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In this randomized, controlled trial of smokers employed by a large company, financial incentives for participation in a smoking-cessation program and for smoking cessation confirmed by biochemical testing increased cessation rates at 9 or 12 months (15% for the incentive group vs. 5% for the control group). In this trial of smokers employed by a large company, financial incentives for participation in a smoking-cessation program and for smoking cessation confirmed by biochemical testing increased cessation rates at 9 or 12 months (15% for the incentive group vs. 5% for the control group). Smoking remains the leading preventable cause of premature death in the United States, accounting for approximately 438,000 deaths each year. 1 Seventy percent of smokers report that they want to quit, 2 but annually only 2 to 3% of smokers succeed. 3 , 4 Although smoking-cessation programs and pharmacologic therapies have been associated with higher rates of cessation, rates of participation in such programs and use of such therapies are low. 5 , 6 Work sites offer a promising venue for encouraging smoking cessation because employers are likely to bear many of the excess health care costs and productivity losses that are due to missed work . . .

Medicare has reinforced its commitment to voluntary bundled payment by building upon the Bundled Payments for Care Improvement (BPCI) initiative via an ongoing successor program, the BPCI Advanced Model. Although lower extremity joint replacement (LEJR) is the highestvolume episode in both BPCI and BPCI Advanced, there is a paucity of independent evidence about its long-term impact on outcomes and about whether improvements vary by timing of participation or arise from patient selection rather than changes in clinical practice. We found that over three years, compared to no participation, participation in BPCI was associated with a 1.6 percent differential decrease in average LEJR episode spending with no differential changes in quality, driven by early participants. Patient selection accounted for 27 percent of episode savings. Our findings have important policy implications in view of BPCI Advanced and its two participation waves.

Abstract Study Objectives: Fatigue from sleep loss is a risk to physician and patient safety, but objective data on physician sleep and alertness on different duty hour schedules is scarce. This study objectively quantified differences in sleep duration and alertness between medical interns working extended overnight shifts and residents not or rarely working extended overnight shifts. Methods: Sleep–wake activity of 137 interns and 87 PGY-2/3 residents on 2-week Internal Medicine and Oncology rotations was assessed with wrist-actigraphy. Alertness was assessed daily with a brief Psychomotor Vigilance Test (PVT) and the Karolinska Sleepiness Scale. Results: Interns averaged 6.93 hours (95% confidence interval [CI] 6.84–7.03 hours) sleep per 24 hours across shifts, significantly less than residents not working overnight shifts (7.18 hours, 95% CI 7.06–7.30 hours, p = .007). Interns obtained on average 2.19 hours (95% CI 2.02–2.36 hours) sleep during on-call nights (17.5% obtained no sleep). Alertness was significantly lower on mornings after on-call nights compared to regular shifts (p < .001). Naps between 9 am and 6 pm on the first day post‐call were frequent (90.8%) and averaged 2.84 hours (95% CI 2.69–3.00 hours), but interns still slept 1.66 hours less per 24 hours (95% CI 1.56–1.76 hours) compared to regular shift days (p < .001). Sleep inertia significantly affected alertness in the 60 minutes after waking on-call. Conclusions: Extended overnight shifts increase the likelihood of chronic sleep restriction in interns. Reduced levels of alertness after on-call nights need to be mitigated. A systematic comparison of sleep, alertness, and safety outcomes under current and past duty hour rules is encouraged.

