Differences in time-based task characteristics help to explain the age-prospective memory paradox.

Prior prospective memory (PM) research shows paradoxical findings-young adults outperform older adults in laboratory settings, but the reverse is found in naturalistic settings. Moreover, young-old outperform old-old adults in laboratory settings, but show no age differences in naturalistic settings. Here we highlight how time-based task characteristics have differed systematically between studies conducted in laboratory (time-interval cues) and naturalistic settings (time-of-day cues) and argue that this apparent paradox is a function of comparing disparate task types. In three experiments, we tested this hypothesis using analogous paradigms across settings, with event-based, time-of-day, and time-interval cued PM tasks. Experiment 1 compared young (n = 40) and older (n = 53) adults on a laboratory paradigm that measured PM tasks embedded in a virtual, daily life narrative; and on a conceptually parallel paradigm using a customized smartphone application (MEMO) in actual daily life. Results revealed that on the MEMO, older adults outperformed young adults on the time-of-day tasks but did not differ on the time-interval or event-based task. In contrast, older adults performed worse than young adults in the laboratory. Experiment 2 compared PM performance in young-old (n = 64) and old-old (n = 40) adults using the same paradigms. Young-old outperformed old-old adults in the laboratory; however, group differences were not evident in daily life. Experiment 3 compared young (n = 42) and older (n = 41) adults, and largely replicated the findings of Experiment 1 using a more demanding version of MEMO. These findings provide novel and important insights into the limiting conditions of the age-PM paradox and the need for a finer theoretical delineation of time-based tasks.

Task characteristics influence facial emotion recognition age-effects: A meta-analytic review.

Relative to their young counterparts, older adults are poorer at recognizing facial expressions. A 2008 meta-analysis of 17 facial emotion recognition data sets showed that these age-related difficulties are not uniform. Rather, they are greatest for the emotions of anger, fear, and sadness, comparative with happiness and surprise, with no age-effect found for disgust. Since then, there have been many methodological advances in assessing emotion recognition. The current comprehensive meta-analysis systematically tested the influence of task characteristics (e.g., photographs vs. videos). The meta-analysis included 102 data sets that compared facial emotion recognition in older and young adult samples (N = 10,526). With task type combined, the pattern of age-effects across emotions was mostly consistent with the previous meta-analysis (i.e., largest age-effects for anger, fear, sadness; no effect for disgust). However, the magnitude and direction of age-effects were strongly influenced by elements of task design. Specifically, videos produced relatively moderate age-effects across all emotions, which indicates that older adults may not exhibit a positivity effect for facial emotion recognition. For disgust recognition, older adults demonstrated superior accuracy to young adults for the most common image set (Pictures of Facial Affect). However, they were poorer than young adults at recognizing this emotion for all other stimulus formats and image sets, which suggests that they do not retain disgust recognition. We discuss the implications that such diversity in the age-effects produced by different facial emotion recognition task designs has for understanding real-world deficits and task selection in future emotion recognition studies. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The role of time-monitoring behaviour in time-based prospective memory performance in younger and older adults.

Time-based prospective memory (TB-PM) is the ability to remember to perform an action at a specific moment in the future. Accurate TB-PM performance requires several cognitive processes that are known to decline in normal ageing. This study aimed to examine associations between TB-PM performance and executive functions and time perception in younger and older adults. TB-PM was assessed with the Virtual Week paradigm. Using a within-subjects experimental manipulation, participants performed TB-PM tasks both when a clock was in constant view and when it was hidden behind a button. Results showed that younger adults performed significantly better than older adults on all TB-PM task types, and checked the clock more often, and more strategically. Clock availability improved TB-PM performance in all participants. Correlational analyses showed that TB-PM accuracy was positively related to clock-checking frequency but unrelated to time perception. Relationships between executive functions and TB-PM differed across age groups as well as TB-PM task types. The findings suggest that different cognitive processes are required for different types of TB-PM tasks and in different ages. These results highlight the importance of considering TB-PM task parameters when investigating the role of cognitive processes in PM performance and their contribution to age-related PM decline.

Age-Related Preservation of Trust Following Minor Transgressions.

