Testing Promising Behavioral Economic Interventions to Promote Enrollment Diversity in Cardiovascular Cohort Studies

Study Overview
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Brief Summary
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Problem. Randomized clinical trials (RCTs) are the best way to determine if interventions are safe and effective. Usually only a small number of eligible patients enroll. This is because trials require people to consent to be enrolled and randomized. Black and Hispanic people are more likely to develop heart disease. They are also more likely to have risk factors for heart disease that are not controlled. Yet they are very under-represented in heart disease trials. This raises concerns about if trial results can be applied to the general population. Trial sponsors are required to enroll patients that reflect the racial and ethnic diversity of real-world people. Black and Hispanic people continue to enroll in trials at a lower rate. The goal of this study is to conduct a series of small randomized trials to test recruitment strategies to increase how many Black and Hispanic people enroll in heart disease clinical trials without diminishing trust. The investigators will test different recruitment strategies for participant enrollment in a few different areas. They will study the method of outreach, the way messages are framed, defaults, and enrollment incentives. They will run smaller recruitment strategy trials within larger parent trials (e.g. Penn Medicine Biobank cohort study). They will run a small recruitment strategy trial to test each approach and then include what they learned in the next small trial.

Detailed Description
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Randomized clinical trials (RCTs) are the gold standard for determining the effectiveness and safety of drugs, medical devices, or healthcare delivery interventions. However, because RCTs require participants to consent to enrollment and randomization, typically only a minority of eligible patients enroll, raising concerns regarding the generalizability of trial results. Though Black and Hispanic individuals are disproportionately more likely to have uncontrolled risk factors for cardiovascular disease and to develop cardiovascular disease, they are substantially underrepresented in cardiovascular RCTs. In one review of 143 cardiovascular clinical trials conducted between 2008 and 2017, just 2.1% of enrollees were Black and 2.1% were Hispanic. Such low rates of enrollment have persisted despite mandates by funding and regulatory authorities that trial sponsors aim to enroll patient populations in RCTs that reflect the racial and ethnic diversity of real-world populations of patients with the disease under study. The failure of these recommendations to meaningfully increase the racial and ethnic diversity of RCT participants indicates a need for new and innovative strategies. Behavioral economics is a scientific field of inquiry that incorporates principles from economics and psychology to better describe how individuals behave and to influence their behavior. While standard economics assumes that individuals are rational expected utility maximizers, behavioral economics recognizes that individuals' decision-making is limited by thinking capacity, available information, and time. As such, decision-making is governed by heuristics, or cognitive shortcuts. For instance, rather than trying to assess the myriad risks and benefits of participating in a research study, individuals may decide not to participate because the invitation to participate isn't from someone whose name they recognize or a perception that people like themselves do not participate. Knowledge of common heuristics can be leveraged to influence choices by modifying the context in which decisions are made, such as by changing default options or how choices are framed. Marketing studies have demonstrated the effectiveness of appeals to altruism, perceived scarcity (This product is desirable because it is hard to get), and social proof (Are people like me using this product or service?) in increasing responsiveness to outreach, and these techniques can be re-purposed to increase representativeness of RCTs. Challenging social circumstances can be thought of as a tax on individuals' cognitive bandwidth, underscoring the opportunity to increase RCTs' racial and ethnic diversity by simplifying the enrollment process to make it easier to enroll, increasing the trustworthiness of communications, and reframing participation to make it more attractive. The reasons for low enrollment of patients from underrepresented racial and ethnic groups in cardiovascular RCTs are multifactorial. Typically, RCTs that enroll vast majorities of patients from global regions with few Black or Hispanic patients will not enroll populations representative of U.S. demographics. Moreover, Black and Hispanic individuals are often less willing than White individuals to participate in RCTs; they are more likely to face barriers in accessing health services and