Tailored medication adherence incentives for high-risk children with asthma: a pilot study.

Objective: While reminder-based electronic monitoring systems have shown promise in enhancing inhaled corticosteroid (ICS) adherence in select populations, more engaging strategies may be needed in families of children with high-risk asthma. This study assesses the acceptability and feasibility of gain-framed ICS adherence incentives in families of urban, minority children with frequent asthma hospitalization.Methods: We enrolled children aged 5-11 years with multiple yearly asthma hospitalizations in a 2-month, mixed methods, ICS adherence incentive pilot study. All participants received inhaler sensors and a smartphone app to track ICS use. During month 1, families received daily adherence reminders and weekly feedback, and children earned up to $1/day for complete adherence. No reminders, feedback, or incentives were provided in month 2. We assessed feasibility and acceptability using caregiver surveys and semi-structured interviews and ICS adherence using electronic monitoring data.Results: Of the 29 families approached, 20 enrolled (69%). Participants were primarily Black (95%), publicly insured (75%), and averaged 2.9 asthma hospitalizations in the prior year. Fifteen of the 16 caregivers (94%) surveyed at month 2 liked the idea of receiving adherence incentives. Mean adherence was significantly higher in month 1 compared with month 2 (80% vs. 33%, mean difference = 47%; 95% CI [33, 61], p < 0.001). Caregivers reported that their competing priorities often limited adherence, while incentives helped motivate child adherence.Conclusions: ICS adherence incentives were acceptable and feasible in a high-risk cohort of children with asthma. Future studies should assess the efficacy of adherence incentives in enhancing ICS adherence in high-risk children.

Financial incentives to encourage healthy behaviour: an analysis of U.K. media coverage.

BACKGROUND: Policies to use financial incentives to encourage healthy behaviour are controversial. Much of this controversy is played out in the mass media, both reflecting and shaping public opinion. OBJECTIVE: To describe U.K. mass media coverage of incentive schemes, comparing schemes targeted at different client groups and assessing the relative prominence of the views of different interest groups. DESIGN: Thematic content analysis. SUBJECTS: National and local news coverage in newspapers, news media targeted at health-care providers and popular websites between January 2005 and February 2010. SETTING: U.K. mass media. RESULTS: The study included 210 articles. Fifteen separate arguments favourable towards schemes, and 19 unfavourable, were identified. Overall, coverage was more favourable than unfavourable, although most articles reported a mix of views. Arguments about the prevalence and seriousness of the health problems targeted by incentive schemes were uncontested. Moral and ethical objections to such schemes were common, focused in particular on recipients such as drug users or the overweight who were already stereotyped as morally deficient, and these arguments were largely uncontested. Arguments about the effectiveness of schemes and their potential for benefit or harm were areas of greater contestation. Government, public health and other health-care provider interests dominated favourable coverage; opposition came from rival politicians, taxpayers' representatives, certain charities and from some journalists themselves. CONCLUSIONS: Those promoting incentive schemes for people who might be regarded as 'undeserving' should plan a media strategy that anticipates their public reception.

Impact of Financial Incentives on Health Outcomes and Costs of Care among Medicaid Beneficiaries with Diabetes in Hawai'i.

