Heather Klusaritz PhD, MSW, Emily Paterson MPH, Courtney Summers MSW, Nida Al-Ramahi MHA, Nawar Naseer PhD, Helena Jeudin BS, Yuhnis Sydnor BA, Maurice Enoch BA, Nieemah Dollard, Kevin D. Young BA, Neda Khan MHCI, Jeffrey Henne BA, Anna Doubeni MD, Nishaminy Kasbekar PharmD, Yevgeniy Gitelman MD, Patrick J. Brennan MD, Kent Bream MD, Carolyn C. Cannuscio ScD, Richard C. Wender MD, Rachel Feuerstein-Simon MPA, MPH

We describe the efforts of an academic medical institution to implement community-based COVID-19 vaccine clinics in medically underserved neighborhoods in Philadelphia, Pennsylvania. Over a 13-month period (April 2021–April 2022), the initiative delivered 9038 vaccine doses to community members, a majority of whom (57%) identified as Black.

Bender, Whitney MD; Levine, Lisa MD; Durnwald, Celeste MD

The program planned to evaluate whether a postpartum text message–based communication platform improves breastfeeding rates. When stratified by race, Black patients in the intervention arm had 2.6 times higher odds of exclusively breastfeeding at 6 weeks postpartum compared with Black patients in the control arm. Enrollment in the intervention arm decreased the Black–non-Black disparity in the primary outcome. There were no differences in other secondary outcomes.

Eric Bressman, MD, MSHP; Judith A. Long, MD; Katherine Honig; Jarcy Zee, PhD; Nancy McGlaughlin, RN; Carlondra Jointer, MSN, RN; David A. Asch, MD, MBA; Robert E. Burke, MD, MS; Anna U. Morgan, MD, MSc, MSHP

Following up with patients after discharge via text message was associated with a statistically significant 41% lower odds of 30-day use of acute care resources. The readmission rate within 30 days the odds were 55% lower.

Natalie S. Lee, MD, MPH, MSHP, ThaiBinh Luong, PhD, Roy Rosin, MBA, David A. Asch, MD, MBA, Christianne Sevinc, MPH, Mohan Balachandran, MA, MS, Michael Josephs, Matthew H. Rusk, MD, Nicole L. McHenry, MSN, RN, Elizabeth L. Asch, et al.

The University of Pennsylvania Health System implemented a prototype chatbot to reduce message burden on clinicians in a text-based remote hypertension management program. The chatbot accurately triaged 99% of patient messages (1,379 of 1,393), with most messages, nearly 75% (1,073), not requiring escalation to the clinician. The authors share both their approach for building while doing using innovation methodology and the lessons learned in developing a chatbot for clinical care.

A. Ogdie, M. Patel, J. Curtis, K. Gavigan, W. B. Nowell, J. Baker

While financial incentives have worked well in patients without arthritis, the estimated effect of the financial incentive in this small study was more modest in patients with RA and PsA. Those that were able to increase their physical activity and meet their step goals had greater improvements in symptoms over the course of the study.

Sara Samimi, MD, Lauren Hahn, MBA, Cameron Gudobba, Nicholas Mollanazar, MD, MBA, Keiya Akiyama, VMD, Carmela Vittorio, MD, Damien Leri, MSEd, MPH, Yevgeniy Gitelman, MD, Christina O’Malley, MHA, Raina Merchant, MD, MSHP, David A. Asch, MD, MBA, Roy Rosin, MBA, Mohan Balachandran, MA, MS, Neda Khan, MHI, Chris Snider, MPH, Kathleen Lee, MD, and Carrie Kovarik, MD

The program enables patients to submit photos via cell phone text attachments rather than using the traditional patient portal, if they prefer. Initial results show improvements in patient compliance and engagement, photo quality, and teledermatology encounters.

Christopher Manz, William Ferrell, Joelle Williamson, Emily Schriver, Jonathan Wakim, Neda Khan, Michael Kopinsky, Peter Edward Gabriel, Mohan Balachandran, Lawrence N. Shulman, Ravi Bharat Parikh

Clinician and patient-directed dashboards based on patient-generated health data did not lead to higher patient-perceived clinician understanding of symptoms and functional status, although this was limited by moderate adherence to remote symptom and step count collection and low frequency of clinician discussion of PROStep data with patients, highlighting challenges to clinical application of these data sources. Further efforts are needed to improve patient-clinician communication about symptoms and functional status.

Whitehouse, C.R., Knowles, M., Long, J.A. et al.

This pilot study revealed that a home-based exercise program with activity monitoring, feedback and financial incentives resulted increased daily steps, 6-minute walking distance and overall compliance with the program in PAD patients with claudication.

Ravi B Parikh, William Ferrell, Jonathan Wakim, Joelle Williamson, Neda Khan, Michael Kopinsky, Mohan Balachandran, Peter E Gabriel, Yichen Zhang, Lynn M Schuchter, Lawrence N Shulman, Jinbo Chen, Mitesh S Patel, Christopher R Manz

This trial tests the impact of an intervention consisting of presenting remote PGHD via clinician dashboards, with or without a patient active choice intervention, on shared patient–clinician understanding of symptoms and functional status.

S Ryan Greysen;Kimberly J Waddell;Mitesh S Patel

Participants within the “sweet spot” that balances recommended sleep (7-9 hours/night) and physical activity (>5000 steps/day) reported better functional outcomes after 13 weeks compared with participants outside the “sweet spot.” Wearable sleep and activity trackers may provide opportunities to hone postdischarge monitoring and target a “sweet spot” of recommended levels for both sleep and activity needed for optimal recovery.

Kathleen Lee, MD, Kit Delgado MD, Anna Morgan, MD, et al.

This is a letter to NEJM that summarizes the results of a pragmatic randomized control trial to evaluate the difference in outcomes between patient subjective self-reported dyspnea and objective (pulse oximeter) dyspnea for remote monitoring of patients with COVID or exhibiting COVID-like symptoms. Summary: No difference. While this applies specifically in the context of this condition, it is something to consider and evaluate in the context of remote patient monitoring programs to see whether devices are indeed worth the investment and the challenges that go along with them.

Jamie M. Faro, PhD and Sarah L. Cutrona, MD, MPH

An editorial on COVID Watch. The last line summarizes it all - In short, the system saved lives.

Austin S. Kilaru, MD, Stefanie B. Porges, MD, Lindsay Grossman, BA, M. Kit Delgado, MD, Anna U. Morgan, MD, Krisda H. Chaiyachati, MD, David A. Asch, MD, S. Ryan Greysen, MD, Amy C. Lockwood, DNP, Keith C. Hemmert, MD, Susan McGinley, CRNP, Nancy Mannion, DNP, Ann Marie Huffenberger, DBA, Eric Bressman, MD, Nina O’Connor, MD, Neda Khan, MHCI, Mohan Balachandran, MS, Christopher K. Snider, MPH, Aria Xiong, MS, Nandita Mitra, PhD, Kathleen C. Lee, MD

Strategies to maintain hospital capacity during the COVID-19 pandemic included reducing hospital length of stay (LOS) for infected patients. This program sought to evaluate the association between LOS and enrollment in the COVID Accelerated Care Pathway, which consisted of a hospital observation protocol and post-discharge automated text message–based monitoring. This program showed a reduction in hospital length of stay by more than 2 days.

M. Kit Delgado, MD, MS, Anna U. Morgan, MD, MSc, MSHP, David A. Asch, MD, MBA, Ruiying Xiong, MS, Austin S. Kilaru, MD, MSHP, Kathleen C. Lee, MD, David Do, MD, Ari B. Friedman, MD, PhD, Zachary F. Meisel, MD, MPH, MSHP, Christopher K. Snider, MPH, Doreen Lam, BA, Andrew Parambath, BA, Christian Wood, BA, Chidinma M. Wilson, BA, BS, Michael Perez, BS, BA, Deena L. Chisholm, MPH, Sheila Kelly, MPH, Christina J. O’Malley, MHA, Nancy Mannion, DNP, RN, CEN, Ann Marie Huffenberger, DBA, RN, NEA-BC, Susan McGinley, CRNP, Mohan Balachandran, MA, MS, Neda Khan, BS, Nandita Mitra, PhD, Krisda H. Chaiyachati, MD, MPH, MSHP

A secondary analysis of data from Watch patients showed that enrollment in an automated text messaging service among community-dwelling adults newly diagnosed with COVID-19 in outpatient settings was associated with reduced mortality (up to 68%), potentially explained by increased and earlier presentation to the ED by those benefiting from early interventions. These results reveal a model for outpatient health system management of patients with COVID-19 and possibly other conditions where the early detection of clinical declines is critical.