to have mistrust of medical researchers, due to concerns about historic and ongoing scientific misconduct. Newer means of communication, including patient portals, may increase or decrease representativeness depending on how they are deployed. However, few studies have systematically evaluated recruitment strategies in randomized fashion. As with any intervention, the effectiveness of different recruitment strategies is best assessed by testing different alternatives in RCTs. Accordingly, the overarching goal of this project is to conduct a series of RCTs to rigorously, systematically, and iteratively test strategies designed to increase enrollment of Black and Hispanic individuals in prospective cohort studies without diminishing trust. The investigators will embed RCTs of changes to the decision-making context, or nudges, in the context of recruitment for prospective cohort studies because these studies' large sample size will facilitate accelerated rapid-cycle testing of multiple nudges, with results from each recruitment RCT incorporated in the next round of testing. Since the nudges are layered on top of existing cohort recruitment methods - changing only the method of outreach, message framing, or incentive structure - they are low cost, and the number of nudges that can be tested is bound primarily by the size of the cohort to be enrolled. The investigative group is uniquely positioned to conduct these studies. First, the investigators have conducted some of the only RCTs evaluating different RCT recruitment strategies. Second, they have established relationships with multiple cohort studies enrolling tens of thousands of patients with cardiovascular diseases. Third, they have extensive experience applying insights from behavioral economics to health behaviors. The RCTs will sequentially test different strategies for participant enrollment in the following realms: method of outreach, message framing and default settings, and enrollment incentives. The primary outcome of each recruitment RCT will be the enrollment fraction of Black and Hispanic participants - the number of Black and Hispanic patients enrolled divided by the number attempted to be contacted. Because Black and Hispanic populations are heterogeneous, the investigators will also report the effect of each approach on enrollment fraction stratified according to socioeconomic status (SES), assessed using the Area Deprivation Index, a community-level SES metric. Other key secondary outcomes will include the overall enrollment fraction and the population-to-prevalence ratio, defined as the enrollment fraction of Black and Hispanic patients divided by the overall enrollment fraction. Across sequential RCTs of behaviorally-informed recruitment strategies, the investigators will accomplish the following specific aims: Aim 1. To evaluate the effect of method of outreach on representativeness. First, patients will all receive a message via email (or traditional mail, if no email address is on file) with information about a cohort study and how to enroll and will be randomized to receive an additional message via text message or patient portal. In a subsequent RCT, potential participants will be randomized to receive this message from their personal clinician or from the research team. Aim 2. To evaluate the effect of message framing across three domains - appeal to altruism versus a standard approach to recruitment, social proof versus scarcity versus neither, and opt-in versus opt-out - on representativeness. The investigators will evaluate each different framing choice in 3 sequential RCTs that will be embedded in existing large cohort studies. Aim 3. To evaluate different incentive structures on representativeness. In a final 2 × 2 RCT, the investigators will evaluate gain- versus loss-framed incentives and guaranteeing the full incentive versus providing part of the incentive as chance to win a lottery. Participants will be randomized to a small, guaranteed incentive or a smaller guaranteed incentive plus a 1 in 40 chance to win a larger amount, and further randomized to be promised this money ('gain frame') or have it deposited in a virtual account ('loss frame').

Official Title
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Testing Promising Behavioral Economic Interventions to Promote Enrollment Diversity in Cardiovascular Cohort Studies

Conditions
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Cardiovascular Diseases

Intervention / Treatment
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* Behavioral: Method of Contact
* Behavioral: Source of Contact
* Behavioral: Framing Method (Appeal to Altruism)
* Behavioral: Framing Method (Social Proof or Perceived Scarcity)
* Behavioral: Framing Method (Opt-Out)
* Behavioral: Incentive Structure


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: must have active medical records in site's electronic medical record system. Exclusion Criteria: an electronic portal account (e.g. MyPennMedicine) have previously been contacted to enroll in the parent trial (e.g. Penn Medicine Biobank)

