Financial Incentives vs Usual Care May Not Improve LDL-C Levels

LDL particles, lipoprotein
LDL particles, lipoprotein
Researchers sought to determine whether financial incentives for statin adherence, a reduction in LDL cholesterol (LDL-C) levels, or both could lower LDL-C.

Using financial incentives did not improve low-density lipoprotein cholesterol (LDL-C) levels in patients, according to study findings published in JAMA Network Open.

For the randomized clinical trial ( Identifier: NCT02246959), researchers from the University of Pennsylvania enrolled patients (N=764) who were receiving statins due to increased risk for atherosclerotic cardiovascular disease (ASCVD) because of suboptimal LDL-C levels. Between 2015 and 2018, patients were assessed for LDL-C at baseline, 3, 6, 9, 12, and 18 months, and their statin medications were distributed in smart pill bottles to monitor for adherence.

All participants received up to $325 for completing study milestones. Patients were randomized to control (no additional financial incentive; n=190), process (incentive for statin adherence; n=194), outcome (incentive for decreased LDL-C; n=187), or process plus outcome (incentives for adherence and decreased LDL-C; n=193) groups. Patients in the incentive cohorts who were fully adherent could earn an average of $1.40 per day, or an additional $504.

Study participants had a mean age of 62.4 ±10.0 years; baseline LDL-C was 138.8±37.6 mg/dL; 51.2% were women; 58.0% were White individuals; 43.3% had a college degree; 44.2% earned $50,000 annually or more; 40.6% had diabetes; and 39.0% had ASCVD.

At 12 months, the mean decrease in LDL-C was -36.9 mg/dL for the control, -40.0 mg/dL for the process, -41.6 mg/dL for the outcome, and -42.8 mg/dL for the process plus outcome cohorts.

The difference in LDL-C between the control group and financial incentive cohorts at 18 months, 6 months after incentives ended, was lower than 5 mg/dL.

A subgroup analysis found significant difference between control and process plus outcome groups among Black individuals (P =.001); individuals with baseline LDL-C greater than 160 mg/dL (P =.002); ASCVD (P =.02); income less than $50,000 (P =.01); and among women (P =.04). For the process group, significant differences were observed among Black individuals (P =.02) and those with ASCVD (P =.03). For the outcomes group, significant effects were observed among Black individuals (P =.047) and those who earned less than $50,000 (P =.047).

Over the 12 months, the median incentives received were $445 (interquartile range [IQR], $365-$535) for the process, $252 (IQR, $126-$504) for the outcome, and $366 (IQR, $274-$450) for the process plus outcome groups.

This study was limited by measuring a surrogate feature of ASCVD, LDL-C, due to the fact it was easy to measure.

These data indicated that financial incentives were not more effective among all patients than usual care for lowering LDL-C levels.

“Financial incentives may help patients focus on the importance of statins and LDL-C levels, but clearly, incentives were insufficient in this trial and the results raise the question whether present bias is the key barrier to the formation of healthy habits,” the study authors said. “Patients may also need support for diverse personal barriers that they may face, such as challenging living conditions. Future studies might combine incentives with interventions, such as motivational interviewing, for patients who feel that bad health is inevitable or who struggle to change their routines.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Reese PP, Barankay I, Putt M, et al. Effect of financial incentives for process, outcomes, or both on cholesterol level change: a randomized clinical trial. JAMA Netw Open. 2021;4(10):e2121908. doi:10.1001/jamanetworkopen.2021.21908