Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial

Abstract

BACKGROUND: Uncontrolled hypertension contributes to disparities in cardiovascular outcomes. Patient intervention strategies informed by behavioral economics and social psychology could improve blood pressure (BP) control in disadvantaged minority populations. OBJECTIVE: To assess the impact on BP control of an intervention combining short-term financial incentives with promotion of intrinsic motivation among highly disadvantaged patients. DESIGN: Randomized controlled trial. PARTICIPANTS: Two hundred seven adults (98% African American or Latino) aged 18 or older with uncontrolled hypertension attending Federally Qualified Health Centers. INTERVENTION: Six-month intervention, combining financial incentives for measuring home BP, recording medication use, BP improvement, and achieving target BP values with counseling linking hypertension control efforts to participants' personal reasons to stay healthy. MAIN MEASURES: Primary outcomes: percentage achieving systolic BP (SBP) < 140 mmHg, percentage achieving diastolic BP (DBP) < 90 mmHg, and changes in SBP and DBP, all after 6 months. Priority secondary outcomes were SBP < 140 mmHg, DBP < 90 mmHg, and BP change at 12 months, 6 months after the intervention ended. KEY RESULTS: After 6 months, rates of achieving target BP values for intervention and control subjects respectively was 57.1% vs. 40.2% for SBP < 140 mmHg (adjusted odds ratio (AOR) 2.53 (1.13-5.70)), 79.8% vs 70.1% for DBP < 90 mmHg (AOR 2.50 (0.84-7.44)), and 53.6% vs 40.2% for achieving both targets (AOR 2.04 (0.92-4.52)). However, at 12 months, the groups did not differ significantly in these 3 measures: 39.5% vs 35.0% for SBP (AOR 1.20 (0.51-2.83)), 68.4% vs 75.0% for DBP (AOR 0.70 (0.24-2.09)), and 35.5% vs 33.8% for both (AOR 1.03 (0.44-2.42)). Change in absolute SBP and DBP did not differ significantly between the groups at 6 or 12 months. Exploratory post hoc analysis revealed intervention benefit only occurred among individuals whose providers intensified their regimens, but not among those with intensification but no intervention. CONCLUSIONS: The intervention achieved short-term improvement in SBP control in a highly disadvantaged population. Despite attempts to enhance intrinsic motivation, the effect was not sustained after incentives were withdrawn. Future research should evaluate combined patient/provider strategies to enhance such interventions and sustain their benefit. TRIAL REGISTRATION: NCT01402453; http:// clinicaltrials.gov/show/NCT01402453 KEY WORDS: hypertension; healthcare disparities; patient behavior; financial incentives, behavioral economics. J Gen Intern Med

An intervention study for impact assessment of health education by empowered community health workers in improving treatment and diet adherence in hypertension

“…Health education from well informed community health workers has indeed became a factor that improved hypertensive patients practice on hypertension self-management such as medication adherence and low salt diet compliance. [ 11 13 15 17 18 19 20 21 ] In this study, the proportion of hypertensive patients' with good medication adherence and low salt diet compliance were increased after health education on community health worker. It showed that community health workers were able to affect the hypertensive patients' behavior in the community.…”

Effect of Financial Incentives on Hypertension Control: A Multicenter Randomized Controlled Trial in China

“…Financial incentives are proven to induce changes in health-related behavior, such as smoking cessation, weight loss, glycemic control, and hypertension control, thereby aiding in disease management. 11 , 14 , 16 , 17 , 24 , 25 Nevertheless, providing financial incentives to patients with hypertension is not always effective. Kaboli et al 11 used 3 interventions to encourage patients to talk to their doctors about antihypertensive medication intensification.…”

“…After 12 months, improved BP control was evident only in the group receiving all 3 interventions. Shapiro et al 14 offered intervention participants a combination of fixed payments, contingent payments, and lotteries (eg, payment per mm Hg of improved BP, or a lottery card, to meet the health goals set by the researchers) in a highly disadvantaged minority population. This study revealed that financial incentives for measuring home BP aid in achieving short-term improvement in systolic BP control.…”

“…Details of the study protocol have been published elsewhere. 14 Our analysis followed the CONSORT 2010 recommendations for the analysis of RCT data. This trial was compliant with the 1975 Declaration of Helsinki guidelines and approved by the Shengjing Hospital of China Medical University Medical Ethics Committee (No.…”

Capsule Commentary on Shapiro et al., Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial

“…S hapiro and colleagues assessed the efficacy of an intervention that combines monetary incentives and promotion of intrinsic motivation to improve blood pressure (BP) control among low-income and racial/ethnic minority patients. 1 Uncontrolled hypertension is a leading cause of premature death in these subgroups. 2 The investigators found short-term improvements in BP control at 6 months when the incentives ended, although the effects had largely faded by 12 months.…”