SummaryAt the Philadelphia Veterans Affairs Medical Center, African-American veterans with uncontrolled diabetes earned payments for reducing their glucose levels over a 6-month period. Rewards ranged from $100 for dropping the level by one percentage point to $200 for cutting it by two percentage points or to 6.5 percent (a level consistent with good control). The program did not have a meaningful impact on blood glucose control. Only about a third of participants qualified for either incentive, and the average participant's blood glucose level fell by only 0.4 points, a statistically insignificant decline that meaningfully lagged the 1.1-point improvement seen in a comparison group of similar patients receiving support from peer mentors. (More information on the mentoring program can be found in the related profile: Telephone-Based Mentoring From Demographically Similar Peers Improves Diabetes Control in African-American Veterans.)
Developing OrganizationsPhiladelphia VA Medical Center
Date First Implemented2009
Problem AddressedCompared to whites, African Americans disproportionately suffer from type 2 diabetes, struggle more with glucose control, and experience higher rates of diabetes-related complications. Financial incentives can be an effective tool for improving health-related behavior, but they have not been applied and tested as a way to improve diabetes control.
- Higher incidence among African Americans: About a quarter of African Americans between the ages of 65 and 74 suffer from diabetes, and overall, African Americans are 1.8 times more likely than non-Hispanic whites to have the disease.1 At the Philadelphia Veterans Affairs (VA) Medical Center, 45 percent of patients with diabetes are African American.
- Poorer control, more complications: Compared with whites, African Americans with diabetes tend to have worse glucose control, which leads to more disease-related complications, including eye disease, amputations, and kidney disease. For example, African Americans with diabetes are roughly 1.5 times more likely to develop retinopathy and 2.7 times more likely to have a lower limb amputated than are whites with the disease.1
- Unrealized potential of financial incentives: Financial incentives have been shown to be effective in improving some health-related behaviors, such as medication adherence, diet and exercise, and smoking.2 Prior to this initiative, financial incentives had not been tested as a way to improve diabetes control.
Description of the Innovative ActivityAt the Philadelphia VA Medical Center, African-American veterans with uncontrolled diabetes could earn payments for reducing blood glucose levels over a 6-month period. Rewards ranged from $100 for dropping the level by one percentage point to $200 for cutting it by two or more points, or to 6.5 percent. Key program elements are described below:
- Patient enrollment: The program served African American men and women with diabetes between the ages of 50 and 70 who used the medical center's primary care clinic and whose last two hemoglobin tests were above 8 percent, indicating a persistent problem in controlling glucose levels and a high risk of diabetes-related complications. Eligible patients received a letter and followup phone call describing the financial incentives. Those interested could sign up at the hospital.
- Initial measurement and goal-setting: Those who signed up had their glucose level tested. Program staff called them a day later to provide the results and to give them 6-month targets for bringing glucose levels under control and earning the incentives.
- Financial incentives: Participants who reduced blood glucose levels by one percentage point earned $100, and those dropping it two or more percentage points, or to a level of 6.5 percent (indicating good control of the disease) earned $200. For example, patients with a starting level of 11 percent earned $100 for reducing it to between 9.1 and 10 percent, and $200 for reaching 9 percent or lower. A patient with a starting level of 8 percent could earn $100 for reducing it to between 6.6 and 7.0 percent, and $200 for achieving a level of 6.5 percent or lower.
ResultsThe program did not have a meaningful impact on blood glucose control. Only about a third of participants qualified for either incentive, and the average participant's blood glucose level fell by only 0.4 percentage points, a statistically insignificant decline that meaningfully lagged the 1.1-point improvement seen in a comparison group of patients receiving support from peer mentors.
- Few qualified for an incentive: Slightly more than a third of patients (14 out of 40) qualified for any incentive, including six who reduced their glucose levels by two percentage points and eight others who reduced it by between one and two points. Roughly the same number of participating patients (15) experienced an increase in average blood glucose levels.
- Statistically insignificant improvement: The average participant experienced a 0.4 percentage-point decline in blood glucose level, from 9.5 to 9.1 percent. While this level of improvement can reduce an individual's chances of developing diabetes-related complications, it did not meet the test of statistical significance for a sample of this size, and thus one cannot be confident that the program actually led to the improvement. In addition, this degree of improvement meaningfully lagged the 1.1-point average improvement (from 9.8 to 8.7 percent) seen in a comparison group of 38 patients matched with peer mentors. More information on this peer-mentoring program can be found in a related profile: Telephone-Based Mentoring From Demographically Similar Peers Improves Diabetes Control in African-American Veterans.
- Combine incentives with support: While financial incentives alone may not have much of an impact, combining them with sources of support to help patients control diabetes might be effective. Examples could include periodic phone calls from peer mentors or nurses who provide practical guidance and counseling related to self-management and behavior change.
- Consider more regular feedback and payments: Under this program, incentive payments came as a lump sum at the end of the 6-month period, with participants having to achieve significant reductions to qualify for any incentive. Participants received no feedback along the way to help them understand if they were making progress toward established goals. However, studies of other incentive programs suggest that they may be more effective when participants receive regular contact and when payments are more frequent and based on incremental improvement.3 For example, this program might have worked better if patients had received weekly or monthly feedback and if more frequent, smaller incentives were available to reward modest declines in glucose levels. (See the bullet below that describes another program being tested that adopts this approach.)
- Consider including regret as motivator: Research on financial incentives has also found that regret can be an effective motivational tool.4 In fact, as part of a separate study, members of the research team that oversaw this program are testing the effectiveness of more frequent contact and feedback; smaller, more frequent incentives; and regret. Participants are being asked to call each morning to report their glucose levels based on the results of a finger-stick test. Those whose results are within a targeted range have a 1 in 10 chance of winning $10 that day, and a 1 in 100 chance of winning $100. To create the potential for regret, all participants (both those who call and those who do not) are entered into the lottery. Anyone who does not call but gets picked receives a phone call telling them how much money they could have won had they called and met the daily target.
Contact the InnovatorJudith Long, MD
Division of General Internal Medicine
1201 Blockley Hall
423 Guardian Drive
Philadelphia, PA 19104-6021
Innovator DisclosuresDr. Long reported having no financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesLong JA, Jahnle EC, Richardson DM, et al. Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial. Ann Intern Med. 2012;156:416-24. [PubMed]
Shacter HE, Shea JA, Akhabue E, et al. A qualitative evaluation of racial disparities in glucose control. Ethn Dis. 2009;19:121-7. [PubMed]
Volpp KG, Pauly MV, Loewenstein G, et al. P4P4P: an agenda for research on pay-for-performance for patients. Health Aff (Millwood). 2009;28(1):206-14. [PubMed]
Volpp KG, Troxel AB, Pauly MV, et al. A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med. 2009;360:699-709. [PubMed]
Saffrey C, Summerville A, Roese NJ. Praise for regret: People value regret above other negative emotions. Motiv Emot. 2008;32(1):46-54. [PubMed]
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Original publication: July 18, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 17, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.