Speaker
Alexander Fanaroff, MD, MHS
Assistant Professor of Medicine
Perelman School of Medicine
University of Pennsylvania
Keywords
Gamification; Financial Incentives; Physical Activity; Behavioral Economics
Key Points
- Observational studies have found an inverse association between steps per day and risk for all-cause mortality and cardiovascular events. Though national surveys indicate the vast majority of people believe that exercise has many health benefits, many don’t exercise.
- Behavioral economics seeks to explain why people make the decisions they do using concepts from economics and psychology. Dr. Fanaroff discussed how known biases in decision making – immediacy bias, status quo bias, and the endowment effect – create a disconnect between the “planner” self and the “doer” self. This framework can be used to understand why people don’t exercise, even when they know they should.
- Another barrier that the research team identified was that existing guidelines from the American College of Cardiology and American Heart Association lack specificity and strong supporting evidence. Dr. Fanaroff ultimately introduced an alternative recommendation based on their findings.
- The research team sought to leverage our existing biases in order to facilitate a sustained increase in physical activity. In a randomized controlled trial, they compared the effectiveness of gamification, financial incentives, and a combination of the two on increasing physical activity over a 12-month intervention period and a 6-month follow-up period.
- After noting a discrepancy between the proportion of Black patients in the target population and participant population, the research team adjusted their recruitment strategy until they had a representative group. While direct-to-patient recruitment avoids biases related to who physicians invite to clinical trials, it may introduce biases related to who trusts researchers enough to join a study.
- The research team found that gamification and financial incentives were roughly equally effective, leading to about 500 more steps per day than the control group. The combination arm saw the biggest improvement, with about 850 more steps per day than the control group. In practice, gamification is the more scalable and inexpensive of the interventions.
- If stakeholders are to pay for an intervention like this, large scale clinical trials are needed to show improvements in patient-centered outcomes or clinical events.
Discussion Themes
Pharmaceutical interventions are not expected to be effective once treatment has ceased. If a behavioral intervention is shown to be effective during the period in which it’s administered, should it be held to a standard of long-term sustainability?
Patients set their own step count goals according to their baseline when the trial started.
The components of the intervention guided by behavioral economic theory, i.e. the immediacy of the innovation, the loss (rather than gain) of cash and/or points, and the support partners, differentiates it from the gamification built in to many wearables and fitness trackers.