January 2025
JAMA Network Open
This randomized clinical trial examines the effects of a gamified program for older adults to meet daily and weekly step goals following radical cystectomy procedures.
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January 2025
JAMA Network Open
This randomized clinical trial examines the effects of a gamified program for older adults to meet daily and weekly step goals following radical cystectomy procedures.
July 2024
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17 Reads
INTRODUCTION Physical activity is associated with reduced risk of cognitive and functional decline but scalable, sustainable interventions for populations at risk for Alzheimer's disease (AD) and AD and related dementias (ADRD) are lacking. METHODS A 12‐week randomized‐controlled trial was conducted with a 3‐week follow‐up using a national AD prevention registry (GeneMatch). The control group (n = 50) set step goals and received daily feedback. The intervention group (n = 44) also received a behaviorally designed game based on achieving step goals and reinforced by a support partner. RESULTS Intervention participants (94 participants, mean age 70, 78% female) had greater change in mean daily step count than control of 1699 steps/day (95% confidence interval [CI], 1149–2249), P < 0.0001, which was sustained in the follow‐up period at 1219 steps/day (95% CI, 455–1983), P = 0.0018. Carriers of the apolipoprotein E ε4 gene (high risk) did not perform differently than non‐carriers; however, high self‐reported risk perception was associated with higher activity. DISCUSSION A gamified intervention was effective in promoting and sustaining higher physical activity in older adults at genetic risk for AD/ADRD. Highlights A simple game played with a support partner increased walking in older adults at risk for Alzheimer's disease (AD). The game also increased minutes of moderate‐to‐vigorous physical activity per day. Perception of lifelong AD risk was associated with increased activity but genetic risk (apolipoprotein E ε4+) was not. TRIAL REGISTRATION ClinicalTrials.gov: NCT05069155
July 2024
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2 Reads
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3 Citations
American Heart Journal
June 2024
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60 Reads
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8 Citations
Nature
Encouraging routine COVID-19 vaccinations is likely to be a crucial policy challenge for decades to come. To avert hundreds of thousands of unnecessary hospitalizations and deaths, adoption will need to be higher than it was in the autumn of 2022 or 2023, when less than one-fifth of Americans received booster vaccines1,2. One approach to encouraging vaccination is to eliminate the friction of transportation hurdles. Previous research has shown that friction can hinder follow-through³ and that individuals who live farther from COVID-19 vaccination sites are less likely to get vaccinated⁴. However, the value of providing free round-trip transportation to vaccination sites is unknown. Here we show that offering people free round-trip Lyft rides to pharmacies has no benefit over and above sending them behaviourally informed text messages reminding them to get vaccinated. We determined this by running a megastudy with millions of CVS Pharmacy patients in the United States testing the effects of (1) free round-trip Lyft rides to CVS Pharmacies for vaccination appointments and (2) seven different sets of behaviourally informed vaccine reminder messages. Our results suggest that offering previously vaccinated individuals free rides to vaccination sites is not a good investment in the United States, contrary to the high expectations of both expert and lay forecasters. Instead, people in the United States should be sent behaviourally informed COVID-19 vaccination reminders, which increased the 30-day COVID-19 booster uptake by 21% (1.05 percentage points) and spilled over to increase 30-day influenza vaccinations by 8% (0.34 percentage points) in our megastudy. More rigorous testing of interventions to promote vaccination is needed to ensure that evidence-based solutions are deployed widely and that ineffective but intuitively appealing tools are discontinued.
