Effect of Pay-for-Performance Incentives on Quality of Care in Small Practices With Electronic Health Records: A Randomized Trial
IMPORTANCE Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capab...
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| Veröffentlicht in: | JAMA : the journal of the American Medical Association 2013-09, Vol.310 (10), p.1051-1059 |
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| creator | Bardach, Naomi S Wang, Jason J De Leon, Samantha F Shih, Sarah C Boscardin, W. John Goldman, L. Elizabeth Dudley, R. Adams |
| description | IMPORTANCE Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied. OBJECTIVE To assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative. DESIGN, SETTING, AND PARTICIPANTS A cluster-randomized trial of small ( |
| doi_str_mv | 10.1001/jama.2013.277353 |
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John ; Goldman, L. Elizabeth ; Dudley, R. Adams</creator><creatorcontrib>Bardach, Naomi S ; Wang, Jason J ; De Leon, Samantha F ; Shih, Sarah C ; Boscardin, W. John ; Goldman, L. Elizabeth ; Dudley, R. Adams</creatorcontrib><description>IMPORTANCE Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied. OBJECTIVE To assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative. DESIGN, SETTING, AND PARTICIPANTS A cluster-randomized trial of small (<10 clinicians) primary care clinics in New York City from April 2009 through March 2010. A city program provided all participating clinics with the same EHR software with decision support and patient registry functionalities and quality improvement specialists offering technical assistance. INTERVENTIONS Incentivized clinics were paid for each patient whose care met the performance criteria, but they received higher payments for patients with comorbidities, who had Medicaid insurance, or who were uninsured (maximum payments: $200/patient; $100 000/clinic). Quality reports were given quarterly to both the intervention and control groups. MAIN OUTCOMES AND MEASURES Comparison of differences in performance improvement, from the beginning to the end of the study, between control and intervention clinics for aspirin or antithrombotic prescription, blood pressure control, cholesterol control, and smoking cessation interventions. Mixed-effects logistic regression was used to account for clustering of patients within clinics, with a treatment by time interaction term assessing the statistical significance of the effect of the intervention. RESULTS Participating clinics (n = 42 for each group) had similar baseline characteristics, with a mean of 4592 (median, 2500) patients at the intervention group clinics and 3042 (median, 2000) at the control group clinics. Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription (12.0% vs 6.1%, difference: 6.0% [95% CI, 2.2% to 9.7%], P = .001 for interaction term), blood pressure control (no comorbidities: 9.7% vs 4.3%, difference: 5.5% [95% CI, 1.6% to 9.3%], P = .01 for interaction term; with diabetes mellitus: 9.0% vs 1.2%, difference: 7.8% [95% CI, 3.2% to 12.4%], P = .007 for interaction term; with diabetes mellitus or ischemic vascular disease: 9.5% vs 1.7%, difference: 7.8% [95% CI, 3.0% to 12.6%], P = .01 for interaction term), and in smoking cessation interventions (12.4% vs 7.7%, difference: 4.7% [95% CI, −0.3% to 9.6%], P = .02 for interaction term). Intervention clinics performed better on all measures for Medicaid and uninsured patients except cholesterol control, but no differences were statistically significant. CONCLUSIONS AND RELEVANCE Among small EHR-enabled clinics, a P4P incentive program compared with usual care resulted in modest improvements in cardiovascular care processes and outcomes. Because most proposed P4P programs are intended to remain in place more than a year, further research is needed to determine whether this effect increases or decreases over time. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00884013</description><identifier>ISSN: 0098-7484</identifier><identifier>EISSN: 1538-3598</identifier><identifier>DOI: 10.1001/jama.2013.277353</identifier><identifier>PMID: 24026600</identifier><identifier>CODEN: JAMAAP</identifier><language>eng</language><publisher>Chicago, IL: American Medical Association</publisher><subject>Adult ; Biological and medical sciences ; Cardiovascular Diseases - prevention & control ; Cardiovascular Diseases - therapy ; Chronic Disease - therapy ; Clinical medicine ; Clinical outcomes ; Disease Management ; Electronic health records ; Electronic Health Records - utilization ; Female ; General aspects ; Group Practice - statistics & numerical data ; Health participants ; Humans ; Hypertension - prevention & control ; Hypertension - therapy ; Male ; Medical sciences ; Middle Aged ; Miscellaneous ; New York City ; Pay for performance ; Physicians ; Practice Patterns, Physicians ; Primary Health Care ; Public health. Hygiene ; Public health. Hygiene-occupational medicine ; Quality Improvement ; Quality of care ; Registries ; Reimbursement, Incentive ; Smoking Cessation</subject><ispartof>JAMA : the journal of the American Medical Association, 2013-09, Vol.310 (10), p.1051-1059</ispartof><rights>2014 INIST-CNRS</rights><rights>Copyright American Medical Association Sep 11, 2013</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://jamanetwork.com/journals/jama/articlepdf/10.1001/jama.2013.277353$$EPDF$$P50$$Gama$$H</linktopdf><linktohtml>$$Uhttps://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2013.277353$$EHTML$$P50$$Gama$$H</linktohtml><link.rule.ids>64,230,314,777,781,882,3327,27905,27906,76238,76241</link.rule.ids><backlink>$$Uhttp://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&idt=27674691$$DView record in Pascal Francis$$Hfree_for_read</backlink><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/24026600$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Bardach, Naomi S</creatorcontrib><creatorcontrib>Wang, Jason J</creatorcontrib><creatorcontrib>De Leon, Samantha F</creatorcontrib><creatorcontrib>Shih, Sarah C</creatorcontrib><creatorcontrib>Boscardin, W. John</creatorcontrib><creatorcontrib>Goldman, L. Elizabeth</creatorcontrib><creatorcontrib>Dudley, R. Adams</creatorcontrib><title>Effect of Pay-for-Performance Incentives on Quality of Care in Small Practices With Electronic Health Records: A Randomized Trial</title><title>JAMA : the journal of the American Medical Association</title><addtitle>JAMA</addtitle><description>IMPORTANCE Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied. OBJECTIVE To assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative. DESIGN, SETTING, AND PARTICIPANTS A cluster-randomized trial of small (<10 clinicians) primary care clinics in New York City from April 2009 through March 2010. A city program provided all participating clinics with the same EHR software with decision support and patient registry functionalities and quality improvement specialists offering technical assistance. INTERVENTIONS Incentivized clinics were paid for each patient whose care met the performance criteria, but they received higher payments for patients with comorbidities, who had Medicaid insurance, or who were uninsured (maximum payments: $200/patient; $100 000/clinic). Quality reports were given quarterly to both the intervention and control groups. MAIN OUTCOMES AND MEASURES Comparison of differences in performance improvement, from the beginning to the end of the study, between control and intervention clinics for aspirin or antithrombotic prescription, blood pressure control, cholesterol control, and smoking cessation interventions. Mixed-effects logistic regression was used to account for clustering of patients within clinics, with a treatment by time interaction term assessing the statistical significance of the effect of the intervention. RESULTS Participating clinics (n = 42 for each group) had similar baseline characteristics, with a mean of 4592 (median, 2500) patients at the intervention group clinics and 3042 (median, 2000) at the control group clinics. Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription (12.0% vs 6.1%, difference: 6.0% [95% CI, 2.2% to 9.7%], P = .001 for interaction term), blood pressure control (no comorbidities: 9.7% vs 4.3%, difference: 5.5% [95% CI, 1.6% to 9.3%], P = .01 for interaction term; with diabetes mellitus: 9.0% vs 1.2%, difference: 7.8% [95% CI, 3.2% to 12.4%], P = .007 for interaction term; with diabetes mellitus or ischemic vascular disease: 9.5% vs 1.7%, difference: 7.8% [95% CI, 3.0% to 12.6%], P = .01 for interaction term), and in smoking cessation interventions (12.4% vs 7.7%, difference: 4.7% [95% CI, −0.3% to 9.6%], P = .02 for interaction term). Intervention clinics performed better on all measures for Medicaid and uninsured patients except cholesterol control, but no differences were statistically significant. CONCLUSIONS AND RELEVANCE Among small EHR-enabled clinics, a P4P incentive program compared with usual care resulted in modest improvements in cardiovascular care processes and outcomes. Because most proposed P4P programs are intended to remain in place more than a year, further research is needed to determine whether this effect increases or decreases over time. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00884013</description><subject>Adult</subject><subject>Biological and medical sciences</subject><subject>Cardiovascular Diseases - prevention & control</subject><subject>Cardiovascular Diseases - therapy</subject><subject>Chronic Disease - therapy</subject><subject>Clinical medicine</subject><subject>Clinical outcomes</subject><subject>Disease Management</subject><subject>Electronic health records</subject><subject>Electronic Health Records - utilization</subject><subject>Female</subject><subject>General aspects</subject><subject>Group Practice - statistics & numerical data</subject><subject>Health participants</subject><subject>Humans</subject><subject>Hypertension - prevention & control</subject><subject>Hypertension - therapy</subject><subject>Male</subject><subject>Medical sciences</subject><subject>Middle Aged</subject><subject>Miscellaneous</subject><subject>New York City</subject><subject>Pay for performance</subject><subject>Physicians</subject><subject>Practice Patterns, Physicians</subject><subject>Primary Health Care</subject><subject>Public health. Hygiene</subject><subject>Public health. Hygiene-occupational medicine</subject><subject>Quality Improvement</subject><subject>Quality of care</subject><subject>Registries</subject><subject>Reimbursement, Incentive</subject><subject>Smoking Cessation</subject><issn>0098-7484</issn><issn>1538-3598</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2013</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNpdkc2LEzEYxoMobl29iwcJiOBlajL5mngQllLdhQXrWvAYMpnETclM1mRmod78z83QWj9yyAvJ733ePHkAeI7REiOE3-50r5c1wmRZC0EYeQAWmJGmIkw2D8ECIdlUgjb0DDzJeYfKwkQ8Bmc1RTXnCC3Az7Vz1owwOrjR-8rFVG1sKqXXg7HwqmzD6O9thnGAnycd_Lif4ZVOFvoBful1CHCTtBm9KdRXP97CdSiSKQ7ewEurQzm5sSamLr-DF_BGD13s_Q_bwW3yOjwFj5wO2T471nOw_bDeri6r608fr1YX15UmDR0r6xxFziEsGe9w6yQ3ljMqmTGCsZazWnDUdo3FRMpWMttJ1LHGUkt1Q1tyDt4fZO-mtrfdbCvpoO6S73Xaq6i9-vdm8LfqW7xXtPwZQU0ReHMUSPH7ZPOoep-NDUEPNk5ZYUpqXiPeoIK--g_dxSkNxd1MiZpgJGWh0IEyKeacrDs9BiM1x6vmeNUcrzrEW1pe_m3i1PA7zwK8PgI6Gx1cKin6_IcTXFAuceFeHLh5wmmsIAJRSn4BxAG3JQ</recordid><startdate>20130911</startdate><enddate>20130911</enddate><creator>Bardach, Naomi S</creator><creator>Wang, Jason J</creator><creator>De Leon, Samantha F</creator><creator>Shih, Sarah C</creator><creator>Boscardin, W. 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John</au><au>Goldman, L. Elizabeth</au><au>Dudley, R. Adams</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Effect of Pay-for-Performance Incentives on Quality of Care in Small Practices With Electronic Health Records: A Randomized Trial</atitle><jtitle>JAMA : the journal of the American Medical Association</jtitle><addtitle>JAMA</addtitle><date>2013-09-11</date><risdate>2013</risdate><volume>310</volume><issue>10</issue><spage>1051</spage><epage>1059</epage><pages>1051-1059</pages><issn>0098-7484</issn><eissn>1538-3598</eissn><coden>JAMAAP</coden><abstract>IMPORTANCE Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied. OBJECTIVE To assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative. DESIGN, SETTING, AND PARTICIPANTS A cluster-randomized trial of small (<10 clinicians) primary care clinics in New York City from April 2009 through March 2010. A city program provided all participating clinics with the same EHR software with decision support and patient registry functionalities and quality improvement specialists offering technical assistance. INTERVENTIONS Incentivized clinics were paid for each patient whose care met the performance criteria, but they received higher payments for patients with comorbidities, who had Medicaid insurance, or who were uninsured (maximum payments: $200/patient; $100 000/clinic). Quality reports were given quarterly to both the intervention and control groups. MAIN OUTCOMES AND MEASURES Comparison of differences in performance improvement, from the beginning to the end of the study, between control and intervention clinics for aspirin or antithrombotic prescription, blood pressure control, cholesterol control, and smoking cessation interventions. Mixed-effects logistic regression was used to account for clustering of patients within clinics, with a treatment by time interaction term assessing the statistical significance of the effect of the intervention. RESULTS Participating clinics (n = 42 for each group) had similar baseline characteristics, with a mean of 4592 (median, 2500) patients at the intervention group clinics and 3042 (median, 2000) at the control group clinics. Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription (12.0% vs 6.1%, difference: 6.0% [95% CI, 2.2% to 9.7%], P = .001 for interaction term), blood pressure control (no comorbidities: 9.7% vs 4.3%, difference: 5.5% [95% CI, 1.6% to 9.3%], P = .01 for interaction term; with diabetes mellitus: 9.0% vs 1.2%, difference: 7.8% [95% CI, 3.2% to 12.4%], P = .007 for interaction term; with diabetes mellitus or ischemic vascular disease: 9.5% vs 1.7%, difference: 7.8% [95% CI, 3.0% to 12.6%], P = .01 for interaction term), and in smoking cessation interventions (12.4% vs 7.7%, difference: 4.7% [95% CI, −0.3% to 9.6%], P = .02 for interaction term). Intervention clinics performed better on all measures for Medicaid and uninsured patients except cholesterol control, but no differences were statistically significant. CONCLUSIONS AND RELEVANCE Among small EHR-enabled clinics, a P4P incentive program compared with usual care resulted in modest improvements in cardiovascular care processes and outcomes. Because most proposed P4P programs are intended to remain in place more than a year, further research is needed to determine whether this effect increases or decreases over time. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00884013</abstract><cop>Chicago, IL</cop><pub>American Medical Association</pub><pmid>24026600</pmid><doi>10.1001/jama.2013.277353</doi><tpages>9</tpages></addata></record> |
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| ispartof | JAMA : the journal of the American Medical Association, 2013-09, Vol.310 (10), p.1051-1059 |
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| source | MEDLINE; American Medical Association Journals |
| subjects | Adult Biological and medical sciences Cardiovascular Diseases - prevention & control Cardiovascular Diseases - therapy Chronic Disease - therapy Clinical medicine Clinical outcomes Disease Management Electronic health records Electronic Health Records - utilization Female General aspects Group Practice - statistics & numerical data Health participants Humans Hypertension - prevention & control Hypertension - therapy Male Medical sciences Middle Aged Miscellaneous New York City Pay for performance Physicians Practice Patterns, Physicians Primary Health Care Public health. Hygiene Public health. Hygiene-occupational medicine Quality Improvement Quality of care Registries Reimbursement, Incentive Smoking Cessation |
| title | Effect of Pay-for-Performance Incentives on Quality of Care in Small Practices With Electronic Health Records: A Randomized Trial |
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