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Financial Incentives to Translate ALLHAT Into Practice: A Randomized Trial

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ClinicalTrials.gov Identifier: NCT00302718
Recruitment Status : Completed
First Posted : March 14, 2006
Results First Posted : December 15, 2014
Last Update Posted : April 24, 2015
Sponsor:
Collaborator:
National Heart, Lung, and Blood Institute (NHLBI)
Information provided by (Responsible Party):
VA Office of Research and Development ( US Department of Veterans Affairs )

Study Type Interventional
Study Design Allocation: Randomized;   Intervention Model: Parallel Assignment;   Masking: None (Open Label);   Primary Purpose: Health Services Research
Condition Hypertension
Interventions Behavioral: Physician-level financial incentives
Behavioral: Practice-level financial incentives
Behavioral: Physician- and practice-level financial incentives
Enrollment 83
Recruitment Details We enrolled non-physician primary care personnel at the hospitals randomized to the two study arms that tested the effect of practice-level incentives. Only data from physicians were used to assess both physician-level and practice-level performances. This participant enrollment table does not include data on the non-physician participants.
Pre-assignment Details  
Arm/Group Title Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control)
Hide Arm/Group Description

Examines the effect of physician-level financial incentives on hypertension quality of care

Physician-level financial incentives: Enrolled physician participants were eligible to receive financial incentives based on their performance during a 4-month interval on the hypertension care study outcomes.

Examines the effect of practice-level financial incentives on hypertension quality of care

Practice-level financial incentives: Enrolled practices (physician participants and non-physician primary care personnel) were eligible to receive financial incentives based on the performance of the practice during a 4-month interval on the hypertension care study outcomes.

Examines the effect of physician and practice-level financial incentives on hypertension quality of care

Physician- and practice-level financial incentives: Enrolled subjects were eligible to receive financial incentives based on performance during a 4-month interval on the hypertension care study outcomes. This arm tested the effect of combined financial incentives.

Physician participants in the control group did not receive any financial incentives. They received audit and feedback performance reports at the end of each performance period like the intervention groups.
Period Title: Overall Study
Started 20 21 21 21
Completed 19 20 19 19
Not Completed 1 1 2 2
Reason Not Completed
Participant left the hospital             1             0             0             1
Withdrawal by Subject             0             1             0             0
Participant left primary care setting             0             0             2             1
Arm/Group Title Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control) Total
Hide Arm/Group Description

Examines the effect of physician-level financial incentives on hypertension quality of care

Physician-level financial incentives: Enrolled physician participants were eligible to receive financial incentives based on their performance during a 4-month interval on the hypertension care study outcomes.

Examines the effect of practice-level financial incentives on hypertension quality of care

Practice-level financial incentives: Enrolled practices (physician participants and non-physician primary care personnel) were eligible to receive financial incentives based on the performance of the practice during a 4-month interval on the hypertension care study outcomes.

Examines the effect of physician and practice-level financial incentives on hypertension quality of care

Physician- and practice-level financial incentives: Enrolled subjects were eligible to receive financial incentives based on performance during a 4-month interval on the hypertension care study outcomes. This arm tested the effect of combined financial incentives.

