Effects of Body Mass Index and Pay-for-Performance Program on Risk of Death in Patients with Type 2 Diabetes: A Nationwide Cohort Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Data Sources and Participants
2.2. Variables Description
2.3. Statistical Analysis
3. Results
3.1. Essential Characteristics of Patients with Type 2 Diabetes and Mortality Rate per 1000 Person-Years
3.2. Comparison of Mortality Rate per 1000 Person-Years in DM Patients with Different BMIs in P4P or Non-P4P Program
3.3. The Effects of BMI and P4P on the Risk of Death in Patients with Type 2 Diabetes and Related Factors
3.4. Comparing the Effects of P4P on Death Risk in Patients with Type 2 Diabetes at Different BMI Levels by Stratified Analysis
4. Discussion
5. Limitations
6. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Variable | Total | % | non-P4P | P4P | p-Value | ||
---|---|---|---|---|---|---|---|
n | % | n | % | ||||
Total | 6354 | 100.00 | 4408 | 69.37 | 1946 | 30.63 | |
BMI | <0.001 | ||||||
BMI < 18.5 | 133 | 2.09 | 108 | 2.45 | 25 | 1.28 | |
18.5 ≤ BMI < 24 | 2064 | 32.48 | 1483 | 33.64 | 581 | 29.86 | |
24 ≤ BMI < 27 | 2064 | 32.48 | 1421 | 32.24 | 643 | 33.04 | |
27 ≤ BMI < 30 | 1240 | 19.52 | 834 | 18.92 | 406 | 20.86 | |
BMI ≥ 30 | 853 | 13.42 | 562 | 12.75 | 291 | 14.95 | |
P4P | |||||||
No | 4408 | 69.37 | - | - | - | - | |
Yes | 1946 | 30.63 | - | - | - | - | |
Survival | <0.001 | ||||||
No | 5192 | 81.71 | 3474 | 78.81 | 1718 | 88.28 | |
Yes | 1162 | 18.29 | 934 | 21.19 | 228 | 11.72 | |
Sex | 0.236 | ||||||
Male | 3328 | 52.38 | 2331 | 52.88 | 997 | 51.23 | |
Female | 3026 | 47.62 | 2077 | 47.12 | 949 | 48.77 | |
Age | <0.001 | ||||||
20–44 | 1020 | 16.05 | 684 | 15.52 | 336 | 17.27 | |
45–54 | 1619 | 25.48 | 1043 | 23.66 | 576 | 29.60 | |
55–64 | 1760 | 27.70 | 1163 | 26.38 | 597 | 30.68 | |
65–74 | 1228 | 19.33 | 901 | 20.44 | 327 | 16.80 | |
≥75 | 727 | 11.44 | 617 | 14.00 | 110 | 5.65 | |
Education Level | 0.041 | ||||||
None or Literate | 917 | 14.43 | 673 | 15.27 | 244 | 12.54 | |
Elementary | 2299 | 36.18 | 1561 | 35.41 | 738 | 37.92 | |
Junior | 998 | 15.71 | 684 | 15.52 | 314 | 16.14 | |
Senior | 1276 | 20.08 | 894 | 20.28 | 382 | 19.63 | |
College or above | 846 | 13.31 | 586 | 13.29 | 260 | 13.36 | |
Missing | 18 | 0.28 | |||||
Marital Status | 0.001 | ||||||
Married | 4715 | 74.21 | 3218 | 73.00 | 1497 | 76.93 | |
