A Randomized Trial of Incentivization to Maximize Retention For Real-Time Symptom and Activity Monitoring Using Ecological Momentary Assessment in Pediatric Concussion

Abstract

To determine the incentivization strategy that maximizes patient adherence to report symptoms and activity via ecological momentary assessment (EMA) following pediatric concussion. Concussion is a common pediatric injury. Traditionally, outcome assessment has occurred at discrete points-in-time, days or weeks apart, relying on patient's subjective recall of symptoms and activity. EMA is a behavioral measurement approach that allows for reporting of real-time symptoms and behaviors in real-life settings. While feasible in adolescents, the ideal strategy to maximize responsiveness from the emergency department (ED) setting is unknown. This was a randomized controlled trial of patients age 13-18 with concussion presenting to an urban, academic pediatric ED within 5 days of injury. Patients were randomized to one of 4 incentive-based arms: 2 dynamic (loss-based and streak) and 2 flat-rate (monetary and electronic device). Through the ReCoUPS app, patients reported symptoms 3 times per day and cognitive activity once each evening for 3 weeks. Physical activity (step count) and sleep were monitored using a FitBit (which was kept by the participant in the electronic device flat-rate arm). The primary outcome was proportion of prompts to which patients responded. Secondary outcomes included daily symptom change and time to symptom resolution. Thirty participants were enrolled, median age 15.5 years, 60% female. Median proportion completed was 81% in the loss-based arm, 59% in the streak accrual arm, 50% in the FitBit-received arm, and 57% monetary flat rate arm. Retention was higher in the dynamic compared to the flat arms (68% v. 54%, p = 0.065). There was no significant difference between morning, afternoon, and evening symptoms. Sixty-four percent of participants had symptom resolution during the 3-week follow-up. Dynamic incentivization showed higher rates of response to tri-daily symptom prompts compared with flat-fee incentivization. This data shows tracking concussed youth using EMA from ED is feasible using a dynamic incentivization strategy.