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Publication Briefs

Study Suggests Improvement in VA Patient Outcomes Related to Pay-for-Performance Remains after Removal of Incentives

Pay-for-Performance (P4P) has become a central strategy for improving the quality of healthcare in the US, Canada, and the UK, and such programs have become widely adopted. Despite the growing prevalence of P4P programs, numerous questions persist about their effectiveness in improving quality of care, particularly about sustainability once the incentive is removed. A multi-year P4P initiative within the VA healthcare system included the adoption and removal of performance-based incentives for selected quality measures. This observational cohort study sought to investigate the sustainability of performance levels following removal of performance-based incentives. Investigators focused on seven inpatient quality of care measures for acute coronary syndrome, heart failure, and pneumonia that were linked to performance-based incentives. The study sample included 128 acute care VA hospitals and 313,600 VA patient records that were assessed across the seven measures between 2004 and 2010.


  • Performance improvements that occurred across 128 VA hospitals for three common conditions among Veterans - acute coronary syndrome, heart failure, and pneumonia - were sustained for up to three years after performance-based incentives were removed.
  • For six of the seven performance measures, mean performance was over 90% prior to removal of the incentives. The only measure that did not demonstrate significant improvement over the study period was the heart failure measure for ACE-inhibitor/ARB therapy prior to admission.


  • This study included a relatively small number of performance measures, as well as a relatively brief post-incentive removal period of between one and three years.
  • This study does not indicate how performance may change if incentives are removed before a high level of performance is reached.
  • The absence of a comparison group limited the investigators' ability to isolate the effects of the performance-based incentives from other factors, such as a secular trend or public reporting that may have contributed to changes in the performance measures during the study period.

This project was funded by HSR&D (IIR 08-067). All authors, except Dr. Kaboli, are part of HSR&D's Center for Organization, Leadership, and Management Research, Boston, MA. Dr. Kaboli is part of HSR&D's Comprehensive Access and Delivery Research and Evaluation Center, Iowa City, IA.

PubMed Logo Benzer J, Young G, Burgess J, Baker E, Mohr D, Charns M, and Kaboli P. Sustainability of Quality Improvement Following Removal of Performance-Based Incentives. Journal of General Internal Medicine August 9, 2013;Epub ahead of print.

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