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Pay for Performance, Quality of Care, and Outcomes in Acute Myocardial Infarction
Seth W. Glickman, MD, MBA;
Fang-Shu Ou, MS;
Elizabeth R. DeLong, PhD;
Matthew T. Roe, MD, MHS;
Barbara L. Lytle, MS;
Jyotsna Mulgund, MS;
John S. Rumsfeld, MD, PhD;
W. Brian Gibler, MD;
E. Magnus Ohman, MD;
Kevin A. Schulman, MD;
Eric D. Peterson, MD, MPH
JAMA. 2007;297:2373-2380.
Context Pay for performance has been promoted as a tool for improving quality of care. In 2003, the Centers for Medicare & Medicaid Services (CMS) launched the largest pay-for-performance pilot project to date in the United States, including indicators for acute myocardial infarction.
Objective To determine if pay for performance was associated with either improved processes of care and outcomes or unintended consequences for acute myocardial infarction at hospitals participating in the CMS pilot project.
Design, Setting, and Participants An observational, patient-level analysis of 105 383 patients with acute non–ST-segment elevation myocardial infarction enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines (CRUSADE) national quality-improvement initiative. Patients were treated between July 1, 2003, and June 30, 2006, at 54 hospitals in the CMS program and 446 control hospitals.
Main Outcome Measures The differences in the use of ACC/AHA class I guideline recommended therapies and in-hospital mortality between pay for performance and control hospitals.
Results Among treatments subject to financial incentives, there was a slightly higher rate of improvement for 2 of 6 targeted therapies at pay-for-performance vs control hospitals (odds ratio [OR] comparing adherence scores from 2003 through 2006 at half-year intervals for aspirin at discharge, 1.31; 95% confidence interval [CI], 1.18-1.46 vs OR, 1.17; 95% CI, 1.12-1.21; P = .04) and for smoking cessation counseling (OR, 1.50; 95% CI, 1.29-1.73 vs OR, 1.28; 95% CI, 1.22-1.35; P = .05). There was no significant difference in a composite measure of the 6 CMS rewarded therapies between the 2 hospital groups (change in odds per half-year period of receiving CMS therapies: OR, 1.23; 95% CI, 1.15-1.30 vs OR, 1.17; 95% CI, 1.14-1.20; P = .16). For composite measures of acute myocardial infarction treatments not subject to incentives, rates of improvement were not significantly different (OR, 1.09; 95% CI, 1.05-1.14 vs OR, 1.08; 95% CI, 1.06-1.09; P = .49). Overall, there was no evidence that improvements in in-hospital mortality were incrementally greater at pay-for-performance sites (change in odds of in-hospital death per half-year period, 0.91; 95% CI, 0.84-0.99 vs 0.97; 95% CI, 0.94-0.99; P = .21).
Conclusions Among hospitals participating in a voluntary quality-improvement initiative, the pay-for-performance program was not associated with a significant incremental improvement in quality of care or outcomes for acute myocardial infarction. Conversely, we did not find evidence that pay for performance had an adverse association with improvement in processes of care that were not subject to financial incentives. Additional studies of pay for performance are needed to determine its optimal role in quality-improvement initiatives.
Author Affiliations: Center for Clinical and Genetic Economics (Drs Glickman and Schulman) and the Outcomes Research and Assessment Group (Mss Ou, Lytle, and Mulgund and Dr Peterson), Duke Clinical Research Institute (Drs DeLong, Roe, Ohman, and Peterson), and the Department of Surgery, Division of Emergency Medicine (Dr Glickman), and the Health Sector Management Program, Fuqua School of Business (Dr Schulman), Duke University Medical Center, Durham, NC; the Section of Cardiology, Denver VA Medical Center, Denver, Colo (Dr Rumsfeld); and the Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio (Dr Gibler).
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