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Financial Incentives for Completion of Fecal Occult Blood Tests Among Veterans: A 2-Stage, Pragmatic, Cluster, Randomized, Controlled TrialFinancial Incentives for Completion of Fecal Occult Blood Tests Among Veterans

Jeffrey T. Kullgren, MD, MS, MPH*; Tanisha N. Dicks, MBA; Xiaoying Fu, PhD; Diane Richardson, PhD; George L. Tzanis, MD; Martin Tobi, MB, ChB; and Steven C. Marcus, PhD
[+] Article, Author, and Disclosure Information

* Former Robert Wood Johnson Foundation Clinical Scholar.

This article is part of the Annals supplement “RWJF Clinical Scholars in Pursuit of the Value Proposition: Evaluations of Low-Cost Innovations for Prevention and Management of Conditions.” The Robert Wood Johnson Foundation provided funding for publication of this supplement. Carol M. Mangione, MD, MPH (co-director of the RWJF Clinical Scholars Program at the University of California, Los Angeles); Jaya K. Rao, MD, MHS (Annals Deputy Editor); and Christine Laine, MD, MPH (Annals Editor in Chief), served as editors for this supplement.


From the Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, and University of Michigan Medical School, Ann Arbor, Michigan, and Philadelphia Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, Pennsylvania.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government.

Acknowledgment: The authors thank Kathy Chicano, CRNP, of the Philadelphia Veterans Affairs Medical Center for her assistance with implementation of this study and Keith Davies of the Veterans Affairs Center for Health Equity Research and Promotion for his assistance with assembling administrative data for the study analyses.

Grant Support: By a grant from the Veterans Affairs Center for Health Equity Research and Promotion, which is a Veterans Affairs Health Services Research & Development Center of Innovation, and by the Robert Wood Johnson Foundation.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-3015.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Kullgren (e-mail, jkullgre@med.umich.edu). Data set: Not available.

Requests for Single Reprints: Jeffrey T. Kullgren, MD, MS, MPH, Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI 48113-0170; e-mail, jkullgre@med.umich.edu.

Current Author Addresses: Dr. Kullgren: Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI 48113.

Ms. Dicks and Drs. Fu, Richardson, Tzanis, and Tobi: Philadelphia Veterans Affairs Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104.

Dr. Marcus: University of Pennsylvania School of Social Policy and Practice, 3701 Locust Walk, Philadelphia, PA 19104.

Author Contributions: Conception and design: J.T. Kullgren, X. Fu, M. Tobi, S.C. Marcus.

Analysis and interpretation of the data: J.T. Kullgren, X. Fu, D. Richardson, M. Tobi, S.C. Marcus.

Drafting of the article: J.T. Kullgren, T.N. Dicks.

Critical revision of the article for important intellectual content: J.T. Kullgren, T.N. Dicks, X. Fu, D. Richardson, M. Tobi, S.C. Marcus.

Final approval of the article: J.T. Kullgren, T.N. Dicks, X. Fu, D. Richardson, M. Tobi, S.C. Marcus.

Provision of study materials or patients: T.N. Dicks, G.L. Tzanis.

Statistical expertise: X. Fu, D. Richardson, S.C. Marcus.

Obtaining of funding: J.T. Kullgren, X. Fu, S.C. Marcus.

Administrative, technical, or logistic support: T.N. Dicks, G.L. Tzanis.

Collection and assembly of data: T.N. Dicks.


Ann Intern Med. 2014;161(10_Supplement):S35-S43. doi:10.7326/M13-3015
Text Size: A A A

Background: Rates of patient completion of fecal occult blood tests (FOBTs) are often low.

Objective: To examine whether financial incentives increase rates of FOBT completion.

Design: A 2-stage, parallel-design, pragmatic, cluster, randomized, controlled trial with clustering by clinic day (ClinicalTrials.gov: NCT01516489).

Setting: Primary care clinic of the Philadelphia Veterans Affairs Medical Center.

Patients: 1549 patients who were prescribed an FOBT (unique samples of 713 patients for stage 1 and 836 patients for stage 2).

Intervention: In stage 1, patients were assigned to usual care or receipt of $5, $10, or $20 for FOBT completion. In stage 2, different patients were assigned to usual care or receipt of $5, a 1 in 10 chance of $50, or entry into a $500 raffle for FOBT completion.

Measurements: Primary outcome was FOBT completion within 30 days. Preplanned subgroup analyses examined 30-day FOBT completion by previous nonadherence to a prescribed FOBT.

Results: In stage 1, none of the incentives increased rates of FOBT completion. In stage 2, a 1 in 10 chance of $50 increased FOBT completion compared with usual care (between-group difference, 19.6% [95% CI, 10.7% to 28.6%]; P < 0.001) but a $5 fixed payment and entry into a raffle for $500 did not. None of the incentives were more effective among patients who had previously been nonadherent to an FOBT than among patients who had previously completed an FOBT.

Limitations: Single Veterans Affairs medical center setting, short follow-up, use of 3-sample rather than 1-sample immunochemical FOBTs, limited power to detect small effects of incentives, inability to evaluate cost-effectiveness.

Conclusion: A 1 in 10 chance of receiving $50 was effective at increasing rates of FOBT completion, but 5 other tested incentives were not.

Primary Funding Source: Veterans Affairs Center for Health Equity Research and Promotion.

Figures

Grahic Jump Location
Figure 1.

Study flow diagram: stage 1.

FOBT = fecal occult blood test.

Grahic Jump Location
Grahic Jump Location
Figure 2.

Study flow diagram: stage 2.

FOBT = fecal occult blood test.

Grahic Jump Location

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