title: A Pilot Randomized Trial of Financial Incentives or Coaching to Lower Serum Phosphorus in Dialysis Patients.
abstract: OBJECTIVE
  Among chronic hemodialysis patients, hyperphosphatemia is common and associated with mortality. Behavioral economics and complementary behavior-change theories may offer valuable approaches to achieving phosphorus (PO4) control. The aim was to determine feasibility of implementing financial incentives and structured coaching to improve PO4 in the hemodialysis setting.
  
  
  METHODS
  This pilot randomized controlled trial was conducted in 3 urban dialysis units for 10 weeks among 36 adults with elevated serum PO4 (median >5.5 mg/dL over 3 months).
  
  
  METHODS
  Twelve participants each were randomized to: (1) financial incentives for lowering PO4, (2) coaching about dietary and medication adherence, or (3) usual care. PO4 was measured during routine clinic operations. Each incentives arm participant received the equivalent of $1.50/day if the PO4 was ≤5.5 mg/dL or >5.5 mg/dL but decreased ≥0.5 mg/dL since the prior measurement. The coach was instructed to contact coaching arm participants at least 3 times per week.
  
  
  METHODS
  The outcome measures included: (1) enrollment rate, (2) dropout rate, and (3) change in PO4 from beginning to end of 10-week intervention period.
  
  
  RESULTS
  Of 66 eligible patients, 36 (55%) enrolled. Median age was 53 years, 83% were black race, and 78% were male. Median baseline PO4 was 6.0 (interquartile range 5.6, 7.5). Using stratified generalized estimation equation analyses, the monthly decline in PO4 was -0.32 mg/dL (95% CI -0.60, -0.04) in the incentives arm, -0.40 mg/dL (-0.60, -0.20) in the coaching arm, and -0.24 mg/dL (-0.60, 0.08) in the usual care arm. No patients dropped out. All intervention arm participants expressed interest in receiving similar support in the future.
  
  
  CONCLUSIONS
  This pilot trial demonstrated good feasibility in enrollment and implementation of novel behavioral health strategies to reduce PO4 in dialysis patients.
authors.affiliation: Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: peter.reese@uphs.upenn.edu.
authors.forename: Peter P
authors.initials: PP
authors.lastname: Reese
authors.affiliation: NYU Langone Medical Center, New York, New York.
authors.forename: Ofole
authors.initials: O
authors.lastname: Mgbako
authors.affiliation: Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Adam
authors.initials: A
authors.lastname: Mussell
authors.affiliation: Lankenau Hospital, Wynnewood, Pennsylvania.
authors.forename: Vishnu
authors.initials: V
authors.lastname: Potluri
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Zahra
authors.initials: Z
authors.lastname: Yekta
authors.affiliation: School of Arts & Sciences, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Simona
authors.initials: S
authors.lastname: Levsky
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Scarlett
authors.initials: S
authors.lastname: Bellamy
authors.affiliation: Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut; Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Chirag R
authors.initials: CR
authors.lastname: Parikh
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Justine
authors.initials: J
authors.lastname: Shults
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Karen
authors.initials: K
authors.lastname: Glanz
authors.affiliation: Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Harold I
authors.initials: HI
authors.lastname: Feldman
authors.affiliation: Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Kevin
authors.initials: K
authors.lastname: Volpp
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D005240:Feasibility Studies; D006293:Health Promotion / Q000379:methods; D054559:Hyperphosphatemia / Q000097:blood / Q000628:therapy; D007676:Kidney Failure, Chronic / Q000097:blood / Q000628:therapy; D009042:Motivation; D010349:Patient Compliance; D010758:Phosphorus / Q000097:blood; D010865:Pilot Projects; D006435:Renal Dialysis; D012201:Reward
chemical_list: D010758:Phosphorus