Cody E. Cotner,MD; Mohan Balachandran,MA,MS; David Do,MD; Will Ferrell, MPH; Neda Khan,BS; Michael Kopinsky, BSE; Suzanne McGettigan,MSN,CRNP; Anna U. Morgan,MD,MSc,MSHP; Lindsey Zinck,MSN,RN; Lynn M. Schuchter,MD; Lawrence N. Shulman,MD; David A. Asch, MD,MBA; Christopher R. Manz,MD,MSHP; and Ravi B. Parikh,MD,MPP

A variant of COVID Watch. Median time from escalation to triage call was 11.5 minutes. Four (15%) patients presented to the ED without first escalating their care via our program. Participant satisfaction was high (Net Promoter Score: 100, n = 4).

Sarah J. Fendrich, Mohan Balachandran & Mitesh S. Patel

Smartphones and wearable devices can be used to remotely monitor health behaviors, but little is known about how individual characteristics influence sustained use of these devices. This leverages techniques such as latent class analysis (LCA) and uses a broad range of data to classify individuals into specific behavioral phenotypes. This in turn can be used to predict usage and adherence to physical activity regimes epecially following hospital discharges.

Kimberly J. Waddell, Mitesh S. Patel, Kayla Clark, Tory O. Harrington, S. Ryan Greysen

Participants in the gamification arm also select a support partner who receives weekly updates on their progress in the game. The primary outcome is change in daily steps from baseline during the intervention period. The secondary outcome is difference in the proportion of days participants achieved their daily step goal. Results from this trial will inform future, larger studies that leverage insights from behavioral economics to help improve daily physical activity post-stroke.

Natalie S Lee, Sheila Kelly, Helen Koenig, Linden Lalley-Chareczko, Gerald Van Buskirk, Krisda H Chaiyachati

This is a parternship between University of Pennsylvania and Philadel-phia FIGHT, a federally qualified health center. PrEP Retention Coordinators (PRCs) are non-clinician FIGHT staff who currently text patients on PrEP ad hoc to improve retention and adherence.The aim of this study is to co-design an automated texting intervention with PRCs and patients to systematically identify patients experiencing barriers to PrEP. With PRCs, we developed a series of automated text screening questionsto be administered over 3 months, the standard interval between PrEP follow-up appointments. We also co-designed the criteria and protocols for escalatingcases to PRCs for further intervention.

Cody Cotner, Christopher Manz, Mohan Balachandran, Will Ferrell, Neda Khan, Michael Kopinsky, Suzanne McGettigan, Anna Morgan, Lindsey Zinck, Lynn Mara Schuchter, Lawrence N. Shulman, David Asch, Ravi Bharat Parikh

Patients with cancer are at greater risk of developing severe symptoms and dying from COVID-19 than the general population. Early detection of worsening symptoms and rapid nurse practitioner assessment may identify patients with cancer and suspected COVID-19 who require escalation of care while limiting strain on healthcare resources. Patients with concerning symptoms were adherent with Cancer COVID Watch and mostly managed in the outpatient setting. Efforts to manage symptomatic patients with cancer during future pandemics could use a similar approach. This was a modification of the COVID Watch program applied specifically to cancer patients and monitored by oncologists.

Mitesh S. Patel, MD, MBA; Dylan S. Small, PhD; Joseph D. Harrison, MBDS; Victoria Hilbert, MPH, RD; Michael P. Fortunato, BA; Ai Leen Oon, BA; Charles A. L. Rareshide, MS; Kevin G. Volpp, MD, PhD

In this randomized clinical trial of 361 adults with overweight or obesity and uncontrolled type 2 diabetes, gamification interventions designed to enhance support or competition each significantly increased physical activity relative to controls during the 1-year intervention, but gamification with collaboration did not significantly change physical activity relative to controls. All study arms had significant reductions in weight and hemoglobin A1c levels from baseline, but none of the gamification interventions resulted in significant differences in these outcomes relative to controls.

Katherine L. Milkman, Mitesh S. Patel, Linnea Gandhi, Heather Graci, Dena Gromet, Hung Ho,, Joseph Kay, Timothy Lee, Modupe Akinola, John Beshears, Jon Bogard, Alison Buttenheim, Christopher Chabris, Gretchen B. Chapman, James J. Choi, Hengchen Dai, Craig R. Fox, Amir Goren, Matthew Hilchey, Jillian Hmurovic, Leslie John, Dean Karlan, Melanie Kim, David Laibson, Cait Lamberton, Brigitte C. Madrian, Michelle N. Meyer, Maria Modanu , Jimin Nam, , Renante Rondina, Silvia Saccardo, Maheen Shermohammed, Dilip Soman, Jehan Sparks, Caleb Warren, Megan Weber, Ron Berman, Chalanda Evans, Christopher Snider, Eli Tsukayama, Christophe Van den Bulte, Kevin Volpp, Angela Duckworth

This is the formal publication of the Flu study which was published earlier in a pre-release on SSRN. Which as a quick reminder - Powered by Way to Health, this study was run at Penn Medicine and Geisinger. In the fall of 2020, close to 50,000 patients received one of 19 different messages prior to a healthy visit to their primary care provider. In the new study, roughly a third of the messages BCFG tested significantly increased flu shot uptake. The top performing message set—designed by Jon Bogard, Craig Fox, Jehan Sparks, and Megan Weber from the University of California at Los Angeles, and Matt Hilchey, Melanie Kim, Dilip Soman, and Renante Rondina from the University of Toronto, in collaboration with BCFG—boosted vaccination rates by 11%.

Kathleen C. Lee, MD, Nida Al-Ramahi, MHA, Lauren Hahn, MBA, Terrilynn Donnell, Lillian J. Schonewolf, Neda Khan, Christina O’Malley, MHA, Utsha G. Khatri, MD, Ellen Pearlman, MS, Mohan Balachandran, MA, David A. Asch, MD, MBA, W. L. Herndon, Colleen Mallozzi, MBA, RN, Judith Green-McKenzie, MD, MPH, Nishaminy Kasbekar, PharmD, Christopher Cullom, MBA, Sharon Carney, MD, Reverend William Shaw, DMin, Patricia Sullivan, PhD, Phil Okala, MHA, Patrick J Brennan, MD & Eugenia South, MD, MS

The Covid-19 vaccine rollout has been highly inequitable, with white individuals being vaccinated at higher rates than Black individuals in 38 states. In just 2 weeks, we designed and launched a community clinic model. As of March 2021, we have run three 7-hour clinics, vaccinating a total of 2,821 people, of whom 85% were Black. Logistical innovations allowed the clinics to operate line-free throughout most of the day and with a Net Promoter score of 94, evidencing outstanding patient satisfaction.

Mitchell JA, Morales KH, Williamson AA, Huffnagle N, Eck C, Jawahar A, Juste L, Fiks AG, Zemel BS, Dinges DF.

A mobile health platform that can capture sleep data and remotely communicate with families was developed and deployed. Promising candidate intervention components will be further investigated under the optimization phase of the MOST framework.

Michael G. Tecce, DO, Lauren Hahn, MBA, Bethany Welch, PA-C, MHS, David Okawa, MBA, Daniel J. Wendler, MD, Saiesh Kalva, Mohan Balachandran, MA, MS, M. Kit Delgado, MD, MS, Christopher K. Snider, MPH, Danielle Flynn, MSN, RN, Roy Rosin, MBA, Raina M. Merchant, MD, MSHP, Joseph Serletti, MD & Kathleen C. Lee, MD

This program challenged a long-standing status quo that required patients to commute to and from the clinic for drain management and removal. High patient satisfaction scores reflected not only this convenience, but also a design that reimagined the delivery of education and clinical services while ensuring a more patient-centric return to independence. CARe, which, in a Covid-19 environment allowed patients to reliably receive uninterrupted postoperative care safely in their homes, has been expanded to additional surgical patient populations across multiple hospitals and home health agencies.

