In Series 3 Episode 1 of the Health Points podcast hosts Ben and Pete sit down with Dr. Alexander Fanaroff, an interventional cardiologist and Assistant Professor of Medicine at the University of Pennsylvania, to discuss his groundbreaking research on using gamification and financial incentives to boost physical activity among patients with cardiovascular disease.
Dr. Fanaroff's journey into medicine and cardiology was driven by his fascination with complex problems and his desire to help people. His specialization in cardiology revealed a common challenge: many patients wanted to increase their physical activity but struggled to begin. This observation led him to explore the potential of gamification—using game-like elements to motivate and engage patients.
One of the key insights from this episode is the difficulty of behavior change, particularly in the context of physical activity. Dr. Fanaroff explains that concepts from behavioral economics, such as status quo bias (the tendency to stick with what we know) and immediacy bias (favoring immediate rewards over future benefits), play significant roles in this challenge. These biases make it hard for individuals to start and maintain new exercise routines, even when they understand the long-term benefits.
The advantages of regular physical activity are well-documented. Exercise can lead to weight loss, improved mood, better sleep, and enhanced cardiovascular health. Dr. Fanaroff notes that his patients who engage in regular physical activity report feeling better, being able to participate in more activities, and enjoying a longer health span. These benefits extend beyond physical health, contributing to overall well-being and quality of life.
Dr. Fanaroff addresses concerns about the safety of exercise for patients with cardiovascular disease. He emphasizes that, when done responsibly, the immediate risks are minimal. Symptoms like chest pain or shortness of breath during exertion should be seen as signals to slow down and rest, rather than indicators of impending heart attacks. Starting with moderate activity levels and gradually increasing intensity can help mitigate risks.
The centerpiece of this episode is Dr. Fanaroff's BEACTIVE study, which aimed to evaluate the effectiveness of gamification and financial incentives in promoting physical activity among patients at high risk of cardiovascular events. The study involved 1,050 participants, divided into four groups: attention control, gamification, financial incentives, and a combination of gamification and financial incentives.
Participants were equipped with Fitbit devices to track their baseline step counts over two weeks. They then set personalized goals to increase their daily steps by 33-50%. The attention control group received daily text messages about their progress. The financial incentives group had money added to a virtual account, with deductions for not meeting goals. The gamification group earned points and levels, with social support partners providing encouragement. The combination group received both financial and gamification interventions.
The study revealed significant increases in physical activity across all groups, with gamification and financial incentives proving more effective than the control. The gamification group increased their activity by approximately 1,900 steps per day, while the financial incentives group saw an increase of about 1,600 steps. The combination group showed a high increase at around 1,800 steps. Importantly, these gains persisted even after the interventions ended, demonstrating the lasting impact of gamification.
For health and gamification professionals, this episode offers valuable insights into the design and implementation of effective health gamification projects. Dr. Fanaroff suggests that the approach used in the control group—setting goals and monitoring progress—can be easily replicated in clinical practice. Health systems can implement scalable gamification programs to motivate patients, leveraging the cost-effectiveness and accessibility of wearable devices and text messaging.
Looking ahead, Dr. Fanaroff aims to apply these gamification strategies to patients with symptomatic cardiovascular diseases, such as heart failure and peripheral artery disease, where physical activity can alleviate symptoms. He also envisions larger studies to confirm the long-term benefits of gamification in reducing cardiovascular events.
Dr. Fanaroff's work highlights the potential of gamification to transform cardiovascular health. By understanding the behavioural barriers to physical activity and leveraging innovative strategies, healthcare providers can help patients lead healthier, more active lives. The BEACTIVE study's promising results pave the way for future research and practical applications in clinical settings.
Tune in to this episode to gain a deeper understanding of how gamification and financial incentives can be used to motivate physical activity, and discover best practices for designing and implementing your own health gamification projects. Whether you're interested in the comparative effectiveness of financial rewards versus gamification rewards or looking for inspiration to enhance your current initiatives, this episode is packed with valuable insights and actionable takeaways.
You can listen to this episode below:
Episode Transcript:
00:00:06 Ben
Hey everyone and welcome to another episode of Health Points where we talk about anything and everything, gamification and health. I'm Ben and here with me today is my cohost Pete.
00:00:16 Pete
Great to be here.
