Patient financial incentives to improve asthma management: a systematic review

Abstract

Objectives: The objectives of this systematic review are to identify studies that assess the effectiveness of patient-directed financial incentive interventions to improve asthma management behaviours, determine overall effectiveness of financial incentives, identify design characteristics of effective interventions and assess the impact on longer-term outcomes in the context of asthma.

Design: Systematic review with narrative synthesis.

Data sources: Electronic databases (MEDLINE, Embase, Global Health, PsycINFO, CINAHL, PubMed and Web of Science) and grey literature sources (NHS Digital, CORE, ProQuest, Clinical Trials Register and EU Clinical Trials Register) were searched in November 2021 and updated March 2023.

Eligiblity criteria: Eligible articles assessed financial incentives to improve asthma management behaviours (attendance at appointments, medication adherence, tobacco smoke/allergen exposure, inhaler technique and asthma education) for patients with asthma or parents/guardians of children with asthma. Eligible study design included randomised controlled, controlled or quasi-randomised trials and retrospective/prospective cohort, case-controlled or pilot/feasibility studies.

Synthesis: A narrative synthesis was conducted; eligible studies were grouped by asthma management behaviours and financial incentive framework domains.

Results: We identified 4268 articles; 8 met the inclusion criteria. The studies were from the USA (n=7) and the UK (n=1). Asthma management behaviours included attendance at appointments (n=4), reduction in smoke exposure (n=1) and medication adherence (n=3). Five studies demonstrated positive behaviour change, four of which were significant (attendance at appointments (n=3) showed significant differences between intervention and control: 73% and 49% in one study, 46.3% and 28.9% in another, and 35.7% and 18.9%, respectively; medication adherence (n=1) showed significant change from 80% during intervention to 33% post intervention). These four significant studies used 'positive gain', 'certain', 'fixed' financial incentives of smaller magnitude, given for 'all' instances of behaviour.

Conclusion: There is some evidence that patient-directed financial incentives improve asthma management behaviours. However, in view of the wide heterogeneity in study design and measured outcomes, determining overall effectiveness was challenging.

Prospero registration number: CRD42021266679.

Keywords: Adult thoracic medicine; Asthma; Paediatric thoracic medicine.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart.

Figure 2

RoB2 and ROBINS-I results for all eligible, included studies. RoB2, Cochrane Risk of Bias Tool for Randomised Trials; ROBINS-I, Cochrane Risk of Bias in Non-randomised Studies of Interventions.