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Get paid to take your pills? Strong Inquirer report covers all the ins and outs

In this Thursday, May 10, 2012, file photo, a doctor holds Truvada pills at her office in San Francisco.

Gallery: Penn study: Pay patients to take their pills

Statins are proven to reduce the risk of heart attack and stroke, yet as many as half of patients with prescriptions eventually stop taking the pills.

A possible solution, says a team of University of Pennsylvania researchers:

Pay the patients.

And for those whose good pill-taking habits lead to lower levels of LDL (“bad”) cholesterol, give their physicians a bonus as well.

While the field of medicine has moved increasingly toward paying doctors for performance, there has been little controlled research on whether it works. Studies of patients, meanwhile, have found that incentives can encourage healthy behaviors such as giving up cigarettes.

But in a study of 1,503 patients announced Sunday, the Penn team reported that the most effective approach, at least where statins are concerned, may be to reward both patient and physician.

“In some respects, it takes two to tango,” said lead author David A. Asch, a professor at Penn’s Perelman School of Medicine.

The study, whose authors also included Penn’s Kevin Volpp and scientists from Harvard and the Geisinger Health System in Danville, Pa., was published online in the Journal of the American Medical Association.

Still to come is an analysis of whether the amounts paid in the study – up to $1,024 over the course of a year – would be worth it, in terms of avoiding the costs of treating a certain number of heart attacks and strokes.

Treatment for a heart attack commonly runs into the tens of thousands of dollars, not to mention the cost of the lost productivity and reduced quality of life.

Asch said the team picked the $1,024 figure based on rough estimates, but said that it was in the realm of what would be reasonable.

“You can imagine that this might actually be worth it,” he said.

The researchers compared four different approaches for distributing that sum.

In one group, patients at risk of heart disease earned an average of $2.80 every day they took a statin, as measured by electronic pill bottles that transmitted a wireless signal when the lids were opened.

In a second group, only the doctors were eligible for bonus money, paid out in two installments. The physicians could earn up to $1,024 for each patient who lowered their cholesterol by a specified amount each quarter.

In a third group, both patients and doctors could get paid, but they split the money – getting up to half of the $1,024 each. And in a fourth control group, neither patient nor doctor got a bonus.

Patients in all four groups lowered their LDL cholesterol numbers somewhat. But in the groups where only the patient or doctor earned bonuses, the amounts of improvement were statistically no different from that in the no-money group.

The biggest drop in LDL cholesterol came in the group with both patient and doctor earning bonuses: 33.6 points on average over the course of a year, compared with a drop of 25.1 points in the no-money group.

Physicians not involved with the research said it was intriguing, but urged further study.

“I think this is an important first step, but it would be nice to replicate it in real life,” said Ohio State University cardiologist Martha Gulati.

The fact that cholesterol levels dropped in all four patient groups was especially encouraging, said Melissa Y. Wei, a University of Michigan Medical School researcher who has studied why many patients stop taking statins.

That suggests factors besides money were helping to encourage patient compliance, she said.

Asch, the study’s lead author, agreed. For example, all patients got the electronic pill bottles, so they may have been better at taking pills because they felt they were being watched, he said.

But even in the study, fewer than half of patients were taking their pills on a regular basis by the end.

Why are patients so uncommitted?

Some may experience improvement and decide, incorrectly, that it is safe to stop taking the daily pills, said Ohio State’s Gulati, editor of the American College of Cardiology’s CardioSmart magazine.

Another reason, she said, is that a minority of patients suffer side effects from the drugs, such as muscle pain. But in the Penn study, the authors excluded any patients who had previously experienced side effects.

Even if money helps, the notion of paying people to do the right thing may rub some the wrong way.

“We shouldn’t have to,” said Bobbi Cecco, president of the Hackensack, N.J., chapter of the Mended Hearts patient support group. “But if that’s what it comes down to . . .”

Wei, the Michigan physician, said she already is motivated to help her patients stick with their medicine.

“Financial incentives wouldn’t change my values or patient care,” she said. “I am also an idealist.”

Participants in the Penn study ranged in age from 18 to 80, and all were at risk of heart disease. At the start of the study, they had an average LDL number of about 160, which is considered high.

But while the study was underway, the leading medical societies moved away from asking patients to hit specific LDL targets. Now they are urged to take statins when indicated by an online calculator that takes a variety of risk factors into account.

The Penn study did not explore specific elements of the patient-doctor interaction that could lead to better habits.

Also unclear: if money works, how long would payments need to continue? And who would pay? Insurance?

Researchers followed the patients for an additional three months after the payouts stopped, and did not see any backsliding, Asch said. Beyond that, who knows?