00:00:16 Ben
And joining us today, we have of us Doctor Alexander Fanaroff, who was a medical doctor of interventional cardiology and Assistant Professor of medicine in the Division of Cardiology at the University of Pennsylvania. He has a specific interest in increasing physical activity in patients with cardiovascular disease.
And published a research paper this year exploring the effectiveness of gamification and financial incentives, or both of them to increase physical activity among patients with high risk of cardiovascular events. Alexander it's great to have you on the show.
00:00:54 Alexander
Great to be here.
00:00:55 Ben
Wonderful stuff. So you have quite the bio. You'd be great to know more about your background, what led you into medicine, what led you into cardiology and what led you into gamification?
00:01:06 Alexander
Yes. So I am an interventional cardiologist at the University of Pennsylvania. Like you said, I came to medicine, I think because I found the questions interesting and the ability to help.
People interesting and then became a researcher because I thought that it was an opportunity to help people on a larger scale and to sort of help solve some of the problems that I saw every day when I was seeing patients. So I I trained in in clinical research and clinical trials at Duke University of North Carolina and then came up here to the University of Pennsylvania.
Where I've been building a research programme focused on changing patient behaviour and changing provider behaviour as well to try and improve the the way that we deliver care and So what led me to gamification? Well, limited physical activity, I'll say, and it's motivation is when I see patients in clinic.
Most of them tell me they want to do more. They want to exercise more. They want to because they know that it's beneficial to them. They know that it reduces their risk of cardiovascular events. They know that it can help them feel better, but most of them really have a hard time starting. They sort of don't know where to start and that that really led me to to think about, you know, how can I?
00:02:14 Alexander
Help them how can I help them do something they want to do that I know is. Good for them and I started working with some folks when I came to Penn that are behavioural economists and and they sort of drew me. Into the world. Of thinking about how people make decisions and how we can affect people, make decisions and that led to to this idea of gamification. So that's that's sort of how I came. Around to it.
00:02:35 Pete
So what's what's the background to the problem? So like? Why isn't it working your doctor telling you to do some more exercise to get you started?
00:02:44 Alexander
We know. That behaviour change is hard.
And we there are all these concepts and behavioural economics that explain the way that people make decisions and and the way that that people don't necessarily make decisions that are always in their best.
00:03:00 Alexander
Because there are things like status quo bias, which sort of suggests that we don't want to change, and there are things like immediacy bias, which is the idea that we really discount any future benefits in favour of more proximal cost. So those two things together.
I think explain a lot of the reason that people have a hard time starting a physical activity. Programme. Just that it's hard to make changes and it's hard to get off the couch when sitting on the couch is good and you know, for some of our patients with with cardiovascular disease, they have symptoms when they try to when they try to move more and we can talk about this a little bit. More later? Maybe, but. Physical activity in some of these patients that have symptoms related to physical activity actually helps reduce symptoms with physical activity in the future. So physical activity begets.
An easier time doing physical activity but starting is hard and so I think that that is what limits people in general from doing more physical activity and then specifically for some of our cardiovascular patients that have symptoms when they when they try to move around.
00:04:10 Ben
Makes a huge amount of sense, so in that case you mentioned about the benefits of physical activity within your previous clinical practise current clinical practise. What do you see or what do feedback do you get from patients who are being more physically active?
00:04:24 Alexander
When patients are more physically active. First of all, I see I see some of them lose weight. Not all of them, but I see them generally.
00:04:33 Alexander
Feel better? They feel better about themselves. They're able to do more. You know, I'm I'm a cardiologist, so most of the patients I see are older. So they tell me that they're able to chase after grandkids and hike and just stay active longer. I think that.
00:04:52 Alexander
You know the there, there are all sorts of benefits of physical activity that we see in sort of the in sort of the literature where we see that people that take more steps per day are less likely to die of cardiovascular causes are less likely to die of all causes or less likely to die of cancer, have better controlled blood pressure, have better controlled cholesterol, better controlled.
00:05:12 Alexander
Diabetes. They sleep better, they have less depression. There are all these benefits that we know from the literature. But. But really when when I see patients that are physically active, they can do the things that they want to do longer. They have a longer health span. And I think that that's that's.
00:05:27 Alexander
Of all the things that my patients want, that is what they what they tell me they want the most is to be healthier, for longer and do the things that. They want to do. Could.
