背景：
糖尿病是一種全球關注的疾病，其盛行率在過去幾十年中穩步上升。作為一種以持續高血糖為特徵的慢性代謝性疾病，糖尿病由於其長期併發症和相關的治療費用，給醫療保健系統帶來了越來越大的經濟負擔。除了經濟影響之外，糖尿病還顯著降低預期壽命，這主要是由於大血管和小血管併發症以及癌症風險增加。大血管併發症，如心血管疾病、中風和周邊動脈疾病，是糖尿病患者死亡的主要原因。小血管併發症，包括糖尿病腎病變、視網膜病變和神經病變，進一步降低生活品質並增加導致健康失能的可能性。此外，新出現的證據表明，糖尿病與某些癌症的風險增加有關，進一步加劇了對糖尿病人存活率的影響。

糖尿病最具破壞性的併發症之一是下肢截肢，通常是由周邊神經病變、周邊動脈疾病和傷口癒合不良引起的。糖尿病足潰瘍和感染是截肢的重要危險因子，使糖尿病成為全球非創傷性下肢截肢的主要原因。 下肢截肢不僅影響糖尿病人的活動能力和生活品質，而且由於這些病人中受害器官合併症的高盛行率，還與預期壽命的大幅縮短有關。

為了處理併發症並降低成本，台灣於1996年8月在宜蘭縣啟動了多科別的「糖尿病共享照護網絡」小規模初步試驗。2001年11月，全國性的糖尿病論質計酬（P4P）方案開始實施。到 2022 年，照護率持續增加至 60%。我的博士論文包含兩個研究:(1) P4P方案和照護連續性對下肢截肢的影響，(2)P4P方案對糖尿病患者預期壽命損失的影響。了解這些影響對於評估旨在改善患者治療結果的醫療保健政策的有效性是必要的。透過分析支付方案和照護連續性的影響，我的研究目的在深入了解可以減少糖尿病相關併發症並提高高風險族群存活率的策略，為基於證據的政策建議和強有力的政策執行奠定基礎。

方法：
(1) 下肢截肢是一根基於台灣人口的研究，使用 1997 年至 2013 年的健保資料，追蹤期間為 2010-2013年。我們比較了15,650名參加糖尿病論質計酬的糖尿病患者，與一組依年齡與性別以1比4比例配對的非糖尿病論質計酬對照組民眾。本研究計算照護連續性(COCI) 的時間加權平均值，並將其納入在與時間相關的 Cox 比例風險模型中，以評估 P4P 和 COCI 對 截肢 風險的影響，同時控制病患個人和區域層級特徵。
(2) 本研究從糖尿病主題檔中選擇了2004 年至2015 年歷年新診斷的糖尿病患者，年齡在40 歲至64 歲之間，其中P4P 組為503,662 人，非P4P 組為450,071 人，並追蹤到 2018 年底，使用 Kaplan-Meier 存活分析。本研究透過Monte Carlo 方法從台灣的人口動態統計中模擬了每組的年齡、性別和日曆年匹配的參考組。本研究建立了一個基於對數勝算轉換的相對生存率(logit-transformed relative survival)的限制性立方樣條模型(restricted cubic spline model)，對每組與其匹配的參考組之間的logit 轉換相對生存率進行分析，並反覆應用滾動演算法，按收案間隔進行分層分析，將每個指標組的生存函數外推至壽命終點，以估計預期壽命，從參照組比對以獲得預期壽命損失。

結果：
(1) 在四年的下肢截肢追蹤期間 2010-2013，1816 名受試者經歷了下肢截肢手術。 P4P 組 (n=153) 的累積下肢截肢手術 風險率顯著低於非 P4P 組 (n=1663)（風險比HR = 0.37，95% CI = 0.31–0.43）。在時間依賴性 Cox 比例風險模型中，P4P 組的調整後風險比 (aHR) 為 0.35（p < 0.0001）。以低 COCI (< 0.50) 組為參考，中 COCI 組的 下肢截肢手術 aHR 為 0.49 (p < 0.0001)，高 COCI (≥ 0.80) 組的下肢截肢手術 aHR 為 0.23 (p < 0.001)。
(2) 預期壽命(LE) 損失的研究中分層分析的結果顯示，加入論質計酬計劃(P4P組)越早，預期壽命損失的時間越短:加入間隔<1年的損失為0.06 ± 0.72年，間隔1-4年為0.05 ± 0.59年，間隔5-9年為10.01 ± 0.11年，間隔為10-15 年為12.77 ± 0.14年 (p<0.001)。相較之下，非 P4P 組的預期壽命損失為 2.60 ± 0.14 年。