Allison H. Oakes, PhD, Jonathan A. Epstein, MD, Arupa Ganguly, PhD, Frederic D. Bushman, PhD, Ned C. Haubein, PhD, Christianne Sevinc, MPH, Sarah Fendrich, BA, Ai Leen Oon, BA, Andrew Parambath, BA, MEd, Kayla Clark, BA, Chalanda N. Evans, BS & Mitesh S. Patel, MD, MBA

To safely reopen schools and businesses, widespread surveillance testing for Covid-19 will be necessary. We quickly designed and implemented a surveillance testing program that remotely enrolls participants, uses automated bidirectional text message communications, incorporates symptom monitoring, and automatically reports test results.

Katherine L. Milkman, Mitesh S. Patel, Linnea Gandhi, Heather Graci, Dena Gromet, Hung Ho,, Joseph Kay, Timothy Lee, Modupe Akinola, John Beshears, Jon Bogard, Alison Buttenheim, Christopher Chabris, Gretchen B. Chapman, James J. Choi, Hengchen Dai, Craig R. Fox, Amir Goren, Matthew Hilchey, Jillian Hmurovic, Leslie John, Dean Karlan, Melanie Kim, David Laibson, Cait Lamberton, Brigitte C. Madrian, Michelle N. Meyer, Maria Modanu , Jimin Nam, , Renante Rondina, Silvia Saccardo, Maheen Shermohammed, Dilip Soman, Jehan Sparks, Caleb Warren, Megan Weber, Ron Berman, Chalanda Evans, Christopher Snider, Eli Tsukayama, Christophe Van den Bulte, Kevin Volpp, Angela Duckworth

Powered by Way to Health, this study was run at Penn Medicine and Geisinger. In the fall of 2020, close to 50,000 patients received one of 19 different messages prior to a healthy visit to their primary care provider. In the new study, roughly a third of the messages BCFG tested significantly increased flu shot uptake. The top performing message set—designed by Jon Bogard, Craig Fox, Jehan Sparks, and Megan Weber from the University of California at Los Angeles, and Matt Hilchey, Melanie Kim, Dilip Soman, and Renante Rondina from the University of Toronto, in collaboration with BCFG—boosted vaccination rates by 11%.

Mitesh S. Patel, MD,MBA; Chethan Bachireddy, MD,MS; Dylan S. Small, PhD; Joseph D. Harrison, MS; Tory O. Harrington, MS; Ai Leen Oon, BA; Charles A. L. Rareshide, MS; Christopher K. Snider, MPH; Kevin G. Volpp, MD, PhD

What’s the best way to set goals to help economically disadvantaged patients at elevated risk for heart attacks improve healthy behaviors? In a new clinical trial out today in JAMA Cardiology, we found significant improvements in physical activity during a gamification intervention when a patient chose their step goal (rather than being assigned) and when targets were implemented immediately (rather than gradually). This led to a 1400 step per day increase compared to control for 16 weeks and then this level was sustained during an additional 8 weeks of follow-up. With just one text message per day, the average patient in the intervention walked about 120 miles more than the average patient in control! The study was powered by Way to Health.

Fukaya E, Welden S, Bukari A, Khan Z, Leeper N, Mohler E.

This pilot study revealed that a home-based exercise program with activity monitoring, feedback and financial incentives resulted increased daily steps, 6-minute walking distance and overall compliance with the program in PAD patients with claudication.

Nadim Mahmud, MD, MS, MPH, MSCE; David A. Asch, MD, MBA; Jessica Sung, BA; Catherine Reitz, MPH; Mary S. Coniglio, MBA; Caitlin McDonald, MPH; Donna Bernard, MSN; Shivan J. Mehta, MD, MBA, MSHP

This randomized clinical trial found that automated text message reminders and instructions did not improve outpatient colonoscopy adherence, although future studies may identify patient subgroups that benefit from this approach.

Benda NC, Alexopoulos GS, Marino P, Sirey JA, Kiosses D, Ancker JS.

Participants demonstrated the feasibility of use of the intervention, successfully completing 99% of their assigned tasks during the pilot. Findings were used to address usability barriers in preparation for future clinical trials. Our results highlight the importance completing usability assessment and involving older adults in the intervention design process when incorporating technology into care.

Shivan J. Mehta, Eric Hume, Andrea B. Troxel, Catherine Reitz, Laurie Norton, Hannah Lacko, Caitlin McDonald, Jason Freeman, Noora Marcus, Kevin G. Volpp, David A. Asch

In this randomized clinical trial of 242 patients, the remote monitoring program did not increase rate of discharge to home after hip and knee arthroplasty, and gamification and social support did not increase activity levels. However, a significant reduction in rehospitalizations among those assigned to the intervention was found.

Anahita Davoudi, Natalie S Lee, Corey Chivers, Timothy Delaney, Elizabeth L Asch, Catherine Reitz, Shivan J Mehta, Krisda H Chaiyachati, Danielle L Mowery

The paper identified unique interaction phenotypes among patients engaging with an automated text message platform for remote BP monitoring. Only the minimalist communication style was associated with achieving target BP. Identifying and understanding interaction phenotypes may be useful for tailoring future automated texting interactions and designing future interventions to achieve better BP control.

Charles D Scales Jr, Alana C Desai, Jonathan D Harper, H Henry Lai, Naim M Maalouf, Peter P Reese, Gregory E Tasian, Hussein R Al-Khalidi, Ziya Kirkali, Hunter Wessells, Urinary Stone Disease Research Network

The article describes the rationale and design of the Prevention of Urinary Stones with Hydration (PUSH) study, a randomized trial of a multi-component behavioral intervention program to increase and maintain high fluid intake. Participants are randomized (1:1 ratio) to intervention or control arm. The target sample size is 1642 participants.

Louise B Russell, Laurie A Norton, David Pagnotti, Christianne Sevinc, Sophia Anderson, Darra Finnerty Bigelow, Lauren G Iannotte, Michael Josephs, Ryan McGilloway, Iwan Barankay, Mary E Putt, Peter P Reese, David A Asch, Lee R Goldberg, Shivan J Mehta, Monique S Tanna, Andrea B Troxel, Kevin G Volpp

This article explains how to frame the costing problem, including how to think about costs associated with the control group, and describes methods for collecting data on individual costs: specifications for costing a technology platform that supports the specialized functions required, how to set up a time log to collect data on the time staff spend on implementation, and issues in getting data on device, overhead, and financial incentive costs.

Xisui Shirley Chen , Sujatha Changolkar, Amol S. Navathe, Kristin A. Linn, Gregory Reh, Gregory Szwartz, David Steier, Sarah Godby, Mohan Balachandran, Joseph D. Harrison, Charles A. L. Rareshide, Mitesh S. Patel

Participants often vary in their response to behavioral interventions, but methods to identify groups of participants that are more likely to respond are lacking. In this secondary analysis of a randomized clinical trial, we used baseline characteristics to group participants into distinct behavioral phenotypes and evaluated differential responses to a physical activity intervention. Engagement varies significantly across the identified phenotypes. The hope is to leverage this methodology to improve patient engagement across multiple clinical domains.

Amardeep Grewal, MD, Andrea Ngan, BA, Brenda Laventure, BA, Lauren Southwick, MA, Elissa Klinger, BA, Raina Merchant, MD

OnCare Connect connected, supported, and strengthened care at our institution. The patient-centered support texting platform that was created was able to detects symptoms earlier and creates pathways to support patients. OnCare Connect was additionally able to extend care capacity for care teams and provide quality and reliable care, resulting in fewer grade 3+ toxicities compared to matched control patients.

Henderson BR, Flaherty CM, Floyd GC, You J, Xiao R, Bryant-Stephens TC, Miller VA, Feudtner C, Kenyon CC

The aim of this study is to determine the marginal effects of a financial incentive–based intervention on inhaled corticosteroid adherence, health care system use, and costs.

