1
|
Moore SG, Richter G, Modjtahedi BS. Factors Affecting Glaucoma Medication Adherence and Interventions to Improve Adherence: A Narrative Review. Ophthalmol Ther 2023; 12:2863-2880. [PMID: 37698824 PMCID: PMC10640536 DOI: 10.1007/s40123-023-00797-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 08/15/2023] [Indexed: 09/13/2023] Open
Abstract
Glaucoma is a leading cause of vision loss. First line therapy for primary open angle glaucoma (POAG) are topical ocular hypotensive drops. Patient adherence with topical therapy for glaucoma is a significant challenge with a reported adherence of 60%. The purpose of this review is to discuss factors associated with glaucoma adherence (including demographic factors, cost, patient education, health beliefs, treatment burden and regimen, and physical limitations) and to explore potential interventions to improve medication adherence. Articles included in this review were found by searching PubMed and Google Scholar using the key words "Glaucoma Treatment Adherence" and "Glaucoma Treatment Compliance." Data from this review demonstrates that higher medication cost, lower patient education/literacy levels, and being of African and Hispanic descent are associated with lower medication adherence rates. The data is inconclusive on whether medication regimen complexity lowers patient medication adherence rates. Interventions that have successfully improved medication adherence rates for minority patients have focused on building trust and addressing fears and false beliefs. For cost, explicit physician communication to patients regarding medication cost is important and can help the physician determine any patient concerns about cost. Outside the USA, adherence has been improved through adherence-contingent rebate systems and government subsidies. Most interventions that aim to increase adherence target patient education and literacy with the following interventions demonstrating efficacy: written instructions targeting glaucoma-specific health literacy, literacy level appropriate glaucoma education videos, and interactive and personalized educational programs. More clinic infrastructure and programs that utilize patient reminder tools and patient educators could help physicians and patients in support of these personalized action plans.
Collapse
Affiliation(s)
- Shannan G Moore
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, 91101, USA
| | - Grace Richter
- Department of Ophthalmology, Southern California Permanente Medical Group, Los Angeles Medical Center, Los Angeles, CA, USA
- Eye Monitoring Center, Kaiser Permanente Southern California, 1011 Baldwin Park Boulevard, Balwin Park, CA, 91706, USA
| | - Bobeck S Modjtahedi
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, 91101, USA.
- Eye Monitoring Center, Kaiser Permanente Southern California, 1011 Baldwin Park Boulevard, Balwin Park, CA, 91706, USA.
- Department of Research and Evaluation, Southern California Permanente Medical Group, N Los Robles Avenue, Pasadena, CA, 91101, USA.
| |
Collapse
|
2
|
Rathinavelu JK, Muir KW, Majette NT, Woolson S, Olsen MK, Flaharty K, Newman-Casey PA, Kirshner M. Qualitative Analysis of Barriers and Facilitators to Glaucoma Medication Adherence in a Randomized Controlled Trial Intervention. Ophthalmol Glaucoma 2023; 6:626-635. [PMID: 37343624 DOI: 10.1016/j.ogla.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/14/2023] [Accepted: 06/05/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE In the Medication Adherence In Glaucoma To Improve Care trial, 200 veterans with medically-treated glaucoma were randomized to an intervention designed to improve glaucoma medication adherence or to usual care. In the 6 months after intervention, the mean proportion of doses taken on schedule was higher for participants in the intervention group compared with controls (0.85 vs. 0.62, P < 0.001). The purpose of this study was to use a mixed-methods approach to compare barriers and facilitators with adherence among participants through qualitative analysis of structured interviews. DESIGN This is an analysis of