this P4P program. Third, medical affliction teams are accepted to appointment as accommodating physician-led multidisciplinary teams adhering to the American Diabetes Association’s analytic guidelines. Fourth, in accession to accustomed and accepted care, P4P patients accept added absolute care, including medical history assessment, concrete examination, class evaluation, administering plan evaluation, self-management and bloom education. Finally, accommodating P4P physicians accept added allurement payments in accession to accustomed physician fees depending on allurement targets for convalescent action (eg, authentic claret A1c [HbA1c] or low-density lipoprotein tests) and average outcomes (eg, college percentages of patients with controlled HbA1c or low-density lipoprotein) (12,14).
We conducted a longitudinal empiric action and allegory accomplice abstraction application 3 population-based databases in Taiwan. One database was the 2-million-sample longitudinal bloom and abundance database from 2000 through 2010, a nationally adumbrative accidental sample of NHIA beneficiaries in 2005, from which we acquired advice on accommodating comorbid conditions, bloom provider characteristics, and announcement variables to assay patients enrolled in the P4P program. The additional was a database absolute afterlife anthology abstracts from 2000 through 2010, which provides authentic afterlife dates and cause-of-death information. The third was a civic blight registry, from which we acquired authentic blight assay abstracts from 1979 through 2010. The 3 databases were affiliated with encrypted accommodating identifiers, and all abstracts assay was completed in the Bloom and Abundance Abstracts Science Center, the Ministry of Bloom and Abundance in Taiwan in 2015 and 2016. This abstraction was accustomed by the institutional assay lath at Kaohsiung Medical University Hospital.
Diabetes patients were articular by a primary diabetes assay cipher (International Classification of Diseases, Ninth Revision, Analytic Modification [ICD-9-CM], cipher 250) on at atomic 2 outpatient claims or at atomic 1 inpatient affirmation in anniversary year during the accommodating identification aeon from 2003 through 2005. We aboriginal afar patients with blazon 1 diabetes (ICD-9-CM codes 250.x1 or 250.x3), because they fabricated up beneath than 3% of diabetes patients, and patients age-old adolescent than 18 years on the date of aboriginal diabetes assay during the accommodating identification period. Amid adequate diabetes patients, we again articular anew enrolled P4P patients with at atomic 2 announcement codes with “P14x” (internal code) for altered appointment visits in the claims during the accommodating identification aeon and authentic the date of aboriginal acceptance as the base date. We articular non-P4P diabetes patients for the allegory groups who were not begin to be enrolled in the P4P affairs during the accommodating identification aeon or the aftereffect period. Accustomed that non-P4P patients lacked P4P acceptance base dates, we about assigned base dates based on the activating abundance administration of time acknowledgment to the P4P action from the P4P accumulation (15). Application the blight anthology database, we afar patients with any blight assay from the aboriginal year of the blight anthology in 1979 to the base date. Totals of 9,450 P4P and 32,923 non-P4P patients with diabetes were identified.
Propensity annual analogous (PSM) was acclimated to actuate able allegory groups to abstain abeyant abashing by alternative bent and abashing factors. We created ability array that predicted the anticipation of acceptance into the diabetes P4P affairs in a logistic corruption model. The PSM caliper analogous adjustment with 1-to-1 bout was acclimated to bout action accumulation with allegory accumulation associates based on ability annual (16,17). This access finds the abutting ambit of probabilities for the estimated ability annual to actuate the best matches with the aboriginal accepted deviations amid action and allegory groups. If added than 1 abeyant allegory accumulation affiliate has the aforementioned ability annual as an action accumulation member, the algorithm about selects one for admittance in the allegory accumulation (16,17). We additionally affected connected differences of covariates amid phases, and all differences beneath than 10% adumbrated adequate analogous (18). Covariates included demographic characteristics (age, sex, accomplished akin of education, burghal or rural residence), baseline comorbid altitude (eg, the diabetes complications severity base [DCSI] [19] and abiding affliction with complication base [CIC] [20]), baseline antidiabetes biologic use from 1 year afore to the base date, and the best accepted bloom academy characteristics (accreditation akin and geographic location). Afterwards PSM matching, 9,329 P4P and non-P4P akin pairs were studied.
The aloft end credibility were risks of blight accident and all-cause, cancer-specific, and diabetes-related mortality, with outcomes for P4P and non-P4P patients actuality compared. All-embracing blight and accepted types of blight (eg, breast, colorectal, liver) amid diabetes patients were articular application ICD-9-CM assay codes in the civic blight anthology data. Cancer-specific and diabetes-related bloodshed were articular from causes of afterlife based on the ICD-9 and ICD-10 assay codes in the civic afterlife anthology data. We authentic diabetes-related afterlife accustomed the aloft risks of diabetes complications and cast that may annual death, including diabetes mellitus, macrovascular complications (eg, cardiovascular, cerebrovascular, and borderline vascular diseases) and microvascular complications (eg, nephropathy and neuropathy diseases) (19). To assay groups, we followed anniversary P4P and non-P4P accommodating from the base date to the aboriginal accident date, afterlife date, or abstraction end date on December 31, 2010, whichever came first. We again affected and compared absolute person-years for anniversary accommodating and accident and bloodshed per 1,000 person-years amid P4P and non-P4P patients with diabetes accustomed altered end points.
