Financial Incentives Deter Attendance for Diabetic Eye Screening

Becky McCall

September 21, 2016

MUNICH — An offer of £10 in cash or entrance to a lottery with the possibility to win £1000, designed to incentivize attendance at a diabetic retinopathy screening, actually had the opposite effect, shows a new London-based study.

Gaby Judah, PhD, a psychologist from the Centre for Health Policy, Imperial College London, United Kingdom, presented the findings here at the European Association for the Study of Diabetes (EASD) 2016 Annual Meeting.

"Not only did we find that it wasn't effective, but there were significantly lower rates of attendance in the incentivized groups combined than in the control group," reported Dr Judah. "Financial incentives seem to be reducing diabetic eye screening attendance. This was particularly the case for the lottery incentive."

The finding came as a surprise, because financial incentives have been used effectively to change other healthcare behaviors — for example, to improve medication adherence or to encourage attendance for screening for breast and cervical cancer, said Dr Judah.

But bringing money into situations is not always the answer. "This shows that every health context is different. We can't just transfer incentives across from one situation to another," she added.

IDEAS Trial Explored Financial Incentives in Poorly Attending Area

Attendance for the UK national diabetic eye screening program in the country overall is generally high, currently running at 81%, but in this study — Incentives in Diabetic Eye Assessment by Screening (IDEAS) — Dr Judah and colleagues targeted a "hard-to-reach" group with very low attendance rates to see whether financial incentives would improve the uptake.

Patients with either type 1 or type 2 diabetes included in the randomized controlled trial were those who had been invited to a screening in the previous 24 months but who had not attended. The 1051 participants were aged 16 or over and lived in the Kensington, Chelsea, and Westminster areas of London. The socioeconomic status of participants was recorded.

Two incentive schemes were tested: a fixed incentive, where a standard invitation letter was sent with a voucher redeemable for £10 cash if the patient attended (n = 312); and a lottery incentive comprising an invitation letter plus a voucher for a lottery with a one in 100 chance of winning £1000 if screening were attended (n = 304). The control was a standard letter of invitation to attend screening (n = 435).

Attendance rates were very low in all groups: in the control group, 7.82% of people attended, and in the combined incentive groups, only 4.38% attended, which was significantly fewer.

"In fact those in the incentive groups combined were 44% less likely to attend than controls, which is the opposite to our hypothesis about incentive uptake and shows us that incentives are not effective at promoting attendance and are actually associated with lower attendance rates in this study," Dr Judah noted.

Taking the two incentive groups separately, the fixed-incentive group had an attendance rate of 5.45%, and the lottery-incentive group 3.29%, showing that invitees in the lottery group were a significant 58% less likely to attend than controls.

"There were no significant differences comparing fixed incentive vs controls, or fixed vs the lottery incentive," she added.

Also, there were no differences in attendance between the control vs incentive groups according to levels of deprivation, which were classed as medium and high.

"This suggests that deprivation did not affect how likely it was for the incentive to…impact on attendance," she observed.

Feelings of Distrust With Financial Incentives

In an attempt to interpreting the findings, Dr Judah suggested that because these people had not attended eye screening for a long time or had never attended in many instances, there might have been an underlying mistrust or fear of the screening service.

"Being offered money to do something that you are already distrustful of can reinforce negative feelings. The offer of a large amount of money in the lottery group supports this."

When asked why they had not attended screening previously, participant responses fell into three categories: organizational problems (60%); practical/logistical reasons (20%); or they did not think they needed to attend (20%).

"I think we need to further explore some of the underlying reasons why these people are not attending and then use appropriate techniques to encourage them, whether reminders by text or educational messaging or some social support," Dr Judah pointed out.

Commenting on the study, moderator Raphael Simo, MD, from
the Hospital Universitari Vall d'Hebron, Barcelona, Spain, observed that he would like to have seen more stratification of results according to salary.

"To me it was unclear whether the salary and the socioeconomic status were really taken into account. In my view, if you have a low salary you are likely to attend more frequently if there is an economic incentive. But people might also be reluctant to participate because they feel it is something experimental."

He suggested comparing a high socioeconomic community with a low socioeconomic group, where people have greater need for the financial incentive.

Dr Judah and Dr Simo have declared no relevant financial relationships.

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European Association for the Study of Diabetes 2016 Annual Meeting; September 14, 2016; Munich, Germany. Abstract 123.

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