interviews conducted from patients participating in a clinical trial. PARTICIPANTS Participants from the intervention arm were separated into quartiles based on medication adherence according to the electronic monitor to sample from high and low responders to the intervention. We interviewed 23 participants; 11 participants with low adherence and 12 with high adherence. METHODS Interviews were conducted over telephone and transcribed. Staff members used grounded theory to conduct content analysis and code the transcribed interviews. The iterative process produced categories of common barriers and facilitators for medication adherence. MAIN OUTCOME MEASURES The frequency of responses addressing common barriers and facilitators were compared between participants with high and low adherence. RESULTS In the lowest- and highest-adherence groups, a difficult schedule was the most cited barrier for regular drop usage (63.6% and 58.3%, respectively). In the lowest and highest-adherence groups, the most cited facilitator for adherence was use of the smart bottle (100% and 91.7%, respectively). In the lowest-adherence group, 72.7% of participants cited that improved ability to administer drops was a benefit from the intervention. In the highest-adherence group, 75% of participants cited increased disease knowledge and formation of habits as facilitators from the intervention. Of the 22 of 23 participants who mentioned the smart bottle, 100% cited that they had increased adherence and would continue using the smart bottle. CONCLUSIONS Using dosing reminders and personalized patient education may be important avenues for addressing difficulties with adhering to an eye drop schedule to improve glaucoma self-management. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Collapse
Affiliation(s)
| | - Kelly W Muir
- Department of Ophthalmology, Duke University, Durham, North Carolina; Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina.
| | - Nadya T Majette
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Sandra Woolson
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Maren K Olsen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | | | | | - Miriam Kirshner
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| |
Collapse
|
3
|
Quaranta L, Novella A, Tettamanti M, Pasina L, Weinreb RN, Nobili A. Adherence and Persistence to Medical Therapy in Glaucoma: An Overview. Ophthalmol Ther 2023; 12:2227-2240. [PMID: 37311908 PMCID: PMC10441906 DOI: 10.1007/s40123-023-00730-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/28/2023] [Indexed: 06/15/2023] Open
Abstract
Glaucoma is a group of progressive optic neuropathies characterized by loss of retinal ganglion cells and visual field deterioration. Despite the fact that the underlying pathophysiology of glaucoma remains unknown, elevated intraocular pressure (IOP) is a well-established risk factor, and the only factor that can be modified. Robust evidence from epidemiological studies and clinical trials has clearly demonstrated the benefits of IOP control in reducing the risk of glaucoma progression. IOP-lowering therapy by the means of eye drops remains a first-line treatment option. However, like other chronic and asymptomatic conditions, many patients with glaucoma have difficulties in maintaining high rates of adherence persistence to prescribed medications. On average, patients with chronic medical conditions take 30-70% of the prescribed medication doses, and on average 50% discontinue medications in the first months of therapy. The ophthalmic literature shows similarly low rates of adherence to treatment. Indeed, poor adherence is associated with disease progression and increased complication rates, as well as healthcare costs. The present review analyzes and discusses the causes of variability of the adherence to the prescribed drugs. The education of patients about glaucoma and the potential consequences of insufficient adherence and persistence seems fundamental to maximize the probability of treatment success and therefore prevent visual disability to avoid unnecessary healthcare costs.
