Yu-Ching Chen; Wei-Ming Wang; Boniface J. Lin; Jung-Der Wang; Li-Jung Elizabeth Ku

doi:10.4093/dmj.2025.0943

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Response Early Enrollment in Diabetes Pay-for-Performance Program Reduced Loss of Life Expectancy in Newly-Diagnosed Patients with Type 2 Diabetes Mellitus (Diabetes Metab J 2025;49:1051-63): Yu-Ching Chen^1,2, Wei-Ming Wang³, Boniface J. Lin^4,5, Jung-Der Wang^1,6, Li-Jung Elizabeth Ku¹; Diabetes & Metabolism Journal 2026;50(1):205-207.
DOI: https://doi.org/10.4093/dmj.2025.0943
Published online: January 1, 2026

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¹Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan

²Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan

³Department of Statistics and Information Science, Fu Jen Catholic University, New Taipei City, Taiwan

⁴College of Medicine, Fu Jen Catholic University, New Taipei, Taiwan

⁵College of Medicine, National Taiwan University, Taipei, Taiwan

⁶Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

Corresponding authors: Li-Jung Elizabeth Ku

Department of Public Health, College of Medicine, National Cheng Kung University, No. 1, University Road, Tainan 701, Taiwan E-mail: eljku@mail.ncku.edu.tw

Jung-Der Wang

Department of Public Health, College of Medicine, National Cheng Kung University, No. 1, University Road, Tainan 701, Taiwan E-mail: jdwang121@gmail.com

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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See the letter "Early Enrollment in Diabetes Pay-for-Performance Program Reduced Loss of Life Expectancy in Newly-Diagnosed Patients with Type 2 Diabetes Mellitus (Diabetes Metab J 2025;49:1051-63)" on page 192.

We appreciate the thoughtful and insightful comments by Professor Qazi on our recently published article, “Early enrollment in diabetes pay-for-performance program reduced loss of life expectancy in newly-diagnosed patients with type 2 diabetes mellitus” [1]. We also would like to thank the editor for the opportunity to discuss our article further on the potential confounding of selection bias, monthly income, education attainment, urbanization, healthcare provider, competing risks, glucagon like peptide-1 (GLP-1) agonists and sodium-glucose cotransporter 2 (SGLT-2) inhibitors on mortality.

Diabetes mellitus has been the sole criterion for enrollment in Taiwan’s pay-for-performance (P4P) program since its implementation in 2001. With an average follow-up duration of 7.64 years from 2002 to 2017, Liao et al. [2] conducted a mortality study for Taiwan’s P4P group of 1,307,963 newly-diagnosed diabetes patients. Using income ≤US $555 per month as the reference, the adjusted hazard ratio (HR) was 0.86 (95% confidence interval [CI], 0.86 to 0.87) for $556–732; HR, 0.81 (95% CI, 0.80 to 0.82) for $733–925; HR, 0.78 (95% CI, 0.77 to 0.80) for $926–1,165; HR, 0.73 (95% CI, 0.72 to 0.74) for $1,166–1,470; and HR, 0.74 (95% CI, 0.73 to 0.75) for ≥US $1,471 [2]. When elementary-educated or illiterate (n=667,419, 51.03%) served as the reference, the adjusted HR of mortality was 0.81 (95% CI, 0.80 to 0.82) for junior high, 0.67 (95% CI, 0.66 to 0.68) for senior high, and 0.53 (95% CI, 0.52 to 0.54) for college or above [2]. They explored the interaction between P4P and education attainment, expressed as P4P×education attainment, and found that with P4P×elementary-educated or illiterate as the reference, the adjusted HR was 0.97 (95% CI, 0.95 to 0.99) for P4P×junior high, 0.97 (95% CI, 0.94 to 0.99) for P4P×senior high, and 0.97 (95% CI, 0.92 to 1.01) for P4P×college or above. It suggested that P4P program enhanced health literacy [3], improved medication adherence [4], and attenuated the impact of educational attainment.

