Background: Pay-for-performance programs are designed to link payments to clinical outcomes. We investigated the characteristics of hospitals in the United States, such as size and volume, that were associated with the receipt of a clinical performance bonus in a nationwide pay-for-performance program involving hip and knee replacement.

Methods: We obtained hospital-level outcomes data from a nationwide pay-for-performance demonstration project on hip and knee replacement. We obtained data on the hospital's size, procedure volume, and case-mix index as well as whether it was a teaching hospital and then performed a multivariate analysis to determine which factors were associated with the receipt of a performance bonus.

Results: Hospital size and revenue were not associated with the receipt of a performance bonus. Top-performance hospitals tended to be those specialized in orthopaedics (p < 0.002). Multivariate analysis revealed that high-performance hospitals tended to perform a high volume of hip and knee replacements (p < 0.008), to be teaching hospitals (p < 0.037), and to be located in the Midwestern United States (p < 0.001).

Conclusions: Teaching hospitals that perform a high volume of hip and knee replacements will tend to succeed should pay-for-performance programs be enacted nationwide.