Background Physical activity reduces the risk of major cardiovascular events, but many people who are most at-risk do not get enough exercise. In the BE ACTIVE randomized controlled trial, - a study in which text messages were used to communicate with participants– game playing (gamification), financial incentives, and the combination of gamification plus financial incentives increased physical activity from baseline more than control over a 12-month intervention period. Participants randomized to gamification plus financial incentives maintained a significantly greater increase than control over the 6-month post-intervention follow-up. To understand the impact of the interventions on motivation and performance we conducted semi-structured interviews with a subset of participants. Methods Using extreme case sampling, interviewees were selected from participants who were randomized to an intervention arm and were identified as either high or low performers based on their change from baseline to the end of the trial in mean daily step count. During semi-structured telephone interviews, participants were asked their thoughts and feelings about the trial, motivations for participation, and about specific aspects of the intervention. Interviews were conducted within 6 months after the participant completed participation in the trial. Thematic analysis was conducted inductively and deductively, and identified themes were mapped onto the COM-B Framework to understand the interaction between different themes. Results We achieved saturation after conducting interviews with 55 participants (30 high performers and 25 low performers); 19 in the gamification arm, 19 in the financial incentives arm, and 17 in the gamification plus financial incentives arm. Based on qualitative interviews, the importance of individual accountability via goal setting and feedback appears to be a primary factor in behavior change in this trial; however, the combination of accountability with the opportunity of access to the intervention had additional impact on the results. Conclusion Gamification and financial incentives both increased physical activity in the BE ACTIVE study, but results may be improved by tailoring interventions based on participants’ personal traits and level of social support to optimize motivation. (328 words) Trial registration NCT03911141 Registration date: 04/09/2019.

ABSTRACT BACKGROUND Home wireless device monitoring could play an important role in improving the health of patients with poorly controlled chronic diseases, but daily engagement rates among these patients may be low. OBJECTIVE To test the effectiveness of two different magnitudes of financial incentives for improving adherence to remote-monitoring regimens among patients with poorly controlled diabetes. DESIGN Randomized, controlled trial. (Clinicaltrials.gov Identifier: NCT01282957). PARTICIPANTS Seventy-five patients with a hemoglobin A1c greater than or equal to 7.5 % recruited from a Primary Care Medical Home practice at the University of Pennsylvania Health System. INTERVENTIONS Twelve weeks of daily home-monitoring of blood glucose, blood pressure, and weight (control group; n  = 28); a lottery incentive with expected daily value of $2.80 ( n  = 26) for daily monitoring; and a lottery incentive with expected daily value of $1.40 ( n  = 21) for daily monitoring. MAIN MEASURES Daily use of three home-monitoring devices during the three-month intervention (primary outcome) and during the three-month follow-up period and change in A1c over the intervention period (secondary outcomes). KEY RESULTS Incentive arm participants used devices on a higher proportion of days relative to control (81 % low incentive vs. 58 %, P  = 0.007; 77 % high incentive vs. 58 %, P  = 0.02) during the three-month intervention period. There was no difference in adherence between the two incentive arms ( P  = 0.58). When incentives were removed, adherence in the high incentive arm declined while remaining relatively high in the low incentive arm. In month 6, the low incentive arm had an adherence rate of 62 % compared to 35 % in the high incentive arm ( P  = 0.015) and 27 % in the control group ( P  = 0.002). CONCLUSIONS A daily lottery incentive worth $1.40 per day improved monitoring rates relative to control and had significantly better efficacy once incentives were removed than a higher incentive.

In response to the escalating global obesity crisis and its associated health and financial burdens, this paper presents a novel methodology for analyzing longitudinal weight loss data and assessing the effectiveness of financial incentives. Drawing from the Keep It Off trial—a three-arm randomized controlled study with 189 participants—we examined the potential impact of financial incentives on weight loss maintenance. Given that some participants choose not to weigh themselves because of small weight change or weight gains, which is a common phenomenon in many weight-loss studies, traditional methods, for example, the Generalized Estimating Equations (GEE) method tends to overestimate the effect size due to the assumption that data are missing completely at random. To address this challenge, we proposed a framework which can identify evidence of missing not at random and conduct bias correction using the estimating equation derived from pairwise composite likelihood. By analyzing the Keep It Off data, we found that the data in this trial are most likely characterized by non-random missingness. Notably, we also found that the enrollment time (i.e., duration time) would be positively associated with the weight loss maintenance after adjusting for the baseline participant characteristics (e.g., age, sex). Moreover, the lottery-based intervention was found to be more effective in weight loss maintenance compared with the direct payment intervention, though the difference was non-statistically significant. This framework's significance extends beyond weight loss research, offering a semi-parametric approach to assess missing data mechanisms and robustly explore associations between exposures (e.g., financial incentives) and key outcomes (e.g., weight loss maintenance). In essence, the proposed methodology provides a powerful toolkit for analyzing real-world longitudinal data, particularly in scenarios with data missing not at random, enriching comprehension of intricate dataset dynamics.

