Pay-for-performance programme for early CKD: impact on survival and costs in Taiwan

Background

Chronic kidney disease (CKD) is a growing non-communicable disease burden globally and a major public health challenge in Taiwan, which has one of the highest prevalences of dialysis. A national pay-for-performance (P4P) multidisciplinary care (MDC) programme was implemented for early-stage CKD (stages 1-3A). This study evaluates the impact on survival and healthcare costs.

Methods

Using Taiwan’s National Health Insurance claims linked to death registry data, adults diagnosed with stages 1-3A CKD in 2017 were followed until 2022. P4P MDC participants were matched 1:1 to non-participants by age, sex, Charlson comorbidity index score, diabetes, hypertension, and propensity score. Five-year cumulative CKD-related medical costs (US$) and life-years (LYs) gained were measured. Generalized linear regressions with bootstrapping were used to calculate the incremental cost-effectiveness ratio (ICER). A composite renal endpoint (progression to advanced CKD, dialysis, or acute kidney injury) was analyzed using Fine and Gray’s subdistribution hazard models with death as competing risk.

Results

Among 303,024 matched pairs (mean age 66.4 years; 53.8% female; 62.6% with diabetes), the P4P group had a lower risk of composite renal endpoint than non-participants (adjusted subdistribution hazard ratio 0.557, 95% CI 0.549-0.565). The P4P group had lower adjusted CKD-related inpatient costs (−US$203, 95% CI − 212 to − 196) and outpatient costs (−US$20, 95% CI − 21 to − 19). The adjusted ICER was −US$976 per LY gained for inpatient costs (95% CI − 1,019 to − 931) and −US$95 per LY gained for outpatient costs (95% CI − 99 to − 89), indicating programme dominance.

Conclusions

The early CKD P4P programme is a cost-effective public health intervention, offering a scalable model for managing the CKD epidemic. These findings support expansion of multidisciplinary P4P frameworks in chronic disease policies.

Key messages

• A nationwide P4P multidisciplinary care programme for early CKD reduced disease progression and was cost-saving over five years.

• Investment in early-stage CKD MDC care offers a scalable model for chronic disease policies in universal health systems.