00:05:37 Ben
Degree more and we're all living longer, but we're not living better, longer lives that that improve health span as opposed to just lifespan is a really key thing. And I think talking about, as you mentioned, a lot of these benefits can be months to years away from people being active and actually focusing on that feeling better, being able to do something.
Tomorrow or next week, more than you can today. That immediately bias is then reduced, so actually they can attain in the short term completely agree.
00:06:06 Alexander
Yeah, I I think so. I mean, you know those benefits are they're they're weeks and months away. So I think for some that's even hard and I think that's where this idea of unification comes in. But I I I totally agree that you know I see patients that when they get more physically active see benefits in, in weeks and months and by and converse when I see patients that. Reduce their physical activity because of a life event. They notice it pretty quickly and it takes them. It takes them a little while to build back up to feeling the way they did before.
00:06:36 Ben
So just before we go into your research. Just what are the? Risks, then, for people living with cardiovascular disease, of being active, because if, if they're experiencing symptoms already, if they're maybe doing a little bit of activity and maybe have some heightened sensations and symptoms, are there risks or do the benefits outweigh those risks?
00:06:56 Alexander
We really don't see any risks of physical activity per se. So I mentioned that people have symptoms and you know, for some people this might be chest pain with the exertion or shortness of breath, exertion or in people with with blockages and leg arteries, it could be could be pain in their legs when they walk.
These symptoms are important and they're distressing to people, but having chest pain physical activity is not a sign of an impending heart attack. There's no evidence that increasing physical activity contributes to heart attacks as long as people do it responsibly.
And you know, don't try to get up off the couch and run a marathon. The risks of physical activity, the immediate risk of physical activity to even people with heart disease are pretty negligible. What I tell my patients is that if they have symptoms, that is a sign that their body is telling them to slow down.
00:07:56 Alexander
And that they should rest till the symptoms get better and then they should. They should pick back up again and I tell them when they're first starting out to really only do something that they could have a conversation with somebody while they're doing it. Never get so out of breath.
That you can't have a conversation with somebody and you know that's not necessarily an evidence based recommendation, but it seems to work for my patients, you know, in in the, in the, in the study that we're going to talk about the active study, we saw no adverse events specifically related to to physical activity.
Aside from orthopaedic injuries, essentially when people when older adults start to exercise more, they get, you know. Hip pain and knee pain and some of them had to, you know, just by chance. Some of them wound up having hip and knee replacements during the study period, which which we saw in in the data. But these are, I think that for most for many patients, these sorts of orthopaedic issues are are either inevitable. And certainly outweighed by the benefits.
00:09:03 Ben
Yeah, from an MSK orthopaedic point of view, yes, the benefits still outweigh the risks. And if those people had hip and knee replacements, they were probably going to have them. It wasn't the programme itself that led them there. If anything, it may have delayed some if in the replacements or other participants in the study.
In that case, Alexander, let's go deeper into it, then talk us through the study, talk us through where the idea came from the process into applying for it, and interestingly, ethical approval is we speak to a lot of researchers and on health points and the ethical approval process around gamification and research can be really challenging. Yeah.
00:09:39 Alexander
Yes. So the idea for this comes from from work that our group here at Penn has been doing actually since before I got here looking at different approaches to increased physical activity and different ways to incorporate behavioural economic concepts into into these studies, so.
You know, some of the first studies that that our group did sort of developed this gamification intervention that we wound up testing in smaller cohorts, tried to use ties between family members and other social groups to.
00:10:17 Alexander
Drive physical activity changes and essentially the study is sort of sort of grew in size and duration and what these initial studies showed is that. For. Physical activity increases to be meaningful. They have to be sustained because that's how they lead to, you know. Longer term, changes in functional capacity and reductions in risk, so and we didn't know that. And then the other thing we didn't know is how did gamification compare with financial incentives because that has implications for, you know, public health and designing programmes like this so.
00:11:06 Alexander
What this study was intended to do was to answer the question of did this gamification intervention and these financial incentives interventions that we've developed over other studies and shown increased physical activity? Do they work over a longer term period? Can't will patients stay engaged through a year?
After a year, will the will the changes that we see in physical activity persist after that? And then the and the other thing was was designed to do was to compare gamification and financial incentives so that we know you know is is 1 approach better or are they about?
