Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. How to build and evaluate an integrated health care system for chronic patients: study design of a clustered randomised controlled trial in rural China The Use of Physician Financial Incentives and Feedback to Improve Pediatric Preventive Care in Medicaid Managed Care Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation Financial incentives to improve adherence to antipsychotic maintenance medication in non-adherent patients: a cluster randomised controlled trial. A systematic review of the use of financial incentives and penalties to encourage uptake of healthy behaviors: protocol Are financial incentives cost-effective to support smoking cessation during pregnancy? Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial. Recorded quality of primary care for patients with diabetes in England before and after the introduction of a financial incentive scheme: a longitudinal observational study Prepayment with office-based physicians in publicly funded programs: results from the Children's Medicaid Program. STI in remote communities: improved and enhanced primary health care (STRIVE) study protocol: a cluster randomised controlled trial comparing ‘usual practice’ STI care to enhanced care in remote primary health care services in Australia The Cessation in Pregnancy Incentives Trial (CPIT): study protocol for a randomized controlled trial Incentive payments to general practitioners aimed at increasing opportunistic testing of young women for chlamydia: a pilot cluster randomised controlled trial Randomized trial of four financial-incentive programs for smoking cessation. Computer Physician Order Entry: Benefits, Costs, and Issues Some Recent Developments on Financial Incentives for Smoking Cessation Among Pregnant and Newly Postpartum Women Changes in Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007 Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care. Assessing Care of Vulnerable Elders: ACOVE Project Overview Does the implementation of a new payment system for hospital services induce changes in the quality of health care? Experiences from Germany Healthcare providers’ views on the acceptability of financial incentives for breastfeeding: a qualitative study Patient navigation and financial incentives to promote smoking cessation in an underserved primary care population: A randomized controlled trial protocol.
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 / design This r and omized 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 r and omization , 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 review s 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 . Discussion We briefly describe the rationale for the interventions being studied , as well as the major design choices . Rigorous research design s such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements . Trial Registration http://www . clinical BACKGROUND This study tested the effects of two organizational support processes , the provision of financial incentives for superior clinical performance and the availability of a  patient ( smoker ) registry and proactive telephone support system for smoking cessation , on provider adherence to accepted practice guidelines and associated patient outcomes . METHODS Forty clinics of a large multispecialty medical group practice providing primary care services were r and omly allocated to study conditions . Fifteen clinics each were assigned to the experimental conditions " control " ( distribution of printed versions of smoking cessation guidelines ) and " incentive " ( financial incentive pay-out for reaching preset clinical performance targets ) .  Ten clinics were r and omized to receive financial incentives combined with access to a central ized patient registry and intervention system ( " registry " ) . Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients ' smoking cessation behaviors . RESULTS  Patients ' tobacco use status  was statistically significant ( P < 0.01 ) more frequently identified in clinics with the opportunity for incentives and access to a registry than in clinics in the control condition . Patients visiting registry clinics accessed counseling programs statistically significantly more often ( P < 0.001 ) than patients receiving care in the control condition . Other endpoints did not statistically significantly differ between the experimental conditions . CONCLUSIONS The impact of financial incentives and a patient registry/intervention system in improving smoking cessation clinical practice s and patient behaviors was mixed . Additional research is needed to identify conditions under which such organizational support processes result in significant health care quality improvement and warrant the investment Background While integrated health care system has been proved an effective way to help improving patient health and system efficiency , the exact behaviour model and motivation approach are not so clear in poor rural areas where health human re sources and continuous service provision are urgently needed . To gather solid evidence , we initiated a comprehensive intervention project in Qianjiang District , southwest part of rural China in 2012 . And after one-year 's pilot , we developed an intervention package of team service , comprehensive pathway and prospect ive- and performance-based payment system . Methods To testify the potential influence of payment interventions , we use clustered r and omised controlled trial , 60 clusters are grouped into two treatment groups and one control group to compare the time and group differences . Difference-in-differences model and structural equation modelling will be used to analyse the intervention effects and pathway . The outcomes are : quality of care , disease burden , supplier cooperative behaviour and patient utilisation behaviour and system efficiency . Repeated multivariate variance analysis will be used to statistically examine the outcome differences . Discussion This is the first trial of its kind to prove the effects and efficiency of integrated care . Though we adopted r and omised controlled trial to gather the highest rank of evidence , still the fully r and omisation was hard to realise in health policy reform experiment . To compensate , the design er should take efforts on control for the potential confounders as much as possible . With this trial , we assume the effects will come from : ( 1 ) improvement on the quality of life through risk factors control and lifestyles change on patient 's behaviours ; ( 2 ) improvement on quality of care through continuous care and coordinated supplier behaviours ; ( 3 ) improvement on the system efficiency through active interaction between suppliers and patients . Conclusion The integrated care system needs collaborative work from different levels of caregivers . So it is extremely important to consider the supplier cooperative behaviour . In this trial , we introduced payment system to help the delivery system integration through providing financial incentives to motivate people to play their roles . Also , the multidisciplinary team , the multi-institutional pathway and system global budget and pay-for-performance payment system could afford as a solution Objective . Immunizations and other cost-effective preventive services remain underused by many children , especially those living in poverty . Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns , we design ed and tested an intervention combining these strategies . We studied whether a system of semiannual assessment and feedback , coupled with financial incentives , could improve pediatric preventive care in a Medicaid health maintenance organization ( HMO ) . Methodology . We r and omly assigned primary care sites serving children in a Medicaid HMO to one of three groups : a feedback group ( where physicians received written feedback about compliance scores ) , a feedback and incentive group ( where physicians received feedback and a financial bonus when compliance criteria were met ) , and a control group . We evaluated compliance with pediatric preventive care guidelines  through semiannual chart audits during the years 1993 to 1995 . Results . Compliance with pediatric preventive care improved dramatically in the study period . Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores ( from 56%–73 % ) , as well as scores for immunizations ( from 62%–79 % ) and other preventive care ( from 54%–71 % ) . However , no significant differences were observed between either intervention group and the control group , nor were there any interaction ( group-by-time ) effects . Conclusions . Feedback to physicians , with or without financial incentives , did not improve pediatric preventive care in this Medicaid HMO during a time of rapid , secular improvements in care . Possible explanations include the context and timing of the intervention , the magnitude of the financial incentives , and lack of physician awareness of the intervention BACKGROUND Evidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed . We assessed the effect of performance-based payment of health-care providers ( payment for performance ; P4P ) on use and quality of child and maternal care services in health-care facilities in Rw and a. METHODS 166 facilities were r and omly assigned at the district level either to begin P4P funding between June , 2006 , and October , 2006 ( intervention group ; n=80 ) , or to continue with the traditional input-based funding until 23 months after study baseline ( control group ; n=86 ) . R and omisation was done by coin toss . We surveyed facilities and 2158 households at baseline and after 23 months . The main outcome measures were prenatal care visits and institutional deliveries , quality of prenatal care , and child preventive care visits and immunisation . We isolated the incentive effect from the re source effect by increasing comparison facilities ' input-based budgets by the average P4P payments made to the treatment facilities . We estimated a multivariate regression specification of the difference-in-difference model in which an individual 's outcome is regressed against a dummy variable , indicating whether the facility received P4P that year , a facility-fixed effect , a year indicator , and a series of individual and household characteristics . FINDINGS Our model estimated that facilities in the intervention group had a 23 % increase in the number of institutional deliveries and increases in the number of preventive care visits by children aged 23 months or younger ( 56 % ) and aged between 24 months and 59 months ( 132 % ) . No improvements were seen in the number of women completing four prenatal care visits or of children receiving full immunisation schedules . We also estimate an increase of 0·157 st and ard deviations ( 95 % CI 0·026 - 0·289 ) in prenatal quality as measured by compliance with Rw and an prenatal care clinical practice guidelines . INTERPRETATION The P4P scheme in Rw and a had the greatest effect on those services that had the highest payment rates and needed the least effort from the service provider . P4P financial performance incentives can improve both the use and quality of maternal and child health services , and could be a useful intervention to accelerate progress towards Millennium Development Goals for maternal and child health . FUNDING World Bank 's Bank-Netherl and s Partnership Program and Spanish Impact Evaluation Fund , the British Economic and Social Research Council , Government of Rw and a , and Global Development Network BACKGROUND Poor adherence to long-term antipsychotic injectable ( LAI ) medication in patients with psychotic disorders is associated with a range of negative outcomes . No psychosocial intervention has been found to be consistently effective in improving adherence . OBJECTIVES To test whether or not offering financial incentives is effective and cost-effective in improving adherence and to explore patient and clinician experiences with such incentives . DESIGN A cluster r and omised controlled trial with economic and nested qualitative evaluation . The intervention period lasted for 12 months with 24 months ' follow-up . The unit of r and omisation was mental health teams in the community . SETTING Community teams in secondary mental health care . PARTICIPANTS Patients with a diagnosis of schizophrenia , schizoaffective psychosis or bipolar illness , receiving ≤ 75 % of their prescribed LAI medication . In total , 73 teams with 141 patients ( intervention n = 78 and control n = 63 ) were included . INTERVENTIONS Participants in the intervention group received £ 15 for each LAI medication . Patients in the control group  received treatment as usual . MAIN OUTCOME MEASURES PRIMARY OUTCOME adherence to LAI medication  ( the percentage of received out of those prescribed ) . SECONDARY OUTCOMES percentage of patients with at least 95 % adherence ; clinical global improvement ; subjective quality of life ; satisfaction with medication ; hospitalisation ; adverse events ; and costs . Qualitative evaluation : semistructured interviews with patients in the intervention group and their clinicians . RESULTS PRIMARY OUTCOME outcome data were available for 131 patients .  Baseline adherence was 69 % in the intervention group and 67 % in the control group . During the intervention period , adherence was significantly higher in the intervention group than in the control group ( 85 % vs. 71 % ) [ adjusted mean difference 11.5 % , 95 % confidence interval ( CI ) 3.9 % to 19.0 % ; p = 0.003 ] . Secondary outcome : patients in the intervention group showed statistically significant improvement in adherence of at least 95 % ( adjusted odds ratio 8.21 , 95 % CI 2.00 to 33.67 ; p = 0.003 ) and subjective quality of life ( difference in means 0.71 , 95 % CI 0.26 to 1.15 ; p = 0.002 ) . Follow-ups : after incentives stopped , adherence did not differ significantly between groups , neither during the first 6 months ( adjusted difference in means -7.4 % , 95 % CI -17.0 % to 2.1 % ; p = 0.175 ) nor during the period from month 7 to month 24 ( difference in means -5.7 % , 95 % CI -13.1 % to 1.7 % ; p = 0.130 ) . Cost-effectiveness : the average costs of the financial incentives was £ 303 . Overall costs per patient were somewhat higher in the intervention group , but the difference was not significant . Semistructured interviews : the majority of patients and clinicians reported positive experiences with the incentives beyond their monetary value . These included improvement in the therapeutic relationship . The majority of both patients and clinicians perceived no negative impact after the intervention was stopped after 1 year . CONCLUSIONS Financial incentives are effective in improving adherence to LAI medication . Health-care costs ( including costs of the financial incentive ) are unlikely to be increased substantially by this intervention . Once the incentives stop , the advantage is not maintained . The experiences of both patients and clinicians are largely , but not exclusively , positive . Whether or not financial incentives are effective for patients with more favourable background , those on oral mediation or for shorter or longer time periods remains unknown . TRIAL REGISTRATION Current Controlled Trials IS RCT N77769281 . FUNDING This project was funded by the National Institute for Health Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 20 , No. 70 . See the NIHR Journals Library website for further project information Background The use of financial incentives and penalties to encourage uptake of healthy behaviors is increasingly seen as a viable intervention in developed countries . Previous review s of the effectiveness of financial incentives and penalties for encouraging the uptake of healthy behaviors have focused on individual behaviors making it difficult to draw overall conclusions about the effectiveness of such interventions . This systematic review will explore the effectiveness of financial incentives and penalties for encouraging a wide range of behaviors , including : smoking cessation , increased physical activity , healthier