A Multicomponent Motivational Intervention to Improve
Adherence Among Adolescents With Poorly Controlled Type 1
Diabetes: A Pilot Study
Catherine Stanger,1PHD, Stacy R. Ryan,2PHD, Leanna M. Delhey,1BA, Kathryn Thrailkill,3MD,
Zhongze Li,4MS, Zhigang Li,4PHD, and Alan J. Budney,1PHD
1Department of Psychiatry, Geisel School of Medicine at Dartmouth,2University of Texas Health Science
Center at San Antonio,3University of Arkansas for Medical Sciences, and4Norris Cotton Cancer Center,
Dartmouth Hitchcock Medical Center
Correspondence concerning this article should be address to Catherine Stanger, PhD, Department of
Psychiatry, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH 03756, USA.
Received November 4, 2012; revisions received April 7, 2013; accepted April 9, 2013
contingency management (CM) for adolescents with poorly controlled type 1 diabetes.
of 17 adolescents, age 12–17 years (M¼14.8, SD¼1.5), with type 1 diabetes (duration M¼6.2 years,
SD¼4.5) and mean HbA1c of 11.6% (SD¼2.5%) were enrolled. Adolescents and their parents received 14
weeks of motivational interviewing, clinic-based CM, and parent-directed CM that targeted increased blood
glucose monitoring (BGM). ResultsAdolescents significantly increased their BGM (p<.001) and showed
significantly improved HbA1c levels (glycemic control) from pre-to posttreatment
(p<.0001).Conclusions The magnitude of improvements in the frequency of BGM and glycemic control
in adolescents with type 1 diabetes is encouraging and will be tested in a randomized controlled trial.
To adapt and pilot test a multicomponent motivational intervention that includes family-based
Key wordscognitive behavior therapy; contingency management; motivational interviewing; type 1 diabetes.
Diabetes is a leading cause of death in the United States
and is associated with significant mortality and economic
cost (Centers for Disease Control and Prevention, 2008).
Although improved in recent decades, persons with diabe-
tes have mortality rates 5.6 times higher than those in the
general population (Secrest, Becker, Kelsey, LaPorte, &
Orchard, 2010). The incidence of type 1 diabetes among
teens increased significantly over the past 25 years (Vehik
et al., 2007), so that ?1 in 500 adolescents ages 12–19
have type 1 diabetes (Centers for Disease Control and
Prevention, 2008; The Writing Group for the SEARCH
for Diabetes in Youth Study Group, 2007). Unfortunately,
teens, even with intensive insulin regimens, have much
poorer glycemic control than adults (Diabetes Control
and Complications Trial Research Group, 1994).
Glycemic control (measured via HbA1c levels) is a
powerful determinant of diabetes outcomes (Diabetes
Control and Complications Trial Research Group, 1994).
In the short term, higher HbA1c is directly related to
hospitalization and increased costs (Menzin et al., 2010).
Blood glucose monitoring (BGM) frequency is a robust
predictor of glycemic control (Guilfoyle, Crimmins, &
Hood, 2011; Helgeson, Honcharuk, Becker, Escobar, &
Siminerio, 2011). BGM adherence is a promising target
for teens, whose rates are generally low (Anderson et al.,
2009), because daily monitoring can be objectively mea-
sured and reinforced. Parental monitoring can also posi-
tively affect teen adherence to BGM and other aspects of
the medical regimen (Anderson, Ho, Brackett, Finkelstein,
& Laffel, 1997; Ellis et al., 2007a; Horton, Berg, Butner, &
Studies with teens provide some support for the
efficacy of individual and family-based treatments that in-
clude the goal of increasing BGM for teens (Channon et al.,
Journal of Pediatric Psychology 38(6) pp. 629–637, 2013
Advance Access publication May 22, 2013
Journal of Pediatric Psychology vol. 38 no. 6 ? The Author 2013. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
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by guest on November 4, 2015
2007; Ellis et al., 2007b; Franklin, Waller, Pagliari, &
Greene, 2006; Nansel et al., 2007; Salamon, Hains,
Fleischman, Davies, & Kichler, 2009; Wysocki et al.,
2008). However, across these studies, BGM frequency re-
mained low (<3? daily; ?6? daily is recommended for
teens with poor glycemic control) (Diabetes Care, 2010),
with treatment gains often lasting <6 months (Alam, Sturt,
Lall, & Winkley, 2009). In addition, only small to moder-
ate effect sizes on HbA1c (ES¼0.13–0.35) (Alam et al.,
2009) were observed, with mean HbA1c remaining
>8.5%, well above the recommended target of <7.5%
(Silverstein et al., 2005). Thus, more effective interventions
are needed to improve BGM adherence and glycemic con-
trol among teens with type 1 diabetes who consistently are
not at the American Diabetes Association (ADA) blood glu-
To address this problem, motivational interviewing
(MI) and cognitive behavior therapy (CBT) were combined
with a family-based contingency management (CM) inter-
vention. The MI intervention has been tested with teens
with type 1 diabetes in a prior trial (Channon et al., 2007).
