Elsevier

Preventive Medicine

Volume 36, Issue 3, March 2003, Pages 291-299
Preventive Medicine

Regular article
The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines

https://doi.org/10.1016/S0091-7435(02)00052-XGet rights and content

Abstract

Background

This study tested the effects of two organizational support processes, the provision of financial incentives for superior clinical performance and the availability of a patient (smoker) registry and proactive telephone support system for smoking cessation, on provider adherence to accepted practice guidelines and associated patient outcomes.

Methods

Forty clinics of a large multispecialty medical group practice providing primary care services were randomly allocated to study conditions. Fifteen clinics each were assigned to the experimental conditions “control” (distribution of printed versions of smoking cessation guidelines) and “incentive” (financial incentive pay-out for reaching preset clinical performance targets). Ten clinics were randomized to receive financial incentives combined with access to a centralized patient registry and intervention system (″registry″). Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients’ smoking cessation behaviors.

Results

Patients’ tobacco use status was statistically significant (P < 0.01) more frequently identified in clinics with the opportunity for incentives and access to a registry than in clinics in the control condition. Patients visiting registry clinics accessed counseling programs statistically significantly more often (P < 0.001) than patients receiving care in the control condition. Other endpoints did not statistically significantly differ between the experimental conditions.

Conclusions

The impact of financial incentives and a patient registry/intervention system in improving smoking cessation clinical practices and patient behaviors was mixed. Additional research is needed to identify conditions under which such organizational support processes result in significant health care quality improvement and warrant the investment.

Section snippets

Background

The recent Institute of Medicine Report, Crossing the Quality Chasm: A New Health System for the 21st Century [1], issued a broad call for redesigning the health care system, in order to better meet patients’ needs and improve outcomes. To accomplish this goal health care organizations are charged with identifying managerial strategies that facilitate the creation of care environments or organizational support systems that ensure optimal care delivery by, for example, increased provider

Design

A three-condition group randomized efficient (unbalanced) evaluation design was employed. The three experimental conditions are represented by (1) no intervention/ control (distribution of printed versions of the smoking cessation guidelines) (“control”), (2) financial incentives for reaching preset clinical performance targets (“incentive”), and (3) financial incentives for reaching preset clinical performance targets combined with access to a centralized smoker registry and intervention

Organizational support process i: financial incentives for reaching preset clinical performance targets

The medical group’s management decided to set and communicate clinical performance targets that would trigger a pay-out of financial incentives if reached. Management decided that 75% of all patients over 18 should have their tobacco status clearly identified at each visit and documented in their medical records for their last; and 65% of smokers should have provision of advice to quit smoking documented in their medical record for the last visit to trigger incentive payout for a clinic.

Practice pattern end points

At baseline no differences were found between the experimental conditions with respect to identification of tobacco use, provision of advice to quit, and assistance in quitting (i.e., information about or prescription for smoking cessation aids) at the most recent clinic visit. Rates of these practice patterns improved dramatically between Summer 1999 and Summer 2000. Overall, identification of smokers at the most recent visit, advising smokers to quit, and providing assistance to quit improved

Discussion

This study evaluated the effects of two promising but understudied organizational support processes hypothesized to impact improvement in preventive care quality. The organizational support processes are represented by financial incentives for meeting preset clinical practice targets and coupling a patient (smoker) registry and telephone intervention system with targeted clinical practices. Specifically, their impact on the improvement of clinical smoking cessation practices and associated

Acknowledgements

This study was supported in part by a grant from the Robert Wood Johnson Foundation (Grant 036023). The investigators are grateful to Allina Hospitals & Clinics and the management and staff of the Allina Medical Clinic in their support of this effort. The following Allina Medical Clinic sites generously participated in the efforts described in this manuscript: Annandale, Buffalo, Cambridge, Champlin, Cokato, Coon Rapids Family Practice, Coon Rapids Internal Medicine, Coon Rapids Women’s Health,

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