Provider participation, patient enrollment and attrition in a national diabetes disease management program in Taiwan: Determinants and policy implications

There has been rapid application of diabetes disease management to many different health care systems in the past few years. To address the issue of low provider and patient participation in the national diabetes disease management (DDM) program in Taiwan, we conducted three studies for this dissertation.; The first study presents a systemic review of the current application of DDM programs in various health care systems and factors related to provider and patient participation. Evidence showed that diabetes disease management programs, if well implemented, improved care processes and patient short-term outcomes in adult diabetic patients in managed care organizations and community clinics in the US and Europe. The scale of DDM programs varied greatly among health plans and countries. Most studies did not report percentages of provider participation and patient participation. Methodological issues are discussed and areas of future research have been identified.; The second study is a cross-sectional survey of physicians to explore the relationship between physician perceptions of program incentives and their participation in the DDM program in Taiwan. Results showed that many physicians were unclear about the DDM program. Physician participation was significantly related to practice setting. Multivariate analyses revealed that the effects of various dimensions of perception of program incentives depend on the stages (adoption, implementation, and maintenance) of physician participation. Physicians older than 45 years were more likely to participate with increases in the scores of favorable perceptions of program incentives as compared to younger physicians. There was significant interaction between perception of financial incentives and perception of professional incentives on physician participation.; The third study represents a retrospective observational study of patient participation using administrative databases of the National Health Insurance program in Taiwan. Patients older than 65 years were less likely to be enrolled than younger patients (7% vs. 10%). 16% of diabetic patients in the middle region (served by the Middle branch of the Bureau of National Health Insurance) were enrolled in the DDM program while enrollment rates in other regions were 8% or less. Patients seeking diabetes care mostly at physician offices and medical centers were less likely to get access to the DDM program than those in district and regional hospitals (6% vs. 12%). Multivariate analyses revealed that high risk patients such as the elderly with insulin use and those with unstable comorbidities (e.g. ischemic heart disease, congestive heart failure) were more likely to participate in the program. Adverse dropout among program enrollees was significant. The sets of predictive factors related to early attrition and late attrition of enrolled patients were different.; In conclusion, there is an urgent need to design and implement effective participation interventions targeted at organization and individual levels, especially to address the issues of low provider and patient participation in the national diabetes disease management program in Taiwan. We propose eight policy recommendations to policy makers and program managers to enhance the public health impact of the program.