Divorced | 266 | 4.19 | 177 | 4.02 | 89 | 4.57 | |
Widowed | 704 | 11.08 | 517 | 11.73 | 187 | 9.61 | |
Never married | 661 | 10.40 | 491 | 11.14 | 170 | 8.74 | |
Missing | 8 | 0.13 | |||||
Urbanization of Residence Area | 0.006 | ||||||
Level 1 | 1326 | 20.87 | 962 | 21.82 | 364 | 18.71 | |
Level 2 | 1929 | 30.36 | 1309 | 29.70 | 620 | 31.86 | |
Level 3 | 940 | 14.79 | 658 | 14.93 | 282 | 14.49 | |
Level 5 | 1237 | 19.47 | 830 | 18.83 | 407 | 20.91 | |
Level 4 | 199 | 3.13 | 154 | 3.49 | 45 | 2.31 | |
Level 6 | 420 | 6.61 | 284 | 6.44 | 136 | 6.99 | |
Level 7 | 303 | 4.77 | 211 | 4.79 | 92 | 4.73 | |
Monthly Salary (NTD) | 0.042 | ||||||
≤17,280 | 1403 | 22.08 | 1018 | 23.09 | 385 | 19.78 | |
17,281–22,800 | 2879 | 45.31 | 1979 | 44.90 | 900 | 46.25 | |
22,801–28,800 | 417 | 6.56 | 273 | 6.19 | 144 | 7.40 | |
28,801–36,300 | 502 | 7.90 | 339 | 7.69 | 163 | 8.38 | |
36,301–45,800 | 546 | 8.59 | 373 | 8.46 | 173 | 8.89 | |
≥45,801 | 607 | 9.55 | 426 | 9.66 | 181 | 9.30 | |
CCI | 0.013 | ||||||
0 | 3550 | 55.87 | 2425 | 55.01 | 1125 | 57.81 | |
1 | 1354 | 21.31 | 969 | 21.98 | 385 | 19.78 | |
2 | 819 | 12.89 | 552 | 12.52 | 267 | 13.72 | |
≥3 | 631 | 9.93 | 462 | 10.48 | 169 | 8.68 | |
DCSI | <0.001 | ||||||
0 | 4942 | 77.78 | 3458 | 78.45 | 1484 | 76.26 | |
1 | 706 | 11.11 | 420 | 9.53 | 286 | 14.70 | |
2 | 547 | 8.61 | 409 | 9.28 | 138 | 7.09 | |
≥3 | 159 | 2.50 | 121 | 2.75 | 38 | 1.95 | |
Smoking | 0.211 | ||||||
Never | 4526 | 71.23 | 3110 | 70.55 | 1416 | 72.76 | |
Everyday | 1525 | 24.00 | 1083 | 24.57 | 442 | 22.71 | |
Quit | 297 | 4.67 | 210 | 4.76 | 87 | 4.47 | |
Missing | 6 | 0.09 | |||||
Drinking | 0.013 | ||||||
Never | 4618 | 72.68 | 3216 | 72.96 | 1402 | 72.05 | |
Once a week | 880 | 13.85 | 577 | 13.09 | 303 | 15.57 | |
Almost every day | 843 | 13.27 | 606 | 13.75 | 237 | 12.18 | |
Missing | 13 | 0.20 | |||||
Weekly Energy Expenditure in Exercise | 0.044 | ||||||
No exercise | 2997 | 47.17 | 2123 | 48.16 | 874 | 44.91 | |
<500 kcal | 1193 | 18.78 | 819 | 18.58 | 374 | 19.22 | |
≥500 kcal | 2156 | 33.93 | 1459 | 33.10 | 697 | 35.82 | |
Missing | 8 | 0.13 | |||||
Primary Health Care Organizations | <0.001 | ||||||
Medical center | 1242 | 19.55 | 909 | 20.62 | 333 | 17.11 | |
Regional hospital | 1946 | 30.63 | 1223 | 27.75 | 723 | 37.15 | |
District hospital | 1274 | 20.05 | 887 | 20.12 | 387 | 19.89 | |
Community clinic | 1892 | 29.78 | 1389 | 31.51 | 503 | 25.85 |
