title: 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.
abstract: 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.
  
  
  METHODS
  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.
authors.affiliation: Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan. Electronic address: hsiehhm@gmail.com.
authors.forename: Hui-Min
authors.initials: HM
authors.lastname: Hsieh
authors.affiliation: Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Taiwan. Electronic address: lth@kmu.edu.tw.
authors.forename: Tsung-Hsien
authors.initials: TH
authors.lastname: Lin
authors.affiliation: Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan. Electronic address: ichen@kmu.edu.tw.
authors.forename: I-Chen
authors.initials: IC
authors.lastname: Lee
authors.affiliation: Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. Electronic address: d810100@cc.kmu.edu.tw.
authors.forename: Chun-Jen
authors.initials: CJ
authors.lastname: Huang
authors.affiliation: Graduate Institute of Medical Genetics, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Endocrinology and Metabolism, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. Electronic address: sjshin@kmu.edu.tw.
authors.forename: Shyi-Jang
authors.initials: SJ
authors.lastname: Shin
authors.affiliation: Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan; Research Education and Epidemiology Center, Changhua, Taiwan. Electronic address: chiu@kmu.edu.tw.
authors.forename: Herng-Chia
authors.initials: HC
authors.lastname: Chiu
mesh_terms: D000328:Adult; D000368:Aged; D002318:Cardiovascular Diseases / Q000191:economics / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000191:economics; D019468:Disease Management; D005260:Female; D006801:Humans; D015994:Incidence; D007345:Insurance Claim Review; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009313:National Health Programs / Q000191:economics; D017063:Outcome Assessment, Health Care; D057216:Propensity Score; D016016:Proportional Hazards Models; D012052:Reimbursement, Incentive / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D040242:Risk Reduction Behavior; D013624:Taiwan
keywords: Diabetes care; Disease management; Macrovascular complications; Pay-for-performance; Preventive care