Anna U. Morgan, MD, MSc, MSHP, Mohan Balachandran, MA, MS, David Do, MD, Doreen Lam, BA, Andrew Parambath, BA, MEd, Krisda H. Chaiyachati, MD, MPH, MSHP, Nancy M. Bonalumi, DNP, RN, CEN, FAEN, Susan C. Day, MD, MPH, Kathleen C. Lee, MD & David A. Asch, MD, MBA

An innovation team at the University of Pennsylvania Health System demonstrates how an automated text-messaging system can remotely monitor patients with confirmed or suspected Covid-19 at home and quickly support worsening patients with human care.

Shivan J.Mehta, Catherine Reitz, Tess Niewood, Kevin G.Volpp, David A.Asch

In a randomized trial of participants who underwent risk assessment for CRC with vs without financial incentive, the financial incentive increased CRC risk assessment completion but did not result in a greater completion of screening colonoscopy.

J A Mitchell, C Eck, J Hickey, N Huffnagle, A G Fiks, B S Zemel, D F Dinges, A A Williamson

Despite high parent-child acceptability of a mobile child sleep extension intervention, individual and contextual barriers may limit long-term adherence. Tailoring healthy sleep messages to target these factors could improve sustained benefits to child sleep.

Jourdan E.Triebwasser, Matthew K.Janssen, Adi Hirshberg, Sindhu K.Srinivas

Text-based BP monitoring performed similarly in an implementation cohort compared to the trial participants. This program is scalable to manage postpartum hypertension and reduce racial disparities in postpartum care in women with hypertensive disorders of pregnancy.

Mitesh Patel, MD, MBA, MS; Daniel Polsky, PhD; Kevin Volpp, MD, PhD; Edward H. Kennedy, PhD; Dylan S. Small, PhD; Chalanda Evans; Charles Rareshide

According to a new Penn Medicine Study, doctors who track their patients’ physical activity might have more luck doing it with smartphones than wearable fitness devices. “Most people with smartphones take them everywhere they go. Since carrying the phone is already a built-in habit, it makes it much easier to use the device to track activity levels,” says Mitesh Patel, the director of Penn Medicine’s Nudge Unit.

Jeffrey Leinert, MS, PhD, Mitesh Patel, MD, MBA, MS

Latent class analysis was used to identify patient sub-groups that were successfully impacted by the study intervention. Three groups of participants were identified: “Kin teams,” “Distant teams,” and “Married teams.” “Kin teams” lost more weight after the intervention in the gamification and gamification with PCP sharing arms. The “Distant teams” lost similar amounts of weight in all 3 arms but did not keep it off during maintenance. The “Married teams” lost the most weight across all 3 arms and kept it off following the intervention.

Heather M.Greysen, Catherine Reale, Ashley Mercedes, Mitesh S. Patel, Dylan Small, Christopher Snider, Charles Rareshide, Scott D. Halpern, S. Ryan Greysen

The objective in the Mobility and Outcomes for Validated Evidence – Incentive Trial (MOVE IT) study is to examine the impact of a gamification intervention with social support that uses insights from behavioral economics to increase physical activity among general medical and oncology patients in the 13- weeks post-hospital discharge using a wearable device to track physical activity.

David A. Asch, MD, MBA, Kevin B. Mahoney, DBA, Roy Rosin, MBA

Successful innovation requires experimentation—following many of the same pathways of the successful science that has brought us CAR-T cell therapy and CRISPR. But health care change requires we tinker with the health care system we depend on, affecting critical resources organizations understandably protect. To support the people determined to drive change quickly, we need to find ways to bend institutional norms safely.

Adi Hirshberg, MD; Mary D.Sammel, ScD; Sindhu K.Srinivas, MD, MSCE

Although nonblack women attended in-office (usual care) postpartum blood pressure checks twice as often as black women, the use of a text-based monitoring system resulted in overall higher compliance (>90%) in both race groups and no racial differences in blood pressure ascertainment. Given that most strokes and maternal morbidity from pregnancy-related hypertension occur within 10 days of delivery, text messaging has the potential to be an innovative way to engage hypertensive women of all races equally shortly after delivery and may be further evaluated as a means to reduce disparities in other aspects of postpartum care.

Mitesh S. Patel, MD, MBA, MS; Dylan S. Small, PhD; Joseph D. Harrison, BS; Michael P. Fortunato, BA; Ai Leen Oon, BA; Charles A. L. Rareshide, MS; Gregory Reh, MS; Gregory Szwartz, MS; James Guszcza, PhD; David Steier, PhD; Pameljit Kalra, MS; Victoria Hilbert, MPH, RD

Small changes to the design of gamification can lead to important differences in effectiveness - In this randomized clinical trial of 602 overweight and obese adults from 40 states across the United States, gamification interventions with support, collaboration, and competition significantly increased physical activity compared with the control group during the 24-week intervention. The competition arm had the greatest increase in physical activity from baseline during the intervention; during the 12-week follow-up, physical activity was lower in all arms, but remained significantly greater in the competition arm than in the control arm.

Nadim Mahmud, MD, MS, MPH, Sahil D. Doshi, MD, Mary S. Coniglio, MBA, Michelle Clermont, MD, Donna Bernard, MSN, Catherine Reitz, MPH, Vandana Khungar, MD, MSc, David A. Asch, MD, MBA, Shivan J. Mehta, MD, MBA, MSHP

Background. Numerous barriers to outpatient colonoscopy completion exist, causing undue procedure cancellations and poor bowel preparation. We piloted a text message navigation program to improve colonoscopy adherence. Method. We conducted a prospective study of patients aged 18 to 75 years scheduled for outpatient colonoscopy at an urban endoscopy center in April 2018. An intervention arm consisting of bidirectional, automated text messages prior to the procedure was compared with a usual care arm. We enrolled 21 intervention patients by phone and randomly selected 50 controls. Outcomes included colonoscopy appointment adherence, bowel preparation quality, and colonoscopy completion. Results. The arms had similar demographics and comorbidities. Intervention patients had higher colonoscopy appointment adherence (90% vs. 62%, p = 0.049). There were no significant differences in preparation quality or procedure completeness. Poststudy surveys indicated high patient satisfaction and perceived usefulness of the program. Conclusion. A bidirectional, automated texting navigation program improved colonoscopy adherence rates as compared with usual care.

Shivan J. Mehta, Kevin G. Volpp, Andrea B. Troxel, Susan C. Day, Raymond Lim, Noora Marcus, Laurie Norton, Sophia Anderson, David A. Asch

Despite good measured adherence, neither feedback with electronic pill bottles nor bidirectional text messaging about medication adherence improved blood pressure control. Adherence to prescribed medications was not improved enough to affect BP control or it was not the primary driver of poor control.

Chalanda N.Evans, Kevin G.Volpp, Daniel Polsky, Dylan S. Small, Edward H.Kennedy, Kelsey Karpink, Rachel Djaraher, Nicole Mansi, Charles A.L.Rareshide, Mitesh S.Patel

Daily behaviors play a significant role in individuals' longer-term health [4,5]. However, most readmission prediction models do not include data about these behaviors. Our trial has demonstrated that collecting these types of data is feasible. The use of wearable technology allowed for remote monitoring of patient generated physical activity data which provided reliable data, was easy to use, and scaled. The findings from this study will help to understand the ways in which these data sources can improve the identification of patients at high-risk of hospital readmission.

Putt ME, Reese PP, Volpp KG, et al.

This pilot study revealed that a home-based exercise program with activity monitoring, feedback and financial incentives resulted increased daily steps, 6-minute walking distance and overall compliance with the program in PAD patients with claudication.

Adi Hirshberg, MD, Katy Mahraj, MSI, Sindhu K. Srinivas, MD, MSCE

Postpartum preeclampsia contributes to a substantial portion of maternal morbidity and mortality in the United States. We used innovation methodology to develop a text-based surveillance system using Way To Health known as Heart Safe Motherhood to target this clinical problem and define a new approach to care delivery.

