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IIR 04-349 – HSR&D Study

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IIR 04-349
RCT of Financial Incentives to Translate ALLHAT into Practice
Laura A Petersen MD MPH
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: December 2005 - September 2012

BACKGROUND/RATIONALE:
Contradictory findings and varying methods of implementation of pay-for-performance programs leave many questions unanswered, and a number of authors have called for more evidence to enhance decision making about the use of performance-based payments. Furthermore, as health care organizations restructure their primary care delivery models to implement the patient-centered medical home and other models of accountable care, financial arrangements that reward the health care provider team will become of more interest to payers and policy makers. Therefore, we used a cluster randomized controlled trial to test the effect of explicit financial incentives to reward guideline-recommended care for hypertension in the VA primary care setting. Inadequate blood pressure (BP) control results in excess cases of coronary artery disease, congestive heart failure, renal insufficiency, peripheral arterial disease, and stroke. Even small reductions in BP translate into significant reduction in risk of morbidity and mortality and reduced health systems costs.

OBJECTIVE(S):
The goals of the study were to: (1) determine the effect of group-level financial incentives on processes and outcomes of care for outpatients with hypertension; (2) evaluate the persistence of the effect of incentives; (3) identify any unintended consequences of these explicit incentives on patients and/or the health care delivery system; (4) determine the relative cost-effectiveness of providing incentives; and (5) evaluate whether measures of compliance with JNC 7guidelines obtained via detailed chart review can be approximated using automated processing of structured fields from electronic health record (AP-EHR) data.

METHODS:
We randomized 83 primary care physicians and 42 non-physician staff (e.g., nurses) from 5 VA Networks. The financial incentive intervention phase included a 4-month performance baseline period and 4 consecutive 4-month performance periods, followed by a 12-month wash-out. Physicians earned incentives for prescribing JNC 7 guideline-recommended antihypertensive medications and achieving guideline-recommended BP thresholds or appropriately responding to uncontrolled BP within 6 weeks. For each physician per performance period, these measures were assessed via chart review for a random sample of 40 patients with hypertension. The aggregated earnings of the physician participants were equally distributed between the physician and non-physician participants in the group.

We performed a repeated measures longitudinal analysis to evaluate the effect of the intervention. The unit of analysis was the physician. We evaluated 2 different predictors for each study outcome: (1) each incentive arm versus the control arm and (2) group-level incentive arms versus the control arm. Models were developed independently for each predictor and each outcome. We used linear regression to model the effect of the washout period on providers' performance. The dependent variable was the physician's performance in the post-washout period and a covariate in the model was the physician's performance for the final intervention period. We constructed a maximal model using scientifically relevant covariates selected a priori, and then performed backward elimination to delete variables of no value, arriving at our final models.


FINDINGS/RESULTS:
The average total of the group-level incentive payments across the intervention period for the physicians was $1,648 and $1,540 for the non-physician staff. In an adjusted model, the rate of change in the proportion of the physician's patients achieving BP control or receiving an appropriate response to uncontrolled BP was 3.71 percentage points greater over the course of the study for physicians in the group incentive arms than for physicians in the control arm (p<0.01). This means that a typical study physician in the arms receiving a group-level incentive with a panel size of 1,000 patients with hypertension would be expected to have about 37 additional patients achieving BP control or receiving an appropriate response to uncontrolled BP after one year of exposure to the intervention. We did not find significant differences in the rate of change in the proportion of patients receiving guideline-recommended medications in any of the intervention arms compared to the control arm.

Given providers' performance in the final intervention period, we found performance for the BP control or appropriate response outcome significantly decreased in the post-washout performance period for the group incentive arms when compared to the control arm.

Among eligible patients, we assessed measures unrelated to hypertension treatment (e.g., glycemic control, colorectal cancer (CRC) screening) before the intervention (baseline) and for the final intervention performance period. We did not find any significant differences on the unrelated measures between the control arm patients and patients treated by providers receiving incentives. For example, in the final intervention performance period, 80.4% of eligible patients in the control arm and 78.7% of patients in the incentive arms had received appropriate CRC screening (p=0.44). We did not find a greater incidence of hypotension among patients treated by providers in the incentive arms versus controls.

We did not evaluate the cost effectiveness of the intervention because blood pressure fell less than 3 mm Hg in high-risk groups over the course of the study.

Compared to data collected via chart review, total incentive earnings for the final intervention period for appropriate medications and BP control decreased by 11.7% and 4.0%, respectively, using AP-EHR data (e.g., CDW). Compared to chart review data, 84.6% of cases had the same comorbidity history in the AP-EHR data. In the chart review data, 72.3% received guideline-recommended medications compared to only 64.1% in the AP-EHR data (kappa = 0.50). Based on AP-EHR data, 66.8% had controlled BP compared to 69.5% in the chart review data (kappa = 0.87).

