Importance The Million Hearts Cardiovascular Disease (CVD) Risk Reduction Model pays provider organizations for measuring and reducing Medicare patients’ cardiovascular risk.

Objective To assess whether the model increases the initiation or intensification of antihypertensive medications or statins among patients with blood pressure or low-density lipoprotein (LDL) cholesterol levels above guideline thresholds for treatment intensification.

Design, Setting, and Participants This prespecified secondary analysis of a cluster-randomized, pragmatic trial included primary care and cardiology practices, health care centers, and hospital-based outpatient departments across the US. Participants included Medicare patients who were enrolled into the model in 2017 by participating organizations and who were at high risk and at medium risk of a myocardial infarction or stroke in 10 years. Patient outcomes were analyzed for 1 year postenrollment (through December 2018) using an intent-to-treat design. Analysis began November 2019.

Interventions US Centers for Medicare & Medicaid Services paid organizations for risk stratifying Medicare patients and reducing CVD risk among high-risk patients through discussing risk scores, developing individualized risk reduction plans, and following up with patients twice yearly.

Main Outcomes and Measures Initiating or intensifying statin or antihypertensive therapy within 1 year of enrollment, measured in Medicare Part D claims, and LDL cholesterol and systolic blood pressure levels approximately 1 year after enrollment, measured in usual care and reported to Centers for Medicare & Medicaid Services via a data registry (data complete for 51% of high-risk enrollees). The study’s primary outcome (incidence of first-time myocardial infarction and stroke) is not reported because the trial is ongoing.

Results A total of 330 primary care and cardiology practices, health care centers, and hospital-based outpatient departments and 125 436 Medicare patients were included in this analysis. High-risk patients in the intervention group had a mean (SD) age of 74 (4.1), 15 213 (63%) were male, 21 657 (90%) were receiving antihypertensive medication at baseline, and 16 558 (69%) were receiving statins. Almost all (21 791 [91%]) high-risk intervention group patients had above-threshold systolic blood pressure level (>130 mm Hg), LDL cholesterol level (>70 mg/dL), or both. Patients in the intervention group with these risk factors were more likely than control patients (8127 [37.3%] vs 4753 [32.4%]; adjusted difference in percentage points, 4.8; 95% CI, 2.9-6.7; P < .001) to initiate or intensify statins or antihypertensive medication. Centers for Medicare & Medicaid Services did not pay for CVD risk reduction for medium-risk enrollees, but initiation or intensification rates for these enrollees were also higher in the intervention vs control groups (12 668 [27.9%] vs 7544 [24.8%]; adjusted difference in percentage points, 3.1; 95% CI, 1.9-4.3; P < .001). Among high-risk enrollees with clinical data approximately 1 year after enrollment, LDL cholesterol level was slightly lower in the intervention vs control groups (mean [SD], 89 [31.8] vs 91 [32.1] mg/dL; adjusted difference in percentage points, −1.8; 95% CI, −2.9 to −0.6; P = .002), as was systolic blood pressure (mean [SD], 133 [15.7] vs 135 [16.4] mm Hg; adjusted difference in percentage points, −1.7; 95% CI, −2.8 to −0.6; P = .003).

Conclusions and Relevance In this study, a pay-for-performance model led to modest increases in the use of CVD medications in a range of organizations, despite high medication use at baseline.

重要性 Million Hearts 心血管疾病 (CVD) 风险降低模型向医疗服务提供者组织支付费用以衡量和降低 Medicare 患者的心血管风险。

目的 评估该模型是否增加了血压或低密度脂蛋白 (LDL) 胆固醇水平高于治疗强化指导阈值的患者的抗高血压药物或他汀类药物的开始或强化。

设计、设置和参与者 这项预先指定的对集群随机、实用试验的二次分析包括美国各地的初级保健和心脏病学实践、医疗保健中心和医院门诊部。参与者包括参与组织于 2017 年加入该模型的医疗保险患者，这些患者在 10 年内处于心肌梗塞或中风的高风险和中等风险。使用意向治疗设计分析了入组后 1 年（至 2018 年 12 月）的患者结局。分析于 2019 年 11 月开始。

干预措施 美国医疗保险和医疗补助服务中心通过讨论风险评分、制定个性化的风险降低计划和每年两次对患者进行随访，向医疗保险患者的风险分层和降低高危患者的 CVD 风险支付费用。

主要结果和措施 在入组后 1 年内开始或加强他汀类药物或抗高血压治疗，在 Medicare D 部分索赔中测量，在入组后大约 1 年测量 LDL 胆固醇和收缩压水平，在常规护理中测量并报告给医疗保险和医疗补助中心通过数据注册表提供服务（51% 的高风险参与者的数据完整）。该研究的主要结果（首次心肌梗死和中风的发生率）未报告，因为该试验正在进行中。

结果 共有 330 家初级保健和心脏病学实践、保健中心和医院门诊部以及 125 436 名医疗保险患者被纳入本分析。干预组的高危患者平均 (SD) 年龄为 74 (4.1) 岁，15 213 名 (63%) 为男性，21 657 名 (90%) 在基线时正在接受抗高血压药物治疗，16 558 名 (69%)正在接受他汀类药物。几乎所有 (21 791 [91%]) 高危干预组患者的收缩压水平（>130 mm Hg）、LDL 胆固醇水平（>70 mg/dL）或两者均高于阈值。具有这些风险因素的干预组患者比对照组患者更有可能（8127 [37.3%] vs 4753 [32.4%]；调整后的百分点差异，4.8；95% CI，2.9-6.7；P < .001) 开始或强化他汀类药物或抗高血压药物。医疗保险和医疗补助服务中心没有为降低中等风险参与者的 CVD 风险付费，但干预组与对照组相比，这些参与者的启动或强化率也更高（12 668 [27.9%] vs 7544 [24.8%]；调整后的百分点差异，3.1；95% CI，1.9-4.3；P  < .001）。在入组后约 1 年有临床数据的高风险入组者中，干预组与对照组相比，LDL 胆固醇水平略低（平均 [SD]，89 [31.8] vs 91 [32.1] mg/dL；调整后的百分点差异, -1.8; 95% CI, -2.9 至 -0.6; P = .002），收缩压也是如此（平均 [SD]，133 [15.7] vs 135 [16.4] mm Hg；调整后的百分点差异，-1.7；95% CI，-2.8 至 -0.6；P  = . 003)。

结论和相关性 在本研究中，按绩效付费模式导致一系列组织中 CVD 药物的使用适度增加，尽管基线药物使用率很高。