The same.
Those, those are the main questions we're trying to answer. So the study was funded by the National Institutes of Health. Here in the United States.
The you know, we applied for the grant and and got it, I think on the strength of our of our preliminary research and you know the the Nice thing about the fact that we have so much military research is that ethical approvals were not terribly challenging. You know our our IRB institution of reward at the University of Pennsylvania.
00:12:09 Alexander
Has seen this before and sort of knows what to expect and understands what we're doing.
And I think that, you know, one of one of the keys is really just, you know, we're not going to harm people with this, that the, you know, all we're doing is is sort of asking them to walk more and and helping motivate them to walk more. And actually that to study we we had a we had a A data safety and monitoring board that that met as well and I think.
You know, perhaps that allied some concerns as far as ethics, but we really didn't have any trouble with ethical approvals for this study.
00:12:46 Ben
In that case, how big was your sample? How many did you need to include?
00:12:51 Alexander
So we wound up enrolling 1050 patients, so 150 or so were randomised to attention control and then 300 each to gamification, financial incentives and the combination of gamification.
Less financial incentives and we were powered to detect a change and steps between the control group in any of the intervention groups of about 750 steps per day.
Which is, you know, sort of a reasonable, a reasonable change and one that that corresponds pretty well with the number of steps, I guess. You know, there's a, there's a linear association between steps per day and and reduction in mortality. And so this gives, you know, a reasonable change in in mortality.
Based on the observational studies that we saw, so that was that was the number of patients that that we enrolled.
The way that we enrol patients, I think was a little different than how clinical trials in cardiology tend to enrol. We essentially took a hands off approach to recruitment. We contacted patients by e-mail or text message with a link to our study platform.
A web-based study platform and patients that we're interested in and clicked the link were taken to our study website where they where they enrolled. They completed informed consent online through a process that we developed that sort of make sure that they read the whole thing and and understand. And it. Completed baseline questionnaires and then we mailed them a Fitbit device so a little bit of a of a of a different approach to to enrollment. And I think that one of the things that that we thought that we we we have to contact about 100,000 patients to enrol 1000 and most of those patients. Didn't click on the link at all, so you know most people got an e-mail and they were like, well, this is spam or they got a text message because now we get we get spam text messages and they and they just ignored it of people that navigate to the site and learn more about the study, the uptake was was much higher.
00:15:06 Ben
I mean, you look at other marketing, communication and advertising, I think 1% success rate through to actually taking part in the programme. I think it's pretty good. Yeah, it's pretty good going, but it highlights for these large sample sizes you need to engage huge potential participants in the study.
And the cost of that of more traditional research programmes, whether it be a research assistant going to meet these people, setting them up, it would have been impractical from a cost perspective. But actually it's it's this is the way the world works and actually inviting people to be part of a study like that replicates what a future service would look like too. So I think that's. Just a real. Real data. I think it's a really good way to do sample selection.
00:15:48 Alexander
There are obviously some downsides in that you get a population of patients that is interested in your study, but I think that's true of any. Of any clinical trial.
And I agree that if this were rolled out by a health system or anything like that, you know the patients that wanted to be the ones that would, we're looking at ways to adjust our outreach to make it more attractive people to, to help sort of cut through their people spam philtres a little bit and we're we're having some success with it.
That I think that that's, you know, the question is you know can we can we do better and I think I think we always can and that's we're working on.
00:16:23 Ben
So in that case, what was the gamification element and what was the financial incentive that people were offered?
00:16:30 Alexander
Yeah. So I'll. Back up a little bit and tell you about the design of the design of the studies. I think that's important to understanding the gamification. So we sent people a Fitbit device and they wore it for two weeks to to set their baseline step count and the data was transmitted directly to our research team by Fitbit. Through this platform we have for for clinical research and gamification. Research called the called the way to health platform that we have at Penn.
So they all participants wore the the Fitbit for two weeks and we used the second week of data to determine their baseline step count. And we use the second week because when you give people a Fitbit, they start walking more because they have this new toy. And so once people have their baseline step count, we sent them a text message and asked them to set a goal.
To increase their their daily steps by 33 to 50% above baseline and we let them set their own goal because we actually have some. We've done some studies showing that when people set their own goals, they're more likely to reach it than when you give them a goal.
