title: Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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).
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00302718.
authors.affiliation: Health Policy and Quality Program, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas 77030, USA. laura.petersen@va.gov
authors.forename: Laura A
authors.initials: LA
authors.lastname: Petersen
authors.forename: Kate
authors.initials: K
authors.lastname: Simpson
authors.forename: Kenneth
authors.initials: K
authors.lastname: Pietz
authors.forename: Tracy H
authors.initials: TH
authors.lastname: Urech
authors.forename: Sylvia J
authors.initials: SJ
authors.lastname: Hysong
authors.forename: Jochen
authors.initials: J
authors.lastname: Profit
authors.forename: Douglas A
authors.initials: DA
authors.lastname: Conrad
authors.forename: R Adams
authors.initials: RA
authors.lastname: Dudley
authors.forename: LeChauncy D
authors.initials: LD
authors.lastname: Woodard
mesh_terms: D000368:Aged; D001794:Blood Pressure; D003695:Delivery of Health Care / Q000458:organization & administration; D005260:Female; D019983:Guideline Adherence; D006787:Hospitals, Veterans; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D007022:Hypotension; D008297:Male; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital; D010348:Patient Care Team / Q000191:economics* / Q000592:standards; D010820:Physicians / Q000191:economics* / Q000592:standards; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D011320:Primary Health Care; D012052:Reimbursement, Incentive; D016896:Treatment Outcome
references.citation: N Engl J Med. 2007 Feb 1;356(5):486-96
references.pmid: 17259444
references.citation: Arch Intern Med. 2003 Dec 8-22;163(22):2677-8
references.pmid: 14662620
references.citation: Am J Manag Care. 2012 Oct 01;18(10):e378-91
references.pmid: 23145846
references.citation: Stat Med. 2010 Feb 20;29(4):504-20
references.pmid: 20013937
references.citation: JAMA. 2012 Sep 12;308(10):1015-23
references.pmid: 22968890
references.citation: N Engl J Med. 2012 Nov 8;367(19):1852-3
references.pmid: 23134388
references.citation: J Gen Intern Med. 2010 Feb;25(2):100-1
references.pmid: 19953336
references.citation: JAMA. 2002 Dec 18;288(23):2981-97
references.pmid: 12479763
references.citation: Ann Intern Med. 2012 May 15;156(10):728-35
references.pmid: 22586010
references.citation: JAMA. 2003 May 21;289(19):2560-72
references.pmid: 12748199
references.citation: Cochrane Database Syst Rev. 2011 Sep 07;(9):CD008451
references.pmid: 21901722
references.citation: N Engl J Med. 2012 Apr 26;366(17):1606-15
references.pmid: 22455751
references.citation: Health Policy. 2007 Jan;80(1):179-93
references.pmid: 16624440
references.citation: Health Aff (Millwood). 2011 Apr;30(4):690-8
references.pmid: 21471490
references.citation: Med Care. 2003 Oct;41(10):1173-82
references.pmid: 14515113
references.citation: Ann Intern Med. 2006 Aug 15;145(4):265-72
references.pmid: 16908917
references.citation: Control Clin Trials. 1981 Jun;2(2):93-113
references.pmid: 7273794
references.citation: J Clin Epidemiol. 1996 Apr;49(4):435-9
references.pmid: 8621994
references.citation: Health Aff (Millwood). 2010 May;29(5):819-26
references.pmid: 20439867
references.citation: Circulation. 2012 May 22;125(20):2462-8
references.pmid: 22515976
references.citation: Ann Intern Med. 2012 Dec 18;157(12):889-99
references.pmid: 23247940
references.citation: MMWR Morb Mortal Wkly Rep. 2011 Feb 4;60(4):103-8
references.pmid: 21293325
references.citation: Implement Sci. 2011 Oct 03;6:114
references.pmid: 21967830
references.citation: BMJ. 2010 May 11;340:c1898
references.pmid: 20460330
references.citation: Annu Rev Public Health. 2009;30:357-71
references.pmid: 19296779
references.citation: N Engl J Med. 2012 Nov 8;367(19):1821-8
references.pmid: 23134382