Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial

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.

Figure 1

Participant Enrollment Abbreviations: IRB, Institutional Review Board; PC, primary care; PCP, primary care practitioners; PI, principal investigator; R&D, Research & Development ^aNon-physician participants included 7 registered nurses, 4 nurse practitioners, 4 registered nurse case managers, 1 physician assistant, and 1 pharmacist. ^bNon-physician participants included 10 licensed practical nurses, 9 registered nurses, 3 medical support assistants, 2 registered nurse care coordinators, and 1 pharmacist. ^cNon-physician participant ^dTwo additional non-physicians left the practice-level incentives group during the intervention. One new non-physician was enrolled. ^eSeven non-physicians left the physician- and practice-level incentives group during the intervention. Two new non-physicians were enrolled. ^fData from physicians only were used to assess both physician-level and practice-level performances; each physician participant received >/= 2 more instances of the intervention.

Figure 2

Figure 2(A and B). Unadjusted Proportion of Physicians’ Patients Meeting the Rewarded Clinical Measures by Study Group A. Blood Pressure Control or Appropriate Response to Uncontrolled Blood Pressure B. Use of Guideline-Recommended Antihypertensive Medications ^a19 physicians participated in the baseline period; 760 patient charts reviewed. 18 physicians participated in the final intervention period; 720 patient charts reviewed. 13 physicians in the post-washout period; 520 patient charts reviewed. ^b18 physicians participated in the baseline period; 720 patient charts reviewed. 19 physicians participated in the final intervention period; 760 patient charts reviewed. 17 physicians in the post-washout period; 680 patient charts reviewed. ^c17 physicians participated in the baseline period; 680 patient charts reviewed. 15 physicians participated in the final intervention period; 600 patient charts reviewed. 11 physicians in the post-washout period; 440 patient charts reviewed. ^d18 physicians participated in the baseline period; 720 patient charts reviewed. 19 physicians participated in the final intervention period; 760 patient charts reviewed. 14 physicians in the post-washout period; 560 patient charts reviewed.

Figure 2

Figure 2(A and B). Unadjusted Proportion of Physicians’ Patients Meeting the Rewarded Clinical Measures by Study Group A. Blood Pressure Control or Appropriate Response to Uncontrolled Blood Pressure B. Use of Guideline-Recommended Antihypertensive Medications ^a19 physicians participated in the baseline period; 760 patient charts reviewed. 18 physicians participated in the final intervention period; 720 patient charts reviewed. 13 physicians in the post-washout period; 520 patient charts reviewed. ^b18 physicians participated in the baseline period; 720 patient charts reviewed. 19 physicians participated in the final intervention period; 760 patient charts reviewed. 17 physicians in the post-washout period; 680 patient charts reviewed. ^c17 physicians participated in the baseline period; 680 patient charts reviewed. 15 physicians participated in the final intervention period; 600 patient charts reviewed. 11 physicians in the post-washout period; 440 patient charts reviewed. ^d18 physicians participated in the baseline period; 720 patient charts reviewed. 19 physicians participated in the final intervention period; 760 patient charts reviewed. 14 physicians in the post-washout period; 560 patient charts reviewed.