The MI, CBT, and CM interventions were originally devel-
oped to treat adolescent substance abuse (Stanger, Budney,
Kamon, & Thostensen, 2009) and were adapted for ado-
lescents with poorly controlled type 1 diabetes to target
teen coping skills, BGM frequency, and parental monitor-
ing. Others have also reported success adapting substance
use interventions for teens with type 1 diabetes (Channon
et al., 2007; Ellis et al., 2005; Raiff & Dallery, 2010).
Similar behavior analytic principles can be applied to
address the challenging behaviors and enhance motivation
to change in teens who are not effectively managing their
type 1 diabetes and those who abuse substances. Our par-
allel intervention for teen substance abuse has been dem-
onstrated to motivate change in teen behavior (promote
compliance with substance abstinence goal) in the context
of low motivation and poor parental monitoring (Stanger
et al., 2009). The current pilot study was conducted to
determine the feasibility and outcomes of this MI/
CBTþCM intervention for improving the management of
poorly controlled type 1 diabetes in adolescents.
Motivational Interviewing/Cognitive Behavior
Motivational interviewing (MI) has targeted a broad range
of health behaviors, including adherence in teens with di-
abetes (Channon et al., 2007; Rollnick, Mason, & Butler,
1999). In a randomized trial, the MI intervention selected
for the current study resulted in small, but significant,
improvements among adolescents with type 1 diabetes in
HbA1c and quality-of-life measures up to 12 months later
(Channon et al., 2007). In the current study, the Channon
MI intervention was supplemented with CBT skills adapted
from an evidence-based curriculum developed for teens
with substance use problems (Webb, Scudder, Kaminer,
& Kadden, 2001). This CBT curriculum includes several
general coping skills designed to improve decision making.
The combination of MI and CBT has been shown to be
more effective than CBT alone for adults with diabetes,
supporting the potential utility of combined MI/CBT inter-
ventions for teens with diabetes (Ismail et al., 2008).
Further, in the substance abuse literature, MI and CBT
have been frequently combined with CM, and this combi-
nation of study treatments has repeatedly been found to
improve long-term outcomes relative to single-modality in-
terventions (Budney, Moore, Rocha, & Higgins, 2006;
Higgins, Silverman, & Heil, 2008).
Incentives/Contingency Management (CM)
CM involves the systematic reinforcement of desired behav-
iors (e.g., BGM). Ten of 11 randomized trials showed that
incentives led to greater medical adherence than tested
alternatives for blood pressure control, appointment atten-
dance, and immunization rates (Giuffrida & Torgenson,
1997). Tangible incentives have also been effective in im-
proving healthy habits such as losing weight (Volpp et al.,
2008a), lowering cholesterol (Bloch et al., 2006), adhering
to daily medication (Volpp et al., 2008b), and promoting
tobacco, alcohol, and drug abstinence (Higgins et al.,
2008). The proposed incentive intervention rearranges
the consequences of BGM by providing immediate rewards
for monitoring, and immediate negative consequences for
not monitoring. The use of incentives to increase BGM
among teens with type 1 diabetes has been reported in
one case series (Raiff & Dallery, 2010). In this study,
four teens increased daily monitoring from an average
1.7 times daily to 5.7 times daily over 5 days, when mon-
etary incentives were available for submitting videos over
the internet that documented BGM. A recent study offered
adults with type 2 diabetes increasing incentives for reduc-
ing HbA1c by 1 or 2 percentage points (or to 6.5%) at a 6-
month follow up assessment, and showed mean reductions
of 0.45 percentage points, which was not significant rela-
tive to usual care (Long, Jahnle, Richardson, Loewenstein,
& Volpp, 2012). These results suggest that more frequent
incentives may be necessary as well as targeting a specific
self-care behavior that might lead to improved glycemic
control (e.g., BGM).