And the other nice thing about sort of setting a goal at a percentage of their baseline is that.
It makes it achievable.
That to them, rather than saying your goal is to 10,000 steps when some of these when when our average patient took about. 5000 steps per day we let them. We let them set their own goal in sort of a reasonable range. So once they set their goal, we then randomise them to three arms. The Attention Control Group got a text message every day telling them whether they met their goal the day before. And that was the only.Intervention they got.
00:18:01 Alexander
The financial incentives arm we put $14.00 into a virtual account. Every week and every day, they didn't meet their goal, they lost $2.00 and they got a text message saying you didn't meet your goal. Yesterday you lost $2.00. You have $12.00 left this week or you met your goal yesterday. You kept your money. Great job. You still have $14.00 in your account for this week.
And then the gamification arm was sort of a similar design where we used loss framing. So every week we gave participants 70 points.
And on days that they met their goal, they kept 10 points on days that they didn't meet their goal, they lost 10 points and they got a text message every day telling them where they met their goal, whether they, whether they kept their lost their points and how many points they had for the week. At the end of each week, participants that had 40 or more points.
Upper level Christmas that had 40 had had fewer than 40 points moved down a level, and there were 5 levels. Blue, bronze, silver, gold and platinum, and the levels were, you know, essentially meaningless. But they they did give a a status for people to to, to hang on to.
And at the end of the intervention, participants in the two highest levels got a trophy and they knew they would. They would get a trophy if they if they stayed in the in the top 2 levels. The other thing we did for the gamification, our participants is every eight weeks, participants in the two lowest levels were contacted and given a given an option to readjust their goal as long as they kept it.
Within the within the original. Metres and they were also reset back to the silver level so they wouldn't sort of be languishing in the in the lower levels. And then in the gamification arm, each participant identified as social support partner, so a family member or friend that they thought cared about them and that at the beginning study participated in a three-way phone call with our study team where they talked about.
Ways that the support partner could help the participant increase physical activity and then got an e-mail every week telling them how their how their participant was doing in the study and reminding them of of things they talked about to how they could help their their.
Their participant in the study. So that was the implication. And then the gamification and financial incentives arm, the group that got both really just got both. There was no integration of the two intentions, they just. They just got both.
00:20:22 Ben
If I was in the design some gamification elements for a health motivational programme, you've ticked a lot of boxes for Alexander. I'm just thinking about.
Some number of sessions that people I've done before of different speakers and you've taken like the best of a very long bunch and and actually has gone into so many underpinning theories of gamification and you've really done your homework on designing that into. Mention. Yeah, that was that.
00:20:46 Alexander
Was the goal and and it was. It was sort of developed their iterative process where we we were you know our group was was lucky enough to be able to sort of have seed funding and and smaller grants to test really a number of different approaches. You know we we did a the group before I got here did a whole trial where we tested. Goal setting approaches so you know whether they set their own goal versus versus have a goal set for them.
And you know, we did a there was a study looking at competition versus support versus cooperation, you know, so so really had a had an opportunity to sort of refine this intervention over a number of years and and come to something that that we think.
Makes sense?
00:21:30 Ben
So what did you find?
00:21:32 Alexander
So I think the first thing we found.
Is that just? Just the control arm, so just having people set a goal and then reminding of that goal every day increased physical activity. By 1400 steps from baseline. So that's we get, we'll get, I'll get back to that. I think that that's an important finding, but that's that's a pretty substantial effect and I guess not just having them set the goal and reminding them but. Also, knowing that the study team was watching them so.
The gamification arm increased physical activity by 1900 steps 950 steps from baseline through the end of the 12 month intervention period. So about 500 steps more than the control arm.
And financial incentives. Was was about the same about 500 steps per day, more than the than the control over the 12 month follow up period.
And then the combination increased physical activity by about 870 steps more than the control over the 12 month over the 12 month follow up period.
And then after 12 months.
All of the all the patients, all the participants were switched to the control condition and we just followed them for an additional six months and we saw that the that the daily steps in all arms decreased at that.
So control from baseline through the end of the six month follow up period, we're taking about 12150 steps more than their baseline. Gamification was taking about 1700 steps more than baseline, again about 450 more than control financial incentives about 1600 steps more than their baseline, so about about 300. More than the control arm and then the combination of of of gamification, plus financial incentives, about 1800 steps more from baseline. So about 600 more other than the control so. I think that the summary is that we had.
