The impact of regional medical resources and pay for performance on socioeconomics inequities in health care quality and health outcome of diabetic patients - A multilevel analysis

• Main Authors: Pei-Ching Chen, 陳珮青
• Other Authors: Yue-Chune Lee
• Format: Others
• Language: zh-TW
• Published: 2012
• Online Access: http://ndltd.ncl.edu.tw/handle/67745095803941686125

博士 === 國立陽明大學 === 衛生福利研究所 === 100 === Diabetes is a global health problem, there are nearly 6%% of adults have diabetes in the world. Past studies found that low socio-economic position of people with diabetes obtain the poor quality of care and health outcomes. However, no study explored the different levels of socio-economic position simultaneously with diabetes patients in healthcare quality and health outcomes disparities, and there was no study had explored the impact of the regional health care resources on these disparities. The purpose of this article is to assess the inequities on healthcare quality and health outcomes for patients with diabetes mellitus with different levels of socio-economic position and to assess the impact of the regional health care resources on those inequities by using multi-level analysis. The reform of payment policies by using quality and performance as the incentive mechanism to improve the quality of health care, also referred to as Pay-for-Performance (P4P), has become increasingly popular in the world. In 2001, the Bureau of National Health Insurance in Taiwan implemented a quality-based payment system or P4P program for five diseases, one of which was diabetes mellitus. Previous studies reported that positive results through improved performance and better outcomes. Some studies had explored the impacts of P4P on racial or ethnical disparities, but there was no study explored the impacts of P4P on socio-economic disparities. This article is the first one to assess the impact of P4P on socio-economic position inequities in healthcare quality and health outcomes for patients with diabetes mellitus. This study used the Longitudinal Health Insurance Database 2005 (LHID2005), with a population–representative cohort of 1 million out of the 22.72 million National Health Insurance enrollees. The study had two population consisted of patients having a regular place of care diagnosed with DM between 1999 and 2004, and with new DM case between 2000 and 2005. The socio-economic position included two parts: one is neighborhood level incluing the average discretionary income each person of one year and the proportion of residents with a university degree, and the other is individual level including income and occupation. The healthcare quality is measuring process quality of care for diabetes mellitus patients. The P4P requestes 10 types of regular examinations for diabetes patients, such as HbA1c, lipid, and ophthalmoscopic etc. The healthcare outcomes constituted binary variables are measuring the utilization of an emergency or a preventable hospitalization. The patients were divided into two groups: (1) the P4P group, who had received comprehensive care for at least one year between 2001 and 2005, (2) the control group, who were never enrolled in the diabetes mellitus pay-for-performance programs. Because the diabetes P4P program is voluntary for the health care providers, and providers are given the freedom to decide which patients to enroll in the program, we adopted the propensity score matching in this study. The P4P and the non-P4P groups were 1:4 matched using the greedy matching algorithm from an initial 8-digit to 1-digit. Statistical analyses were conducted using SAS statistical software, version 9.1 and HLM 6.08, and P < 0.05 was considered statistically significant. There were three findings in this study: 1. There are individual socio-economics position inequities on healthcare quality and health outcomes of patients with diabetes mellitus. The inequitiesof neighborhood socio-economics position was only on health outcome of preventable hospitalization. 2. The regional health care resources had impacts on socio-economics position inequities in healthcare quality and health outcomes, except on emergency utilization. 3. The DM P4P can reduce the inequalities of socio-economics position on healthcare quality and health outcomes. Based on the above findings, we have three recommendations: 1. The govement should have policies to improve the socio-economics position inequities, especially for the low socio-economics position patients with diabetes. 2. Continually promote the diabetes shared-care network, through cooperations between the physicians and hospitals to form a network to provide care for the diabetes patient and reduce the increase of emergency situations. 3. Continually execute the P4P program, and monitor the healthcare inequities for the low socio-economics position patients. The assess indicator should including negative health outcome such as emergency or preventable hospitalization. We also have three suggestions for future research: 1.To explore the reasons why different occupation of patients have worse health outcome. 2.To use different medical resources, such as the number of metabolic specialist physician, to clarify the regional medical resources interaction effect between socio-economic position and health. 3.To conduct a long-term follow-up study using other health outcome indicators, such as blindness, kidney dialysis or death, to explore the long-term health outcome of the P4P program.