Tracy H. Urech

Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care A Randomized Trial

IMPORTANCE Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory. OBJECTIVE To test the effect of explicit financial incentives to reward guideline-recommended hypertension care. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists). INTERVENTIONS Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports. MAIN OUTCOMES AND MEASURES Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension. RESULTS Mean (SD) total payments over the study were

Impact of comorbidity type on measures of quality for diabetes care.

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Will hypertension performance measures used for pay-for-performance programs penalize those who care for medically complex patients?

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Frequency and correlates of treatment intensification for elevated cholesterol levels in patients with cardiovascular disease.

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How Variability in the Institutional Review Board Review Process Affects Minimal-Risk Multisite Health Services Research

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Correlates of Repeat Lipid Testing in Patients With Coronary Heart Disease

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Treating Chronically Ill People with Diabetes Mellitus with Limited Life Expectancy: Implications for Performance Measurement

248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout. CONCLUSIONS AND RELEVANCE Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these findings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00302718.

Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol

ObjectiveStudies provide conflicting results about the impact of comorbid conditions on the quality of chronic illness care. We assessed the effect of comorbidity type (concordant, discordant, or both) on the receipt of guideline-recommended care among patients with diabetes. Research DesignPatients were assigned to 1 of 4 condition groups: diabetes-concordant (hypertension, ischemic heart disease, hyperlipidemia), and/or diabetes-discordant (arthritis, depression, chronic obstructive pulmonary disease) conditions, or neither. We evaluated hemoglobin A1c, blood pressure, and low-density lipoprotein cholesterol readings at index and measured overall good quality of diabetes care, including a 6-month follow-up interval. We assessed the effect of condition group on overall good quality of care with logistic regression and generalized ordered logistic regression. ResultsWe assigned 35,872 patients to the diabetes comorbid condition groups, ranging from 2.0% in the discordant-only group to 58.0% in the concordant-only group. Patients with both types of conditions were more likely than those with no comorbidities to receive overall good quality for glycemic [odds ratio (OR), 2.13; 95% confidence interval (CI), 1.86-2.41], blood pressure (OR, 1.62; 95% CI, 1.40-1.84), and low-density lipoprotein cholesterol (OR, 3.57; 95% CI, 3.08-4.05) control within 6 months of an index visit. They were also more likely to receive overall good quality for all 3 quality measures combined (OR, 2.17; 95% CI, 1.96-2.39). ConclusionsPatients with the greatest clinical complexity were more likely than less complex patients to receive high quality diabetes care, suggesting that increased complexity does not necessarily predispose chronically ill patients to receiving poorer care. However, caution should be used in treating certain patient groups, such as the elderly, for whom adherence to multiple condition-specific guidelines may lack benefit or cause harm.

Calculations of Financial Incentives for Providers in a Pay-for-Performance Program: Manual Review Versus Data From Structured Fields in Electronic Health Records.

Background— There is concern that performance measures, patient ratings of their care, and pay-for-performance programs may penalize healthcare providers of patients with multiple chronic coexisting conditions. We examined the impact of coexisting conditions on the quality of care for hypertension and patient perception of overall quality of their health care. Methods and Results— We classified 141 609 veterans with hypertension into 4 condition groups: those with hypertension-concordant (diabetes mellitus, ischemic heart disease, dyslipidemia) and/or -discordant (arthritis, depression, chronic obstructive pulmonary disease) conditions or neither. We measured blood pressure control at the index visit, overall good quality of care for hypertension, including a follow-up interval, and patient ratings of satisfaction with their care. Associations between condition type and number of coexisting conditions on receipt of overall good quality of care were assessed with logistic regression. The relationship between patient assessment and objective measures of quality was assessed. Of the cohort, 49.5% had concordant-only comorbidities, 8.7% had discordant-only comorbidities, 25.9% had both, and 16.0% had none. Odds of receiving overall good quality after adjustment for age were higher for those with concordant comorbidities (odds ratio, 1.78; 95% confidence interval, 1.70 to 1.87), discordant comorbidities (odds ratio, 1.32; 95% confidence interval, 1.23 to 1.41), or both (odds ratio, 2.25; 95% confidence interval, 2.13 to 2.38) compared with neither. Findings did not change after adjustment for illness severity and/or number of primary care and specialty care visits. Patient assessment of quality did not vary by the presence of coexisting conditions and was not related to objective ratings of quality of care. Conclusions— Contrary to expectations, patients with greater complexity had higher odds of receiving high-quality care for hypertension. Subjective ratings of care did not vary with the presence or absence of comorbid conditions. Our findings should be reassuring to those who care for the most medically complex patients and are concerned that they will be penalized by performance measures or patient ratings of their care.

Financial incentives to control hypertension in patients--reply.

BACKGROUND Although current performance measures define low-density-lipoprotein cholesterol (LDL-C) levels <100 mg/dL in patients with cardiovascular disease (CVD) as good quality, they provide a snapshot and do not address whether treatment intensification was performed to manage elevated LDL-C levels. METHODS We determined the proportion of patients with CVD (n = 22,888) with LDL-C <100 mg/dL and the proportion with uncontrolled LDL-C levels (≥100 mg/dL) who received treatment intensification within the 45-day follow-up in a Veterans Affairs Network. We evaluated facility, provider, and patient correlates of treatment intensification. RESULTS Low-density-lipoprotein cholesterol levels were at goal in 16,350 (71.4%) patients. An additional 2,093 (one third of those eligible for treatment intensification) received treatment intensification. Controlling for clustering between facilities and patients illness severity: history of diabetes (odds ratio [OR] 1.15, 95% CI 1.01-1.32), hypertension (OR 1.19, 95% CI 1.01-1.42), good medication adherence (OR 2.20, 95% CI 1.91-2.54), and a higher number of lipid panels (OR 1.20, 95% CI 1.14-1.27) were associated with treatment intensification. Patients older than 75 years (OR 0.65, 95% CI 0.56-0.75) and women (OR 0.66, 95% CI 0.43-1.00) were less likely to receive treatment intensification. Teaching status of the facility, physician or specialist primary care provider, and patients race were not associated with treatment intensification. CONCLUSIONS Only one third of the CVD patients with elevated LDL-C received treatment intensification. Diabetic and hypertensive patients were more likely to receive treatment intensification, whereas, older patients, female patients, and patients with poor medication adherence were less likely to receive treatment intensification. Our findings highlight areas for quality improvement initiatives.