Physician participants in the control group did not receive any financial incentives. They received audit and feedback performance reports at the end of each performance period like the intervention groups. Total of all reporting groups
Overall Number of Baseline Participants 19 20 19 19 77
Hide Baseline Analysis Population Description
Distribution of Physician Characteristics Across Study Groups
Age, Continuous   [1] 
Mean (Standard Deviation)
Unit of measure:  Years
Number Analyzed 19 participants 20 participants 19 participants 19 participants 77 participants
45  (8) 48  (8) 44  (6) 48  (7) 46  (8)
[1]
Measure Description: One physician participant in the physician-level incentive arm declined to provide age data.
Sex: Female, Male  
Measure Type: Count of Participants
Unit of measure:  Participants
Number Analyzed 19 participants 20 participants 19 participants 19 participants 77 participants
Female
11
  57.9%
8
  40.0%
9
  47.4%
6
  31.6%
34
  44.2%
Male
8
  42.1%
12
  60.0%
10
  52.6%
13
  68.4%
43
  55.8%
Race/Ethnicity, Customized   [1] 
Measure Type: Number
Unit of measure:  Participants
Number Analyzed 19 participants 20 participants 19 participants 19 participants 77 participants
White 7 7 9 8 31
Black 3 2 1 0 6
Asian Indian 5 5 6 5 21
Other 4 6 3 6 19
[1]
Measure Description: These data describe the race of the physician participants.
Region of Enrollment  
Measure Type: Number
Unit of measure:  Participants
United States Number Analyzed 19 participants 20 participants 19 participants 19 participants 77 participants
19 20 19 19 77
1.Primary Outcome
Title Proportion of the Physicians' Patients With Blood Pressure Control or Appropriate Response to Uncontrolled Blood Pressure
Hide Description This measure reports the unadjusted proportion of physicians' patients meeting the study outcome for the first performance period (baseline). Data are based on review of the electronic health records for 40 patients with hypertension randomly selected from each physician's panel. We used the guidelines from the "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)" to determine if the physicians' patients achieved the recommended blood pressures thresholds and if providers appropriately responded to uncontrolled blood pressure. Appropriate responses included increasing the dosage of a guideline-recommended antihypertensive medication or recommending a lifestyle modification to patient with Stage 1 hypertension.
Time Frame Baseline period (August-November 2007)
Show Outcome Measure DataHide Outcome Measure Data
Hide Analysis Population Description
The number of physicians listed is those who participated in the baseline period. The participant flow diagram describes the final number of physicians who received at least two instances of the intervention and were included in the repeated-measures longitudinal analysis.
Arm/Group Title Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control)
Hide Arm/Group Description:

Examines the effect of physician-level financial incentives on hypertension quality of care

Physician-level financial incentives: Enrolled physician participants were eligible to receive financial incentives based on their performance during a 4-month interval on the hypertension care study outcomes.

Examines the effect of practice-level financial incentives on hypertension quality of care

Practice-level financial incentives: Enrolled practices (physician participants and non-physician primary care personnel) were eligible to receive financial incentives based on the performance of the practice during a 4-month interval on the hypertension care study outcomes.

Examines the effect of physician and practice-level financial incentives on hypertension quality of care

Physician- and practice-level financial incentives: Enrolled subjects were eligible to receive financial incentives based on performance during a 4-month interval on the hypertension care study outcomes. This arm tested the effect of combined financial incentives.

Physician participants in the control group did not receive any financial incentives. They received audit and feedback performance reports at the end of each performance period like the intervention groups.
Overall Number of Participants Analyzed 19 18 17 18
Overall Number of Units Analyzed
Type of Units Analyzed: Patient records
760 720 680 720
Measure Type: Number
Unit of Measure: percentage of physicians' patients
75 80 79 86
2.Primary Outcome
Title Proportion of Physicians' Patients With Blood Pressure Control or Appropriate Response to Uncontrolled Blood Pressure
Hide Description This measure reports the unadjusted proportion of physicians' patients meeting the study outcome for the fifth and final intervention performance period. Data are based on review of the electronic health records for 40 patients with hypertension randomly selected from each physician's panel. We used the guidelines from the "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)" to determine if the physicians' patients achieved the recommended blood pressures thresholds and if providers appropriately responded to uncontrolled blood pressure. Appropriate responses included increasing the dosage of a guideline-recommended antihypertensive medication or recommending a lifestyle modification to patient with Stage 1 hypertension.
Time Frame Final intervention period (April-July 2009)
Show Outcome Measure DataHide Outcome Measure Data
Hide Analysis Population Description
The number of physicians listed is those who participated in the final intervention period. The participant flow diagram describes the final number of physicians who received at least two instances of the intervention and were included in the repeated-measures longitudinal analysis.
Arm/Group Title Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control)
Hide Arm/Group Description:

Examines the effect of physician-level financial incentives on hypertension quality of care

Physician-level financial incentives: Enrolled physician participants were eligible to receive financial incentives based on their performance during a 4-month interval on the hypertension care study outcomes.

Examines the effect of practice-level financial incentives on hypertension quality of care

Practice-level financial incentives: Enrolled practices (physician participants and non-physician primary care personnel) were eligible to receive financial incentives based on the performance of the practice during a 4-month interval on the hypertension care study outcomes.

Examines the effect of physician and practice-level financial incentives on hypertension quality of care

Physician- and practice-level financial incentives: Enrolled subjects were eligible to receive financial incentives based on performance during a 4-month interval on the hypertension care study outcomes. This arm tested the effect of combined financial incentives.

