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Diabetes Pay-For-Performance Programs Reduce All-Cause Mortality

Apr 14, 2020
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Mit Suthar, PharmD. Candidate, LECOM School of Pharmacy 

Diabetes mellitus continues to grow as a global healthcare problem and is associated with significant microvascular and macrovascular complications; how can diabetes pay-for-performance programs help? 

Around 40% of the adult US population is at an increased risk of developing diabetes during their lifetime. The World Health Organization (WHO) projected that the number of people with diabetes would increase from 177 million in 2000 to 300 million by the year 2025. Unfortunately, in 2020 it is already estimated that 415 million people are living with the disease, which is around 1 in 11 adults worldwide. Per the World Health Organization, in 2016, an estimated 1.6 million deaths were directly caused by diabetes. Another 2.2 million deaths were attributable to high blood glucose in 2012.  
Many countries, including the USA, UK, and Germany, have established diabetes pay-for-performance (P4P) programs to improve the quality of diabetes care. 


In P4P payment models, incentives are given to providers, care organizations, and other healthcare stakeholders to achieve performance objectives. Medicare and Medicaid support the value-based purchasing model since it encourages providers to be more efficient and penalizes high costs, poor patient outcomes, and medical errors. 

A study published by Medicine assessed the effect of a diabetes P4P program on all-cause mortality in patients with newly diagnosed T2DM. 5478 patients with T2DM were recruited and enrolled in the P4P within five years of their diabetes diagnosis between January 1st, 2002 and December 31st, 2010. The control group consisted of patients who were not enrolled in the P4P program. 

The authors of the study explained: “Previous studies have reported that patients enrolled in P4P programs had better adherence to the guideline-recommended examinations, had better clinical processes of care (e.g., HbA1c) and intermediate outcomes, decreased diabetes-related hospitalizations and inpatient costs, but increased rates of severe hypoglycemia requiring emergency medical care and increased outpatient expenses due to more regular follow-up visits.”  

The authors also noted that “Patients with type 2 diabetes are associated with a two-fold increase in mortality and a reduction in life expectancy by about six years compared with individuals without diabetes.” 

A multivariate Cox proportional hazard model analysis was used to evaluate the effect of the P4P program and adherence on all-cause mortality. The study revealed that 250 patients died in the P4P program, whereas 395 patients died in the control group (mortality rate 104 vs. 169 per 10,000 person-years, respectively, P < .0001). The control group was also shown to suffer from higher comorbidities. 

The researchers observed that the participants of the P4P program had better adherence and a more significant reduction in mortality. Reassuringly, they also found that patients who participated in the P4P program within five years of their diabetes diagnosis have significantly reduced all-cause mortality. This effect was even more prominent in patients in the P4P program who practiced better adherence. 

The adjusted hazard ratio (aHR) for all-cause mortality was calculated at 0.58 (95% CI, 0.48-0.69). Furthermore, in those participants with a minimum 1-year and 2-year good P4P adherence, there was an even more significant reduction in mortality, with an adjusted hazard ratio (95% CI) of 0.48 (0.38-0.62) and 0.36 (0.26-0.49), respectively. 

“The positive effects of the P4P program existed across age- and disease-specific groups except for those with stroke, cancer, and psychosis, which may be explained by high competing mortality of these diseases and poor compliance due to the underlying diseases and conditions that can lead to a diminished P4P effect,” the authors stated. “In the subgroup analysis, the patients with a longer regular adherence to the P4P program had a greater reduction in mortality rate. Hence, both participating in and adhering to the P4P program played an important role in contributing to the reduction of mortality in patients with newly diagnosed type 2 diabetes.” 

Earlier observation studies from Germany have suggested the benefit of a diabetes disease management program and how it improves patient survival. However, this study by Miksch et al. had excluded patients who were younger than 50 years old, those with a longer duration of diabetes, and patients enrolled mainly from a single or regional health fund. Thus, it can be argued that the study was not representative of the entire German population and that the generalizability of the results is limited due to poor patient selection. 

This P4P study displayed drastic reductions in all-cause mortality within five years in patients with T2DM, and the benefits were even more pronounced in patients with better adherence. The authors of the study promote P4P programs as a means to reduce the higher risks associated with the ever-growing population of people with diabetes and improve long-term survival. 

Practice Pearls: 

  • Participants of the P4P program within five years of diagnosis of T2DM were associated with a significant reduction in all-cause mortality 
  • Patients with better adherence had significantly increased survival rates 
  • P4P programs should be promoted to deal with the substantial economic burden that preventable complications place on healthcare systems 


Reference for “Diabetes Pay-For-Performance Programs Reduce All-Cause Mortality”:
Kung, Fang-Ping, et al. “Diabetes Pay-for-Performance Program Can Reduce All-Cause…: Medicine.” Medicine, Feb. 2020, journals.lww.com/md-journal/FullText/2020/02140/Diabetes_pay_for_performance_program_can_reduce.62.aspx.

Mit Suthar, PharmD. Candidate, LECOM School of Pharmacy 


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