Testing the incremental effectiveness of pay-for-performance to improve implementation of a motivational interviewing brief intervention for substance use disorders in HIV settings: Results of a parallel cluster-randomized type 3 hybrid trial

Background: Substance use disorders (SUDs) have a serious adverse impact on the physical and mental well-being of people with HIV. Previously, using a 39-site dual-randomized type 2 hybrid trial design, findings from the Substance Abuse Treatment to HIV Care Project supported the Implementation and Sustainment Facilitation (ISF) strategy to improve implementation and effectiveness of a motivational interviewing brief intervention (MIBI) for SUD within HIV service settings across the United States (US). Building on this trial, this parallel cluster-randomized type 3 hybrid trial aimed to test the incremental effectiveness of a pay-for-performance (P4P), a form of the “alter incentive/allowance structures” strategy. Methods: Twenty-six HIV service organizations, their staff participants (N=87), and their client participants (N=341) were cluster-randomized to one of two implementation conditions. The control condition included staff-focused training, feedback, and consultation (TFC) and team-focused implementation and sustainment (ISF). The experimental condition included TFC+ISF as well as P4P (TFC+ISF+P4P). P4P used financial incentives to reward MIBI implementation (US$10 per MIBI delivered) and MIBI implementation at or above a pre-defined level of quality (US$10 per demonstration). In addition to these outcomes, past 4-week changes/reductions in client participant’s days of primary substance use and anxiety symptoms were examined. Results: The addition of P4P had a large and significant effect on the number of MIBIs implemented ( d =1.30, p<.05) and reduction in anxiety ( d= -1.54), but there was no impact on days of substance use. P4P had large effects on MIBI quality ( d =1.24) and MIBI implementation effectiveness ( d =1.28), but these were not significant ( p <.10). Conclusions: P4P is a form of the “alter incentive/allowance structures” strategy. Its function is to reward the implementation of a clinical innovation. Rewarding implementation is consistent with the theory of implementation effectiveness, which suggests implementation climate (i.e., the extent to which implementation is expected, supported, and rewarded) is a key antecedent of implementation effectiveness (i.e., the consistency and quality of implementation). We found that P4P had a significant, positive impact on MIBI implementation in HIV service settings, but client-level outcomes were mixed. Future research should examine the effectiveness of the P4P strategy to improve implementation and sustainment of other evidence-based innovations. Trial registration: ClinicalTrials.gov: NCT04687917. Registered 12/18/2020.