dietary intake , sensible patterns of alcohol consumption , safe sun , safe sex , and primary preventive clinical behaviors . Methods Systematic methods will be used to search existing literature and screen studies for inclusion . All studies that meet the following inclusion criteria will be included in the review : participants were 18 years old or older and living in high-income countries ; interventions included cash or cash-like incentives to promote the uptake of healthy behaviors , or cash or cash-like penalties to discourage unhealthy behaviors ; the comparator was usual care or no intervention ; study design was r and omized controlled trial , cluster r and omized controlled trial , controlled before and after study , or interrupted time series analysis . Two review ers will independently screen the publications to ensure they meet the inclusion criteria . Quality will be assessed by two research ers , working independently , using the Cochrane risk of bias tool . Meta- analysis will be conducted , if appropriate . Any studies identified as at ‘ high risk of bias ’ will be excluded from meta- analysis . Discussion This systematic review will provide policy-relevant recommendations for the use of financial incentives and penalties as a method of encouraging uptake of healthy behaviors AIMS To investigate the cost-effectiveness of up to £ 400 worth of financial incentives for smoking cessation in pregnancy as an adjunct to routine health care . DESIGN Cost-effectiveness analysis based on a Phase II r and omized controlled trial ( RCT ) and a cost-utility analysis using a life-time Markov model . SETTING The RCT was undertaken in Glasgow , Scotl and . The economic analysis was undertaken from the UK National Health Service ( NHS ) perspective . PARTICIPANTS A total of 612 pregnant women r and omized to receive usual cessation support plus or minus financial incentives of up to £ 400 vouchers ( US $ 609 ) , contingent upon smoking cessation . MEASUREMENTS Comparison of usual support and incentive interventions in terms of cotinine-vali date d quitters , quality -adjusted life years ( QALYs ) and direct costs to the NHS . FINDINGS The incremental cost per quitter at 34 - 38 weeks pregnant was £ 1127 ($1716).This is similar to the st and ard look-up value derived from Stapleton & West 's published ICER tables , £ 1390 per quitter , by looking up the Cessation in Pregnancy Incentives Trial ( CIPT ) incremental cost ( £ 157 ) and incremental 6-month quit outcome ( 0.14 ) . The life-time model result ed in an incremental cost of £ 17 [ 95 % confidence interval ( CI ) = -£93 , £ 107 ] and a gain of 0.04 QALYs ( 95 % CI = -0.058 , 0.145 ) , giving an ICER of £ 482/QALY ( $ 734/QALY ) . Probabilistic sensitivity analysis indicates uncertainty in these results , particularly regarding relapse after birth . The expected value of perfect information was £ 30 million ( at a willingness to pay of £ 30 000/QALY ) , so given current uncertainty , additional research is potentially worthwhile . CONCLUSION Financial incentives for smoking cessation in pregnancy are highly cost-effective , with an incremental cost per quality -adjusted life years of £ 482 , which is well below recommended decision thresholds IMPORTANCE 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 . DESIGN , SETTING , AND PARTICIPANTS Cluster r and omized 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 ) . INTERVENTIONS 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 . MAIN OUTCOMES AND MEASURES Among a r and om 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 AND RELEVANCE Individual financial incentives , but not practice -level or combined incentives , result ed in greater blood pressure control or appropriate response to uncontrolled blood pressure ; none of the incentives result ed 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 . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00302718 Background The UK 's Quality and Outcomes Framework ( QOF ) was introduced in 2004/5 , linking remuneration for general practice s to recorded quality of care for chronic conditions , including diabetes mellitus . We assessed the effect of the incentives on recorded quality of care for diabetes patients and its variation by patient and practice characteristics . Methods Using the General Practice Research Data base we selected a stratified sample of 148 English general practice s in Engl and , contributing data from 2000/1 to 2006/7 , and obtained a r and om sample of 653 500 patients in which 23 920 diabetes patients identified . We quantified annually recorded quality of care at the patient-level , as measured by the 17  QOF diabetes indicators , in a composite score and analysed it longitudinally using an Interrupted Time Series design . Results Recorded quality of care improved for all subgroups in the pre-incentive period . In the first year of the incentives , composite quality improved over- and -above this pre-incentive trend by 14.2 % ( 13.7–14.6 % ) . By the third year the improvement above trend was smaller , but still statistically significant , at 7.3 % ( 6.7–8.0 % ) . After 3 years of the incentives , recorded levels of care varied significantly for patient gender , age , years of previous care , number of co-morbid conditions and practice diabetes prevalence . Conclusions The introduction of financial incentives was associated with improvements in the recorded quality of diabetes care in the first year . These improvements included some measures of disease control , but most captured only documentation of recommended aspects of clinical assessment , not patient management or outcomes of care . Improvements in subsequent years were more modest . Variation in care between population groups diminished under the incentives , but remained substantial in some cases This paper is a report of the results of a demonstration design ed to provide empirical evidence regarding the effects of alternative approaches to paying physicians for serving children in the Medicaid program : ( 1 ) visit fees set at twice regular Medicaid fees in return for physician agreement to manage utilization and ( 2 ) capitation and financial risk-sharing along with the same physician agreement to manage utilization .  Participating physicians were assigned r and omly to either of the two payment groups . Comparisons of utilization and expenditures were made between these two plans and the regular Medicaid program ( fee-for-service , low fees ) . Results showed no adverse effect of capitation payments on primary care visits to office-based physicians . Capitation physician referrals to specialists decreased relative to all other groups studied , consistent with the theory that the financial incentives in capitation will lead primary care physicians to reduce referrals to specialists Background Despite two decades of interventions , rates of sexually transmissible infections ( STI ) in remote Australian Aboriginal communities remain unacceptably high . Routine notifications data from 2011 indicate rates of chlamydia and gonorrhoea among Aboriginal people in remote setting s were 8 and 61 times higher respectively than in the non-Indigenous population . Methods / design STRIVE is a stepped-wedge cluster r and omised trial design ed to compare a sexual health quality improvement program ( SHQIP ) to usual STI clinical care delivered in remote primary health care services . The SHQIP is a multifaceted intervention comprising annual assessment s of sexual health service delivery , implementation of a sexual health action plan , six-monthly clinical service activity data reports , regular feedback meetings with a regional coordinator , training and financial incentive payments . The trial clusters comprise either a single community or several communities grouped together based on geographic proximity and cultural ties . The primary outcomes are : prevalence of chlamydia , gonorrhoea and trichomonas in Aboriginal residents aged 16–34 years , and performance in clinical management of STIs based on best practice indicators . STRIVE will be