A randomized trial of a pay-for-performance program targeting clinician referral to a state tobacco quitline.
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.


CONCLUSIONS
A pay-for-performance program increases referral to tobacco quitline services, particularly among clinics with a history of less engagement in quality improvement activities.
Department of Internal Medicine, University of Minnesota, Minneapolis, MN 55455, USA. lcan@umn.edu
Lawrence C
LC
An
James H
JH
Bluhm
Steven S
SS
Foldes
Nina L
NL
Alesci
Colleen M
CM
Klatt
Bruce A
BA
Center
William S
WS
Nersesian
Mark E
ME
Larson
Jasjit S
JS
Ahluwalia
Marc W
MW
Manley
D006801:Humans; D015994:Incidence; D015397:Program Evaluation; D012017:Referral and Consultation / Q000191:economics*; D012052:Reimbursement, Incentive / Q000191:economics*; D012189:Retrospective Studies; D012907:Smoking / Q000191:economics / Q000453:epidemiology; D016540:Smoking Cessation / Q000191:economics*; D000074606:Smoking Prevention; D015996:Survival Rate; D014481:United States / Q000453:epidemiology