Big gains in physical activity in all arms, including the control arm. But the gamification and financial incentives both increased, increased activity more than the control arm. I think substantially more 500 steps per day is more with benefits that were.
Attenuated at follow up after after we got rid of intervention, but that persisted.
And I think that one way to think about the results is that is I think there are a few takeaways. So I think that the first one is that gamification, financial incentives and the combination are both more effective. Are all more effective than control and increasing physical activity? I think that they are also in all of interventions, including control, were effective at increasing.
Activity substantially above participants baseline. So if you look at, if you look at daily physical activity, you see a big increase after they set their goal that persists throughout follow up. You know it declines but it it does persist and I think that that's that's meaning.
Tail and then the last bit is that gamification, you know, by everything that we looked at is as they're more effective than financial incentives, which I think has big implications for thinking about how to design incentive programmes for increasing physical.
00:24:30 Ben
Activity completely agree. I think the fact that benefits persisted beyond the intervention and that. That was higher in the gamification arm and the financial. Too. Uh. One of the things that we've had chats a lot about health on health points is do you only get the benefits for gamification during the time you're involved in gamification and actually having the follow up over six months is so valuable because there are so few studies that I ever read that do this, that.
Beyond the intervention itself, it's a brilliant study and given the size of the population you engaged, it's really powerful. Yeah, incredible. Work.
00:25:07 Alexander
Thank you. Yeah, I agree. And I you know, I I think that that you know gamification is interesting because the marginal costs over time are so small. So you you could imagine a health system, you know.
Just sort of. Putting their patients do gamification programme in perpetuity, because you know all all it costs is you know the the cost is marginal once you get them engaged, you know they they can stay engaged. But I think that, you know, I think that that that's one way to think about results and the other way is to think that you know when you get people to make behaviour to change their behaviour.
00:25:44 Alexander
Some of that persists. You know, in in some people and I think that.
You know, and I think that's that's because people recognise that physical activity makes them feel better and and people want to do more physical activity and and once they get started, I think, you know you you start to build habits. You know one thing that that I think would be interesting to look at in the future is you know.
Can you design a system where people get gamification for long and build a habit and then it goes away and then when they need it, it comes back because you know what I see in my patients is that that, you know, often life events intervene and make them do less make make them less physically active and and they they need a boost to get started again.
Can we use gamification as that sort of boost?
00:26:32 Pete
That's a really good point. I like that because often we've talked about. Gamification should make itself obsolete. You should. It should be like a scaffolding to build the new habits in, but what you've cottoned onto with the life events is that yeah, life gets in the way and people need a a start. To get off again. You mentioned like you you've after the study. You then looked at the next six months in the control status. Are there any plans to look at these patients again in like 12 months, 24 months and see if there's still a difference?
00:27:08 Alexander
I wish we had those plans. We don't. Once the patients, the patients consented to have their data sent to us for 18 months. And and after that we won't get their data. But one thing you said though about, you know, thinking about gamification is a scaffolding that that should that should go away.
You know, it's interesting to me and and I hear this too, when we're talking about this study, how can you prove he will stay engaged for a longer term? How can you prove that these, that these benefits will will persist after you get rid of the invention? And to me, I I see how I see people are saying that. But I also think that it's something of a I don't, I don't necessarily agree with the premise.
If I were testing another intervention that was a drug to lower cholesterol. I would never. Say well, when I when people stopped taking this medicine, their cholesterol goes back up again. I mean, that's, you know, like that that's that doesn't make any sense. And I think that we have a cost effectiveness analysis of our intervention coming.
We're we're going to do it. These physical activity interventions are they're so cost effective compared to other things that we. Still, it just I think it just it tends to reflect the way that people think about physical activity as something that people should just be able to do and a question of willpower or desire or like a personal failing. If you don't get enough physical activity rather than like a consequence of of.
Psychology and you know the world and human nature and you know it just it doesn't part of me wants to just reject this premise that that physical activity should just be something that we we start people on and they should be able to continue on their own.
00:28:47 Ben
What do you think the learnings? I also can't wait to see the cost of cost effective analysis coming out. What do you think the learnings and implications are for for clinical practise generally, are the learnings here more for organisations who Fitbit, Google, Apple watches? Or are the learnings here more for the clinicians and patients?
