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 than people who were not offered financial rewards, a new study shows.
The preliminary findings from the Behavioral Economics Trial to Enhance Regulation of Blood Pressure (BETTER-BP) were presented during a late-breaking science session during the American Heart Association's Scientific Sessions 2025 in New Orleans on November 9 and simultaneously published as a full manuscript in the Journal of the American College of Cardiology (JACC).
"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," said John A. Dodson, MD, MPH, principal investigator and lead author of the study. Dr. Dodson is the director of NYU Langone's Geriatric Cardiology Program and an associate professor in the Department of Medicine's Leon H. Charney Division of Cardiology at NYU Langone Health.
BETTER-BP included 400 adults from three community health clinics in New York City. These clinics primarily serve patients with Medicaid and those without health insurance—groups that often struggle with uncontrolled blood pressure and have difficulty following prescribed treatments. High blood pressure is a major risk factor for heart attacks and strokes, and it can often be controlled through consistent medication use.
The participants were randomly split into two groups. About two-thirds were entered into a program in which they could win cash rewards for taking their blood pressure medication, and the remaining third were in a control group that didn't get this incentive. Before the study began, everyone reported that they were not consistently taking their medication as prescribed.
To track how often participants took their pills, Dr. Dodson and the research team used electronic pill bottles that recorded each time the bottles were opened, rather than relying on participants to self-report. At the start of the study, the average systolic blood pressure (the top number in a blood pressure reading) was 139 mm Hg. For reference, the American Heart Association's 2025 guideline says a normal systolic blood pressure is below 120 mm Hg.
Participants in the rewards group were entered in a daily drawing for cash prizes from $5 to $50, but only if they opened their pill bottle the day before, showing that they took their blood pressure medication. Each day, they received a text message about whether they won money. If they missed a dose, the study app sent a reminder that they could have been eligible for a reward if they had taken their medication. Those in the control group didn't receive text messages or have a chance to win money.
The study lasted 12 months—6 months with rewards, followed by 6 months without, to see if participants' healthy habits continued when the incentives stopped.
Among the study's key findings:
- Financial incentives appear to have doubled consistent medication use. About 71 percent of participants in the rewards group opened their blood pressure medication regularly (at least 80 percent of the time during the six-month study period), compared with 34 percent in the control group.
- Both groups saw similar drops in blood pressure. After six months, average systolic blood pressure fell by 6.7 mm Hg in the rewards group and 5.8 mm Hg in the control group.
- The improvements didn't last once the rewards stopped. After the incentives ended, participants' medication habits returned to what they were before the study.
"Financial incentives clearly worked during the study—people in the rewards group took their medication much more consistently," said Dr. Dodson.
But we were surprised that this didn't lead to significantly better blood pressure control. It's unclear whether participants opened the bottles without taking the medication, or if other untracked factors, like different medications or lifestyle behavior, affected their blood pressure. We were also surprised that adherence dropped once the rewards ended. This shows how complex behavior changes really are. There's still a lot we need to understand about what helps people stick with healthy habits long term."
John A. Dodson, Director, Geriatric Cardiology Program, NYU Langone
The study had several limitations. The electronic pill bottles tracked when participants opened their bottles, but not whether they actually took their medication. Also, researchers monitored only one blood pressure medication per person, even though many participants were prescribed multiple drugs to manage their blood pressure. In addition, blood pressure was measured in clinic at just three points—at the start of the study, at 6 months, and at 12 months (6 months after the rewards ended)—rather than through more-frequent home monitoring, which might have produced different results.
Study details, background, and design:
- The study included 400 adults diagnosed with high blood pressure who were prescribed at least one blood pressure medication and who had a systolic reading above 140 mm Hg within the past year.
- Of these, 265 participants were in the rewards group and 135 were in the control group.
- Participants had a median age of 57, and 60.5 percent were women. By self-reported race and ethnicity, 61.5 percent identified as Hispanic, 20.3 percent as Black, 3.3 percent as non-Hispanic White, 2.8 percent as Asian, and 12.3 percent as another race or ethnicity.
- In addition to high blood pressure, 54.5 percent of participants had obesity (BMI≥30) and 46.5 percent had type 2 diabetes.
- More than 70 percent of participants were covered by Medicaid (due to having low income or a disability) or had no health insurance.
BETTER-BP was supported by the National Heart, Lung, and Blood Institute and the National Institutes of Health (R01HL148275).
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