Many countries have implemented pay-for-performance programs to improve the quality of care. The structure of these programs, however, can have perverse consequences beyond improving care for patients. To investigate this possibility, we studied the pattern of enrollment of patients with diabetes in the first five years of a pay-for-performance program in Taiwan's National Health Insurance Program from 2001 through 2005. Taiwan's program did sharply improve quality of care for enrolled patients, producing 100 percent or nearly 100 percent adherence to all process measures. But at the same time, only a minority of the nation's patients with diabetes were enrolled, because the program's design encouraged physicians not to enroll their most complicated patients. By "cherry-picking" the healthiest patients most likely to perform well on selected measures, physicians were able to game the system and potentially reap the rewards of higher pay-for-performance payments without actually improving the care of all of their diabetic patients. Our study provides a cautionary tale, emphasizing the importance of proper program design so that quality is improved on the broadest scale.

Background: Glucose-free dialysis solutions may be more biocompatible owing to the physiological pH and the lack of glucose degradation products, and the effects can be reflected by the changes in some markers of peritoneal mesothelial cells (PMC). Method: Peritoneal effluents were collected in 17 CAPD patients after one daily exchange of glucose-containing dialysate to Nutrineal (1.1% amino acid-based PDF), and human PMC were cultured from peritoneal effluent and treated with various peritoneal dialysis (PD) solutions. Results: The level of cancer antigen 125 (CA125) in peritoneal effluent increased significantly after using Nutrineal® for 3 months (p = 0.045), whereas that of procollagen I peptide (PICP) remained unaltered. Production of CA125 by human PMC showed a time-responsive increase after stimulation with Nutrineal and Extraneal (icodextran-based PDF). An increased expression of CA125 was observed in cultured human PMC treated with various PD solutions, and the increase induced by Nutrineal was lower than that induced by 4.25% Dianeal® and Extraneal®. A lower increase was also observed for lactate dehydrogenase (LDH). The levels of heat shock protein 70 (HSP70), however, were not altered. Conclusion: Nutrineal is more biocompatible to the peritoneal membrane than the conventional PD solutions tested herein, reflected by both the in vivo and in vitro response of CA125.

UNSTRUCTURED Background and Purposes: The change in reimbursement policy of erythropoietin application to peritoneal dialysis (PD) patients by Taiwan National Health Insurance (NHI) system provided a natural experimental venue to examine whether cardiovascular risk differs while keeping hematocrit (Hct) below 30% or over 30%. This study intended to analyze the impact of loosening erythropoietin payment criteria for PD patients on their cardiovascular outcomes. Methods: Two cohorts of incident PD patients before and after the relaxation of NHI’s erythropoietin payment criteria were identified as Cohort 1 and Cohort 2, respectively, and further matched by propensity scores and then followed up for cardiovascular events. There were 1,759 patients in Cohort 1 and 2,981 patients in Cohort 2. After propensity score matching, 1,754 subjects were selected from each cohort. The outcome measures were cardiovascular events and were analyzed through Cox regressions. Findings and Conclusion: For the composite cardiovascular endpoint, Cohort 2 patients had significantly lower risk than Cohort 1. The risk reduction was observed only in diabetic patients. After loosening erythropoietin payment criteria, less cardiovascular risks were observed, particularly for diabetic patients. It is concluded that for diabetic PD patients, maintaining a Hct level higher than 30% is crucial for reducing the cardiovascular risk.

The aim of the present study is to examine whether overweight or obese people in Taiwan have an inadequate intake of selected micronutrients. A population-based study was conducted using data from the Nutrition and Health Survey in Taiwan (NAHSIT) 2013–2016. We evaluated fourteen nutrient intakes using the 24 h dietary recall method. The dietary reference intake (DRI) adherence was estimated by the prevalence of participants whose intake was lower than the recommended dietary allowance (RDA) or adequate intakes (AIs) for selected micronutrients. Body mass index (BMI) ≥ 27 kg/m2 and waist circumference (WC), with men having WC ≥ 90 cm or women having WC ≥ 80 cm, were defined as obesity. A total of 3075 participants aged 19 years and above were included. After adjusting for confounders, we found that obese women have a lower DRI adherence of vitamin C (odds ratio (OR) 0⋅73, 95 % confidence interval (CI) 0⋅56, 0⋅95) and magnesium (OR 0⋅72, 95 % CI 0⋅54, 0⋅95), compared with normal-weight women. Obese men have a higher DRI adherence of vitamin B3 (OR 1⋅70, 95 % CI 1⋅29, 2⋅23), iron (OR 1⋅46, 95 % CI 1⋅06, 2⋅00) and zinc (OR 1⋅41, 95 % CI 1⋅07, 1⋅85), compared with normal-weight men. Similar findings were found using WC to define obesity. We conclude that obese women may have insufficient intakes of vitamin A, vitamin C and magnesium.

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