In fact, professor Boniface J. Lin—now 95 years old—founded the Taiwanese Association of Diabetes Educators (TADE) in March 1996 and has made enduring contributions to diabetes care in Taiwan. At the inception of the P4P program in 2001, he already recognized the obstacles posed by limited health literacy and the potential for selection bias. Earlier, in August 1996, he persuaded his colleagues and officials of the National Health Insurance (NHI) administration to launch a pilot study of a modified Diabetes Shared Care Network designed to provide multidisciplinary, patient-centered diabetes care. Today, TADE includes 11,604 members, among them physicians, nurses, nutritionists, pharmacists, rehabilitation therapists, and social workers. This professional workforce has been instrumental in addressing challenges related to health literacy and selection bias, which may explain why analyses have shown no significant interaction between educational attainment and participation in the P4P program. Furthermore, in the 2010 National Census of Taiwan [5], 18.07% of the 40- to 64-year-old cohort were elementary-educated or illiterate, compared with 51.03% in the study by Liao et al. [2], effectively demonstrating that selection bias in favor of the P4P group seemed unlikely.

When the degrees of urbanization of the residential region were classified into seven levels of urbanization with level 1 referred to the highest degrees of urbanization, Liao et al. [2] also found the adjusted HR of mortality was 1.07 (95% CI, 1.05 to 1.08) for level 2; HR, 1.11 (95% CI, 1.09 to 1.12) for level 3; HR, 1.18 (95% CI, 1.17 to 1.20) for level 4; HR, 1.20 (95% CI, 1.18 to 1.22) for level 5; HR, 1.23 (95% CI, 1.21 to 1.25) for level 6; and HR, 1.27 (95% CI, 1.25 to 1.29) for level 7. However, there is no consistent trend of reduced mortality across four levels of healthcare facilities.

Another study applied competing risk regression models to analyze the effects of P4P on risks of the following outcomes over 5 years and showed a significant contribution of P4P program on mortality: P4P patients (n=9,329) had lower risks of adjusted subdistribution HR (aSHR) 0.58 (95% CI, 0.55 to 0.63) for all-cause mortality; aSHR, 0.54 (95% CI, 0.49 to 0.60) for diabetes-related mortality; and aSHR, 0.85 (95% CI, 0.73 to 1.00) for cancer-specific mortality than non-P4P patients (n=9,329) [6]. Evidence for cancer-specific mortality reduction seemed less robust, indicating the need for further research with larger samples and longer follow-up.

In Table 3 of our study, the subgroup of individuals with an interval of 5 to 9 years before enrollment in P4P program had similar distributions of baseline comorbidities to the non-P4P group. The loss of life expectancy was 2.60 years for the non-P4P group and 10.01 years for the subgroup with an interval of 5 to 9 years, respectively. Patients with 5 to 9 years’ diabetes duration entered the P4P program with established comorbidities, leading to a greater loss of life expectancy. Furthermore, as shown in Supplementary Table 5, the loss of life expectancy was 2.60±0.14 years for the non-P4P group and 3.55±0.25 years for the entire P4P group (P<0.001). It seemed that delayed enrollment and neglected care in this subgroup increased mortality.

Among GLP-1 agonists, the adjusted HR of all-cause mortality was 0.86, 0.85, and 0.80 for exenatide, liraglutide, and semaglutide, respectively [7]. The reimbursement in Taiwan NHI began in May 2011 for exenatide, in October 2012 for liraglutide, and in July 2018 for semaglutide. However, NHI stipulated that their prescriptions were reimbursed under the following restrictions: (1) no combination with DPP-4 inhibitors or SGLT-2 inhibitors [8]; (2) after maximum tolerated dose of metformin and/or a sulfonylurea, and in combination with one of the following agents for at least 6 months, patients still showed glycosylated hemoglobin >8.5%: SGLT-2 inhibitors, DPP-4 inhibitors, fixed-dose combination of SGLT-2 inhibitors and DPP-4 inhibitors or insulin. Reimbursement for SGLT2 inhibitors began in May 2016. As our study cohort was enrolled from 2001 to 2015 and followed until the end of 2018, the potential confounding by the use of these two classes of medications could be low. However, we agree that future studies exploring the interaction between GLP-1 agonists, SGLT-2 inhibitors, and the P4P program are warranted to clarify their impact on all-cause mortality.