Stanger et al.
by guest on November 4, 2015
Teaching parents to use incentives (contingency con-
tracting) is a common approach used in behavioral family
therapy to treat a wide range of child and adolescent be-
haviors (Eyberg, Nelson, & Boggs, 2008) and has been
used to improve adherence among adolescents with diabe-
tes (Carroll, DiMeglio, Stein, & Marrero, 2011; Schafer,
Glasgow, & McCaul, 1982). A randomized trial using sim-
ilar incentive procedures demonstrated the efficacy of this
approach in substance using teens (Stanger et al., 2009).
Inthe currentstudy, we
multicomponent intervention would lead to significant in-
creases in BGM, and secondary improvements in parent
and teen reports of diabetes self-care behaviors and in
Adolescents were recruited from the Arkansas Children’s
Hospital Endocrinology Clinic. A total of 17 adolescents,
(5 males) ages 12–17 years (M¼14.8; SD¼1.5), and their
parent(s) were enrolled. Twelve teens were non-Hispanic,
Caucasian, four were African American, and one was mul-
tiracial. Inclusion criteria were a diagnosis of type 1 diabe-
tes, duration of disease >18 months, and poor glycemic
control operationalized as HbA1c ?8% for the past 6
months (mean of two values) and most recent HbA1c
?8%. Exclusion criteria were pregnancy/breast feeding,
active psychosis, and/or severe medical or psychiatric ill-
ness that would limit participation (no participants were
(SD¼2.5%; range¼8.4%–16.8%; see Table I for HbA1c
values for each subject). Mean time since diagnosis was 6.2
years (SD¼4.5, range¼1.5–14.4). Families had a mean
Hollingshead (1975) 9-step socioeconomic status (SES)
basedon parental occupation
range¼3–9), which is equivalent to jobs such as bank
clerk/teller, cashier, clerical worker, dental/medical assis-
tant, and sales (retail), and 47% of teens had public insur-
ance. The primary participating parent had on average 13.4
years of education (SD¼2.1, range¼8–17 years), and
70.6% were two-parent families. Insulin administration
methods were multiple daily injections (n¼7), pump
(n¼9), and injections plus pump (n¼1).
Families were screened by their treating endocrinologist at
a quarterly appointment and referred to the research pro-
gram. Pretreatment HbA1c obtained clinically at this visit
was used in analyses. All teens meeting the study inclusion
criteria were offered the opportunity to participate. Parents
and teens provided consent/assent, and procedures were
approved by the IRB at the University of Arkansas for
Medical Sciences. HbA1c results were obtained with con-
sent from the medical record, and teens received a study
blood glucose meter (Bayer Contour), and test strips as
necessary throughout the intervention. On average,
intake appointments were
range¼1–29) after the pretreatment HbA1c date. End of
treatment HbA1c was obtained on average 102.7 days
(91day target), and 3-month follow-up (94day target)
HbA1c was obtained on average 120.6 days (SD¼56.0,
range¼59–258) after the end of treatment.
