Effect of a Pay-for-Performance Program on Renal Outcomes Among Patients With Early-Stage Chronic Kidney Disease in Taiwan

Abstract

Background: With the promising outcomes of the pre-ESRD (end-stage renal disease) pay-for-performance (P4P) program, the National Health Insurance Administration (NHIA) of Taiwan launched a P4P program for patients with early chronic kidney disease (CKD) in 2011, targeting CKD patients at stages 1, 2, and 3a. This study aimed to examine the long-term effect of the early-CKD P4P program on CKD progression. Methods: We conducted a matched cohort study using electronic medical records from a large healthcare delivery system in Taiwan. The outcome of interest was CKD progression to estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2 between P4P program enrolees and non-enrolees. The difference in the cumulative incidence of CKD progression between the P4P and non-P4P groups was tested using Gray’s test. We adopted a cause-specific (CS) hazard model to estimate the hazard in the P4P group as compared to non-P4P group, adjusting for age, sex, baseline renal function, and comorbidities. A subgroup analysis was further performed in CKD patients with diabetes to evaluate the interactive effects between the early-CKD P4P and diabetes P4P programs. Results: The incidence per 100 person-months of disease progression was significantly lower in the P4P group than in the non-P4P group (0.44 vs. 0.69, P<.0001), and the CS hazard ratio (CS-HR) for P4P program enrolees compared with non-enrolees was 0.61 (95% CI: 0.58–0.64, P<.0001). The results of the subgroup analysis further revealed an additive effect of the diabetes P4P program on CKD progression; compared to none of both P4P enrolees, the CS-HR for CKD disease progression was 0.60 (95% CI: 0.54–0.67, P<.0001) for patients who were enrolled in both early-CKD P4P and diabetes P4P programs. Conclusion: The present study results suggest that the early-CKD P4P program is superior to usual care to decelerate CKD progression in patients with early-stage CKD.

Diabetes Pay-for-Performance Program Participation and Dialysis Risk in Relation to Educational Attainment: A Retrospective Cohort Study

“…The time for joining a P4P program was far longer than in the study mentioned above; therefore, this study found that the participation of diabetic patients in the program prolonged the time it would have taken to enter the stage of terminal renal disease, thus lowering the risk of dialysis significantly compared with non-participants. This result was consistent with the literature [61,62].…”

Effectiveness of Nationwide COPD Pay-for-Performance Program on COPD Exacerbations in Taiwan

“… 43 , 44 Empirical findings have also demonstrated that P4P programs in Taiwan have improved health outcomes in patients with diabetes, breast cancer, hepatitis B and C, and early chronic kidney disease; these improvements are associated with guideline adherence. 23 , 25 , 27 , 29 , 30 , 45 Taiwan’s COPD P4P program requires health care providers to provide patient-centered comprehensive care according to the Taiwan COPD guidelines, with additional financial bonuses for those who achieve high-quality performance on the prescribed quality indicators. Although this incentive design may encourage physicians to modify their behaviors and improve guideline adherence, the incentives are presently too few to sufficiently cover all activities in the P4P program.…”

Urinary non-albumin protein-creatinine ratio is an independent predictor of mortality in patients with type 2 diabetes: a retrospective cohort study

“…Moreover, the National Health Insurance Administration launched a pre-ESRD P4P program in 2006 and an early chronic kidney disease (CKD) P4P program in 2011 to deliver adequate care for patients with proteinuria or CKD. UPCR is a screening marker and is considered one of the inclusion indicators in these countrywide P4P programs for the patients with a risk of CKD progression 27 , 28 .…”