A study that was presented as part of the American College of Rheumatology (ACR) Convergence 2020 assessed how a financial incentive may benefit patients with inflammatory arthritis who struggle to do physical activity—even when the incentive is taken away.

Study author Ben Nowell, PhD, Director of Patient-Centered Research at the Global Healthy Living Foundation and CreakyJoints Patient community, and Principal Investigator (PI) of the ArthritisPower research registry, discussed the results of the study with DocWire News, as well as commented on the power of completely virtual studies in the era of the COVID-19 pandemic.

Dr. Nowell: Hello, my name is Ben Nowell and I’m the Director of Patient-Centered Research at the Global Healthy Living Foundation and CreakyJoints Patient community. I’m also the PI of our ArthritisPower research registry, a Patient-Powered Research Network that we started six, seven years ago with the rheumatology researchers at the University of Alabama at Birmingham. I’m delighted today to provide an overview of our poster presentation [for ACR Convergence 2020]. It’s abstract number 546 and the PI of the study and the lead author on the poster is Alexis Ogdie. She’s a rheumatologist at Penn School of Medicine in Philadelphia.

The title of this poster is Stepping Up for Inflammatory Arthritis. It was a pilot trial to test behavioral economic strategy to increase physical activity in inflammatory arthritis. So just to give a little context, we know that regular physical activity may have benefits for patients with inflammatory arthritis, specifically in this case, rheumatoid arthritis (RA) and psoriatic arthritis (PsA). But patients with active disease often don’t want to increase their activity for a number of reasons.

We know from behavioral economics, which is a field that combines psychology and economics, that this theory of loss aversion has been effective at motivating behavior to increase physical activity in non-arthritis patients. So the objective of this study was to assess the feasibility and efficacy of a loss aversion, financial incentive for increasing step counts and improving disease symptoms among RA and PsA patients with active disease.

We designed a double-blind, randomized, controlled, six-month pilot trial with the patients with RA and PsA. We required that to be eligible, participants needed to have active disease, which was defined as one or more swollen joints, and a RAPID3 score >three. And as you’ll recall the range on the RAPID3 measure is from zero to 30, with a score <3 indicating remission.

The primary outcome that we looked at in this was a change in a RAPID3 score between the two arms. We also collected other measures and visits, and weekly check-ins occurred using virtual trial platforms. We used Way To Health and the Arthritis Power app. The Arthritis Power was used specifically for RAPID3, and we also collected a number of other measures—patient pain, patient global, Patient-Reported Outcomes Measurement Information System (PROMIS) sleep interference, PROMIS fatigue measure—throughout the trial. Patients who enrolled in the trial were given a commercial grade smartwatch—in this case it was a Fitbit Alta. They received that at baseline and then they completed a two-week run-in period to assess their average step count. We wanted to get a sense from each patient about how many steps they were normally going each day.

Then patients were then asked to choose or set their own step count goal for each day and then complete a commitment contract. After selection of their step count goal, then participants were randomized to either the intervention or no intervention. In this case, the intervention was that financial incentive. The intervention arm received this financial loss aversion incentive, which basically meant that each month patients would start with $75 in their account, and they would lose $2.50 for each day that they did not reach their step count goal. And then after 12 weeks of the intervention—so at week 14 of the trial—the incentive was removed and then patients continued to be followed all the way up to 26 weeks so we could see how long the effects of the incentive persisted.

In the small trial we randomized 27 patients; 22 of them completed the trial. And on average, receiving the incentive actually resulted in more steps per day, 714 more steps per day on average over the first 14 weeks. And it also resulted in a greater probability of reaching, excuse me, 10,000 steps per day. There was not a significant difference in the RAPID3 score at 14 weeks across comparing intervention versus the non-intervention arm. But after adjusting for baseline RAPID3, the 14-week RAPID3 scores were lower … So it means better control of disease activity in the group that achieved their step count goals at least half of the time. And that was the difference that exceeded the minimal clinically important difference for the RAPID3. Among the patients who achieved their step count goals more than half of the days, we also observed that there was more improvement in their sleep quality and their fatigue, and their overall wellbeing. So [improvements in] those other symptom measures that we captured.

In conclusion, a couple of things to say about this one is that it’s pretty exciting that we can do these kinds of trials that are, essentially, completely virtual or almost completely virtual to collect information from patients both in a passive way, using a smartwatch, and then also having them complete their PROMs. And we learned that although financial incentives have worked well in patients without arthritis, the estimated effect of the financial incentive in this very small study was modest for patients with RA and PsA. However, those that were able to increase their physical activity and meet their step count goals did have a greater improvement in their symptoms over the course of the study. But again, I think the real excitement of a study like this is that it demonstrates that it’s feasible to do this kind of remote data capture for a trial of this kind. Thanks for your interest.

For more information on Dr. Nowell’s research, click here to watch another interview, “Dr. Nowell Talks About RA Patient Engagement in Smartwatch Study.”