Variable | Total | Death (N) | Total Person-Years | Incidence/1000 Person-Years | p-Value # |
---|---|---|---|---|---|
Total | 6354 | 1162 | 51,233.56 | 22.68 | - |
BMI | |||||
BMI < 18.5 | 133 | 60 | 982.83 | 61.05 | <0.001 |
18.5 ≤ BMI < 24 | 2064 | 512 | 17,090.74 | 29.96 | - |
24 ≤ BMI < 27 | 2064 | 319 | 16,610.69 | 19.20 | <0.001 |
27 ≤ BMI < 30 | 1240 | 159 | 9947.51 | 15.98 | <0.001 |
BMI ≥ 30 | 853 | 112 | 6601.78 | 16.97 | <0.001 |
P4P | |||||
No | 4408 | 934 | 32,503.77 | 28.74 | - |
Yes | 1946 | 228 | 18,729.79 | 12.17 | <0.001 |
Sex | |||||
Male | 3328 | 686 | 25,940.12 | 26.45 | - |
Female | 3026 | 476 | 25,293.43 | 18.82 | <0.001 |
Age | |||||
20–44 | 1020 | 69 | 8430.75 | 8.18 | - |
45–54 | 1619 | 144 | 13,703.10 | 10.51 | 0.088 |
55–64 | 1760 | 230 | 14,817.12 | 15.52 | <0.001 |
65–74 | 1228 | 362 | 9906.48 | 36.54 | <0.001 |
≥75 | 727 | 357 | 4376.11 | 81.58 | <0.001 |
Education Level | |||||
None or Literate | 917 | 313 | 8001.55 | 39.12 | - |
Elementary | 2299 | 496 | 19,195.10 | 25.84 | <0.001 |
Junior | 998 | 126 | 7814.75 | 16.12 | <0.001 |
Senior | 1276 | 139 | 9586.19 | 14.50 | <0.001 |
College or above | 846 | 78 | 6523.90 | 11.96 | <0.001 |
Missing | 18 | ||||
Marital Status | |||||
Married | 4715 | 758 | 38,788.19 | 19.54 | - |
Divorced | 266 | 40 | 1946.93 | 20.55 | 0.758 |
Widowed | 704 | 203 | 5935.65 | 34.20 | <0.001 |
Never married | 661 | 159 | 4509.52 | 35.26 | <0.001 |
Missing | 8 | ||||
Urbanization of Residence Area | |||||
Level 1 | 1326 | 221 | 10,999.86 | 20.09 | - |
Level 2 | 1929 | 309 | 15,803.21 | 19.55 | 0.004 |
Level 3 | 940 | 171 | 7619.56 | 22.44 | 0.001 |
Level 5 | 1237 | 253 | 9580.61 | 26.41 | 0.047 |
Level 4 | 199 | 43 | 1495.23 | 28.76 | 0.384 |
Level 6 | 420 | 92 | 3272.64 | 28.11 | 0.874 |
Level 7 | 303 | 73 | 2462.44 | 29.65 | 0.735 |
Monthly Salary (NTD) | |||||
≤17,280 | 1403 | 340 | 11,247.83 | 30.23 | - |
17,281–22,800 | 2879 | 572 | 24,138.51 | 23.70 | <0.001 |
22,801–28,800 | 417 | 45 | 3301.53 | 13.63 | <0.001 |
28,801–36,300 | 502 | 58 | 3768.27 | 15.39 | <0.001 |
36,301–45,800 | 546 | 67 | 4045.07 | 16.56 | <0.001 |
≥45,801 | 607 | 80 | 4732.34 | 16.90 | <0.001 |
CCI | |||||
0 | 3550 | 406 | 28,926.31 | 14.04 | - |
1 | 1354 | 266 | 10,878.79 | 24.45 | <0.001 |
2 | 819 | 200 | 6834.13 | 29.26 | <0.001 |
≥3 | 631 | 290 | 4594.32 | 63.12 | <0.001 |
DCSI | |||||
