Using pay for performance to improve treatment implementation for adolescent substance use disorders: results from a cluster randomized trial

Arch Pediatr Adolesc Med. 2012 Oct;166(10):938-44. doi: 10.1001/archpediatrics.2012.802.


Objective: To test whether pay for performance (P4P) is an effective method to improve adolescent substance use disorder treatment implementation and efficacy.

Design: Cluster randomized trial.

Setting: Community-based treatment organizations.

Participants: Twenty-nine community-based treatment organizations, 105 therapists, and 986 adolescent patients (953 with complete data).

Intervention: Community-based treatment organizations were assigned to 1 of the following conditions: the implementation-as-usual (IAU) control condition or the P4P experimental condition. In addition to delivering the same evidence-based treatment (ie, using the Adolescent Community Reinforcement Approach [A-CRA]), each organization received standardized levels of funding, training, and coaching from the treatment developers. Therapists in the P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (ie, A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions (ie, target A-CRA) that has been found to be associated with significantly improved patient outcomes.

Main outcome measures: Outcomes included ACRA competence (ie, a therapist-level implementation measure), target A-CRA (ie, a patient-level implementation measure), and remission status (ie, a patient-level treatment effectiveness measure).

Results: Relative to therapists in the IAU control condition, therapists in the P4P condition were significantly more likely to demonstrate A-CRA competence (24.0% vs 8.9%; event rate ratio, 2.24; 95% CI, 1.12- 4.48; P=.02). Relative to patients in the IAU control condition, patients in the P4P condition were significantly more likely to receive target A-CRA (17.3% vs 2.5%; odds ratio, 5.19; 95% CI, 1.53-17.62; P=.01). However, no significant differences were found between conditions with regard to patients' end-of-treatment remission status.

Conclusion: Pay for performance can be an effective method of improving treatment implementation.

Trial registration: Identifier: NCT01016704

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Clinical Competence / economics*
  • Clinical Competence / standards
  • Community Mental Health Services / economics*
  • Community Mental Health Services / methods
  • Community Mental Health Services / standards
  • Female
  • Humans
  • Intention to Treat Analysis
  • Logistic Models
  • Male
  • Middle Aged
  • Propensity Score
  • Reimbursement, Incentive*
  • Substance-Related Disorders / economics
  • Substance-Related Disorders / therapy*
  • Treatment Outcome

Associated data