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Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study

BMJ 2016; 353 doi: (Published 09 May 2016) Cite this as: BMJ 2016;353:i2214
  1. Jose F Figueroa, instructor of medicine1 3,
  2. Yusuke Tsugawa, research associate1,
  3. Jie Zheng, statistician1,
  4. E John Orav, associate professor2 3,
  5. Ashish K Jha, professor of medicine1 4
  1. 1Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
  2. 2Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
  3. 3Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
  4. 4Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA
  1. Correspondence to: A K Jha ajha{at}
  • Accepted 12 April 2016


Objective To determine the impact of the Hospital Value-Based Purchasing (HVBP) program—the US pay for performance program introduced by Medicare to incentivize higher quality care—on 30 day mortality for three incentivized conditions: acute myocardial infarction, heart failure, and pneumonia.

Design Observational study.

Setting 4267 acute care hospitals in the United States: 2919 participated in the HVBP program and 1348 were ineligible and used as controls (44 in general hospitals in Maryland and 1304 critical access hospitals across the United States).

Participants 2 430 618 patients admitted to US hospitals from 2008 through 2013.

Main outcome measures 30 day risk adjusted mortality for acute myocardial infarction, heart failure, and pneumonia using a patient level linear spline analysis to examine the association between the introduction of the HVBP program and 30 day mortality. Non-incentivized, medical conditions were the comparators. A secondary outcome measure was to determine whether the introduction of the HVBP program was particularly beneficial for a subgroup of hospital—poor performers at baseline—that may benefit the most.

Results Mortality rates of incentivized conditions in hospitals participating in the HVBP program declined at −0.13% for each quarter during the preintervention period and −0.03% point difference for each quarter during the post-intervention period. For non-HVBP hospitals, mortality rates declined at −0.14% point difference for each quarter during the preintervention period and −0.01% point difference for each quarter during the post-intervention period. The difference in the mortality trends between the two groups was small and non-significant (difference in difference in trends −0.03% point difference for each quarter, 95% confidence interval −0.08% to 0.13% point difference, P=0.35). In no subgroups of hospitals was HVBP associated with better outcomes, including poor performers at baseline.

Conclusions Evidence that HVBP has led to lower mortality rates is lacking. Nations considering similar pay for performance programs may want to consider alternative models to achieve improved patient outcomes.


  • Contributors: All authors conceived and designed the study, analyzed and interpreted the data, and critically revised the manuscript for important intellectual content. AKJ acquired the data. JZ, JFF, and YT carried out the statistical analysis. JFF drafted the manuscript. AKJ supervised the study and is the guarantor.

  • Funding: This study received no support from any organization.

  • Competing interests: All authors have completed the ICJME uniform disclosure form at and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was reviewed and granted exemption by the Harvard T. H. Chan School of Public Health Office of Human Research Administration.

  • Data sharing: No additional data available.

  • Transparency: The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

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