Collapse
Affiliation(s)
| | - Alessio Novella
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Mauro Tettamanti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Luca Pasina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Robert N Weinreb
- Viterbi Family Department of Ophthalmology, and Shiley Eye Institute, Hamilton Glaucoma Center, University of California San Diego, La Jolla, CA, USA
| | | |
Collapse
|
4
|
Ayyala-Somayajula D, Dodge JL, Farias A, Terrault N, Lee BP. Healthcare affordability and effects on mortality among adults with liver disease from 2004 to 2018 in the United States. J Hepatol 2023; 79:329-339. [PMID: 36996942 PMCID: PMC10524480 DOI: 10.1016/j.jhep.2023.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/16/2023] [Accepted: 03/19/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND & AIMS Liver disease is associated with substantial morbidity and mortality, likely incurring financial distress (i.e. healthcare affordability and accessibility issues), although long-term national-level data are limited. METHODS Using the National Health Interview Survey from 2004 to 2018, we categorised adults based on report of liver disease and other chronic conditions linked to mortality data from the National Death Index. We estimated age-adjusted proportions of adults reporting healthcare affordability and accessibility issues. Multivariable logistic regression and Cox regression were used to assess the association of liver disease with financial distress and financial distress with all-cause mortality, respectively. RESULTS Among adults with liver disease (n = 19,407) vs. those without liver disease (n = 996,352), those with cancer history (n = 37,225), those with emphysema (n = 7,937), and those with coronary artery disease (n = 21,510), the age-adjusted proportion reporting healthcare affordability issues for medical services was 29.9% (95% CI 29.7-30.1%) vs. 18.1% (95% CI 18.0-18.3%), 26.5% (95% CI 26.3-26.7%), 42.2% (95% CI 42.1-42.4%), and 31.6% (31.5-31.8%), respectively, and for medications: 15.5% (95% CI 15.4-15.6%) vs. 8.2% (95% CI 8.1-8.3%), 14.8% (95% CI 14.7-14.9%), 26.1% (95% CI 26.0-26.2%), and 20.6% (95% CI 20.5-20.7%), respectively. In multivariable analysis, liver disease (vs. without liver disease, vs. cancer history, vs. emphysema, and vs. coronary artery disease) was associated with inability to afford medical services (adjusted odds ratio [aOR] 1.84, 95% CI 1.77-1.92; aOR 1.32, 95% CI 1.25-1.40; aOR 0.91, 95% CI 0.84-0.98; and aOR 1.11, 95% CI 1.04-1.19, respectively) and medications (aOR 1.92, 95% CI 1.82-2.03; aOR 1.24, 95% CI 1.14-1.33; aOR 0.81, 95% CI 0.74-0.90; and aOR 0.94, 95% CI 0.86-1.02, respectively), delays in medical care (aOR 1.77, 95% CI 1.69-1.87; aOR 1.14, 95% CI 1.06-1.22; aOR 0.88, 95% CI 0.79-0.97; and aOR 1.05, 95% CI 0.97-1.14, respectively), and not receiving the needed medical care (aOR 1.86, 95% CI 1.76-1.96; aOR 1.16, 95% CI 1.07-1.26; aOR 0.89, 95% CI 0.80-0.99; aOR 1.06, 95% CI 0.96-1.16, respectively). In multivariable analysis, among adults with liver disease, financial distress (vs. without financial distress) was associated with increased all-cause mortality (aHR 1.24, 95% CI 1.01-1.53). CONCLUSIONS Adults with liver disease face greater financial distress than adults without liver disease and adults with cancer history. Financial distress is associated with increased risk of all-cause mortality among adults with liver disease. Interventions to improve healthcare affordability should be prioritised in this population. IMPACT AND IMPLICATIONS Adults with liver disease use many medical services, but long-term national studies regarding the financial repercussions and the effects on mortality for such patients are lacking. This study shows that adults with liver disease are more likely to face issues affording medical services and prescription medication, experience delays in medical care, and needing but not obtaining medical care owing to cost, compared with adults without liver disease, adults with cancer history, are equally likely as adults with coronary artery disease, and less likely than adults with emphysema-patients with liver disease who face these issues are at increased risk of death. This study provides the impetus for medical providers and policymakers to prioritise interventions to improve healthcare affordability for adults with liver disease.