Mitesh Patel, MD, MBA, Stacey Chang, Kevin Volpp, MD, PhD

Our group is using gamification to help patients with uncontrolled diabetes, heart disease, and cancer. We have found that incorporating principles from behavioral economics is not hard or expensive, but instead requires attention to detail. Subtle changes to program design and communications can have an outsized impact on how patients behave. That’s why embedding behavioral insights into gamification could represent a significant opportunity to improve health and wellbeing.

Joseph D. Harrison, Jeremy M. Jones, Dylan S. Small, Charles A.L. Rareshide, Gregory Szwartz, David Steier, James Guszcza, Pameljit Kalra, Brian Torio, Gregory Reh, Victoria Hilbert, Mitesh S. Patel

This was a four-arm, randomized, controlled trial of 602 overweight and obese adults to evaluate the effectiveness of gamification interventions that leverage insights from behavioral economics to enhance either supportive, competitive, or collaborative social incentives. Daily step counts are monitored using wearable devices that transmit data to the study platform. Participants established a baseline step count, selected a step goal increase, and then were randomly assigned to control or one of three interventions for a 24-week intervention and 12-week follow-up period. To understand predictors of strong or poor performance, we had participants complete validated questionnaires on a range of areas including their personality, risk preferences, social network, and habits relating to physical activity, eating, and sleep. Trial enrollment was conducted in partnership with Deloitte Consulting and included employees from 40 states across the US. The STEP UP Trial represents a scalable model and interventions found to be effective could be deployed more broadly to increase physical activity.

Shivan J. Mehta,Kevin G. Volpp,David A. Asch,Lee R. Goldberg,Louise B. Russell,Laurie A. Norton,Lauren G. Iannotte, Andrea B. Troxel

The EMPOWER trial incorporates leading-edge approaches in human motivation, derived from behavioral economics, with contemporary technology to provide scale and exception handling at low cost. The trial is also implemented within the naturalized environment of a health system, as much as possible taking advantage of the existing journeys of patients and workflows of clinicians. A goal of this pragmatic design is to limit resource utilization and also to test an intervention that would need minimal modification to be translated from research into a new way of practice.

Zarina S. Ali, Tracy M. Flanders, Ali K. Ozturk, Neil R. Malhotra, Lena Leszinsky, Brendan J. McShane, Diana Gardiner, Kristin Rupich, H. Isaac Chen, James Schuster, Paul J. Marcotte, Michael J. Kallan, M. Sean Grady, Lee A. Fleisher and William C. Welch

Enhanced recovery after surgery (ERAS) protocols address pre-, peri-, and postoperative factors of a patient’s surgical journey. The authors sought to assess the effects of a novel ERAS protocol on clinical outcomes for patients undergoing elective spine or peripheral nerve surgery. total of 201 patients underwent surgical care via an ERAS protocol and were compared to a total of 74 patients undergoing traditional perioperative care (control group). The 2 groups were similar in baseline demographics. Intravenous opioid medications postoperatively via patient-controlled analgesia was nearly eliminated in the ERAS group (0.5% vs 54.1%, p < 0.001). This change was not associated with an increase in the average or daily pain scores in the ERAS group. At 1 month following surgery, a smaller proportion of patients in the ERAS group were using opioids (38.8% vs 52.7%, p = 0.041). The ERAS group demonstrated greater mobilization on postoperative day 0 (53.4% vs 17.1%, p < 0.001) and postoperative day 1 (84.1% vs 45.7%, p < 0.001) compared to the control group. Postoperative Foley use was decreased in the ERAS group (20.4% vs 47.3%, p < 0.001) without an increase in the rate of straight catheterization (8.1% vs 11.9%, p = 0.51).

Ankur Pandya, PhD; David A. Asch, MD, MBA; Kevin G. Volpp, MD, PhD; Stephen Sy, MS; Andrea B. Troxel, ScD; Jingsan Zhu, MBA; Milton C. Weinstein, PhD; Meredith B. Rosenthal, PhD; Thomas A. Gaziano, MD, MSc

This study suggests that the financial incentives shared between patients and physicians for LDL-C level control meet conventional standards of cost-effectiveness, but these results appeared to be sensitive to assumptions about the durations of LDL-C level reductions and years of intervention costs included, as well as to the choice of time horizon.

Glanz K, Shaw PA, Hoffer K, Chung A, Zhu J, Wu R, Huang QE, Choi JR, Volpp KG

Identifying effective strategies for treating obesity is a clinical challenge and a public health priority. This study demonstrated that multi-site employee-based recruitment for a weight-control intervention study is feasible but may need additional time for coordination between diverse environments.

Krutsinger DC, McMahon J, Stephens-Shields AJ, Bayes B, Brooks S, Hitsman BL, Lubitz SF, Reyes C, Schnoll RA, Ryan Greysen S, Mercede A, Patel MS, Reale C, Barg F, Karlawish J, Polsky D, Volpp KG, Halpern SD

The most common and conceptually sound ethical concerns with financial incentives for research participation are that they may (1) represent undue inducements by blunting peoples' perceptions of research risks, thereby preventing fully informed consent; or (2) represent unjust inducements by encouraging enrollment preferentially among the poor. Neither of these concerns has been shown to manifest in studies testing the effects of incentives on decisions to participate in hypothetical randomized clinical trials (RCTs), but neither has been assessed in real RCTs.

Harhay MO, Troxel AB, Brophy C, Saulsgiver K, Volpp KG, Halpern SD

Financial Incentives Promote Smoking Cessation Directly, Not by Increasing Use of Cessation Aids

Tasian GE, Ross M, Song L, Audrain-McGovern J, Wiebe D, Warner SG, Henderson B, Patel A, Furth SL.

Unawareness of water volume consumed and low responsiveness to the perceived need to drink more were associated with low water intake. Interventions that help adolescents recognize when and identify how to increase water intake may be effective in reducing stone recurrence.

Mehta SJ, Asch DA, Troxel AB, Lim R, Lewey J, Wang W, Zhu J, Norton L, Marcus N, Volpp KG.

Pharmacy claims data provide useful but not complete data for medication adherence monitoring. New wireless technologies have the potential to provide additional data about clinical outcomes.

Kurtzman GW, Day SC, Small DS, Lynch M, Zhu J, Wang W, Rareshide CAL, Patel MS.

Using digital health devices to track behavior with a partner led to significant weight loss through 36 weeks, but the gamification interventions were not effective at promoting weight loss when compared to control.

Neel P. Chokshi, Srinath Adusumalli, Dylan S. Small, Alexander Morris, Jordyn Feingold, Yoonhee P. Ha, Marta D. Lynch, Charles A.L. Rareshide, Victoria Hilbert and Mitesh S. Patel

ACTIVE REWARD was a 24‐week home‐based, remotely monitored, randomized trial with a 16‐week intervention (8‐week ramp‐up incentive phase and 8‐week maintenance incentive phase) and an 8‐week follow‐up. Patients used wearable devices to track step counts and establish a baseline. Patients in control received no other interventions. Loss‐framed financial incentives with personalized goal setting significantly increased physical activity among ischemic heart disease patients using wearable devices during the 16‐week intervention, and effects were sustained during the 8‐week follow‐up.

Rebecca H Kim, MD, MPH ; Mitesh S Patel, MD, MBA, MS

Veterans engaged in using wearable devices at high rates

William S. Yancy Jr., Pamela A. Shaw, Lisa Wesby, Victoria Hilbert, Lin Yang, Jingsan Zhu, Andrea Troxel, David Huffman, Gary D. Foster, Alexis C. Wojtanowski & Kevin G. Volpp

Compared with the active control of daily texting based on daily home weighing, lottery-based and direct monetary incentives provided no additional benefit for weight loss maintenance. Or in other words, texting and reminders were equally effective as financial incentives.

Scott D. Halpern, M.D., Ph.D., Michael O. Harhay, Ph.D., Kathryn Saulsgiver, Ph.D., Christine Brophy, Andrea B. Troxel, Sc.D., and Kevin G. Volpp, M.D., Ph.D.

