• Amelia M Bond, Kevin G Volpp, Ezekiel J Emanuel, Kristen Caldarella, Amanda Hodlofski, Lee Sacks, Pankaj Patel, Kara Sokol, Salvatore Vittore, Don Calgano, Carrie Nelson, Kevin Weng, Andrea Troxel, and Amol Navathe.
• Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA. amb2036@med.cornell.edu.
• J Gen Intern Med. 2019 Sep 1; 34 (9): 1737-1743.

BackgroundPay-for-performance (P4P) has been used expansively to improve quality of care delivered by physicians. However, to what extent P4P works through the provision of information versus financial incentives is poorly understood.ObjectiveTo determine whether an increase in information feedback without changes to financial incentives resulted in improved physician performance within an existing P4P program.Intervention/ExposureImplementation of a new registry enabling real-time feedback to physicians on quality measure performance.DesignObservational, predictive piecewise model at the physician-measure level to examine whether registry introduction associated with performance changes. We used detailed physician quality measure data 3 years prior to registry implementation (2010-2012) and 2 years after implementation (2014-2015). We also linked physician-level data including age, gender, and board certification; group-level data including registry click rates; and patient panel data including chronic conditions.ParticipantsFour hundred thirty-four physicians continuously affiliated with Advocate from 2010 to 2015.Main MeasuresPhysician performance on ten quality metrics.Key ResultsWe found no consistent pattern of improvement associated with the availability of real-time information across ten measures. Relative to predicted performance without the registry, average performance increased for two measures (childhood immunization status-rotavirus (p < 0.001) and diabetes care-medical attention for nephropathy (p = 0.024)) and decreased for three measures (childhood immunization status-influenza (p < 0.001) and diabetes care-HbA1c testing (p < 0.001) and poor HbA1c control (p < 0.001)). Results were consistent for subgroup analysis on those most able to improve, i.e., physicians in the bottom tertile of performance prior to registry introduction. Physicians who improved most were in groups that accessed the registry more than those who improved least (8.0 vs 10.0 times per week, p = 0.010).ConclusionsMore frequent provision of information, provided in real-time, was insufficient to improve physician performance in an existing P4P program with high baseline performance. Results suggest that electronic registries may not themselves drive performance improvement. Future work should consider testing information feedback enhancements with financial incentives.

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