Is it both and and how do we implement them? There's great research here that one of the toughest things is actually taking published research to put it into actual clinical practise. Where does it go next?
00:29:18 Alexander
So I think the first the implication for a clinician that's seeing patients right now is that what we did in the control. Arm is pretty replicable in in routine clinical practise. Many of my patients have Fitbits or Apple watches, and you know, even more of them have iPhones or other smartphones that track steps. What we did in the control arm was we got people, we got people to figure out what their baseline was. We had them set a goal and then we. Cared about, we we had somebody cared about what? What their staff count. Was.
So you know that I think is replicable in practise where you know you can say to your patient, take out your take out your your phone. Let's see how many steps a day you're taking. Let's set a goal to increase. That by 30. 5% and when you come back, I'm gonna look at your phone with you, and we're gonna see how many steps. You too.
And I think that's that's pretty replicable in clinical practise. I don't think that that you know a doctor is going to be, you know, running a gamification invention or offering their patients money. But I think they can do that. I think that the the implications for health systems.
00:30:23 Alexander
Are that you know, especially once you see once we see the cost effectiveness analysis, these are programmes that are effective and that are that are cost effective. Hurt. Not that expensive and not that hard to scale. I mean we didn't, you know, we didn't, we didn't have specialised personnel, we didn't have physical therapists talking to patients. We had clinical research coordinators, you know, running, doing these these three-way phone calls with patients and support partners and then everything else was automated. So it's this is it's a scalable.
00:30:52 Alexander
Programme, you know, as I think about where the evidence has to go to really convince health systems and payers, the gap here is that we know that people that take more. Steps. Live longer and have longer, longer health spans, longer lifespans. We know that gamification can increase physical activity. What we don't know is whether increasing physical activity in that way, those are the changes in in outcomes that that patients care about. So.
00:31:23 Alexander
If I increase physical activity with the gamification intervention, are patients going to live longer? Are they gonna? Have fewer heart attacks.
You know the observational research which suggests that they should, but observational research is is, you know, not always, not always proven, right.
00:31:40 Ben
I think it's really interesting about that more, more a coach than a clinician is about actually that accountability of the patient or the person kind of knowing that someone's checking in. Are they hitting their goals? And I guess that could be peer accountability as well. It's just having that someone to be responsible to report too.
So that's a really interesting learning and element from it.
I guess it would be great to know. Now do you know any other examples of in gamification that you really like or any other examples that you've been you've been seeing recently?
00:32:11 Alexander
I don't think I've seen any in the in the health context necessarily. I think that you know what we tried to do was really design something that was that was simple and that didn't require people to play it because these are these are older adults that maybe less tech savvy. So it sort of the game came to them and they were playing it whether they wanted to or not. You know, unless they actively. Was to to drop out of the study, but I I think that that broadly what I would be interested in and and some of the things that that I've seen that I think have been successful sort of in.
00:32:40 Alexander
You know things I've seen in my own life are the idea of streaks. We didn't incorporate streaks into into our game that, you know, if I have either pick an element, a game element that that we're missing. That's sort of what I go with.
00:32:55 Ben
And I guess before I move into the final questions, Alexander, are there any other things that you learned for the study that you want to talk about?
Will raise as we think that some some real key learnings or. Nuggets. Yeah. So that I think.
00:33:05 Alexander
This is a pretty big programme and we have a qualitative research elements too. We interviewed a bunch of participants and that's that's also forthcoming.
That analysis, but I think that people were not or people said they were not motivated by the game and they were not motivated by money. The financial incentives armed and they were really motivated to change their behaviour. And I think that that's.
That's a really important learning. You know, I think that that people were motivated by the game. I think that the the results showed that that the game was motivating.
00:33:35 Alexander
But it's not that they wanted to like, move through the levels or score or get the points they really wanted to make themselves healthier and and the game was a was a vehicle for that, I think. And I think that, you know, especially for. Games to increase physical activity increase healthy behaviours. I think that it's important to put.
00:33:56 Alexander
What patients want at the centre of it and to foreground it for them so that they realise that you know, to make, to make it clear to them that they're not just playing a game, but they're they're playing a game, that that is designed to help them do the. Things that they.
Want to do to make them make themselves healthier? And I think I think that's that's an important learning point.