Adolescents and their parents received 14 weekly, 1-hr
sessions of MI/CBT, clinic-based CM, and parent-directed
CM as described below. Therapists were masters’ level cli-
nicians. Therapists met weekly with the first author for
supervision and case review. Therapists completed struc-
tured adherence checklists after each session, documenting
their completion of treatment components.
range¼69–162) after the firstsession
Table I. Blood Glucose Monitoring (BGM) and HbA1c Pre- and
BGM times per dayHbA1c %
of treatment Intake
aThese two participants did not complete treatment and did not provide meter
data at the end of treatment assessment.
bValue obtained via laboratory blood test.
cValues of ‘‘>14.0’’ using point of care testing were scored as 14.0 for analyses.
dThis participant moved away unexpectedly in week 9 of treatment and did not
have access to a computer. This participant’s week 9 data were used above as the
end of treatment value.
eThese two participants did not complete treatment but did provide meter data at
the end of treatment assessment.
Teen Diabetes Adherence
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Teens received weekly individual MI/CBT. MI included a
menu of intervention components (Channon, Huws-
Thomas, Gregory, & Rollnick, 2005). Therapists reviewed
BGM and other self-care behaviors using MI exercises de-
signed to build awareness of costs and benefits of change,
identify and weigh alternatives, choose alternative behav-
iors, and set goals while avoiding confrontation. CBT com-
ponents (adapted from Webb et al., 2001) included
functional analysis (identify antecedents/consequences of
missed/skipped BGM and other self-care behaviors),
increasing social support, effective communication, prob-
lem solving, mood management, and anger management.
Teens were rewarded for a BGM frequency of ?6 times/day
increasing gradually up to ?5 days per week. The goal of
having teens test ?6 times daily is based on standard rec-
ommendations (Diabetes Care, 2010), which specify that
monitoring should occur a minimum of 3 times a day (i.e.,
before meals), plus those on multiple injection therapy or
pumps or who do not meet glycemic targets (i.e., the target
population) are to add monitoring after meals (Diabetes
Care, 2010). Bedtime and/or nocturnal monitoring are rec-
ommended if a hypoglycemia risk exists.
In weeks 1 and 2, teens earned $10 weekly for bring-
ing their blood glucose meters to the session for download.
Incentives were paid in gift cards or certificates from local
merchants chosen by teens. Starting in week 3, teen incen-
tives were contingent on meeting a personalized weekly
monitoring goal. Incentives were earned for BGM ?6
times a day (tests spaced>1 hour apart) on one day
more than the prior week, up to a maximum of 5 days
per week. Unmet goals remained unchanged for the next
week. The first week a goal was met was worth $10. The
incentive value increased by $5 for each consecutive week a
goal was met. To further increase the likelihood of contin-
uous monitoring at targeted levels, a $10 bonus was earned
for each week in which the teen exceeded the monitoring
goal. If the monitoring goal was not met incentives were
reset to the initial level ($10), where they escalated again
under the same schedule. Missed counseling sessions did
not result in loss of incentives, provided the meter was
uploaded (this could be done over the internet) or brought
in to the clinic. Maximum teen earnings were $590. This
reinforcement schedule was identical to that used in our
teen substance abuse trials (Stanger et al., 2009).
Parent-directed CM involved establishing a daily BGM
contract to increase the adolescent’s BGM. The parent was
directed to review their adolescent’s BG meter daily.
Parents met weekly with a therapist to learn to develop
and implement a blood glucose monitoring contingency
contract (BGMC). The BGMC, which focused on daily
BGM frequency, specified positive and negative conse-
quences the parent(s) would implement in response to
teen monitoring. Families selected diverse incentives and
consequences they felt were appropriate, provided they
could be used daily. Incentives and consequences some-
times changed over the course of the intervention based on
family needs, teen preferences, and efficacy. Examples of
daily rewards used by families included later bedtimes,
healthy snack foods, and small amounts of money (e.g.,
$2 a day toward a cell phone purchase). Examples of con-
sequences used included household chores and restricted
access to TV, internet, and cell phone.