Physician participants in the control group did not receive any financial incentives. They received audit and feedback performance reports at the end of each performance period like the intervention groups.
Overall Number of Participants Analyzed 18 19 15 19
Overall Number of Units Analyzed
Type of Units Analyzed: Patient records
720 760 600 760
Measure Type: Number
Unit of Measure: percentage of physicians' patients
84 85 88 86
3.Primary Outcome
Title Proportion of Physicians' Patients With Blood Pressure Control or Appropriate Response to Uncontrolled Blood Pressure
Hide Description This measure reports the unadjusted proportion of physicians' patients meeting the study outcome for the post-washout performance period. Data are based on review of the electronic health records for 40 patients with hypertension randomly selected from each physician's panel. We used the guidelines from the "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)" to determine if the physicians' patients achieved the recommended blood pressures thresholds and if providers appropriately responded to uncontrolled blood pressure. Appropriate responses included increasing the dosage of a guideline-recommended antihypertensive medication or recommending a lifestyle modification to patient with Stage 1 hypertension.
Time Frame After the washout period (May-August 2011)
Show Outcome Measure DataHide Outcome Measure Data
Hide Analysis Population Description
The number of physicians listed is those who participated in the post-washout performance period. The participant flow diagram describes the final number of physicians who received at least two instances of the intervention and were included in the repeated-measures longitudinal analysis.
Arm/Group Title Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control)
Hide Arm/Group Description:

Examines the effect of physician-level financial incentives on hypertension quality of care

Physician-level financial incentives: Enrolled physician participants were eligible to receive financial incentives based on their performance during a 4-month interval on the hypertension care study outcomes.

Examines the effect of practice-level financial incentives on hypertension quality of care

Practice-level financial incentives: Enrolled practices (physician participants and non-physician primary care personnel) were eligible to receive financial incentives based on the performance of the practice during a 4-month interval on the hypertension care study outcomes.

Examines the effect of physician and practice-level financial incentives on hypertension quality of care

Physician- and practice-level financial incentives: Enrolled subjects were eligible to receive financial incentives based on performance during a 4-month interval on the hypertension care study outcomes. This arm tested the effect of combined financial incentives.

Physician participants in the control group did not receive any financial incentives. They received audit and feedback performance reports at the end of each performance period like the intervention groups.
Overall Number of Participants Analyzed 13 17 11 14
Overall Number of Units Analyzed
Type of Units Analyzed: Patient records
520 680 440 560
Measure Type: Number
Unit of Measure: percentage of physicians' patients
83 82 83 87
4.Primary Outcome
Title Proportion of Physicians' Patients Prescribed Guideline-recommended Antihypertensive Medications
Hide Description This measure reports the unadjusted proportion of physicians' patients meeting the study outcome for the first performance period (baseline). Data are based on review of the electronic health records for 40 patients with hypertension randomly selected from each physician's panel. We used the "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)" to evaluate use of guideline-recommended antihypertensive medications. Assessing use of guideline-recommended medications included collecting information about the patient's compelling conditions (e.g., diabetes mellitus) as well as allergies and refusals to antihypertensive medications.
Time Frame Baseline period (August-November 2007)
Show Outcome Measure DataHide Outcome Measure Data
Hide Analysis Population Description
The number of physicians listed is those who participated in the baseline period. The participant flow diagram describes the final number of physicians who received at least two instances of the intervention and were included in the repeated-measures longitudinal analysis.
Arm/Group Title Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control)
Hide Arm/Group Description:

Examines the effect of physician-level financial incentives on hypertension quality of care

Physician-level financial incentives: Enrolled physician participants were eligible to receive financial incentives based on their performance during a 4-month interval on the hypertension care study outcomes.

Examines the effect of practice-level financial incentives on hypertension quality of care

Practice-level financial incentives: Enrolled practices (physician participants and non-physician primary care personnel) were eligible to receive financial incentives based on the performance of the practice during a 4-month interval on the hypertension care study outcomes.

Examines the effect of physician and practice-level financial incentives on hypertension quality of care

Physician- and practice-level financial incentives: Enrolled subjects were eligible to receive financial incentives based on performance during a 4-month interval on the hypertension care study outcomes. This arm tested the effect of combined financial incentives.

