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

Objective The aims of this study were to determine the incentivization strategy that maximizes patient adherence to report symptoms and activity via ecological momentary assessment (EMA) after pediatric concussion, and assess the feasibility of tracking concussed youth using EMA from the emergency department (ED) setting. Methods This study was a randomized controlled trial of participants ages 13 to 18 years with concussion presenting to an urban, academic pediatric ED within 5 days of injury. Participants were randomized to 1 of 4 incentive arms: 2 dynamic (loss-based and streak) and 2 control flat-rate (monetary and electronic device). Participants 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 (kept by participants in the device flat-rate arm). The primary outcome was proportion of prompts to which participants responded. Secondary outcomes included differential response rates by demographics, and comparison of outcome determination between EMA and subsequent clinical visits. Results Thirty participants were enrolled, with a median age of 15.5 years and 60% female. Median cumulative proportion of prompts responded to was 68.3% (interquartile range, 47.6%–82.5%) in the dynamic arms versus 54.0% (interquartile range. 20.6%–68.3%) in the flat-rate arms, P = 0.065. There were nonsignificant differences in median response by sex (65.9% for female vs 40.0% for male, P = 0.072), race/ethnicity (61.9% for non-Hispanic White vs 43.7% for non-Hispanic Black participants, P = 0.097), and insurance (61.9% for private insurance vs 47.6% for public insurance, P = 0.305). Recovery at 3 weeks was discernible for all but 2 participants (93.3%) using EMA data, compared with only 9 participants (30.0%) ( P < 0.001) from clinical visits. Conclusions Dynamic incentivization showed higher rates of response to tridaily symptom prompts compared with flat-rate incentivization. These data show tracking concussed youth using EMA from the ED is feasible using a dynamic incentivization strategy, with improved ability to discern outcomes compared with prospective monitoring using follow-up clinical visits.