Dyad Linked Incentives is a research study and remote care program powered by

This fully virtual study to investigate how a dyad linked incentive strategy compares to individual incentives for patients taking a single medication. Dyad-linked incentives work by jointly rewarding two linked individuals for both adhering to their medication regimen, adding both social support and peer accountability to traditional incentive structures.
Principle Investigators: Jonathan Cloughesy
Institution: Duke Center for Advanced Hindsight
Trial Design: Decentralized / Virtual


Prescription medications are a part of life for nearly 70% of Americans. When taken properly, medication can help manage chronic conditions and reduce patient mortality. However, an estimated 50% of medications for chronic diseases are not taken as prescribed, resulting in up to 50% of failed treatments, 125,000 deaths per year, and between $100 to $300 billion in additional healthcare expenditures.

Dyad-linked incentives, a cost-efficient behavioral economics intervention, has the potential to improve medication adherence, reduce mortality and mitigate unnecessary healthcare costs from noncompliance. Dyad-linked incentives work by jointly rewarding two linked individuals for both adhering to their medication regimen, adding both social support and peer accountability to traditional incentive structures. In doing so, dyad-linked incentives aim to develop a shared value of health among a community of teams nationwide.

Team incentive structures have demonstrated effectiveness in the context of financial savings and worker productivity; however, research applying team incentives to health behavior is limited. Importantly, no research has been conducted evaluating dyad-linked incentives in the context of medication adherence for chronic disease management. Investigating the effects of dyad-linked incentives in this context has large policy implications, as improving medication compliance is among the most effective approaches to prevent worsening health outcomes of individuals with chronic disease, reduce mortality, and relieve the logistical and financial strain on the healthcare system.

Incentives have the potential to save the healthcare system billions of dollars each year by reducing medication non-compliance. Still, the efficacy and cost-effectiveness of existing incentive programs can be greatly improved. Dyad-linked incentives offer a promising approach to achieve this end. However, absent a large, randomized controlled trial, the ability of dyad-linked incentives to improve medication adherence cannot be conclusively determined.

Research Approach and Activities

Our research addresses the following three questions:

  1. Do dyad-linked incentives offer a cost-effective approach to improve medication adherence among patients with a chronic disease?
  2. Which mechanisms are responsible for the hypothesized effects of dyad-linked incentives on medication adherence?
  3. Do dyad-linked incentives promote habit formation and continued adherence after incentives are removed?

This research will be conducted using a randomized controlled trial with four groups: dyad-linked incentives, individual incentives with a teammate, individual incentives without a teammate, and a baseline control. We hypothesize that dyad-linked incentives will lead to large and sustained increases in adherence to a daily medication regimen compared with both individual incentives groups and the control group. Further, we hypothesize that the intervention will be driven by guilt aversion, teammate closeness and social support, although additional mechanisms will be measured and evaluated.

Participants assigned to receive a dyad-linked incentive or an individual incentive with a teammate will be placed on a team with another participant, while participants assigned to an individual incentive without a teammate will not be paired with a teammate. Teammates will receive feedback about their partner’s behavior and can provide social support via an anonymous messaging platform. Participants in both individual incentive conditions will receive an incentive for each day they adhere to their medication regimen, whereas participants in the dyad-linked incentive condition will receive an incentive for each day they and their teammate both adhere to their medication regimens. Participants in the baseline control condition will not receive any intervention.

Eligible participants will be recruited from state health insurance plans managed by Centene Corporation. To recruit participants for the study, Centene will email and text participants that have been prescribed one or more medications to manage one or more of the following chronic diseases: congestive heart failure, type II diabetes, hypertension, chronic obstructive pulmonary disease, depression, and asthma. Participants interested in enrolling will be directed to a study website where they can be consented and enroll in the study. We will aim to recruit approximately 360 participants per condition, based on a repeated-measures multilevel model analysis over a 3-month period. Power analyses indicate that 1,040 total participants will allow us to detect a difference of 5% between conditions, or an increase of approximately 5 days of medication adherence over the 90-day intervention period, assuming a 20% attrition rate.

Our research partnership with Centene Corporation, the largest Medicaid managed care organization in the U.S., and the Centene Center for Health Transformation, which has been active since 2015, will provide access to members’ medication adherence data based on pick-up and refill records from member pharmacies. Self-report data collected via SMS will provide an additional measure of medication adherence. Disease-specific outcome measures will also be provided by Centene. Survey data will measure mechanisms of action and other psychological variables of interest.

Research Team

The proposed research study is a collaboration between the Center for Advanced Hindsight at Duke University, the Centene Corporation, and the Centene Center for Health Transformation at Washington University in St. Louis. Centene Corporation is the largest Medicaid managed care organization in the U.S. with more than 30 years of experience operating government-sponsored healthcare programs. All research, including experimental design, intervention implementation, self-report data collection, data analysis, and result dissemination will be conducted by the Center for Advanced Hindsight. The Centene Center for Health Transformation and Centene Corporation will be responsible for participant recruitment, claims data collection, and incentive distribution.

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