Impact of the pay-for-performance program on lower extremity amputations in patients with diabetes in Taiwan

Abstract

Patients with diabetes are at a high risk of lower extremity amputations and may have a reduced life expectancy. Taiwan has implemented a diabetes pay-for-performance (P4P) program providing team care to improve the control of disease and avoid subsequent complications. Few studies investigated the effects of adopting a nationalized policy to decrease amputation risk in diabetes previously. Our study aimed to analyze the impact of the P4P programs on the incidence of lower extremity amputations in Taiwanese patients with diabetes.This was a population-based cohort study using the Taiwan National Health Insurance Research Database (which provided coverage for 98% of the total population in Taiwan) from 1998 to 2007. Patients with diabetes were identified based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes. We linked procedure codes to inpatient claims to identify patients hospitalized for nontraumatic lower extremity amputations.A total of 9738 patients with diabetes with amputations were enrolled (mean age ± standard deviation: 64.4 ± 14.5 years; men: 63.9%). The incidence of nontraumatic diabetic lower extremity amputations decreased over the time period studied (3.79–2.27 per 1000 persons with diabetes). Based on the Cox proportional hazard regression model, male sex (hazard ratio: 1.83, 95% confidence interval [CI] 1.76–1.92), older age, and low socioeconomic status significantly interact with diabetes with respect to the risks of amputation. Patients who did not join the P4P program for diabetes care had a 3.46-fold higher risk of amputation compared with those who joined (95% CI 3.19–3.76).The amputation rate in Taiwanese diabetic patients decreased over the time period observed. Diabetes in patients with low socioeconomic status is associated with an increased risk of amputations. Our findings suggested that in addition to medical interventions and self-management educations, formulate and implement of medical policies, such as P4P program, might have a significant effect on decreasing the diabetes-related amputation rate.

Nationwide trends in the epidemiology of diabetic foot complications and lower-extremity amputation over an 8-year period

“…The type of diabetes, ethnicities, age distribution, comorbidities and the utility of medical resource may all attribute to the difference. Sheen et al reported a similar decrease of LEAs in patients with diabetes between 1998 and 2007 (3.79 and 2.27/1000/year) 19. Although the authors suggested the impact of pay-for-performance programme in Taiwan, this conclusion may be over-reaching because only 12% coverage rate of that programme for patients with diabetes at that time 26.…”

“…Because of the robust and comprehensive nature of the Taiwan National Health System database, we were able to report the in-hospital foot diseases characteristics between years 2000 and 2009 18. The annual incidence of diabetes-related LEA in Taiwan between 1998 and 2007 was 3.79 and 2.27/1000/year, respectively 19…”

Risk factors for diabetic foot complications in type 2 diabetes—A systematic review

“…Research Database (NHIRD, Taiwan). 41,45 However, in all three cases, different subpopulations were included in the studies, and different risk factors were analysed in each of the publications.…”

“…The characteristics of all 31 articles, which were published between 1995 and 2019, are shown in Table 1. Six studies were performed in China, 32,33,36,39,51,54 five in the United States, 30,34,44,49,52 three in Taiwan, 41,45,46 two in the UK, 26,35 Denmark 28,29 and Saudi Arabia, 25,37 and one study each in Australia, 27 Austria, 40 Finland, 48 Ghana, 43 Italy, 47 New Zealand, 42 Pakistan, 53 Republic of Nauru 38 and Singapore. 50 In addition, two multinational studies were included, one of which was conducted in Europe (UK, Switzerland, Germany, in which the proportion of female patients was as low as 2.6%.…”

“…52 The mean duration of diabetes ranged from 3.7 years to more than 13 years 25,28 in the different patient populations; however, this value was not stated in nine of the 31 articles. 24,26,34,41,45,47,48,50,52 The mean follow-up time in longitudinal studies varied between one year 24,39 and 13 years. 44 The methodological aspects and the corresponding limitations of the particular studies are summarized in foot gangrene (FG) was assessed in addition.…”