Aim: Commencement of haemodialysis with an arteriovenous fistula (AVF) or arteriovenous graft (AVG) is associated with improved survival compared with commencement with a central venous catheter. In 2011-12, Queensland Health made incentive payments to renal units for early referred patients who commenced peritoneal dialysis (PD), or haemodialysis with an AVF/AVG. The aim of this study was to determine if pay-for-performance improved clinical care. Methods: All patients who commenced dialysis in Australia between 2009 and 2014 and were registered with the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) were included. A multivariable regression model was used to compare rates of commencing dialysis with a PD catheter or permanent AVF/AVG during the pay-for-performance period (2011-12) with periods prior (2009-2010) and after (2013-2014). Results: A total 10,858 early referred patients commenced dialysis during the study period, including 2058 in Queensland. In Queensland, PD as first modality increased with time (p < 0.001) but there was no change in AVF/AVG rate at first haemodialysis (p = 0.5). In a multivariate model using the pay-for-performance period as reference, the odds ratio for commencement with PD or haemodialysis with an AVF/AVG in Queensland was 1.02 (95%CI 0.81-1.29) in 2009-10 and 1.28 (95%CI 1.01-1.61) in 2013-14. There was no change for the rest of Australia (0.97 95%CI 0.87-1.09 in 2009-10 and 1.00 95%CI 0.90-1.11 in 2013-14). Conclusion: Pay-for-performance did not improve rates of commencement of dialysis with PD or an AVF/AVG during the payment period. A lag effect on clinical care may explain the improvement in later years.