title: A test of financial incentives to improve warfarin adherence.
abstract: BACKGROUND
  Sub-optimal adherence to warfarin places millions of patients at risk for stroke and bleeding complications each year. Novel methods are needed to improve adherence for warfarin. We conducted two pilot studies to determine whether a lottery-based daily financial incentive is feasible and improves warfarin adherence and anticoagulation control.
  
  
  METHODS
  Volunteers from the University of Pennsylvania Anticoagulation Management Center who had taken warfarin for at least 3 months participated in either a pilot study with a lottery with a daily expected value of $5 (N = 10) or a daily expected value of $3 (N = 10). All subjects received use of an Informedix Med-eMonitor System with a daily reminder feature. If subjects opened up their pill compartments appropriately, they were entered into a daily lottery with a 1 in 5 chance of winning $10 and a 1 in 100 chance of winning $100 (pilot 1) or a 1 in 10 chance of winning $10 and a 1 in 100 chance of winning $100 (pilot 2). The primary study outcome was proportion of incorrect warfarin doses. The secondary outcome was proportion of INR measurements not within therapeutic range. Within-subject pre-post comparisons were done of INR measurements with comparisons with either historic means or within-subject comparisons of incorrect warfarin doses.
  
  
  RESULTS
  In the first pilot, the percent of out-of-range INRs decreased from 35.0% to 12.2% during the intervention, before increasing to 42% post-intervention. The mean proportion of incorrect pills taken during the intervention was 2.3% incorrect pills, compared with a historic mean of 22% incorrect pill taking in this clinic population. Among the five subjects who also had MEMS cap adherence data from warfarin use in our prior study, mean incorrect pill taking decreased from 26% pre-pilot to 2.8% in the pilot. In the second pilot, the time out of INR range decreased from 65.0% to 40.4%, with the proportion of mean incorrect pill taking dropping to 1.6%.
  
  
  CONCLUSIONS
  A daily lottery-based financial incentive demonstrated the potential for significant improvements in missed doses of warfarin and time out of INR range. Further testing should be done of this approach to determine its effectiveness and potential application to both warfarin and other chronic medications.
authors.affiliation: Center for Health Equity Research & Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA. volpp70@mail.med.upenn.edu
authors.forename: Kevin G
authors.initials: KG
authors.lastname: Volpp
authors.forename: George
authors.initials: G
authors.lastname: Loewenstein
authors.forename: Andrea B
authors.initials: AB
authors.lastname: Troxel
authors.forename: Jalpa
authors.initials: J
authors.lastname: Doshi
authors.forename: Maureen
authors.initials: M
authors.lastname: Price
authors.forename: Mitchell
authors.initials: M
authors.lastname: Laskin
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Kimmel
mesh_terms: D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use*; D016022:Case-Control Studies; D005240:Feasibility Studies; D006801:Humans; D055118:Medication Adherence; D009042:Motivation; D010865:Pilot Projects; D012201:Reward; D014859:Warfarin / Q000627:therapeutic use*; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D014859:Warfarin