The study randomly assigned 6006 smokers employed by 54 companies to one of four smoking-cessation interventions or to usual care. In this pragmatic trial of smoking cessation, financial incentives added to free cessation aids resulted in a higher rate of sustained smoking abstinence than free cessation aids alone. Among smokers who received usual care (information and motivational text messages), the addition of free cessation aids or e-cigarettes did not provide a benefit.

Hirshberg A, Downes K, Srinivas S

Text-based monitoring is more effective in obtaining blood pressures and meeting current clinical guidelines in the immediate postdischarge period in women with pregnancy-related hypertension compared with traditional office-based follow-up.

Kessler JB, Troxel AB, Asch DA, Mehta SJ, Marcus N, Lim R, Zhu J, Shrank W, Brennan T, Volpp KG

Automated alerts were effective at improving medication adherence. Assigning a medication adherence partner did not statistically significantly affect adherence rates.

Chén C. Kenyon, MD, MS, Siobhan M. Gruschow, MPH, MEd, William O. Quarshie, MS, Heather Griffis, PhD, Michelle C. Leach, BS, Joseph J. Zorc, MD, MSCE, Tyra C. Bryant-Stephens, MD, Victoria A. Miller, PhD & Chris Feudtner, MD, PhD, MPH

Within a high-risk pediatric cohort, electronic monitoring of ICS use and adherence reminders delivered via text message were feasible for most participants, but there was no signal of effect. Adherence trajectories following severe exacerbation were suboptimal, demonstrating an important opportunity for asthma care improvement.

Patel MS, Volpp KG, Rosin R, Bellamy SL, Small DS, Heuer J, Sproat S, Hyson C, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Asch DA

Combined lottery incentives were most effective in increasing physical activity

Mitesh S. Patel, MD, MBA, MS; Luca Foschini, PhD; Gregory W. Kurtzman, BA; Jingsan Zhu, MBA, MS; Wenli Wang, MS; Charles A.L. Rareshide, MS; Susan M. Zbikowski, PhD

Describes rates of initial use of activity trackers, sustained use after 6 months, and step counts across different sociodemographic characteristics from a wellness program offered across the United States.

Mitesh S. Patel, MD, MBA, MS; Emelia J. Benjamin, MD, ScM; Kevin G. Volpp, MD, PhD; Caroline S. Fox, MD, MPH; Dylan S. Small, PhD; Joseph M. Massaro, PhD; Jane J. Lee, PhD; Victoria Hilbert, MPH, RD; Maureen Valentino, BA; Devon H. Taylor, MPH; Emily S. Manders, BS; Karen Mutalik, BS; Jingsan Zhu, MBA, MS; Wenli Wang, MS; Joanne M. Murabito, MD, ScM

Gamification designed to leverage insights from behavioral economics to enhance social incentives significantly increased physical activity among families in the community.

Charlene A. Wong, MD, MSHP; Victoria A. Miller, PhD; Kathryn Murphy, PhD; Dylan Small, PhD; Carol A. Ford, MD; Steven M. Willi, MD; Jordyn Feingold, MAPP; Alexander Morris, BS; Yoonhee P. Ha, MSc, MPhil; Jingsan Zhu, MS, MBA2; Wenli Wang, MS2; Mitesh S. Patel, MD, MBA, MS2

In a randomized clinical trial including 90 adolescents and young adults with poorly controlled type 1 diabetes, daily financial incentives improved glucose monitoring in the intervention group (50.0%) vs the control group (18.9%) but did not affect their glycemic control. Financial incentives showed promise for improving glucose monitoring behaviors among adolescents and young adults with type 1 diabetes

Tianyu Liu, David A.Asch, Kevin G.Volpp, Jingsan Zhu, Wenli Wang, Andrea B. Troxel, Aderinola Adejare, Darra D. Finnerty, Karen Hoffer, Judy A. Shea

PCPs participating in a P4P program generally agree with the concept of financial incentives and are open to sharing incentives between physicians and patients. Physician beliefs about incentives may have an influence on patient outcomes, particularly in a shared incentive setting, but more research is needed to elucidate the exact nature of this interaction.

Kevin G. Volpp, MD, PhD; Andrea B. Troxel, ScD6; Shivan J. Mehta, MD, MBA, MSHP; Laurie Norton, MA; Jingsan Zhu, MS, MBA; Raymond Lim, MA; Wenli Wang, MS; Noora Marcus, MA; Christian Terwiesch, PhD; Kristen Caldarella, MHA; Tova Levin, MBA; Mike Relish, MA; Nathan Negin, MD; Aaron Smith-McLallen, PhD; Richard Snyder, MD; Claire M. Spettell, PhD; Brian Drachman, MD; Daniel Kolansky, MD; David A. Asch, MD, MBA

In this randomized clinical trial of 1509 patients following acute myocardial infarction, there were no statistically significant differences between study arms in time to first rehospitalization for a vascular event or death, medication adherence, or cost.

George L. Anesi, Scott D. Halpern, Michael O. Harhay, Kevin G. Volpp, Kathryn Saulsgiver

In efforts to combat tobacco dependence, most smoking cessation programs offer individuals who smoke the choice of a target quit date. However, it is uncertain whether the time to the selected quit date is associated with participants’ chances of achieving sustained abstinence. In a pre-specified secondary analysis of a randomized clinical trial of four financial-incentive programs or usual care to encourage smoking cessation (Halpern et al. in N Engl J Med 372(22):2108–2117, doi:10.1056/NEJMoa1414293, 2015), study participants were instructed to select a quit date between 0 and 90 days from enrollment. Among those who selected a quit date and provided complete baseline data (n = 1848), we used multivariable logistic regression to evaluate the association of the time to the selected quit date with 6- and 12-month biochemically-confirmed abstinence rates. In the fully adjusted model, the probability of being abstinent at 6 months if the participant selected a quit date in weeks 1, 5, 10, and 13 were 39.6, 22.6, 10.9, and 4.3%, respectively.

Judy A. Shea, PhD; Aderinola Adejare, BA; Kevin G. Volpp, MD, PhD; Andrea B. Troxel, ScD; Darra Finnerty, MPH; Karen Hoffer, BS; Thomas Isaac, MD, MPH, MBA; Meredith Rosenthal, PhD; Thomas D. Sequist, MD, MPH; and David A. Asch, MD, MBA

Patients who enrolled in a trial to lower low-density lipoprotein cholesterol spoke positively of the multifaceted intervention: pillbox monitoring and financial incentives were socially acceptable

Meredith B. Rosenthal, Andrea B. Troxel, Kevin G. Volpp, Walter F. Stewart, Thomas D. Sequist, James B. Jones, AnneMarie G. Hirsch, Karen Hoffer, Jingsan Zhu, Wenli Wang, Amanda Hodlofski, Darra Finnerty, Jack J. Huang, David A. Asch

Patient characteristics can have a significant impact on response to incentives and other interventions

Adams SA, Leach MC, Feudtner C, Miller VA, Kenyon CC

This study will add to the literature by providing foundational feasibility data on which elements of a mobile health text-message reminder intervention may need to be modified to suit the needs and constraints of high-risk urban minority populations.

Kristin A.HarkinsBA, Jeffrey T.Kullgren MD, MS, MPH; Scarlett L.Bellamy ScD; Jason Karlawish MD; Karen Glanz PhD, MPH

Incentive schemes that use donations to a charity of choice, personal financial incentives, or a combination of the two can each increase older adults’ initial uptake of increased levels of walking.

Peter P. Reese, MD, MSCE, Roy D. Bloom, MD, Jennifer Trofe-Clark, PharmD, Adam Mussell, MA, Daniel Leidy, BA, Simona Levsky, BS, Jingsan Zhu, MS, MBA, Lin Yang, MS, Wenli Wang, MS, Andrea Troxel, ScD, Harold I. Feldman, MD, MSCE, Kevin Volpp, MD, PhD

Provider notification and customized reminders appear promising in helping patients achieve better medication adherence, but these strategies require evaluation in trials powered to detect differences in clinical outcomes

Ashok Reddy, Tiffany L. Huseman, Anne Canamucio, Steven C. Marcus, David A. AschK, evin Volpp, Judith A. Long

Simple nudges such as reminders and feedback reports to either a patient or a partner may facilitate improved medication adherence.

