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$25 Nearly Doubled Black and Hispanic Clinical Trial Enrollment
LDI and CHIBE Fellows Find Small Cash Incentives May Help Close Gaps in Heart Research
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The people most harmed by heart disease are poorly represented in research on promising new treatments. But small financial incentives could help change that, according to LDI Fellows and CHIBE-Affiliated Faculty Alexander C. Fanaroff, Kevin Volpp, Scott Halpern, Rachel Kohn, Alisa Stephens-Shields, and collaborators.
The team from Penn’s Behavioral Economics to Transform Trial Enrollment Representativeness (BETTER) Center, which focuses on behavioral economics, tested ways to increase enrollment of Black and Hispanic patients in clinical trials through the ITERATE study, funded by the American Heart Association (AHA).
Small financial incentives proved to be the most effective of four strategies tested to make research more representative. Providing a $25 incentive nearly doubled participation among underrepresented groups.
These findings matter because clinical trials identify new treatments and should include the people who will use them in the real world.
Four Sequential Trials Tested Multiple Recruitment Strategies
From October 2023 to November 2024, the researchers invited more than 26,000 patients to enroll in the Penn Medicine BioBank, a collection of biological samples donated by patient volunteers and linked to clinical information for research purposes.
The team randomly assigned patients to receive different outreach messages in a series of four randomized clinical trials (RCTs). The most successful messaging for enrolling patients was then incorporated into the next trial. Figure 1 shows the design.
- RCT 1 tested the method of outreach, comparing email alone vs. text message alone vs. email and text message, among 4,581 Black and Hispanic patients. In this RCT, text messages prompted more responses than email alone. Therefore, both were carried forward as the method of outreach in the subsequent RCTs.
- RCT 2 tested the source of outreach among 1,902 Black and Hispanic patients, comparing an invitation from the research team to one from a clinic the patient visited in the past three months. This trial found slightly higher enrollment from the clinical team outreach (1.8% vs. 1.0%). Clinical team outreach was carried forward in the next 2 RCTs.
- RCT 3 tested message framing by comparing an appeal to altruism, i.e., “your participation can help members of your community,” to an appeal to peer influence, i.e., “many people like you have participated,” to a standard message with a control with no framing, involving 3,217 Black and Hispanic patients. Enrollment rates ranged from 3.2% to 4.1%, but neither message framing significantly outperformed the control message, so the control was carried forward in the final RCT.
- RCT 4 tested financial incentives, comparing no incentive to $25, to $15 plus a 5% chance to win $200, to a 5% chance to win $500, to a 1% chance to win $2,500. With 8,629 Black and Hispanic patients, this trial was the largest of the four. While only 2.5% or participants enrolled with no incentive, participation rates jumped to 5.5%–6.8% across the various cash and lottery-based incentive formats.
Financial Incentives Raised Enrollment Among Many Groups
The financial incentives raised enrollment across the board, including among those with Medicaid insurance, those living in more disadvantaged communities (measured by the area deprivation index), and patients younger than 65. Comparing guaranteed dollar amounts and chances to win money in a lottery revealed that no incentive structure was superior to any other.
Work Continues on Ways to Improve Research Representativeness
More research is occurring at the BETTER Center, led by LDI Senior Fellow Scott Halpern and housed within the PAIR Center. The effort is part of the American Heart Association Science of Diversity in Clinical Trials Strategically Focused Research Network (SFRN), which brings together six centers to improve representation in clinical trials focused on heart health.
A follow-up project, called OSPREY, is underway to determine whether other strategies can improve the representativeness of RCTs.
The study, “Messaging Informed by Behavioral Economics and Representativeness in Clinical Research Enrollment: Four Randomized Clinical Trials,” was published in JAMA Network Open on July 16, 2026. Authors include Alexander C. Fanaroff, Nirali Patel, Casey Whitman, Adina Lieberman, Shira Blady, Colleen Morse Kripke, Nawar Naseer, Joellen Weaver, Modele Ogunniyi, Rachel Kohn, Alanna A. Morris, Alisa Stephens-Shields, Kevin G. Volpp, and Scott D. Halpern.
Author
Emma Britez Ferrante
Manager of Communications and Engagement, Palliative and Advanced Illness Research (PAIR) Center
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