NEW ORLEANS — Would people be more likely to take their blood pressure medications if they had a chance to win money each time they opened the bottle? A recent study suggests they might, but that still may not lead to lower blood pressure.

And once the lottery ends, so might their adherence.

“In a safety-net population, a behavioral economics-based lottery doubled the rate of adequate antihypertensive medication adherence from baseline to 6 months,” said John Dodson, MD, MPH, director of the Geriatric Cardiology Program at NYU Langone Health and an associate professor of medicine and population health at New York University Grossman School of Medicine, New York City.

But that better adherence didn’t translate into better blood pressure control, namely a reduction in systolic blood pressure measured in office at 6 months, he said.

“Further, increased medication adherence was not sustained after the lottery was removed,” Dodson added. “These findings suggest that other strategies will be required for long-term behavior change.” 

Dodson reported results of the BETTER-BP study at American Heart Association (AHA) Scientific Sessions 20025. The data were published simultaneously in the Journal of the American College of Cardiology.

The study enrolled 400 adults with hypertension. Researchers randomly assigned participants in a 2:1 fashion to a mobile health text-based lottery, with a chance to win $5 or $50 when they opened an electronically monitored drug bottle containing their blood pressure medicine, or no incentive. The lottery-eligible group received passive monitoring from 6 to 12 months. The study aimed to see how the lottery improved systolic blood pressure.

Participants’ median age was 57 years. About 60% of both groups were women, 61.5% were Hispanic individuals, and 20.3% were Black individuals. More than 70% of participants were on Medicaid or were uninsured.

Lottery ‘Winners’

For the 6 months the lottery was on, good adherence, defined as taking their prescribed antihypertensives at least 80% of the time, was more common among the lottery group — 71% compared with 34% in the group that didn’t qualify for cash payments.

But once the lottery ended, so did the high adherence rate. “In the period from 6 to 12 months when the lottery was removed, the rate of adequate adherence was similar between arms, being achieved by 31% in the intervention arm and 26% in the control arm,” Dodson said.

After 6 months, the average change in systolic blood pressure was similar in both groups: a drop of 6.7 mm Hg in the lottery group and 5.8 mm Hg in the control group (P = .62). In the second half of the study period, systolic blood pressure at 12 months decreased to 0.2 mm Hg in the lottery group and increased to 3.6 mm Hg in the control group, Dodson said.

He acknowledged the study had a number of limitations. These included a focus on monitoring one medication when several study participants were taking two or more antihypertensive medications, the use of in-office rather than home-based blood pressure monitoring, and the use of the electronic monitoring device to determine adherence rather than blood testing.

Potential Problems

BETTER-BP was a “well-done, pragmatic study,” said Adam Bress, PharmD, MS, a cardiovascular pharmacist at the University of Utah and Veterans’ Affairs Salt Lake City Health Care System, Salt Lake City.

“Overall, it was a clear success in changing medication-taking behavior, but with no physiologic effect on blood pressure, which sets up the question: Why didn’t better adherence lower blood pressure?” said Bress, who served as a discussant for the trial.

He offered several potential answers:

• use of in-office blood pressure monitoring only may have missed blood pressure changes between visits
• the study did not account for participants’ medication changes and only monitored one medication
• control individuals may have taken their medications in anticipation of the 6-month study visit, which may have driven down average blood pressure measures
• the baseline systolic blood pressure was in the 130-to-140 mm Hg range, which may have left less room for improvement

Bress said future studies might also explore simplified regimens, such as single-pill combinations monitored electronically.

“In short, the behavior changed,” Bress said. “Now we need to make sure the clinical systems around that behavior change as well so that adherence success can truly translate into better outcomes.”

Dodson reported serving on the scientific advisory boards of AliveCor and ISHI Health. Bress reported no relevant disclosures.

Richard Mark Kirkner is a medical journalist based in Philadelphia.