title: Healthcare system effects of pay-for-performance for smoking status documentation.
abstract: OBJECTIVE
  To evaluate the impact on smoking status documentation of a payer-sponsored pay-for-performance (P4P) incentive that targeted a minority of an integrated healthcare delivery system's patients.
  
  
  METHODS
  Three commercial insurers simultaneously adopted P4P incentives to document smoking status of their members with 3 chronic diseases. The healthcare system responded by adding a smoking status reminder to all patients' electronic health records (EHRs). We measured change in smoking status documentation before (2008-2009) and after (2010-2011) P4P implementation by patient P4P eligibility.
  
  
  METHODS
  The P4P-eligible patients were compared primarily with a subset of non-P4P-eligible patients who resembled P4P-eligible patients and also with all non-P4P-eligible patients. Multivariate models adjusted for patient and provider characteristics and accounted for provider-level clustering and preimplementation trends.
  
  
  RESULTS
  Documentation increased from 48% of 207,471 patients before P4P to 71% of 227,574 patients after P4P. Improvement from 56% to 83% occurred among P4P-eligible patients (adjusted odds ratio [AOR], 3.6; 95% confidence interval [CI], 2.9-4.5) and from 56% to 80% among the comparable subset of non-P4P-eligible patients (AOR, 3.0; 95% CI, 2.3-3.9). The difference in improvement between groups was significant (AOR, 1.3; 95% CI, 1.1-1.4; P = .009).
  
  
  CONCLUSIONS
  A P4P incentive targeting a minority of a healthcare system's patients stimulated adoption of a system wide EHR reminder and improved smoking status documentation overall. Combining a P4P incentive with an EHR reminder might help healthcare systems improve treatment delivery for smokers and meet "meaningful use" standards for EHRs.
authors.affiliation: Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA. gkruse@partners.org
authors.forename: Gina R
authors.initials: GR
authors.lastname: Kruse
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.forename: Jennifer H K
authors.initials: JH
authors.lastname: Kelley
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Linder
authors.forename: Jonathan S
authors.initials: JS
authors.lastname: Einbinder
authors.forename: Nancy A
authors.initials: NA
authors.lastname: Rigotti
mesh_terms: D000293:Adolescent; D000328:Adult; D002908:Chronic Disease; D003695:Delivery of Health Care; D004282:Documentation; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D008297:Male; D008329:Managed Care Programs; D008404:Massachusetts / Q000453:epidemiology; D008875:Middle Aged; D011785:Quality Assurance, Health Care / Q000191:economics; D012052:Reimbursement, Incentive; D012907:Smoking / Q000453:epidemiology*; D055815:Young Adult
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