Stepped‐Wedge Randomized Clinical Trial of Social Marketing Strategies to Improve Adherence to Remote Monitoring Among Veterans with Pacemakers and Implantable Cardioverter‐Defibrillators
Authors: Dhruva Sanket , Raitt Merritt , Tarasovsky Gary , Whooley Mary 
Published: September 2021

Research ObjectiveRemote monitoring of pacemakers and implantable cardioverter‐defibrillators (ICDs) is a Class 1, Level of Evidence A professional society recommendation and considered standard‐of‐care because it is associated with reduced hospitalizations, death, and need for in‐person pacemaker and ICD checks. However, only 2/3 of patients are adherent to remote monitoring; non‐adherent patients do not receive any benefits of remote monitoring. We sought to compare the effect of two social marketing implementation strategies (protect/warn vs encourage/reward) on improving adherence to remote monitoring among Veterans with pacemakers and ICDs who were non‐adherent to remote monitoring.Study DesignFirst, we designed two informational postcards: 1) a protect/warn postcard describing risks of non‐adherence to remote monitoring (such as delayed notification of heart problems and increased risk of death) and 2) an encourage/reward postcard that framed the same content with a positive/beneficial message. Both postcards contained patient instructions on how to send remote monitoring transmissions. We then conducted a stepped‐wedge randomized controlled trial (RCT). In the first wave, patients were randomized to be mailed a postcard with either one of two messages (protect/warn vs encourage/reward) or no postcard. In the second wave, all patients were mailed a postcard with one of the two messages. In both waves, patients who did not transmit within 1 month were mailed a second postcard with the identical message approximately 1 month later. The primary outcome was the proportion of Veterans who sent a remote monitoring transmission at 10 weeks.Population StudiedWe included Veterans with pacemakers and ICDs who had sent at least one remote monitoring transmission within the past 2 years, but who had missed their last transmission by at least 10 days.Principal FindingsThere were 6331 patients randomized to be mailed a postcard (3166 to a protect/warn message and 3165 to an encourage/reward message) and 2400 controls who were not mailed a postcard (first wave only). The mean age was 73.3 years (standard deviation, 10.3), 98% were men, 76% were White, and 17% were Black or African‐American. Roughly one‐third (37%) had a pacemaker and two‐thirds (62%) had an ICD. A total of 324 postcards (5.1%) were returned as undeliverable. Overall, 2974 patients (49.5%) who received a postcard sent a remote monitoring transmission at 70 days, compared to 565 patients (23.5%) who did not receive a postcard (absolute difference 26.0%, p < 0.001). There was no significant difference in transmission rates between patients randomized to the protect/warn versus the encourage/ reward message (p = 0.51). Twenty‐six percent of patients who sent a transmission did so only after the second postcard was mailed.ConclusionsThis stepped‐wedge RCT found that informational postcards can significantly improve adherence to remote monitoring among patients with pacemakers and ICDs. There was no difference between a protect/warn and encourage/reward social marketing implementation strategy.Implications for Policy or PracticeMailing informational postcards to patients with pacemakers or ICDs who are non‐adherent with remote monitoring can improve adherence. This intervention could improve patient outcomes and reduce the need for avoidable in‐person visits, which is particularly important during the COVID‐19 pandemic.Primary Funding SourceDepartment of Veterans Affairs.