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BACKGROUND/RATIONALE:
Despite compelling evidence of the benefits of treatment, hypertension is controlled in less than one-quarter of US citizens. While some of the reasons for poor blood pressure control are due to poor compliance on the part of patients, there is significant under-treatment of hypertension on the part of physicians. This is one example of what the Institute of Medicine calls the "chasm' between what we know, and how we practice. Translation of scientific knowledge from trials such as the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial [ALLHAT] into clinical practice is lagging. Heightened awareness of "bottlenecks" in the translation of research knowledge into clinical practice has raised enthusiasm about using creative methods, including financial incentives, to improve translation. Indeed, pharmaceutical companies have been using financial incentives to change physician behavior for decades.
OBJECTIVE(S):
Using a cluster randomized controlled trial, we will test the effect of explicit physician-level and group-level financial incentives to promote the provision of guideline-recommended anti-hypertensive medications in ideal candidates for them and improved control of hypertension in the VA primary care setting. The VA is funding the group-level financial incentives arms of the study, and the National Institutes of Health (NIH) is funding the physician-level financial incentives arms of the study.
METHODS:
A total of 84 primary care physician subjects from 12 VA hospitals will be asked to participate. The 12 hospitals will be randomized to one of the four study arms: (1) physician-level financial incentive + audit and feedback; (2) group-level financial incentive + audit and feedback; (3) physician- and group-level financial incentives + audit and feedback; and (4) audit and feedback only (control arm). Use of guideline-recommended anti-hypertension medications in ideal candidates for them and the proportion of patients with hypertension who achieve national (JNC-7) guideline-recommended blood pressure goals or receive appropriate treatment in response to an elevated blood pressure reading will be the primary dependent variables. Physicians and provider groups in the incentive arms will receive a bonus for each instance that they prescribe guideline-recommended anti-hypertensive medications and each instance the patient meets guideline-recommended blood pressure goals or receives appropriate treatment in response to an elevated blood pressure reading. Cross-sectional analyses at three time points will be used to compare the effect of the interventions, with feedback to individual physicians in both arms at five time points over the 20-month study. Data on comorbid conditions, treatment, medications, and blood pressure for the three prior months will be collected from a sample of each physician's practice. We will use analytic methods appropriate for a cluster-randomized trial, as patients are nested within physicians, who are further nested in hospitals.
FINDINGS/RESULTS:
There no findings to report at this time. The study intervention (the 20-month financial intervention) has not started.
IMPACT:
If we demonstrate that financial incentives can improve translation of research into practice, this research will spur application to other diseases. There are no published data on the duration of the effect of financial incentives, so the assessment of the duration of the effect will guide implementation. For example, incentives might be targeted for brief periods to high priority translation activities, then rotated to the next priority intervention after a defined period. The assessment of a quality of care measure unrelated to hypertension will provide information about whether the incentive results in a decline in the quality of unrelated care, perhaps due to competing demands for limited time. In this era of rising health care costs and limited resources, we will determine whether financial incentives are cost-effective. Thus, the findings from this study will provide critical information needed to implement methods of "paying for performance" and will be directly applicable to such programs for the 40.5 million Medicare beneficiaries and to staff-model health care delivery systems that collectively cover in excess of 18 million individuals.
PUBLICATIONS:
None at this time.
DRA:
Chronic Diseases, Health Services and Systems
DRE:
Quality of Care, Resource Use and Cost
Keywords:
Cardiovasc’r disease, Primary care
MeSH Terms:
none
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