Financial Incentives and Diabetes Disease Control in Employees: A Retrospective Cohort Analysis

Financial incentives in the management of diabetes: a systematic review

METHODS

Web of Science, Cochrane library and PubMed were systematically searched up to January 2024 to identify studies examining the impact of financial incentives on diabetes management in patients. Studies were evaluated based on the robustness of their methodology, participant numbers, and quality scores. The Cochrane risk-of-bias tool was applied for randomized controlled trials, while the Newcastle-Ottawa Scale was used for non-randomized controlled trials to assess study quality. Due to the heterogeneity of the included studies, a narrative synthesis approach was utilized.

RESULTS

In the study, we included 12 published research studies. Five studies investigated the influence of financial incentives on patient behavior, all demonstrating a significant positive impact on behaviors such as blood glucose monitoring, medication adherence, and physical activity. 10 studies analyzed the impact of financial incentives on HbA1c levels in diabetes patients. Among them, 5 studies reported that financial incentives could improve HbA1c levels through longitudinal historical comparisons. The other 5 studies did not find significant improvements compared to the control group. Three studies explored long-term effects, two studies targeting the adolescent population had no impact, and one study targeting adults had a positive impact.

CONCLUSIONS

In summary, this review found that financial incentives can positively influence patient behavior and enhance compliance, but their impact on HbA1c levels is inconsistent. Financial incentives may help adult patients maintain behavior even after the withdrawal of incentives.

The nudge strategies for weight loss in adults with obesity and overweight: A systematic review and meta-analysis

Obesity and overweight conditions have become major health challenges worldwide. The exploration of effective weight loss strategies is essential. Nudges are currently advancing approaches that represent a new and better method for changing the behaviors of people. However, the effectiveness of nudge interventions on weight loss in overweight people who may be obese has not been synthesized in a systematic manner. In this study, a systematic literature search was performed. Only randomized controlled trials (RCTs) were considered. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated as summary statistics. In total, 25 RCTs involving a population of 5,929 individuals were included. Significant effects of the nudge strategy on weight loss (WMD: -0.96 kg, 95% CI: -1.49 to -0.43), body mass index (WMD: -0.3 kg/m², 95% CI: -0.41 to -0.19) and waist circumference (WMD: -0.75 cm, 95% CI: -1.23 to -0.27) were observed. The subgroup analysis showed that the reduction in body weight associated with nudge interventions was significant in younger and more obese people. Moreover, the effect of nudge intervention on weight loss weakened over time. Overall, the nudge strategy can promote changes in weight loss, body mass index and waist circumference of adults, albeit at a mild magnitude and in particular types of individuals. Nudge strategies can be recommended to clinical practitioners and policy-makers to promote obesity management.

Influence of Incentive Design and Organizational Characteristics on Wellness Participation and Health Outcomes

OBJECTIVE

To explore how changing incentive designs influence wellness participation and health outcomes.

METHODS

Aggregated retrospective data were evaluated using cluster analysis to group 174 companies into incentive design types. Numerous statistical models assessed between-group differences in wellness participation, earning incentives, and over-time differences in health outcomes.

RESULTS

Four incentive design groups based on requirements for earning incentives were identified. The groups varied in support for and participation in wellness initiatives within each company. All four design types were associated with improved low density lipoprotein (LDL) (P < 0.01), three with improved blood pressure (P < 0.001), and two with improved fasting glucose (P < 0.03). No incentive plan types were associated with improved body mass index (BMI), but designs predominantly focused on health outcomes (eg, Outcomes-Focused) exhibited a significant increase over time in BMI risk.

CONCLUSION

Incentive design and organizational characteristics impact population-level participation and health outcomes.

The Impact of Financial Incentives on Behavior and Self-Management of Uncontrolled Type 2 Diabetes: Pre- and Post-Quasiexperimental Study

Introduction

Noncommunicable diseases are one of the main challenges that affect health worldwide and have been found to be increasing in both low- and middle-income countries compared with high-income countries. The aim of this study was to assess the impact of financial incentives and a comprehensive care program focusing on patients' behavior and self-management of uncontrolled type 2 diabetes (glycosylated hemoglobin [HbA1c] ≥ 7), as well as modifiable risk factors for disease complications in a Saudi Arabian population.

Methods

This quasiexperimental study, using a pre- and postevaluation approach, was used to compare the level of HbA1c among patients with uncontrolled diabetes before and after the financial incentives and comprehensive care program were implemented. Financial awards were given to patients who achieved a significantly greater decrease in HbA1c levels with his/her responsible physician. The study population included 702 Saudi Arabian patients with type 2 diabetes from 14 regions and 34 primary healthcare centers in the Kingdom of Saudi Arabia. All of these patients (≥ 15 years old) with uncontrolled type 2 diabetes who attended local primary healthcare centers in Saudi Arabia for a follow-up visit from February to October 2018.