BACKGROUND:Medication adherence after myocardial infarction remains low. Pharmacy claims have typically been used to measure medication adherence, but electronic pill bottles may offer additional information. OBJECTIVE:The main objectives of this study were to compare the association of adherence measured by prescription claims and remote monitoring technologies with cardiovascular events. RESEARCH DESIGN:This study was a secondary analysis of a remote monitoring intervention to increase medication adherence in myocardial infarction patients. SUBJECTS:In total, 682 myocardial infarction patients were randomized to the intervention group with both medical and pharmacy benefits. MEASURES:Pharmacy claims adherence was measured using proportion of days covered (PDC) and GlowCap adherence (GC) was measured as the proportion of days the pill bottle was opened. We compared the association of PDC and GC adherence for statins with time to first vascular readmission or death and assessed model fit using Akaike information criterion and Bayesian information criterion and the likelihood ratio test. RESULTS:Higher PDC was significantly associated with a lower hazard rate for vascular readmissions or death (hazard ratio=0.435; P=0.009). There was also an association between GC adherence and vascular readmissions or death (hazard ratio=0.313; P≤0.001). Adding the GC adherence variable to the model using only PDC improved the model fit (likelihood ratio test, P=0.001), as well as vice versa (P=0.050). CONCLUSIONS:Pharmacy claims data provide useful but not complete data for medication adherence monitoring. New wireless technologies have the potential to provide additional data about clinical outcomes.

Background. Financial incentives and peer networks could be delivered through eHealth technologies to encourage older adults to walk more. Methods. We conducted a 24-week randomized trial in which 92 older adults with a computer and Internet access received a pedometer, daily walking goals, and weekly feedback on goal achievement. Participants were randomized to weekly feedback only (Comparison), entry into a lottery with potential to earn up to $200 each week walking goals were met (Financial Incentive), linkage to four other participants through an online message board (Peer Network), or both interventions (Combined). Main outcomes were the proportion of days walking goals were met during the 16-week intervention and 8-week follow-up. W e conducted a content analysis of messages posted by Peer Network and Combined arm participants. Results. During the 16-week intervention, there were no differences in the proportion of days walking goals were met in the Financial Incentive (39.7%; p = .78), Peer Network (24.9%; p = .08), and Combined (36.0%; p = .77) arms compared with the Comparison arm (36.0%). During 8 weeks of follow-up, the proportion of days walking goals were met was lower in the Peer Network arm ( 18.7%; p = .025) but not in the Financial Incentive (29.3%; p = .50) or Combined (24.8%; p = .37) arms, relative to the Comparison arm (34.5%). Messages posted by participants focused on barriers to walking and provision of social support. Conclusions. Financial incentives and peer networks delivered through eHealth technologies did not result in older adults walking more.

Background Heart failure (HF) is one of the most common reasons for hospital admission and is a major cause of morbidity, mortality, and increasing health care costs. The EMPOWER study was a randomized trial that used remote monitoring technology to track patients’ weight and diuretic adherence and a state-of-the-art approach derived from behavioral economics to motivate adherence to the reverse monitoring technology. Objective The goal was to explore patient and clinician perceptions of the program and its impact on perceived health outcomes and better understand why some patients or clinicians did better or worse than others in response to the intervention. Approach This was a retrospective qualitative study utilizing semi-structured interviews with 43 patients and 16 clinicians to understand the trial’s processes, reflecting on successes and areas for improvement for future iterations of behavioral economic interventions. Key results Many patients felt supported, and they appreciated the intervention. Many also appreciated the lottery intervention, and while it was not an incentive for enrolling for many respondents, it may have increased adherence during the study. Clinicians felt that the intervention integrated well into their workflow, but the number of alerts was burdensome. Additionally, responses to alerts varied considerably by provider, perhaps because there are no professional guidelines for alerts unaccompanied by severe symptoms. Conclusion Our qualitative analysis indicates potential areas for additional exploration and consideration to design better behavioral economic interventions to improve cardiovascular health outcomes for patients with HF. Patients appreciated lottery incentives for adhering to program requirements; however, many were too far along in their disease progression to benefit from the intervention. Clinicians found the amount and frequency of electronic alerts burdensome and felt they did not improve patient outcomes. Trial registration ClinicalTrials.gov Identifier: NCT02708654.