conducted over five years comprising one and a half years of trial initiation and community consultation , three years of trial conditions , and a half year of data analysis . The trial was initiated in 68 remote Aboriginal health services in the Northern Territory , Queensl and and Western Australia . Discussion STRIVE is the first cluster r and omised trial in STI care in remote Aboriginal health services . The trial will provide evidence to inform future culturally appropriate STI clinical care and control strategies in communities with high STI rates . Trial registration Australian and New Zeal and Clinical Trials Registry Background Seventy percent of women in Scotl and have at least one baby , making pregnancy an opportunity to help most young women quit smoking before their own health is irreparably compromised . By quitting during pregnancy their infants will be protected from miscarriage and still birth as well as low birth weight , asthma , attention deficit disorder and adult cardiovascular disease . In the UK , the NICE guidelines : ‘ How to stop smoking in pregnancy and following childbirth ’ ( June 2010 ) highlighted that little evidence exists in the literature to confirm the efficacy of financial incentives to help pregnant smokers to quit . Its first research recommendation was to determine : Within a UK context , are incentives an acceptable , effective and cost-effective way to help pregnant women who smoke to quit ? Design and methods This study is a phase II exploratory individually r and omized controlled trial comparing st and ard care for pregnant smokers with st and ard care plus the additional offer of financial voucher incentives to engage with specialist cessation services and /or to quit smoking during pregnancy .  Participants ( n = 600 ) will be pregnant smokers identified at maternity booking who , when contacted by specialist cessation services , agree to having their details passed to the NHS Smokefree Pregnancy Study Helpline to discuss the trial . The NHS Smokefree Pregnancy Study Helpline will be responsible for telephone consent and follow-up in late pregnancy . The primary outcome will be self reported smoking in late pregnancy verified by cotinine measurement . An economic evaluation will refine cost data collection and assess potential cost-effectiveness while qualitative research interviews with clients and health professionals will assess the level of acceptance of this form of incentive payment . The research questions are : What is the likely therapeutic efficacy ? Are incentives potentially cost-effective ? Is individual r and omization an efficient trial design without introducing outcome bias ? Can incentives be introduced in a way that is feasible and acceptable ? Discussion This phase II trial will establish a workable design to reduce the risks associated with a future definitive phase III multicenter r and omized controlled trial and establish a framework to assess the costs and benefits of financial incentives to help pregnant smokers to quit . Trial registration Current Controlled Trials IS RCT Background Financial incentives have been used for many years internationally to improve quality of care in general practice . The aim of this pilot study was to determine if offering general practitioners ( GP ) a small incentive payment per test would increase  chlamydia testing in women aged 16 to 24 years , attending general practice . Methods General practice clinics ( n = 12 ) across Victoria , Australia , were cluster r and omized to receive either a $ AUD5 payment per chlamydia test or no payment for testing 16 to 24 year old women for chlamydia . Data were collected on the number of chlamydia tests and patient consultations undertaken by each GP over two time periods : 12 month pre-trial and 6 month trial period . The impact of the intervention was assessed using a mixed effects logistic regression model , accommodating for clustering at GP level . Results Testing increased from 6.2 % ( 95 % CI : 4.2 , 8.4 ) to 8.8 % ( 95 % CI : 4.8 , 13.0 ) ( p = 0.1 ) in the control group and from 11.5 % ( 95 % CI : 4.6 , 18.5 ) to 13.4 % ( 95 % CI : 9.5 , 17.5 ) ( p = 0.4 ) in the intervention group . Overall , the intervention did not result in a significant increase in chlamydia testing in general practice . The odds ratio for an increase in testing in the intervention group compared to the control group was 0.9 ( 95 % CI : 0.6 , 1.2 ) . Major barriers to increased chlamydia testing reported by GPs included a lack of time , difficulty in remembering to offer testing and a lack of patient awareness around testing . Conclusions A small financial incentive alone did not increase chlamydia testing  among young women attending general practice . It is possible small incentive payments in conjunction with reminder and feedback systems may be effective , as may higher financial incentive payments . Further research is required to determine if financial incentives can increase testing in Australian general practice , the type and level of financial scheme required and whether incentives needs to be part of a multi-faceted package . Trial Registration Australian New Zeal and Clinical Trial Registry ACTRN12608000499381 BACKGROUND Financial incentives promote many health behaviors , but effective ways to deliver health incentives remain uncertain . METHODS We r and omly assigned CVS Caremark employees and their relatives and friends to one of four incentive programs or to usual care for smoking cessation . Two of the incentive programs  targeted individuals , and two targeted groups of six participants . One of the individual-oriented programs and one of the group-oriented programs entailed rewards of approximately $ 800 for smoking cessation ; the others entailed refundable deposits of $ 150 plus $ 650 in reward payments for successful participants . Usual care included informational re sources and free smoking-cessation aids . RESULTS Overall , 2538 participants were enrolled . Of those assigned to reward-based programs , 90.0 % accepted the assignment , as compared with 13.7 % of those assigned to deposit-based programs ( P<0.001 ) . In intention-to-treat analyses , rates of sustained abstinence from smoking through 6 months were higher with each of the four incentive programs ( range , 9.4 to 16.0 % ) than with usual care ( 6.0 % ) ( P<0.05 for all comparisons ) ; the superiority of reward-based programs was sustained through 12 months . Group-oriented and individual-oriented programs were associated with similar 6-month abstinence rates ( 13.7 % and 12.1 % , respectively ; P=0.29 ) . Reward-based programs were associated with higher abstinence rates than deposit-based programs ( 15.7 % vs. 10.2 % , P<0.001 ) . However , in instrumental-variable analyses that accounted for differential acceptance , the rate of abstinence at 6 months was 13.2 percentage points ( 95 % confidence interval , 3.1 to 22.8 ) higher in the deposit-based programs than in the reward-based programs among the estimated 13.7 % of the participants who would accept participation in either type of program . CONCLUSIONS Reward-based programs were much more commonly accepted than deposit-based programs , leading to higher rates of sustained abstinence from smoking .  