Money Might Motivate Kids With Type 1 Diabetes to Test More

Miriam E Tucker

October 24, 2017

Financial incentives may encourage teenagers with type 1 diabetes to monitor their blood glucose levels more often, but that may not translate to improved glycemic control, new research suggests.

Findings from the Behavioral Economic Incentives to Improve Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes (BE IN CONTROL) trial were published online October 23 in JAMA Pediatrics by Charlene A Wong, MD, of the department of pediatrics, Duke Clinical Research Institute, Duke University, Durham, North Carolina.

Among 90 adolescents with baseline HbA1c levels above 8%, those randomized to receive $60 in financial incentives in each of 3 months performed significantly more blood glucose tests during the time they were receiving the incentives — as assessed by a glucometer synched with a smartphone app via Bluetooth — but their glycemic control didn't improve from baseline relative to those who didn't receive the incentives. 

Despite the lack of effect on the primary outcome of glycemic control, this study is one of the first to demonstrate that financial incentives for adolescents and young adults can motivate behavior change, Dr Wong and colleagues note.

"Identifying interventions that empower young people to manage their disease effectively is crucial. Financial incentives and smartphone-connected glucometers proved to be promising tools that deserve further exploration in adolescents and young adults with type 1 diabetes," they write.   

However, the study also found that the teens did not continue their increased level of monitoring after the incentives were removed.

In an accompanying editorial, Shelagh Mulvaney, PhD, and Joyce M Lee, MD, MPH, of Vanderbilt University, Nashville, Tennessee, say, "Regardless of the relative feasibility and our enthusiasm for a new incentive-based technology paradigm for chronic disease management, we must caution that interventions that target a single behavioral process, such as frequency of [blood glucose] monitoring, may not be as effective as multicomponent interventions that address emotional, social, or family processes to help facilitate diabetes self-management in the long term. Therefore, incentive-based approaches will likely need to be integrated with other intervention components to achieve a sustainable or meaningful effect on health outcomes in adolescents."

In an interview, pediatric endocrinologist Michelle Katz, MD, MPH, of the Joslin Diabetes Center, Boston, Massachusetts, commented, "The financial reward incentivized blood glucose monitoring and so this behavior improved. However, [the intervention]…was likely not enough to impact all the behaviors that bridge between blood glucose monitoring and improving glycemic control, like counting carbs and administering an insulin bolus."

And, she also noted, "It can be really hard to turn a short-term behavior change into a habit. Many of these teens were probably told to check their blood glucose monitoring at least four times per day for years before taking part in the trial. It's great that the trial was able to motivate a temporary increase in blood glucose monitoring, but not surprising that teens slipped back into their old habits."

Giving Money and Taking It Away

The 90 study participants were aged 14 to 20 and recruited from the type 1 diabetes population who receive care at the Children's Hospital of Philadelphia during 2015–2016. All were advised to check their blood glucose levels four times a day and to achieve at least one reading within the target range 70 to 180 mg/dL.

Those randomized to the intervention were given monthly $60 virtual accounts, from which $2 was deducted for each day they didn't achieve the monitoring and target glucose goals. Each day they would receive a text or an email — their choice — telling them whether they'd achieved the goal or not and advising them of their remaining account balance. At the end of each of the 3 months, they received the remaining money via a reloadable debit card.

The incentives were discontinued after the initial 3 months and all subjects were followed for another 3 months. HbA1c was measured and online surveys administered after the incentive period and again after the 3-month follow-up without the incentives.

More Monitoring, but Same Control Level

The primary outcome, change in HbA1c levels at 3 months compared with baseline, did not differ between those who received the intervention and the controls, from 9.84% to 9.27% vs 9.88% to 9.44%, respectively (adjusted difference -0.08 percentage points, P = .80). The adjusted difference at 6 months, -0.03, was also insignificant (= .93).

On the other hand, the proportion of days achieving both the glucose-monitoring frequency and single blood glucose level within target goals over the study period was significantly better with the financial incentive, 50.0% vs just 18.9% among the controls (= .003 for the adjusted 27.2% difference).

In both groups, more than 85% of the days not achieving the goals were due to lack of sufficient blood glucose checks, while only 10% to 15% were due to not having at least one blood glucose measure in range, with 25.3% and 46.3%, respectively, of the intervention and control groups performing zero blood glucose measures during the study period.

During the 3-month follow-up period after the incentives were stopped, the proportions achieving the daily goals dropped to 15.3% in the intervention group and 8.7% for the controls (adjusted difference 3.9%, = .20). Also during follow-up, the percentage of days with zero readings jumped to 65.8% with the intervention and 75.0% for the controls.

Dr Katz noted that even though these study subjects were selected specifically because they were less adherent, "25% of days without any glucose readings does seem high to me. I'd like to believe that sometimes teens just couldn't find the study meter and used a spare meter instead. There certainly are some teens who are highly resistant to checking blood glucose levels, though....That's what makes some of the new technology so nice."

In the surveys, the participants had generally positive feedback regarding the benefit of daily financial incentives but mixed ideas about the ideal financial amount and how the intervention should be structured. Some felt that the money should have accumulated upward per success, rather than diminish with failure.

Dr Katz said that her approach to motivating teens to take control includes focusing on small successes, such as showing up for appointments, checking their blood sugar, or taking more insulin boluses than they used to, ie, "something small that we can build on."

And, she added, "I try to focus on how they feel in the short term, that they will feel better or have more energy or perform better on their sports teams if they take better care of themselves. We try to set realistic goals such as checking one more time a day or bolusing for their afternoon snack. Teens tend to be focused on the here and now, so I try to emphasize current impacts more than avoiding long-term complications."

The study was supported by the National Center for Advancing Translational Science, the Institute for Translational Medicine and Therapeutics at the University of Pennsylvania, and the division of adolescent medicine at the Children's Hospital of Philadelphia. Dr Wong has no relevant financial relationships; disclosures for the couathors are listed in the paper. Dr Lee is a paid consultant for Unitio and has received grant funding from Lenovo; Dr Mulvaney reports no relevant financial relationships. Dr Katz has no relevant financial relationships.

JAMA Pediatrics. Published online October 23, 2017. Abstract, Editorial

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