The Hawai'i Patient Reward And Incentives to Support Empowerment (HI-PRAISE) project, part of the Medicaid Incentives for Prevention of Chronic Diseases program of the Affordable Care Act, examined the impact of financial incentives on Medicaid beneficiaries with diabetes. It included an observational pre-post study which was conducted at nine Federally Qualified Health Centers (FQHCs) between 2013 to 2015. The observational study enrolled 2,003 participants. Participants could earn up to $320/year in financial incentives. Primary outcomes were change in hemoglobin A1c, blood pressure, and cholesterol; secondary outcomes included compliance with American Diabetes Association (ADA) standards of diabetes care and cost effectiveness. Generalized estimating equation models were used to assess differences in clinical outcomes and general linear models were utilized to estimate the medical costs per patient/day. Changes in clinical outcomes in the observational study were statistically significant: mean hemoglobin A1c decreased from 8.56% to 8.24% (P < .0001); mean systolic blood pressure decreased from 125.16 to 124.18 mm Hg (P = .0137); mean diastolic blood pressure decreased from 75.54 to 74.78 mm Hg (P = .0005); total cholesterol decreased from 180.77 to 174.21 mg/dl (P < .0001); and low-density lipoprotein decreased from 106.17 to 98.55 mg/dl (P < .0001). Improved ADA compliance was also observed. A key limitation was a reduced sample size due to participant's fluctuating Medicaid eligibility status. HI-PRAISE showed no reduction in total health cost during the project period.

The Efficacy of Using Financial Incentives to Change Unhealthy Behaviors Among a Rural Chronically Ill and Uninsured Population.

PURPOSE: To measure the effects of weight loss, medication compliance, and physical activity financial incentives delivered by health providers to uninsured patients. DESIGN: Full factorial (orthogonal) randomized design. SETTING: Primary care clinic in rural Mississippi. PARTICIPANTS: A total of 544 uninsured adult patients with diabetes or hypertension. All patients were enrolled in the clinic's care management program. INTERVENTION: Patients randomly received 0, 1, 2, or 3 financial incentives. Incentives for weight loss, medication compliance, and physical activity were awarded quarterly over 1 year. MEASURES: Weight loss, medication compliance, physical activity, and 6 clinical measures related to diabetes and hypertension. ANALYSIS: Cross-section and panel data regression models were used to compare outcomes for those who received incentives to those who did not receive incentives and to measure interaction effects. RESULTS: Effects of the weight loss incentive were positive but statistically insignificant (-3.7 lb; P = .106), while medication compliance was high in both the treatment and control groups (+2.37 percentage points; P = .411), and physical activity take-up was very limited. Effects on clinical outcomes, as well as interaction effects between incentives, were mixed and generally statistically insignificant. CONCLUSION: This study found little to no evidence that these financial incentives had beneficial effects on the incentivized behaviors in this setting. Likewise, the study found no effects on clinical outcomes nor any systematic evidence of interaction effects between 2 and 3 incentives.

Maternal Behavioral Health: Fertile Ground for Behavior Analysis.

The World Health Organization has identified four behavioral health priorities as risk factors for noncommunicable diseases in maternal populations: tobacco use, harmful alcohol use, poor nutrition, and lack of physical activity. These risk factors also significantly affect pregnant and immediately postpartum mothers, doubling the health risk and economic burden by adversely affecting maternal and birth or infant outcomes. Psychosocial and behavioral interventions are ideal for pregnant and immediately postpartum women as opposed to pharmacotherapy. Among other behavioral interventions, the use of incentives based on the principles of reinforcement has been a successful yet controversial way to change health behaviors. Implementing an incentive-based intervention in maternal health often brings up social validity concerns. The existing guideline on how to develop and conduct research in incentive-based interventions for maternal health lacks enough information on the specific variables to control for to maintain the intervention's effectiveness. This article outlines some of the critical variables in implementing an effective behavior-analytic intervention and addressing social validity concerns to change maternal behaviors in a sustainable manner, along with specific research topics needed in the field to prevent adverse maternal, birth, and infant outcomes.

Evaluating the Carrot Rewards App, a Population-Level Incentive-Based Intervention Promoting Step Counts Across Two Canadian Provinces: Quasi-Experimental Study.

