It’s a strange-sounding name for a medical outfit, but the Penn Medicine Nudge Unit is just that: a unit that nudges. Director Mitesh Patel, M.D., MBA, M.S., and colleagues at the University of Pennsylvania’s Perelman School of Medicine design interventions that align patient behaviors and decision-making with long-term health goals: making the right choices obvious to patients, and making those choices easier to select.
As a primary care physician at the Corporal Michael J. Crescenz Veterans Affairs Medical Center in Philadelphia, Pennsylvania, Patel realizes that nudging patients – many of whom he sees only once or twice a year – toward healthy behavior is no simple task. “One of the challenges we often have,” he said, “is that we’re talking to patients about how they should be more physically active or lose weight, and about changing their behavior. But then they leave our office, and we don’t see them for six months or a year – or some longer period. And we don’t have any way to interact with them outside of the visit.”
Patel’s recent research has focused on monitoring patient activity and weight – often with the use of consumer fitness wearables from manufacturers such as Apple®, Fitbit, or Samsung – combined with incentives for behavior change. “In most cases,” he said, “just giving someone a device and a smartphone is not effective in changing their behavior. But if you combine it with the right behavior change strategy, it can be really effective.”
In recent studies Patel led for the University of Pennsylvania, his team issued activity monitors to recently discharged heart patients and monitored their progress toward a target goal of activity. His studies have used both financial incentives – setting up a modest account and subtracting money when goals aren’t met – and “gamification” incentives, aimed at families who earn or lose points based on whether family members meet their goals.
“In most cases,” he said, “just giving someone a device and a smartphone is not effective in changing their behavior. But if you combine it with the right behavior change strategy, it can be really effective.”
His studies have shown that these structured behavior modifications, followed closely with wearable activity monitors, can sustain behavior changes for up to six months, a vast improvement over patients who are simply given the monitors. “There’s a lot of good evidence to show that half of the people who get a wearable device stop using it within a couple of weeks to a month,” Patel said. He’s in the process of launching his first study to compare the effectiveness of these incentives among veterans who are overweight or obese, with a body mass index (BMI) of 25 or greater. His team will track step counts and minutes of moderate to vigorous physical activity among groups of veterans working with each incentive scheme, and compare outcomes.
Step counts and rates are fairly simple data for measuring physical activity, but Patel said that among consumer wearables, those are the only two measures he trusts for his purposes. “We’ve found they’re fairly good at tracking step counts,” he said. “But other studies have found that their monitoring of other things, like sleep and heart rate and calories, is actually not that great. The technology isn’t there yet. You have to really trust the data in order to make use of it.”
It’s one of the biggest issues facing wearable technology today: Stories abound of wearable technologies on the threshold of revolutionizing treatments for certain diseases or disorders, but we’re not there yet, particularly in the area of medical-grade wearables designed to inform clinical decision-making. There are a few at work today: The Zio® wireless patch, a small adhesive patch that can be worn on the chest to monitor heart arrhythmias for up to two weeks, was cleared in 2011; four continuous glucose monitors (CGMs) have been cleared by the federal Food and Drug Administration (FDA) for use in monitoring diabetes. Last year KardiaBand, manufactured by AliveCor, became the first medical device accessory approved for the Apple Watch by the FDA, and several other devices – including a blood pressure monitoring smartwatch, a sleep apnea-monitoring Fitbit, and a wristband that will monitor a wider range of biometric information such as blood oxygen saturation and respiratory rate – are on the near horizon.
In the meantime, Department of Veterans Affairs (VA) researchers continue to explore how wearable devices might be used to improve patient care. At the VA’s Advanced Platform Technology (APT) Center in Cleveland, Ohio, clinicians and IT engineers work together to study how remote sensing can be used in rehabilitative medicine. Applications currently being developed by teams at the APT Center include:
- A wearable sensor, part of a smoking cessation intervention, that captures hand-to-mouth smoking motions and is sophisticated enough to differentiate them from other movements (i.e., answering a phone call or drinking). The sensor cues the sending of tailored intervention video content to the relapsed smoker.
- A customizable cloth-like pressure sensor that can be inserted between the end of a residual amputated limb and a prosthetic. The sensor maps the pressure distribution, sends that data to a visualization system, and allows for prostheticians to redistribute forces that might lead to skin ulceration.
- A “smart” wheelchair cushion that senses how hard and how long pressure is distributed over itself. With the use of algorithms that analyze pressure data, the cushion will alter its shape and stiffness in response.
- A wearable gait laboratory, an insole array of sensors that monitors slips and trip and falls in everyday environments through analysis of gait parameters, balance controls, and body postures.