IMPACT:
This trial addresses the needs of policy makers and payers for information about a clinically relevant intervention in routine practice. We are not aware of other ongoing randomized trials of pay for performance directed at physicians and provider groups. To our knowledge, we are one of the first to test studies to whether the effect of incentives is sustained after the incentives cease. With the implementation of PACT into the primary care setting, improving team-based health care delivery is an imperative in the VA, and understanding how to structure group awards is essential. Our assessment of kappa results using AP-EHR data will aid with possible implementation of the incentives.

PUBLICATIONS:

Journal Articles

  1. Hysong SJ, SoRelle R, Broussard Smitham K, Petersen LA. Reports of unintended consequences of financial incentives to improve management of hypertension. PLoS ONE. 2017 Sep 21; 12(9):e0184856.
  2. Petersen LA, Ramos KS, Pietz K, Woodard LD. Impact of a Pay-for-Performance Program on Care for Black Patients with Hypertension: Important Answers in the Era of the Affordable Care Act. Health services research. 2017 Jun 1; 52(3):1138-1155.
  3. Hysong SJ, Kell HJ, Petersen LA, Campbell BA, Trautner BW. Theory-based and evidence-based design of audit and feedback programmes: examples from two clinical intervention studies. BMJ quality & safety. 2017 Apr 1; 26(4):323-334.
  4. Petersen LA, Simpson K, Pietz K, Urech TH, Hysong SJ, Profit J, Conrad DA, Dudley RA, Woodard LD. Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial. JAMA. 2013 Sep 11; 310(10):1042-50.
  5. Hysong SJ, Simpson K, Pietz K, SoRelle R, Broussard Smitham K, Petersen LA. Financial incentives and physician commitment to guideline-recommended hypertension management. The American journal of managed care. 2012 Oct 1; 18(10):e378-91.
  6. Woodard LD, Landrum CR, Urech TH, Wang D, Virani SS, Petersen LA. Impact of clinical complexity on the quality of diabetes care. The American journal of managed care. 2012 Sep 1; 18(9):508-14.
  7. Petersen LA, Simpson K, Sorelle R, Urech T, Chitwood SS. How variability in the institutional review board review process affects minimal-risk multisite health services research. Annals of internal medicine. 2012 May 15; 156(10):728-35.
  8. Petersen LA, Urech T, Simpson K, Pietz K, Hysong SJ, Profit J, Conrad D, Dudley RA, Lutschg MZ, Petzel R, Woodard LD. Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol. Implementation science : IS. 2011 Oct 3; 6(1):114.
  9. Virani SS, Steinberg L, Murray T, Negi S, Nambi V, Woodard LD, Bozkurt B, Petersen LA, Ballantyne CM. Barriers to non-HDL cholesterol goal attainment by providers. The American journal of medicine. 2011 Sep 1; 124(9):876-80.e2.
  10. Woodard LD, Urech T, Landrum CR, Wang D, Petersen LA. Impact of comorbidity type on measures of quality for diabetes care. Medical care. 2011 Jun 1; 49(6):605-10.
  11. Petersen LA, Woodard LD, Henderson LM, Urech TH, Pietz K. Will hypertension performance measures used for pay-for-performance programs penalize those who care for medically complex patients? Circulation. 2009 Jun 16; 119(23):2978-85.
  12. Petersen LA, Simpson K, Urech T, Woodard L, Hysong S, Dudley RA. Do financial incentives to health care providers generate greater interest in adhering to performance measures than audit and feedback alone. Journal of general internal medicine. 2009 Apr 1; 24(S1):S58-S59.
  13. Petersen LA. Pay for performance in myocardial infarction: are we reaping the rewards? National Clinical Practice of Cardiovascular Medicine. 2008 Mar 1; 5(3):134-5.
  14. Petersen LA, Urech TH, Byrne MM, Pietz K. Do financial incentives in a globally budgeted healthcare payment system produce changes in the way patients are categorized? A five-year study. The American journal of managed care. 2007 Sep 1; 13(9):513-22.
  15. Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does pay-for-performance improve the quality of health care? Annals of internal medicine. 2006 Aug 15; 145(4):265-72.
Journal Other

  1. Petersen LA, Woodard LD, Urech TH. Financial incentives to control hypertension in patients--reply. JAMA : the journal of the American Medical Association. 2014 Jan 15; 311(3):303-4.
  2. Woodard LD, Petersen LA. Improving the performance of performance measurement. [Editorial]. Journal of general internal medicine. 2010 Feb 1; 25(2):100-1.
  3. Petersen A, Woodard D, Urech, Daw, Sookanan. Does Pay for Performance Improve the Quality of Health Care? [Letter to the Editor]. Annals of internal medicine. 2007 Jan 1; 146(7):538-539.
Conference Presentations

