A Randomized Trial of a Pay-for-Performance Program Targeting Clinician Referral to a State Tobacco Quitline | Lifestyle Behaviors | JAMA Internal Medicine | JAMA Network
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Centers for Disease Control and Prevention, Annual smoking-attributable mortality, years of potential life lost, and productivity losses: United States, 1997-2001.  MMWR Morb Mortal Wkly Rep 2005;54 (25) 625- 628PubMedGoogle Scholar
Cromwell  JBartosch  WJFiore  MCHasselblad  VBaker  TAgency for Health Care Policy and Research, Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation.  JAMA 1997;278 (21) 1759- 1766PubMedGoogle ScholarCrossref
Thompson  RSMichnich  MEFriedlander  LGilson  BGrothaus  LCStorer  B Effectiveness of smoking cessation interventions integrated into primary care practice.  Med Care 1988;26 (1) 62- 76PubMedGoogle ScholarCrossref
Goldstein  MGNiaura  RWilley-Lessne  C  et al.  Physicians counseling smokers: a population-based survey of patients' perceptions of health care provider-delivered smoking cessation interventions.  Arch Intern Med 1997;157 (12) 1313- 1319PubMedGoogle ScholarCrossref
Thorndike  ANRigotti  NAStafford  RSSinger  DE National patterns in the treatment of smokers by physicians.  JAMA 1998;279 (8) 604- 608PubMedGoogle ScholarCrossref
An  LCBernhardt  TSBluhm  J  et al.  Treatment of tobacco use as a chronic medical condition: primary care physicians' self-reported practice patterns.  Prev Med 2004;38 (5) 574- 585PubMedGoogle ScholarCrossref
Schroeder  SA What to do with a patient who smokes.  JAMA 2005;294 (4) 482- 487PubMedGoogle ScholarCrossref
Fiore  MBailey  WCohen  S  et al.  Treating Tobacco Use and Dependence: Clinical Practice Guideline.  Rockville, MD US Dept of Health and Human Services, Public Health Service2000;
Stead  LFPerera  RLancaster  T Telephone counselling for smoking cessation [update of: Cochrane Database Syst Rev. 2003;(1):CD002850].  Cochrane Database Syst Rev 2006; (3) CD002850PubMedGoogle Scholar
Lichtenstein  EGlasgow  RELando  HAOssip-Klein  DJBoles  SM Telephone counseling for smoking cessation: rationales and meta-analytic review of evidence.  Health Educ Res 1996;11 (2) 243- 257PubMedGoogle ScholarCrossref
Ossip-Klein  DJMcIntosh  S Quitlines in North America: evidence base and applications.  Am J Med Sci 2003;326 (4) 201- 205PubMedGoogle ScholarCrossref
Ossip-Klein  DJGiovino  GAMegahed  N  et al.  Effects of a smoker's hotline: results of a 10-county self-help trial.  J Consult Clin Psychol 1991;59 (2) 325- 332PubMedGoogle ScholarCrossref
Zhu  SHStretch  VBalabanis  MRosbrook  BSadler  GPierce  JP Telephone counseling for smoking cessation: effects of single-session and multiple-session interventions.  J Consult Clin Psychol 1996;64 (1) 202- 211PubMedGoogle ScholarCrossref
Zhu  SHAnderson  CMTedeschi  GJ  et al.  Evidence of real-world effectiveness of a telephone quitline for smokers.  N Engl J Med 2002;347 (14) 1087- 1093PubMedGoogle ScholarCrossref
North American Quitline Consortium, Quitline Maps & Facts. North American Quitline Consortium Web site. http://www.naquitline.org/welcome.asp. Accessed March 22, 2007
Bentz  CJBayley  KBBonin  KEFleming  LHollis  JFMcAfee  T The feasibility of connecting physician offices to a state-level tobacco quit line.  Am J Prev Med 2006;30 (1) 31- 37PubMedGoogle ScholarCrossref
Perry  RJKeller  PAFraser  DFiore  MC Fax to quit: a model for delivery of tobacco cessation services to Wisconsin residents.  WMJ 2005;104 (4) 37- 40PubMedGoogle Scholar
Rewarding Provider Performance, Aligning Incentives in Medicare.  Washington, DC National Academies Press2007;
Epstein  AM Pay for performance at the tipping point.  N Engl J Med 2007;356 (5) 515- 517PubMedGoogle ScholarCrossref
Rosenthal  MBLandon  BENormand  SLFrank  RGEpstein  AM Pay for performance in commercial HMOs.  N Engl J Med 2006;355 (18) 1895- 1902PubMedGoogle ScholarCrossref
 Deficit Reduction Act of 2005, Pub L 109-171, §5001 (2005) 
Petersen  LAWoodard  LDUrech  TDaw  CSookanan  S Does pay-for-performance improve the quality of health care?  Ann Intern Med 2006;145 (4) 265- 272PubMedGoogle ScholarCrossref
