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Objectives: This study examined the relationship between claims-based and patient-reported continuity of care (COC) measures and investigated the effects of the 2 types of COC measures on subjective and objective health care outcomes., Study Design: A prospective, cross-sectional, correlational survey design was used. A nationwide face-to-face interview survey of community-dwelling older adults was conducted, and the survey participants' health claims records were retrieved and linked under the universal health insurance system of Taiwan in 2018., Methods: Health care outcomes were measured subjectively (patient satisfaction and perceived lack of coordination) and objectively (likelihood of hospital admissions and emergency department [ED] visits). COC was measured using claims-based and multidimensional patient-reported COC. Ordered logit and logit models were used to examine the relationship between the 2 types of COC measures, and health care outcomes were measured subjectively and objectively. Average marginal effects with bootstrapped SEs were computed for health care outcomes., Results: This study demonstrated that the correlations of claims-based and patient-reported COC measures were quite low and mainly insignificant. A higher claims-based COC was significantly associated with a lower likelihood of hospital admissions, ED visits, and perceived lack of coordination. No significant relationship was identified between claims-based COC and patient satisfaction. Participants reporting higher COC had better patient satisfaction and less perceived lack of coordination. However, no relationship was identified between patient-reported COC and the likelihood of hospital admissions and ED visits., Conclusions: The correlation between claims-based and patient-reported COC measures is low, and claims-based and patient-reported COC measures are associated with different subjective and objective health care outcomes. We suggest that claims-based COC indicators representing the pattern of physician visits might be considered a unique dimension of COC.

Objectives: To examine the association between service volume and guideline adherence via multiyear observations., Study Design: Repeated cross-sectional study., Methods: This study employed nationwide claims data from Taiwan's National Health Insurance scheme and identified patients with newly diagnosed type 2 diabetes from 2001, 2005, and 2009; a new prescription guideline for diabetes care was introduced in 2006. Physician service volume was measured by the number of total outpatients with diabetes. The outcome variable indicated whether a patient was receiving metformin, the guideline-recommended antihyperglycemic agent, at the index date., Results: Patients visiting physicians who had high or medium volumes of patients with diabetes were more likely to receive metformin than patients visiting physicians who had low volumes; the odds ratios (ORs) were 2.48 (95% CI, 2.03-3.04) and 1.76 (95% CI, 1.45-2.13), respectively. Patients with newly diagnosed diabetes in 2009 and 2005 were more likely to receive metformin than their counterparts in 2001, with ORs of 12.00 (95% CI, 11.19-12.86) and 2.44 (95% CI, 2.30-2.59), respectively. We also found that patients who visited younger physicians, physicians with fewer practice years, physicians practicing in large-scale hospitals, or physicians practicing in urban areas were more likely to receive metformin than their counterparts., Conclusions: In the process of implementing a new practice guideline for treating patients with diabetes, physicians with higher patient volumes are more likely to adhere to the guideline recommendation.

Objectives: Recent studies have revealed significant variation in medication adherence among patients with chronic conditions. Little is known about the effect of continuity of care (COC) on changes in medication adherence. This study aims to identify medication adherence trajectories among patients with newly diagnosed diabetes, as well as to examine the association of COC and medication adherence among various adherence trajectories., Methods: This study utilized a longitudinal design with a 6-year follow-up, from 2002 to 2008, under a universal health insurance program in Taiwan. Subjects 18 years or older with type 2 diabetes that was newly diagnosed in 2002 were included in the study. The main outcome was medication adherence measured by medication possession ratio each year. Group-based trajectory models were used for analysis., Results: Four medication adherence trajectories were identified: persistent adherence (39.9%), increasing adherence (27.5%), decreasing adherence (12.0%), and nonadherence (20.6%). Patients with high or medium COC index scores were more likely to be adherent to medications than those with low COC index scores in all of the trajectory adherence groups., Conclusions: This study demonstrated the heterogeneity in patients' medication adherence and identified 4 distinct trajectories of medication adherences among those with newly diagnosed type 2 diabetes. Improving COC may lead to better medication adherence in all of the adherence trajectory groups.

