In Reply Drs Lesser and McCormack note limitations to relying on LDL-C measurement as an intermediate end point to assess what physicians really want to improve, which is cardiovascular risk.
Despite known limitations, LDL-C targets offered important advantages in our trial. First, when the trial was initiated, LDL-C targets were a dominant clinical guideline. Second, targets are intuitively appealing to patients and clinicians, and the lack of targets in current guidelines may pose challenges to motivating adherent behaviors. Third, although quarterly LDL-C assessments might be more variable than desired, their perceived validity may be more important than their actual validity when considering patient adherence and adoption of healthier behaviors. Although financial incentives could motivate inappropriate patient behavior (eg, pretending to take medications), awareness of quarterly measurement of the outcome likely mitigates adoption of such behaviors. Even if quarterly LDL-C measurements are noisy, they might discourage gaming behavior to the extent that participants believe they are accurate.
Troxel AB, Asch DA, Volpp KG. Financial Incentives and Cholesterol Levels—Reply. JAMA. 2016;315(15):1658. doi:10.1001/jama.2016.0315