A Trial of Behavioral Economic Interventions to Reduce Cardiovascular Disease (CVD) Risk

Cardiovascular disease (CVD) is the leading cause of death in the United States. Despite
strong evidence that reducing low-density lipoproteins (LDL) with statins successfully lowers
CVD risk, physicians under-prescribe statins, physicians fail to intensify treatment when
indicated, and more than 50% of patients stop taking statins within one year of first
prescription, though such therapy typically should be life-long. In this study, we will test
the effectiveness of different behavioral economic interventions in increasing statin use and
reducing LDL cholesterol among patients with poor cholesterol control who are at very high
risk for CVD. The application of conceptual approaches from behavioral economics offers
considerable promise in advancing health and health care. Pay for performance initiatives
represent one such potential application, but one in which incorporating the underlying
psychology of decision makers has not generally been done, and experimental tests have not
been conducted. We will test these approaches among primary care physicians and their
patients at very high risk of CVD at Geisinger Health System and University of Pennsylvania
outpatient clinics. Using a 4-arm, cluster-randomized controlled trial, we aim to answer
these questions: [1] How does the provision of provider incentives compare to the provision
of patient incentives, to a combination of patient and provider incentives, or to no
incentives at all? [2] Are results sustained after incentives and other interventions are
withdrawn? [3] How do these approaches compare in implementation, acceptability, cost, and
cost-effectiveness?

Inclusion Criteria:

- Physicians: All primary care providers who have at least 5 patients who meet
eligibility criteria will be eligible.

- Patients: 10-year CVD risk of between 10-20% who do not have an LDL below 140 mg/dl or
10-year CVD risk of at least 20% (including those with preexisting CHD) who do not
have an LDL below 120 mg/dl will be the primary inclusion criteria. We have chosen to
include all patients meeting these inclusion criteria regardless of their reported
adherence to statins, as there clearly is room for improvement in the LDL through a
combination of physician and patient actions.

Exclusion Criteria:

- Patients will be excluded if they have a known allergy or history of side effects to
statins, will not or cannot give consent, or have a markedly shortened life expectancy
(diagnosis of metastatic cancer, end-stage renal disease on dialysis, or dementia).