The Effect of Financial Incentives on Quality Measures in the Treatment of Diabetes Mellitus: a Randomized Controlled Trial

Abstract

Background: Financial incentives are often used to improve quality of care in chronic care patients. However, the evidence concerning the effect of financial incentives is still inconclusive.

Objective: To test the effect of financial incentives on quality measures (QMs) in the treatment of patients with diabetes mellitus in primary care. We incentivized a clinical QM and a process QM to test the effect of financial incentives on different types of QMs and to investigate the spill-over effect on non-incentivized QMs.

Design/participants: Parallel cluster randomized controlled trial based on electronic medical records database involving Swiss general practitioners (GPs). Practices were randomly allocated.

Intervention: All participants received a bimonthly feedback report. The intervention group additionally received potential financial incentives on GP level depending on their performance.

Main measures: Between-group differences in proportions of patients fulfilling incentivized QM (process QM of annual HbA1c measurement and clinical QM of blood pressure level below 140/95 mmHg) after 12 months.

Key results: Seventy-one GPs (median age 52 years, 72% male) from 43 different practices and subsequently 3838 patients with diabetes mellitus (median age 70 years, 57% male) were included. Proportions of patients with annual HbA1c measurements remained unchanged (intervention group decreased from 79.0 to 78.3%, control group from 81.5 to 81.0%, OR 1.09, 95% CI 0.90-1.32, p = 0.39). Proportions of patients with blood pressure below 140/95 improved from 49.9 to 52.5% in the intervention group and decreased from 51.2 to 49.0% in the control group (OR 1.16, 95% CI 0.99-1.36, p = 0.06). Proportions of non-incentivized process QMs increased significantly in the intervention group.

Conclusion: GP level financial incentives did not result in more frequent HbA1c measurements or in improved blood pressure control. Interestingly, we could confirm a spill-over effect on non-incentivized process QMs. Yet, the mechanism of spill-over effects of financial incentives is largely unclear.

Trial registration: ISRCTN13305645.

Keywords: diabetes mellitus; financial incentives; improvement; primary care; quality of care; spill-over effect.