• Use of guideline-recommended anti-hypertensive medications in ideal candidates for them, achievement of JNC-7 BP guidelines, and appropriate hypertension treatment responses [ Time Frame: Primary outcomes measured for baseline period (a 4-month period prior to start of the study intervention), during the 20-month intervention period, and for a 4-month period following a 7-month washout period ] [ Designated as safety issue: No ]
  

• CRC screening, LDL cholesterol levels, HbA1c levels, and beta blocker use [ Time Frame: Secondary outcomes measured for baseline period, during the 20-month intervention period, and the post-washout period ] [ Designated as safety issue: No ]
  

Background:

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 (BP) 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. 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.

Objectives:

The goals of this study are to: (1) determine the effect of physician-level financial incentives on processes and outcomes of care for outpatients with hypertension; (2) assess the impact of group-level financial incentives; (3) ascertain whether there are additive or synergistic effects of physician- plus group-level financial incentives; (4) evaluate the persistence of the effect of financial incentives after the intervention ceases; and (5) identify any negative impacts of financial incentives on patients, providers, or health care organizations.

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). Study sites in the group only and provider+group will include non-physician participants (e.g., nurses, pharmacists). 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 3 time points will be used to compare the effect of the interventions, with audit and feedback to physicians and provider groups in both arms at 5 time points over the intervention period. Data on comorbid conditions, treatment, medications, and blood pressure 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.