Effect of Financial Incentives on Glucose Monitoring Adherence and Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes: A Randomized Clinical Trial

Importance Glycemic control often deteriorates during adolescence and the transition to young adulthood for patients with type 1 diabetes. The inability to manage type 1 diabetes effectively during these years is associated with poor glycemic control and complications from diabetes in adult life. Objective To determine the effect of daily financial incentives on glucose monitoring adherence and glycemic control in adolescents and young adults with type 1 diabetes. Design, Setting, and Participants The Behavioral Economic Incentives to Improve Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes (BE IN CONTROL) study was an investigator-blinded, 6-month, 2-arm randomized clinical trial conducted between January 22 and November 2, 2016, with 3-month intervention and follow-up periods. Ninety participants (aged 14-20) with suboptimally controlled type 1 diabetes (hemoglobin A 1c [HbA 1c ] >8.0%) were recruited from the Diabetes Center for Children at the Children’s Hospital of Philadelphia. Interventions All participants were given daily blood glucose monitoring goals of 4 or more checks per day with 1 or more level within the goal range (70-180 mg/dL) collected with a wireless glucometer. The 3-month intervention consisted of a $60 monthly incentive in a virtual account, from which $2 was subtracted for every day of nonadherence to the monitoring goals. During a 3-month follow-up period, the intervention was discontinued. Main Outcomes and Measures The primary outcome was change in HbA 1c levels at 3 months. Secondary outcomes included adherence to glucose monitoring and change in HbA 1c levels at 6 months. All analyses were by intention to treat. Results Of the 181 participants screened, 90 (52 [57.8%] girls) were randomized to the intervention (n = 45) or control (n = 45) arms. The mean (SD) age was 16.3 (1.9) years. The intervention group had significantly greater adherence to glucose monitoring goals in the incentive period (50.0% vs 18.9%; adjusted difference, 27.2%; 95% CI, 9.5% to 45.0%; P  = .003) but not in the follow-up period (15.3% vs 8.7%; adjusted difference, 3.9%; 95% CI, −2.0% to 9.9%; P  = .20). The change in HbA 1c levels from baseline did not differ significantly between groups at 3 months (adjusted difference, −0.08%; 95% CI, −0.69% to 0.54%; P  = .80) or 6 months (adjusted difference, 0.03%; 95% CI, −0.55% to 0.60%; P  = .93). Conclusions and Relevance Among adolescents and young adults with type 1 diabetes, daily financial incentives improved glucose monitoring adherence during the incentive period but did not significantly improve glycemic control. Trial Registration clinicaltrials.gov Identifier:NCT02568501