Group-oriented incentive programs were no more effective than individual-oriented programs . ( Funded by the National Institutes of Health and CVS Caremark ; Clinical Trials.gov number , NCT01526265 . ) In 1998 , the Institute of Medicine 's ( IOM 's ) National Roundtable on Health Care Quality noted that the quality of health care in the United States has substantial problems and that the problems will be addressed only through profound changes to the current health care system ( 1 ) . The recent IOM report ( 2 ) , Crossing the Quality Chasm , contained an unsettling list of studies documenting the prevalence of poor- quality care in the United States . Another IOM report ( 3 ) , To Err Is Human , focused specifically on the current state of patient safety and ways to improve it . All three of these reports recognized the potential for information technology to be an important agent for change . Computer physician order entry ( CPOE ) allows physicians to enter orders directly into a computer rather than h and writing them ( 46 ) . Because CPOE introduces supportive technology into orderingone of the key processes in medicineit has the potential to address many quality problems . Computer physician order entry affords a health care organization opportunities to st and ardize practice ; incorporate clinical decision support into daily practice ; improve interdepartmental communication ; facilitate patient transfers ; and capture data for management , research , and quality monitoring . It provides physicians and other clinicians with an environment that is more appropriate than a paper-based setting to the complexities of today 's medicine . Patients also can have the comfort of knowing that sophisticated technologies are being applied to help ensure their safety . Because implementing CPOE is an expensive and complex project that touches almost all aspects of the health care operation ( 4 ) , only a few health care organizations in the United States have implemented it ( 4 , 7 , 8) . However , such stakeholders as business , government ( 9 ) , and payers ( 10 ) are creating pressures and incentives for organizations to adopt CPOE . In particular , the Leapfrog Group ( 11 ) , a coalition of the country 's largest employers who are eager to acknowledge and reward health-related quality improvement efforts , has identified CPOE as one of three important leaps that organizations can take to substantially improve patient safety . Many health care organizations are moving forward with CPOE efforts . In 2002 , 67 % of respondents to a survey conducted at the Health Information Management and Systems Society ( HIMSS ) Annual Conference said that their organizations were planning to implement CPOE ; 21 % said that they were currently implementing it , and 29 % said that they were actively discussing it ( 12 ) . As health care organizations decide whether and when to tackle the hurdles of implementing CPOE , they should keep in the forefront of their minds the ways in which this technology can be used to improve health care quality and efficiency . We examine the potential benefits , costs , and other important issues associated with CPOE . Benefits of CPOE The National Roundtable on Health Care Quality ( 1 ) recognized that problems in health care quality fall into three categories : the underuse , overuse , and misuse of health care services . The Roundtable noted that reducing the overuse and misuse of health services leads to an increase in health care quality while decreasing costs . Reducing underuse increases quality but may increase costs .  Computerized physician order entry may affect all three categories of health care quality problems , as well as inefficiencies in the health care system . Table 1 lists studies that have evaluated the effect of CPOE on various aspects of health care . Table 1 . Studies Showing the Effect of Computer Physician Order Entry on Health Care Variables Several studies have shown that CPOE can reduce underuse . Dexter and colleagues ( 13 ) found that , for eligible patients , reminders in CPOE systems increased ordering rates for prophylactic aspirin for coronary artery disease , pneumococcal vaccine , influenza vaccine , and prophylactic subcutaneous heparin . Teich and colleagues ( 14 ) also found an increase in the use of  prophylactic subcutaneous heparin  with CPOE . Overhage and colleagues ( 15 ) demonstrated that compliance with the monitoring of drug levels doubled when automated ordering reminders were implemented . The effect of CPOE on care may depend greatly on the subtle details of the application design . In one evaluation , a decision support feature did not increase compliance with guidelines ( 16 ) ; however , success was realized after the design of the feature was enhanced ( 13 ) . Inappropriate admissions accounted for much of the overuse documented by the IOM report ( 2 ) ; CPOE applications may not be able to affect this problem . However , overuse of diagnostic procedures ( 31 , 32 ) and antibiotics ( 33 ) has been well documented and can be addressed by CPOE . As part of the interaction with the user , CPOE can present cost data ( 17 , 18 ) , previous results ( 19 , 20 ) , and information about the likelihood of finding an abnormal result ( 21 , 34 ) , all of which have been shown to reduce the overuse of diagnostic tests . In one trial , the Centers for Disease Control and Prevention 's guidelines for vancomycin use were embedded in a CPOE application ; 28 % ( P < 0.02 ) fewer patients were prescribed vancomycin or had their  vancomycin order renewed as compared with CPOE without the automated guidelines ( 26 ) . Of two CPOE-based interventions design ed to reduce the use of radiology examinations , one was successful ( 22 ) , while another had minimal impact ( 23 ) . In summary , more study is needed to underst and which quality problems are best suited to remedy by computerized intervention and which system design s are most successful in achieving behavioral change . Misuse of medications is an important concern that leads to various safety problems , including serious medication errors and preventable adverse drug events , as highlighted in the IOM 's recent report ( 3 ) . Two studies that examined the root cause of serious medication errors ( 35 , 36 ) showed that about half were ordering errors such as an incorrect choice of medication for the patient 's condition , an incorrect dose of the medication given the patient 's physiologic state ( for example , renal insufficiency or advanced age ) , and prescribing a medication to which the patient was known to be allergic . Computer physician order entry systems have the potential to address these problems , and studies have shown that CPOE systems can reduce medication errors ( 24 , 25 ) and associated costs and injuries ( 27 ) . The features of CPOE that promote the safe use of medications include patient-specific dosing suggestions ( 14 , 28 , 37 ) , reminders to monitor drug levels ( 15 ) , reminders to choose an appropriate drug ( 14 , 15 , 26 , 27 ) , checking for drugallergy and drugdrug interactions , st and ardized order sets ( that is , departmentally sanctioned predefined collection s of orders that promote safety and efficiency , especially in complex situations ) , increased legibility , automated communication to ancillary departments , and easy access to patient data and reference information while ordering ( 37 ) . A CPOE application with an integrated antibiotic advisor has been shown to reduce the rates of excessive drug dosages and antibiotic-susceptibility mismatches ( 27 ) . Additional medication-related benefits can be realized if CPOE is well integrated with other components of the medication process . The benefits of interfacing CPOE to a pharmacy application have been described ( 38 ) , and interfacing a CPOE application and an electronic medical administration record at one institution eliminated transcription errors ( 29 ) . Although the IOM report ( 3 ) focused on the misuse of medications in the inpatient setting , new data suggest that the magnitude of the problem is similar in the outpatient setting ( 3941 ) . Emerging technologies that automate prescribing and electronically link the ordering provider , the pharmacy , and the patient may address many medication-related problems in the ambulatory environment . Of note , CPOE applications are complex and are intended for use in complex health care environments . Although CPOE has the potential to reduce many sources of error , organizations must take care as CPOE is implemented so that new kinds of errors will not be introduced ( 25 , 42 ) . Most evaluations of CPOE have examined its effect on specific components of the care process , such as the use of diagnostic testing or medication error rates . A few studies have examined the effect of CPOE on overall hospital costs and length of stay . Evans and colleagues ( 27 ) demonstrated reduced