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

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 clinicaltrials.gov Identifier: NCT01016704