“People wonder whether you’re going to create good habits,” he said. “Obviously it takes a physician to prescribe it, and a patient to take it.”




Tom AvrilInquirer Staff Writer



Penn study: Pay patients to take their pills

Our Review Summary

Nurse Giving Medicine To Senior Patient In Nursing HomeResearchers studied about 1,500 patients with blood cholesterol levels that put them at risk for heart disease and stroke to try to encourage them (via cash) to take their medicines – statins. Results were mixed, but the doctor-and-patient pairs who both received cash rewards showed the best results in lowering cholesterol levels. This story does an excellent job of explaining the study, providing great context on the underlying problems related to medication adherence, and quoting experts not involved in the study This is a lucid and well-rounded article on a very interesting topic.


Why This Matters

Solving behavioral issues that prevent patients from taking their medications is an important challenge. Even in this study, even with rewards, fewer than half the patients treated for high cholesterol levels kept taking their medication as prescribed. Many of the established Good Ideas in medicine (medications, etc) are stymied by downstream hurdles — doctors don’t prescribe the treatment as often as they should, patients don’t follow through, etc. Statins are a great example. It is really important to examine these gaps and design clever, cost-effective ways to close them.


Does the story adequately discuss the costs of the intervention?


The story discusses costs in a very interesting way – because the point of the research was modifying human behavior by paying “rewards” of cash to patients and sometimes doctors. What we didn’t find in the story is the “cost” of manpower to run a program like this. How much would it cost (besides the actual cost of $1,204 per patient-doctor pair) to administer this? How practical is it?

We applaud the writer for including this paragraph – giving the real context that matters most. Italics added by editor.

“Still to come is an analysis of whether the amounts paid in the study – up to $1,024 over the course of a year – would be worth it, in terms of avoiding the costs of treating a certain number of heart attacks and strokes.”

Overall, the story does an excellent job of addressing the cost trade-offs.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?


There were four patient groups. The story does a great job of describing the precise benefits, in terms of blood cholesterol, that each patient group showed (if any).

The group that benefited the most was the one where both patients and doctors received incentives. That group showed a drop of 33.6 points in LDL cholesterol, compared to a 25.1 drop in the group that received no money. It may have been useful to include a sense of how that reduction might translate into reduced risk of a heart attack (one could use the risk calculator the story mentions to calculate an estimate, or ask one of the sources to help with this).

But while quantifying the drops in cholesterol is important, we also wanted to know whether the incentives actually translated to increased compliance with the medication regimen. Other factors beyond the medication usage (diet, genetics, etc.) may have impacted participants’ cholesterol levels, so it would be interesting to know if the cholesterol results were confirmed by the medication adherence findings.

Does the story adequately explain/quantify the harms of the intervention?


The story does a nice job describing some of the subtle downsides associated with the pay-for-taking-meds approach as well as the side effects of the meds themselves.

All four groups in the study, even those who did not receive any payment, were issued electronic pill bottles. As one commenter said “they might have felt they were being watched.” The bottles sent a signal of some sort when opened, so that researchers would know who opened the top. Another commenter pointed out that if money as incentive works for a short-term, how do we know patients would continue past the payment stage?

These limitations are part of why one outside commenter described the results as “a nice first step.”

Does the story seem to grasp the quality of the evidence?


The story makes clear the methods and comparison in the randomized controlled study, and the quality of evidence. It includes important elements like study size and study design, and it touches on some limitations.

Does the story commit disease-mongering?


There is no disease mongering.

Does the story use independent sources and identify conflicts of interest?


The story goes beyond just “satisfactory.” Extra stars for including a patient (who was not involved) who is an advocate in this area, as well as researchers not involved in the study. The piece does a great job on this.

Does the story compare the new approach with existing alternatives?


The alternatives in this case would be other ways to motivate patients to take statins, and we think the story does this well.

Does the story establish the availability of the treatment/test/product/procedure?


The story makes clear that paying cash to patients to take medicine is an experimental idea, not something that your local doctor is likely to offer. But with that said, it might have been helpful to ask one of the sources about how widespread this approach is and in what contexts it is being used (there are examples around the country).

Does the story establish the true novelty of the approach?


The story accurately suggests that’s what’s novel here is paying both patients and physicians to improve compliance. The story could have been clearer about the fact that there are a number of other studies looking at patient financial incentives. The story mentions one example (related to smoking) in the introduction, but it could have gone further.

Does the story appear to rely solely or largely on a news release?


The story does not rely on a news release, but is a fine example of where extra reporting can provide context.

Total Score: 10 of 10 Satisfactory


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