Background: Gamification and social incentives, such as family/peer engagement in goal-setting and feedback, are increasingly used by employers and health plans to promote physical activity and lose weight in outpatient settings but these approaches have not been used to improve mobility and reduce hospital-associated functional decline after hospital discharge.

Methods: 12-week randomized, controlled trial of gamification with social incentives among patients admitted to general medicine and oncology services in one large, academic medical center. All participants were supplied with a wearable device to track daily steps. The control group (n=118) received feedback from the device but no other interventions. The intervention group (n=114) entered into a 12-week game using insights from behavioral economics to assign points and levels for achieving step goals that was reinforced by social incentives including a support partner (family/peer) who received information on the participant’s progress and agreed to provide support and encouragement. The primary outcome was mean change in daily step count from baseline through the 12-week intervention. Secondary measures were change in functional status (difficulty with ADL/IADLs and walking) and acute care utilization (ED visits and readmissions) within this period. We also collected detailed patient-reported characteristics such as sleep habits, quality of life, size and strength of social network (social engagement).

Results: We recruited a diverse sample (N=232): 57% non-White; 61% female; 44% annual income <$50k; mean age, 40. Participants in the intervention arm had greater change in mean daily step count which did not reach statistical significance (adjusted difference, 270; 95% CI, -214, 754; p=0.27); however, subgroup analyses showed that participants with higher levels of social engagement showed marked improvement in step counts (adjusted difference, 1,124; 95% CI, 409, 1841; p=0.002) - FIGURE 1. Participants in this subgroup also had less functional decline (4% compared to 12% control) and fewer 30-day readmissions (8.3% vs. 15% control). Intervention participants age 50-65 also had less functional decline (16% vs. 19% control) - FIGURE 2.

Conclusions: Gamification with social incentives was effective in promoting higher mobility and reducing functional decline in patients with higher social engagement but was not effective in those with lower engagement; these patients may need additional support to benefit from interventions to improve post-discharge mobility.

IMAGE 1: Figure 1: Primary Outcome: Mean Step Increase above Baseline by Week after Discharge

IMAGE 2: Figure 2: Prevalence of Functional Decline after Discharge by Sub-group