Alexander C. Fanaroff

Background: Social determinants of health (SDOH) are increasingly recognized as contributors to disparities in cardiovascular outcomes. However, their incremental value in risk prediction models for ST‐segment–elevation myocardial infarction (STEMI) death remains uncertain. Methods: We analyzed hospital admissions for STEMI between 2018 and 2020 using the American Heart Association's GWTG‐CAD (Get With The Guidelines–Coronary Artery Disease) registry. Logistic regression models were constructed: a clinical model including demographic, clinical, and medical history variables, and a full SDOH model that additionally incorporated zip code–level SDOH (college graduation, high school graduation, per‐capita income, poverty, foreign‐born status, and median household income). Discrimination was assessed using the concordance statistic/area under the receiver operating characteristic curve, and incremental value was evaluated with DeLong's test. Missing data were addressed with multiple imputation by chained equations. Results: The imputed cohort included 749 410 STEMI admissions (median age, 62 years, 72% men). Both the clinical and SDOH models demonstrated excellent discrimination (concordance statistic, 0.95; area under the receiver operating characteristic curve, 0.85), with no meaningful difference in overall predictive performance. In exploratory analyses, the addition of high school graduation, college graduation, per‐capita income, poverty, and foreign‐born status each had a modest statistical improvement in model discrimination, whereas median household income did not. Conclusions: Incorporating SDOH variables into an already high‐performing clinical risk model for in‐hospital STEMI death did not meaningfully enhance prediction. These findings indicate that short‐term, in‐hospital survival is primarily driven by immediate clinical factors rather than upstream socioenvironmental risks.

Importance: Prospective clinical research studies are challenged by low enrollment rates and underrepresentation of individuals from racial and ethnic minority groups. Objective: To determine the effect of electronic message content on study enrollment among racial and ethnic groups. Design, Setting, and Participants: Four sequential randomized clinical trials (RCTs) were conducted between October 30, 2023, and November 13, 2024, in which University of Pennsylvania Health System patients (aged ≥18 years) were contacted electronically via email, text message, or both. The most effective arm from each RCT served as the control in the subsequent observational study. This analysis of all 4 RCTs was performed on the intention-to-treat principle from December 2024 through September 2025. Intervention: Messages varied by method, source, framing, and incentive structure. Main Outcomes and Measures: The primary outcome was enrollment fraction (number enrolled divided by total contacted) among Black and Hispanic participants. Overall enrollment fraction was a secondary outcome. Results: Overall, 26 215 patients were contacted and 26 029 were offered enrollment in the Penn Medicine BioBank; 63.2% were Black and 7.2% were Hispanic. Their mean (SD) age was 60.5 (17.9) years, and 60.1% were female. In the first recruitment RCT (RCT 1) (n = 8038), the enrollment fraction among 4581 Black and Hispanic patients was 0% with email, 0.5% with text, and 0.2% with email plus text ( P = .06 for text vs email; P = .20 for email plus text vs email). Due to technical issues, more than 80% of participants who attempted to consent in RCT 1 failed; consent attempts were higher with text (4.8%) and email plus text (4.4%) than email alone (0.6%) ( P < .001 for text vs email and email plus text vs email). In RCT 2 (n = 4271), the enrollment fraction among 1902 Black and Hispanic patients was 1.0% with research team outreach and 1.8% with clinical team outreach ( P = .12). In RCT 3 (n = 3217 Black and Hispanic patients), the enrollment fraction was 3.2% with a control message, 3.6% with an appeal to altruism, and 4.1% with an appeal to social proof ( P > .05 for all comparisons). In RCT 4 (n = 10 689), the enrollment fraction among 8629 Black and Hispanic patients was 2.5% with no incentive, 6.8% with $25, 5.5% with $15 plus a 5% chance at $200, 5.8% with a 5% chance at $500, and 6.5% with a 1% chance at $2500 ( P < .001 for each incentive vs no incentive; P > .05 for each incentive compared with another). Conclusions and Relevance: In this series of RCTs, the enrollment fraction among Black and Hispanic patients was improved with outreach by text message and with an incentive. Trial Registration: ClinicalTrials.gov Identifier: NCT05827718

Background: Supervised exercise therapy improves walking performance in patients with peripheral artery disease (PAD), but few participate. Interventions leveraging concepts from behavioral economics increase physical activity in patients at high cardiovascular risk, but barriers to physical activity differ in patients with PAD. Methods: In this randomized controlled trial, conducted from October 2020 through January 2024, patients with PAD were provided with a wearable fitness tracker, established a baseline daily step count, and set a step goal increase. They were randomly assigned to attention control or to gamification. The control group received feedback from the fitness tracker but no other interventions for 24 weeks. The gamification group was entered into a 16‐week game designed using insights from behavioral economics and received educational text messages. No intervention occurred during an 8‐week postintervention follow‐up period. Results: A total of 103 patients (mean age, 70±9 years; 54 [52%] men, 74 (72%) with exertional lower extremity symptoms) were randomized to attention control (n=52) or gamification (n=51). Compared with controls, gamification participants had a greater increase in mean daily steps from baseline during the intervention period (adjusted difference, 920 [95% CI, −22 to 1861]; P =0.06) that became statistically significant during the follow‐up period (adjusted difference, 1074 [95% CI, 133–2015]; P =0.03). Conclusions: In this randomized clinical trial, gamification increased physical activity compared with attention control over a 24‐week follow‐up. This intervention may represent a scalable approach for increasing physical activity in patients with PAD who are not able to participate in supervised exercise therapy. Registration: URL: https://clinicaltrials.gov/study/NCT04536012 ; Unique Identifier: NCT04536012.