Results

The mean age, in years, of the sample was 56.14 (± SD = 9.909); slightly more than half of the patients 401 (57.1%) were females. Most of the participants 645 (91.9%) were married, and 381(54.3%) patients were housewives. Linear mixed modeling revealed that all groups showed improvements over time in the primary outcome of HbA1c levels (p = 0.009), Including the secondary outcomes of body mass index and systolic and diastolic blood pressure (p = 0.04, < 0.001, 0.019 respectively).

Conclusions

Patient behavior was improved, which was reflected by decreases in HbA1c, body mass index, and blood pressure levels. A comprehensive care program is recommended by healthcare providers to increase awareness among patients with diabetes to reduce other risk factors. These kinds of interventions positively motivate patients with diabetes to control their health measurements and to adopt a healthy lifestyle.

A Digital Health Intervention (SweetGoals) for Young Adults With Type 1 Diabetes: Protocol for a Factorial Randomized Trial

BACKGROUND

Many young adults with type 1 diabetes (T1D) struggle with the complex daily demands of adherence to their medical regimen and fail to achieve target range glycemic control. Few interventions, however, have been developed specifically for this age group.

OBJECTIVE

In this randomized trial, we will provide a mobile app (SweetGoals) to all participants as a "core" intervention. The app prompts participants to upload data from their diabetes devices weekly to a device-agnostic uploader (Glooko), automatically retrieves uploaded data, assesses daily and weekly self-management goals, and generates feedback messages about goal attainment. Further, the trial will test two unique intervention components: (1) incentives to promote consistent daily adherence to goals, and (2) web health coaching to teach effective problem solving focused on personalized barriers to self-management. We will use a novel digital direct-to-patient recruitment method and intervention delivery model that transcends the clinic.

METHODS

A 2x2 factorial randomized trial will be conducted with 300 young adults ages 19-25 with type 1 diabetes and (Hb)A_1c ≥ 8.0%. All participants will receive the SweetGoals app that tracks and provides feedback about two adherence targets: (a) daily glucose monitoring; and (b) mealtime behaviors. Participants will be randomized to the factorial combination of incentives and health coaching. The intervention will last 6 months. The primary outcome will be reduction in A_1c. Secondary outcomes include self-regulation mechanisms in longitudinal mediation models and engagement metrics as a predictor of outcomes. Participants will complete 6- and 12-month follow-up assessments. We hypothesize greater sustained A_1c improvements in participants who receive coaching and who receive incentives compared to those who do not receive those components.

RESULTS

Data collection is expected to be complete by February 2025. Analyses of primary and secondary outcomes are expected by December 2025.

CONCLUSIONS

Successful completion of these aims will support dissemination and effectiveness studies of this intervention that seeks to improve glycemic control in this high-risk and understudied population of young adults with T1D.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04646473; https://clinicaltrials.gov/ct2/show/NCT04646473.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/27109.

Process- and Outcome-Based Financial Incentives to Improve Self-Management and Glycemic Control in People with Type 2 Diabetes in Singapore: A Randomized Controlled Trial

BACKGROUND

Sub-optimally controlled diabetes increases risks for adverse and costly complications. Self-management including glucose monitoring, medication adherence, and exercise are key for optimal glycemic control, yet, poor self-management remains common.

OBJECTIVE

The main objective of the Trial to Incentivize Adherence for Diabetes (TRIAD) study was to determine the effectiveness of financial incentives in improving glycemic control among type 2 diabetes patients in Singapore, and to test whether process-based incentives tied to glucose monitoring, medication adherence, and physical activity are more effective than outcome-based incentives tied to achieving normal glucose readings.

METHODS

TRIAD is a randomized, controlled, multi-center superiority trial. A total of 240 participants who had at least one recent glycated hemoglobin (HbA1c) being 8.0% or more and on oral diabetes medication were recruited from two polyclinics. They were block-randomized (blocking factor: current vs. new glucometer users) into the usual care plus (UC +) arm, process-based incentive arm, and outcome-based incentive arm in a 2:3:3 ratio. The primary outcome was the mean change in HbA1c at month 6 and was linearly regressed on binary variables indicating the intervention arms, baseline HbA1c levels, a binary variable indicating titration change, and other baseline characteristics.