Rosenthal  MBFrank  RG What is the empirical basis for paying for quality in health care?  Med Care Res Rev 2006;63 (2) 135- 157PubMedGoogle ScholarCrossref
Norton  EC Incentive regulation of nursing homes.  J Health Econ 1992;11 (2) 105- 128PubMedGoogle ScholarCrossref
Hillman  ALRipley  KGoldfarb  NNuamah  IWeiner  JLusk  E Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care.  Am J Public Health 1998;88 (11) 1699- 1701PubMedGoogle ScholarCrossref
Hillman  ALRipley  KGoldfarb  NWeiner  JNuamah  ILusk  E The use of physician financial incentives and feedback to improve pediatric preventive care in Medicaid managed care.  Pediatrics 1999;104 (4, pt 1) 931- 935PubMedGoogle ScholarCrossref
Kouides  RWBennett  NMLewis  BCappuccio  JDBarker  WHLaForce  FMPrimary-Care Physicians of Monroe County, Performance-based physician reimbursement and influenza immunization rates in the elderly.  Am J Prev Med 1998;14 (2) 89- 95PubMedGoogle ScholarCrossref
Christensen  DBNeil  NFassett  WESmith  DHHolmes  GStergachis  A Frequency and characteristics of cognitive services provided in response to a financial incentive.  J Am Pharm Assoc (Wash) 2000;40 (5) 609- 617PubMedGoogle Scholar
Roski  JJeddeloh  RAn  L  et al.  The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines.  Prev Med 2003;36 (3) 291- 299PubMedGoogle ScholarCrossref
Grady  KELemkau  JPLee  NRCaddell  C Enhancing mammography referral in primary care.  Prev Med 1997;26 (6) 791- 800PubMedGoogle ScholarCrossref
Fairbrother  GHanson  KLFriedman  SButts  GC The impact of physician bonuses, enhanced fees, and feedback on childhood immunization coverage rates.  Am J Public Health 1999;89 (2) 171- 175PubMedGoogle ScholarCrossref
Fairbrother  GSiegel  MJFriedman  SKory  PDButts  GC Impact of financial incentives on documented immunization rates in the inner city: results of a randomized controlled trial.  Ambul Pediatr 2001;1 (4) 206- 212PubMedGoogle ScholarCrossref
Schillo  BAWendling  ASaul  JLuxenberg  MGLachter  RChristenson  MAn  LC Expanding access to nicotine replacement therapy through Minnesota's QUITLINE partnership.  Tob Control 2007;16 ((suppl 1)) i37- i41PubMedGoogle ScholarCrossref
Velicer  WFFava  JLProchaska  JOAbrams  DBEmmons  KMPierce  JP Distribution of smokers by stage in three representative samples.  Prev Med 1995;24 (4) 401- 411PubMedGoogle ScholarCrossref
Conroy  MBMajchrzak  NERegan  SSilverman  CBSchneider  LIRigotti  NA The association between patient-reported receipt of tobacco intervention at a primary care visit and smokers' satisfaction with their health care.  Nicotine Tob Res 2005;7 ((suppl 1)) S29- S34PubMedGoogle ScholarCrossref
Rosenthal  MBFrank  RGLi  ZEpstein  AM Early experience with pay-for-performance: from concept to practice.  JAMA 2005;294 (14) 1788- 1793PubMedGoogle ScholarCrossref
Lindenauer  PKRemus  DRoman  S  et al.  Public reporting and pay for performance in hospital quality improvement.  N Engl J Med 2007;356 (5) 486- 496PubMedGoogle ScholarCrossref
Rogers  EM Diffusion of Innovations. 5th ed. New York, NY Free Press2003;
Farrelly  MHussin  ABauer  UE Effectiveness and cost-effectiveness of television, radio and print advertisements in promoting the New York smokers' quitline.  Tob Control 2007;16 ((suppl 1)) i21- i23PubMedGoogle ScholarCrossref
Mosbaek  CHAustin  DFStark  MJLambert  LC The association between advertising and call to a tobacco quitline.  Tob Control 2007;16 ((suppl 1)) i24- i29PubMedGoogle ScholarCrossref
Fiore  MCCroyle  RTCurry  SJ  et al.  Preventing 3 million premature deaths and helping 5 million smokers quit: a national action plan for tobacco cessation.  Am J Public Health 2004;94 (2) 205- 210PubMedGoogle ScholarCrossref
Solberg  LIMaciosek  MVEdwards  NMKhanchandani  HSGoodman  MJ Repeated tobacco-use screening and intervention in clinical practice: health impact and cost effectiveness.  Am J Prev Med 2006;31 (1) 62- 71PubMedGoogle ScholarCrossref
Bentz  CJBayley  KBBonin  KE  et al.  Provider feedback to improve 5A's tobacco cessation in primary care: a cluster randomized clinical trial.  Nicotine Tob Res 2007;9 (3) 341- 349PubMedGoogle ScholarCrossref
Original Investigation
October 13, 2008

