The Association of Patient Educational Attainment With Cardiac Rehabilitation Adherence and Health Outcomes.

PURPOSE: Participating in cardiac rehabilitation (CR) after a cardiac event provides many clinical benefits. Patients of lower socioeconomic status (SES) are less likely to attend CR. It is unclear whether they attain similar clinical benefits as patients with higher SES. This study examines how educational attainment (one measure of SES) predicts both adherence to and improvements during CR. METHODS: This was a prospective observational study of 1407 patients enrolled between January 2016 and December 2019 in a CR program located in Burlington, VT. Years of education, smoking status (self-reported and objectively measured), depression symptom level (Patient Health Questionnaire), self-reported physical function (Medical Outcomes Survey), level of fitness (peak metabolic equivalent, peak oxygen uptake, and handgrip strength), and body composition (body mass index and waist circumference) were obtained at entry to, and for a subset (n = 917), at exit from CR. Associations of educational attainment with baseline characteristics were examined using Kruskal-Wallis or Pearson's χ 2 tests as appropriate. Associations of educational attainment with improvements during CR were examined using analysis of covariance or logistic regression as appropriate. RESULTS: Educational attainment was significantly associated with most patient characteristics examined at intake and was a significant predictor of the number of CR sessions completed. Lower educational attainment was associated with less improvement in cardiorespiratory fitness, even when controlling for other variables. CONCLUSIONS: Patients with lower SES attend fewer sessions of CR than their higher SES counterparts and may not attain the same level of benefit from attending. Programs need to increase attendance within this population and consider program modifications that further support behavioral changes during CR.

Contingency Management for Patients Receiving Medication for Opioid Use Disorder: A Systematic Review and Meta-analysis.

Importance: Medication treatment for opioid use disorder (MOUD) is efficacious, but comorbid stimulant use and other behavioral health problems often undermine efficacy. Objective: To examine the association of contingency management, a behavioral intervention wherein patients receive material incentives contingent on objectively verified behavior change, with end-of-treatment outcomes for these comorbid behavioral problems. Data Sources: A systematic search of PubMed, Cochrane CENTRAL, Web of Science, and reference sections of articles from inception through May 5, 2020. The following search terms were used: vouchers OR contingency management OR financial incentives. Study Selection: Prospective experimental studies of monetary-based contingency management among participants receiving MOUD. Data Extraction and Synthesis: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline, 3 independent investigators extracted data from included studies for a random-effects meta-analysis. Main Outcomes and Measures: Primary outcome was the association of contingency management at end-of-treatment assessments with 6 clinical problems: stimulant use, polysubstance use, illicit opioid use, cigarette smoking, therapy attendance, and medication adherence. Random-effects meta-analysis models were used to compute weighted mean effect size estimates (Cohen d) and corresponding 95% CIs separately for each clinical problem and collapsing across the 3 categories assessing abstinence and the 2 assessing treatment adherence outcomes. Results: The search identified 1443 reports of which 74 reports involving 10 444 unique adult participants met inclusion criteria for narrative review and 60 for inclusion in meta-analyses. Contingency management was associated with end-of-treatment outcomes for all 6 problems examined separately, with mean effect sizes for 4 of 6 in the medium-large range (stimulants, Cohen d = 0.70 [95% CI, 0.49-0.92]; cigarette use, Cohen d = 0.78 [95% CI, 0.43-1.14]; illicit opioid use, Cohen d = 0.58 [95% CI, 0.30-0.86]; medication adherence, Cohen d = 0.75 [95% CI, 0.30-1.21]), and 2 in the small-medium range (polysubstance use, Cohen d = 0.46 [95% CI, 0.30-0.62]; therapy attendance, d = 0.43 [95% CI, 0.22-0.65]). Collapsing across abstinence and adherence categories, contingency management was associated with medium effect sizes for abstinence (Cohen d = 0.58; 95% CI, 0.47-0.69) and treatment adherence (Cohen d = 0.62; 95% CI, 0.40-0.84) compared with controls. Conclusions and Relevance: These results provide evidence supporting the use of contingency management in addressing key clinical problems among patients receiving MOUD, including the ongoing epidemic of comorbid psychomotor stimulant misuse. Policies facilitating integration of contingency management into community MOUD services are sorely needed.

