title: Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol.
abstract: BACKGROUND
  Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment, hypertension is controlled in less than one-half of United States citizens.
  
  
  METHODS
  This randomized controlled trial tests whether explicit financial incentives promote the translation of guideline-recommended care for hypertension into clinical practice and improve blood pressure (BP) control in the primary care setting. Using constrained randomization, we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms: physician-level incentive; group-level incentive; combination of physician and group incentives; and no incentives (control). All participants at the hospital (cluster) were assigned to the same study arm. We enrolled 83 full-time primary care physicians and 42 non-physician personnel. The intervention consisted of an educational session about guideline-recommended care for hypertension, five audit and feedback reports, and five disbursements of incentive payments. Incentive payments rewarded participants for chart-documented use of guideline-recommended antihypertensive medications, BP control, and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention. To identify potential unintended consequences of the incentives, the study team interviewed study participants, as well as non-participant primary care personnel and leadership at study sites. Chart reviews included data collection on quality measures not related to hypertension. To evaluate the persistence of the effect of the incentives, the study design includes a washout period.
  
  
  CONCLUSIONS
  We briefly describe the rationale for the interventions being studied, as well as the major design choices. Rigorous research designs such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements.
  
  
  BACKGROUND
  http://www.clinicaltrials.govNCT00302718.
authors.affiliation: Health Policy and Quality Program, Michael E, DeBakey VA Medical Center Health Services Research and Development Center of Excellence, and Section for Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA. laurap@bcm.tmc.edu
authors.forename: Laura A
authors.initials: LA
authors.lastname: Petersen
authors.forename: Tracy
authors.initials: T
authors.lastname: Urech
authors.forename: Kate
authors.initials: K
authors.lastname: Simpson
authors.forename: Kenneth
authors.initials: K
authors.lastname: Pietz
authors.forename: Sylvia J
authors.initials: SJ
authors.lastname: Hysong
authors.forename: Jochen
authors.initials: J
authors.lastname: Profit
authors.forename: Douglas
authors.initials: D
authors.lastname: Conrad
authors.forename: R Adams
authors.initials: RA
authors.lastname: Dudley
authors.forename: Meghan Z
authors.initials: MZ
authors.lastname: Lutschg
authors.forename: Robert
authors.initials: R
authors.lastname: Petzel
authors.forename: Lechauncy D
authors.initials: LD
authors.lastname: Woodard
mesh_terms: D005260:Female; D019983:Guideline Adherence / Q000458:organization & administration; D006787:Hospitals, Veterans / Q000458:organization & administration; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital / Q000458:organization & administration; D011897:Random Allocation; D012052:Reimbursement, Incentive / Q000458:organization & administration*; D012107:Research Design; D018401:Sample Size