Physician participants in the control group did not receive any financial incentives. They received audit and feedback performance reports at the end of each performance period like the intervention groups.
Overall Number of Participants Analyzed 19 18 17 18
Overall Number of Units Analyzed
Type of Units Analyzed: Patient records
760 720 680 720
Measure Type: Number
Unit of Measure: percentage of physicians' patients
61 56 65 63
5.Primary Outcome
Title Proportion of Physicians' Patients Prescribed Guideline-recommended Antihypertensive Medications
Hide Description This measure reports the unadjusted proportion of physicians' patients meeting the study outcome for the fifth and final intervention performance period. Data are based on review of the electronic health records for 40 patients with hypertension randomly selected from each physician's panel. We used the "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)" to evaluate use of guideline-recommended antihypertensive medications. Assessing use of guideline-recommended medications included collecting information about the patient's compelling conditions (e.g., diabetes mellitus) as well as allergies and refusals to antihypertensive medications.
Time Frame Final intervention period (April-July 2009)
Show Outcome Measure DataHide Outcome Measure Data
Hide Analysis Population Description
The number of physicians listed is those who participated in the final intervention performance period. The participant flow diagram describes the final number of physicians who received at least two instances of the intervention and were included in the repeated-measures longitudinal analysis.
Arm/Group Title Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control)
Hide Arm/Group Description:

Examines the effect of physician-level financial incentives on hypertension quality of care

Physician-level financial incentives: Enrolled physician participants were eligible to receive financial incentives based on their performance during a 4-month interval on the hypertension care study outcomes.

Examines the effect of practice-level financial incentives on hypertension quality of care

Practice-level financial incentives: Enrolled practices (physician participants and non-physician primary care personnel) were eligible to receive financial incentives based on the performance of the practice during a 4-month interval on the hypertension care study outcomes.

Examines the effect of physician and practice-level financial incentives on hypertension quality of care

Physician- and practice-level financial incentives: Enrolled subjects were eligible to receive financial incentives based on performance during a 4-month interval on the hypertension care study outcomes. This arm tested the effect of combined financial incentives.

Physician participants in the control group did not receive any financial incentives. They received audit and feedback performance reports at the end of each performance period like the intervention groups.
Overall Number of Participants Analyzed 18 19 15 19
Overall Number of Units Analyzed
Type of Units Analyzed: Patient records
720 760 600 760
Measure Type: Number
Unit of Measure: percentage of physicians' patients
73 65 80 72
6.Primary Outcome
Title Proportion of Physicians' Patients Prescribed Guideline-recommended Antihypertensive Medications
Hide Description This measure reports the unadjusted proportion of physicians' patients meeting the study outcome for the post-washout performance period. Data are based on review of the electronic health records for 40 patients with hypertension randomly selected from each physician's panel. We used the "Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)" to evaluate use of guideline-recommended antihypertensive medications. Assessing use of guideline-recommended medications included collecting information about the patient's compelling conditions (e.g., diabetes mellitus) as well as allergies and refusals to antihypertensive medications.
Time Frame After the washout period (May-August 2011)
Show Outcome Measure DataHide Outcome Measure Data
Hide Analysis Population Description
The number of physicians listed is those who participated in the post-washout performance period. The participant flow diagram describes the final number of physicians who received at least two instances of the intervention and were included in the repeated-measures longitudinal analysis.
Arm/Group Title Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control)
Hide Arm/Group Description:

Examines the effect of physician-level financial incentives on hypertension quality of care

Physician-level financial incentives: Enrolled physician participants were eligible to receive financial incentives based on their performance during a 4-month interval on the hypertension care study outcomes.

Examines the effect of practice-level financial incentives on hypertension quality of care

Practice-level financial incentives: Enrolled practices (physician participants and non-physician primary care personnel) were eligible to receive financial incentives based on the performance of the practice during a 4-month interval on the hypertension care study outcomes.

Examines the effect of physician and practice-level financial incentives on hypertension quality of care

Physician- and practice-level financial incentives: Enrolled subjects were eligible to receive financial incentives based on performance during a 4-month interval on the hypertension care study outcomes. This arm tested the effect of combined financial incentives.