0 | 4942 | 760 | 39,569.14 | 19.21 | - |
1 | 706 | 135 | 6396.50 | 21.11 | 0.313 |
2 | 547 | 191 | 4029.83 | 47.40 | <0.001 |
≥3 | 159 | 76 | 1238.08 | 61.39 | <0.001 |
Smoking | |||||
Never | 4526 | 747 | 37,833.21 | 19.74 | - |
Everyday | 1525 | 303 | 10,946.25 | 27.68 | <0.001 |
Quit | 297 | 111 | 2426.88 | 45.74 | <0.001 |
Missing | 6 | ||||
Drinking | |||||
Never | 4618 | 932 | 38,379.95 | 24.28 | - |
Once a week | 880 | 104 | 6776.01 | 15.35 | <0.001 |
Almost everyday | 843 | 125 | 5979.73 | 20.90 | 0.116 |
Missing | 13 | ||||
Weekly Energy Expenditure in Exercise | |||||
No exercise | 2997 | 615 | 22,852.01 | 26.91 | - |
<500 kcal | 1193 | 199 | 9958.23 | 19.98 | <0.001 |
≥500 kcal | 2156 | 346 | 18,376.51 | 18.83 | <0.001 |
Missing | 8 | ||||
Primary Healthcare Organizations | |||||
Medical center | 1242 | 280 | 10,397.39 | 26.93 | - |
Regional hospital | 1946 | 408 | 16,027.29 | 25.46 | 0.469 |
District hospital | 1274 | 265 | 10,196.84 | 25.99 | 0.678 |
Community clinic | 1892 | 209 | 14,612.03 | 14.30 | <0.001 |
Non-P4P | P4P | ||||||||
---|---|---|---|---|---|---|---|---|---|
Variable | Total | Death (N) | Total Person-Years | Incidence/ 1000 Person-Years | Total | Death (N) | Total Person-Years | Incidence/ 1000 Person-Years | p-Value # |
Total | 4408 | 934 | 32,503.77 | 28.74 | 1946 | 228 | 18,729.79 | 12.17 | <0.001 |
BMI | |||||||||
BMI < 18.5 | 108 | 52 | 696.91 | 74.62 | 25 | 8 | 285.92 | 27.98 | 0.010 |
18.5 ≤ BMI < 24 | 1483 | 411 | 11,189.29 | 36.73 | 581 | 101 | 5901.45 | 17.11 | <0.001 |
24 ≤ BMI < 27 | 1421 | 252 | 10,435.89 | 24.15 | 643 | 67 | 6174.80 | 10.85 | <0.001 |
27 ≤ BMI < 30 | 834 | 126 | 6148.21 | 20.49 | 406 | 33 | 3799.30 | 8.69 | <0.001 |
BMI ≥ 30 | 562 | 93 | 4033.47 | 23.06 | 291 | 19 | 2568.32 | 7.40 | <0.001 |
Sex | |||||||||
Male | 2331 | 556 | 16,693.68 | 33.31 | 997 | 130 | 9246.44 | 14.06 | <0.001 |
Female | 2077 | 378 | 15,810.08 | 23.91 | 949 | 98 | 9483.35 | 10.33 | <0.001 |
Age | |||||||||
20–44 | 684 | 57 | 5385.08 | 10.58 | 336 | 12 | 3045.67 | 3.94 | 0.002 |
45–54 | 1043 | 111 | 8048.34 | 13.79 | 576 | 33 | 5654.76 | 5.84 | <0.001 |
55–64 | 1163 | 155 | 8901.86 | 17.41 | 597 | 75 | 5915.26 | 12.68 | 0.024 |
65–74 | 901 | 286 | 6646.42 | 43.03 | 327 | 76 | 3260.07 | 23.31 | <0.001 |
≥75 | 617 | 325 | 3522.07 | 92.28 | 110 | 32 | 854.04 | 37.47 | <0.001 |
CCI | |||||||||
