Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care
Authors: Laura A. Petersen, Kate Simpson, Kenneth Pietz, Tracy H. Urech, Sylvia J. Hysong, Jochen Profit, Douglas A. Conrad, R. Adams Dudley, LeChauncy D. Woodard
Journal: JAMA (2013)

<h3>Importance</h3> Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory. <h3>Objective</h3> To test the effect of explicit financial incentives to reward guideline-recommended hypertension care. <h3>Design, Setting, and Participants</h3> 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). <h3>Interventions</h3> 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. <h3>Main Outcomes and Measures</h3> 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. <h3>Results</h3> 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. <h3>Conclusions and Relevance</h3> 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. <h3>Trial Registration</h3> clinicaltrials.gov Identifier:NCT00302718