Adi Hirshberg,MD, Marianne D. Bittle,MSN,RNC–OB, Matthew VanDerTuyn,MID, Katy Mahraj,MSI, David A. Asch,MD,MBA, Roy Rosin,MBA, Ian Bennett,MD,PhD, Sindhu K. Srinivas,MD,MSCE

Our results suggest that remote blood pressure monitoring via text message communication engages patients and shows promise as a convenient and effective means of hypertension surveillance in the immediate postpartum period, in accordance to ACOG guidelines

Tianyu Liu, David A.Asch, Kevin G.Volpp, Jingsan Zhu, Wenli Wang, Andrea B.Troxel, Aderinola Adejare, Darra D.Finnerty, Karen Hoffer, Judy A.Shea

In primary care practices, shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a statistically significant difference in reduction of LDL-C levels at 12 months. This reduction was modest, however, and further information is needed to understand whether this approach represents good value

Stephen E. Kimmel, Andrea B. Troxel, Benjamin French, George Loewenstein, Jalpa A. Doshi, Todd E. H. Hecht, Mitchell Laskin, Colleen M. Brensinger, Chris Meussner, Kevin Volpp

Automated reminders led to the largest improvements in anticoagulation control, although without impacting measured adherence. Lottery‐based reminders improved measured adherence but did not lead to improved anticoagulation control.

Shivan J. Mehta, MD, MBA, MSHP; Andrea B. Troxel, ScD; Noora Marcus, MA; Christina Jameson, BS; Devon Taylor, BS; David A. Asch, MD, MBA; Kevin G. Volpp, MD, PhD

For low-risk interventions, opt-out approaches can improve the efficiency of recruitment, expand the intervention to those who are otherwise less likely to participate, and increase generalizability of clinical trials to a broader population.

Pamela A Shaw, William S Yancy, Jr, Lisa Wesby, Victoria Ulrich, Andrea B Troxel, David Huffman, Gary D Foster, Kevin Volpp

Obesity continues to be a serious public health challenge. Rates are increasing worldwide, with nearly 70% of the US adults overweight or obese, leading to increased clinical and economic burden. While successful approaches for achieving weight loss have been identified, techniques for long-term maintenance of initial weight loss have largely been unsuccessful. Financial incentive interventions have been shown in several settings to be successful in motivating participants to adopt healthy behaviors.

Andrea B. Troxel, ScD; Andrea B. Troxel, ScD; Andrea B. Troxel, David A. Asch, MD, MBA, Shivan J. Mehta, MD, MBA, MSHP, Laurie Norton, MA, Devon Taylor, BS, Tirza A. Calderon, MPH, Raymond Lim, MA, Jingsan Zhu, MS, MBA, Daniel M. Kolansky, MD, Brian M. Drachman, MD, Kevin G. Volpp, MD, PhD

Coronary artery disease is the single leading cause of death in the United States, and medications can significantly reduce the rate of repeat cardiovascular events and treatment procedures. Adherence to these medications, however, is very low.

Mitesh S. Patel, MD, MBA, MS, Kevin G. Volpp, MD, PhD, Roy Rosin, MBA, Scarlett L. Bellamy, ScD, Dylan S. Small, PhD, Michele A. Fletcher, CPA, Rosemary Osman-Koss, BS, Jennifer L. Brady, MA, RD, LDN, Nancy Haff, MD, Samantha M. Lee, BSE, Lisa Wesby, MS, Karen Hoffer, BS, David Shuttleworth, MS, Devon H. Taylor, BS, Victoria Hilbert, MPH, RD, Jingsan Zhu, MBA, MS, Lin Yang, MS, Xingmei Wang, MS, David A. Asch, MD, MBA

Social comparison to the 50th percentile with financial incentives was most effective for increasing physical activity.

Mitesh S. Patel, David A. Asch, Roy Rosin, Dylan S. Small, Scarlett L. Bellamy, Kimberly Eberbach, Karen J. Walters, Nancy Haff, Samantha M. Lee, Lisa Wesby, Karen Hoffer, David Shuttleworth, Devon H. Taylor, Victoria Hilbert, Jingsan Zhu, Lin Yang, Xingmei Wang, Kevin G. Volpp

Financial incentives rewarded for a combination of individual and team performance were most effective for increasing physical activity.

Jeffrey T. Kullgren, MD, MS, MPH, Andrea B. Troxel, ScD, George Loewenstein, PhD, Laurie A. Norton, MA, Dana Gatto, BS, Yuanyuan Tao, MS, Jingsan Zhu, MS, MBA, Heather Schofield, MS, PhD, Judy A. Shea, PhD, David A. Asch, MD, MBA, Thomas Pellathy, PhD, Jay Driggers, MBA, Kevin G. Volpp, MD, PhD

Participation in deposit contracts to promote weight loss was low, and matching deposits did not increase participation. For deposit contracts to impact population health, ongoing participation will need to be higher.

Peter P. Reese, Judd B. Kessler, Jalpa A. Doshi, Joelle Friedman, Adam S. Mussell, Caroline Carney, Jingsan Zhu, Wenli Wang, Andrea Troxel, Peinie Young, Victor Lawnicki, Swapnil Rajpathak, Kevin Volpp

Medication nonadherence is an important obstacle to cardiovascular disease management.

Loewenstein G, Price J, Volpp K

Over a 3- or 5-week period, students received an incentive for eating a serving of fruits or vegetables during lunch. Relative to an average baseline rate of 39%, providing small incentives doubled the fraction of children eating at least one serving of fruits or vegetables. Two months after the end of the intervention, the consumption rate at schools remained 21% above baseline for the 3-week treatment and 44% above baseline for the 5-week treatment. These findings indicate that short-run incentives can produce changes in behavior that persist after incentives are removed.

Scott D. Halpern, Benjamin French, Dylan S. Small, Kathryn Saulsgiver, Michael O. Harhay, Janet Audrain-McGovern, George Loewenstein, David A. Asch, and Kevin G. Volpp

Heterogeneity among smokers in their acceptance and response to different forms of incentives suggests potential benefits of targeting behavior-change interventions based on patient characteristics.

Mitesh S. Patel, David A. Asch, Andrea B. Troxel, Michele Fletcher, Rosemary Osman-Koss, Jennifer Brady, Lisa Wesby, Victoria Hilbert, Jingsan Zhu, Wenli Wang, and Kevin G. Volpp

The apparent failure of the incentives to promote weight loss suggests that employers that encourage weight reduction through workplace wellness programs should test alternatives to the conventional premium adjustment approach by using alternative incentive designs, larger incentives, or both.

Mitesh S. Patel, David A. Asch, Andrea B. Troxel, Michele Fletcher, Rosemary Osman-Koss, Jennifer Brady, Lisa Wesby, Victoria Hilbert, Jingsan Zhu, Wenli Wang, and Kevin G. Volpp

The apparent failure of the incentives to promote weight loss suggests that employers that encourage weight reduction through workplace wellness programs should test alternatives to the conventional premium adjustment approach by using alternative incentive designs, larger incentives, or both.

David A. Asch, MD; Andrea B. Troxel, ScD; Walter F. Stewart, PhD, MPH; Thomas D. Sequist, MD, MPH; James B. Jones, PhD; AnneMarie G. Hirsch, PhD, MPH; Karen Hoffer, BS; Jingsan Zhu, MBA; Wenli Wang, MS; Amanda Hodlofski, MPH; Antonette B. Frasch, MD; Mark G. Weiner, MD; Darra D. Finnerty, BS; Meredith B. Rosenthal, PhD; Kelsey Gangemi, MPH; Kevin G. Volpp, MD, PhD

In primary care practices, shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a statistically significant difference in reduction of LDL-C levels at 12 months. This reduction was modest, however, and further information is needed to understand whether this approach represents good value

Becker NV, Asch DA, Kullgren JT, Bellamy SL, Sen AP, Volpp KG.

To determine if two widely used behavioral change measures-Stages of Change (SoC) and Patient Activation Measure (PAM)-correlate with each other, are affected by financial incentives, or predict positive outcomes in the context of incentive-based health interventions.