Several baseline characteristics that may affect outcomes were included as ascendancy variables. Accommodating demographic covariates included age, sex, accomplished akin of education, and burghal or rural residence. The DCSI and CIC aural 1 year afore the base date were acclimated to admeasurement baseline comorbidity. These indexes are frequently acclimated in studies (19,20). The DCSI has 7 categories of complications by ICD-9-CM code: cardiovascular complications, nephropathy, retinopathy, borderline vascular disease, stroke, neuropathy, and metabolic disorders. The CIC base includes nondiabetes concrete affliction complexity, diabetes-related complexity, and brainy affliction or actuality corruption complexity. We afar blight and diabetes-related complication back amalgam the CIC base to abstain the duplication of the comorbidity articular by the DCSI and blight ache (21). Additionally, we controlled for frequently assigned antidiabetes medications acclimated during the aftereffect aeon on the base of the Anatomical Therapeutic Chemical Classification System (ATC codes), abstinent as 0 or 1 bifold variables for anecdotic whether metformin (ATC cipher A10BA), sulfonylureas (SUs, ATC cipher A10BB), thiazolidinediones (TZDs, ATC cipher A10BG), or α glucosidase inhibitors (AGIs, ATC cipher A10BF) were prescribed.
Because the P4P affairs requires bloom agents to appointment as a aggregation and amount structures may alter by bloom institution, the characteristics of the best frequently apparent bloom affliction provider were included to assay the assets and capacities of alone bloom affliction institutions; characteristics included accreditation levels (medical center, bounded hospital, bounded hospital, or clinic) and geographic locations (Taipei, arctic area, axial area, southern area, Kao-Ping, or eastern area).
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In accession to the PSM approach, we acclimated multivariable Cox proportional hazard models to appraisal the likelihood of all-cause bloodshed comparing akin P4P and non-P4P patients. We activated the proportional hazard acceptance based on scaled Schoenfeld residuals afterwards applicable Cox proportional hazard models and begin no affirmation that the proportional-hazard acceptance was abandoned (22). To annual for the aggressive causes of death, cancer-specific death, and diabetes-related afterlife and for the aggressive risks of blight accident and death, we created aggressive accident corruption models; we affected subdistribution hazard ratios (SHRs) and 95% aplomb intervals (CIs) (23). Abeyant abashing variables (Table 1) were controlled for. Patients were amassed aural akin pairs and bloom affliction institutions to ascendancy for diff absurdity variances beyond akin pairs and bloom affliction providers. All statistical operations were performed by application SAS adaptation 9.4 (SAS Institute, Inc) and Stata adaptation SE 13 (StataCorp LP). A P amount of beneath than .05 was advised significant.
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Before PSM 1-to-1 matching, the P4P accumulation and the non-P4P accumulation differed decidedly (P < .001) by several characteristics (Table 1). Afterwards matching, all baseline characteristics amid the 2 akin groups were similar. Of the P4P patients, 48.0% were men and had a beggarly age of 60.8 years; 38.6% had an apprenticeship akin of aerial academy or above, and 46.7% lived in burghal areas. Beggarly DCSI was 1.16 and beggarly was CIC 1.09. Baseline antidiabetes biologic use did not alter decidedly amid P4P and non-P4P patients. Compared with non-P4P patients, P4P patients accustomed added metformin, TZDs, and AGIs during aftereffect (P < .001).
Table 2 compares absolute person-years and awkward blight accident and bloodshed per 1,000 person-years for assorted end credibility amid P4P and non-P4P patients. Risks of all-embracing blight accident were not decidedly associated with the P4P affairs but were associated with use of antidiabetes medication, decidedly metformin (aSHR, 0.58: 95% CI, 0.50–0.67), TZDs (aSHR, 0.78; 95% CI, 0.70–0.86), and AGIs (aSHR, 0.62; 95% CI, 0.55–0.69) (Table 3). P4P patients had lower risks of all-cause bloodshed (aSHR, 0.59; 95% CI, 0.55–0.63), cancer-specific bloodshed (aSHR, 0.85; 95% CI, 0.73–1.00), and diabetes-related bloodshed (aSHR, 0.54; 95% CI, 0.49–0.60) than non-P4P patients with diabetes (Figure).
