Cost-Effectiveness of Gamification, Financial Incentives, or Both to Increase Physical Activity among Patients with Elevated Risk for Cardiovascular Disease.

BACKGROUND:The BE ACTIVE trial (Behavioral Economic Approaches to Increase Physical Activity Among Patients with Elevated Risk for Cardiovascular Disease) documented the effectiveness, compared with an attention control arm that received daily text messages, of gamification, financial incentives, or gamification+financial incentives to increase steps/day. Increases in daily step count are associated with longer life expectancy, but understanding the cost-effectiveness of these interventions is essential for payers and other stakeholders seeking to implement findings. METHODS:We built a probabilistic Markov model to compare intervention costs with lifetime estimates of life-years and quality-adjusted life-years for 2 sets of comparisons: (1) each behavioral intervention versus attention control, and (2) each trial arm, including attention control, versus no intervention. Since the durability of changes in steps/day post-intervention is unknown, we modeled optimistic, intermediate, and pessimistic scenarios. RESULTS:Over the 12-month intervention, per-participant cost to deliver attention control was $878, gamification $938, financial incentives $1534, and gamification+financial incentives $1712. Compared with attention control, gamification's cost-effectiveness ranged from $261 (95% CI, 259-263) per life-year gained if mean steps/day during the last 18 weeks of follow-up are maintained (optimistic), to $30 550 (95% CI, 30 503-30 597) per life-year if steps/day continue to decline at the rate observed during the full 26-week follow-up (pessimistic). Gamification+financial incentives cost <$50 000/life-year only under the optimistic and intermediate scenarios. Financial incentives was dominated by gamification and gamification+financial incentives. When all 4 trial arms, including attention control, were compared with no intervention, gamification again cost <$50 000/life-year across all durability scenarios. CONCLUSIONS:Across a range of scenarios about the durability of increases in steps/day post-intervention, gamification consistently cost <$50 000 per life-year gained, the threshold for high value interventions set by American College of Cardiology/American Heart Association guidelines. Gamification+financial incentives was high-value except in the pessimistic scenario. Financial incentives was dominated. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT03911141.