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

Marcel Bilger, Mitesh Shah, Ngiap Chuan Tan, Cynthia Y L Tan, Filipinas G Bundoc, Joann Bairavi, Eric A Finkelstein, Marcel Bilger, Mitesh Shah, Ngiap Chuan Tan, Cynthia Y L Tan, Filipinas G Bundoc, Joann Bairavi, Eric A Finkelstein

Abstract

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.

Trial registration: ClinicalTrials.gov NCT02224417.

Conflict of interest statement

The authors do not have any conflicts of interest to declare.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Participant timeline
Fig. 2
Fig. 2
Sample of the study leaflet on self-management
Fig. 3
Fig. 3
Text messages sent to participants. CRC Clinical Research Coordinator, SMS short message service, SGD Singapore dollars, TRIAD Trial to Incentivize Adherence for Diabetes, UC + usual care plus
Fig. 4
Fig. 4
Participant flow diagram. UC + usual care plus
Fig. 5
Fig. 5
Missing observations. UC + usual care plus

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