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Table 1 Characteristics of included studies

From: Financial incentives in the management of diabetes: a systematic review

Study, country, registration number

Participants (n), age, duration

Features of the financial incentives

Intervention

Results

Individual behaviour

Diabetes control

Cost effectiveness

Long et al. [12], U.S, NCT01125956 (2010-05-19)

Diabetes (118), 50–70, 6-month

Cash, Arm3: $100 by dropping HbA1c by 1% and $200 by dropping it by 2% or to a HbA1c of 6.5%

Arm1: Control (n = 39)

Arm2: Peer Mentoring (n = 39)

Arm3: Financial incentive (n = 40)

Mean change in HbA1c

   Arm1: −0.01 (95% CI −0.52 to 0.51)

Arm2: −1.08 (95% CI −1.62 to −0.54)*

Arm3: −0.46 (95% CI −1.02 to 0.10)

(*, vs. arm1 P < 0.05)

Sen et al. [13], U.S, NCT01282957(2011-01-25)

Diabetes (75), 54.3 (mean age), 3-month intervention and 3-month follow-up

Cash, Arm 2: lottery incentive with expected daily value of $2.8 for daily blood glucose monitoring

Arm3: lottery incentive with expected daily value of $1.40 for daily blood glucose monitoring

Arm1: Control (n = 28)

Arm2: Low-incentive (n = 26)

Arm3: High-incentive (n = 21)

Total adherence rates

intervention period

Arm1: 58%

Arm2: 81%*

Arm3: 77%*

follow-up period

Arm1: 27%

Arm2: 62%*

Arm3: 35%

(*, vs. arm1 P < 0.05)

Misra-Hebert et al. [14], U.S

Type 1 and 2 diabetes (3184), more than 90% of individuals aged over 40 years, 1 year

Noncash, 15% health insurance premium discount ($300-$600) tied to achievement of clinical goals

Employee Patients (E): financial incentive; Matched Non-Employee Comparison Group (C)

2010–2011 Cohort

E (727); C (727)

2011–2012 Cohort

E (865); C (865)

Mean change year 2–year 1 in HbA1c

2010–2011 Cohort

E: −0.08; C: −0.05

2011–2012 Cohort

E: −0.18*; C: −0.26*

(*, vs. year 1, P < 0.05)

Fernandes et al. [15], U.S

Type 1 and 2 diabetes (320), >18, 11–20 month

Noncash, up to $320/year, blood glucose monitoring ≤ $20; diabetes education session ≤ $20; pneumococcal or influenza vaccination ≤ $10; retinal eye examination ≤ $20; urine microalbumin test ≤ $10; cholesterol testing ≤ $20; HbA1c testing ≤ $20; reduction in HbA1c by 1% ≤ $20; HbA1c at 7% goal ≤ $50; blood pressure control < 140/90 mmHg ≤ $20; low density lipoprotein cholesterol < 100 mg/dL ≤ $20; if applicable, smoking cessation class ≤ $20; counseling with behavioral health ≤ $20; and achieve weight loss of 7% ≤ $50 for those with a BMI ≤ 25

Arm1: Control (n = 159)

Arm2: Financial incentive (n = 161)

No statistically significant improvements in HbA1c

No reduction in total health cost

Fernandes et al. [16], U.S

Type 1 and 2 diabetes (2003), 54.1 (mean age), 1–2 year

Noncash, up to $320/year, blood glucose monitoring ≤ $20; diabetes education session ≤ $20; pneumococcal or influenza vaccination ≤ $10; retinal eye examination ≤ $20; urine microalbumin test ≤ $10; cholesterol testing ≤ $20; HbA1c testing ≤ $20; reduction in HbA1c by 1% ≤ $20; HbA1c at 7% goal ≤ $50; blood pressure control < 140/90 mmHg ≤ $20; low density lipoprotein cholesterol < 100 mg/dL ≤ $20; if applicable, smoking cessation class ≤ $20; counseling with behavioral health ≤ $20; and achieve weight loss of 7% ≤ $50 for those with a BMI ≤ 25

Arm1: Financial incentive (n = 2003)

Percentage of annual eye exams increased from 38.7 to 46.9%; Screening for microalbumin increased from 38.6 to 50%; Attendance of diabetes education sessions increased from 16.8 to 41.6%;

Testing for HbA1c and lipids increased from 54.3 to 77.1% and 45.6 to 62.6% respectively

Mean HbA1c decreased from 8.56 to 8.24% (P < 0.0001)

The amount billed and paid increased by 60.0 and 61.9%, respectively

Miranda et al. [22], Peru, NCT02891382 (2016-09-07)

Type 2 diabetes (54), 55 (mean age), 3-month

Cash, $25 for lost one kilogram in two weeks; $62 by dropping HbA1c < 1%; $124 by dropping it HbA1c ≥ 1% or to a HbA1c ≤ 6.5%. (In Arm 1 and Arm 2, the participant received the reward. In Arm 3, both the participant and their partner received 50% of the cash reward each.)