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Sequential Assignment
Interventional Model Description: RCT #1: three-arm trial of three methods to contact patients (text v. email v. email+text) / RCT #2: three-arm trial of two sources of contact (personal physician v. research team) / RCT #3: two-arm trial of framing methods (appeal to altruism vs. no appeal) / RCT #4: three-arm trial of framing methods (social proof v. perceived scarcity v. neither) / RCT #5: two-arm trial of framing methods (opt-in v. opt-out) / RCT #6: four-arm trial of incentive structure (gain-framed v. loss-framed; guarantee v. lottery)
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: RCT #1, Arm #1: Contact Method, Text Only<br>Potential participants in the parent trial will be randomized to receive a message via text message. This message will invite them to participate in the parent trial. | Behavioral: Method of Contact<br>* Behavioral Intervention studied here is the method of contact (text vs. email vs. email+text).<br>|
| Active Comparator: RCT #1, Arm #2: Contact Method, Email Only<br>Potential participants in the parent trial will be randomized to receive a message via email. This message will invite them to participate in the parent trial. | Behavioral: Method of Contact<br>* Behavioral Intervention studied here is the method of contact (text vs. email vs. email+text).<br>|
| Active Comparator: RCT #1, Arm #3: Contact Method, Email+Text<br>Potential participants in the parent trial will be randomized to receive a message via email and text message. This message will invite them to participate in the parent trial. | Behavioral: Method of Contact<br>* Behavioral Intervention studied here is the method of contact (text vs. email vs. email+text).<br>|
| Active Comparator: RCT #2, Arm #1: Source of Contact, Personal Physician<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. The sender of the message will be the person's personal physician. | Behavioral: Source of Contact<br>* Behavioral Intervention studied here is source of contact (personal physician vs. research team)<br>|
| Active Comparator: RCT #2, Arm #2: Source of Contact, Research Team<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. The sender of the message will be the research team. | Behavioral: Source of Contact<br>* Behavioral Intervention studied here is source of contact (personal physician vs. research team)<br>|
| Active Comparator: RCT #3, Arm #1: Framing Method, Appeal to Altruism<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. The message will appeal to the person's altruism, for example: Research studies like this one often do not include enough Black individuals. If Black people are not included in research like this, then doctors have less information about how cardiovascular disease might affect them and how new treatments could be used to improve their health. Your participation in this research can help doctors better understand how to treat members of your community in the future. | Behavioral: Framing Method (Appeal to Altruism)<br>* Behavioral Intervention studied here is the framing method appeal to altruism<br>|
| No Intervention: RCT #3, Arm #2: Framing Method, No Appeal to Altruism<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. The message will include no appeal to altruism. | |
| Active Comparator: RCT #4, Arm #1: Framing Method, Social Proof<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. The message will include language about social proof, i.e. information about participation of individuals similar to the person being contacted. For example, the message will include language such as: Clinical research studies and the development of effective new medications would not have been possible without the participation of thousands of people like you. | Behavioral: Framing Method (Social Proof or Perceived Scarcity)<br>* Behavioral Interventions studied here are the framing methods social proof and perceived scarcity<br>|
| Active Comparator: RCT #4, Arm #2: Framing Method, Perceived Scarcity<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. The message will include language emphasizing constraints on enrollment/limited number of available spots for participating, i.e. perceived scarcity, For example, the message will include language such as: There are a limited number of slots available in this study, and enrollment is only possible in the next 4 weeks. | Behavioral: Framing Method (Social Proof or Perceived Scarcity)<br>* Behavioral Interventions studied here are the framing methods social proof and perceived scarcity<br>|
| No Intervention: RCT #4, Arm #3: Framing Method, No Social Proof, No Perceived Scarcity<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. The message will include no language about social proof or perceived scarcity. | |
| No Intervention: RCT #5, Arm #1: Framing Method, Opt-In<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. Instructions on how to enroll in the parent trial will be the same as all previous arms. | |