  1. Petersen LA. Data Transparency: Necessary but not Necessarily Sufficient for Changing Quality in Health Care. Paper presented at: University of Pennsylvania Invited Presentation; 2016 Jun 23; Philadelphia, PA.
  2. Petersen LA, SoRelle R, Smithan KB, Hysong SJ. Unintended Consequences of Pay for Performance to Improve Management of Hypertension: A qualitative examination of study participants’ experiences. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 9; San Diego, CA.
  3. Petersen LA, Simpson K, Pietz K, Woodard LD. Impact of a Pay-for-Performance Program on Care for Minority Patients with Hypertension: Important Answers in the Era of the Affordable Care Act. Poster session presented at: Baylor College of Medicine Quality and Safety Annual Conference; 2014 May 15; Houston, TX.
  4. Simpson KL, Woodard L, Pietz KC, Petersen LA. Do financial incentives for guidelines adherence improve HTN care for African-Americans patients? A multi-site RCT. Paper presented at: VA HSR&D National Meeting; 2012 Jul 18; Washington, DC.
  5. Petersen LA, Simpson K, Pietz K, Lutschg MZ, Hysong SJ, Profit J, Petzel R, Woodard LD. Do financial incentives for guideline adherence improve care of hypertension in the VA primary care setting? Paper presented at: VA HSR&D National Meeting; 2012 Jul 17; Washington, DC.
  6. Petersen LA, Urech T, Simpson K, Woodard LD, Kuebeler M, Dudley RA, Lutschg MZ. Impact of using data from structured fields in electronic health records vs. chart abstracted data on calculations of financial incentives for health care providers in a pay-for-performance program. Poster session presented at: AcademyHealth Annual Research Meeting; 2012 Jun 24; Orlando, FL.
  7. Urech T, Simpson K, Woodard LD, Virani S, Kuebeler M, Dudley RA, Lutschg MZ, Petersen LA. Measuring guideline-recommended care of hypertension: Agreement between chart review and automated processing of electronic medical record data. Poster session presented at: AcademyHealth Annual Research Meeting; 2012 Jun 24; Orlando, FL.
  8. Petersen LA, Urech TH, Simpson K, Woodard LD, Virani S, Kuebeler MK, Lutschg M, Dudley RA. Impact of using administrative vs, chart-abstracted data on calculations of financial incentives for health care providers in a pay-for-performance program. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2012 May 9; Orlando, FL.
  9. Petersen LA, Simpson K, Woodard LD, Pietz KC, Urech TH, Lutschg MZ, Hysong SJ. Do financial incentives for guideline adherence improve care of hypertension in the primary care setting: A multi-Site RCT. Paper presented at: AcademyHealth Annual Research Meeting; 2011 Jun 13; Seattle, WA.
  10. Petersen LA, Simpson K, Woodard LD, Pietz KC, Urech TH, Zimmer M, Hysong SJ, Conrad D, Profit J, Dudley RA. Do financial incentives for guidelines adherence improve care of hypertension in the primary care setting? A multi-site RCT. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 4; Phoenix, AZ.
  11. Petersen LA, Simpson K, Urech T, Woodard L, Hysong S, Dudley RA. Incorporating equity into quality improvements agendas. Paper presented at: RWJ Foundation Aligning Forces for Quality National Meeting; 2010 Nov 18; Orlando, FL.
  12. Petersen LA, Woodard LD, Simpson K. Financial incentives generate greater interest in performance than audit and feedback alone. Poster session presented at: RWJ Foundation Finding Answers Annual Grantee Conference; 2009 Oct 1; Chicago, IL.
  13. Petersen LA. Benefits and unintended consequences of pay-for-performance programs. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.
  14. Petersen LA, Simpson K, Urech T, Woodard L, Hysong S, Dudley RA. Do financial incentives to health care providers generate greater interest in adhering to performance measures than audit and feedback alone? Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.
  15. Petersen LA, Simpson K, Urech T, Woodard L, Hysong S, Dudley RA. Do financial incentives to health care providers generate greater interest in adhering to performance measures than audit and feedback alone? Poster session presented at: Society of General Internal Medicine Annual Meeting; 2009 May 13; Miami, FL.
  16. Petersen A, Woodard, Henderson M, Urech H, Pietz. Will Performance Measures used for Pay-For-Performance Programs Penalize Those Who Care for Medically Complex Patients? Paper presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 10; Denver, CO.
  17. Petersen LA. Development and Implementation of Performance Measures in the Department of Veterans Affairs Medical System: a research perspective. Paper presented at: AcademyHealth Annual Research Meeting; 2007 Jun 1; Orlando, FL.
  18. Petersen LA. Pay for Performance: Is there a link between process and outcomes measures? Paper presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2007 May 1; Washington, DC.
  19. Petersen LA, Nguyen LC, Urech TH, Zimmer M, Alsarraj A, Soliz E, Petzel R. 46 IRB submissions and counting: how variability in the IRB review process impacts multi-site VA health services research. Presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA.
  20. Petersen LA. Is Pay for Performance Effective in Improving the Quality of Health Care. Paper presented at: Society of General Internal Medicine Annual Meeting; 2006 Apr 26; Houston, TX.
  21. Petersen A. Is Pay for Performance Effective in Improving the Quality of Health Care? A Project in Partnership with VA Networks. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.


DRA: Health Systems
DRE: Prevention
Keywords: Cardiovasc’r disease, Primary care
MeSH Terms: none

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