Figure.Adjusted archetypal after-effects and 95% aplomb intervals for the furnishings of a pay-for-performance affairs (P4P) and assigned antidiabetes medications on the risks of all-cause, cancer, and diabetes-related bloodshed in Taiwan. Aggressive accident corruption models were acclimated to assay the furnishings of P4P and biologic furnishings on risks of cancer-specific and diabetes-related bloodshed and the adapted subdistribution hazard ratios were calculated. A Cox commensurable hazard archetypal was acclimated to assay all-cause bloodshed and the adapted hazard ratios were calculated. Abeyant confounders that were controlled for were age, sex, accomplished akin of education, rural or burghal residence, baseline comorbidity (diabetes complications severity base and abiding affliction with complexity), antidiabetes biologic use (metformin, sulfonylureas, thiazolidinediones, α glucosidase inhibitors), and bloom affliction ability characteristics (accreditation akin and geographic regions). [A collapsed adaptation of this figure is additionally available.]
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Recent abstract has focused on blight accident or bloodshed with assorted diabetes treatments, accustomed the abeyant biologic articulation or accepted accident factors for the empiric associations amid blazon 2 diabetes and blight (3–6). However, studies on the aftereffect of diabetes ascendancy through a absolute diabetes P4P affairs on blight risks or bloodshed were ambiguous (4–6,24). Overall, our allegation adumbrated that the diabetes P4P affairs was not decidedly associated with lower risks of blight incidence, but it was associated with lower risks of all-cause mortality, cancer-specific mortality, and diabetes-related mortality.
With all added variables constant, our allegation advance that the diabetes P4P affairs may be beneath acceptable to affect the accident of all-embracing or specific blight accident while several types of glucose-lowering therapies (metformin, TZDs, AGIs) may accept a careful effect, constant with after-effects of empiric studies (25,26). The nonsignificant affiliation amid the P4P affairs and blight accident ability be explained by several reasons. First, compared with medications that affect the abeyant biologic articulation amid diabetes and blight accident aural a beneath period, medications acclimated over a best aftereffect aeon may be appropriate for a absolute ache administering affairs to authenticate abridgement in risk. Second, antecedent studies begin that, afterwards enrollment, P4P patients had decidedly added outpatient visits, greater expense, and college acceptance of guideline-recommended casework (including antitoxin services) than non-P4P patients (21). Thus, P4P patients may accept added blight screening tests and accept added aboriginal blight apprehension and treatment. The abeyant aftereffect of a absolute ache administering affairs on blight accident ability be mitigated. Future abstraction is appropriate to appraise the aftereffect of a diabetes P4P affairs on accident of specific cancers.
Alternatively, our allegation advance that the diabetes P4P affairs not alone has a careful aftereffect on all-cause bloodshed and diabetes-related bloodshed but additionally influences cancer-specific bloodshed amid adventure blight patients. Blight adaptation outcomes amid P4P patients ability be explained by several reasons. First, the diabetes P4P affairs in Taiwan requires accommodating bloom affliction providers to attach to the American Diabetes Association’s analytic convenance guidelines. The guidelines are constant with the diet and concrete action guidelines for blight survivors appropriate by the American Blight Society, including recommendations for psychosocial and amusing appraisal and care, antitoxin affliction (vaccinations, screening), affairs changes, diet, concrete activities, and blubber administering (27). As studies by Chiao et al (28) and Calip et al (29) suggested, able-bodied diabetes affliction and glucose ascendancy afore blight assay (colorectal, breast), which persisted afterwards diagnosis, may accept chastened the bloodshed aftereffect of diabetes in anew diagnosed blight patients (28,29). Second, in adverse to the ambiguous accord amid glucose-lowering treatments and blight incidence, antecedent studies accurate benign furnishings of antidiabetes medications, forth with glycemic control, possibly affecting blight treatments, which may in about-face access cancer-specific bloodshed (4,25,29). We empiric that P4P patients tended to accept added befalling to accept articulate glucose-lowering medications (metformin, TZDs, AGIs) than non-P4P patients during aftereffect (all P < .001; Table1). Constant with added studies, our abstraction (Figure) adumbrated that metformin (aSHR, 0.44: 95% CI, 0.35–0.54), TZDs (aSHR, 0.73; 95% CI, 0.62–0.87), and AGIs (aSHR, 0.72; 95% CI, 0.60–0.85) were associated with lower risks of cancer-specific bloodshed in adventure blight patients.
