People with high blood pressure were twice as likely to take their blood pressure medication regularly when offered daily chances to win cash rewards, yet they did not achieve better blood pressure measurements compared to people who were not offered financial rewards, according to a preliminary late-breaking science presentation today at the American Heart Association's Scientific Sessions 2025. The meeting, Nov. 7-10, in New Orleans, is a premier global exchange of the latest scientific advancements, research and evidence-based clinical practice updates in cardiovascular science.
The Behavioral Economics Trial To Enhance Regulation of Blood Pressure (BETTER-BP) study included 400 adults with high blood pressure who received care at three community health clinics in New York City. These clinics provide health care mainly to people with Medicaid coverage (who are low-income or disabled) and people without health insurance. Both groups often have higher rates of uncontrolled blood pressure and are less likely to consistently take their blood pressure medication, according to prior studies. Not taking blood pressure medication as directed can increase the risk of heart attack and stroke, according to the American Heart Association.
The participants were randomly assigned to one of two groups: 1) two-thirds were eligible to win cash rewards for taking their blood pressure medication, and 2) one-third were in a control group that was not offered the chance to win cash for taking their blood pressure medication. All of the participants self-reported that they did not take their blood pressure medication as prescribed before the study began. Researchers used electronic pill bottles to monitor how often participants opened their medication bottles during the study period (as a measure of daily medication use), rather than relying on patients self-reporting this information. The average systolic blood pressure (the top number) among all participants was 139 mm Hg at the time of enrollment in the study. (Normal systolic blood pressure is less than 120 mm Hg, according to the American Heart Association's 2025 High Blood Pressure Guideline.)
We're always looking for ways to improve medication adherence among our patients with heart disease, and high blood pressure is one of the most preventable risk factors for heart disease."
John Dodson, M.D., principal investigator of the study and associate professor of medicine and population health, NYU Grossman School of Medicine, New York City
Participants in the rewards group were entered into a daily drawing for a cash reward ranging from $5-$50 if they had opened their pill bottle the previous day (indicating that they had taken their blood pressure medication). They received daily text messages informing them if they had won any money. In addition, people who did not open their medication bottle (indicating they had skipped their previous day's dose) received a text message from the study app reminding them they could have potentially won a cash reward if they had taken their medication the previous day. People in the control group did not receive any text messages and were not eligible to win any cash rewards.
The study monitored participants for 12 months total: six months of the rewards program followed by six months of additional monitoring without rewards to look for changes in medication-taking habits after the financial incentives ended.
The study's key findings include:
- Financial incentives doubled consistent medication use, with 71% of participants in the rewards group opening their medication regularly (at least 80% of the time over the six-month study period), compared to 34% of people in the control group who were not given the opportunity to receive cash rewards.
- People in both groups experienced similar reductions in systolic blood pressure at six months. People in the rewards group had an average 6.7 mm Hg reduction compared to an average 5.8 mm Hg reduction in the control group.
- After the cash rewards ended, the study found that those participants reverted to their previous behavior of not consistently taking their medication as prescribed.
"Financial incentives clearly worked to change behavior during the study period because people in the rewards group took their medication much more consistently. However, we were surprised that the behavior change didn't translate to significantly better blood pressure control," Dodson said. "It is unclear if there was no change because they opened the bottles but didn't take the medication tracked, or if a different medication or lifestyle behavior not tracked in the study impacted their blood pressure."
"We were also surprised that people did not keep taking their medication as prescribed after the rewards program ended. This shows that improving medication adherence is more complex than we thought. There are still many unknown factors we need to understand in order to help people adopt long-term behavior changes," he added.
The study had several limitations. The electronic pill bottles only monitored whether the bottles were opened, not whether the participants actually took the medication. Researchers monitored only one blood pressure medication per participant, even though many participants were prescribed multiple medications for high blood pressure. The study also used standardized office blood pressure measurements taken at three points during the trial (at enrollment, after six months and at 12 months, six months after the end of the rewards program), rather than more frequent home monitoring, which may have yielded different results.
Study details, background and design:
- The study included 400 adults with a diagnosis of high blood pressure who were prescribed at least one blood pressure medication and had at least one systolic blood pressure measurement of over 140 mm Hg in the past year.
- There were 265 people in the rewards group and 135 in the control (no rewards) group.
- Participants were a median age of 57 years old; 60.5% were women; 61.5% of participants self-identified as Hispanic, 20.3% as Black, 3.3% as non-Hispanic white, 2.8% as Asian and 12.3% as other.
- In addition to having high blood pressure, 54.5% of participants had obesity (BMI ≥30), and 46.5% had Type 2 diabetes.
- More than 70% of participants were covered by Medicaid (due to having low income or a disability) or they had no health insurance.
Abstinence or limiting alcohol intake may lead to clinically meaningful blood pressure reductions