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November 14, 2025
3 min read
Key takeaways:
- A lottery-style incentive program featuring a cellularly monitored pill bottle improved adherence to antihypertensive medication.
- BP change did not follow.
- More data on behavioral management of BP are needed.
NEW ORLEANS — A study utilizing financial incentives tied to use of an electronically monitored pill bottle improved tracked adherence to antihypertensive medications, but gaps remained in actual BP change, a speaker reported.
BETTER-BP, presented at the American Heart Association Scientific Sessions and simultaneously published in the Journal of the American College of Cardiology, was a randomized trial conducted at three safety-net clinics in New York City to evaluate the potential benefit of an economic reward “lottery” system to improve adherence to patients’ BP medications.
A lottery-style incentive program featuring a cellularly monitored pill bottle improved adherence to antihypertensive medication. Image: Adobe Stock
“Hypertension is one of the most treatable risk factors for the prevention of heart disease. However, many patients don’t take their blood pressure medications as prescribed,” John A. Dodson, MD, MPH, associate professor and director of the geriatric cardiology program at NYU Grossman School of Medicine, said during a press conference. “We hypothesized that using behavioral economics, which combines economics and psychology to understand human behavior that is not always rational, would improve antihypertensive medication adherence and lower blood pressure.”
For the BETTER-BP trial, the researchers enrolled 400 patients who self-reported poor adherence to their BP medication while being prescribed at least one antihypertensive drug with a systolic BP of 140 mm Hg or more (median age, 57 years; 61% women; 20% Black). More than 70% had Medicaid or no insurance.
Participants were randomly assigned 2:1 to a text message-based lottery incentivized adherence program utilizing behavioral economic principles plus passive adherence monitoring or passive adherence monitoring alone.
Passive adherence monitoring was conducted via cellular-enabled pill bottle containing patients’ antihypertensive medication that registered a signal when the bottle was opened. This monitoring was administered to both trial groups.
Patients assigned to the lottery intervention received daily text messages confirming their adherence or nonadherence and whether their prior day’s adherence won them the day’s monetary prize. This continued for 6 months, after which they received passive adherence monitoring alone without financial incentive through month 12.
At 6 months, 71% of patients assigned to the lottery intervention achieved adequate adherence as determined by electronic pill bottle vs. 34% in the control group (adjusted RR = 2.04; 95% CI, 1.58-2.63); however, change in systolic BP did not significantly differ between the groups (intervention, 6.7 mm Hg; control, 5.9 mm Hg; P = .62) , according to the presentation.
After the 6-month lottery period until 12 months, adherence between the two groups was similar, at 31% in the intervention arm vs. 26% in the control arm (aRR = 1.17; 95% CI, 0.83-1.65), according to the researchers.
John A. Dodson
“This did not translate to a significant reduction in office-measured systolic blood pressure vs. control over the same time period,” Dodson said during the press conference. “Increased adherence was not sustained after the lottery was removed, and these findings suggest that other strategies will be required for long-term behavior change.”
Keith C. Ferdinand
After the presentation, Keith C. Ferdinand, MD, FAHA, FACC, FASPC, FNLA, FPCNA (hon), Gerald S. Berenson Endowed Chair in Preventive Cardiology, professor of medicine in the John W. Deming Department of Medicine at Tulane University School of Medicine and a member of the Healio | Cardiology Today Editorial Board, discussed how addressing nonadherence may be more complex than providing economic incentives.
“Nonadherence is a real problem. Over 50% of people who have hypertension have medications and aren’t taking them. … The study should be congratulated, helping people help themselves,” Ferdinand said. “Using this lottery approach, where the person had to open the cap to get entered into the lottery, did they really take the medicine, or did they just open the cap? We don’t know.
A 2022 scientific statement from the AHA concluded that “providing financial incentives for adherence, including lotteries and other approaches, have not consistently shown to improve medication adherence,” Ferdinand said. “We need targeted interventions to identify and eliminate these disparities based on race, ethnicity, sex, gender, geography, socioeconomic status, ability and disability. This is not just a moral issue; it’s a practical imperative. The investigations that were done with BETTER-BP, although negative, should be lauded for that effort.”
Perspective
In my prior role as provost and trying to incentivize students, we use lotteries a lot, and that’s the concept Dodson was discussing under behavioral economics. We did learn that when you provided an incentive, you do improve adherence. When it goes away, you lose adherence. Are there other ways to improve adherence that are financially motivated? What if you just paid individuals $1 a day if they took their medication? Would that work? There are alternatives that we should try.
Hypertension is silent. There’s no reason for someone to feel they need to take their medication. So the incentive then has to come from a desire to take care of your health. You have to understand the long-term consequences of hypertension, and finding ways to incentivize people to do this in the absence of physical symptoms driving them is critical.
Given the long-term cost of the downstream consequences of hypertension, like stroke, heart attack, cognitive impairment, etc, maintaining brain and heart health is critical. It’s probably cheaper to pay someone to take a drug than [pay for] these long-term consequences years later.
Donna K. Arnett, BSN, MSPH, PhD, FAHA
Dean of the College of Public Health
Chief Executive and Academic Officer
College of Public Health
University of Kentucky
Disclosures: Arnett reports no relevant financial disclosures.
Sources/Disclosures
Source:
Dodson JA. LBS.05 Practice changing trials in blood pressure control. Presented at: American Heart Association Scientific Sessions; Nov. 7-10, 2025; New Orleans.
Reference:
Disclosures:
Dodson reports serving on scientific advisory boards for AliveCor and ISHI Health. Ferdinand reports no relevant financial disclosures.
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