Collapse
Affiliation(s)
- Divya Ayyala-Somayajula
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jennifer L Dodge
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Albert Farias
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Brian P Lee
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| |
Collapse
|
5
|
Muñoz-Villegas P, Martínez-Bautista H, Olvera-Montaño O. Determinants of adherence to treatment in patients with ophthalmic conditions. Expert Rev Clin Pharmacol 2023; 16:1249-1259. [PMID: 37978952 DOI: 10.1080/17512433.2023.2279740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND The objective of this study was to identify and determine factors associated with patients' ophthalmic adherence in common ocular conditions from randomized clinical trials (RCT). RESEARCH DESIGN METHODS A univariate analysis with proportions, a bivariate analysis using polychoric correlations, and logistic regression (LR) models were used. The collected dataset was made up of records from RCT. Using three validated LR models, factors were identified and ranked based on their adjusted odds ratio and their statistical significance to adherence. RESULTS A total of 1,087 valid patients were included in this analysis, of which 88.96% presented adherence. All models were calibrated, had a good performance, were well specified and cost-effective using the Hosmer-Lemeshow test, metrics for class imbalance, link test approach and Akaike's criteriums, respectively. CONCLUSION We identified as determinants for encouraging good ophthalmic adherence the adverse events presented, duration of the study, female sex, and older age; other determinants such as medical condition, protocol treatment, type of treatment and disease are all risk factors for adherence. Improvements in ophthalmic adherence may be achieved by focused attention to young male patients with chronic degenerative diseases such as glaucoma or ocular hypertension (especially those who need combination therapy) and developing medications with reduced side effects.
Collapse
Affiliation(s)
- Patricia Muñoz-Villegas
- Regional Medical Affairs Department, Laboratorios Sophia, Zapopan, Jalisco, México
- Centro de Investigación en Matemáticas A.C. (CIMAT), Unidad Aguascalientes, Aguascalientes, México
| | | | - Oscar Olvera-Montaño
- Regional Medical Affairs Department, Laboratorios Sophia, Zapopan, Jalisco, México
| |
Collapse
|
6
|
Vandenplas Y, Simoens S, Turk F, Vulto AG, Huys I. Applications of Behavioral Economics to Pharmaceutical Policymaking: A Scoping Review with Implications for Best-Value Biological Medicines. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2022; 20:803-817. [PMID: 35972683 PMCID: PMC9379236 DOI: 10.1007/s40258-022-00751-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Pharmaceutical policies are generally based on the assumption that involved stakeholders make rational decisions. However, behavioral economics has taught us that this is not always the case as people deviate from rational behavior in rather predictable patterns. This scoping review examined to what extent behavioral concepts have already been applied in the pharmaceutical domain and what evidence exists about their effectiveness, with the aim of formulating future applications and research hypotheses on policymaking for best-value biologicals. METHODS A scoping literature review was conducted on the evidence of behavioral applications to pharmaceuticals. Scientific databases (Embase, MEDLINE, APA PsycArticles, and Scopus) were searched up to 20 October, 2021. RESULTS Forty-four full-text scientific articles were identified and narratively described in this article. Pharmaceutical domains where behavioral concepts have been investigated relate to influencing prescribing behavior, improving medication adherence, and increasing vaccination uptake. Multiple behavioral concepts were examined in the identified studies, such as social norms, defaults, framing, loss aversion, availability, and present bias. The effectiveness of the applied interventions was generally positive, but depended on the context. Some of the examined interventions can easily be translated into effective policy interventions for best-value biological medicines. However, some applications require further investigation in a research context. CONCLUSIONS Applications of behavioral economics to pharmaceutical policymaking are promising. However, further research is required to investigate the effect of behavioral applications on policy interventions for a more sustainable market environment for best-value biological medicines.