00:34:14 Ben
Fully, fully agree. Where do you think the future of gamification and health is going? What's the next two 5-10 years look? Like.
00:34:21 Alexander
Yeah. So what I'm doing, I'll say is I I am applying these ideas to patients that have symptomatic cardiovascular diseases. So to patients with heart failure that get short of breath when they walk and in whom, we know that if we can help them walk more, then they will get less short of breath.
They walk in the future and the patients with primary disease who have pain their legs when they walk and we know that if we can help them walk more of the the pain gets better. So that's that's the direction that that that's One Direction that that I want to take this in is to is.
To you know, this study, the BEACTIVE study position simplification in the in the prevention realm, we're trying to prevent cardiovascular events in these people. We're trying to make them healthier so they don't have cardiovascular events. I think that there is an equal opportunity to use gamification, increase physical activity as a treatment for diseases that get better with exercise.
And I'm a cardiologist, so I think about I think about peripheral disease and heart failure. But I think that there are other examples outside of cardiology and then and then the other direction. And this is this is potentially a little bit longer off. But I think that our study sort of sets the table for this is.
Be active with 1000 patients. I'd like to do a 10,000 patient study where we where we continue the intervention for two or three years and we see if we can reduce heart attacks and strokes. The evidence was the the observational evidence would suggest that we can that that changes on the magnitude of what we achieved and.
00:35:51 Alexander
And be active would would reduce heart attacks and strokes.
But I'd like to see if it really can, and I think that to me that bit those two questions are where you can, where if we can answer those questions in the affirmative, we can say you know in patients that are at risk for cardiovascular disease gamification.
The increased physical activity also reduces hard cardiovascular events and we can say in patients that have cardiovascular disease that are limited by symptoms and gamification intervention increases functional capacity and makes them feel. Better.
I think if we can answer those questions in the affirmative, then it's going to be challenging for.
Yeah. For these inventions not to be adopted because they are so scalable, the costs are are minimal compared to some other interventions that we that we routinely that routinely use and they're so accessible to patients, you know, with the with the equity of of of wearable devices.
And and text messaging and all that stuff and and you know we we didn't we didn't use anything that's hard to get in our study and so if we can if we can move the evidence in that direction that is when I think it starts to get.
You know, to the point where it has to be implemented.
00:37:14 Pete
That's great. Obviously, it would be great to get you back to hear about the qualitative analysis and the cost effectiveness analysis. But right now, what can you tell us in general? Like is, is there a sheer scale of difference? What can you give away?
00:37:30 Alexander
In terms of cost effectiveness?
00:37:32 Pete
Yeah.
00:37:33 Alexander
Yeah, so the analysis is ongoing. I think that the one thing we can say is that, you know, financial incentives appear to be dominated by gamification. They're much more expensive and they worked less well in our study. But I think that in terms of in terms of cost effectiveness compared with with control, it's highly cost effective in terms of cost.
Redness versus versus sort of a usual care. It's it's going to be, you know, in the United States we use less than $50,000 per per per life year gain. It's it's going to be well below that I think.
But I think that that, you know, stay tuned, the the analysis is sort of ongoing and that. But I think that you know sort of under under a number of different assumptions for how long the the benefits last, how big the the effect that mortality is. I I think that.
That these are the gamification invention in particular, and to a lesser extent, potentially the combination intervention of financial status plus simplification are gonna are gonna.
Be highly cost effective.
00:38:41 Ben
Alexander, it's been great having on the health points today. Learned so much, talked about physical activity being hugely beneficial for people living with cardiovascular disease with the benefits far outweighing the risks. However, the motivation for patients can be a big barrier and through a study that be active.
00:39:00 Ben
Study it demonstrates that gamification is as or more effective than financial incentives to motivate people living with cardiovascular disease. To be more active during the programme and more importantly, beyond the gamification.
Too, and there may be something around having a coach works. It was it was setting the goals, having those self selected goals but and having them monitored with people having accountability designed into the gamification and designing to the goals which may be what's creating that deep motivation that seems to be working with people with cardiovascular disease.
But may work for any health condition to increase that physical activity. It's been great having on the show, say Alexander.
00:39:40 Pete
It's been fantastic having you on the show. This is really insightful stuff. I love it.
00:39:45 Alexander
Thank you so much for having me. This is great.