Behavioral Economics and Medication Adherence for Hypertension: A Randomized Clinical Trial

Clinical Snapshot

Key Findings

• P Value: Adherence: P<0.001; BP: P=0.62

• Effect Size: Adherence: Risk ratio 2.04 (doubled adherence rate); BP: Mean difference -0.9 mmHg (not significant)

• Primary Outcome: No significant difference in systolic BP reduction at 6 months (-6.7 mmHg intervention vs -5.8 mmHg control, P=0.62)

• Nnt Or Sensitivity: NNT approximately 3 for achieving adequate adherence (71% vs 34% = 37% absolute risk reduction)

• Confidence Interval: Adherence RR: 95% CI 1.58-2.63; BP difference CI not provided

Clinical Application

Requires SMS infrastructure and lottery system setup; relatively low-cost intervention scalable in primary care settings Applicable to Aboriginal and Torres Strait Islander populations and socioeconomically disadvantaged groups; could integrate with existing chronic disease management programs and potentially PBS adherence initiatives Adults with poorly controlled hypertension and poor medication adherence, particularly in socioeconomically disadvantaged populations

Abstract

BACKGROUND: Nonadherence to antihypertensive medications is common. Mobile health (mHealth)-based behavioral economic interventions may improve adherence, but remain largely untested, especially in vulnerable populations. OBJECTIVE: The study sought to test whether an mHealth incentive lottery would lower systolic blood pressure (SBP) and improve adherence. METHODS: BETTER-BP (Behavioral Economics Trial To Enhance Regulation of Blood Pressure) was a randomized trial conducted in 3 safety-net clinics in New York City. Eligible participants were adults with hypertension prescribed at least 1 antihypertensive medication, with SBP >140 mm Hg, and poor self-reported adherence. In the intervention arm, an incentive lottery was administered via SMS messaging. All participants received passive adherence monitoring. The intervention lasted 6 months, with continued monitoring until 12 months. The primary clinical endpoint was change in SBP at 6 months. The primary process endpoint was adequate antihypertensive medication adherence (≥80% days adherent) from baseline to 6 months. RESULTS: Four-hundred participants (265 intervention:135 control) were enrolled with median age 57 years, 60.5% women, 61.5% Hispanic, and 20.3% non-Hispanic Black. Over 70% had Medicaid or no insurance. At 6 months, intervention arm participants were twice as likely to achieve adequate adherence (71% vs 34%; adjusted risk ratio: 2.04; 95% CI: 1.58-2.63), but there was no significant change in mean SBP (-6.7 mm Hg intervention vs -5.8 mm Hg control; P = 0.62). From 6 to 12 months, adherence was similar (31% intervention vs 26% control; adjusted risk ratio: 1.17; 95% CI: 0.83-1.65). CONCLUSIONS: In a diverse safety-net population, the BETTER-BP intervention doubled the rate of adequate antihypertensive medication adherence but did not reduce SBP at 6 months.

References

1. 1.Dodson, J. A., Adhikari, S., Schoenthaler, A. M., Shimbo, D., Berman, A. N., Levy, N., Hanley, K., Richardson, S., Varghese, A., Meng, Y., Pena, S., de Brito, S., Gutierrez, Y., Rojas, M., Rosado, V., Olkhinha, E., & Troxel, A. B. (2026). Behavioral economics and medication adherence for hypertension: A randomized clinical trial. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2025.10.062