June/July 2016

What’s in it for Me? Behavioral Economics to Improve Teens’ Glycemic Control

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When young patients with type 1 diabetes reach adolescence and young adulthood, they tend to “fall off the cliff” and don’t take their medications or visit their healthcare providers on a consistent basis. This can send their glycemic control into a spiral leading toward short- and long-term medical complications. A collaborative pilot research project by investigators at The Children’s Hospital of Philadelphia and the University of Pennsylvania is taking a unique approach to steady this patient population’s adherence to recommended care practices.

“We’re applying a behavioral economic incentive technique called loss aversion to see if it motivates young people to improve their glycemic control by getting them to check their blood glucose levels more frequently and respond to their blood glucose levels in ways that are appropriate,” said co-principal investigator of the study Charlene Wong, MD, MSHP, a health services researcher and adolescent medicine fellow at CHOP and Penn.

Here’s how the concept of loss aversion fits into the study design, as Dr. Wong explained: Study participants have goals to check their blood glucose four times a day using a wireless glucometer and to take action when needed to keep their levels in a certain range, such as by administering correction doses of insulin. These goals are based on recommendations from the American Diabetes Association and CHOP’s division of Endocrinology and Diabetes. At the beginning of the month, each participant is given $60 in an electronic account. Each day that a participant is not adherent to the goals, he loses two dollars from the account. An automated daily text message or email sends the participant a reminder of where the account balance stands.

“We think that loss aversion could be a particularly strong incentive among youth because it is concrete,” Dr. Wong said. “They realize that this is money that they’re giving me, and I’m losing it by not doing the things that I’m expected to do as part of my routine care.”

In the fall, the study team began recruiting patients who were receiving care from CHOP’s Diabetes Center for Children, and they enrolled 90 participants ages 14 to 20; half were included in the intervention arm that lasted for three months. A second phase of the study will continue for another three months, except the intervention group will no longer receive the financial incentives.

The researchers check the participants’ hemoglobin A1C, which is a lab measure of glycemic control, at the start of the study, after three months, and at the end of six months to make comparisons. They also will conduct exit interviews to get participants’ perspectives on whether or not they found the study’s incentive design beneficial.

“The goal of using the incentives is to help participants identify ways to build in daily glucose monitoring practices into their usual routines of daily life,” Dr. Wong said. “And then, even after the incentives go away, our hope is that the study participants will be able to maintain the good habits that they’ve established.”

The study team is using an innovative web-based platform called Way to Health, which was created by Penn’s Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute (LDI CHIBE), to conduct the study. The platform automates many of the research functions necessary to perform these sorts of behavioral economic randomized controlled trials using devices such as wireless activity trackers and other mobile health applications to test ways of improving health behaviors. The wireless glucometers automatically upload study participants’ glucose readings to the Way to Health platform study site, so the researchers know whether or not they’re adhering to their daily glucose monitoring goals.

In addition, the pilot study aims to build the foundation for future work with adolescents and young adults using behavioral economic principles and Way to Health. The study team will gather feedback on how youth friendly the Way to Health platform is perceived to be and if the study participants have any recommendations to increase its appeal to young users.

“Part of doing this pilot study is to see how these techniques work with youth populations,” Dr. Wong said. “If it’s successful, we would anticipate doing larger trials with young patients with type 1 diabetes and expanding our research to apply these same techniques into other disease categories with populations of adolescents and young adults.”

The study team is currently collecting data on the 90 participants who are enrolled and expect to analyze and report on results by the end of the year. Dr. Wong’s co-principal investigator is Mitesh Patel, MD, MBA, assistant professor of Medicine and Health Care Management at the Perelman School of Medicine and The Wharton School at Penn, and an LDI CHIBE faculty member. They also are collaborating with Carol Ford, MD, chief of the Craig-Dalsimer Division of Adolescent Medicine at CHOP; Steve Willi, MD, director of the Diabetes Center for Children at CHOP; Kathryn Murphy, RN, PhD, associate director of the Diabetes Center; and Victoria Miller, PhD, director of research for Adolescent Medicine. This project was supported in part by the Institute for Translational Medicine and Therapeutics of the Perelman School of Medicine at Penn.

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