May 2024
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26 Reads
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1 Citation
Journal of Medical Internet Research
Background Patients with advanced cancer undergoing chemotherapy experience significant symptoms and declines in functional status, which are associated with poor outcomes. Remote monitoring of patient-reported outcomes (PROs; symptoms) and step counts (functional status) may proactively identify patients at risk of hospitalization or death. Objective The aim of this study is to evaluate the association of (1) longitudinal PROs with step counts and (2) PROs and step counts with hospitalization or death. Methods The PROStep randomized trial enrolled 108 patients with advanced gastrointestinal or lung cancers undergoing cytotoxic chemotherapy at a large academic cancer center. Patients were randomized to weekly text-based monitoring of 8 PROs plus continuous step count monitoring via Fitbit (Google) versus usual care. This preplanned secondary analysis included 57 of 75 patients randomized to the intervention who had PRO and step count data. We analyzed the associations between PROs and mean daily step counts and the associations of PROs and step counts with the composite outcome of hospitalization or death using bootstrapped generalized linear models to account for longitudinal data. Results Among 57 patients, the mean age was 57 (SD 10.9) years, 24 (42%) were female, 43 (75%) had advanced gastrointestinal cancer, 14 (25%) had advanced lung cancer, and 25 (44%) were hospitalized or died during follow-up. A 1-point weekly increase (on a 32-point scale) in aggregate PRO score was associated with 247 fewer mean daily steps (95% CI –277 to –213; P<.001). PROs most strongly associated with step count decline were patient-reported activity (daily step change –892), nausea score (–677), and constipation score (524). A 1-point weekly increase in aggregate PRO score was associated with 20% greater odds of hospitalization or death (adjusted odds ratio [aOR] 1.2, 95% CI 1.1-1.4; P=.01). PROs most strongly associated with hospitalization or death were pain (aOR 3.2, 95% CI 1.6-6.5; P<.001), decreased activity (aOR 3.2, 95% CI 1.4-7.1; P=.01), dyspnea (aOR 2.6, 95% CI 1.2-5.5; P=.02), and sadness (aOR 2.1, 95% CI 1.1-4.3; P=.03). A decrease in 1000 steps was associated with 16% greater odds of hospitalization or death (aOR 1.2, 95% CI 1.0-1.3; P=.03). Compared with baseline, mean daily step count decreased 7% (n=274 steps), 9% (n=351 steps), and 16% (n=667 steps) in the 3, 2, and 1 weeks before hospitalization or death, respectively. Conclusions In this secondary analysis of a randomized trial among patients with advanced cancer, higher symptom burden and decreased step count were independently associated with and predictably worsened close to hospitalization or death. Future interventions should leverage longitudinal PRO and step count data to target interventions toward patients at risk for poor outcomes. Trial Registration ClinicalTrials.gov NCT04616768; https://clinicaltrials.gov/study/NCT04616768 International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2021-054675
May 2024
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16 Reads
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2 Citations
NEJM AI
April 2024
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60 Reads
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10 Citations
Circulation
Background: Physical activity is associated with a lower risk of major adverse cardiovascular events, but few individuals achieve guideline recommended levels of physical activity. Strategies informed by behavioral economics increase physical activity, but their longer-term effectiveness is uncertain. We sought to determine the effect of behaviorally-designed gamification, loss-framed financial incentives, or the combination on physical activity compared with attention control over 12-month intervention and 6-month post-intervention follow-up periods. Methods: Between May 2019 and January 2024, participants with clinical ASCVD or 10-year risk of myocardial infarction, stroke, or cardiovascular death ≥ 7.5% by the pooled cohort equation were enrolled in a pragmatic randomized clinical trial. Participants received a wearable device to track daily steps, established a baseline, selected a step goal increase, and were randomly assigned to control (n = 151), behaviorally-designed gamification (n = 304), loss-framed financial incentives (n = 302), or gamification + financial incentives (n = 305). The trial’s primary outcome was change in mean daily steps from baseline through the 12-month intervention period. Results: A total of 1062 patients (mean [SD] age 67 [8], 61% female, 31% non-white) were enrolled. Compared with controls, participants had significantly greater increases in mean daily steps from baseline during the 12-month intervention in the gamification arm (adjusted difference, 538.0; 95% CI, 186.2-889.9; P = 0.0027), financial incentives arm (adjusted difference, 491.8; 95% CI, 139.6-844.1; P = 0.0062), and gamification + financial incentives arm (adjusted difference, 868.0; 95% CI, 516.3-1219.7; P < 0.0001). During 6-month follow-up, physical activity remained significantly greater in the gamification + financial incentives arm than in the control arm (adjusted difference, 576.2; 95% CI, 198.5-954; P = 0.0028) but was not significantly greater in the gamification (adjusted difference, 459.8; 95% CI, 82.0-837.6; P = 0.0171) or financial incentives (adjusted difference, 327.9; 95% CI, -50.2 to 706; P = 0.09) arms, after adjusting for multiple comparisons. Conclusions: Behaviorally-designed gamification, loss-framed financial incentives, and the combination of both increased physical activity compared with control over a 12-month intervention period, with the largest effect in gamification + financial incentives. These interventions could be a useful component of strategies to reduce cardiovascular risk in high-risk patients.