Carolyn C. Cannuscio, ScD, Roxanne Dupuis, MSPH, Amy Graves, BA, Jane W. Seymour, MPH, Sarah Kounaves, MSc, Emily Strupp, BA, Damien Leri, MSEd, Rosemary Frasso, PhD, David Grande, MD, Zachary F. Meisel, MD

Adolescents and young adults with food allergies are at increased risk of adverse events, including death from anaphylaxis. Epinephrine is the cornerstone of emergency response, yet few individuals with serious food allergies consistently carry their emergency medication. A mixed-methods randomized controlled trial in young adults with food allergies investigated the carrying of epinephrine auto-injectors using financial incentives plus text message reminders vs text message reminders alone. Epinephrine carriage was assessed 10 times during the 49-day intervention using rapid-reply cell phone photographs plus daily code words. Although the intervention and control groups reported favorable impressions of text message-based reminder systems, the intervention group performed significantly better than the control group on a photograph-based measurement of epinephrine carriage.

Samuel T. Kuna, MD; David Shuttleworth Luqi Chi, MD; Sharon Schutte-Rodin, MD; Eliot Friedman, MD; Hengyi Guo; Sandeep Dhand, MD; Lin Yang, MS; Jingsan Zhu, MS, MBA; Scarlett L. Bellamy, ScD; Kevin G. Volpp, MD, PhD; David A. Asch, MD, MBA

Positive airway pressure adherence is significantly improved by giving patients Web access to information about their use of the treatment. Inclusion of a financial incentive in the first week had no additive effect in improving adherence.

Haff N, Patel MS, Lim R, Zhu J, Troxel AB, Asch DA, Volpp KG.

Financial incentives designed using concepts from behavioral economics were effective for promoting health behavior change. There were no large and consistent relationships between the effectiveness of financial incentives and observable demographic characteristics. Second-order examinations of incentive structure suggest potential relationships among the effectiveness of financial incentives, incentive structure, and the demographic characteristics of race and income.

Scott D. Halpern, M.D., Ph.D., Benjamin French, Ph.D., Dylan S. Small, Ph.D., Kathryn Saulsgiver, Ph.D., Michael O. Harhay, M.P.H., Janet Audrain-McGovern, Ph.D., George Loewenstein, Ph.D., Troyen A. Brennan, M.D., J.D., David A. Asch, M.D., M.B.A., and Kevin G. Volpp, M.D., Ph.D.

Reward-based programs were much more commonly accepted than deposit-based programs, leading to higher rates of sustained abstinence from smoking. Group-oriented incentive programs were no more effective than individual-oriented programs

Haff N, Patel MS, Lim R, Zhu J, Troxel AB, Asch DA, Volpp KG.

Evaluate the use of behavioral economics to design financial incentives to promote health behavior change and to explore associations with demographic characteristics

Meredith A. Case, BA; Holland A. Burwick; Kevin G. Volpp, MD, PhD; Mitesh S. Patel, MD, MBA, MS

Many smartphone applications and wearable devices were accurate for tracking step counts. Data from smartphones were only slightly different than observed step counts, but could be higher or lower. Wearable devices differed more and 1 device reported step counts more than 20% lower than observed. Step counts are often used to derive other measures of physical activity, such as distance or calories burned. Underlying differences in device accuracy may be compounded in these measures.

Meredith A. Case, BA; Holland A. Burwick; Kevin G. Volpp, MD, PhD; Mitesh S. Patel, MD, MBA, MS

The objective of this study was to evaluate the accuracy of smartphone applications and wearable devices compared with direct observation of step counts, a metric successfully used in interventions to improve clinical outcomes.

Mitesh S. Patel, MD, MBA, MS; David A. Asch, MD, MBA; Kevin G. Volpp, MD, PhD

The notion is that by recording and reporting information about behaviors such as physical activity or sleep patterns, these devices can educate and motivate individuals toward better habits and better health. The gap between recording information and changing behavior is substantial, however, and while these devices are increasing in popularity, little evidence suggests that they are bridging that gap.

Jeffrey T. Kullgren, MD, MS, MPH, Kristin A. Harkins, BA,d Scarlett L. Bellamy, ScD, Amy Gonzales, PhD, Yuanyuan Tao, MS, Jingsan Zhu, MS, MBA, Kevin G. Volpp, MD, PhD, David A. Asch, MD, MBA, Michele Heisler, MD, MPA, and Jason Karlawish, MD

Financial incentives and peer networks could be delivered through eHealth technologies to encourage older adults to walk more.

Aditi P. Sen, Taylor B. Sewell, E. Brooks Riley, Beth Stearman, Scarlett L. Bellamy, Michelle F. Hu, Yuanyuan Tao, Jingsan Zhu, James D. Park, George Loewenstein, David A. Asch, Kevin G. Volpp

Home wireless device monitoring could play an important role in improving the health of patients with poorly controlled chronic diseases, but daily engagement rates among these patients may be low.

Jeffrey T. Kullgren, MD, MS, MPH, Andrea B. Troxel, ScD, George Loewenstein, PhD, David A. Asch, MD, MBA, Laurie A. Norton, MA, Lisa Wesby, MS, Yuanyuan Tao, MS, Jingsan Zhu, MS, MBA, and Kevin G. Volpp, MD, PhD

Test the effectiveness of two financial incentive designs for promoting weight loss among obese employees

David A. Asch, MD, Kevin G. Volpp, MD, PhD

This Issue Brief describes the development and use of a new web-based IT platform, Way to Health, to deliver and evaluate behavioral interventions to improve health.

David A. Asch, M.D., M.B.A., Ralph W. Muller, M.A., and Kevin G. Volpp, M.D., Ph.D.

Even patients with chronic illness might spend only a few hours a year with a doctor or nurse, but they spend 5000 waking hours each year engaged in everything else — including deciding whether to take prescribed medications or follow other medical advice, deciding what to eat and drink and whether to smoke, and making other choices about activities that can profoundly affect their health.

Andrea B. Troxel, ScD and Kevin G. Volpp, MD, PhD

This study highlights that in the context of smoking cessation we have much to learn about the effectiveness of incentives; what is clear is that the current literature provides inadequate evidence to make a determination. More adequately powered studies that test variations in incentive design, magnitude, and payment schedule are needed to determine the effectiveness of this approach in increasing the rate of smoking cessation.

Judith A. Long, MD, Erica C. Jahnle, BA, Diane M. Richardson, PhD, George Loewenstein, PhD, and Kevin G. Volpp, MD, PhD

Compared to whites, African Americans have a greater incidence of diabetes, decreased control, and higher rates of micro-vascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes.

Judith A. Long, MD, Erica C. Jahnle, BA, Diane M. Richardson, PhD, George Loewenstein, PhD, and Kevin G. Volpp, MD, PhD

The objective of this study was to determine whether peer mentors or financial incentives are superior to usual care in helping African American Veterans improve their glycosylated hemoglobin (HbA1c) levels which was validated.

Scott D Halpern, David A Asch, Kevin G Volpp

In summary, there is great conceptual strength to the idea that commitment contracts can provide a way to health for the millions of people struggling to modify health behaviours that they themselves recognise as harmful. However, before they are implemented we need a careful assessment of key design features.

Kevin G. Volpp, M.D., Ph.D., Andrea B. Troxel, Sc.D., Mark V. Pauly, Ph.D., Henry A. Glick, Ph.D., Andrea Puig, B.A., David A. Asch, M.D., M.B.A., Robert Galvin, M.D., M.B.A., Jingsan Zhu, M.B.A., Fei Wan, M.S., Jill DeGuzman, B.S., Elizabeth Corbett, M.L.S., Janet Weiner, M.P.H., and Janet Audrain-McGovern, Ph.D.

In this study of employees of one large company, financial incentives for smoking cessation significantly increased the rates of smoking cessation.

Kevin G Volpp, George Loewenstein, Andrea B Troxel, Jalpa Doshi, Maureen Price, Mitchell Laskin and Stephen E Kimmel

A daily lottery-based financial incentive demonstrated the potential for significant improvements in missed doses of warfarin and time out of INR range.