Financial Incentives to Translate ALLHAT Into Practice: A Randomized Trial

Background:

Despite compelling evidence of the benefits of treatment, hypertension is controlled in less
than one-quarter of US citizens. Using a cluster randomized controlled trial, we tested the
effect of explicit physician-level and practice-level financial incentives to promote the
provision of guideline-recommended anti-hypertensive medications and improved control of
hypertension in the VA primary care setting.

Objectives:

The goals were to: (1) determine the effect of physician-level financial incentives on
processes and outcomes of care for outpatients with hypertension; (2) assess the impact of
practice-level incentives; (3) ascertain whether there were additive or synergistic effects
of physician- and practice-level incentives; (4) evaluate the persistence of the effect of
incentives after the intervention ceases; and (5) identify any negative impacts of incentives
on patients, providers, or health care organizations.

Methods:

We randomized 12 VA hospital-based outpatient clinics to the following arms: (1)
physician-level incentives; (2) practice-level incentives; (3) physician- and practice-level
incentives; and (4) no incentives. We enrolled 83 primary care physicians and 42 practice
group members (e.g., nurses). All participants received audit and feedback performance
reports. Study measures included the use of guideline-recommended anti-hypertensive
medications and the proportion of patients who achieved national (JNC 7)
guideline-recommended blood pressure goals or received an appropriate response to
uncontrolled blood pressure. The intervention period consisted of five four-month performance
periods. For each period, trained reviewers collected medications, blood pressure readings,
comorbid conditions, medication allergies, and lifestyle recommendations from the VA
electronic health record system for a sample of eligible patients from the physicians'
panels. After the final performance report, we implemented a 12-month washout period. To
determine the impact of incentives for the intervention period, we performed a
repeated-measures longitudinal analysis using the hospital as a random effect. We evaluated
the rate of change in the proportion of patients who met the study measures over time for the
intervention group physicians. We assessed post-washout performance using a linear analysis
with clustering by hospital. To evaluate unintended consequences of the incentives, we
examined the incidence of hypotension in the physicians' panels.

Status:

The study is completed. The primary findings were published in September 2013 in the Journal
of the American Medical Association (JAMA). We are currently preparing manuscripts describing
findings from the study's secondary aims.

Inclusion Criteria:

Study participants had to be full-time primary care physicians employed by the Veterans
Health Administration (VA) at one of the 12 VA hospitals that participated in the study.

We defined a full-time primary care physician as spending at least 0.60 full-time
equivalent (FTE) delivering patient care services in the primary care setting or having a
panel size of at least 500 patients at the time of study arm randomization. The primary
care settings included internal medicine, primary care medical clinics, and women's health
care clinics. The trial did not actively recruit patients into the study. This study
retrospectively reviewed a random sample of health records of eligible patients that had
clinical encounters with the physician participants.

Exclusion Criteria:

The study did not include VA physicians that were trainees.