costs ( $ 26 325 vs. $ 35 283 ; P < 0.005 ) and length of stay ( 10.0 days vs. 12.9 days ; P < 0.003 ) in patients in an intensive care unit when the suggestions of a computerized antibiotic advisor incorporated into the ordering process were followed . A r and omized , controlled trial at one hospital ( 30 ) indicated that inpatient costs were 12.7 % lower ( P < 0.02 ) and the length of stay was 0.89 day shorter ( P = 0.11 ) for patients on general medicine wards that used  CPOE  with decision support . In a time-series design , Mekhjian and colleagues ( 29 ) documented a decreased length of stay at one of two study hospitals from 3.91 days to 3.71 days ( P = 0.02 ) ; the length of stay at the other hospital in the study did not change , and overall costs at the two study hospitals did not change . Research ers are study ing ways that CPOE can help physicians plan a therapeutic regimen ( 43 , 44 ) . Such planning systems hold special promise for improving quality and safety ; however , they involve complex modeling of diagnosis and therapeutics ( 45 ) . To be successful , planning programs must be integrated tightly into the workflow of the application and must not require excessive additional data entry by the physician . To date , attempts at integrating complex clinical guidelines into CPOE have met with limited success ( 46 , 47 ) , largely because published guidelines , although suitable in printed form for use by practicing clinicians , have been difficult to translate Smoking during pregnancy is a leading preventable cause of poor pregnancy outcomes and immediate and longer-term adverse health outcomes among exposed offspring . Developing more effective smoking cessation interventions for pregnant women has been a public health priority for more than 30 years . We review developments over the past 3 years ( 2012–2015 ) on the use of financial incentives to promote smoking cessation among pregnant women . We search ed the literature for reports on primary and secondary analyses and review s of controlled trials on this topic published in peer- review ed journals using the search engine PubMed , review ed bibliographies of published articles , and consulted expert colleagues . The search revealed several important developments , with the following three being especially noteworthy . First , the review identified four new r and omized controlled trials , three of which further supported the efficacy of this treatment approach . One of the three trials supporting efficacy also included the first econometric analysis of this treatment approach showing financial incentives with pregnant smokers to be highly cost-effective . Second , two Cochrane review s were published during this 3-year period covering the more recent and earlier efficacy trials . Meta-analyses in both review s supported the efficacy of the approach . Lastly , the first effectiveness trial was reported demonstrating that  financial incentives increased abstinence rates above control levels when implemented by obstetrical clinic staff in a large urban hospital working with community tobacco interventionists . Overall , there is a growing and compelling body of evidence supporting the efficacy and cost-effectiveness of  financial incentives for smoking cessation among pregnant women PURPOSE Major primary care reforms have been introduced in recent years in the United Kingdom , including financial incentives to improve clinical quality and provide more rapid access to care . Little is known about the impact of these changes on patient experience . We examine patient reports of quality of care between 2003 and 2007 , including r and om sample s of patients on practice lists and patients with long-term conditions . METHODS We conducted a cross-sectional design study of family practice s in which  question naires were sent to serial sample s of patients in 42 representative general practice s in Engl and . Question naires sent to sample s of patients with chronic disease ( asthma , angina , and diabetes ) and r and om sample s of adult patients ( excluding patients who reported any long-term condition ) in 2003 , 2005 , and 2007 addressed issues of access , communication , continuity of care , coordination , nursing care , and overall satisfaction . RESULTS There were no significant changes in quality of care reported by either group of patients between 2003 and 2007 for communication , nursing care , coordination , and overall satisfaction . Some aspects of access improved significantly for patients with chronic disease , but not for the r and om sample s of patients . Patients in both sample s reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care . Most scores were significantly higher for the chronic illness sample s than for the r and om sample s of patients in 2003 , even after adjusting for age . CONCLUSIONS There was a modest improvement in access to care for patients with chronic illness , but all patients now find it somewhat harder to obtain continuity of care . This outcome may be related to the incentives to provide rapid appointments or to the increased number of specialized clinics in primary care . The possibility of unintended effects needs to be considered when introducing pay for performance schemes OBJECTIVES A r and omized controlled trial evaluated the impact of feedback and financial incentives on physician compliance with cancer screening guidelines for women 50 years of age and older in a Medicaid health maintenance organization ( HMO ) . METHODS Half of 52 primary care sites received the intervention , which included written feedback and a financial bonus .  Mammography , breast exam , colorectal screening , and Pap testing compliance rates were evaluated . RESULTS From 1993 to 1995 , screening rates doubled overall ( from 24 % to 50 % ) , with no significant differences between intervention and control group sites . CONCLUSIONS Financial incentives and feedback did not improve physician compliance with cancer screening guidelines in a Medicaid HMO Civilization and modern medicine now allow an unprecedented number of people to survive to old age . Not only has the definition of old evolved , but the aims of medical care for the elderly have progressed far beyond survival to maximizing functional and cognitive status , improving quality of life , and preserving productivity . Although many health problems in older age can be prevented or postponed by medical interventions , the quality of medical care for older persons remains largely unexamined . Previous work on quality -of-care measurement has focused on specific diseases or aspects of care , and in some cases targeted only a slice of the older population ( 16 ) . Such targeted approaches may not present a fair picture of overall quality and may lead to unintended incentives ( gaming the system ) ( 7 ) . Although broad systems of quality -of-care evaluation are less susceptible to gaming , they seldom include quality indicators focused on aspects of care important to older sick persons ( 8 , 9 ) . Substantial variation in preferences may make quality of care for older adults particularly difficult to measure . For example , older adults do not consistently prefer care that prolongs life , particularly if this care occurs at the expense of comfort . Furthermore , many ill , older adults can not advocate for themselves and may have no family members or friends to do so on their behalf . Thus , objective measures of the care they receive are particularly important . The Assessing Care of Vulnerable Elders ( ACOVE ) project endeavored to develop a comprehensive set of  quality - assessment tools for ill older persons . Because ill older persons constitute a heterogeneous cohort that is not easily delineated , we created a system to identify high-risk , community-dwelling individuals and targeted the most important clinical conditions affecting them . Specifically , our goals for this project were the following : 1 . Develop a definition of vulnerable elders that delineates a group of community-living persons 65 years of age and older who are at high risk for death or functional decline , and develop a system to identify them . 