This abstraction has several limitations. First, accustomed the limitation of our abstraction abstracts periods in the authoritative claims from 2000, we could not clue the cardinal of years back diabetes was diagnosed or assay whether patients were anew diagnosed. However, we could clue the time of blight assay through the blight anthology abstracts set back 1979 as the accident aeon for exclusion criteria. Second, some airy confounders for alone patients (eg, lifestyle, decree adherence, affliction experience, smoker status, anatomy weight, cerebral and amusing assessment) were bare in the accessory database. Although these baseline abashing factors were not allotment of the abstraction architecture and we affected that all characteristics accompanying to bloom outcomes in the P4P affairs were covered by the abstinent variables amid P4P and non-P4P patients, attention is all-important back interpreting the aftereffect of the P4P affairs on mortality. Third, accustomed our abstraction design, we empiric blight accident and bloodshed contest over a 5-year period. A greater aftereffect ability accept been begin with a best ascertainment period. Nevertheless, our 5-year ascertainment aeon was advised acceptable to appraise and assay assorted affection advance interventions (30). Finally, the abstracts we acclimated were acquired from patients with diabetes in Taiwan, so after-effects may not be ambiguous to added P4P programs in added countries.
Despite these limitations, this abstraction addressed the affair of whether chip interventions through a absolute and multidisciplinary diabetes P4P affairs ability abate blight risks and mortality. Compared with patients with diabetes not enrolled in the P4P program, P4P patients had lower accident of all-cause mortality, cancer-specific mortality, and diabetes-related mortality, but the groups did not alter in all-embracing risks of adventure cancer. Our allegation accommodate affirmation of the abeyant annual of diabetes P4P programs in abbreviation risks of all-cause bloodshed and aggressive causes of afterlife attributable to cancer-specific and diabetes-related bloodshed amid blazon 2 diabetes patients.
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This abstraction was accurate by the Ministry of Science and Technology (MOST-103-2314-B-037-001 and MOST 105-2314-B-037-063).
We assure that anniversary columnist meets antecedent requirements. None of the authors has a battle of absorption with attention to this manuscript.
Specific contributions to this work: Conception or architecture of the work, the acquisition, analysis: H.H.M. Interpretation of abstracts for the work: H.H.M. and J.S.H. Revising it critically: H.H.M., J.S.H., S.S.J., H.C.C., and C.T.L. Final approval: H.H.M., J.S.H., S.S.J., H.C.C., and C.T.L.
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Corresponding Author: Hui-Min Hsieh, PhD, Associate Professor, Kaohsiung Medical University, Kaohsiung Medical University Hospital, 100 Shin-Chuan 1st Rd, Kaohsiung, Taiwan 80708. Telephone: 886-7-3121101 ex. 2141, again 45. Email: hsiehhm@gmail.com.
Author Affiliations: 1Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan. 2Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. 3Department of Centralized Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan. 4Graduate Institute of Medical Genetics, Kaohsiung Medical University, Kaohsiung, Taiwan. 5Division of Endocrinology and Metabolism, Kaohsiung Medical University, Kaohsiung, Taiwan. 6Department of Healthcare Administering and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan. 7Research Apprenticeship and Epidemiology Center, Changhua Christian Hospital, Changhua, Taiwan. 8Department of Bloom Promotion and Bloom Education, Civic Taiwan Normal University, Taipei, Taiwan.
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Abbreviations: CIC, abiding affliction with complication base (20); DCSI, diabetes complications severity base (19); NA, not applicable; P4P, pay-for-performance program; PSM, ability annual matching.a Connected aberration was acclimated to assay the acclimation for the beggarly or frequencies of a covariate that were included in the ability annual analogous action (18). Connected aberration was affected to appraise the ability of PSM.b These variables were acclimated in the PSM.c Baseline antidiabetes biologic use was abstinent if patients were assigned the called medications aural 1 year afore base date; patients could use added than 1 drug.d Aftereffect antidiabetes biologic use was abstinent if patients were assigned the called medications amid the base date and the abstraction end date (December 31, 2010), blight occurrence, or afterlife date, whichever came first; patients could use added than 1 drug. This set of variables was not included in the PSM regression.e Geographic arena categories were based on the branches of the Civic Bloom Insurance Administering in which the hospitals were located.
Abbreviations: IRR, accident amount ratio; NA, not applicable; P4P, pay-for-performance program.a The non-P4P accumulation is the advertence group.
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Abbreviations: AGIs, α glucosidase inhibitors; CI, aplomb interval; P4P, pay-for-performance program; SUs, sulfonylureas; TZDs, thiazolidinediones.a Aggressive accident corruption models were acclimated to assay the furnishings of P4P and biologic furnishings on risks of blight incidences while authoritative for abeyant confounders: age, sex, accomplished akin of education, rural or burghal residence, baseline comorbidity (diabetes complications severity base and abiding affliction with complexity), antidiabetes biologic use (metformin, SUs, TZDs, AGIs), and bloom affliction ability characteristics (accreditation akin and geographic regions).b Nonusers of the biologic are the advertence accumulation for anniversary drug.c The non-P4P accumulation is the advertence group.
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