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

Slides

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.