Performance Evaluation of the Pay-for-Performance Program and Directly Observerd Treatment, Short-course for Tuberculosis Control

Background: Taiwan Centers for Disease Control (CDC) and Bureau of National Health Insurance (BNHI) implemented the tuberculosis (TB) pay-for-performance (P4P) program in 2001 to improve health care qualities and case management, and which program was broadly adopted in 2004. A nationwide campaign “Directly Observed Treatment, Short-course” (DOTS) was then introduced in 2006. Objectives: The objective of the study was to evaluate the efficacy of TB P4P program, and to explore treatment outcomes and health care utilizations. The other purpose was cost-effectiveness analysis of P4P and DOTS programs. Methods: This study recruited 15,557 TB cases who were reported to the Taiwan CDC in 2004, and then linked with health care utilization claimed data from BNHI. To improve the comparability of the two groups, we used Propensity Score Matching to compare the performance between cases with and without P4P program, and also used multinomial logistic regression model to investigate the efficacy of P4P. In the other part of the study, the study recruited 10,766 cases diagnosed in 2006-2007 and eligible for DOTS stage I (sputum smear positive cases). Data linking to BNHI was to analyze the medical utilization (direct costs). To explore social productivity loss of patients and family members, we used data from Directorate-General of Budget, Accounting and Statistics survey of human resources database to explore the indirect costs, and the study represented societal perspective costs. Results: The results showed that no significant difference in case characteristics between two groups with and without P4P program. The study revealed that P4P group had a higher Outpatient Department (OPD) utilization rate of 14% (P<0.001), but no significance in hospital admission or emergency utilization. Total medical costs in P4P group were 4.6% lower (NTD. 6,450; USD. $215) than non-P4P group. Odds Ratio of treatment success was 1.56 times higher than non-P4P group. (OR: 1.38-1.76, P<0.001). Death rate in the P4P group was 3.9% lower than non-P4P group. Comparing group with P4P and DOTS, group with P4P only, group with DOTS only, and group without P4P or DOTS, P4P and DOTS group had inferior medical conditions, but had the highest treatment success rate (83.1%), group without P4P or DOTS had the lowest treatment success rates of 24.2%. Regarding to the direct costs, average cost of group without P4P or DOTS were the lowest (NTD. 66,707; USD. $2223.6), while of P4P and DOTS group were the highest (NTD. 93,331; USD. $3111.0). As for societal perspective costs, including loss of social productivity of patients and family member companions, group without P4P or DOTS had the lowest average costs of NTD. 83,767 (USD. $2,792.3), whereas P4P and DOTS group had the highest of NTD. 109,266 (USD. $3,642.2). As for Average Cost-effectiveness Ratio (ACER), P4P group was NT121,335 (USD. $4,044.5), DOTS group as NT171,226 (USD. $5,707.5), P4P and DOTS group as NT131,530 (USD. $4,384.3), and conventional TB treatment was NT346,187 (USD. $11,539.6) . Overall, P4P group had the lowest expenditures of per treatment success case. Comparing with multiple programs, we adopted Incremental Cost-Effectiveness Ratio (ICER), the P4P was the most cost-effective program. According to WHO-CHOICE (CHOosing Interventions that are Cost-Effective), adopting ACER to evaluate programs, P4P and DOTS programs were all highly cost-effective interventions. Conclusion: The TB P4P program can improve health care outcomes, and save the health care expenditure. Secondly, patients enrolled both in P4P and DOTS programs, had the best treatment outcomes. Considering direct and indirect costs in societal perspective, P4P program costs the lowest with average. P4P and DOTS programs are both highly cost-effective intervention programs according to the World Health Organization standard (WHO-CHOICE, CHOosing Interventions that are Cost-Effective).