Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial
Abstract Background Pay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. This study examined the incremental cost-effectiveness of a P4P strategy found to be highly effective in improving the implementation and effectiveness of the Ad...
| Main Authors: | , , , , |
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| Format: | Article |
| Language: | English |
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BMC
2018-07-01
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| Series: | Implementation Science |
| Subjects: | |
| Online Access: | http://link.springer.com/article/10.1186/s13012-018-0774-1 |
| _version_ | 1811215867389673472 |
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| author | Bryan R. Garner Aung K. Lwin Gail K. Strickler Brooke D. Hunter Donald S. Shepard |
| author_facet | Bryan R. Garner Aung K. Lwin Gail K. Strickler Brooke D. Hunter Donald S. Shepard |
| author_sort | Bryan R. Garner |
| collection | DOAJ |
| description | Abstract Background Pay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. This study examined the incremental cost-effectiveness of a P4P strategy found to be highly effective in improving the implementation and effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment (EBT) for adolescent substance use disorders (SUDs). Methods Building on a $30 million national initiative to implement A-CRA in SUD treatment settings, urn randomization was used to assign 29 organizations and their 105 therapists and 1173 patients to one of two conditions (implementation-as-usual (IAU) control condition or IAU+P4P experimental condition). It was not possible to blind organizations, therapists, or all research staff to condition assignment. All treatment organizations and their therapists received a multifaceted implementation strategy. In addition to those IAU strategies, therapists in the IAU+P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions found to be associated with significantly improved patient outcomes (target A-CRA). Incremental cost-effectiveness ratios (ICERs), which represent the difference between the two conditions in average cost per treatment organization divided by the corresponding average difference in effectiveness per organization, and quality-adjusted life years (QALYs) were the primary outcomes. Results At trial completion, 15 organizations were randomized to the IAU condition and 14 organizations were randomized to the IAU+P4P condition. Data from all 29 organizations were analyzed. Cluster-level analyses suggested the P4P strategy led to significantly higher average total costs compared to the IAU control condition, yet this average increase of 5% resulted in a 116% increase in the average number of months therapists demonstrated competence in treatment delivery (ICER = $333), a 325% increase in the average number of patients who received the targeted dosage of treatment (ICER = $453), and a 325% increase in the number of days of abstinence per patient in treatment (ICER = $8.134). Further supporting P4P as a cost-effective implementation strategy, the cost per QALY was only $8681 (95% confidence interval $1191–$16,171). Conclusion This study provides experimental evidence supporting P4P as a cost-effective implementation strategy. Trial registration NCT01016704. |
| first_indexed | 2024-04-12T06:30:45Z |
| format | Article |
| id | doaj.art-d9bc6c1b4e1a493088fcf6b87c3a836e |
| institution | Directory Open Access Journal |
| issn | 1748-5908 |
| language | English |
| last_indexed | 2024-04-12T06:30:45Z |
| publishDate | 2018-07-01 |
| publisher | BMC |
| record_format | Article |
| series | Implementation Science |
| spelling | doaj.art-d9bc6c1b4e1a493088fcf6b87c3a836e2022-12-22T03:44:02ZengBMCImplementation Science1748-59082018-07-0113111110.1186/s13012-018-0774-1Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trialBryan R. Garner0Aung K. Lwin1Gail K. Strickler2Brooke D. Hunter3Donald S. Shepard4RTI InternationalSchneider Institutes for Health Policy, The Heller School, MS035, Brandeis UniversitySchneider Institutes for Health Policy, The Heller School, MS035, Brandeis UniversityMinnesota Department of Human ServicesSchneider Institutes for Health Policy, The Heller School, MS035, Brandeis UniversityAbstract Background Pay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. This study examined the incremental cost-effectiveness of a P4P strategy found to be highly effective in improving the implementation and effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment (EBT) for adolescent substance use disorders (SUDs). Methods Building on a $30 million national initiative to implement A-CRA in SUD treatment settings, urn randomization was used to assign 29 organizations and their 105 therapists and 1173 patients to one of two conditions (implementation-as-usual (IAU) control condition or IAU+P4P experimental condition). It was not possible to blind organizations, therapists, or all research staff to condition assignment. All treatment organizations and their therapists received a multifaceted implementation strategy. In addition to those IAU strategies, therapists in the IAU+P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions found to be associated with significantly improved patient outcomes (target A-CRA). Incremental cost-effectiveness ratios (ICERs), which represent the difference between the two conditions in average cost per treatment organization divided by the corresponding average difference in effectiveness per organization, and quality-adjusted life years (QALYs) were the primary outcomes. Results At trial completion, 15 organizations were randomized to the IAU condition and 14 organizations were randomized to the IAU+P4P condition. Data from all 29 organizations were analyzed. Cluster-level analyses suggested the P4P strategy led to significantly higher average total costs compared to the IAU control condition, yet this average increase of 5% resulted in a 116% increase in the average number of months therapists demonstrated competence in treatment delivery (ICER = $333), a 325% increase in the average number of patients who received the targeted dosage of treatment (ICER = $453), and a 325% increase in the number of days of abstinence per patient in treatment (ICER = $8.134). Further supporting P4P as a cost-effective implementation strategy, the cost per QALY was only $8681 (95% confidence interval $1191–$16,171). Conclusion This study provides experimental evidence supporting P4P as a cost-effective implementation strategy. Trial registration NCT01016704.http://link.springer.com/article/10.1186/s13012-018-0774-1Implementation researchCost-effectivenessSubstance useAdolescent |
| spellingShingle | Bryan R. Garner Aung K. Lwin Gail K. Strickler Brooke D. Hunter Donald S. Shepard Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial Implementation Science Implementation research Cost-effectiveness Substance use Adolescent |
| title | Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial |
| title_full | Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial |
| title_fullStr | Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial |
| title_full_unstemmed | Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial |
| title_short | Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial |
| title_sort | pay for performance as a cost effective implementation strategy results from a cluster randomized trial |
| topic | Implementation research Cost-effectiveness Substance use Adolescent |
| url | http://link.springer.com/article/10.1186/s13012-018-0774-1 |
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