title: Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels: A Randomized Clinical Trial.
abstract: OBJECTIVE
  Financial incentives to physicians or patients are increasingly used, but their effectiveness is not well established.
  
  
  OBJECTIVE
  To determine whether physician financial incentives, patient incentives, or shared physician and patient incentives are more effective than control in reducing levels of low-density lipoprotein cholesterol (LDL-C) among patients with high cardiovascular risk.
  
  
  METHODS
  Four-group, multicenter, cluster randomized clinical trial with a 12-month intervention conducted from 2011 to 2014 in 3 primary care practices in the northeastern United States. Three hundred forty eligible primary care physicians (PCPs) were enrolled from a pool of 421. Of 25,627 potentially eligible patients of those PCPs, 1503 enrolled. Patients aged 18 to 80 years were eligible if they had a 10-year Framingham Risk Score (FRS) of 20% or greater, had coronary artery disease equivalents with LDL-C levels of 120 mg/dL or greater, or had an FRS of 10% to 20% with LDL-C levels of 140 mg/dL or greater. Investigators were blinded to study group, but participants were not.
  
  
  METHODS
  Primary care physicians were randomly assigned to control, physician incentives, patient incentives, or shared physician-patient incentives. Physicians in the physician incentives group were eligible to receive up to $1024 per enrolled patient meeting LDL-C goals. Patients in the patient incentives group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. Physicians and patients in the shared incentives group shared these incentives. Physicians and patients in the control group received no incentives tied to outcomes, but all patient participants received up to $355 each for trial participation.
  
  
  METHODS
  Change in LDL-C level at 12 months.
  
  
  RESULTS
  Patients in the shared physician-patient incentives group achieved a mean reduction in LDL-C of 33.6 mg/dL (95% CI, 30.1-37.1; baseline, 160.1 mg/dL; 12 months, 126.4 mg/dL); those in physician incentives achieved a mean reduction of 27.9 mg/dL (95% CI, 24.9-31.0; baseline, 159.9 mg/dL; 12 months, 132.0 mg/dL); those in patient incentives achieved a mean reduction of 25.1 mg/dL (95% CI, 21.6-28.5; baseline, 160.6 mg/dL; 12 months, 135.5 mg/dL); and those in the control group achieved a mean reduction of 25.1 mg/dL (95% CI, 21.7-28.5; baseline, 161.5 mg/dL; 12 months, 136.4 mg/dL; P < .001 for comparison of all 4 groups). Only patients in the shared physician-patient incentives group achieved reductions in LDL-C levels statistically different from those in the control group (8.5 mg/dL; 95% CI, 3.8-13.3; P = .002).
  
  
  CONCLUSIONS
  In primary care practices, shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a statistically significant difference in reduction of LDL-C levels at 12 months. This reduction was modest, however, and further information is needed to understand whether this approach represents good value.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01346189.
authors.affiliation: University of Pennsylvania, Philadelphia2Department of Veterans Affairs, Philadelphia, Pennsylvania.
authors.forename: David A
authors.initials: DA
authors.lastname: Asch
authors.affiliation: University of Pennsylvania, Philadelphia.
authors.forename: Andrea B
authors.initials: AB
authors.lastname: Troxel
authors.affiliation: Sutter Health System, Sacramento, California.
authors.forename: Walter F
authors.initials: WF
authors.lastname: Stewart
authors.affiliation: Partners Healthcare System, Boston, Massachusetts5Harvard Medical School, Boston, Massachusetts.
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Sequist
authors.affiliation: Sutter Health System, Sacramento, California.
authors.forename: James B
authors.initials: JB
authors.lastname: Jones
authors.affiliation: Geisinger Health System, Danville, Pennsylvania.
authors.forename: AnneMarie G
authors.initials: AG
authors.lastname: Hirsch
authors.affiliation: University of Pennsylvania, Philadelphia.
authors.forename: Karen
authors.initials: K
authors.lastname: Hoffer
authors.affiliation: University of Pennsylvania, Philadelphia.
authors.forename: Jingsan
authors.initials: J
authors.lastname: Zhu
authors.affiliation: University of Pennsylvania, Philadelphia.
authors.forename: Wenli
authors.initials: W
authors.lastname: Wang
authors.affiliation: University of Pennsylvania, Philadelphia.
authors.forename: Amanda
authors.initials: A
authors.lastname: Hodlofski
authors.affiliation: University of Pennsylvania, Philadelphia.
authors.forename: Antonette B
authors.initials: AB
authors.lastname: Frasch
authors.affiliation: Temple University School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Weiner
authors.affiliation: University of Pennsylvania, Philadelphia.
authors.forename: Darra D
authors.initials: DD
authors.lastname: Finnerty
authors.affiliation: Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
authors.forename: Meredith B
authors.initials: MB
authors.lastname: Rosenthal
authors.affiliation: University of Pennsylvania, Philadelphia.
authors.forename: Kelsey
authors.initials: K
authors.lastname: Gangemi
authors.affiliation: University of Pennsylvania, Philadelphia2Department of Veterans Affairs, Philadelphia, Pennsylvania.
authors.forename: Kevin G
authors.initials: KG
authors.lastname: Volpp
mesh_terms: D000465:Algorithms; D002318:Cardiovascular Diseases / Q000097:blood / Q000517:prevention & control*; D008078:Cholesterol, LDL / Q000097:blood*; D003324:Coronary Artery Disease / Q000097:blood / Q000188:drug therapy; D060909:Economics, Behavioral; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008297:Male; D008404:Massachusetts; D055118:Medication Adherence / Q000523:psychology; D008875:Middle Aged; D009042:Motivation; D010358:Patient Participation / Q000191:economics* / Q000523:psychology; D010414:Pennsylvania; D011320:Primary Health Care / Q000191:economics*; D012016:Reference Values; D012052:Reimbursement, Incentive / Q000191:economics / Q000458:organization & administration / Q000706:statistics & numerical data; D016037:Single-Blind Method; D013997:Time Factors; D016903:Drug Monitoring
chemical_list: D008078:Cholesterol, LDL; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors