{"doi":"10.1161/circulationaha.124.069531","title":"Effect of Gamification, Financial Incentives, or Both to Increase Physical Activity Among Patients at High Risk of Cardiovascular Events: The BE ACTIVE Randomized Controlled Trial","abstract":"BACKGROUND: Physical activity is associated with a lower risk of major adverse cardiovascular events, but few individuals achieve guideline-recommended levels of physical activity. Strategies informed by behavioral economics increase physical activity, but their longer-term effectiveness is uncertain. We sought to determine the effect of behaviorally designed gamification, loss-framed financial incentives, or their combination on physical activity compared with attention control over 12-month intervention and 6-month postintervention follow-up periods. METHODS: Between May 2019 and January 2024, participants with clinical atherosclerotic cardiovascular disease or a 10-year risk of myocardial infarction, stroke, or cardiovascular death of ≥7.5% by the Pooled Cohort equation were enrolled in a pragmatic randomized clinical trial. Participants received a wearable device to track daily steps, established a baseline, selected a step goal increase, and were randomly assigned to control (n=151), behaviorally designed gamification (n=304), loss-framed financial incentives (n=302), or gamification+financial incentives (n=305). The primary outcome of the trial was the change in mean daily steps from baseline through the 12-month intervention period. RESULTS: A total of 1062 patients (mean±SD age, 67±8; 61% female; 31% non-White) were enrolled. Compared with control subjects, participants had significantly greater increases in mean daily steps from baseline during the 12-month intervention in the gamification arm (adjusted difference, 538.0 [95% CI, 186.2–889.9]; P =0.0027), financial incentives arm (adjusted difference, 491.8 [95% CI, 139.6–844.1]; P =0.0062), and gamification+financial incentives arm (adjusted difference, 868.0 [95% CI, 516.3–1219.7]; P <0.0001). During the 6-month follow-up, physical activity remained significantly greater in the gamification+financial incentives arm than in the control arm (adjusted difference, 576.2 [95% CI, 198.5–954]; P =0.0028), but it was not significantly greater in the gamification (adjusted difference, 459.8 [95% CI, 82.0–837.6]; P =0.0171) or financial incentives (adjusted difference, 327.9 [95% CI, −50.2 to 706]; P =0.09) arms after adjustment for multiple comparisons. CONCLUSIONS: Behaviorally designed gamification, loss-framed financial incentives, and the combination of both increased physical activity compared with control over a 12-month intervention period, with the largest effect in gamification+financial incentives. These interventions could be a useful component of strategies to reduce cardiovascular risk in high-risk patients. 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Patel","orcid":"0000-0002-5997-9984","position":1,"is_corresponding":false},{"id":516001,"name":"Neel Chokshi","orcid":"0000-0003-1662-4312","position":2,"is_corresponding":false},{"id":1060969,"name":"Samantha Coratti","orcid":null,"position":3,"is_corresponding":false},{"id":1060333,"name":"David Farraday","orcid":"0009-0006-7710-3245","position":4,"is_corresponding":false},{"id":281588,"name":"Laurie Norton","orcid":"0000-0002-2112-9669","position":5,"is_corresponding":false},{"id":415407,"name":"Charles Rareshide","orcid":"0000-0001-8642-4549","position":6,"is_corresponding":false},{"id":478038,"name":"Jingsan Zhu","orcid":null,"position":7,"is_corresponding":false},{"id":491006,"name":"Tamar Klaiman","orcid":"0000-0001-8718-5674","position":8,"is_corresponding":false},{"id":695268,"name":"Julia E. Szymczak","orcid":"0000-0002-3230-8670","position":9,"is_corresponding":false},{"id":476956,"name":"Louise B. Russell","orcid":"0000-0003-3599-0991","position":10,"is_corresponding":false},{"id":415406,"name":"Dylan S. Small","orcid":"0000-0003-4928-2646","position":11,"is_corresponding":false},{"id":281592,"name":"Kevin G. Volpp","orcid":"0000-0003-3389-6707","position":12,"is_corresponding":false},{"id":787074,"name":"Alexander C. Fanaroff","orcid":"0000-0002-9060-5307","position":0,"is_corresponding":true}],"reference_count":44,"raw_metadata":null,"created_at":"2026-07-19T01:57:09.067930Z","pmid":"38583084","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}