Does pay for performance improve cardiovascular care in a "real-world" setting?

The objective was to investigate the impact of a pay-for-performance program (P4P) on quality care and outcomes among cardiovascular disease (CVD) patients. Claims data were used to identify CVD patients in a commercial plan in 1999-2006. Multivariate analyses were employed to examine the impact of P4P on quality care (lipid monitoring and treatment) and quality care on outcomes (new coronary events, hospitalizations, and lipid control). Patients who were treated by physicians participating in P4P were more likely to receive quality care than patients who were not. Patients who received quality care were less likely to have new coronary events (odds ratio [OR] = 0.80; 95% confidence interval [CI] = 0.69-0.92), be hospitalized (OR = 0.76; 95% CI = 0.69-0.83), or have uncontrolled lipids (OR = 0.67; 95% CI = 0.61-0.73) than patients who did not. A P4P program was associated with increased lipid monitoring and treatment. Receipt of this quality care was associated with improved lipid control and reduced likelihood of new coronary events and hospitalizations.

Heart failure patients receiving ACEIs/ARBs were less likely to be hospitalized or to use emergency care in the following year.

Angiotensin-converting enzyme inhibitors (ACEIs) have been shown to decrease morbidity and mortality in heart failure (HF) patients in randomized-controlled trials; observational studies have confirmed this benefit among patients discharged with HF. Investigating the benefit of ACEIs or angiotensin receptor blockers (ARBs) among general HF patients has important implications for quality-of-care measurement and quality initiatives. The objective of this study is to assess the impact of receipt of ACEIs/ARBs among patients with HF on hospitalization, emergency care, and healthcare cost during the following year. Using administrative data, we identified HF patients between 2000 and 2005 in a large health plan (n=2,396 patients). We conducted multivariate analysis to assess the impact of receipt of an ACEI/ARB on likelihood of hospitalization and emergency care, and on total healthcare cost. We found that patients who received ACEIs/ARBs were less likely to be hospitalized (odds ratio [OR]=0.82, p<.05) or use emergency care (OR=0.82, p<.05) in the following year. Receipt of ACEIs/ARBs was not associated with significantly increased cost. Incentivizing the receipt of ACEIs/ARBs in a general population with HF may be a suitable target for pay-for-performance programs, disease management programs, or newer complementary frameworks, such as value-based insurance design.

Impact of a pay-for-performance program on low performing physicians.

Studies have shown that the lowest performing physicians in pay-for-performance (P4P) programs improved the most; however, it is unclear whether this would occur without the P4P program or be sustained. The objective of this study is to investigate the impact of P4P in a Preferred Provider Organization (PPO) on low performing physicians over a 4-year period. We used administrative claims data from a PPO health plan in Hawaii, which implemented a P4P program, and a PPO plan in the South, which did not implement a P4P program. The difference-indifference model was used to compare the quality scores between the two physician groups in preventive measures, a heart failure measure, and an HbA1c testing measure. We found that P4P programs may be effective in incentivizing low performing physicians to improvement quality of care and sustain improvement, and the positive benefit of the P4P program may not be realized until the 3rd or 4th year of the program.

The effect of a PPO pay-for-performance program on patients with diabetes.

OBJECTIVES: To investigate the effectiveness of a pay-for-performance program (P4P) to increase the receipt of quality care and to decrease hospitalization rates among patients with diabetes mellitus. STUDY DESIGN: Longitudinal study of patients with diabetes enrolled in a preferred provider organization (PPO) between January 1, 1999, and December 31, 2006. METHODS: We used multivariate analyses to assess the effect of seeing P4P-participating physicians on the receipt of quality care (ie, glycosylated hemoglobin and low-density lipoprotein cholesterol testing) and on hospitalization rates, controlling for patient characteristics. RESULTS: Patients with diabetes who saw P4P-participating physicians were more likely to receive quality care than those who did not (odds ratio, 1.16; 95% confidence interval, 1.11-1.22; P <.001). Patients with diabetes who received quality care were less likely to be hospitalized than those who did not (incident rate ratio, 0.80; 95% confidence interval, 0.80-0.85; P <.001). During 1 year, there was no difference in hospitalization rates between patients with diabetes who saw P4P-participating physicians versus those who did not. However, patients with diabetes who saw P4P-participating physicians in 3 consecutive years were less likely to be hospitalized than those who did not (incident rate ratio, 0.75; 95% confidence interval, 0.61-0.93; P <.01). CONCLUSIONS: A P4P can significantly increase the receipt of quality care and decrease hospitalization rates among patients with diabetes in a PPO setting. Although it is possible that the differences observed between P4P-participating physicians and non-P4P-participating physicians were due to selection bias, we found no significant difference in the receipt of quality care between patients with diabetes who saw new P4P-participating physicians versus non-P4P-participating physicians during the baseline year. Further research should focus on defining the effect of P4Ps on intermediate outcomes such as glycosylated hemoglobin and low-density lipoprotein cholesterol levels.

Major depression associated with rates of cardiovascular disease state transitions.

OBJECTIVE: To compare patients with and without major depression with respect to their rates of transition to several stages of cardiovascular disease progression. STUDY DESIGN: Retrospective observational study. METHODS: The study used administrative data from a large insurer in Hawaii to evaluate associations of major depression with cardiovascular progression. Analyses used competing-risks models, models that allow more than 1 type of possible outcome event at the transition stages. All analyses were adjusted for age and sex. RESULTS: Among nearly 600,000 healthy members, those with major depression in the past year were 50% to 100% more likely than controls to develop hypertension or dyslipidemia. Rates were increased to a similar magnitude (1) among patients with hypertension or dyslipidemia who subsequently developed either the other condition or coronary artery disease and (2) among patients with hypertension and dyslipidemia who developed coronary artery disease or congestive heart failure. Transition rates to coronary artery disease or congestive heart failure also were increased 50% to 100% among patients with diabetes, hypertension, and dyslipidemia. The sequence of associations remained as strong examining depression 1-2 years in the past as with depression in the past year. CONCLUSIONS: The results show a pattern of faster transitions for patients with major depression compared with patients without major depression across both the early and later stages of cardiovascular progression. Health plans offer a setting where patients with depression can be identified and where interventions might be undertaken to minimize the possible effects of depression on transition rates.