Arm1: Individual incentives (n = 18)

Arm2: Mixed incentives-altruism (n = 18)

Arm3: Mixed incentives-cooperation (n = 18)

Mean change in HbA1c

Arm1: −1.4 ± 1.4*

Arm2: −0.9 ± 1.2*#

Arm3: −1.1 ± 1.6*#

(*, vs. baseline within arm P < 0.05; #, vs. arm1 P = 0.05)

Egede et al. [17], U.S, NCT02722499 (2016-03-30)

Type 2 diabetes (60), 57.4 (mean age), 3-month

Cash, up to $300, Arm1: absolute percentage drop in HbA1c; Arm2: uploading glucose measurements using home testing, and absolute percentage drop in HbA1c; Arm3: uploading glucose measurements using home testing, attending weekly phone educational sessions, and absolute percentage drop in HbA1c

Arm1: Low frequency incentive (n = 20)

Arm2: Moderate frequency incentive (n = 20)

Arm3: High frequency incentive (n = 20)

3-month mean drop in HbA1c

Arm1: −1.25%*

Arm2: −1.73%*

Arm3: −1.74%*

(*, vs. baseline within arm P < 0.05)

Incremental cost effectiveness ratios (ICER) to decrease HbA1c by 1%

Arm1: −1100 (95% CI −2363 to 162)

Arm2: −1100 (95% CI −1716 to −484)

Arm3: −1100 (95% CI −1549 to −651)

Bilger et al. [21], Austria, NCT02224417 (2014-08-25)

Diabetes (240), 55.23 (mean age), 6-month

Cash, up to $10.36 weekly, Arm2: $2.59 weekly by measuring blood glucose on three non-consecutive days, $0.37 daily by taking medication, and $0.74 daily by completing 8000 steps, Arm3: $1.48 weekly for achieving one pre-meal glucose reading within 4–7 mmol/L, $5.18 for two such readings, or $10.36 for three readings within this range in a week

Arm1: usual care plus (n = 61)

Arm2: process-based incentive (n = 87)

Arm3: outcome-based incentive (n = 92)

Incremental effect of incentive (Arm2+Arm3 vs. Arm1)

1.Mean no. of glucose readings days

0.40 (95% CI 0.04 to 0.76)

2.Mean no. of medication adherent days

0.72 (95% CI 0.05 to 1.38)

3.Mean no. of physically active days

1.12 (95% CI 0.38 to 1.86)

Incremental effect of Arm3 vs. Arm2

1.Mean no. of glucose readings days

−0.06 (95% CI −0.45 to 0.32)

2.Mean no. of medication adherent days

−0.64 (95% CI −1.32 to 0.04)

3.Mean no. of physically active days

−1.37 (95% CI −2.13 to −0.06)

Incremental effect of incentive (Arm2+Arm3 vs. Arm1)

1.Mean change in HbA1c

−0.31 (95% CI −0.67 to 0.06)

2.Proportion of participants who had improvement in HbA1c at month 6

0.18 (95% CI 0.04 to 0.31)

3.Mean no. of glucose readings within acceptable range

0.32 (95% CI 0.07 to 0.57)

Incremental effect of Arm3 vs. Arm2

1.Mean change in HbA1c

−0.05 (95% CI −0.42 to 0.31)

2.Proportion of participants who had improvement in HbA1c at month 6

−0.02 (95% CI −0.14 to 0.11)

3.Mean no. of glucose readings within acceptable range

0.07 (95% CI −0.21 to 0.34)

Mashru et al. [20], Canada

Type 1 or 2 diabetes (116), >18, 2-years

Noncash, $5 gift card for every HbA1c test, up to a maximum of two gift cards

Arm1: financial incentive + remind letter

(n = 60)

Arm2: remind letter (n = 56)

Average number of HbA1c tests completed

Arm1: 4.23 ± 2.18*

Arm2: 3.65 ± 2.01

(*, vs. Arm2 P < 0.05)

Al Kathiry et al. [23], Saudi Arabia

Type 2 diabetes (702), 56.14 (mean age), 9-month

Cash, $400 to patients and $534 to physicians for achieving the target HbA1c level

Arm1: financial incentive

The average HbA1c

difference between the first and the third visits was 0.69 (±SD = 2.80) with P < 0.001

Wong et al. [18], U.S

Type 1 Diabetes (90), 16.3 (mean age), 3-month intervention and 3-month follow-up

Cash, Participants were required to achieve daily blood glucose monitoring goals of at least 4 checks per day, with at least 1 reading within the range of 3.9–10 mmol/L, using a wireless glucometer, with a $60 monthly incentive deposited into a virtual account during the 3-month intervention, with $2 deducted for each day of nonadherence to monitoring goals

Arm1: Control (n = 45)

Arm2: Financial incentive (n = 45)

Proportion of participant-days achieving glucose monitoring goals

Incentive Period

Arm1: 18.9

Arm2: 50*

Follow-up Period

Arm1: 8.7

Arm2: 15.3

(*, vs. Arm1 P < 0.05)

Mean change in HbA1c

Incentive Period

Arm1: −0.24 (95% CI −0.66 to 0.17)

Arm2: −0.56 (95% CI −0.97 to −0.14)

Follow-up Period

Arm1: −0.17 (95% CI −0.51 to 0.17)

Arm2: −0.43 (95% CI −0.89 to 0.03)

Nally et al. [19], U.S

Type 1 Diabetes (17), 15.9 (mean age), 16-week intervention and 8-week follow-up

Cash, up to $717, $1 daily for wearing and calibrating the CGM twice daily and $1 daily for administering at least 3 mealtime insulin boluses daily. $3 bonus for remaining in auto mode at least 70% of the time in the first week, and the bonuses increased by $5 per week for each consecutive week up to a cap of $13 per week, $5 weekly reinforcements for uploading their insulin pump and CGM data to CareLink, $10 per week in weeks 7 to 16 for informing study staff by email or text that they had reviewed their CareLink data and how they planned to adjust their treatment regimen during the following week, $90 for reviewing the CareLink Sensor Daily Overlay Report derived from the insulin pump and CGM

Arm1: Financial incentive (17)

Mean HbA1c levels

baseline: 8.6

6-week: 8.1*

12-week: 8.1*

16-week: 8.0*

24-week: 8.3

(*, vs. baseline P < 0.05)

  1. HbA1c glycated haemoglobin, CGM continuous glucose monitoring