BACKGROUND: The Carrot Rewards app was developed as part of an innovative public-private partnership to reward Canadians with loyalty points, exchangeable for retail goods, travel rewards, and groceries for engaging in healthy behaviors such as walking. OBJECTIVE: This study examined whether a multicomponent intervention including goal setting, graded tasks, biofeedback, and very small incentives tied to daily step goal achievement (assessed by built-in smartphone accelerometers) could increase physical activity in two Canadian provinces, British Columbia (BC) and Newfoundland and Labrador (NL). METHODS: This 12-week, quasi-experimental (single group pre-post) study included 78,882 participants; 44.39% (35,014/78,882) enrolled in the Carrot Rewards "Steps" walking program during the recruitment period (June 13-July 10, 2016). During the 2-week baseline (or "run-in") period, we calculated participants' mean steps per day. Thereafter, participants earned incentives in the form of loyalty points (worth Can $0.04 ) every day they reached their personalized daily step goal (ie, baseline mean+1000 steps=first daily step goal level). Participants earned additional points (Can $0.40) for meeting their step goal 10+ nonconsecutive times in a 14-day period (called a "Step Up Challenge"). Participants could earn up to Can $5.00 during the 12-week evaluation period. Upon meeting the 10-day contingency, participants could increase their daily goal by 500 steps, aiming to gradually increase the daily step number by 3000. Only participants with ≥5 valid days (days with step counts: 1000-40,000) during the baseline period were included in the analysis (n=32,229).The primary study outcome was mean steps per day (by week), analyzed using linear mixed-effects models. RESULTS: The mean age of 32,229 participants with valid baseline data was 33.7 (SD 11.6) years; 66.11% (21,306/32,229) were female. The mean daily step count at baseline was 6511.22. Over half of users (16,336/32,229, 50.69%) were categorized as "physically inactive," accumulating <5000 daily steps at baseline. Results from mixed-effects models revealed statistically significant increases in mean daily step counts when comparing baseline with each study week (P<.001). Compared with baseline, participants walked 115.70 more steps (95% CI 74.59 to 156.81; P<.001) at study week 12. BC and NL users classified as "high engagers" (app engagement above sample median; 15,511/32,229, 48.13%) walked 738.70 (95% CI 673.81 to 803.54; P<.001) and 346.00 (95% CI 239.26 to 452.74; P<.001) more steps, respectively. Physically inactive, high engagers (7022/32,229, 21.08%) averaged an increase of 1224.66 steps per day (95% CI 1160.69 to 1288.63; P<.001). Effect sizes were modest. CONCLUSIONS: Providing very small but immediate rewards for personalized daily step goal achievement as part of a multicomponent intervention increased daily step counts on a population scale, especially for physically inactive individuals and individuals who engaged more with the walking program. Positive effects in both BC and NL provide evidence of replicability.

Financial Incentives for Medicaid Beneficiaries With Diabetes: Lessons Learned From HI-PRAISE, an Observational Study and Randomized Controlled Trial.

PURPOSE: The Hawaii Patient Reward and Incentives to Support Empowerment (HI-PRAISE) project examined the impact of financial incentives on Medicaid beneficiaries with diabetes. DESIGN: Observational pre-post study and randomized controlled trial (RCT). SETTING: Federally qualified health centers (FQHCs) and Hawaii Kaiser Permanente. PARTICIPANTS: The observational study included 2003 Medicaid beneficiaries with diabetes from FQHCs. The RCT included 320 participants from Kaiser Permanente. INTERVENTION: Participants could earn up to $320/year of financial incentives for a minimum of 1 year. MEASURES: (1) Clinical outcomes of change in hemoglobin A1c (HbA1c), blood pressure, and cholesterol; (2) compliance with American Diabetes Association (ADA) standards of diabetes care; and (3) cost effectiveness. ANALYSIS: Generalized estimating equation models were used to assess differences in clinical outcomes. General linear models were utilized to estimate the medical costs per patient/day. RESULTS: Changes in clinical outcomes in the observational study were statistically significant. Mean HbA1c decreased from 8.56% to 8.24% ( P < .0001) and low-density lipoprotein decreased from 106.17 mg/dL to 98.55 mg/dL ( P < .0001). No significant differences were found between groups in the RCT. Improved ADA compliance was observed. No reduction in total health cost during the project period was demonstrated. CONCLUSION: The HI-PRAISE found no conclusive evidence that financial incentives had beneficial effect on diabetes clinical outcomes or cost saving measures.

