| Summary: | 碩士 === 國立臺灣大學 === 健康政策與管理研究所 === 105 === Background and purpose: Asthma is a common chronic disease. Patients need regular medical treatment and medication, and have self-management ability in order to avoid the risk of acute exacerbations. Therefore, Taiwan has implemented the pay-for-performance (P4P) program for asthma, and encouraged medical institutions to join the program to strengthen the tracking management and health education for asthma patients. However, the P4P program for asthma in Taiwan is not effect-based payment, but bundled payment. There are few past studies regarding whether asthma P4P program can improve the care process and outcome. Although those studies suggest that the program does help increasing the outpatient visits, reducing acute medical resource utilization and improve patients’ condition, most of them are regional and single group before-and-after experimental design. Nation-wide asthma P4P studies are also lacking. In addition, past studies has found there is risk selection issue in diabetes P4P program, but has not explored if this is also the case for asthma. This study aims to explore the effect of asthma P4P program on care process and outcome, and whether there exist the phenomenon of health disparity in risk selection. To carry on large sample database study for asthma, measures for appropriate asthma severity classification are necessary. Severity is an important disease characteristic. Patients with different disease severity grades have different prognoses and are suitable for different methods of treatment. Several severity classification criteria are commonly used abroad, but which of them is the most appropriate is still open to debate. Moreover, Domestic research on asthma severity is also absent. Hence, this study attempts to establish an assessment model of asthma severity classification based on the prescribed medication for each patient, and explore if the patient characteristics of asthma patients affect whether they join the P4P program, leading to risk selection issue, and if joining the program makes difference in asthma tracking and care, thus influencing care outcome.
Materials and methods: This study is a retrospective cohort study. We used National Health Insurance Research Database to filter out 4,157 newly-diagnosed asthma cases between 2007-2008, and conducted data tracking. We first developed an assessment model of asthma severity classification, and then explored whether there is difference in patients’ acute exacerbations under medication-based classification through survival analysis, in order to examine the appropriateness of the established classification criterion. Subsequently, we explored if patient characteristics and severity affects whether patients join the asthma P4P program. Lastly, with patient characteristics and severity controlled, we examined if care process is the mediator for the relationship between whether patients joining the program and their care outcomes.
Results: Under medication-based asthma severity classification, after some of the groups being merged, the difference between the follow-up emergency and hospitalization of each group reached significant level. The assessment model can divide the patients into three or two stages. Each Patient’s severity, degree of urbanization, and his doctor’s age and the level of the medical institution he goes to, all affect whether the patient joins the asthma P4P program. There is higher probability for patients with moderate to severe severity, living in highly urbanized area, receiving treatment in primary clinics and having younger doctors to join the program. Examining the relationship between whether patients joining the asthma P4P program and their care processes and outcomes, after controlling other variables, we found that the independent variable “joining the P4P program” does not significantly influence the care process mediator “outpatient visits three times or above in a year”. Also, the mediator “outpatient visits three times or above in a year” has statistically significant influence on some of the care outcomes, but the independent variable “joining the P4P program” does not significantly influence the care outcomes. Therefore, there is no mediation between the three.
Conclusion and suggestions: The cherry-picking in the diabetes P4P program does not happen in the asthma P4P program, and the asthma P4P program has no significant influence on asthma tracking and care ou tcome. Considering not many patients participating in the program, institutional adjustment and incentive increasing may be necessary. Suggestions for future studies include further improvement to the classification method, with the introduction of clinical primary data for compare and confirmation, and development of classification method suitable for underage patients to extend the subjects of study.
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