Chi- Chen

Continuity of care, medication adherence, and health care outcomes among patients with newly diagnosed type 2 diabetes: a longitudinal analysis.

Background:The effects of continuity of care (COC) on health care outcomes are well established. However, the mechanism of this association is not fully understood. Objective:The objective of this study was to examine the relationship between COC and medication adherence, as well as to investigate the mediating effect of medication adherence on the association between COC and health care outcomes, in patients with newly diagnosed type 2 diabetes. Research Design and Subjects:This study utilized a longitudinal design and included a 7-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. Patients aged 18 years or older who were first diagnosed with type 2 diabetes in 2002 were included in the study. Random intercept models were conducted to assess the temporal relationship between COC, medication adherence, and health care outcomes. Results:Patients with high or intermediate COC scores were more likely to be adherent to medications than those with low COC scores [odds ratio (OR), 3.37; 95% confidence interval (CI), 3.15–3.60 and OR, 1.84; 95% CI, 1.74–1.94, respectively]. In addition, the association between COC and health care outcomes was partly mediated by better medication adherence in patients with newly diagnosed type 2 diabetes. Conclusions:Improving the COC for patients with type 2 diabetes may result in higher medication adherence and better health care outcomes.

A longitudinal examination of a pay-for-performance program for diabetes care: evidence from a natural experiment.

Background:Numerous studies have examined the impacts of pay-for-performance programs, yet little is known about their long-term effects on health care expenses. Objectives:This study aimed to examine the long-term effects of a pay-for-performance program for diabetes care on health care utilization and expenses. Methods:This study represents a nationwide population-based natural experiment with a 4-year follow-up period under a compulsory universal health insurance program in Taiwan. The intervention groups consisted of 20,934 patients enrolled in the program in 2005, and 9694 patients continuously participated in the program for 4 years. Two comparison groups were selected by propensity score matching from patients seen by the same group of physicians. Generalized estimating equations were used to estimate differences-in-differences models to examine the effects of the pay-for-performance program. Results:Patients enrolled in the pay-for-performance program underwent significantly more diabetes specific examinations and tests after enrollment; the differences between the intervention and comparison groups declined gradually over time but remained significant. Patients in the intervention groups had a significantly higher number of diabetes-related physician visits in only the first year after enrollment and had fewer diabetes-related hospitalizations in the follow-up period. Concerning overall health care expenses, patients in the intervention groups spent more than the comparison group in the first year; however, the continual enrollees spent significantly less than their counterparts in the subsequent years. Conclusions:The program seemed to achieve its primary goal in improving health care and providing long-term cost benefits.

Hospital response to a global budget program under universal health insurance in Taiwan

OBJECTIVES Global budget programs are utilized in many countries to control soaring healthcare expenditures. The present study was designed to evaluate the responses of Taiwanese hospitals to a new global budget program implemented in 2002. METHODS Using data obtained from the Bureau of National Health Insurance (NHI) and two nationwide surveys conducted before and after the global budget program, changes in the length of stay, treatment intensity, insurance claims, and out-of-pocket fees were compared in 2002 and 2004. The analysis was conducted using the Generalized Estimating Equations (GEEs) method. RESULTS Regression models revealed that implementation of the global budget was followed by a 7% increase in length of stay and a 15% increase in the number of prescribed procedures and medications per admission. The claim expenses increased by 14%, and out-of-pocket fees per admission increased by 6%. Among the hospitals, no coalition action was found during the study period. CONCLUSIONS In the present study, it appears that hospitals attempted to increase per-case expense claims to protect their reimbursement from possible discounts under a global budget cap. How Taiwanese hospitals respond to this challenge in the future deserves continued, long-term observation.

Does continuity of care matter in a health care system that lacks referral arrangements

INTRODUCTION Numerous studies have suggested that better continuity of care (COC) can lead to fewer emergency department (ED) visits and fewer hospital admissions. However, these studies were conducted in countries where patients have their own family physician or in countries with referral systems. This study aimed to determine whether the association between lower COC and increased health care utilization may be apparent in a health care system that lacks a family physician or a referral system. METHODS The study population included a total of 134 422 subjects who made four or more visits to physicians in 2005. Negative binominal regressions were performed to examine the effects of three different COC indices on the numbers of hospital admissions and ED visits in 2005 and in the subsequent year (2006). RESULTS The data suggest that lower COC was associated with increased hospital admissions and ED visits in our study population. Compared with the high COC group, subjects in the low and medium COC groups had 42-82% and 39-46% more hospital admissions, respectively, as well as 75-102% and 41-45% more ED visits, respectively, in 2005. Weaker protective effects of COC were also observed in the subsequent year. CONCLUSIONS This study indicates that lower COC is associated with increased hospital admissions and ED visits, even in a health care system that lacks a referral arrangement framework. This suggests that improving the COC is beneficial both for patients and for the health care system.

