Key Points:
- Adherence to antihypertensive medications remains a persistent challenge in clinical practice.
- The BETTER-BP trial randomized participants with poorly controlled hypertension to one of two arms: (1) a financial incentive group eligible for daily cash rewards ($5–$50) contingent on opening an electronic pill bottle; or (2) a control group that used the same pill bottles but received no incentives or reminders.
- Participants in the incentive group were twice as likely to open their pill bottles consistently compared to controls, indicating higher potential adherence, but despite this behavioral change, there was no significant difference in blood pressure reduction between groups at six months.
- Following cessation of the incentives, adherence in the intervention group declined, eliminating prior gains.
- These findings suggest that financial incentives may transiently increase medication-taking behavior, but do not improve blood pressure control and lack durability once incentives are removed.
Poor adherence to anti-hypertensive medication is the most common reason for poor blood pressure control and a major contributor to cardiovascular morbidity and mortality worldwide. Whether providing the opportunity for cash incentives for adherence can meaningfully improve blood pressure management remains uncertain.
On November 8th, 2025, the preliminary results of “The Behavioral Economics Trial To Enhance Regulation of Blood Pressure (BETTER-BP)” were presented at the American Heart Association Scientific Sessions in New Orleans, LA. The purpose of this trial was to evaluate whether daily financial incentives – structured as a lottery-based reward – could improve adherence to antihypertensive medications among low-income adults, and whether such improvements in adherence would translate into better blood pressure control. The design paper was published in Int J Cardiol Cardiovasc Risk Prev in 2022.
This randomized, open-label, behavioral economics trial enrolled 400 adults with hypertension who received care at three community health centers in New York City and who self‑reported suboptimal adherence to at least one prescribed antihypertensive medication. All participants had a prior systolic blood pressure measurement >140 mm Hg within the past year. Individuals were randomized in a 2:1 ratio to either a financial incentive intervention or usual care. Participants in both groups received an electronic medication bottle that recorded when it was opened; those in the intervention group were additionally eligible to win a daily cash reward ranging from $5–$50 contingent on opening the bottle on the prior day, accompanied by daily text notifications. The control group received neither incentives nor text reminders. The intervention lasted 6 months, followed by an additional 6 months of observation without incentives. The primary outcome was medication adherence, defined as opening the electronic medication bottle on ≥80% monitored days. The principal clinical secondary endpoint was change in systolic blood pressure at 6 months.
The median age was ~57 years; most were in Medicaid or uninsured. During the 6‑month intervention period, 71% of participants in the incentive group achieved high adherence (i.e., opening the electronic bottle ≥80% of monitored days), compared with 34% in the control group. Despite this, reductions in systolic blood pressure were similar between groups at 6 months (mean decrease of approximately 6.7 mm Hg in the incentive group vs. 5.8 mm Hg in the control group). After withdrawal of incentives, adherence in the intervention group declined and were similar to the control group by 12 months, indicating no sustained behavioral effect beyond the active incentive period.
Limitations include measurement of pill bottle openings and not pill ingestion. In addition, only one blood pressure pill was monitored per participant. Finally, only clinic blood pressure measurements were used which may have been less sensitive to detect differences between the groups. Generalizability may also be limited.
John Dodson, M.D., associate professor of medicine and population health at the NYU Grossman School of Medicine in New York, NY, concluded: “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. 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.”
