Research investigating medication adherence in high-risk, low-income populations

People with high blood pressure were twice as likely to take their blood pressure medication regularly if given the chance to win a daily cash reward, but their blood pressure readings were no better than those who were not offered a monetary reward, a new study shows.

Preliminary findings from the Behavioral Economics Trial to Enhance Blood Pressure Regulation (BETTER-BP) were presented at the Current Scientific Sessions of the American Heart Association's Scientific Sessions 2025 in New Orleans on November 9, and simultaneously published as a full manuscript. Journal of the American College of Cardiology (jack).

“We are always looking for ways to improve medication adherence in heart disease patients, and high blood pressure is one of the most preventable risk factors,” said John A. Dodson, MD, MPH, principal investigator and first author of the study. Dr. Dodson is Director of the Geriatric Cardiology Program at NYU Langone College and Associate Professor in the Leon H. Charney Department of Cardiology at NYU Langone School of Medicine.

BETTER-BP included 400 adults from three community health clinics in New York City. These clinics primarily serve Medicaid patients and those without health insurance, who have uncontrolled blood pressure and have difficulty following prescribed treatments. High blood pressure is a major risk factor for heart attack and stroke and can often be controlled with consistent medication use.

Participants were randomly divided into two groups. About two-thirds were in a program that offered incentives for taking blood pressure medication, and the remaining third were in a control group that did not receive these incentives. Before the study began, all reported not taking their prescribed medications consistently.

To track how often participants took their medication, Dr. Dodson and the research team used electronic pill bottles to record each time they opened the bottle, rather than relying on participants' self-reports. The mean systolic blood pressure (the highest blood pressure reading) at the beginning of the study was 139 mmHg. For reference, the American Heart Association's 2025 guidelines state that normal systolic blood pressure is less than 120 mm Hg.

Participants in the reward group were entered into a daily drawing to win prizes ranging from $5 to $50, as long as they opened a bottle of medicine and showed they had taken their blood pressure medication the previous day. They received a text message every day letting them know if they had won a prize. If they missed a dose, the study app sent a notification letting them know that they might have been eligible for a reward if they had taken the drug. People in the control group did not receive text messages or have a chance to win prizes.

The study lasted 12 months, with six months rewarded and then six months unrewarded, to see if participants' healthy habits continued even when the rewards were removed.

Key findings of the study include:

• Financial incentives appear to have doubled continued drug use. About 71% of participants in the reward group started taking blood pressure medication regularly (at least 80% during the 6-month study period), compared with 34% of participants in the control group.
• Similar blood pressure reductions were seen in both groups. After 6 months, mean systolic blood pressure decreased by 6.7 mmHg in the reward group and by 5.8 mmHg in the control group.
• Once the reward was stopped, the improvement did not persist. After the incentive ended, participants' medication habits returned to their pre-study state.

“The financial incentive clearly worked during the study. People in the rewarded group took their medication more consistently,” Dr. Dodson said.

However, I was surprised that this did not lead to a significant improvement in blood pressure control. It is unclear whether participants opened the bottle without taking the medication or whether untracked factors such as differences in medication or lifestyle behaviors affected blood pressure. We were also surprised to find that adherence decreased once the reward ended. This shows how complex changing behavior really is. There is still much to understand about what helps people maintain healthy habits long-term. ”

John A. Dodson, Director, Geriatric Cardiology Program, New York University Langone

This study had several limitations. The electronic pill bottles tracked when participants opened the pill bottle, but not whether they actually took the medication. The researchers also monitored only one blood pressure medication per person, even though many participants were prescribed multiple medications to manage their blood pressure. Additionally, blood pressure was measured in the clinic at only three points: at the start of the study, at 6 months, and at 12 months (6 months after compensation ended), rather than more frequent home monitoring, which may have resulted in different results.

Research details, background and design:

• The study included 400 adults diagnosed with high blood pressure, prescribed at least one antihypertensive drug, and had a systolic reading greater than 140 mmHg within the past year.
• Of these, 265 participants were in the reward group and 135 were in the control group.
• The median age of participants was 57 years, and 60.5% were female. In terms of self-reported race and ethnicity, 61.5% were Hispanic, 20.3% were black, 3.3% were non-Hispanic white, 2.8% were Asian, and 12.3% were of another race or ethnicity.
• In addition to hypertension, 54.5% of participants were obese (BMI ≥30) and 46.5% had type 2 diabetes.
• More than 70% of participants were covered by Medicaid (due to low income or disability) or did not have health insurance.

BETTER-BP is supported by the National Heart, Lung, and Blood Institute and the National Institutes of Health (R01HL148275).