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

Details

• Personal Author:
  Conrad DA ; Dudley RA ; Hysong SJ ; Petersen LA ; Pietz K ; Profit J ; Simpson K ; Urech TH ; Woodard LD
• Description:
  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. [Description provided by NIOSH]
• Subjects:
  Behavior Cardiovascular Diseases Cardiovascular System Delivery Of Health Care Health Personnel Occupational Health Safety
• Keywords:
  Blood Pressure Health Care Personnel Hypertension Intervention Effectiveness Medical Care
• ISSN:
  0098-7484
• Document Type:
  Text
• Funding:
  Grant
• Genre:
  Journal Article
• Place as Subject:
  California ; OSHA Region 10 ; OSHA Region 6 ; OSHA Region 9 ; Texas ; Washington
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Volume:
  310
• Issue:
  10
• NIOSHTIC Number:
  nn:20057107
• Citation:
  JAMA 2013 Sep; 310(10):1042-1050
• Contact Point Address:
  Laura A. Petersen, MD, MPH, Health Services Research and Development (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030
• Email:
  laura.petersen@va.gov
• Federal Fiscal Year:
  2013
• Performing Organization:
  University of Washington
• Peer Reviewed:
  True
• Start Date:
  20050701
• Source Full Name:
  Journal of the American Medical Association
• End Date:
  20250630
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:a1952991d48542a6749e7ec4901540b50d34b2aafe821a1bbe588755d1d9f14a0905838759bb79e9d4df90b15f99325e38850ceb29a7b6767475b1175d7f59f9
• Download URL:
  https://stacks.cdc.gov/view/cdc/214563/cdc_214563_DS1.pdf
• File Type:
  [PDF - 455.50 KB ]