There was no effect of a daily lottery plus electronic reminders on mortality and PE/DVT because these outcomes did not occur in any study patient. There was no difference in major bleeding between the daily lottery plus electronic reminder group and control (RR, 1.23 [95% CI, 0.35-4.38]; ARR, 14 more episodes per 1000 [95% CI, 40 fewer to 208 more per 1000]; very low certainty). Other EtD criteria and considerations. Resource require- ments for the daily lottery would be large because the use of an electronic medication monitoring system would be required for each patient, and cost for monetary prizes averaged $3 per patient per day. Furthermore, key stakeholders would probably not find a daily lottery acceptable, and given the requirement for specialized equipment, the intervention is probably not feasible to implement in most settings. Conclusions and research needs for this recommendation. The panel decided on a strong recommendation against the intervention based on very low quality evidence pointing toward harm for all critical outcomes and on the intervention having high costs and probably not being acceptable or feasible. The GRADE approach includes situations in which strong recommendations are warranted despite very low certainty in evidence about the effects, including situations where the panel determined there is high certainty that cost of the intervention outweighs any potential benefits.166 See recommen- dation 13a for additional comments regarding adherence interventions in general and research needs pertaining to this recommendation. For patients receiving anticoagulation therapy for treatment of VTE, the ASH guideline panel suggests against using visual medication schedules (provided to patients at each visit, along with brief counseling) to improve medication adherence (con- ditional recommendation based on very low certainty in the evidence about effects ). Summary of the evidence. 