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Original Investigation
December 2017

Effect of Financial Incentives on Glucose Monitoring Adherence and Glycemic Control Among Adolescents and Young Adults With Type 1 DiabetesA Randomized Clinical Trial

Author Affiliations
  • 1Department of Pediatrics, Duke Clinical Research Institute, Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
  • 2Leonard Davis Institute of Health Economics, Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, Philadelphia
  • 3Division of Adolescent Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine and University of Pennsylvania, Philadelphia
  • 4Division of Pediatric Endocrinology, The Children’s Hospital of Philadelphia, Philadelphia
  • 5Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia
  • 6Division of Pediatric Endocrinology, The Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
  • 7medical student, Icahn School of Medicine at Mount Sinai, New York, New York
  • 8Perelman School of Medicine at the University of Pennsylvania, Philadelphia
  • 9Department of Medicine, Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
  • 10Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia
JAMA Pediatr. 2017;171(12):1176-1183. doi:10.1001/jamapediatrics.2017.3233
Key Points

Question  Do daily financial incentives improve adherence to daily glucose monitoring goals and glycemic control among adolescents and young adults with type 1 diabetes during a 3-month intervention?

Findings  In a randomized clinical trial including 90 adolescents and young adults with poorly controlled type 1 diabetes, daily financial incentives improved glucose monitoring in the intervention group (50.0%) vs the control group (18.9%) but did not affect their glycemic control.

Meaning  Financial incentives showed promise for improving glucose monitoring behaviors among adolescents and young adults with type 1 diabetes.

Abstract

Importance  Glycemic control often deteriorates during adolescence and the transition to young adulthood for patients with type 1 diabetes. The inability to manage type 1 diabetes effectively during these years is associated with poor glycemic control and complications from diabetes in adult life.

Objective  To determine the effect of daily financial incentives on glucose monitoring adherence and glycemic control in adolescents and young adults with type 1 diabetes.

Design, Setting, and Participants  The Behavioral Economic Incentives to Improve Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes (BE IN CONTROL) study was an investigator-blinded, 6-month, 2-arm randomized clinical trial conducted between January 22 and November 2, 2016, with 3-month intervention and follow-up periods. Ninety participants (aged 14-20) with suboptimally controlled type 1 diabetes (hemoglobin A1c [HbA1c] >8.0%) were recruited from the Diabetes Center for Children at the Children’s Hospital of Philadelphia.

Interventions  All participants were given daily blood glucose monitoring goals of 4 or more checks per day with 1 or more level within the goal range (70-180 mg/dL) collected with a wireless glucometer. The 3-month intervention consisted of a $60 monthly incentive in a virtual account, from which $2 was subtracted for every day of nonadherence to the monitoring goals. During a 3-month follow-up period, the intervention was discontinued.

Main Outcomes and Measures  The primary outcome was change in HbA1c levels at 3 months. Secondary outcomes included adherence to glucose monitoring and change in HbA1c levels at 6 months. All analyses were by intention to treat.

Results  Of the 181 participants screened, 90 (52 [57.8%] girls) were randomized to the intervention (n = 45) or control (n = 45) arms. The mean (SD) age was 16.3 (1.9) years. The intervention group had significantly greater adherence to glucose monitoring goals in the incentive period (50.0% vs 18.9%; adjusted difference, 27.2%; 95% CI, 9.5% to 45.0%; P = .003) but not in the follow-up period (15.3% vs 8.7%; adjusted difference, 3.9%; 95% CI, −2.0% to 9.9%; P = .20). The change in HbA1c levels from baseline did not differ significantly between groups at 3 months (adjusted difference, −0.08%; 95% CI, −0.69% to 0.54%; P = .80) or 6 months (adjusted difference, 0.03%; 95% CI, −0.55% to 0.60%; P = .93).

Conclusions and Relevance  Among adolescents and young adults with type 1 diabetes, daily financial incentives improved glucose monitoring adherence during the incentive period but did not significantly improve glycemic control.

Trial Registration  clinicaltrials.gov Identifier: NCT02568501

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