Incentive Use for Improving Maternal Health: Perspective From Behavioral Science.

Incentive use to improve maternal health behavior has been controversial, and guidelines to effectively design and implement such an intervention have been published. This commentary briefly describes a perspective from behavioral science for the existing guideline on the development of an incentive-based intervention to change maternal health behaviors. It is recommended to emphasize the saliency of incentives as an important variable to maintain the intervention effect while addressing barriers to feasibility and sustainability.

Exploring parent attitudes around using incentives to promote engagement in family-based weight management programs.

Incentives can promote adult wellness. We sought to examine whether incentives might help overcome barriers to engagement in child weight management programs and the ideal value, type and recipient of incentives. In 2017, we conducted semi-structured phone interviews with parents of children ≤17 years old, formerly or currently affected by obesity, who had (n = 11) or had never (n = 12) participated in family-based behavioral treatment (FBT) for obesity. Interviews explored the range and type of incentives families would be willing to accept. Interview transcripts were coded and data were analyzed using a thematic analysis. We found that some parents were skeptical about receiving cash incentives. However, once treatment-related costs were identified, some became more interested in reimbursement for out of pocket expenditures. Most parents felt up to $100/month would be adequate and that incentives should be tied to changing behaviors, not BMI. Some interviewees expressed preferences for non-cash incentives (e.g. a gift card) over cash incentives. Parents were willing to share incentives with adolescents, up to $50/month, but there was concern about incentives affecting a child's intrinsic motivation for behavior change. All parents acknowledged that moderate incentives alone couldn't overcome the realities of structural and familial barriers to engaging in weight management programs. In summary, we identified aspects of an incentive program to promote engagement in FBT that would be desirable and feasible to implement. Future quantitative work can reveal the value and structure of incentives that are effective for improving obesogenic health behaviors and outcomes.

Can We Pay for Performance in Behavioral Health Care?

Pay for performance (P4P) has become a popular strategy to reward quality and cost-efficiency in behavioral health care and other health care disciplines. This column presents the results of a literature review of P4P in behavioral health care. Fifteen empirical studies evaluating the outcomes of behavioral health services provided in a P4P system were identified. The limited data suggest that P4P can achieve its desired effect. More research is needed on outcomes, performance, and unintended consequences.

Examining Incentives to Promote Physical Activity Maintenance Among Hospital Employees Not Achieving 10,000 Daily Steps: A Web-Based Randomized Controlled Trial Protocol.

BACKGROUND: The economic burden of physical inactivity in Canada is estimated at Can $6.8 billion (US $5 billion) per year. Employers bear a substantial proportion of the economic costs, as they pay more for inactive workers in health care and other organizational costs. In response, many Canadian employers offer wellness programs, though these are often underutilized. While financial health incentives have been proposed as one way of increasing participation, their longer term effects (ie postintervention effects) are not clear. OBJECTIVE: The objective of this paper is to outline the methodology for a randomized control trial (RCT) examining the longer term impact of an existing physical activity promotion program that is enhanced by adding guaranteed rewards (Can $1 [US $0.74] per day step goal met) in a lower active hospital employee population (less than 10,000 steps per day). METHODS: A 12-week, parallel-arm RCT (with a 12-week postintervention follow-up) will be employed. Employees using Change4Life (a fully automated, incentive-based wellness program) and accumulating fewer than 10,000 steps per day at baseline (weeks 1 to 2) will be randomly allocated (1:1) to standard care (wellness program, accelerometer) or an intervention group (standard care plus guaranteed incentives). All study participants will be asked to wear the accelerometer and synchronize it to Change4Life daily, although only intervention group participants will receive guaranteed incentives for reaching tailored daily step count goals (Can $1 [US $0.74] per day; weeks 3 to 12). The primary study outcome will be mean proportion of participant-days step goal reached during the postintervention follow-up period (week 24). Mean proportion of participant-days step goal reached during the intervention period (week 12) will be a secondary outcome. RESULTS: Enrollment for the study will be completed in February 2017. Data analysis will commence in September 2017. Study results are to be published in the winter of 2018. CONCLUSIONS: This protocol was designed to examine the impact of guaranteed rewards on physical activity maintenance in lower active hospital employees. CLINICALTRIAL: ClinicalTrials.gov NCT02638675; https://clinicaltrials.gov/ct2/show/NCT0 2638675 (Archived by WebCite at http://www.webcitation.org/6g4pvZvhW).