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CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

REFERENCES

1. Chen YC, Wang WM, Lin BJ, Wang JD, Ku LE. Early enrollment in diabetes pay-for-performance program reduced loss of life expectancy in newly-diagnosed patients with type 2 diabetes mellitus. Diabetes Metab J 2025;49:1051-63.Article PubMed PMC PDF
2. Liao YS, Tsai WC, Chiu LT, Kung PT. Educational attainment affects the diagnostic time in type 2 diabetes mellitus and the mortality risk of those enrolled in the diabetes pay-for-performance program. Health Policy 2023;138:104917.Article PubMed
3. Yeh JZ, Wei CJ, Weng SF, Tsai CY, Shih JH, Shih CL, et al. Disease-specific health literacy, disease knowledge, and adherence behavior among patients with type 2 diabetes in Taiwan. BMC Public Health 2018;18:1062.Article PubMed PMC PDF
4. Sheu SJ, Lin WL, Kao Yang YH, Hwu CM, Cheng CL. Pay for performance program reduces treatment needed diabetic retinopathy: a nationwide matched cohort study in Taiwan. BMC Health Serv Res 2018;18:638.Article PubMed PMC PDF
5. Civil Affairs Statistical Yearbook of Interior. 202: Population of 15 years and over by educational attainment Available from: https://ws.moi.gov.tw/001/Upload/OldFile/site_stuff/321/2/year/year_en.html(cited 2025 Nov 8).
6. Hsieh HM, He JS, Shin SJ, Chiu HC, Lee CT. A diabetes pay-for-performance program and risks of cancer incidence and death in patients with type 2 diabetes in Taiwan. Prev Chronic Dis 2017;14:E88.Article PubMed PMC
7. Badve SV, Bilal A, Lee MMY, Sattar N, Gerstein HC, Ruff CT, et al. Effects of GLP-1 receptor agonists on kidney and cardiovascular disease outcomes: a meta-analysis of randomised controlled trials. Lancet Diabetes Endocrinol 2025;13:15-28.Article PubMed
8. Wu JH, Foote C, Blomster J, Toyama T, Perkovic V, Sundstrom J, et al. Effects of sodium-glucose cotransporter-2 inhibitors on cardiovascular events, death, and major safety outcomes in adults with type 2 diabetes: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2016;4:411-9.Article PubMed

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Early Enrollment in Diabetes Pay-for-Performance Program Reduced Loss of Life Expectancy in Newly-Diagnosed Patients with Type 2 Diabetes Mellitus (Diabetes Metab J 2025;49:1051-63)

Diabetes Metab J. 2026;50(1):205-207. Published online January 1, 2026

DOI: https://doi.org/10.4093/dmj.2025.0943

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Early Enrollment in Diabetes Pay-for-Performance Program Reduced Loss of Life Expectancy in Newly-Diagnosed Patients with Type 2 Diabetes Mellitus (Diabetes Metab J 2025;49:1051-63)

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Chen YC, Wang WM, Lin BJ, Wang JD, Ku LJE. Early Enrollment in Diabetes Pay-for-Performance Program Reduced Loss of Life Expectancy in Newly-Diagnosed Patients with Type 2 Diabetes Mellitus (Diabetes Metab J 2025;49:1051-63). Diabetes Metab J. 2026;50(1):205-207.

DOI: https://doi.org/10.4093/dmj.2025.0943.

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