Statins are proven to reduce the risk of heart attack and stroke, yet as many as half of patients with prescriptions eventually stop taking the pills.
A possible solution, says a team of University of Pennsylvania researchers:
Pay the patients.
And for those whose good pill-taking habits lead to lower levels of LDL ("bad") cholesterol, give their physicians a bonus as well.
While the field of medicine has moved increasingly toward paying doctors for performance, there has been little controlled research on whether it works. Studies of patients, meanwhile, have found that incentives can encourage healthy behaviors such as giving up cigarettes.
But in a study of 1,503 patients announced Sunday, the Penn team reported that the most effective approach, at least where statins are concerned, may be to reward both patient and physician.
"In some respects, it takes two to tango," said lead author David A. Asch, a professor at Penn's Perelman School of Medicine.
The study, whose authors also included Penn's Kevin Volpp and scientists from Harvard and the Geisinger Health System in Danville, Pa., was published online in the Journal of the American Medical Association.
Still to come is an analysis of whether the amounts paid in the study - up to $1,024 over the course of a year - would be worth it, in terms of avoiding the costs of treating a certain number of heart attacks and strokes.
Treatment for a heart attack commonly runs into the tens of thousands of dollars, not to mention the cost of the lost productivity and reduced quality of life.
Asch said the team picked the $1,024 figure based on rough estimates, but said that it was in the realm of what would be reasonable.
"You can imagine that this might actually be worth it," he said.
The researchers compared four different approaches for distributing that sum.
In one group, patients at risk of heart disease earned an average of $2.80 every day they took a statin, as measured by electronic pill bottles that transmitted a wireless signal when the lids were opened.
In a second group, only the doctors were eligible for bonus money, paid out in two installments. The physicians could earn up to $1,024 for each patient who lowered their cholesterol by a specified amount each quarter.
In a third group, both patients and doctors could get paid, but they split the money - getting up to half of the $1,024 each. And in a fourth control group, neither patient nor doctor got a bonus.
Patients in all four groups lowered their LDL cholesterol numbers somewhat. But in the groups where only the patient or doctor earned bonuses, the amounts of improvement were statistically no different from that in the no-money group.
The biggest drop in LDL cholesterol came in the group with both patient and doctor earning bonuses: 33.6 points on average over the course of a year, compared with a drop of 25.1 points in the no-money group.
Physicians not involved with the research said it was intriguing, but urged further study.
"I think this is an important first step, but it would be nice to replicate it in real life," said Ohio State University cardiologist Martha Gulati.
The fact that cholesterol levels dropped in all four patient groups was especially encouraging, said Melissa Y. Wei, a University of Michigan Medical School researcher who has studied why many patients stop taking statins.
That suggests factors besides money were helping to encourage patient compliance, she said.
Asch, the study's lead author, agreed. For example, all patients got the electronic pill bottles, so they may have been better at taking pills because they felt they were being watched, he said.
But even in the study, fewer than half of patients were taking their pills on a regular basis by the end.
Why are patients so uncommitted?
Some may experience improvement and decide, incorrectly, that it is safe to stop taking the daily pills, said Ohio State's Gulati, editor of the American College of Cardiology's CardioSmart magazine.
Another reason, she said, is that a minority of patients suffer side effects from the drugs, such as muscle pain. But in the Penn study, the authors excluded any patients who had previously experienced side effects.
Even if money helps, the notion of paying people to do the right thing may rub some the wrong way.
"We shouldn't have to," said Bobbi Cecco, president of the Hackensack, N.J., chapter of the Mended Hearts patient support group. "But if that's what it comes down to . . ."
Wei, the Michigan physician, said she already is motivated to help her patients stick with their medicine.
"Financial incentives wouldn't change my values or patient care," she said. "I am also an idealist."
Participants in the Penn study ranged in age from 18 to 80, and all were at risk of heart disease. At the start of the study, they had an average LDL number of about 160, which is considered high.
But while the study was underway, the leading medical societies moved away from asking patients to hit specific LDL targets. Now they are urged to take statins when indicated by an online calculator that takes a variety of risk factors into account.
The Penn study did not explore specific elements of the patient-doctor interaction that could lead to better habits.
Also unclear: if money works, how long would payments need to continue? And who would pay? Insurance?
Researchers followed the patients for an additional three months after the payouts stopped, and did not see any backsliding, Asch said. Beyond that, who knows?
"People wonder whether you're going to create good habits," he said. "Obviously it takes a physician to prescribe it, and a patient to take it."