Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: Study protocol

Laura A. Petersen, Tracy Urech, Kate Simpson, Kenneth Pietz, Sylvia J. Hysong, Jochen Profit, Douglas Conrad, R. Adams Dudley, Meghan Z. Lutschg, Robert Petzel, Le Chauncy D. Woodard

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13 Scopus citations


Background: Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment, hypertension is controlled in less than one-half of United States citizens.Methods/design: This randomized controlled trial tests whether explicit financial incentives promote the translation of guideline-recommended care for hypertension into clinical practice and improve blood pressure (BP) control in the primary care setting. Using constrained randomization, we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms: physician-level incentive; group-level incentive; combination of physician and group incentives; and no incentives (control). All participants at the hospital (cluster) were assigned to the same study arm. We enrolled 83 full-time primary care physicians and 42 non-physician personnel. The intervention consisted of an educational session about guideline-recommended care for hypertension, five audit and feedback reports, and five disbursements of incentive payments. Incentive payments rewarded participants for chart-documented use of guideline-recommended antihypertensive medications, BP control, and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention. To identify potential unintended consequences of the incentives, the study team interviewed study participants, as well as non-participant primary care personnel and leadership at study sites. Chart reviews included data collection on quality measures not related to hypertension. To evaluate the persistence of the effect of the incentives, the study design includes a washout period.Discussion: We briefly describe the rationale for the interventions being studied, as well as the major design choices. Rigorous research designs such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements.Trial Registration: http://www.clinicaltrials.govNCT00302718.

Original languageEnglish (US)
Article number114
JournalImplementation Science
Issue number1
StatePublished - Oct 3 2011
Externally publishedYes

Bibliographical note

Funding Information:
We gratefully acknowledge the VA Network Directors who provided the financial incentives for this study as well as the VA staff who participated. This work is supported in part by Veterans Affairs Health Services Research & Development (HSR&D) Investigator-Initiated Research (IIR) 04-349 (PI Laura A. Petersen, MD, MPH), NIH RO1 HL079173-01 (PI Laura A. Petersen, MD, MPH), the American Recovery and Reinvestment Act of 2010 (NHLBI 1R01HL079173-S2), and the Houston VA HSR&D Center of Excellence HFP90-020 (PI Laura A. Petersen, MD, MPH). Dr. Petersen was a recipient of the American Heart Association Established Investigator Award (Grant number 0540043N) and was a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar (Grant number 045444) at the time that this study was planned and funded. Dr. Hysong was a recipient of an NHLBI Investigator Research Supplement to Promote Diversity in Health-Related Research (1R01HL079173-S1) during the early stages of the study and is currently a VA HSR&D Career Development Awardee (CDA 07-0181). Dr. Profit’s contribution is supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development #1 K23 HD056298-01 (PI: Jochen Profit, MD, MPH). Dr. Conrad is an awardee of the Robert Wood Johnson Foundation Health Care Financing and Organization Program (Grant number 63214). Dr. Dudley is a Robert Wood Johnson Investigator Awardee in Health Policy. The views expressed are solely of the authors, and do not necessarily represent those of the VA.


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