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

Background With the promising outcomes of the pre-ESRD (end-stage renal disease) pay-for-performance (P۴P) program, the National Health Insurance Administration (NHIA) of Taiwan launched a P۴P program for patients with early chronic kidney disease (CKD) in ۲۰۱۱, targeting CKD patients at stages ۱, ۲, and ۳a. This study aimed to examine the long-term effect of the early-CKD P۴P 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) ۲ between P۴P program enrolees and non-enrolees. The difference in the cumulative incidence of CKD progression between the P۴P and non-P۴P groups was tested using Gray’s test. We adopted a cause-specific (CS) hazard model to estimate the hazard in the P۴P group as compared to non-P۴P 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 P۴P and diabetes P۴P programs.  Results  The incidence per ۱۰۰ person-months of disease progression was significantly lower in the P۴P group than in the non-P۴P group (۰.۴۴ vs. ۰.۶۹, P < .۰۰۰۱), and the CS hazard ratio (CS-HR) for P۴P program enrolees compared with non-enrolees was ۰.۶۱ (۹۵% CI: ۰.۵۸–۰.۶۴, P < .۰۰۰۱). The results of the subgroup analysis further revealed an additive effect of the diabetes P۴P program on CKD progression; compared to none of both P۴P enrolees, the CS-HR for CKD disease progression was ۰.۶۰ (۹۵% CI: ۰.۵۴–۰.۶۷, P < .۰۰۰۱) for patients who were enrolled in both early-CKD P۴P and diabetes P۴P programs. Conclusion  The present study results suggest that the early-CKD P۴P program is superior to usual care to decelerate CKD progression in patients with early-stage CKD.

Keywords:

Pay-For-Performance , Chronic Kidney Disease , Cohort Study , Renal Outcome , Electronic Medical Records , Taiwan