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Original Investigation
August 2017

Effect of Electronic Reminders, Financial Incentives, and Social Support on Outcomes After Myocardial InfarctionThe HeartStrong Randomized Clinical Trial

Author Affiliations
  • 1Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 2Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia
  • 3Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania
  • 4Health Care Management, Wharton School of the University of Pennsylvania, Philadelphia
  • 5Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 6LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
  • 7Division of Biostatistics, New York University, New York
  • 8University of Pennsylvania Health System, Philadelphia
  • 9Operations and Information Management, Wharton School of the University of Pennsylvania, Philadelphia
  • 10Humana, Louisville, Kentucky
  • 11Horizon Blue Cross Blue Shield, Newark, New Jersey
  • 12Independence Blue Shield, Philadelphia, Pennsylvania
  • 13Aetna, Hartford, Connecticut
JAMA Intern Med. 2017;177(8):1093-1101. doi:10.1001/jamainternmed.2017.2449
Key Points

Question  What is the effect of wireless technology and behavioral economic approaches on vascular rehospitalization and medication adherence in a health plan–based intervention for acute myocardial infarction survivors?

Findings  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.

Meaning  A compound intervention did not significantly improve medication adherence or clinical outcomes.

Abstract

Importance  Adherence to medications prescribed after acute myocardial infarction (AMI) is low. Wireless technology and behavioral economic approaches have shown promise in improving health behaviors.

Objective  To determine whether a system of medication reminders using financial incentives and social support delays subsequent vascular events in patients following AMI compared with usual care.

Design, Setting, and Participants  Two-arm, randomized clinical trial with a 12-month intervention conducted from 2013 through 2016. Investigators were blinded to study group, but participants were not. Design was a health plan–intermediated intervention for members of several health plans. We recruited 1509 participants from 7179 contacted AMI survivors (insured with 5 large US insurers nationally or with Medicare fee-for-service at the University of Pennsylvania Health System). Patients aged 18 to 80 years were eligible if currently prescribed at least 2 of 4 study medications (statin, aspirin, β-blocker, antiplatelet agent), and were hospital inpatients for 1 to 180 days and discharged home with a principal diagnosis of AMI.

Interventions  Patients were randomized 2:1 to an intervention using electronic pill bottles combined with lottery incentives and social support for medication adherence (1003 patients), or to usual care (506 patients).

Main Outcomes and Measures  Primary outcome was time to first vascular rehospitalization or death. Secondary outcomes were time to first all-cause rehospitalization, total number of repeated hospitalizations, medication adherence, and total medical costs.

Results  A total of 35.5% of participants were female (n = 536); mean (SD) age was 61.0 (10.3) years. There were no statistically significant differences between study arms in time to first rehospitalization for a vascular event or death (hazard ratio, 1.04; 95% CI, 0.71 to 1.52; P = .84), time to first all-cause rehospitalization (hazard ratio, 0.89; 95% CI, 0.73 to 1.09; P = .27), or total number of repeated hospitalizations (hazard ratio, 0.94; 95% CI, 0.60 to 1.48; P = .79). Mean (SD) medication adherence did not differ between control (0.42 [0.39]) and intervention (0.46 [0.39]) (difference, 0.04; 95% CI, −0.01 to 0.09; P = .10). Mean (SD) medical costs in 12 months following enrollment did not differ between control ($29 811 [$74 850]) and intervention ($24 038 [$66 915]) (difference, −$5773; 95% CI, −$13 682 to $2137; P = .15).

Conclusions and Relevance  A compound intervention integrating wireless pill bottles, lottery-based incentives, and social support did not significantly improve medication adherence or vascular readmission outcomes for AMI survivors.

Trial Registration  clinicaltrials.gov Identifier: NCT01800201

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