1. How can incentives improve recruitment and retention in ways that are effective, efficient and ethical?
Peter Bower, North West Hub for Trials Methodology Research, University of Manchester
Beth Parkinson, Rachel Meacock, Eleonora Fichera, Matt Sutton, Manchester Centre for Health Economics
University of Liverpool (Nicola Harman), University of Bristol (Nicola Mills), University of Aberdeen (Shaun Treweek, Katie Gillies) and Ulster University (Gillian Shorter).
Supported by the MRC Network of Hubs for Trials Methodology Research (MR/L004933/1- N73)

2. Of 50 + topics, two of top three priorities were:
methods to boost recruitment
methods to maximise retention

3. Research priorities Training site staff Communication with patients
Incentives

4. Altruism

5. Money talks… Quality and outcomes framework (QOF) Pay for performance
Fundamental impact on care delivery

6. Current evidence Recruitment (Treweek 2012) Retention (Brueton 2013)
3 studies only (2 hypothetical) but results positive
Retention (Brueton 2013)
There were 14 trials, 13 on survey response, mostly positive with monetary incentives, less with non-monetary

7. 5 RCTs, >1000 patients
£100 for consent (although all paid)

8. Incentives Overall increase: Variable across trials Costly Reach
5.1% in signed consent
5.9% in randomisations
Variable across trials
Decrease of 2.5% to 13.7% increase
Costly
£1961 per additional patient
Reach
No effect on age or social deprivation

9. Methods Scoping review, to identify issues to be considered in design
Assumes incentives are ethical!
Trials and general incentives literature
2 workshops: Technical (design) and user (delivery)
‘Hard and fast truths about what works must be discarded in favour of contextual advice in the general format: in circumstances such as A, try B, or when implementing C, watch out for D’ (Pawson et al 2005)

10. Principal agent theory
Agent 1 (recruiter)
Agent 2 (Patient)
Principal
Agent 1 (recruiter)
Agent 2 (Patient)
Principal has 2 aims:
boost recruitment and retention
obtain a pool of informed and engaged participants
Need to align interests so that agents will choose the optimal effort level

11. Who should incentives be directed towards?
Towards patients, recruiters, or a combination?
Incentives impact on activity, but evidence on who to incentivise is mixed
Generally individual incentives generate more impact, but barriers may be system wide
To ensure value, focus on location of greatest barriers, or where largest gains achievable
Understand current incentives ‘in play’
E.g for patients, barriers are tangible but benefits less so

12. What should be incentivised?
Process (sending invitations) induce more effort than outcome incentives (e.g. recruitment, retention)
more motivated by outcomes they ‘control’
Need strong causal relationship between the process and the desired outcome
Look out for effort diversion with strong incentives around single measures

13. How should incentives be structured?
The literature is more specific on financial incentives
Guaranteed payments are simple to implement
Beneficial effects on incentivised activities, but expensive
More complex schemes can better direct incentives to INCREASED activity, but more time and effort to implement
‘Tournament’ (agents compete for incentives), threshold
fail to increase effort if outcomes not under control, or too complex.
Prize draw or lottery are simple to implement and keep costs certain
Penalties should generate larger impacts, but harder to implement
More complex schemes for larger trials or long-term arrangements

14. Should we use financial or non-financial incentives?
Money, gifts and donations, reputational incentives
Incentives have two kinds of effects:
the standard direct price effect (behaviour more attractive)
indirect psychological effect (e.g. changes attitude to behaviour)
Evidence on the type of incentive which is most effective is inconclusive

15. How big should an incentive be?
Theory states that larger incentives should increase impact, but with diminishing marginal gains with size
Size should reflect the cost of desired action, the marginal benefit of improved outcomes, provider altruism, opportunity cost of public funds
More time intensive/risky trials should require larger incentive payments.
Larger incentives may crowd out intrinsic motivation or lead to undue inducement

16. What is the optimal timing and frequency?
A series of smaller incentives paid at multiple points likely to be more effective than one single payment
Reduce time between action and reward
May be of relevance for retention

17. What are the potential unintended consequences?
Introducing incentives has the potential to induce unintended consequences:
crowding out of altruism
change in the types of patients recruited and retained
gaming, effort diversion, or compromised trial integrity
Must be designed to minimise these effects, safeguards put in place, measures assessed

18. Summary Significant literature on incentive design
Many more options than flat rate of payment
Theoretical and empirical pointers for design

19. Next steps High value initial schemes to test may include:
Tiered schemes for retention
Tournament and other competitive schemes among recruiters
Incentive for patients (cash payments, voucher or charitable donation) or choice
Shared financial incentives between patients and recruiters

20. Questions