Collapse
Affiliation(s)
- Yannick Vandenplas
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Arnold G Vulto
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| |
Collapse
|
7
|
Ha A, Jang M, Shim SR, Kim CY, Chang IB, Kim YK. Interventions for Glaucoma Medication Adherence Improvement: A Network Meta-analysis of Randomized Controlled Trials. Ophthalmology 2022; 129:1294-1304. [PMID: 36028393 DOI: 10.1016/j.ophtha.2022.06.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/30/2022] [Accepted: 06/24/2022] [Indexed: 10/31/2022] Open
Abstract
TOPIC Comparative effectiveness of interventions to improve glaucoma medication adherence. CLINICAL RELEVANCE High adherence to ocular hypotensive therapy is essential for prevention of visual impairment in glaucoma patients. Various types of intervention for adherence enhancement have been proposed, although there is still no firm evidence of their relative efficacies. METHODS We searched PubMed, EMBASE, Scopus, the Cochrane Central Register of Controlled Trials, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov on November 30, 2021. Randomized controlled trials (RCTs) entailing interventions for improved adherence to ocular hypotensive therapy were identified. A network meta-analysis (NMA) was performed, and the following 11 interventions (single category or combinations of categories) were compared: (1) standard of care ([SOC] control), (2) short message service, (3) telephone call, (4) device reminder, (5) motivational interview, (6) multimedia education, (7) physician education, (8) provision of own medical records, (9) incentives, (10) tailored care, and (11) enhanced SOC. The primary outcome was the postintervention mean adherence score. The standardized mean differences (SMDs) were analyzed, and the effectiveness was ranked by P-score (probability of being best treatment). We appraised trials using the Cochrane risk-of-bias tool for RCTs. Confidence of results was assessed by Confidence in Network Meta-analysis. RESULTS We obtained data for 19 RCTs (4981 participants). Tailored care, as inclusive of face-to-face needs assessment and a personalized care plan, was superior to SOC in improving adherence (SMD, 1.28; 95% confidence interval [CI], 0.08-2.48; P-score, 0.810). Multifaceted interventions that included tailored care showed further adherence improvement: tailored care + multimedia education (SMD, 1.44; 95% CI, 0.20-2.67; 0.850) and tailored care + multimedia education + device reminder (SMD, 1.61; 95% CI, 0.75-2.47; 0.914). The ranking of the remaining interventions by P-scores was as follows: incentives (0.606), short message service (0.535), enhanced SOC (0.458), multimedia education (0.430), device reminder (0.429), telephone call (0.401), provision of own medical records (0.391), physician education (0.281), SOC (0.230), and motivational interview (0.165). CONCLUSIONS The NMA indicated that tailored care can improve adherence to glaucoma medication compared with SOC. A multifaceted approach might yield additional improvements.
Collapse
Affiliation(s)
- Ahnul Ha
- Department of Ophthalmology, Jeju National University Hospital, Jeju-si, Korea; Department of Ophthalmology, Jeju National University School of Medicine, Jeju-si, Korea
| | - Mirinae Jang
- Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea
| | - Sung Ryul Shim
- Department of Health and Medical Informatics, Kyungnam University College of Health Sciences, Changwon, Korea
| | - Chung Young Kim
- Department of Ophthalmology, Seogwipo Medical Center, Seogwipo-si, Korea
| | | | - Young Kook Kim
- Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea; Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea; EyeLight Data Science Laboratory, Seoul, Korea.
| |
Collapse
|
8
|
Littman D, Sherman SE, Troxel AB, Stevens ER. Behavioral Economics and Tobacco Control: Current Practices and Future Opportunities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:8174. [PMID: 35805833 PMCID: PMC9266334 DOI: 10.3390/ijerph19138174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/21/2022] [Accepted: 07/02/2022] [Indexed: 11/17/2022]
Abstract
Despite considerable progress, smoking remains the leading preventable cause of death in the United States. To address the considerable health and economic burden of tobacco use, the development of improved tobacco control and treatment interventions is critical. By combining elements of economics and psychology, behavioral economics provides a framework for novel solutions to treat smokers who have failed to quit with traditional smoking cessation interventions. The full range of behavioral economic principles, however, have not been widely utilized in the realm of tobacco control and treatment. Given the need for improved tobacco control and treatment, the limited use of other behavioral economic principles represents a substantial missed opportunity. For this reason, we sought to describe the principles of behavioral economics as they relate to tobacco control, highlight potential gaps in the behavioral economics tobacco research literature, and provide examples of potential interventions that use each principle.