2 . Identify important medical conditions that affect vulnerable elders and for which effective methods of prevention or management exist . 3 . Develop a set of evidence -based , quality -of-care indicators that are relevant to vulnerable elders using systematic literature review s , expert opinion , and the guidance of expert groups and stakeholders . 4 . Design a chart abstract ion tool , interview instrument , and administrative data analytic methods to implement the quality -of-care indicator system . Project Structure : Advisory Boards To make the ACOVE tools as clinical ly useful as possible and to enhance their value to those who may use them , two advisory committees oversaw the project . The Clinical Committee directed the definition of the target population and identified the target conditions . It also review ed the full set of quality indicators assembled by the expert panels ( see the Methods paper ) . The Policy Advisory Committee directed the structure of the quality indicator system and the measurement approach . This committee review ed the sampling system , considered the value of a community surveybased sample versus a sample drawn from administrative data , advised the project on methods of data collection , and advocated the use of process measures rather than outcomes .Project Overview The Appendix lists the members and institutional affiliations of the Clinical Committee and the Policy Advisory Committee and ACOVE investigators and staff . Definition and Selection of the Patient Sample We termed our target sample vulnerable elders . With the assistance of the Clinical Committee , we defined vulnerable elders as persons 65 years of age and older who are at increased risk for death or functional decline . We considered several methods of identifying a community-based sample for measurement , including use of administrative data and survey sampling . The Policy Advisory Committee advised against using a sampling method based solely on administrative data because , by definition , using utilization data to define health status and disease burden disproportionately sample s persons with higher utilization of health services and may not identify persons who are undertreated or underdiagnosed . We selected a survey method that would identify vulnerable elders regardless of the amount of health care they used and that would be versatile for use across venues and health insurance systems . Using the Medicare Current Beneficiary Survey , we determined that functional status is a more important predictor of death and functional decline than are specific clinical conditions . A parsimonious set of factors that could be asked about in a brief interview , including age , self-rated health , and functional disabilities and limitations , predicted functional decline and death . Using these factors , we developed a scoring system that identified 32 % of a nationally representative sample as vulnerable : This group had more than four times the risk for death or functional decline over a 2-year period compared to the lower-scoring majority of the sample ( 10 ) . When we applied this definition to a r and om sample of persons 65 years of age and older enrolled in managed care plans , 21 % of elders were classified as vulnerable . Target Conditions for Assessing Quality of Care We selected the target conditions for quality -of-care assessment using literature review s and a formal group-judgment process . Target conditions were conceptualized as prevalent , important to health status and quality of life , having outcomes affected by medical care , feasible to measure , and geriatric . The Clinical Committee used these criteria to select 21 diseases , geriatric syndromes , physiologic impairments , and clinical situations ( see the Methods article for a list of these 21 conditions ) . The Policy Advisory Committee added a 22nd condition , continuity and coordination of care . According to national survey estimates , the prevalence of the selected conditions ranged from 10 % to 50 % among community-dwelling elders . These conditions accounted for at least 43 % of acute hospital admissions and 33 % of office visits for persons 65 years of age and older . The process of selecting the conditions is discussed in detail elsewhere ( 11 ) . Developing  Quality -of-Care Indicators  for Vulnerable Elders Clinical experts developed potential quality indicators for each target condition using existing guidelines and clinical opinion . Indicators covered the domains of prevention , diagnosis , treatment , and follow-up . Structured literature review s were then performed to assess the evidence supporting a link between the proposed processes of care and improved outcomes in older adults . We subsequently presented the proposed quality indicators and the literature syntheses to panels of experts in geriatric care and medical specialists . These expert panels considered the indicators ' validity and feasibility . On the basis of the panels ' ratings and a comprehensive review of the set by the Clinical Committee , we developed a set of 236  quality indicators  covering the 22 conditions . The Methods article describes this process in detail . This set of indicators was review ed and modified by the American College of PhysiciansAmerican Society of Internal Medicine ( ACPASIM ) Task Force on Aging . The full set of quality indicators with the literature substantiation for 11 of the conditions constitute the remainder of this supplement . A review of the accepted quality indicators reveals their decidedly geriatric nature . Many of them focus on the transfer of information between the health care provider and the patient or patient 's proxy . In addition to disease management , the indicators pay attention to detecting classically underidentified conditions , such as depression , dementia , and functional impairment . Consideration of proportionate care , informed consent , and end-of-life issues permeates the set . Implementing the Quality Indicators We developed instruments to implement the quality indicators using information collected from three sources : the medical record , a patient ( or , if necessary , proxy ) interview , and administrative data . Medical records include all inpatient and outpatient care over a 1-year period . The interview is design ed to be conducted by telephone with the patient to identify aspects of care that are not well captured in the medical record . The  quality indicators  presented here are currently undergoing feasibility testing in two managed care plans . Scoring the quality indicators accounts for clinical circumstances , patient preferences , and patient prognosis . The scoring of each quality indicator accounts for these factors at the following five levels : 1 . Any chart documentation indicating that a care process does not apply to the patient excludes application of this indicator to the patient . 2 . Any care process that is contraindicated because of comorbidity , allergy , or intolerance ( such as contraindications to medication ) excludes application of the indicator to the patient . 3 . If an indicator states that a care process should be offered to a patient , this indicator is satisfied if the care process occurs , if the medical record ( or patient interview ) indicates that the patient rejected the care process , or if the medical record ( or patient interview ) documents that the care process was offered to the patient . 4 . If the medical record contains documentation or if during an interview a patient states that he or she would not want , under any circumstances , to be hospitalized , then the 11 indicators that would require hospitalization do not apply . Similarly , a preference not to accept surgery would exclude from application to that patient the 9 indicators that prescribe surgery or procedures that would lead to surgery . 