Use of electronic nicotine delivery systems (ENDS) among U.S. women of reproductive age: Prevalence, reported reasons for use, and toxin exposure.

Given the rapidly expanding marketplace for Electronic Nicotine Delivery Systems (ENDS), it is important to monitor patterns of use, particularly among vulnerable populations. This study examined ENDS prevalence, reasons for use (i.e., to help quit smoking and for appealing flavors), and toxin exposure among U.S. women of reproductive age using data from the Population Assessment of Tobacco and Health (PATH) Study (2013-17). Exclusive ENDS users, dual users of ENDS and cigarettes, and exclusive cigarette smokers were compared within and between pregnant and not-pregnant women. Among pregnant women, prevalence of exclusive ENDS and dual use was similar (0.8%; 95%CI = 0.4-1.2% vs. 1.4%; 95%CI = 0.9-2.0%, respectively), but exclusive ENDS use was less prevalent than dual use among not-pregnant women (1.1%; 95%CI = 0.9-1.4% vs. 3.7%; 95%CI = 3.3-4.0%, respectively). Most women reported ENDs were used to help quit smoking (66.5-90.0%) and for appealing flavors (57.6-87.4%), and endorsement rates did not differ by use pattern or pregnancy status. Except for metals, toxin exposure was substantially lower for exclusive ENDS users relative to dual users and exclusive cigarette smokers regardless of pregnancy status. Pregnant and not-pregnant U.S. women regularly report using ENDS for help with quitting smoking and for appealing flavors. Although no type or pattern of tobacco/nicotine use is safe, especially during pregnancy, using ENDS exclusively is consistent with lower overall toxin exposure for pregnant and not-pregnant women. This study advances understanding of ENDS use and toxin exposure in women of reproductive age, a population highly vulnerable to the effects of nicotine/tobacco consumption.

Social Smoking Environment and Associations With Cardiac Rehabilitation Attendance.

PURPOSE: Continued cigarette smoking after a major cardiac event predicts worse health outcomes and leads to reduced participation in cardiac rehabilitation (CR). Understanding which characteristics of current smokers are associated with CR attendance and smoking cessation will help improve care for these high-risk patients. We examined whether smoking among social connections was associated with CR participation and continued smoking in cardiac patients. METHODS: Participants included 149 patients hospitalized with an acute cardiac event who self-reported smoking prior to the hospitalization and were eligible for outpatient CR. Participants completed a survey on their smoking habits prior to hospitalization and 3 mo later. Participants were dichotomized into two groups by the proportion of friends or family currently smoking ("None-Few" vs "Some-Most"). Sociodemographic, health, secondhand smoke exposure, and smoking measures were compared using t tests and χ2 tests (P < .05). ORs were calculated to compare self-reported rates of CR attendance and smoking cessation at 3-mo follow-up. RESULTS: Compared with the "None-Few" group, participants in the "Some-Most" group experienced more secondhand smoke exposure (P < .01) and were less likely to attend CR at follow-up (OR = 0.40; 95% CI, 0.17-0.93). Participants in the "Some-Most" group tended to be less likely to quit smoking, but this difference was not statistically significant. CONCLUSION: Social environments with more smokers predicted worse outpatient CR attendance. Clinicians should consider smoking within the social network of the patient as an important potential barrier to pro-health behavior change.

Current smoking as a marker of a high-risk behavioral profile after myocardial infarction.

