<p>In the last decade, there has been a robust increase in research using financial incentives to promote healthy behaviors as behavioral economics and new monitoring technologies have been applied to health behaviors. Most studies of financial incentives on health behaviors have focused on adults, yet many unhealthy adult behaviors have roots in childhood and adolescence. The use of financial incentives is an attractive but controversial strategy in childhood. In this review, we first propose five general considerations in designing and applying incentive interventions to children. These include: (1) the potential impact of incentives on intrinsic motivation, (2) ethical concerns about incentives promoting undue influence, (3) the importance of child neurodevelopmental stage, (4) how incentives interventions may influence health disparities, and (5) how to finance effective programs. We then highlight empirical findings from randomized trials investigating key design features of financial incentive interventions, including framing (loss versus gain), timing (immediate versus delayed), and magnitude (incentive size) effects on a range of childhood behaviors from healthy eating to adherence to glycemic control in type 1 diabetes. Though the current research base on these subjects in children is limited, we found no evidence suggesting that loss-framed incentives perform better than gain-framed incentives in children and isolated studies from healthy food choice experiments support the use of immediate, small incentives versus delayed, larger incentives. Future research on childhood incentives should compare the effectiveness of gain versus loss-framing and focus on which intervention characteristics lead to sustained behavior change and habit formation.</p>

<p><strong>OBJECTIVES: </strong>A relatively small proportion of children with asthma account for an outsized proportion of health care use. Our goal was to use quality improvement methodology to reduce repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalization.</p>

<p><strong>METHODS: </strong>Children ages 2 to 17 with ≥3 asthma-related hospitalizations in the previous year who received primary care at 3 in-network clinics were eligible to receive a bundle of 4 services including (1) a high-risk asthma screener and tailored education, (2) referral to a clinic-based asthma community health worker program, (3) facilitated discharge medication filling, and (4) expedited follow-up with an allergy or pulmonology specialist. Statistical process control charts were used to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital. We then conducted a difference-in-differences analysis to compare changes between those receiving the intervention and a contemporaneous comparison group.</p>

<p><strong>RESULTS: </strong>From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: -20.2 to -1.8; = .02).</p>

<p><strong>CONCLUSIONS: </strong>A multidisciplinary quality improvement intervention reduced health care use in a high-risk asthma population, which was confirmed by using quasi-experimental methodology. In this study, we provide a framework to analyze broader interventions targeted to frequently hospitalized populations.</p>

<p><strong>BACKGROUND: </strong>Poor adherence to inhaled corticosteroid (ICS) medications for children with high-risk asthma is a well-documented and poorly understood problem with a disproportionate prevalence and impact on urban minority children. Financial incentives have been shown as a compelling method to engage a high-risk asthma population, but whether and how adherence can be maintained and lead to sustained high adherence trajectories is unknown.</p>

<p><strong>OBJECTIVE: </strong>To determine the marginal effects of a financial incentive-based ICS adherence intervention on adherence, healthcare system use, and costs in a prospective cohort of child-caregiver dyads.</p>

<p><strong>METHODS: </strong>Participants include 125 children aged 5-12 years who have had at least two hospitalizations or one hospitalization and one emergency room visit for asthma in the prior year and their caregivers. All participants have an electronic inhaler sensor that is linked to a smartphone app to track medication use for 7 months. After one month of observation, participants are randomized to one of three possible arms for a 3-month experiment. Participants in arm 1 receive daily text message reminders, feedback, and nominal gain-framed financial incentives; those in arm 2 receive daily text message reminders and feedback only and those in arm 3 receive no reminders, feedback, or incentives. All participants are then observed for an additional 3 months with no reminders, feedback, or incentives to assess for sustained effects.</p>

<p><strong>RESULTS: </strong>Study enrollment began in September 2019. Estimated primary completion date is June of 2022 and analyses will be completed by June of 2023.</p>

<p><strong>CONCLUSIONS: </strong>The present study will provide data on whether a financial incentive-based mobile-health intervention for promoting ICS use is efficacious in high-risk asthma patients over time.</p>

<p><strong>CLINICALTRIAL: </strong>Clinicaltrial.gov NCT03907410; https://clinicaltrials.gov/ct2/show/NCT03907410.</p&gt;