0 | 2425 | 317 | 18,291.86 | 17.33 | 1125 | 89 | 10,634.45 | 8.37 | <0.001 |
1 | 969 | 219 | 7157.38 | 30.60 | 385 | 47 | 3721.41 | 12.63 | <0.001 |
2 | 552 | 153 | 4150.19 | 36.87 | 267 | 47 | 2683.95 | 17.51 | <0.001 |
≥3 | 462 | 245 | 2904.34 | 84.36 | 169 | 45 | 1689.98 | 26.63 | <0.001 |
DCSI | |||||||||
0 | 3458 | 600 | 25,386.28 | 23.63 | 1484 | 160 | 14,182.85 | 11.28 | <0.001 |
1 | 420 | 100 | 3513.65 | 28.46 | 286 | 35 | 2882.86 | 12.14 | <0.001 |
2 | 409 | 168 | 2772.19 | 60.60 | 138 | 23 | 1257.64 | 18.29 | <0.001 |
≥3 | 121 | 66 | 831.65 | 79.36 | 38 | 10 | 406.44 | 24.60 | 0.001 |
Weekly Energy Expenditure in Exercise | |||||||||
No exercise | 2123 | 519 | 14,926.12 | 34.77 | 874 | 96 | 7925.88 | 12.11 | <0.001 |
<500 kcal | 819 | 152 | 6212.30 | 24.47 | 374 | 47 | 3745.92 | 12.55 | <0.001 |
≥500 kcal | 1459 | 261 | 11,320.28 | 23.06 | 697 | 85 | 7056.22 | 12.05 | <0.001 |
missing | 7 | 1 |
Variable | Unadjusted Model | Adjusted Model | ||||||
---|---|---|---|---|---|---|---|---|
HR | 95% CI | p-Value | HR | 95% CI | p-Value | |||
BMI | ||||||||
BMI < 18.5 | 2.12 | 1.62 | 2.77 | <0.001 | 1.86 | 1.37 | 2.53 | <0.001 |
18.5 ≤ BMI < 24 | 1.00 | - | - | - | 1.00 | - | - | - |
24 ≤ BMI < 27 | 0.66 | 0.57 | 0.76 | <0.001 | 0.83 | 0.71 | 0.97 | 0.023 |
27 ≤ BMI < 30 | 0.54 | 0.46 | 0.65 | <0.001 | 0.83 | 0.68 | 1.02 | 0.070 |
BMI ≥ 30 | 0.59 | 0.48 | 0.73 | <0.001 | 0.95 | 0.75 | 1.20 | 0.668 |
P4P | ||||||||
No | 1.00 | - | - | - | 1.00 | - | - | - |
Yes | 0.39 | 0.34 | 0.45 | <0.001 | 0.55 | 0.44 | 0.69 | <0.001 |
P4P*BMI | ||||||||
P4P*(BMI < 18.5) | 0.86 | 0.41 | 1.82 | 0.699 | ||||
P4P*(18.5 ≤ BMI < 24) | 1.00 | - | - | - | ||||
P4P*(24 ≤ BMI < 27) | 0.39 | 0.30 | 0.49 | <0.001 | ||||
P4P*(27 ≤ BMI < 30) | 0.30 | 0.21 | 0.43 | <0.001 | ||||
P4P*(BMI ≥ 30) | 0.27 | 0.17 | 0.43 | <0.001 | ||||
Sex | ||||||||
Male | 1.00 | - | - | - | 1.00 | - | - | - |
Female | 0.69 | 0.62 | 0.78 | <0.001 | 0.67 | 0.57 | 0.78 | <0.001 |
Age | ||||||||
20–44 | 1.00 | - | - | - | 1.00 | - | - | - |
45–54 | 1.26 | 0.95 | 1.68 | 0.110 | 1.32 | 0.98 | 1.78 | 0.067 |
55–64 | 1.84 | 1.40 | 2.40 | <0.001 | 1.71 | 1.28 | 2.29 | <0.001 |
65–74 | 4.41 | 3.41 | 5.71 | <0.001 | 3.30 | 2.48 | 4.38 | <0.001 |
≥75 | 11.01 | 8.50 | 14.26 | <0.001 | 6.32 | 4.72 | 8.45 | <0.001 |
CCI | ||||||||
0 | 1.00 | - | - | - | 1.00 | - | - | - |
1 | 1.74 | 1.49 | 2.03 | <0.001 | 1.33 | 1.13 | 1.56 | <0.001 |