Continued smoking following myocardial infarction (MI) is strongly associated with increased morbidity and mortality. Patients who continue to smoke may also engage in other behaviors that exacerbate risk. This study sought to characterize the risk profile of a national sample of individuals with previous MI who currently smoke. Data were taken from the 2017 Behavioral Risk Factor Surveillance Survey (United States), with 4.2% of the sample reporting a past MI (N = 26,004). Participants were classified by smoking status (current/former/never) and compared on medical comorbidities and the clustering of modifiable behaviors relevant for secondary prevention (smoking, poor nutrition, problematic alcohol use, physical inactivity, medication adherence). Current smokers were more likely to report other comorbidities including stroke, chronic obstructive pulmonary disease, physical limitations, and poor mental health. Smokers were also less likely to report taking blood pressure and cholesterol medications, and less likely to attend cardiac rehabilitation (examined in a subset of the sample, N = 2181). Current smoking remained an independent predictor of other health-related behaviors even when controlling for age, sex, race, educational attainment, and other comorbidities. In the modifiable risk-factor behavior cluster analysis, the most common pattern among current smokers was having two risk factors, smoking plus one additional risk factor, whereas the most common pattern was zero risk factors among never or former-smokers. Physical inactivity was the most common additional risk factor across smoking statuses. Current smoking is associated with multiple comorbidities and should be considered a marker for a high-risk behavioral profile among patients with a history of MI.

Smartphone-based financial incentives to promote smoking cessation during pregnancy: A pilot study.

Cigarette smoking during pregnancy increases risk for pregnancy complications, growth restriction, and other adverse health outcomes. The most effective intervention for reducing smoking during pregnancy is financial incentives contingent on biochemically-verified smoking abstinence. The present study examined the efficacy of a smartphone-based intervention whereby smoking monitoring and incentive delivery occurred remotely using a mobile app. If efficacious, this remote intervention would allow pregnant women residing in geographically remote areas to benefit from incentives-based cessation interventions. Sixty U.S. pregnant smokers were recruited between May 2018 to May 2019 via obstetrical clinics, Women, Infants, and Children (WIC) offices, and Facebook. Participants were assigned sequentially to one of two treatments: best practices alone (N = 30) or best practices plus financial incentives (N = 30). Outcomes were analyzed using repeated measures analysis based on generalized estimating equations (GEE). Seven-day point prevalence abstinence rates were greater in the incentives versus best practices arms early- (46.7% vs 20.0%, OR = 3.50, 95%CI = 1.11,11.02) and late-antepartum (36.7% vs 13.3%, OR = 3.76, 95%CI = 1.04,13.65), and four- (36.7% vs 10.0%, OR = 5.21, 95%CI = 1.28,21.24) and eight-weeks postpartum (40.0% vs 6.7%, OR = 9.33, 95%CI = 1.87,46.68), although not at the 12- (23.3% vs 10.0%, OR = 2.74, 95%CI = 0.63,11.82) or 24-week (20.0% vs 6.7%, OR = 3.50, 95%CI = 0.65,18.98) postpartum assessments likely due to this pilot study being underpowered for discerning differences at the later assessments, especially 24-weeks postpartum which was three months after treatment completion. These results support the efficacy of this remote, incentives-based intervention for pregnant smokers. Further research evaluating its efficacy and cost-effectiveness in a well-powered, randomized controlled trial appears warranted.

Effects of response cost magnitude on resurgence of human operant behavior.

Extensive research has been dedicated to the study of resurgence following extinction and differential reinforcement of alternative behavior. Less is known about the effects of punishment on resurgence. This study extended previous research by examining whether the magnitude of response cost punishment affects resurgence of human operant behavior. College students engaged in a computer task using the three-phase resurgence procedure where points were used to reinforce target (Phase 1) or alternative (Phase 2) behavior. Across three groups, Phase 2 contingencies for the target response were manipulated. In one group, only extinction was implemented. In the other two groups, response cost was also implemented. Response cost was equal to or double the number of points that could be gained for alternative responding. Resurgence was similar in Phase 3 across the three groups, demonstrating that neither the addition nor the magnitude of punishment differentially affected response recovery under these conditions. Future research should examine other parameters of punishment (e.g., delay, schedule) and how these variables interact with different parameters of alternative reinforcement to increase our understanding of the conditions under which resurgence may be exacerbated or minimized.

Evaluating preference for and reinforcing efficacy of fruits and vegetables compared with salty and sweet foods.

Children diagnosed with autism spectrum disorder are often more selective in their food preferences than their typically developing peers. Additionally, many preferred food selections have minimal nutritional value. We evaluated the preference for, and reinforcing efficacy of, fruits and vegetables compared with salty and sweet foods, which are often used as edible reinforcers. Multiple-stimulus preference assessments were conducted to identify preferred foods, and reinforcer assessments were conducted to determine the reinforcing efficacy of more preferred foods. Fruits and vegetables were sometimes preferred over salty or sweet foods and often functioned as reinforcers. Future research should incorporate fruits and vegetables into preference assessments when identifying putative reinforcers.

