家庭医生激励对2型糖尿病患者医疗费用的影响

Impact of Pay-for-performance Program for Family Physicians on Medical Expenses of Type 2 Diabetics

背景海门区于2018年1月实施家庭医生按绩效支付(P4P)的糖尿病管理模式,激励家庭医生提高服务质量。目的评价P4P模式对2型糖尿病患者血糖控制、服药依从性、医疗服务利用及医疗费用的影响。方法2019年3—6月,对南通市通州区和海门区的2型糖尿病患者(从村卫生室管理的确诊为2型糖尿病患者名单中每隔10例抽取1例患者)进行问卷调查,以实施P4P管理模式的海门区为激励组(n=496),以常规管理的通州区为对照组(n=589),问卷主要包括人口学特征、医疗服务利用、医疗费用、空腹血糖、服药依从性。采用负二项回归、Logistic回归和最小二乘法(OLS)回归分析门诊就诊次数、住院服务利用和医疗费用的影响因素。结果两组2型糖尿病患者教育程度、家庭年均收入、同时患慢性病种数比较,差异有统计学意义(P<0.05)。激励组的空腹血糖、过去1年门诊就诊次数、住院服务利用、医疗总费用低于常规组,激励组服药依从性高于常规组,差异有统计学意义(P<0.05)。多因素回归分析结果显示,校正了人口学特征和空腹血糖后,与常规组相比,激励组患者的门诊就诊次数降低了34.6%(IRR=0.654,P<0.05),药品费用增加了54.96%(eb-1=0.5496,P<0.05),医疗总费用降低了34.43%(eb-1=-0.3443,P<0.05)。进一步将患者按年龄分为<60、60~70、>70岁组后进行多因素回归分析,结果显示与常规组相比,激励组<60、>70岁糖尿病患者的门诊就诊次数分别降低了63.2%(IRR=0.368,P<0.05)和54.2%(IRR=0.458,P<0.05),>70岁的糖尿病患者住院服务利用率降低了48.0%(OR=0.520,P<0.05)。结论P4P模式在一定程度上降低了糖尿病患者的门诊服务的利用和>70岁老年人的住院服务利用,降低了年总医疗费。

Background A diabetes pay-for-performance(P4P)program has been implemented in Haimen District since January 2018,to incentivize family physicians to improve the quality of family physician care for type 2 diabetics.Objective To investigate the impact of P4P program for family physicians on type 2 diabetics'blood glucose control,medication compliance,health service utilization and medical expenses.Methods From March to June 2019,we selected type 2 diabetics from the name list of confirmed type 2 diabetics receiving the management from village health clinics(one was extracted every 10 cases)in Nantongli Tongzhou and Haimen Districts,including 496 with care delivered by family physicians incentivized by the P4P program(incentive group),and 589 with care delivered by family physicians without the program as an incentive(control group),and surveyed them using a questionnaire for collecting their information involving demographics,healthcare utilization,medical expenses,fasting blood glucose and medication compliance.Negative binomial regression,Logistic regression and OLS regression were used to analyze the influencing factors of annual outpatient visits,annual inpatient service utilization and medical costs.Results There were statistically significant differences between the two groups in terms of the distribution of education level and mean number of coexisted chronic diseases,and annual household income(P<0.05).The incentive group had statistically lower mean fasting blood glucose level,less mean number of annual outpatient visits,lower annual inpatient service utilization rate and lower mean annual total medical costs than the control group(P<0.05).The incentive group also showed statistically higher medication compliance(P<0.05).After adjustment for demographic characteristics and fasting blood glucose,multivariate regression analysis found that compared with the control group,the incentive group demonstrated a reduction of 34.6%in mean annual outpatient visits(IRR=0.654,P<0.05),an increase of 54.96%(eb-1=0.5496,P<0.05)in mean annual medication cost,and a decrease of 34.43%(eb-1=-0.3443,P<0.05)in mean annual total medical costs.Further age-based subgroup analysis found that compared with the patients aged<60 and>70 in the control group,the number of outpatient visits of the same age patients in the incentive group decreased by 63.2%(IRR=0.368,P<0.05)and 54.2%(IRR=0.458,P<0.05)respectively;compared with the patients aged>70 in the control group,the utilization rate of inpatient services of the patients aged>70 in the incentive group decreased by 48.0%(OR=0.520,P<0.05).Conclusion The diabetes P4P program for family physicians may partially contribute to reducing the outpatient care utilization in type 2 diabetics,and reducing the annual inpatient service utilization rate and annual total medical costs in over 70-year-old type 2 diabetics.