The impacts of DRG-based payments on health care provider behaviors under a universal coverage system: a population-based study.

OBJECTIVE To examine the impacts of diagnosis-related group (DRG) payments on health care providers behavior under a universal coverage system in Taiwan. METHODS This study employed a population-based natural experiment study design. Patients who underwent coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty, which were incorporated in the Taiwan version of DRG payments in 2010, were defined as the intervention group. The comparison group consisted of patients who underwent cardiovascular procedures which were paid for by fee-for-services schemes and were selected by propensity score matching from patients treated by the same group of surgeons. The generalized estimating equations model and difference-in-difference analysis was used in this study. RESULTS The introduction of DRG payment resulted in a 10% decrease (p<0.001) in patients length of stay in the intervention group in relation to the comparison group. The intensity of care slightly declined with p<0.001. No significant changes were found concerning health care outcomes measured by emergency department visits, readmissions, and mortality after discharge. CONCLUSION The DRG-based payment resulted in reduced intensity of care and shortened length of stay. The findings might be valuable to other countries that are developing or reforming their payment system under a universal coverage system.

Continuity of care, potentially inappropriate medication, and health care outcomes among the elderly: evidence from a longitudinal analysis in Taiwan.

Background:Better continuity of care (COC) is associated with improved health care outcomes, such as decreased hospitalization and emergency department visit. However, little is known about the effect of COC on potentially inappropriate medication. Objectives:This study aimed to investigate the association between COC and the likelihood of receiving inappropriate medication, and to examine the existence of a mediating effect of inappropriate medication on the relationship between COC and health care outcomes and expenses. Methods:A longitudinal analysis was conducted using claim data from 2004 to 2009 under universal health insurance in Taiwan. Participants aged 65 years and older were categorized into 3 equal tertiles by the distribution of COC scores. This study used a propensity score matching approach to assign subjects to 1 of 3 COC groups to increase the comparability among groups. Generalized estimating equations were used to examine the association between COC, potentially inappropriate medication, and health care outcomes and expenses. Results:The results revealed that patients with the best COC were less likely to receive drugs that should be avoided [odd ratios (OR), 0.44; 95% confidence interval (CI), 0.43–0.45) or duplicated medication (OR, 0.22; 95% CI, 0.22–0.23) than those with the worst COC. The findings also indicated that potentially inappropriate medication was a partial mediator in the association between COC and health care outcomes and expenses. Conclusion:Better COC is associated with fewer negative health care outcomes and lower expenses, partially through the reduction of potentially inappropriate medication. Improving COC deserves more attention in future health care reforms.

Effects of continuity of care on medication duplication among the elderly.

Background:The effects of continuity of care on health care outcomes are well documented. However, little is known about the effect of continuity at the physician or the site level on the process of care for patients with multiple chronic conditions (MCCs). Objective:The objective of this study was to examine the effects of physician continuity versus site continuity on duplicated medications received by patients with and without MCCs. Research Design and Subjects:This study utilized a longitudinal design with an 8-year follow-up from 2004 to 2011 of patients aged 65 or older under a universal health insurance program in Taiwan (55,573 subjects and 389,011 subject-years). Generalized estimating equation models with propensity score method were conducted to assess the association between continuity and medication duplication. Results:The rates of subjects receiving duplicated medications ranged from 40.38% to 43.50% with 1.45–1.62 duplicated medications during the study period. The findings revealed that better continuity, either at the physician level or the site level, was significantly associated with fewer duplicated medications. This study also indicated that the physician continuity had a stronger effect on medication duplication than did site continuity. Furthermore, the magnitude of the protective effect of continuity against duplicated medications increased when the patients had more chronic conditions [physician continuity: the marginal effect ranged from −10.7% to −52.9% (all P<0.001); site continuity: the marginal effect ranged from −0.4% (P=0.063) to −31.4% (P<0.001)]. Conclusion:Improving either physician continuity or site continuity may result in fewer duplicated medications, particularly for patients with MCCs.

