Are Financial Incentives for Patients an Effective Treatment for Hypertension Attention-Deficit Disorder?

HomeHypertensionVol. 79, No. 10Are Financial Incentives for Patients an Effective Treatment for Hypertension Attention-Deficit Disorder? Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBAre Financial Incentives for Patients an Effective Treatment for Hypertension Attention-Deficit Disorder? Martin F. Shapiro Martin F. ShapiroMartin F. Shapiro Correspondence to: Martin F. Shapiro, Department of Medicine, Weill Cornell Medical College, 420 East 70th St, LH-367, New York, NY 10021. Email E-mail Address: [email protected] https://orcid.org/0000-0003-1879-5430 Department of Medicine, Weill Cornell Medical College, New York. Search for more papers by this author Originally published7 Sep 2022https://doi.org/10.1161/HYPERTENSIONAHA.122.19892Hypertension. 2022;79:2212–2213This article is a commentary on the followingEffect of Financial Incentives on Hypertension Control: A Multicenter Randomized Controlled Trial in ChinaPopulation-level hypertension control has proved elusive. Among other problems, asymptomatic patients too often fail to take their medicines consistently over time. As Willy Loman’s wife memorably said in “Death of a Salesman, “attention must be paid” Do financial incentives for patients have a role in accomplishing that? Zheng et al1 studied this question in three Chinese cities, randomizing adults with elevated blood pressure readings on consecutive days either to receive usual care plus weekly text messages and an opportunity to have treatment-related questions answered via chat, or to a group which, in addition to the text messages, received 5 yuan ($0.75 USD) weekly for checking and recording their blood pressure and 50 yuan at 1, 3, 6, and 12 months for lowering their blood pressure by at least 10 mm or to below 140/90. Mean systolic readings in the 2 groups were about 160 mm at study entry and fell by about 10 mm at the 1-month follow-up visit. At 3 months, a further decline was significantly greater in the intervention group. However, the decline was almost identical at 6 and 12 months, ending up at 8.9 and 10.2 mm below baseline in the incentive and comparison groups, respectively.See related article, pp 2202–2211Why was the effect at 3 months not sustained? The incentives were quite small (about 1% of annual Chinese household income over a year),2 the frequency of reward was sporadic (gaps of 3 then 6 months after the second one), and there was no incentive for improvement beyond 10 mm, the level achieved in the comparison group (perhaps reflecting the effect of the text messaging, a Hawthorne effect of study participation, and regression to the mean).Yet, even more intensive rewards may not have a sustained effect on hypertension control. We conducted a randomized trial of financial incentives in Los Angeles among hypertensive individuals with annual household incomes averaging <$10 000. Incentive payments were substantially higher relative to income (over $300 in a 6-month period, including payment per mm of improvement up to 25 mm, as well as lottery payments for process achievements). Improved control in intervention relative to control participants was sustained throughout the 6-month intervention. However, 6 months later, there was no difference between groups, although we had included a cointervention intended to increase intrinsic motivation.3There are many patient barriers to effectively controlling chronic diseases, including discounting of risks that are not proximate (“present bias”), avoidance of information that is frightening (the “ostrich effect”) or highly technical (“ambiguity aversion”), knowledge and beliefs about a disease and its treatment, direct and indirect costs of treatment (including time away from work), inattention to the problem (potentially due to competing demands), and lack of belief in one’s ability to control the disease (“self-efficacy”).4 Taking treatment for hypertension requires a lifetime of devotion. Who wants to think about and deal with their hypertension every day for years on end? Even when medications are optimized, these influences on patient behavior can prove to be insurmountable obstacles. While short-term financial incentives can provoke discrete acts, such as going to a postnatal visit or entering a smoking cessation program,5 it is far from clear that such effects can be sustained over a lifetime of treatment for a disease