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Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized
Laura A Petersen1, Kate Simpson, Kenneth Pietz
1Health Policy and Quality Program, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas 77030, USA. laura.petersen@va.gov
Insights
Individual financial incentives improved hypertension care, but not medication use or hypotension rates. The positive effects on blood pressure control were not sustained after the incentive program ended.
Area of Science:
- Health Services Research
- Clinical Quality Improvement
- Health Economics
Background:
- Pay-for-performance programs aim to enhance healthcare quality by aligning financial incentives with desired clinical outcomes.
- Previous studies on pay-for-performance in hypertension care have yielded mixed results regarding effectiveness.
- Understanding the impact of different incentive structures is crucial for optimizing quality improvement initiatives.
Purpose of the Study:
- To evaluate the effectiveness of explicit financial incentives on guideline-recommended hypertension care.
- To compare the impact of individual-level, practice-level, and combined financial incentives on hypertension management.
- To assess the influence of these incentives on blood pressure control, medication adherence, and patient safety.
Main Methods:
- A cluster randomized trial involving 12 Veterans Affairs outpatient clinics.
- 83 primary care physicians and 42 nonphysician personnel participated across 5 performance periods.
- Interventions included individual, practice-level, combined financial incentives, or no incentives, with feedback reports available to all.
Main Results:
- Individual financial incentives significantly improved blood pressure control and appropriate response to uncontrolled blood pressure compared to controls (8.36% increase).
- Practice-level and combined incentives did not show a significant improvement in blood pressure control over controls.
- No significant differences were observed in the use of guideline-recommended medications or the incidence of hypotension across all incentive groups compared to the control group.
- The positive effects on blood pressure control were not sustained after a 12-month washout period.
Conclusions:
- Individual financial incentives demonstrated a modest but significant positive impact on hypertension control.
- Practice-level or combined incentives were less effective in improving hypertension care outcomes.
- The study highlights the need for further research into the sustainability and underlying mechanisms of financial incentives in healthcare quality improvement.
- The findings suggest that incentive design is critical for achieving desired clinical outcomes in hypertension management.
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 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).
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 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 And Relevance:
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.
Trial Registration:
clinicaltrials.gov Identifier: NCT00302718.
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