Importance
Pay for performance is intended to align incentives to promote high-quality care, but results
have been contradictory.
Objective
To test the effect of explicit financial incentives to reward guideline-recommended hypertension
care.
Design, Setting, and Participants
Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and
a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg,
nurses, pharmacists).
Interventions
Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention
participants received up to 5 payments every 4 months; all participants could access feedback
reports.
Main Outcomes and Measures
Among a random sample, number of patients achieving guideline-recommended blood pressure
thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients
prescribed guideline-recommended medications, and number who developed hypotension.
Results
Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the
combined, individual, and practice-level interventions, respectively. The unadjusted baseline and
final percentages and the adjusted absolute change over the study in patients meeting the combined
blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for
the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group,
79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95%
CI, −3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the
change between the proportion of patients with blood pressure control/appropriate response for
individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other
incentive groups did not show a significant change compared with controls for this outcome. For
medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61%
to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to
80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, −0.28% to 9.28%),
respectively. These changes in the use of guideline-recommended medications were not significant in
any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect
of the incentive was not sustained after a washout.
Conclusions and Relevance
Individual financial incentives, but not practice-level or combined incentives, resulted in
greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the
incentives resulted in greater use of guideline-recommended medications or increased incidence of
hypotension compared with controls. Further research is needed on the factors that contributed to
these findings.
Trial Registration
clinicaltrials.gov Identifier: NCT00302718