Collapse
Affiliation(s)
- Dalia Littman
- Department of Population Health, NYU Langone Health, New York, NY 10016, USA; (D.L.); (S.E.S.); (A.B.T.)
| | - Scott E. Sherman
- Department of Population Health, NYU Langone Health, New York, NY 10016, USA; (D.L.); (S.E.S.); (A.B.T.)
- Department of Medicine, VA New York Harbor Healthcare System, New York, NY 10010, USA
| | - Andrea B. Troxel
- Department of Population Health, NYU Langone Health, New York, NY 10016, USA; (D.L.); (S.E.S.); (A.B.T.)
| | - Elizabeth R. Stevens
- Department of Population Health, NYU Langone Health, New York, NY 10016, USA; (D.L.); (S.E.S.); (A.B.T.)
| |
Collapse
|
9
|
Bilger M, Shah M, Tan NC, Tan CYL, Bundoc FG, Bairavi J, Finkelstein EA. Process- and Outcome-Based Financial Incentives to Improve Self-Management and Glycemic Control in People with Type 2 Diabetes in Singapore: A Randomized Controlled Trial. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 14:555-567. [PMID: 33491116 PMCID: PMC8357673 DOI: 10.1007/s40271-020-00491-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sub-optimally controlled diabetes increases risks for adverse and costly complications. Self-management including glucose monitoring, medication adherence, and exercise are key for optimal glycemic control, yet, poor self-management remains common. OBJECTIVE The main objective of the Trial to Incentivize Adherence for Diabetes (TRIAD) study was to determine the effectiveness of financial incentives in improving glycemic control among type 2 diabetes patients in Singapore, and to test whether process-based incentives tied to glucose monitoring, medication adherence, and physical activity are more effective than outcome-based incentives tied to achieving normal glucose readings. METHODS TRIAD is a randomized, controlled, multi-center superiority trial. A total of 240 participants who had at least one recent glycated hemoglobin (HbA1c) being 8.0% or more and on oral diabetes medication were recruited from two polyclinics. They were block-randomized (blocking factor: current vs. new glucometer users) into the usual care plus (UC +) arm, process-based incentive arm, and outcome-based incentive arm in a 2:3:3 ratio. The primary outcome was the mean change in HbA1c at month 6 and was linearly regressed on binary variables indicating the intervention arms, baseline HbA1c levels, a binary variable indicating titration change, and other baseline characteristics. RESULTS Our findings show that the combined incentive arms trended toward better HbA1c than UC + , but the difference is estimated with great uncertainty (difference - 0.31; 95% confidence interval [CI] - 0.67 to 0.06). Lending credibility to this result, the proportion of participants who reduced their HbA1c is higher in the combined incentive arms relative to UC + (0.18; 95% CI 0.04, 0.31). We found a small improvement in process- relative to outcome-based incentives, but this was again estimated with great uncertainty (difference - 0.05; 95% CI - 0.42 to 0.31). Consistent with this improvement, process-based incentives were more effective at improving weekly medication adherent days (0.64; 95% CI - 0.04 to 1.32), weekly physically active days (1.37; 95% CI 0.60-2.13), and quality of life (0.04; 95% CI 0.0-0.07) than outcome-based incentives. CONCLUSION This study suggests that both incentive types may be part of a successful self-management strategy. Process-based incentives can improve adherence to intermediary outcomes, while outcome-based incentives focus on glycemic control and are simpler to administer.
Collapse
Affiliation(s)
- Marcel Bilger
- Health Economics and Policy, Vienna University of Business and Economics, Vienna, Austria.
| | - Mitesh Shah
- SingHealth Polyclinics, Singapore, Singapore
| | | | | | - Filipinas G Bundoc
- Health Services and Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Joann Bairavi
- Health Services and Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Eric A Finkelstein
- Health Services and Systems Research Program, Duke-NUS Medical School, Singapore, Singapore.,Duke Global Health Institute, Duke University, Durham, USA
| |
Collapse
|