Impact of pay-for-performance program on postoperative infection and revision risk in diabetic patients with hip replacement: a Taiwanese Cohort Study.

Abstract

Background: Diabetes Mellitus is a prevalent chronic disease with considerable global health implications. The Pay-for-Performance (P4P) program is a health insurance payment system designed to improve the quality and efficiency of diabetes care. This study explored the effect of P4P participation on postoperative infection, revision surgery risk, and associated factors among patients with type 2 diabetes undergoing hip replacement surgery.

Methods: This retrospective cohort study utilized data from Taiwan's National Health Insurance Research Database (NHIRD), which included a parent population of 2 697 279 individuals with diabetes between 2010 and 2016. A total of 26 682 subjects with type 2 diabetes (P4P: 3 190; non-P4P: 23 492) who met the enrollment criteria were selected. Propensity score matching with a ratio of 1:3 (P4P: non-P4P) was performed, resulting in a final sample of 12 440 participants (P4P = 3 110; non-P4P = 9 330). All participants were followed for postoperative outcomes until 2018. The differences between the two groups in postoperative infection and revision risks were assessed using a bivariate log-rank test. The Cox proportional hazards model with a competing risk approach was employed to estimate relative risks and identify factors associated with postoperative infection and revision surgery.

Results: P4P participants exhibited a lower postoperative infection rate compared with nonparticipants (3.73% vs. 4.56%, P = .042) and a lower relative risk of postoperative infection [adjusted hazard ratio (AHR): 0.80, 95% confidence interval (CI): 0.65-0.99]. The beneficial effect of P4P on infection reduction was significant in specific subgroups: patients aged 55-64 years, with a monthly salary of NT$22 801-NT$28 800, and a Charlson Comorbidity Index (CCI) of 0 (P < .05). Although P4P participants had a lower revision surgery rate (1.54% vs. 2.03%) and a lower relative risk of revision (AHR: 0.90, 95% CI: 0.65-1.24), this difference was nonsignificant (P = .522).

Conclusions: Participation in a P4P program was associated with a lower risk of postoperative infection among patients with diabetes undergoing surgery. However, the impact on revision arthroplasty risk was nonsignificantly different between the P4P and non-P4P. These findings offer valuable insights for health-care policymakers in optimizing diabetes care policies and refining P4P program design.