Objectives: To examine the relationship between medication adherence and healthcare outcomes and expenses and to investigate whether the duration of type 2 diabetes mellitus (T2DM) has a role in the aforementioned relationship., Data Source/study Setting: Health insurance claims data under a universal coverage system in Taiwan., Study Design: Seven years of longitudinal analysis was performed to examine the association between medication adherence of oral antihyperglycemic drugs and outcomes among patients with newly diagnosed T2DM. Generalized estimating equations were conducted to assess the temporal relationship while controlling for unobserved characteristics of patients., Results: Better medication adherence was associated with decreased hospitalization and emergency department (ED) visits for diabetes or related conditions. The results also revealed that medication adherence was negatively associated with the expenses of hospitalization and ED visits for diabetes or related conditions, but medication adherence was positively associated with patients' total healthcare expenses. However, the adherence-related differences in total healthcare expenses began to decrease 5 years after the time of diabetes onset., Conclusions: Adherence to medication can improve healthcare outcomes but is associated with higher total healthcare expenses, especially during the years immediately following the onset of diabetes. Long-term follow-up is needed for further investigation.

Objective: To examine the effects of continuity of care on healthcare utilization and expenses for patients with diabetes mellitus., Study Design: Longitudinal study based on claims data., Methods: Data on healthcare utilization and expenses from a 7-year period (2000-2006) were gathered from claims data of the Taiwanese universal health insurance system. The continuity of care index (COCI) was analyzed, and the values were classified into 3 levels. Outcome variables included the likelihood of hospitalization and emergency department visit, pharmaceutical expenses for diabetes-related conditions, and total healthcare expenses for diabetes-related conditions. A generalized estimating equation that considered the effects of repeated measures for the same patients was applied to examine the effects of continuity of care on healthcare utilization and expenses., Results: Compared with patients who had low COCI scores, patients with high or medium COCI scores were less likely to be hospitalized for diabetes related conditions (odds ratio [OR] 0.26, 95% confidence interval [CI] 0.25, 0.27, and OR 0.58, 95% CI 0.56, 0.59, respectively) or to have diabetes-related emergency department visits (OR 0.34, 95% CI 0.33, 0.36, and OR 0.64, 95% CI 0.62, 0.66, respectively). Patients with low COCI scores incurred $126 more in pharmaceutical expenses than patients with high COCI scores. Furthermore, patients with high COCI scores had greater savings ($737) in total healthcare expenses for diabetes-related conditions than patients with low COCI scores., Conclusion: Better continuity of care was associated with less healthcare utilization and lower healthcare expenses for diabetic patients. Improving continuity of care might benefit diabetic patients.

Objective: To examine the effects of a pay-for-performance (P4P) program for diabetes care in Taiwan., Study Design: A population-based natural experimental design with intervention and comparison groups., Methods: Healthcare service and expense data were extracted from the Taiwanese Bureau of National Health Insurance claim files for 2005 and 2006. The number of essential diabetes-specific exams/tests, healthcare utilization, and pre- and post-intervention expenses were calculated for patients grouped according to P4P status. However, no clinical information was available for analysis. Difference-in-difference analysis was used in statistical regression models with proper distributions for these measures., Results: Patients in the P4P program (n = 12,499) received significantly more diabetes-specific exams and tests after enrollment (3.8 vs 6.4, P <.001) than patients not enrolled in the program (3.5 vs 3.6, P <.001). Patients in the intervention group had an average of 2 more physician visits for diabetes than those in the comparison group (P <.001). Conversely, the intervention group had fewer diabetes-related hospitalizations (-0.027, P = .003). Patients in the intervention group incurred higher expenses due to physician visits but lower expenses due to inpatient services, with a net increase of $104 per person per year (P <.001)., Conclusions: This P4P program for diabetes was associated with a significant increase in regular follow-up visits and evidence-based services, and significantly lower hospitalization costs. The overall cost of care for those in the P4P program was significantly higher, although the total incremental expense was quite small.