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

Study Questions:

What is the impact of explicit physician- and/or practice-level financial incentives on the delivery of guideline-based care for hypertension?


This was a cluster randomized trial of 12 Veterans Affairs outpatient clinics in which 83 primary care physicians and 42 nonphysician personnel (e.g., nurses, pharmacists) participated. Clinics were randomized to one of four study groups: 1) physician-level (individual) incentives, 2) practice-level incentives, 3) physician-level plus practice-level (combined) incentives, and 4) no incentives (control). All participants at a hospital belonged to the same intervention, and participants were informed of their study group assignments. Participants received up to five payments every 4 months, and were also followed for a 12-month washout period to determine the sustainability of the intervention’s effects. The main outcome measures for which participants earned incentives were: number of patients achieving guideline-recommended blood pressure thresholds or an appropriate response to uncontrolled blood pressure and number of patients prescribed guideline-recommended medications.


Change in blood pressure control or appropriate response to uncontrolled blood pressure was significantly greater only in the individual incentives group, compared to control, but was not sustained in the washout. The adjusted estimated absolute change over the study of the patients meeting the combined blood pressure or appropriate response measure was 8.84% (95% confidence interval [CI], 4.20-11.80%) for the individual group, 3.70% (95% CI, 0.24-7.68%) for the practice group, 5.54% (95% CI, 1.92-9.52%) for the combined group, and 0.47% (95% CI, -3.12% to 4.04%) for the control group. Mean (standard deviation) total payments over the study were $4,270 ($459), $2,672 ($153), and $1,648 ($248) for the combined, individual, and practice-level interventions. Of note, the use of guideline-recommended medication in the intervention groups was not significantly different than that in the control group. In a post-hoc analysis, patients cared for by intervention group providers were no more likely to have hypotension than those cared for by the control group.


The authors concluded that individual financial incentives resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure. Practice-level and combined incentives did not have this impact. The effect of the intervention was not sustained in a washout period once the incentive had been withdrawn.


The authors performed a cluster randomized trial in which they investigated the effectiveness of pay for performance in a primary care setting for hypertension. The results are revealing in that only individual financial incentives led to significant changes in blood pressure management. Further research is needed to better understand the economic impact of such incentives directed at chronic disease management and primary care practice, and what factors may contribute to the sustainability of such efforts.

Clinical Topics: Prevention, Hypertension

Keywords: Chronic Disease, Hypotension, Income, Blood Pressure, Reimbursement, Incentive, Veterans, Cardiovascular Diseases, Confidence Intervals, Nurses, Primary Health Care, Hypertension

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