University of Pennsylvania medical researchers, working with five major health insurers, are studying the use of wireless pill bottles, lottery incentives and social support to encourage heart attack patients to keep taking their medication after leaving the hospital.

The problem researchers are wrestling with is significant. Within a year of their heart attacks, only about 40 percent of patients are still taking their prescribed medications, according to Dr. Shivan Mehta, Perelman School of Medicine assistant professor and one of the HeartStrong study investigators.

Adherence rates are suboptimal even among those who receive free medication, he said. Heart attack patients face risk of a repeat occurrence, especially in the year after hospital discharge, but medicines such as aspirin and beta blockers can lower that risk, noted Mehta, director of operations at the Penn Medicine Center for Health Care Innovation.

With funding from the U.S. Centers for Medicare & Medicaid Services, researchers have enrolled nearly 1,100 of the targeted 1,500 study participants from 42 states. Two-thirds of participants are randomly assigned to the program intervention group, while the rest are part of the control group.

"Many of the participants are very, very happy and engaged in this intervention so far," Mehta said, adding that researchers also have received good feedback from participating payors. Participants must be between 18 and 80 years old, taking at least two of four kinds of medications -- aspirin, beta blockers, statins and anti-platelet medicines - and must enroll within 60 days of hospital discharge after heart attack.

"So far we're seeing really encouraging results in terms of adherence," with fairly high rates among patients receiving the program intervention, HeartStrong Principal Investigator and CHIBE Director Dr. Kevin Volpp said.

One of the tools that HeartStrong uses is Vitality Inc.'s GlowCap, a prescription pill bottle cap with a chip that monitors when the container is opened and closed. The chip can wirelessly relay alerts through AT&T's mobile broadband network to the patient, health-care professional or supportive health buddy.

The bottle caps communicate with a web platform, Way to Health, developed by Volpp and Dr. David Asch, Penn professor and executive director of the Penn Medicine Center for Health Care Innovation.

For every day that they take their medications, patients are entered into a lottery in which they have a one in five chance to win $5 and a one in 100 chance to win $50, Volpp said. The HeartStrong program also involves identifying a friend or family member to serve as a social support to help keep the patient on track. A helper receives a text or email if a patient misses two or more doses, prompting a follow-up check on the family member or friend.

Patients also will be assigned to a program engagement adviser.  Social workers and program advisers will become involved only if a patient hasn't taken medication for at least four straight days or needs help that automated services can't resolve, Mehta said. The program is designed to be as automated and scalable as possible, and can be conducted from anywhere, he said, noting that Philadelphia researchers are providing the intervention to patients across the country.

The primary outcome measured in the study will be vascular events, including stroke, heart attack or heart failure, while secondary outcomes will include hospital readmissions, and cost of care and medication adherence as measured by pharmacy claims data.

This type of project is being used by CHIBE investigators to generate data that could be used in helping to shift the health financing model from one focused on treating sick people to one aimed at keeping people healthy, Volpp said. "This kind of initiative could become an important input for how to manage patient populations using technology and behavioral-economic type approaches," he said.

The Wall Street Journal reported on HeartStrong in June.

- Dinah Wisenberg Brin

A joint effort of Penn's LDI Center for Health Incentives and Behavioral Economics and the university's Center for Health Behavior Research, the interdisciplinary program is one of 26 Prevention Research Centers in the country awarded CDC grants for 2014 through 2019, and the first PRC to be funded in Philadelphia.

The core of Penn's PRC will be its work with three local employers -- - the Philadelphia city government, health insurer Independence Blue Cross and the Southeastern Pennsylvania Transportation Authority (SEPTA) -- to explore workplace approaches to help employees lose weight and avoid cardiovascular disease.

Ultimately, the PRC aims to translate its findings into public health programs that can be duplicated and used in the wider community.

"It's designed to be very complementary to what we are already doing and to build on that," said CHIBE Director and PRC Co-Director Dr. Kevin Volpp, a professor at Penn's Perelman School of Medicine and The Wharton School. "It's an exciting opportunity to be at the table with the CDC in one of the agency's flagship health-improvement programs," he said.

Karen Glanz, PhD, MPH

The workplace weight-loss study will compare a behavioral economics approach and environmental strategies, according to PRC Co-Director Karen Glanz, a Penn nursing and epidemiology professor and director of the Center for Health Behavior Research. The PRC doesn't aim to change the workplace environment per se, she said, but rather to give employees tools to support healthy behavioral changes.

That could mean showing employees how to pack more physical activity into their day or how to find a healthy lunch truck, "and how to really look at your environment and use it to your advantage," said Glanz.

Workplace study participants will be assigned to one of four groups - one looking at environmental change management, another examining financial incentives, another assessing a combination of the two, and a control group with no intervention -- according to Glanz, who previously directed the Emory University PRC.

Penn's grant, awarded earlier this year, starts this fall and makes the university eligible for several supplementary financial awards that could add five or six other projects at the outset.

Program leaders aim to pull together people with expertise in areas such as chronic disease prevention, behavioral economics, business organizational behavior, communications, policy implementation and nursing, and use the center as a catalyst to build new programs, said Glanz. The center, for example, expects to connect with other experts to lay the groundwork for establishing evidenced-based programs, she said.

In addition to Penn's medical and nursing schools and Wharton, leadership at the PRC will come from the university's Annenberg Public Policy Center and Children's Hospital of Philadelphia. The Annenberg center's associate director, Amy Jordan, is slated to help to lead a section focused on disseminating research to academic and scientific communities and to local health organizations and news media.

-Steven Schroeder, MD 

Karen Glanz, PhD, MPH

Karen Glanz, PhD, MPH is the George A. Weiss University Professor, Penn Integrates Knowledge (PIK) Professor, Professor of Epidemiology and Nursing, and Director of the Center for Health Behavior Research at the University of Pennsylvania. She is also a Senior Fellow at the Leonard Davis Institute, and Affiliated Faculty Member at CHIBE. 

Funded by:  National Institute on Aging