I usually try to keep the posts current, but I missed a WONDERFUL article a few weeks ago in the NEJM, one that is pivotal in its own right, but especially in the context of good decision making about therapeutic choices and opportunity costs.
The article, by Volpp et all entitled: A Randomized, Controlled Trial of Financial Incentives for Smoking Cessation can be found here: http://content.nejm.org/cgi/content/abstract/360/7/699
In summary, smokers at a large US company, where a smoking cessation program existed before the research began were randomized to receive additional information about the program, versus the same information plus a financial incentive of up to $750 for successfully stopping smoking. At 9-12 months, smoking cessation was 10% higher in the financial incentive group (14.7% vs. 5.0%, P<0.001).
In the 2006 JAMA article on varenicline (Chantix) by Gonzales et al (http://jama.ama-assn.org/cgi/reprint/296/1/47.pdf ), the cessation rates at weeks 9-52 were 8.4% for placebo and 21.9% for varenicline, an absolute gain of 13.5%. (Similar results were reported in the study by Jorenby et al: http://jama.ama-assn.org/cgi/content/abstract/296/1/56?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=varenicline&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT ) Now, given that this branded pharmaceutical sells for ~$120 for a 30 day supply, and that, based on the article by Tonstad (http://jama.ama-assn.org/cgi/reprint/296/1/64.pdf ), many patients are continued on varenicline for 24 weeks or more, the cost of a course of treatment with the drug is approximately $720, just about the same as the financial incentives used in the index article.
And all of this begs the question: Is it better to pay $750 for 6 months of treatment with a drug that has [potentially serious] side effects to achieve ~13% reduction in smoking, or to pay patients to quit smoking to achieve a 10% reduction in smoking without harmful side effects and in fact with POSITIVE side effects (money to spend on pleasurable alternatives to smoking or other necessities)?
The choice is clear to me, and, having failed Chantix, I now consider whether I should offer my brother payment to quit smoking. (I expect to receive a call as soon as he reads this, especially since I haven't mentioned the cotinine tests yet.)
And all of this begs the more important question of why we seek drugs to solve behavioral problems, when good old fashioned greenbacks will do the trick just fine. Why bother with Meridia and Rimonabant and all the other weight loss drugs when we might be able to pay people to lose weight? (See: http://jama.ama-assn.org/cgi/content/abstract/300/22/2631 .) Perhaps one part of Obama's stimulus bill can allocate funds to additional such an experiments, or better yet, to such a social program.
One answer to this question is that the financial incentive to study financial incentives is not as great as the financial incentive to find another profitable pill to treat social ills. (There is after all a "pipeline deficiency" in a number of Big Pharma companies that has led to several mergers and proposed mergers, such as the announcement today of a possible merger of MRK and SGP, two of my personal favorites.) Yet this study sets the stage for more such research. If we are going to pay one way or another, I for one would rather that we be paying people to volitionally change their behavior, rather than paying via third party to reinforce the notion that there is "a pill for everything". As Ben Franklin said, "S/He is the best physician who knows the worthlessness of the most medicines."
I am grateful to Dr. Volpp for pointing me to the work that he recently completed relating to financial incentives for weight loss, of which I was previously unaware. I have edited the post to reflect these data.
ReplyDeleteVery interesting, but I think you leave out one factor in your cost analysis: rewarding good behavior. Approximately 80% of people in this country are nonsmokers, I assume that employers/government would have to pay all of those that "give it up, by not taking it up" an equivalent amount or else face a multitude of individuals that "quit" smoking after 1 cigarette to collect $750.
ReplyDeleteIt is said that the founder of McIntosh Laboratories (the audio equipment manufacturer from which I hope to someday own some gear), paid $100 on the spot to anybody who would quit smoking immediately. If they got caught smoking again, they had to pay him $200. This was in the late 60s. Supposedly nobody was known to have started again. Not a bad Carrot/Stick combo in my eyes.
ReplyDeleteSo now, incorporating Dr. Exline's point, we can have a financial incentive for quitting smoking, a disincentive for bad behavior, and a smaller reward for good behavior. The question is, could you pay for it all with your disincentive profits alone, or would you need to rely on savings to the system from not having smoking associated health problems?
I would also suspect that the form of the inducement/reward matters - meaning $100 does not equal $100. for example, many helaht care plans offer incentives in the way of reduced premiums if you start exercising or stop smoking or check your cholesterol or whatever. I suspect these efforts would be more successful if you simply gave the person a $100 bill if they did it. Similar results have been shown in incentives for response to surveys, for example. People respond to cold hard cash more than checks or gift certificates. May be an opportunity for a comparative effectiveness study....
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