The Use of Mobile Health Technology and Behavioral Economics to Encourage Adherence to Statins in Adolescents With Familial Hypercholesterolemia

Preventing cardiovascular disease (CVD) in children and adolescents depend partly on the efficacy of the patients' self-management of their disease between clinic visits. One example of a health behavior that is particularly important for patients with CVD is medication adherence. Although the development of statins provides an opportunity to substantially reduce this risk of CVD, adherence to statins in both adults and adolescents is frequently inadequate. In recent study of youth prescribed a statin using claims data, nearly 75% of adolescents have at least one 90-day period of nonadherence. In adults, statin nonadherence is often as low as 50% and is associated with an increased risk for of CVD events and all-cause mortality, as well as almost $44 billion annually in additional health care costs. Unfortunately, successful interventions to improve statin adherence in adults are rare and there are no formally tested interventions to improve statin adherence in adolescents.

It is critical novel interventions are developed that address medication adherence in adolescents with chronic diseases that increase the risk of CVD. Studies in adolescents with other diseases demonstrate that they appear to be particularly vulnerable to nonadherence across a wide-variety of conditions, including in adolescents with solid organ transplants and diabetes mellitus. Unfortunately, previous studies using text messaging reminders to take a medication or computerized action plans have not consistently shown positive results. Therefore, the significance of this proposal is that I will pilot a novel mobile health (mHealth) intervention that incorporates two theories in behavioral economics, Present Bias and Loss Aversion, to develop a better understanding of barriers to medication adherence in adolescents with cardiovascular risk factors.

Traditional economic theory suggests that providing individuals with incentives to complete an action will lead to increased frequency of the occurrence of the desired action. However, behavioral economics studies in adult populations suggest that not all incentive structures are effective and that some incentives may act like negative enforcers. Studies suggest that patients are biased towards the present and often discount future risks, which is termed Present Bias. For instance, studies of Present Bias suggest that even small rewards, if provided frequently and immediately after a participant completes a desired task can improve adherence in adults. This strategy can be improved by using the principles of Loss Aversion, which suggest that individuals place more value on money or objects that they have than on new objects of the same value. Therefore, incentives framed as a loss can be more powerful than if it is framed as a gain. Unfortunately, only a few studies in adolescents have incorporated behavioral economics into interventions aimed at behavior change. One promising study in youth with type 1 diabetes mellitus found behavioral economics approaches could influence adherence to insulin regimens and glucose monitoring. Whereas diabetes mellitus is symptomatic if not properly managed, statins typically are used as primary prevention in asymptomatic patients with familial hypercholesterolemia (FH), which may require unique incentive structures. Although monetary incentives have been used with varying degrees of success in adults, it is unclear if these findings translate to adolescents. Adolescents may discount future events more, have different attitudes towards health, and have less mature cognitive function and capacities than adults. In addition, interventions that improve medication adherence are often resource intensive, which decreases the likelihood of larger scale implementation. Using an mHealth application may reduce costs by automating processes previously requiring human time and resources. Further, an mHealth intervention may be more successful as it uses a medium that is ubiquitous in adolescence. For instance, mobile applications that use gamification have demonstrated that adolescents find these health applications engaging and that they are interested in using mHealth in the management of their disease across a diverse set of socioeconomic and cultural backgrounds. As many health behaviors track into adulthood, establishing healthy behaviors early is crucial, which requires using developmentally appropriate interventions to promote adherence and ultimately minimize the risk of CVD.

APPROACH Determine the efficacy of a monetary incentive to improve medication adherence. Aim 1.1 The investigators will determine the baseline adherence level in adolescents with FH prescribed a statin using the Morisky Medication Adherence Scale (MMAS).

Aim 1.2 The investigators will determine the efficacy of a monetary incentive on medication adherence. Patients who are found to have low adherence according to the MMAS in Aim 1.1 will be enrolled into an intervention using the Wellth® mobile health application (Wellth App).