A Randomized Trial of a Pay-for-Performance Program Targeting Clinician Referral to a State Tobacco Quitline

Abstract

Background: Tobacco quitlines offer clinicians a means to connect their patients with evidence-based treatments. Innovative methods are needed to increase clinician referral.Methods: This is a clinic randomized trial that compared usual care (n=25 clinics) vs a pay-for-performance program (intervention) offering $5000 for 50 quitline referrals (n=24 clinics). Pay-for-performance clinics also received monthly updates on their referral numbers. Patients were eligible for referral if they visited a participating clinic, were 18 years or older, currently smoked cigarettes, and intended to quit within the next 30 days. The primary outcome was the clinic's rate of quitline referral (ie, number of referrals vs number of smokers seen in clinic).Results: Pay-for-performance clinics referred 11.4% of smokers (95% confidence interval [CI], 8.0%-14.9%; total referrals, 1483) compared with 4.2% (95% CI, 1.5%-6.9%; total referrals,441) for usual care clinics (P=.001).Rates of referral were similar in intervention vs usual care clinics (n=9) with a history of being very engaged with quality improvement activities (14.1% vs 15.1%, respectively; P=.85). Rates were substantially higher in intervention vs usual care clinics with a history of being engaged (n = 22 clinics; 10.1% vs 3.0%; P = .001) or less engaged (n=18 clinics; 10.1% vs 1.1%; P=.02) with quality improvement. The rate of patient contact after referral was 60.2% (95% CI, 49.7%-70.7%). Among those contacted, 49.4% (95% CI, 42.8%-55.9%) enrolled, representing 27.0% (95% CI, 21.3%-32.8%) of all referrals. The marginal cost per additional quitline enrollee was $300. Conclusion:A pay-for-performance program increases referral to tobacco quitline services, particularly among clinics with a history of less engagement in quality improvement activities.

Implementation of an Electronic Health Record-Based Care Management System to Improve Tobacco Treatment

“…This is within the range of referral rates of smokers to telephone counseling (4 % to 21 %) achieved by care management systems that facilitated referrals directly to community-based quitlines. [10][11][12] Given the impact of smoking cessation on individual patients' health, increasing smokers' contacts with effective treatments has large implications for patients. A distinctive feature of our system, like that implemented in a veteran population, is the location of the TTC within the healthcare system, with full access to medical records.…”

“…An alternative strategy is to have the PCP refer directly to the community-based quitline. [10][11][12][13][16][17][18] While direct referral has advantages in efficiency, existing systems have limited two-way communication with the PCP regarding smokers' treatment preferences and outcomes. The impact of this could be moderated with enhanced feedback from the quitline.…”

“…8 We and others have developed models of tobacco treatment that incorporate some of these elements. [9][10][11][12][13][14] We tested a set of enhanced electronic health record (EHR) functionalities to improve tobacco treatment delivery by primary care providers (PCPs). These functionalities increased smokers' rate of accessing counseling, but PCPs used the tools infrequently.…”

“…14 Another system facilitated referral of smokers to a tobacco care coordinator based within the healthcare system, 9 while other investigators facilitated referral of smokers from a PCP's office to a community-based telephone quitline, located outside the healthcare system. [10][11][12][15][16][17][18] This prior work demonstrates that integrating referrals into the EHR has the potential to improve delivery of tobacco treatment and warrants further study.…”

The Use of Three Strategies to Improve Quality of Care at a National Level

“…However, the overall effect was small and highly context-specific [16,28,49,61,66,67,72]. Three of four studies of physician-level financial incentives, one study of financial incentives directed toward health administrators, and four of five studies of provider-level financial incentives showed positive improvement in quality [3,9,12,28,33,44,48,64]. All but one study of pay-for-performance was conducted in the United States [15].…”