Incentive program for small practices with EHRs results in improvement in CV outcomes

September 10, 2013

A pay-for-performance program in electronic-health-records-(EHR)-enabled small practices led to modest improvements in cardiovascular care processes and outcomes, according to a study in the September 11 issue of JAMA.

"Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices," according to background information in the article. Small practices, where the majority of patients still receive care nationally, historically have provided lower-quality care—especially solo practices—and may have greater obstacles to improving care because they lack the scale and organizational structure to do so. It is possible that EHR-enabled solo and small-group practices will be able to respond to P4P incentives and improve quality, but this has not been demonstrated.

Naomi S. Bardach, M.D., M.A.S., of the University of California, San Francisco, and colleagues performed a randomized trial to assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative. The study randomized small (fewer than 10 clinicians) primary care clinics in New York City from April 2009 through March 2010 to financial incentives and quarterly performance reports or performance reports alone. A city program provided all participating clinics with the same EHR software with decision support and patient registry and quality reporting capabilities. The program also provided on-site quality improvement specialists offering technical assistance. Incentivized clinics were paid for each patient whose care met the performance criteria, but they received higher payments for patients with co-existing illnesses, 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.

The primary outcome measures were a comparison of between-group 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.

The researchers found that performance improved in both groups during the study, with positive changes from baseline for all measures. The adjusted change in performance was higher in the intervention than in the control group for aspirin or antithrombotic prescription for patients with diabetes or ischemic vascular disease [12.0 percent vs. 6.1 percent]; and for blood pressure control in patients with hypertension but without diabetes or ischemic vascular disease [9.7 percent vs. 4.3 percent]; and smoking cessation interventions (12.4 percent vs. 7.7 percent).

For uninsured or Medicaid (non-HMO) patients, changes in measured performance were higher in the intervention clinics than the control clinics (range of adjusted absolute differences, 7.9 percent to 12.9 percent), for all measures but cholesterol control, but the differences were not statistically significant.

"In this cluster-randomized study of P4P incentives, we found that EHR-enabled small practices were able to respond to incentives to improve processes and intermediate outcomes," the authors write. "This provides evidence that, in the context of increasing uptake of EHRs with robust clinical management tools, small practices may be able to improve their quality performance in response to an incentive."

In an accompanying editorial, Rowena J. Dolor, M.D., M.H.S., and Kevin A. Schulman, M.D., of the Duke University School of Medicine, Durham, N.C., comment on the two randomized trials in this issue of JAMA (Bardach et al; Petersen et al) that report the comparative effectiveness of in primary care settings.

"Even though the findings of these 2 studies are encouraging in advancing understanding of the P4P strategy, the reports also raise questions about the solitary focus on clinician performance in achieving these population health goals. Both studies suggest that even with elegant incentives applied at the practice level, gaps in clinical performance still remain. These results suggest that although there is some room for improvement of individual performance, these gaps represent systematic shortcomings rather than an issue with performance at the individual clinician level."

"In a population health model, a variety of strategies is used to achieve success. Some of these strategies would be clinician focused, some technology focused, some community focused, and some patient focused. The appropriate allocation of resources to each of these strategies would be based on economic analysis—how to gain the greatest increase in population health from optimizing interactions across all of these efforts. This type of framework transforms the question from the effectiveness of primary care practice to the effectiveness of primary care service embedded in a community."

Explore further: Pay for performance encouraged physicians to follow blood pressure guidelines

More information: doi:10.l001/jama.2013.277353
doi:10.l001/jama.2013.277575

Related Stories

Pay for performance encouraged physicians to follow blood pressure guidelines

September 10, 2013
When health care pundits began to suggest that pay-for-performance would solve some of health care's woes, Dr. Laura Petersen, professor of medicine at Baylor College of Medicine and director of the Houston VA Health Services ...

Pay for performance may improve treatment implementation for adolescent substance use disorders

August 13, 2012
Pay for performance appears to be associated with improved implementation of an adolescent substance use treatment program, although no significant differences were found in remission status between the pay-for-performance ...

Quality of care measures improve performance

March 4, 2013
Public reporting of how physicians and hospitals perform in quality of care measures leads to improved care for patients. A collaborative team of researchers led by Geoffrey C. Lamb, M.D., professor of internal medicine at ...

Intervention helps improve and maintain better blood pressure control

July 2, 2013
An intervention that consisted of home blood pressure (BP) telemonitoring with pharmacist management resulted in improvements in BP control and decreases in BP during 12 months, compared with usual care, and improvement in ...

Electronic health records with technical assistance can improve patient care in New York City

January 7, 2013
The relationship between a physician practice's adoption of electronic health records (EHR) and quality improvements in patient care remains unclear. However, a new study published in the January issue of Health Affairs by ...

Doctors who go digital provide higher quality healthcare

October 17, 2012
The use of electronic health records is linked to significantly higher quality care, according to a new study by Lisa Kern and her team, from the Health Information Technology Evaluation Collaborative in the US. Their work ...

Recommended for you

High-fat diet in pregnancy can cause mental health problems in offspring

July 21, 2017
A high-fat diet not only creates health problems for expectant mothers, but new research in an animal model suggests it alters the development of the brain and endocrine system of their offspring and has a long-term impact ...

To combat teen smoking, health experts recommend R ratings for movies that depict tobacco use

July 21, 2017
Public health experts have an unusual suggestion for reducing teen smoking: Give just about any movie that depicts tobacco use an automatic R rating.

Opioids and obesity, not 'despair deaths,' raising mortality rates for white Americans

July 20, 2017
Drug-related deaths among middle-aged white men increased more than 25-fold between 1980 and 2014, with the bulk of that spike occurring since the mid-1990s when addictive prescription opioids became broadly available, according ...

Aging Americans enjoy longer life, better health when avoiding three risky behaviors

July 20, 2017
We've heard it before from our doctors and other health experts: Keep your weight down, don't smoke and cut back on the alcohol if you want to live longer.

Parents have critical role in preventing teen drinking

July 20, 2017
Fewer teenagers are drinking alcohol but more needs to be done to curb the drinking habits of Australian school students, based on the findings of the latest study by Adelaide researchers.

Fresh fish oil lowers diabetes risk in rat offspring

July 19, 2017
Fresh fish oil given to overweight pregnant rats prevented their offspring from developing a major diabetes risk factor, Auckland researchers have found.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.