| Active Comparator: RCT #5, Arm #2: Framing Method, Opt-Out<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. Instead of receiving on how to enroll in the parent trial, thy will be told they have been conditionally enrolled in the parent trial, contingent on them providing some additional information, unless they choose to opt out. | Behavioral: Framing Method (Opt-Out)<br>* Behavioral Intervention studied here is the opt-out framing method<br>|
| Active Comparator: RCT #6, Arm #1: Incentive Structure, Gain-framed, Guarantee<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. The message will state that, if the person decides to participate, they will be receive a guaranteed participation incentive (e.g. $50). | Behavioral: Incentive Structure<br>* Behavioral Interventions studied here are gain-framed vs. loss-framed incentives as well as guarantees incentives vs. lottery incentives.<br>|
| Active Comparator: RCT #6, Arm #2: Incentive Structure, Gain-framed, Lottery<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. The message will state that, if the person decides to participate, they will receive a guaranteed participation incentive (e.g. $25) and also be enrolled in a lottery (e.g. 1 in 40 chance) to receive a larger participation incentive (e.g. $1,000). | Behavioral: Incentive Structure<br>* Behavioral Interventions studied here are gain-framed vs. loss-framed incentives as well as guarantees incentives vs. lottery incentives.<br>|
| Active Comparator: RCT #6, Arm #3: Incentive Structure, Loss-framed, Guarantee<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. The message will state that, if the person decides to participate, their participant incentive (e.g. $50) will be placed in a virtual account that they will be able to access once they have enrolled into the parent trial. | Behavioral: Incentive Structure<br>* Behavioral Interventions studied here are gain-framed vs. loss-framed incentives as well as guarantees incentives vs. lottery incentives.<br>|
| Active Comparator: RCT #6, Arm #4: Incentive Structure, Loss-framed, Lottery<br>Potential participants in the parent trial will be randomized to receive a message inviting them to participate in the parent trial. The message will state that, if the person decides to participate, their participant incentive (e.g. $50) will be placed in a virtual account that they will be able to access once they have enrolled into the parent trial. | Behavioral: Incentive Structure<br>* Behavioral Interventions studied here are gain-framed vs. loss-framed incentives as well as guarantees incentives vs. lottery incentives.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Enrollment fraction of Black + Hispanic patients | The number of Black and Hispanic patients who enroll in the cohort study, divided by the total number of Black and Hispanic patients attempted to be contacted for consideration of enrollment | three weeks after all attempts have been made to contact is made | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Enrollment fraction of Black patients | The number of Black patients who enroll in the cohort study, divided by the total number of Black patients attempted to be contacted for consideration of enrollment | three weeks after all attempts have been made to contact is made | 
| Enrollment fraction of Hispanic patients | The number of Hispanic patients who enroll in the cohort study, divided by the total number of Hispanic patients attempted to be contacted for consideration of enrollment | three weeks after all attempts have been made to contact is made | 
| Enrollment fraction by Area Deprivation Index (ADI) quartile | For each ADI quartile, the number of patients who enroll in the cohort study divided by the total number of patients attempted to be contacted for consideration of enrollment | three weeks after all attempts have been made to contact is made | 
| Overall enrollment fraction | The number of all patients who enroll in the cohort study divided by the total number of all patients attempted to be contacted for consideration of enrollment | three weeks after all attempts have been made to contact is made | 
| Participation-to-prevalence ratio (PPR) for Black and Hispanic) patients | The percentage of enrolled participants who identify as Black (or Hispanic) patients divided by the percentage of people who identify as Black (or Hispanic) patient in the target population. | three weeks after all attempts have been made to contact is made | 
| Trust in Medical Researchers Scale | Determined using the Trust in Medical Researchers Scale, a validated 4-item survey to be completed by individuals who decided to enroll in the parent trial. All four items use a 5-point Likert scale and scored accordingly (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). The four items that individuals are asked to rank are: (1) Doctors who do medical research care only about what is best for each patient; (2) Doctors tell their patients everything they need to know about being in a research study; (3) Medical researchers treat people like guinea pigs; (4) I complete trust doctors who do medical research. The negatively-worded item (#3) is reverse-scored. So higher scores indicate more trust in medical researchers, and lower scores indicate less trust. | three weeks after all attempts have been made to contact is made |