Response to name in children with autism: Treatment, generalization, and maintenance.

Deficits in response to name (RTN) are an early indicator of autism spectrum disorder (ASD), and RTN is a treatment goal in many early intervention curricula for children with ASD. However, little research has empirically evaluated methods for increasing RTN in children with ASD. We evaluated a series of conditions designed to increase RTN for 4 children with ASD using a multielement experimental design. The schedules of tangible reinforcement were thinned after mastery and generalization was tested across people and contexts. Tangible reinforcers were necessary to increase RTN for all 4 participants, and the schedule of reinforcement was successfully thinned with all participants after intervention. Generalization was also observed across people and experimental contexts.

Multiple control responses and resurgence of human behavior.

Behavior that was previously extinguished may reoccur, or resurge, when an alternative response contacts extinction or when reinforcement conditions worsen. Researchers have studied resurgence of human responding in laboratory settings with procedures commonly used with nonhumans. In contrast to nonhuman responding, researchers have failed to observe resurgence of the target response at rates that differ from an inactive control response with verbally competent humans. But this may have been the result of using a single control response. The current study examined this possibility by randomly allocating participants (N = 20) to a condition with either two or four control responses. When the alternative response contacted extinction, having more control responses did not reduce overall responding to control options, and aggregated responding to control options were similar to target response rates. Interestingly, most participants responded more to one control response over all other control responses when the alternative response contacted extinction. This study provides additional support for previous research that finds consistent differences between human and nonhuman responding during resurgence procedures. Two potential reasons for variability in human responding during resurgence tests include less time in experimental sessions and the influence of verbal behavior.

Evaluating resurgence procedures in a human operant laboratory.

Resurgence of previously extinguished behavior may occur when a recently reinforced alternative response is placed on extinction. Understanding the conditions that produce and reduce resurgence is important for both basic and applied researchers. Research on resurgence of human behavior may benefit from methods that facilitate comparison and replication of nonhuman animal studies. These studies often include an inactive control response to differentiate resurgence from extinction-induced variability. In contrast, human research typically does not. Sweeney and Shahan (2016) tested a brief, trial-based procedure that included an inactive control response with human participants, but they did not observe resurgence. The current study extended their methods by examining four different conditions in a free-operant task lasting <1h. Modifications across conditions included changing the number of response options available in each phase and how signals associated with each response were presented. Only one condition resulted in responding resembling resurgence. Our results suggest the utility of the inactive control response and the influence of contextual cues in human research should be investigated further.

A Review of the Literature on Remote Monitoring Technology in Incentive-Based Interventions for Health-Related Behavior Change.

Use of technology (e.g., Internet, cell phones) to allow remote implementation of incentives interventions for health-related behavior change is growing. To our knowledge, there has yet to be a systematic review of this literature reported. The present report provides a systematic review of the controlled studies where technology was used to remotely implement financial incentive interventions targeting substance use and other health behaviors published between 2004 and 2015. For inclusion in the review, studies had to use technology to remotely accomplish one of the following two aims alone or in combination: (a) monitor the target behavior, or (b) deliver incentives for achieving the target goal. Studies also had to examine financial incentives (e.g., cash, vouchers) for health-related behavior change, be published in peer-reviewed journals, and include a research design that allowed evaluation of the efficacy of the incentive intervention relative to another condition (e.g., non-contingent incentives, treatment as usual). Of the 39 reports that met inclusion criteria, 18 targeted substance use, 10 targeted medication adherence or home-based health monitoring, and 11 targeted diet, exercise, or weight loss. All 39 (100%) studies used technology to facilitate remote monitoring of the target behavior, and 26 (66.7%) studies also incorporated technology in the remote delivery of incentives. Statistically significant intervention effects were reported in 71% of studies reviewed. Overall, the results offer substantial support for the efficacy of remotely implemented incentive interventions for health-related behavior change, which have the potential to increase the cost-effectiveness and reach of this treatment approach.