2 | 2.02 | 1.71 | 2.40 | <0.001 | 1.52 | 1.27 | 1.82 | <0.001 |
≥3 | 4.43 | 3.81 | 5.16 | <0.001 | 2.43 | 2.04 | 2.88 | <0.001 |
DCSI | ||||||||
0 | 1.00 | - | - | - | 1.00 | - | - | - |
1 | 1.05 | 0.87 | 1.26 | 0.637 | 0.84 | 0.69 | 1.01 | 0.065 |
2 | 2.48 | 2.12 | 2.91 | <0.001 | 1.21 | 1.02 | 1.44 | 0.031 |
≥3 | 3.07 | 2.43 | 3.89 | <0.001 | 1.20 | 0.93 | 1.55 | 0.167 |
Weekly Energy Expenditure in Exercise | ||||||||
No exercise | 1.00 | - | - | - | 1.00 | - | - | - |
<500 kcal | 0.72 | 0.61 | 0.84 | <0.001 | 0.85 | 0.73 | 1.01 | 0.059 |
≥500 kcal | 0.68 | 0.60 | 0.78 | <0.001 | 0.82 | 0.72 | 0.95 | 0.006 |
Non-P4P | P4P | Adj. HR | 95% CI | p-Value | ||||||
---|---|---|---|---|---|---|---|---|---|---|
N | Death | N | Death | (P4P vs. Non-P4P) | ||||||
Variable | n | % | n | % | ||||||
Total | 4408 | 934 | 21.19 | 1946 | 228 | 11.72 | ||||
BMI | ||||||||||
BMI < 18.5 | 108 | 52 | 48.15 | 25 | 8 | 32.00 | 0.11 | 0.04 | 0.38 | <0.001 |
18.5 ≤ BMI < 24 | 1483 | 411 | 27.71 | 581 | 101 | 17.38 | 0.54 | 0.43 | 0.68 | <0.001 |
24 ≤ BMI < 27 | 1421 | 252 | 17.73 | 643 | 67 | 10.42 | 0.49 | 0.37 | 0.66 | <0.001 |
27 ≤ BMI < 30 | 834 | 126 | 15.11 | 406 | 33 | 8.13 | 0.38 | 0.25 | 0.58 | <0.001 |
BMI ≥ 30 | 562 | 93 | 16.55 | 291 | 19 | 6.53 | 0.30 | 0.17 | 0.52 | <0.001 |
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Huang, H.-L.; Kung, C.-Y.; Wang, S.-M.; Kung, P.-T.; Lin, Y.-H.; Chiu, L.-T.; Tsai, W.-C. Effects of Body Mass Index and Pay-for-Performance Program on Risk of Death in Patients with Type 2 Diabetes: A Nationwide Cohort Study. Int. J. Environ. Res. Public Health 2021, 18, 4648. https://doi.org/10.3390/ijerph18094648
Huang H-L, Kung C-Y, Wang S-M, Kung P-T, Lin Y-H, Chiu L-T, Tsai W-C. Effects of Body Mass Index and Pay-for-Performance Program on Risk of Death in Patients with Type 2 Diabetes: A Nationwide Cohort Study. International Journal of Environmental Research and Public Health. 2021; 18(9):4648. https://doi.org/10.3390/ijerph18094648
Chicago/Turabian StyleHuang, Hsiu-Ling, Chuan-Yu Kung, Shun-Mu Wang, Pei-Tseng Kung, Yen-Hsiung Lin, Li-Ting Chiu, and Wen-Chen Tsai. 2021. "Effects of Body Mass Index and Pay-for-Performance Program on Risk of Death in Patients with Type 2 Diabetes: A Nationwide Cohort Study" International Journal of Environmental Research and Public Health 18, no. 9: 4648. https://doi.org/10.3390/ijerph18094648