Glucose management for rewards


Posted Oct 17 , 2019 04:25 AM

Glucose management for rewards: A randomized trial to improve glucose monitoring and associated self‐management behaviors in adolescents with type 1 diabetes.
Wagner J. et al. Pediatric Diabetes 2019_Online July 4

Institute Summary (excerpted from the abstract):

This randomized, controlled trial evaluated a monetary‐based reinforcement intervention for increasing self‐monitoring of blood glucose (SMBG) among youth with poorly controlled type 1 diabetes. After a 2‐week baseline collection of SMBG data, 60 participants were randomized to enhanced usual care (EUC) or Reinforcers. The Reinforcers group earned monetary rewards for SMBG and associated behaviors such as uploading glucose meters. Reinforcers were withdrawn at 24 weeks. A follow‐up evaluation occurred at 36 weeks. Participants in the reinforcers group increased the proportion of days they completed 4 or more SMBG from 14.6% at baseline to 64.4%, 47.5%, and 37.8% at 6, 12, and 24 weeks, respectively. In contrast, EUC participants declined from 22.7% at baseline to 17.5%, 10.5%, and 11.1% (Ps < .01 vs EUC at all time points). Group differences were attenuated but remained significant after withdrawal of reinforcers. Effect sizes for SMBG were very large during reinforcement and large after withdrawal of reinforcers. In the reinforcers group, mean A1c dropped from 9.5% at baseline to 9.0% at week 6 and 9.0% at week 12. For EUC, A1c was 9.2% at baseline and ranged from 9.2% to 9.6% throughout the study (P < .05 vs EUC). Group differences in A1c were no longer significant at weeks 24 and 36. Effect sizes for A1c were small during reinforcement and also after withdrawal of reinforcement.

Why is this important?

Incentivizing behavior is a key tactic in helping patients with diabetes. While different individuals are motivated by different incentives, money seems to be a universal incentive that works! Monetary‐based reinforcement of adolescents with type 1 diabetes caused durable increases in SMBG and associated behaviors that better enable the use of SMBG data. The monetary incentive was quite strong, and the graded approach to monetary rewards was clearly beneficial to adherence with the behaviors being studied. Usually, the behavioral response does wane when the incentives are discontinued, but the residual effect in this study is noteworthy. While there was a difference in A1C levels at 24 weeks in the reinforcer cohort compared to baseline, the study wasn’t powered enough for those differences to be statistically significant. Modification of the reinforcement structure may be needed to sustain improved metabolic control in this challenging age group. Have you used incentives to stimulate behavior change in your patients? What have you found? Your colleagues would love to learn from your experiences!

Concluding Thought: “Call it what you will, incentives are what get people to work harder”: -Nikita Krushchev

Read the Abstract:

NOTE: The article is only available for a charge, however the “reinforcer” stepped monetary rewards process is available at this link. pedi12889-sup-0001-FigureS1.tif