Parents participated in an incentive system similar to
that for teens because parental adherence can be similarly
difficult to achieve and maintain. Parental adherence to
monitoring and consistently rewarding positive teen behav-
ior is expected to sustain teen adherence after treatment
ends. Parents were asked to provide a daily report to the
clinic (voice mail, text message, or e-mail) that was
stamped to identify delivery time. In week 1, parents re-
ceived $10 for attendance if at least one parent and teen
were present and the teen brought his/her meter. In weeks
2 and 3, parents received $10 for sending a daily message
to the clinic on >5 days documenting daily BGM fre-
quency. Starting in treatment week 4 (coincides with
start of home enforcement of BGMC), parent incentives
were contingent on reporting BGM frequency >5/7 days
per week and detailing the daily incentive or consequence
provided to the teen, consistent with the BGMC, with a $5
weekly bonus for calling >5/7 days. After week 4, parent
incentives increased by $5 a week for each consecutive
week of parent compliance with BGM monitoring and con-
tract enforcement. If weekly parent monitoring and con-
tract implementation goals were not met, incentives were
reset to the initial level ($10), where they escalated again
under the same schedule. Maximum parent earnings were
$470. We have used similar incentive procedures with par-
ents in our teen substance use trials (Stanger et al., 2009)
and in a prevention trial showing that daily calling signif-
icantly improved treatment outcomes relative to parenting
intervention alone (Stanger, Ryan, Fu, & Budney, 2011).
The primary outcome variable, BGM frequency, was down-
loaded weekly from the study-provided glucometer during
the 14 weeks of treatment. The mean frequency of BGM
per day and the number of days per week with BGM ?6
times per day during the first and last week of treatment
Stanger et al.
by guest on November 4, 2015
were used in analyses. Teen adherence to diabetes
posttreatment with the Self-Care Inventory (SCI), a
15-item self- and parent-report measure that includes
items focusing on BGM, insulin and food regulation, exer-
cise, and emergency precautions (Lewin et al., 2009).
Scores on the 15 items are averaged and converted to a
0- to 100-point scale (Parent a¼.72; Teen a¼.80). In
addition, glycemic control was assessed using the glycated
hemoglobin test (HbA1c), which measures the non-enzy-
matic glycation status of hemoglobin over the previous 2–3
months, with about half of the value reflecting past month
blood glucose. HbA1c was obtained from medical records
pretreatment, at the end of treatment, and 3 months
wasassessed pre- and
Descriptive statistics regarding treatment completion are
reported as an index of teen and parent acceptance of
MI/CBTþCM. Linear repeated measures mixed models
with random intercepts and fixed treatment effects
(operationalized as the effect of time) were used to test
improvement in BGM, SCI scores, and HbA1c. The
Tukey method was used to adjust p-values for HbA1c
due to multiple comparisons. A repeated measures effect
size is reported for each comparison (drm ¼trm/
trmwas the t-statistic comparing least square means from
the mixed model and n was the pairwise n across time
points for each measure (Rosenthal, 1991). Pre–post
pairwise ns were as follows: BGM (n¼15), teen SCI
(n¼15), parent SCI (n¼16), HbA1c (n¼17). In addition,
pairwise ns for comparisons for HbA1c at 3 months were
Twelve of 17 teens completed the 14-week program; mean
attendance was 12.2 weeks (SD¼3.4), with >80% of
teens attending >75% of weeks. Families were allowed
up to 18 weeks to complete the 14 counseling sessions
to allow for therapist- or client-missed sessions owing to
illness, vacations, or other reasons. On average, families
completed the 14 sessions in 15.7 weeks (SD¼1.3,
range¼14–18). Parents made calls on average 6.3
(SD¼0.3) days per week over the 14 weeks of treatment.
Teens earned an average of $389 (SD¼$213) of $590
possible, and parents earned an average of $352
(SD¼$162) of $470 possible.
The mean number of BGM tests per week and mean
number of days per week with ?6 tests per day increased
significantly over the course of treatment (see Figure 1).
