Tailored Adherence Incentives for Childhood Asthma Medications: A Randomized Clinical Trial

To evaluate the effect of a financial incentive-based intervention on adherence to inhaled maintenance asthma medications in an urban high-risk pediatric minority population during the intervention period.The study population included 106 children aged 5 to 12 years who were prescribed a daily inhaled corticosteroid or corticosteroid/long-acting beta-agonist and had at least 2 asthma exacerbations requiring systemic steroids in the prior year. Most of the participants self-identified as non-Hispanic Black.This study was a 3-arm randomized control clinical trial. Families who successfully completed a 1-month run-in interval were randomized to 1 of 3 arms in a 2:1:2 scheme for a 3-month experiment interval: (1) Full intervention arm—daily text message medication reminders, weekly adherence feedback, and gain-framed, financial incentives of up to $1 per day ($0.25 per maintenance inhaler puff or $0.50 per puff based on 2–4 puffs/d prescribed dosing); (2) Hybrid intervention—daily text message medication reminders and weekly adherence feedback; or (3) Active control—no reminders, feedback, or incentives. The 3-month experiment interval was followed by a 3-month observation interval where all arms reverted to active control conditions and medication adherence monitoring was continued. An electronic Bluetooth-enabled sensor was attached to the child’s inhaler, which measured inhaler actuations to determine medication adherence. The primary outcome measure was the child’s adherence to their maintenance asthma inhaler over the experiment interval. Secondary outcomes included maintenance inhaler adherence during the observation interval, asthma-related health care system use in the year following randomization, and asthma control from baseline to end of experiment interval. The study was powered to detect a difference in average monthly adherence between the full intervention and active control arms.Of the 106 enrolled participants, 99 participants were included in the analysis. During the experiment interval, participants in the full intervention arm had a 15-percentage-point (95% CI, 2–29 percentage points) higher adherence to their inhaled maintenance medication than participants in the active control arm. The study was not powered to determine differences between the hybrid-intervention arm and other arms in the experiment interval. There was no evidence of medication adherence differences between the 3 arms in the observation interval.Participants in the full intervention arm who received financial incentive–enhanced interventions in addition to medication reminders had higher adherence to their inhaled preventive asthma medication as compared with participants in the active control arm. However, once the intervention incentives were discontinued, the higher rate of medication adherence in the full intervention arm was not maintained.Although children in the full intervention arm did have improved asthma inhaler medication adherence during the active intervention period, this effect was not sustained after the incentives were removed. The study was not powered to detect statistical differences between the hybrid-intervention arm and other arms, which makes it difficult to determine whether it was solely the financial incentive that improved maintenance inhaler adherence in the full intervention arm or a combination of intervention components. There were no differences between the 3 arms in hospital admissions, emergency department visits, or oral steroid courses in the year following randomization, nor were there changes in asthma control from baseline to end of the experiment interval; however, this study was also not powered to determine these outcomes. Overall, this study showed a short-term benefit of improved adherence to maintenance asthma inhalers with a multicomponent intervention including financial incentives, but it did not lead to sustained changes. There are a multitude of socioeconomic factors that play a large role in medication adherence, especially in disadvantaged populations. Future studies are needed that investigate strategies for ensuring sustained medication adherence after the incentive program concludes that also address these factors to better promote improved long-term behavioral changes.