Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care: A Randomized Trial | Guidelines | JAMA | JAMA Network
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Original Investigation
September 11, 2013

Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care: A Randomized Trial

Author Affiliations
  • 1Health Policy and Quality Program, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Excellence, Houston, Texas
  • 2Section for Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
  • 3American Heart Association, Southwest Affiliate, Houston, Texas
  • 4University of Washington, Department of Health Services, Seattle
  • 5Philip R. Lee Institute for Health Policy Studies and Department of Medicine, University of California, San Francisco
JAMA. 2013;310(10):1042-1050. doi:10.1001/jama.2013.276303
Abstract

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

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