ACHIEVING CHOLESTEROL GOALS IN PATIENTS WITH DIABETES: A FACTORIAL RANDOMIZED TRIAL OF FINANCIAL INCENTIVES AND PATIENT-CENTERED DECISION AID

Purpose: Statin use is recommended in patients with diabetes to reduce risk of stroke and myocardial infarction; however, studies have documented limited initiation and long-term adherence to statins. We examined the benefit of financial incentives and a patient-centered decision aid in improving cholesterol process (testing) and outcome (LDL<100) measures in a non-referral population of patients with diabetes.

Methods: 58 patients followed at Tufts Medical Center Primary Care were randomized in a 2x2 factorial design to financial incentives or decision aid (vs. usual care). The Tufts Diabetes Statin Decision Aid included values clarification, individualized UKPDS stroke and myocardial infarction risk, statin benefit, costs and harms, and patient intended action. Financial incentives for patients consisted of $20 for testing and $40 for goal achievement. Comparisons were made with Chi-square or Fisher’s Exact Test.

Results: Participants (47% women; 17% Blacks; 10% smokers) had a mean±SD age of 58±12 years, systolic blood pressure of 127±14, hemoglobin A1c of 7.7%±1.7, total cholesterol of 183±49 and HDL of 49±21 mg/dL. At baseline, the mean estimated 10-year risk of stroke or myocardial infarction was 25% if not taking a statin (67% of the cohort) and 18% if taking a statin. 10 participants received usual care only (information sheet, no incentives), 15 decision aid only, 16 financial incentives only and 17 both decision aid and financial incentives.

In the calendar year of the intervention, 30 of 32 (94%) decision aid vs. 23 of 26 (88%) usual care patients had testing (p=0.65), and 30 of 33 (91%) financial incentive vs. 24 of 25 (96%) usual care patients had testing (p=0.63). 25 of 32 (78%) decision aid vs. 13 of 26 (50%) usual care patients achieved the outcome measure of LDL<100 (p=0.049), and 22 of 33 (66%) financial incentive vs. 16 of 25 (64%) usual care patients achieved this goal (p=0.95).

In the following calendar year, 56% decision aid vs. 35% usual care patients met both outcomes, i.e., underwent testing and achieved the LDL goal (p=0.17), and 48% financial incentive vs. 44% usual care patients met both outcomes (p=0.94).

Conclusions: In this factorial randomized controlled trial, neither the decision aid nor financial incentives improved cholesterol testing. The decision aid significantly improved LDL goal achievement, but the improvement attenuated and became non-significant in the following year.