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

Document Type : Original Article

Authors

1 Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan

2 Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

3 School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan

4 Division of Nephrology, Department of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

5 College of Medicine, Chang Gung University, Taoyuan, Taiwan

6 Population Health Research Center, National Taiwan University, Taipei, 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) 2 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.

Keywords


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Articles in Press, Accepted Manuscript
Available Online from 13 April 2021