A Randomized Trial of a Pay-for-Performance Program Targeting Clinician Referral to a State Tobacco Quitline

Author Affiliations

Author Affiliations: Departments of Internal Medicine (Drs An, Klatt, and Ahluwalia) and Family Medicine (Dr Center), University of Minnesota, Minneapolis; Blue Cross and Blue Shield of Minnesota Center for Prevention, Eagan (Mr Bluhm and Drs Foldes, Alesci, and Manley); and Fairview Physicians Associates, Edina, Minnesota (Dr Nersesian and Mr Larson).

Arch Intern Med. 2008;168(18):1993-1999. doi:10.1001/archinte.168.18.1993

Background  Tobacco quitlines offer clinicians a means to connect their patients with evidence-based treatments. Innovative methods are needed to increase clinician referral.

Methods  This is a clinic randomized trial that compared usual care (n = 25 clinics) vs a pay-for-performance program (intervention) offering $5000 for 50 quitline referrals (n = 24 clinics). Pay-for-performance clinics also received monthly updates on their referral numbers. Patients were eligible for referral if they visited a participating clinic, were 18 years or older, currently smoked cigarettes, and intended to quit within the next 30 days. The primary outcome was the clinic's rate of quitline referral (ie, number of referrals vs number of smokers seen in clinic).

Results  Pay-for-performance clinics referred 11.4% of smokers (95% confidence interval [CI], 8.0%-14.9%; total referrals, 1483) compared with 4.2% (95% CI, 1.5%-6.9%; total referrals, 441) for usual care clinics (P = .001). Rates of referral were similar in intervention vs usual care clinics (n = 9) with a history of being very engaged with quality improvement activities (14.1% vs 15.1%, respectively; P = .85). Rates were substantially higher in intervention vs usual care clinics with a history of being engaged (n = 22 clinics; 10.1% vs 3.0%; P = .001) or less engaged (n = 18 clinics; 10.1% vs 1.1%; P = .02) with quality improvement. The rate of patient contact after referral was 60.2% (95% CI, 49.7%-70.7%). Among those contacted, 49.4% (95% CI, 42.8%-55.9%) enrolled, representing 27.0% (95% CI, 21.3%-32.8%) of all referrals. The marginal cost per additional quitline enrollee was $300.

Conclusion  A pay-for-performance program increases referral to tobacco quitline services, particularly among clinics with a history of less engagement in quality improvement activities.