Financial Incentives to Translate ALLHAT Into Practice: A Randomized Trial

• 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 the 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. 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 and improved control of hypertension in the VA primary care setting.

Objectives:

The goals 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 incentives; (3) ascertain whether there are additive or synergistic effects of physician+group-level incentives; (4) evaluate the persistence of the effect of incentives after the intervention ceases; and (5) identify any negative impacts of incentives on patients, providers, or health care organizations.

Methods:

Primary care physicians from 12 VA hospitals will be randomized to the following arms: (1) physician-level incentive; (2) group-level incentive; (3) physician+group incentives; and (4) audit and feedback only. Study sites in the group only and provider+group will include non-physician participants (e.g., nurses). Outcomes include the use of guideline-recommended anti-hypertension medications and the proportion of patients who achieve national (JNC 7) guideline-recommended blood pressure goals or receive 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 all study participants 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.

Status:

We are currently analyzing the post-washout data and preparing manuscripts describing the study's findings.