Teens increased their monitoring frequency from week 1 of
treatment [Least Square Mean (LSM) (95% Confidence
Interval (95% CI))¼3.92 (2.90–4.94)] to week 14 [LSM
(95% CI)¼6.20 (5.13–7.28), t(14)¼?3.87, p¼0.002,
drm¼?1.00]. Number of days per week with 6 or more
tests increased from LSM (95% CI)¼1.35 (0.30–2.40) to
LSM (95% CI)¼5.40
when the week 1 values were imputed for the two par-
ticipants with missing week 14 values. In addition,
parent and teen reports on the SCI showed significant im-
provements from pre- to posttreatment: SCI Parent LSM
(54.02–69.79), t(15)¼?4.83, p¼0.0002, drm¼?1.21;
SCI Teen LSM (95% CI) Pre¼56.51 (50.00–63.02);
Post¼61.90 (55.18–68.61), t(14)¼?2.26, p¼0.041,
HbA1c was significantly lower at the end of treatment
compared with pretreatment [Pre LSM (95% CI)¼11.62%
(10.75%–12.48%), Post¼9.11% (8.25%–9.98%); t(29)¼
5.15, adjusted p<0.0001, drm¼1.25]. Note that four
pretreatment HbA1c values were estimated conservatively
at 14% because the point-of-care testing method has a
maximum value of ‘‘>14%’’. Thus the true improvement
in HbA1c was likely underestimated. Although mean
HbA1c was higher at the 3-month follow-up than at the
end of treatment, this difference was not significant
[3-month LSM (95%CI)¼9.77%
t(29)¼?1.27, adjusted p¼0.42, drm¼?0.34]. The
mean 3-month HbA1c, however, remained significantly
Figure 1. Mean number of blood glucose monitoring (BGM) times
per day and mean number of days per week with ?6 times per day
across the 14 treatment weeks. Note: N¼15; one participant moved
away unexpectedly in week 9 of treatment and did not have access
to a computer. This participant’s 9 week data were used in calculating
the means displayed for weeks 10–14.
Teen Diabetes Adherence
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lower than the pretreatment mean [t(29)¼3.56, adjusted
This pilot study of MI/CBTþCM for teens with poor
control of their type 1 diabetes showed significant improve-
ments in frequency of daily BGM. These results support
the potential efficacy of this adapted intervention, consis-
tent with other adaptations of substance abuse treatments.
Potential common mechanisms for these behavioral inter-
ventions seeking to change adolescent health behavior
include increasing motivation, using skills training and
principles of reinforcement to increase compliance (e.g.,
drug abstinence or adherence to testing), and parental
monitoring. It is important to note that the upward
trend in BGM began prior to the onset of incentives in
week 3, and that we cannot determine whether this
BGM increase would have continued or been sustained
without the contingent incentives. However, teens were
informed at the intake, in the Consent form, and in
sessions 1 and 2 that the goal of the program was to in-
crease BGM frequency to ?6 times per day on ?6 days per
week. Teens were encouraged to increase their BGM fre-
quency immediately to increase their chances of earning
clinic and home incentives for meeting the monitoring goal
in week 3.
We also found significant improvements in parent and
teen reports of the teen’s self-care, and observed significant
improvements in HbA1c that were maintained 3 months
after the end of treatment. Pre- to posttreatment changes
in HbA1c were large, decreasing from 11.6% to 9.1%, with
the largest changes generally observed among teens with
HbA1c<9.5% at the start of treatment did show robust
gains in BGM, which may have long-term benefits if those
gains are maintained. Such improvement in glycemic con-
trol has high clinical significance because every 10% reduc-
tion in HbA1c has been shown to result in 25% to 35%
reductions in sustained retinopathy progression and
microalbuminuria, and clinical neuropathy (The Diabetes
Control and Complications Trial Research Group, 1996).
We hypothesize that increased BGM is the mechanism by
which self-care and HbA1c improve. Despite the large
observed decreases in HbA1c that persisted 3 months
posttreatment, most teens still had HbA1c>8% at the
end of the 14-week treatment program (15/17 teens).
This finding suggests that additional intervention compo-
nents and/or longer duration intervention may be necessary
to further increase and maintain high levels of BGM and
other self-care behaviors that could further reduce HbA1c to
the American Diabetes Association (ADA) target (7.5%).