Physician participants in the control group did not receive any financial incentives. They received audit and feedback performance reports at the end of each performance period like the intervention groups.
Overall Number of Participants Analyzed 13 17 11 14
Overall Number of Units Analyzed
Type of Units Analyzed: Patient records
520 680 440 560
Measure Type: Number
Unit of Measure: percentage of physicians' patients
66 65 73 71
7.Secondary Outcome
Title Colorectal Cancer (CRC) Screening, Low-density Lipoprotein (LDL) Cholesterol Levels, Hemoglobin (Hb) A1c Levels, and Beta Blocker Use
Hide Description [Not Specified]
Time Frame Secondary outcomes measured for baseline period, during the intervention period, and the post-washout period
Outcome Measure Data Not Reported
8.Post-Hoc Outcome
Title Incidence of Hypotension Among All Patients With Hypertension
Hide Description Patients had at least one primary care encounter during the interval assessed. We looked four months from the encounter for evidence of hypotension, either an outpatient systolic blood pressure (BP) < 90 mm Hg, an outpatient diagnosis of hypotension, or both. We combined the intervention arms (physician-level, practice group-level, and combined physician and practice group-level incentives) into one arm due to low frequency of events and low power.
Time Frame February-May 2009
Show Outcome Measure DataHide Outcome Measure Data
Hide Analysis Population Description
All patients with hypertension from the physicians' panel who had an outpatient encounter between February and May 2009. We used data from automated processing of structured fields from electronic health records to evaluate this measure.
Arm/Group Title No Incentives (Control) Intervention Group
Hide Arm/Group Description:
Physician participants in the control group did not receive any financial incentives. They received audit and feedback performance reports at the end of each performance period like the intervention groups.
This group is a combination of the physician and non-physician participants and the patients on the panels of the physician participants from the three intervention arms: physician-level, practice-level, and physician- and practice-level financial incentives.
Overall Number of Participants Analyzed 19 58
Overall Number of Units Analyzed
Type of Units Analyzed: Patient records
3792 14210
Measure Type: Number
Unit of Measure: percentage of all hypertensive patients
1.4 1.2
Time Frame [Not Specified]
Adverse Event Reporting Description [Not Specified]
 
Arm/Group Title Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control)
Hide Arm/Group Description

Examines the effect of physician-level financial incentives on hypertension quality of care

Physician-level financial incentives: Enrolled physician participants were eligible to receive financial incentives based on their performance during a 4-month interval on the hypertension care study outcomes.

Examines the effect of practice-level financial incentives on hypertension quality of care

Practice-level financial incentives: Enrolled practices (physician participants and non-physician primary care personnel) were eligible to receive financial incentives based on the performance of the practice during a 4-month interval on the hypertension care study outcomes.

Examines the effect of physician and practice-level financial incentives on hypertension quality of care

Physician- and practice-level financial incentives: Enrolled subjects were eligible to receive financial incentives based on performance during a 4-month interval on the hypertension care study outcomes. This arm tested the effect of combined financial incentives.

Physician participants in the control group did not receive any financial incentives. They received audit and feedback performance reports at the end of each performance period like the intervention groups.
All-Cause Mortality
Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control)
Affected / at Risk (%) Affected / at Risk (%) Affected / at Risk (%) Affected / at Risk (%)
Total   --/--   --/--   --/--   --/-- 
Show Serious Adverse Events Hide Serious Adverse Events
Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control)
Affected / at Risk (%) Affected / at Risk (%) Affected / at Risk (%) Affected / at Risk (%)
Total   0/19 (0.00%)   0/20 (0.00%)   0/19 (0.00%)   0/19 (0.00%) 
Show Other (Not Including Serious) Adverse Events Hide Other (Not Including Serious) Adverse Events
Frequency Threshold for Reporting Other Adverse Events 0%
Physician-level Incentives Practice-level Incentives Physician- and Practice-level Incentives No Incentives (Control)
Affected / at Risk (%) Affected / at Risk (%) Affected / at Risk (%) Affected / at Risk (%)
Total   0/19 (0.00%)   0/20 (0.00%)   0/19 (0.00%)   0/19 (0.00%) 
Certain Agreements
All Principal Investigators ARE employed by the organization sponsoring the study.
Results Point of Contact
Name/Title: Dr. Laura A. Petersen
Organization: VA HSR&D Center for Innovations in Quality, Effectiveness & Safety (IQuESt)
Phone: 713-794-8623
Publications of Results:
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.
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.
Responsible Party: VA Office of Research and Development ( US Department of Veterans Affairs )
ClinicalTrials.gov Identifier: NCT00302718     History of Changes
Other Study ID Numbers: IIR 04-349
R01HL079173 ( U.S. NIH Grant/Contract )
First Submitted: March 10, 2006
First Posted: March 14, 2006
Results First Submitted: November 21, 2014
Results First Posted: December 15, 2014
Last Update Posted: April 24, 2015