such as hypertension.That does not mean should we abandon incentives as a potential strategy. Rather, we should approach hypertension treatment as we do leukemia: induction, then consolidation, then maintenance therapy, all involving combinations of drugs that work synergistically. Combining medications is widely endorsed in hypertension pharmacotherapy, although clinician inertia remains a problem: many fail to intensify regimens when that is needed. But combination therapy also is needed to address patient behavior. Studies are needed to understand which combinations and sequences of behavioral interventions are effective “treatments” at each stage.Financial incentives may be appropriate for induction in patients who are poorly controlled by getting them to attend to the problem. Such incentives are unlikely to be effective unless they are of sufficient magnitude, structured to promote meaningful reduction, and combined with other measures to address the “sites” of other behavioral barriers such as knowledge, beliefs, and the ostrich effect. Incentives may also play a role in consolidation therapy as other behavioral measures promote a sense of self-efficacy, overcome present bias, and so on. But the maintenance phase of hypertension treatment needs to last a lifetime. Could financial incentives play a role in that? The direct and indirect costs of diseases that can be mitigated with better blood pressure control might well make long-term incentives cost-effective, if they work.At the same time, we should recognize that other behavioral strategies may work better. Victor combined motivation from barbers with medication management by pharmacists to achieve splendid results,6 by overcoming what might appropriately be called hypertension attention deficit disorder, which currently afflicts both clinicians and patients. Clinical trials of combinations and sequences of behavioral and structural interventions to treat this disorder are needed to illuminate the road to population control of hypertension.Article InformationSources of FundingThis article was funded by National Institute of Aging RC4AG039077 and National Institute of Diabetes and Digestive and Kidney Diseases R01DK123205.Disclosures None.FootnotesThe opinions expressed in this article are not necessarily those of the editors nor the American Heart Association.Correspondence to: Martin F. Shapiro, Department of Medicine, Weill Cornell Medical College, 420 East 70th St, LH-367, New York, NY 10021. Email [email protected]cornell.eduReferences1. Zheng L, Liu S, Jiao Yet al.. Effect of financial incentives on hypertension control: a Multi-Center Randomized Controlled Trial in China.Hypertension. 2022; 79:2202–2211. doi: 10.1161/HYPERTENSIONAHA.122.19568.LinkGoogle Scholar2. National Bureau of Statistics of China, Households’ Income and Consumer Expenditure in 2020.http://www.stats.gov.cn/english/PressRelease/202101/t20210119_1812523.html.Google Scholar3. Shapiro MF, Shu SB, Goldstein NJ, Victor RG, Fox CR, Tseng CH, Vangala S, Mogler BK, Reed SB, Villa Eet al.. Impact of a patient-centered behavioral economics intervention on hypertension control in a highly disadvantaged population: a Randomized Trial.J Gen Intern Med. 2020; 35:70–78. doi: 10.1007/s11606-019-05269-zCrossrefMedlineGoogle Scholar4. Mogler BK, Shu SB, Fox CR, Goldstein NJ, Victor RG, Escarce JJ, Shapiro MF. Using insights from behavioral economics and social psychology to help patients manage chronic diseases.J Gen Intern Med. 2013; 28:711–718. doi: 10.1007/s11606-012-2261-8CrossrefMedlineGoogle Scholar5. Volpp KG, Troxel AB, Pauly MV, Glick HA, Puig A, Asch DA, Galvin R, Zhu J, Wan F, DeGuzman Jet al.. A randomized, controlled trial of financial incentives for smoking cessation.N Engl J Med. 2009; 360:699–709. doi: 10.1056/NEJMsa0806819CrossrefMedlineGoogle Scholar6. Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J, Brettler J, Rashid M, Hsu B, Foxx-Drew Det al.. A Cluster-Randomized Trial of blood-pressure reduction in black barbershops.N Engl J Med. 2018; 378:1291–1301. doi: 10.1056/NEJMoa1717250CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesEffect of Financial Incentives on Hypertension Control: A Multicenter Randomized Controlled Trial in ChinaLiqiang Zheng, et al. Hypertension. 2022;79:2202-2211 October 2022Vol 79, Issue 10 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.122.19892PMID: 36070403 Originally publishedSeptember 7, 2022 PDF download Advertisement