The outcomes achieved with this multicomponent
treatment compare favorably with those reported in prior
behavioral trials targeting adherence among teens with type
1 diabetes that generally observed smaller changes in BGM
and HbA1c (Channon et al., 2007; Ellis et al., 2007b;
Franklin et al., 2006; Nansel et al., 2007; Salamon et al.,
2009; Wysocki et al., 2008). For example, a study using
the same MI used in this study (Channon et al., 2007)
observed reductions in HbA1c from 9.3% to 8.7% 24
months after intake, with no change in the comparison
condition. Another trial compared an intensive counseling
intervention (an average of 48 sessions delivered over 6
months) with remaining in usual medical care (Ellis
et al., 2007b). BGM improved significantly among treated
teens from 1.8 times per day pretreatment to 2.6 times per
day post intervention. HbA1c in the treatment group im-
proved significantly (11.4% to 10.7%), but showed no
change among teens in usual care. However, six months
after the end of the intervention, there was no significant
difference in HbA1c between treated and usual care teens.
Despite the limited change in HbA1c, the intervention con-
dition showed significant reductions in hospitalization for
ketoacidosis (Ellis et al., 2008). On average, teens in the
usual care condition were hospitalized 1.28 times over 24
months, compared with 0.67 times in the intervention
condition, suggesting that intervention costs can be at
least partially offset by short-term reductions in medical
costs among these high-risk teens. If the larger changes
in BGM and HbA1c observed in the present study are
replicated and can be maintained over time, this
multicomponent intervention would have high potential
impact on the health and health care costs of teens with
type 1 diabetes.
Cost effectiveness is an important issue that will
impact dissemination for the type of intervention tested
in this study. A strong economic argument for using finan-
cial incentives to motivate teens with poorly controlled di-
abetes to achieve better control could be made if potential
cost savings from good control offset the price of the in-
centives. Cost saving mechanisms can include reduced cur-
rent and future health care costs and increased parent and
future teen productivity. Sharing some of these savings up-
front with patients to help motivate better glycemic control
(i.e., providing incentives) could be a prudent method to
achieve cost-effective improvements in health. Of note, the
Affordable Care Act raises the percentage of employer pre-
miums that can be used for outcome-based wellness incen-
tives from 20% to 30% of total premiums and may lead to
ongoing use of incentive-based programs (Volpp, Asch,
Stanger et al.
by guest on November 4, 2015
Galvin, & Loewenstein, 2011). Public cost savings are also
possible by applying incentives for healthy behaviors in the
Medicaid system (American College of Physicians, 2010).
However, little research is available to guide effective use of
reimbursements as incentives (Marteau, Ashcroft, &
Oliver, 2009), and it will be important for future studies
to address that gap.
This study involved a single condition without a control
group. Thus, it is not possible to draw conclusions about
the efficacy of this intervention, or to test potential
moderators such as age, gender, ethnicity, family status,
or initial HbA1c or mechanisms or secondary outcomes
such as parenting, family conflict, or barriers to self-care.
In addition, HbA1c values should be obtained using the
same measure. However, because we relied on clinical test-
ing for this pilot study, that was not possible for all tests
(for 4/48 tests, a laboratory blood test was used). Also, the
intervention is intensive, requiring weekly clinic visits over
an extended period of time. Finally, HbA1c did not reach
the ADA target, and it will be important to demonstrate
maintenance of positive effects over time.
Results of this pilot study suggest that combining MI/CBT
and contingency management may lead to large improve-
ments in BGM as well as in HbA1c. The intervention
focused on the daily frequency of BGM as the primary
target to improve glycemic control. We hypothesize that
increased monitoring frequency is the mechanism by
which the intervention led to improvements in diabetes
self-care and glycemic control. Frequent monitoring likely
provides teens, parents, and the medical team with infor-
mation that can help teens improve their daily self-care of
diabetes. Improvements in family conflict and parenting
are additional potential mechanisms addressed in this in-
tervention. We are following up on these promising results
in a randomized trial that includes modifications designed
to further enhance efficacy by targeting working memory,
increasing the duration of treatment to 6 months, fading
the use of incentives over time, and providing the counsel-
ing in the family’s home over the internet.
This work was supported by grants from the National
Institutesof Health(grant numbersDA022981,
Conflicts of interest: None declared.
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