結論：
參與 P4P 計劃和提升照護連續性指數 (COCI) 兩者分別和共同降低糖尿病患者下肢截肢的風險。早期加入論質計酬照護與減少預期壽命損失有關，這表明如果在糖尿病診斷後儘早實施論質計酬照護，可能延長生命。

Background:
Diabetes mellitus is a disease of global concern, with its prevalence steadily increasing over the past few decades. As a chronic metabolic disorder characterized by persistent hyperglycemia, diabetes imposes a growing economic burden on healthcare systems due to its long-term complications and associated treatment costs. Beyond financial implications, diabetes significantly reduces life expectancy, primarily due to macrovascular and microvascular complications, as well as an increased risk of cancer. Macrovascular complications, such as cardiovascular disease, stroke, and peripheral artery disease, are major contributors to mortality among diabetic patients. Microvascular complications, including diabetic nephropathy, retinopathy, and neuropathy, further reduce quality of life and increase the likelihood of disabling health outcomes. Additionally, emerging evidence suggests that diabetes is associated with a higher risk of certain cancers, further compounding its impact on survival.
One of the most devastating complications of diabetes is lower extremity amputation (LEA), which often results from peripheral neuropathy, peripheral artery disease, and poor wound healing. Diabetic foot ulcers and infections are significant risk factors for amputation, making diabetes the leading cause of non-traumatic lower limb amputations worldwide. LEA not only affects mobility and quality of life but is also associated with a substantial reduction in life expectancy due to the high prevalence of comorbidities of target organs among these patients.
To address complications and reduce costs, Taiwan launched a pilot trial of multidisciplinary “Diabetes Shared Care Network” in August, 1996. By November, 2001, a nationwide pay-for-performance (P4P) program for diabetes was implemented. In 2022, more than 60% of diabetes patients were enrolled in the P4P program. My PhD dissertation examines (1) the effect of P4P and continuity of care on lower extremity amputation and (2) the impact of pay-for-performance (P4P) programs on loss of life expectancy among diabetes patients. Understanding these associations is essential for evaluating the effectiveness of healthcare policies aimed at improving patient outcomes. By analyzing the role of financial incentives and care continuity, my research aims to provide insights into strategies that can reduce diabetes-related complications and improve survival in this high-risk population, effectively setting the stage for evidence-based policy recommendation and robust implementation.
Methods:
(1) In the initial phase of this study on lower extremity amputation, we employed a design using data from the National Health Insurance Database collected between 1997 and 2013 and followed up from 2010 to 2013. We compared 15,650 diabetic patients enrolled in the P4P program with a control group of non-P4P participants matched by age and sex at a ratio of 1:4. The study assessed the effects of both the P4P program and the COCI on the risk of LEA using time-dependent Cox proportional hazards models that incorporated the Time-Weighted Average (TWA) of COCI, Controlling for both individual-level and regional-level characteristics of patients.
(2) For the second part, we studied a cohort of patients aged 40 to 64, including 503,662 in the P4P group and 450,071 in the non-P4P, from 2004 to 2015, tracking them until 2018 using Kaplan-Meier survival analysis from the Diabetes Mellitus Health Database. This database collects data on all newly diagnosed diabetic patients annually. Age-, gender-, and calendar year-matched referents for each group were simulated using the Monte Carlo method from Taiwan’s vital statistics. A restricted cubic spline model was applied to logit-transformed relative survival for each group, stratified by interval between diabetes diagnosis and enrollment date, and compared to its matched referents, with a rolling-over algorithm used to extrapolate each index group’s survival to estimate lifetime LE, which was then compared to matched referents to determine loss-of-LE.

Results:
(1) In the initial study, out of 1816 subjects who experienced LEA over four years, the P4P group (n=153) had a significantly lower cumulative hazard rate than the non-P4P group (n=1663) (hazard ratio = 0.37). In the time-dependent Cox model, the adjusted hazard ratios (aHR) for the P4P group were 0.35 (p < 0.0001). Using the low COCI (< 0.50) group as a reference, the middle COCI group had an aHR of 0.49 (p < 0.0001), and the high COCI (≥ 0.80) group had an aHR of 0.23 (p < 0.0001).
(2) The second study’s stratified analysis by enrollment interval revealed that earlier enrollment correlated with reduced loss-of-LE: 0.06 ± 0.72 years for <1 year, 0.05 ± 0.59 years for 1-4 years, 10.01 ± 0.11 years for 5-9 years, and 12.77 ± 0.14 years for 10-15 years (p<0.001), versus 2.60 ± 0.14 years for the non-P4P group.

Conclusions:
Participation in the P4P program and enhanced COCI independently and synergistically reduce amputation risks in diabetic patients. Early enrollment in the P4P program is linked with decreased loss of life expectancy, suggesting that timely implementation post-diabetes diagnosis can extend life.

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