5 . If a patient has advanced dementia or a chart-documented poor prognosis ( expected survival < 6 months ) , then Background In 2003 Germany started to replace its per-day hospital payment system by a prospect i ve payment system based on diagnosis related groups ( DRG ) . The primary objective of the program was to increase economic efficiency of hospital care . The introduction was accompanied by fears that quality of care could deteriorate when hospitals withhold necessary care in order to increase profits . Outpatient physicians expected an increase in their workload , which could probably lead to financial losses if it were not followed by an increase of their reimbursement . In order to detect possible adverse effects , the Statutory Health Insurance ( SHI ) was obligated by law to commission independent observational research on this question Background Despite a gradual increase in breastfeeding rates , overall in the UK there are wide variations , with a trend towards breastfeeding rates at 6–8 weeks remaining below 40 % in less affluent areas . While financial incentives have been used with varying success to encourage positive health related behaviour change , there is little research on their use in encouraging breastfeeding . In this paper , we report on healthcare providers ’ views around whether using financial incentives in areas with low breastfeeding rates would be acceptable in principle . This research was part of a larger project looking at the development and feasibility testing of a financial incentive scheme for breastfeeding in preparation for a cluster r and omised controlled trial . Methods Fifty – three healthcare providers were interviewed about their views on financial incentives for breastfeeding . Participants were purposively sample d to include a wide range of experience and roles associated with supporting mothers with infant feeding . Semi-structured individual and group interviews were conducted . Data were analysed thematically drawing on the principles of Framework Analysis . Results The key theme emerging from healthcare providers ’ views on the acceptability of financial incentives for breastfeeding  was their possible impact on ‘ facilitating or impeding relationships ’ . Within this theme several additional aspects were discussed : the mother ’s relationship with her healthcare provider and services , with her baby and her family , and with the wider community . In addition , a key priority for healthcare providers was that an incentive scheme should not impact negatively on their professional integrity and responsibility towards women . Conclusion Healthcare providers believe that financial incentives could have both positive and negative impacts on a  mother ’s relationship with her family , baby and healthcare provider . When design ing a financial incentive scheme we must take care to minimise the potential negative impacts that have been highlighted , while at the same time recognising the potential positive impacts for women in areas where breastfeeding rates are low Despite the high risk of tobacco-related morbidity and mortality among low-income persons , few studies have connected low-income smokers to evidence -based treatments . We will examine a smoking cessation intervention integrated into primary care . To begin , we completed qualitative formative research to refine an intervention utilizing the services of a patient navigator trained to promote smoking cessation . Next , we will conduct a r and omized controlled trial combining two interventions : patient navigation and financial incentives . The goal of the intervention is to promote smoking cessation among patients who receive primary care in a large urban safety-net hospital . Our intervention will encourage patients to utilize existing smoking cessation re sources ( e.g. , quit lines , smoking cessation groups , discussing smoking cessation with their primary care providers ) . To test our intervention , we will conduct a r and omized controlled trial , r and omizing 352 patients to the intervention condition ( patient navigation and financial incentives ) or an enhanced traditional care control condition .  We will perform follow-up at 6 , 12 , and 18 months following the start of the intervention . Evaluation of the intervention will target several implementation variables : reach ( participation rate and representativeness ) , effectiveness ( smoking cessation at 12 months [ primary outcome ] ) , unintended consequences ( e.g. , purchase of illicit substances with incentive money ) , adoption ( use of intervention across primary care suites ) , implementation ( delivery of intervention ) , and maintenance ( smoking cessation after conclusion of intervention ) . Improving the implementation of smoking cessation interventions in primary care setting s serving large underserved population s could have substantial public health impact , reducing cancer-related morbidity/mortality and associated health disparities
The intervention sites admitted statistically significantly more severely ill patients  than nursing homes in the control group .
Despite the
In the report Crossing the Quality Chasm ( 1 ) , the Institute of Medicine called attention to the poor quality of health care in the United States .
The Institute identified numerous factors contributing to poor quality , including the structure of the present health care payment system .
The Institute found that , for certain clinical situations , health care payment arrangements may actually produce disincentives for quality .
The largely untapped potential of the health care payment system to change physician and health care system behavior has stimulated interest in both the scientific literature ( 2 , 3 ) and the popular press ( 4 - 6 ) for linking payments to performance on quality measures .
Several health plans ( 3 , 7 ) and the Centers for Medicare & Medicaid Services are using explicit financial incentives for quality ( 8 , 9 ) .
For example , what types of clinical conditions or health care services should be the target of financial incentives to improve quality : chronic diseases , acute care , or preventive care services ?
How effective ( and cost-effective ) are financial incentives for quality ?
What are the optimum magnitude , frequency , and duration of financial incentives for quality ?
What is the optimum package of nonfinancial interventions ( if any ) to include with financial incentives for quality , for example , audit and feedback , recognition , clinical reminders , academic detailing , or information technology support ( 12 , 13 ) ?
Can we expect the effect of financial incentives to persist after they are stopped ?
Because any effective intervention will have some unanticipated effects , will important patient care activities that are not rewarded financially be neglected ?
The purpose of this paper is to assess the relationship between explicit financial incentives and the provision of high- quality health care by systematic ally review ing empirical studies .
Because the evidence regarding the relationship between the financial incentives embedded in fee-for-service and capitation arrangements and the quality of health care has been thoroughly review ed in previous work ( 14 ) , we focused our review on literature that addresses explicit financial rewards for improving health care quality .
Methods Study Identification and Selection We conducted a systematic search of the English- language literature in PubMed to find articles published between 1 January 1980 and 14 November 2005 whose main objective was to assess the use of explicit financial incentives to improve health care quality .
Access to care is the patient 's attainment of timely and appropriate health care .
Structure of care is a feature of a health care organization or clinician relevant to the provision of health care .
Process of care is a health care service provided to or on behalf of a patient .
Outcome of care is a health state of a patient result ing from health care .
Concurrent comparison groups are important because some studies of quality may show dramatic improvement over time but no statistically significant differences between intervention and comparison groups .