RESULTS

Our findings show that the combined incentive arms trended toward better HbA1c than UC + , but the difference is estimated with great uncertainty (difference - 0.31; 95% confidence interval [CI] - 0.67 to 0.06). Lending credibility to this result, the proportion of participants who reduced their HbA1c is higher in the combined incentive arms relative to UC + (0.18; 95% CI 0.04, 0.31). We found a small improvement in process- relative to outcome-based incentives, but this was again estimated with great uncertainty (difference - 0.05; 95% CI - 0.42 to 0.31). Consistent with this improvement, process-based incentives were more effective at improving weekly medication adherent days (0.64; 95% CI - 0.04 to 1.32), weekly physically active days (1.37; 95% CI 0.60-2.13), and quality of life (0.04; 95% CI 0.0-0.07) than outcome-based incentives.

CONCLUSION

This study suggests that both incentive types may be part of a successful self-management strategy. Process-based incentives can improve adherence to intermediary outcomes, while outcome-based incentives focus on glycemic control and are simpler to administer.

The effectiveness of nudges in improving the self-management of patients with chronic diseases: A systematic literature review

In this systematic literature review, we identify evidence on the effectiveness of nudges in improving the self-management of adults with chronic diseases and derive policy recommendations. We included empirical studies of any design published up to April 12^th, 2018. We synthesized the results of the studies narratively by comparing statistical significance and direction of different nudge types' effects on primary study outcomes. Lastly, we categorized the nudges according to their degree of manipulation and transparency. We identified 26 studies, where 13 were of high or moderate quality. The most commonly tested nudges were reminders, planning prompts, small financial incentives, and feedback. Overall, 8 of 9 studies with a high or moderate quality ranking, focused on self-management outcomes, i.e., physical activity, attendance, self-monitoring, and medication adherence, found that nudges had significant positive effects. However, only 1 of 4 studies of high or moderate quality, analyzing disease control outcomes (e.g., glycemic control), found that nudges had a significant positive effect for one intervention arm. In summary, this review demonstrates that nudges can improve chronic disease self-management, but there is hardly any evidence to date that these interventions lead to improved disease control. Reminders, feedback, and planning prompts appear to improve chronic disease self-management most consistently and are among the least controversial types of nudges. Accordingly, they can generally be recommended to policymakers.

Description of a pharmacist-led diabetes prevention service within an employer-based wellness program

OBJECTIVES

To describe a pharmacist-led diabetes prevention service piloted within an employer-based wellness program.

PRACTICE DESCRIPTION

A pharmacist-led ambulatory care clinic within a school of pharmacy that provides wellness services to university employees.

PRACTICE INNOVATION

Implementation of a diabetes prevention service using opportunistic A1C screening within a biometric screening program. Patients with a prediabetes-level A1C from July 2016 to March 2019 were invited to participate in the National Diabetes Prevention Program (NDPP).

EVALUATION

Comparison of baseline characteristics of participants with normal and elevated A1C. Evaluation of participation in the NDPP and changes in clinical values at the subsequent biometric screening appointment for individuals with a prediabetes-level AlC.

RESULTS

A1C testing of 740 individuals identified 69 participants (9.3%) with a prediabetes-level A1C and 7 (1.0%) with a diabetes-level A1C. Compared with those with a normal A1C (< 5.7%), participants with an elevated A1C were more likely to be older, nonwhite, obese, and physically inactive, to have a sibling with diabetes, higher random blood sugar (RBS), lower high-density lipoprotein (HDL), and more likely to have hypertension. Twelve patients participated in the NDPP, although most attended only 1 session. Attenders had a significantly lower baseline weight and body mass index (BMI). There were no significant differences in the changes in A1C, BMI, weight, RBS, or HDL between attenders and nonattenders approximately 1 year later.

CONCLUSION

This pilot demonstrated that opportunistic A1C testing could be incorporated into an ambulatory care clinic within a pharmacist-led employer-based wellness program. Uptake and retention of the NDPP were poor. Barriers to NDPP participation need to be investigated and addressed to improve service impact.

Paying people to lose weight: the effectiveness of financial incentives provided by health insurers for the prevention and management of overweight and obesity - a systematic review

Curbing the obesity epidemic is likely to require a suite of interventions targeting the obesogenic environment as well as individual behaviour. Evidence suggests that the effectiveness of behaviour modification programmes can be enhanced by financial incentives that immediately reward weight loss behaviour. This systematic review investigated the effectiveness of incentives with a focus on assessing the relative effectiveness of incentives that target different behaviours as well as factors of importance when implementing these programmes in real-world settings (health insurer settings). A narrative review of the academic and grey literature including a variety of study designs was undertaken. Twenty studies met inclusion criteria and were assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Results suggest that incentivizing weight loss is effective in the short term while the incentives are in place. There are various incentive designs, and although the relative effectiveness of each of these on weight loss is not clear, it appears that positive incentives increase the uptake into programmes and may reduce dropouts. As with other weight loss initiatives, there is a need to explore ways to maintain weight loss in the longer term - incentives for weight maintenance could play a role.

