ATLANTA — A trial that used behaviorally designed gamification and financial incentives or a combination of both to get people at cardiovascular risk to be more active demonstrated a significant increase in daily step counts.
The BE ACTIVE trial enrolled 1062 adults with clinical atherosclerotic cardiovascular disease or a heightened 10-year risk for myocardial infarction, stroke, or cardiovascular disease and showed that participants in all four arms, including controls, increased their daily step counts over 18 months.
However, participants given financial incentives or gaming points — or both — had more robust results, Alexander C. Fanaroff, MD, MHS, an assistant professor and interventional cardiologist at the University of Pennsylvania in Philadelphia reported at the American College of Cardiology (ACC) meeting. The results were published online simultaneously in Circulation.
The researchers say this is the largest and longest duration trial of interventions to increase physical activity.
“For someone taking about 5000 steps per day, an increase by 1700 steps would be associated with an increase in life expectancy by about 1.2 years,” Fanaroff told theheart.org | Medscape Cardiology. “And 700 steps was about what our intervention arms achieved compared with their own baseline over an 18-month follow-up, and then a 500-step increase which is about what they achieved compared with controls, which would be associated with about 0.4 years gained.”
Those estimates are based on data extrapolated from observational studies, he said.
Gamification, Financial Incentives
BE ACTIVE gave participants a Fitbit paired to an automated patient communication platform to follow their daily steps. In the gamification arm (n = 300), participants were granted 70 points each week and lost 10 points for each day they failed to meet their step goal. They received daily text messages notifying them of the number of points they had.
Participants in the financial-incentive arm (n = 300) received $14 in a virtual account each week, losing $2 for each day they failed to meet their step goal. If they met their goal, they kept their money. A similar number was assigned to the combination arm and half of that to the control arm. The control arm received daily text messages only.
But even control participants increased their daily step count just not as robustly as the other groups. Through the initial 12-month intervention period, the average increase in baseline daily steps were: 1418 for control, 1945 for gamification, 1915 for financial incentives, and 2297 for combination. In the 6-month follow-up period, those increases slid back some, but were still meaningful: 1245, 1708, 1576, and 1831 steps, respectively.
The trial also calculated change in minutes of moderate to vigorous physical activity (MVPA), for which the Centers for Disease Control and Prevention recommends 150 minutes weekly. The respective weekly MVPA increases in the four arms in the 12-month main intervention period were 40, 55, 57, and 65 minutes.
“We think that these highly scalable, automatically delivered interventions increase physical activity over a longer period in patients at high risk for cardiovascular events and could improve outcomes,” Fanaroff said in presenting the results.
“To me, that’s what’s most exciting: We do think it’s scalable,” Fanaroff told theheart.org | Medscape Cardiology. “When thinking about scaling this, the fact that we have this automated system, once you set it up — some people need help connecting their wearable device to the platform — it sort of runs itself.”
As for who pays for the financial incentive component, Fanaroff said, “That’s a great question.” Further study of incentive programs could provide further evidence to persuade payers and healthcare systems to chip in, he said. “We know that we can increase physical activity,” he said. “We know that physical activity is associated with a reduction in mortality. What we don’t know is that if I increase physical activity in this way, will I reduce mortality? Will I reduce cardiovascular events?”
Self-Motivation Still Important
Incoming ACC President Cathleen Biga, MSN, a cardiac rehabilitation specialist and president and CEO of Cardiovascular Management of Illinois, said that the study presented a unique approach to increasing physical activity in at-risk patients, but that self-motivation is still critical.
“One of the biggest issues that we’ve got in population health is, we don’t move,” Riga said in an interview. “If you pay somebody to do it, if you do ‘at-a-boys,’ if it’s personal gratification — or does it have to be self-induced? You have to want to do it and you have to make it happen in your life. One of the results of the study was, it comes down to the individual and what do they really want to do.”
But the study illustrates the importance of getting the at-risk patient population to increase physical activity, she said. “I thought it was a great start,” Biga added. “It would be interesting to see what they do with it, but I think in our current economic environment I’m not sure how far it goes.”
She also questioned the practicality of widespread adoption of such an approach at this time. “If you go to the bottom line — how easy is this to put in my practice? On a scale of 1 to 10, I think it would be pretty difficult.
The study received funding from the National Institutes of Health. Fanaroff reported no relevant financial relationships. Biga has no relevant financial relationships.
Richard Mark Kirkner is a medical journalist based in the Philadelphia area.
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