Stages of change and patient activation measure scores in the context of incentive-based health interventions.

PURPOSE: To determine if two widely used behavioral change measures-Stages of Change (SoC) and Patient Activation Measure (PAM)-correlate with each other, are affected by financial incentives, or predict positive outcomes in the context of incentive-based health interventions. DESIGN: Secondary analysis of two randomized controlled trials of incentives for weight loss and for improved diabetes self-monitoring. SETTING: Philadelphia, Pennsylvania; Newark, New Jersey. SUBJECTS: A total of 132 obese and 75 diabetic adults enrolled in one of two trials. MEASURES . SoC and PAM scores; weight loss and usage rate of diabetes self-monitoring equipment. ANALYSIS: Multiple regression; Kruskal-Wallis test. RESULTS: We found no association between baseline SoC and PAM scores in either study (p = .30 and p = .89). Regression models showed no association between baseline PAM score and SoC and subsequent outcomes for either study (weight loss study: PAM: p = .14, SoC: p = .1; diabetes study: PAM: p = .45, SoC: p = .61). Change in PAM score and SoC among participants in the intervention groups did not differ by study arm or among participants with better outcomes. CONCLUSION . PAM score and SoC may not effectively predict success or monitor progress among individuals enrolled in incentive-based interventions.

Does incentivising pill-taking 'crowd out' risk-information processing? Evidence from a web-based experiment.

The use of financial incentives for changing health-related behaviours raises concerns regarding their potential to undermine the processing of risks associated with incentivised behaviours. Uncertainty remains about the validity of such concerns. This web-based experiment assessed the impact of financial incentives on i) willingness to take a pill with side-effects; ii) the time spent viewing risk-information and iii) risk-information processing, assessed by perceived-risk of taking the pill and knowledge of its side-effects. It further assesses whether effects are moderated by limiting cognitive capacity. Two-hundred and seventy-five UK-based university staff and students were recruited online under the pretext of being screened for a fictitious drug-trial. Participants were randomised to the offer of different compensation levels for taking a fictitious pill (£0; £25; £1000) and the presence or absence of a cognitive load task (presentation of five digits for later recall). Willingness to take the pill increased with the offer of £1000 (84% vs. 67%; OR 3.66, CI 95% 1.27-10.6), but not with the offer of £25 (79% vs. 67%; OR 1.68, CI 95% 0.71-4.01). Risk-information processing was unaffected by the offer of incentives. The time spent viewing the risk-information was affected by the offer of incentives, an effect moderated by cognitive load: Without load, time increased with the value of incentives (£1000: M = 304.4sec vs. £0: M = 37.8sec, p < 0.001; £25: M = 66.6sec vs. £0: M = 37.8sec, p < 0.001). Under load, time decreased with the offer of incentives (£1000: M = 48.9sec vs. £0: M = 132.7sec, p < 0.001; £25: M = 60.9sec vs. £0: M = 132.7sec, p < 0.001), but did not differ between the two incentivised groups (p = 1.00). This study finds no evidence to suggest incentives "crowd out" risk-information processing. On the contrary, incentives appear to signal risk, an effect, however, which disappears under cognitive load. Although these findings require replication, they highlight the need to maximise cognitive capacity when presenting information about incentivised health-related behaviours.