Effect of Health Plan Financial Incentive Offering on Employees with Prediabetes

BACKGROUND

Prediabetes may be improved or reversed with lifestyle interventions. A worksite wellness program offering financial incentives for participation may be effective in improving the health of employees with prediabetes. We studied the effect of employee health plan financial incentives on health outcomes for employees with prediabetes.

METHODS

We conducted a retrospective cohort study using electronic medical record data from January 2008 to December 2012. Our study participants were employees with prediabetes and propensity-matched non-employees with prediabetes and commercial health insurance, all receiving care within one health system. Exposures included fixed annual financial incentives for program participation and later a premium discount divided between program participation and achievement of goals. We used longitudinal linear mixed models to assess yearly changes in glycosylated hemoglobin (HbA1c), weight, and low-density lipoprotein cholesterol in employees versus non-employees. We also compared outcomes of employees by ever- versus never- program participant status.

RESULTS

Our study population included 1005 employees and 1005 matched non-employees. The yearly reduction in HbA1c for employees versus matched non-employees did not differ in 2008-2010 but was greater in 2010-2012, when incentives were tied to program participation as well as achievement of goals (-0.10% vs -0.08 %, respectively; P for difference in change [DIC] = .01 from 2010 to 2012). Analyses from both periods showed that employees lost more weight per year than matched non-employees (-1.85 vs -0.21 lb [1 lb=0.45 kg] from 2008 to 2010; P for DIC < .001 and -2.35 vs -0.65 lb from 2010 to 2012; P for DIC < .001). Employees who participated in disease management lost more weight than those who did not (-2.14 vs 0.79 lb yearly before 2010 and -2.82 vs -0.91 after January 1, 2010, P for DIC < .01 and < .001, respectively).

CONCLUSION

A worksite wellness program offering health plan financial incentives for participation and outcomes was associated with improvements in weight and HbA1c.

A Scoping Review of Behavioral Economic Interventions for Prevention and Treatment of Type 2 Diabetes Mellitus

PURPOSE OF REVIEW

The purpose of this paper was to review studies of behavioral economic interventions (financial incentives, choice architecture modifications, or commitment devices) to prevent type 2 diabetes mellitus (T2DM) among at-risk patients or improve self-management among patients with T2DM.

RECENT FINDINGS

We found 15 studies that used varied study designs and outcomes to test behavioral economic interventions in clinical, workplace, or health plan settings. Of four studies that focused on prevention of T2DM, two found that financial incentives increased weight loss and completion of a fasting blood glucose test, and two choice architecture modifications had mixed effects in encouraging completion of tests to screen for T2DM. Of 11 studies that focused on improving self-management of T2DM, four of six tests of financial incentives demonstrated increased engagement in recommended care processes or improved biometric measures, and three of five tests of choice architecture modifications found improvements in self-management behaviors. Though few studies have tested behavioral economic interventions for prevention or treatment of T2DM, those that have suggested such approaches have the potential to improve patient behaviors and such approaches should be tested more broadly.

The effect of the USPSTF PSA screening recommendation on prostate cancer incidence patterns in the USA

Guidelines regarding recommendations for PSA screening for early detection of prostate cancer are conflicting. In 2012, the United States Preventive Services Task Force (USPSTF) assigned a grade of D (recommending against screening) for men aged ≥75 years in 2008 and for men of all ages in 2012. Understanding temporal trends in rates of screening before and after the 2012 recommendation in terms of usage patterns in PSA screening, changes in prostate cancer incidence and biopsy patterns, and how the recommendation has influenced physician's and men's attitudes about PSA screening and subsequent ordering of other screening tests is essential within the scope of prostate cancer screening policy. Since the 2012 recommendation, rates of PSA screening decreased by 3-10% in all age groups and across most geographical regions of the USA. Rates of prostate biopsy and prostate cancer incidence have declined in unison, with a shift towards tumours being of higher grade and stage upon detection. Despite the recommendation, some physicians report ongoing willingness to screen appropriately selected men, and many men report intending to continue to ask for the PSA test from their physician. In the coming years, we expect to have an improved understanding of whether these decreased rates of screening will affect prostate cancer metastasis and mortality.