Cardiovascular Disease

Grand Rounds March 13, 2026: Behavioral Economics and Medication Adherence for Hypertension: A Randomized Clinical Trial (John A. Dodson, MD, MPH)

Posted on by Sophia Ramirez

Speaker

John A. Dodson, MD, MPH
Associate Professor of Medicine and Population Health
Director, Geriatric Cardiology Program
Director, Cardiovascular Digital Health Laboratory
NYU Langone Health
NYU Grossman School of Medicine

Keywords

Behavioral Economics; Cardiovascular Disease; Hypertension; Medication Adherence

Key Points

  • Roughly half of patients with cardiovascular disease (CVD) are nonadherent with their medications. This occurs across conditions and for multiple reasons, including cost, side effects, lack of symptoms, and inconvenience. BETTER-BP, a phase 2, multisite trial, sought to test the effect of a lottery on antihypertensive adherence. The lottery intervention was based in behavioral economics, a field that represents a novel and potentially scalable approach to improving medication adherence.
  • In a safety-net population, the lottery doubled adequate antihypertensive medication adherence from baseline to 6 months. This did not translate to a significant reduction in office-measured systolic blood pressure (BP) and increased adherence was not sustained after the lottery was removed. Other strategies will likely be required for long-term behavior change.
  • BETTER-BP had pragmatic components and non-pragmatic components. It was pragmatic in that it utilized minimal exclusion criteria; took place in a real-world setting; used existing medications; paired study visits with regular ambulatory visits; and used the electronic health record to ascertain some measures. It was not pragmatic in that it utilized traditional informed consent; the intervention and monitoring strategies were not usual practice; and the primary outcome was measured via an in-person BP assessment.

Discussion Themes

Dr. Dodson noted that many trials of behavioral economics in CVD medication adherence have not had durable effects on either adherence or clinical outcomes. Even with trials that are positive, no intervention has been a “home run.”

The lottery payouts (ranging from $5 to $50) were based on an estimated daily value intended to influence behavior without being coercive or exceeding study budgets.

Recruitment for the trial was a challenge; the team made approximately 9,000 phone calls to reach their final sample of 400 participants.

Behavioral incentives might be better suited for time-limited interventions, such as smoking cessation, rather than the lifelong management required for conditions like hypertension.

Grand Rounds December 12, 2025: From Eligibility to Enrollment Without a Clinic Visit: The Eat Well Produce Prescription Trial for Patients with Diabetes at Risk of Food Insecurity (Connor Drake, PhD, MPA; Susan Spratt, MD; Abigail Rader, MS)

Posted on by Sophia Ramirez

Speakers

Connor Drake, PhD, MPA
Research Health Scientist
Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)
Durham VA Health System HSR&D
Assistant Professor
Department of Population Health Sciences
Duke University School of Medicine

Susan Spratt, MD
Department of Medicine
Division of Endocrinology, Metabolism, and Nutrition
Department of Family Medicine and Community Health
Duke University School of Medicine

Abigail Rader, MS
PhD Candidate
Department of Population Health Sciences
Duke University School of Medicine

Keywords

Food Insecurity; Groceries; Food as Medicine; Diabetes; Cardiovascular Health; Cardiovascular Disease; Cardiometabolic Health

Key Points

  • In 2022, an estimated 12.8% of American households experienced food insecurity (FI): a lack of consistent access to safe, nutritious, or sufficient food for every person in a household to live an active, healthy life. FI is also associated with increased cardiometabolic health risk. While promising interventions to improve food security (and, by extension, cardiometabolic health) exist, methodological limitations such as a lack of pragmatic designs limit conclusions on their effectiveness.
  • The Eat Well pragmatic trial sought to better understand the real-world effectiveness of a produce prescription program when it came to improving cardiometabolic health-related outcomes and utilization patterns. They found that Eat Well did not improve outcomes among diabetic patients at risk for food insecurity. However, an affirmative outreach approach supported rapid scaling of the program.
  • Produce prescription programs may require greater duration, dose, intensity, and attention to household and implementation factors, including a focus on different at-risk groups, to improve health outcomes. Reducing cost barriers to purchasing fruits and vegetables alone may not be sufficient to improve food security – at least, not enough to improve cardiometabolic health outcomes.

Discussion Themes

Based on initial descriptive analyses, the amount spent on the card had no significant clinical effect – even among the most adherent participants.

Patients often face multiple overlapping social needs (housing, transportation, etc.), and addressing food alone may not be enough for those with the highest complexity. While the intervention was kept simple for scalability’s sake, diabetes management likely requires a more integrated, multi-sector approach that looks at factors like food, exercise, medications, education, behavioral health support, and monitoring.

Future research should identify opportunities to improve implementation, test interventions in higher-risk populations, and collect additional details on patient-reported outcomes.