February 2024
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6 Reads
American Heart Journal
December 2023
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9 Reads
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1 Citation
Sleep Health
October 2023
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19 Reads
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6 Citations
JCO Oncology Practice
PURPOSE Routine collection of patient-generated health data (PGHD) may promote earlier recognition of symptomatic and functional decline. This trial assessed the impact of an intervention integrating remote PGHD collection with patient nudges on symptom and functional status understanding between patients with advanced cancer and their oncology team. METHODS This three-arm randomized controlled trial was conducted from November 19, 2020, to December 17, 2021, at a large tertiary oncology practice. We enrolled patients with stage IV GI and lung cancers undergoing chemotherapy. Over 6 months, patients in two intervention arms received PROStep—weekly text message–based symptom surveys and passive activity monitoring using a wearable accelerometer. PGHD were summarized in dashboards given to patients' oncology team before appointments. One intervention arm received an additional text-based active choice prompt to discuss worsening symptoms or functional status with their clinician. Control patients did not receive PROStep. The coprimary outcomes patient perceptions of oncology team symptom and functional understanding at 6 months were measured on a 1-5 Likert scale (5 = high understanding). RESULTS One hundred eight patients enrolled: 55% male, 81% White, and 77% had GI cancers. Patient-reported clinician understanding did not differ between control and intervention arms for symptoms (4.5 v 4.5; P = .87) or functional status (4.5 v 4.3; P = .31). In the intervention arms, combined patient adherence to weekly symptom reports and daily activity monitoring was 64% and 53%, respectively. Intervention patients in the PROStep versus PROStep + active choice arms reported low burden from wearing the accelerometer (mean burden [standard deviation], 2.7 [1.3] v 2.1 [1.3]; P = .15) and completing surveys (2.1 [1.2] v 1.9 [1.3]; P = .44). CONCLUSION Patients receiving PROStep reported high understanding of symptoms and functional status from their oncology team, although this did not differ from controls.
... • Integrates evidence-based behaviour change techniques [7], including loss framing for financial incentives [23], competition with social incentives [20], and real rewards [7]. ...
April 2021
Behavioral Science & Policy
... Enablers for increasing vaccine uptake include utilizing reminder/recall systems with persuasive health communication [54][55][56], establishing standing orders for both inpatient and ambulatory settings [57,58], improving access (e.g., organizing workplace vaccination clinics [59], establishing ad hoc vaccination outreach services [60], and empowering pharmacists to vaccinate patients [61]), and providing incentives [62]. It is nonetheless important that reward systems are designed in a way that does not unfairly favor late adopters of vaccination [63]. ...
June 2024
Nature
... In the near future, LLMs may help to interpret and communicate insights from wearables and home sensors (such as early adverse event detection) 26 , make basic triage decisions 27 , and coordinate follow-up care (Fig. 3) 28 . LLMs are effective at drafting responses to patient questions, which have been rated by patients as being of high quality and more empathetic than physician responses 29 . ...
May 2024
NEJM AI
... Whilst the optimal strategy and population to target remains unclear for financial incentives, such a strategy may not be durable given its ongoing cost and complexity. Gamification as another form of incentive could be applicable to lipid management, but studies are required [92][93][94]. ...
April 2024
Circulation
... However, the period of hospitalization may favor the worsening of sleep quality, since it refers to a unit that generates stress. 1,2 This decline can impact on the ability to perform exercises, generating a decrease in functional capacity. ...
December 2023
Sleep Health
... Unfortunately, PROs are underused in oncology, especially in real-world settings where adherence is often as low as 50%. Additionally, PRO completion is about 10% lower for nonwhite patients than white patients [80,81]. ...
October 2023
JCO Oncology Practice
... Implementation prompted an 11% increase 21 in patient encounters with documented serious illness conversations and decreased end-of-life spending by $75.33 on average per day. 22 The effects of the algorithm on end-of-life care and SIC rates sustained outside of trial settings at its continued deployment in a large health care system. ...
June 2023
Journal of Clinical Oncology
... In our future work, we propose how we can further increase our model's accuracy and precision given additional data. As our work builds on others, this study is one of many that demonstrate the additive power of data for classifying patient outcomes including deterioration [41][42][43] and readmissions [18,44]. Previous works have considered acute heart failure hospitalizations, systemic inflammatory response syndrome deteriorations (sepsis and cytokine release syndrome), as well as hospital readmissions. ...
May 2023
... 50 Among hospitalized patients, sepsis onset during night shift and at change of shift is associated with longer time to antibiotic administration. 51 Dedicated sepsis response teams have been associated with improved sepsis process of care metrics as well as mortality, though the majority of patients included in these studies had COS and received initial care in the ED. [52][53][54] Further studies to quantify the benefit of sepsis response teams on outcomes among HOS patients are indicated. ...
May 2023
Annals of the American Thoracic Society
... 5 It was not until October 2017 that the opioid epidemic was declared a public health emergency. Tools for judicious prescribing, such as the CDC prescribing guidelines, 6 prescription drug monitoring programs (PDMP), prescribing defaults in the electronic health record, and peer report cards, 7 were key steps to help mitigate opioid overprescribing. However, these efforts were largely voluntary or unmonitored, not broadly followed, and few had sustained success. ...
April 2023
American Journal of Medical Quality