Does pay-for-performance benefit patients with multiple chronic conditions? Evidence from a universal coverage health care system

INTRODUCTION Numerous studies have examined the impact of pay-for-performance (P4P) programmes, yet little is known regarding their effects on continuity of care (COC) and the role of multiple chronic conditions (MCCs). This study aimed to examine the effects of a P4P programme for diabetes care on health care provision, COC and health care outcomes in diabetic patients with and without comorbid hypertension. METHODS This study utilized a large-scale natural experiment with a 4-year follow-up period under a compulsory universal health insurance programme in Taiwan. The intervention groups consisted of patients with diabetes who were enrolled in the P4P programme in 2005. The comparison groups were selected via propensity score matching with patients who were seen by the same group of physicians. A difference-in-differences analysis was conducted using generalized estimating equation models to examine the effects of the P4P programme. RESULTS Significant impacts were observed after the implementation of the P4P programme for diabetic patients with and without hypertension. The programme increased the number of necessary examinations/tests and improved the COC between patients and their physicians. The programme significantly reduced the likelihood of diabetes-related hospital admissions and emergency department visits [odds ratio (OR): 0.71; 95% confidence interval (CI): 0.63-0.80 for diabetic patients with hypertension; OR: 0.74; 95% CI: 0.64-0.86 for patients without hypertension]. However, the effects of the P4P programme diminished to some extent in the second year after its implementation. CONCLUSION This study suggests that a financial incentive programme may improve the provision of necessary health care, COC and health care outcomes for diabetic patients both with and without comorbid hypertension. Health authorities could develop policies to increase participation in P4P programmes and encourage continued improvement in health care outcomes.

Medication supply, healthcare outcomes and healthcare expenses: Longitudinal analyses of patients with type 2 diabetes and hypertension

INTRODUCTION Patients with chronic conditions largely depend on proper medications to maintain health. This study aims to examine, for patients with diabetes and hypertension, whether the appropriateness of the quantity of drug obtained is associated with favorable healthcare outcomes and lower expenses. METHODS This study utilized a longitudinal design with a seven-year follow-up period from 2002 to 2009 under a universal health insurance program in Taiwan. The patients under study were those aged 18 years or older and newly diagnosed with type 2 diabetes or hypertension in 2002. Generalized estimating equations were performed to examine the relationship between medication supply and health outcomes as well as expenses. RESULTS The results indicate that while compared with patients with an appropriate medication supply, patients with either an undersupply or an oversupply of medications tended to have poorer healthcare outcomes. The study also found that an excess supply of medications for patients with diabetes or hypertension resulted in higher total healthcare expenses. CONCLUSION Either an undersupply or an oversupply of medication was associated with unfavorable healthcare outcomes, and that medication oversupply was associated with the increased consumption of health resources. Our findings suggest that improving appropriate medication supply is beneficial for the healthcare system.

Half-Managed Care: A Preliminary Assessment of a Capitation Program in a Health Care System Without Gatekeepers.

In 2011, a novel capitation program was launched in Taiwan under its universal health insurance plan. This study aimed to assess the short-term impact of the program. Two hospitals in the greater Taipei area, one participating in the “loyal patient” model (13,319 enrollees) and one in the “regional resident” model (13,768 enrollees), were analyzed. Two comparison groups were selected by propensity score matching. Generalized estimating equation models with differences-in-differences analysis were used to examine the net effects of the capitation program on health care utilization, expenses, and outcomes. Enrollees in the loyal patient model had fewer physician visits in the host hospital, but more physician visits outside that hospital during the program year than they had the year before. Compared with non-enrollees, the loyal patient model enrollees incurred fewer physician visits (β = −0.042, p < .001), fewer emergency department visits, (β = −0.140, p < .001), and similar total expenses and outcome. For the regional resident model, no differences were found in the number of physician visits, expenses, or outcomes between enrollees and non-enrollees. The novel capitation models in Taiwan had minimal impact on health care utilization after 1 year of implementation and the health care outcome was not compromised.