Objectives: This study assesses age-related differences in the weighting and integration of appearance and behavior cues to trustworthiness. The aim is to assess whether it becomes more difficult with age to detect a cheater in disguise. Method: Young and older adults invested real money in a repeated trust game with trustees who varied on facial expression (smiling, neutral, angry) and return rate (high, low). Trustees were also rated for trustworthiness pre- and post-trust game. Results: Young and older adults learned to disregard appearances to invest more in trustees providing high relative to low returns. Both groups also updated ratings of trustworthiness from pre- to post-trust game in the direction of behavior that was incongruent with appearance. Notably, young (but not older) adults updated ratings of smiling trustees with a high return rate (i.e., returned money on 8 of 10 investments) to reflect reduced trustworthiness in line with the 2 instances of cheating from those trustees. Discussion: The findings show that there are no age-related differences in the way that obvious cheating in disguise is punished with reduced trustworthiness ratings. However, older adults are less vigilant to more subtle cheating in disguise, or are more forgiving of transgressions perceived as minor.

Decision-making, somatic markers and emotion processing in opiate users.

RATIONALE: Opiate use is associated with deficits in decision-making. A possible explanation for these deficits is provided by the somatic marker hypothesis, which suggests that substance users may experience abnormal emotional responses during decision-making involving reward and punishment. This in turn may interfere with the brief physiological arousal, i.e. somatic markers that normally occur in anticipation of risky decisions. To date, the applicability of the somatic marker hypothesis to explain decision-making deficits has not been investigated in opiate users. OBJECTIVES: This study assessed whether decision-making deficits in opiate users were related to abnormal emotional responses and reduced somatic markers. METHODS: Opiate users enrolled in an opiate substitute treatment program (n = 28) and healthy controls (n = 32) completed the Iowa Gambling Task (IGT) while their skin conductance responses (SCRs) were recorded. Participants' emotional responses to emotion-eliciting videos were also recorded using SCRs and subjective ratings. RESULTS: Opiate users displayed poorer decision-making on the IGT than did controls. However, there were no differences between the groups in SCRs; both groups displayed stronger SCRs following punishment than following reward, and both groups displayed stronger anticipatory SCRs prior to disadvantageous decisions than advantageous decisions. There were no group differences in objective or subjective measures of emotional responses to the videos. CONCLUSIONS: The results suggest that deficits in emotional responsiveness are not apparent in opiate users who are receiving pharmacological treatment. Thus, the somatic marker hypothesis does not provide a good explanation for the decision-making deficits in this group.

Decision-making ability in current and past users of opiates: A meta-analysis.

Opiate use is associated with deficits in decision-making. However, the impact of abstinence and co-morbid factors, like head injury and poly-substance abuse, on this ability, is currently unclear. This meta-analysis aimed to assess 1) the magnitude of decision-making deficits in opiate users; 2) whether co-morbid factors moderate the severity of these deficits; 3) whether ex-opiate users demonstrate smaller decision-making deficits than current users; and 4) whether the length of abstinence is related to the magnitude of decision-making deficits. We analysed 22 studies that compared the performance of current and ex-opiate users to healthy controls on decision-making measures such as the Iowa Gambling Task. Current users demonstrated a moderately strong impairment in decision-making relative to controls, which was not significantly moderated by co-morbid factors. The magnitude of the impairment did not significantly differ between studies assessing current or ex-users, and this impairment was not related to length of abstinence. Thus, it appears that opiate users have relatively severe decision-making deficits that persist at least 1.5 years after cessation of use.

Hair cortisol and cognitive performance in working age adults.

It has been hypothesized that prolonged exposure to high cortisol levels results in cognitive impairment. However, previous research into the relationship between cortisol and cognition has produced mixed results, most likely due to difficulties achieving valid estimates of long-term cortisol exposure based on salivary or plasma cortisol assessments at a single time point. Furthermore, there has been little research on the cognitive effects of long-term cortisol exposure in working-age adults. In the present study, hair samples were collected from 246 nurses (89.8% female) aged from 21 to 62 (M=42.0, SD=11.2). Hair cortisol concentrations (HCC) in the proximal 3-cm hair segment were analyzed providing an estimate of integrated cortisol secretion over the 3 month-period prior to hair sampling. Cognition was measured using a battery of 15 neuropsychological tests, measuring core dimensions of memory, inductive reasoning, processing speed, crystalized intelligence and major aspects of executive functioning. HCC was not significantly related to any of the cognitive abilities measured, either before or after controlling for potential moderators such as age, sex, education, health, well-being, work ability and burnout. Tests for nonlinear relationships also yielded non-significant results. Thus, despite the study being well powered, long term cortisol exposure did not appear to be related to cognitive performance in this sample of working-age adults, suggesting that long term cortisol exposure may be less relevant to cognition in younger and middle-aged adults than was previously thought.

Sensitivity and Specificity of a Five-Minute Cognitive Screening Test in Patients With Heart Failure.

BACKGROUND: Cognitive impairment occurs in up to 80% of patients with heart failure (HF). The National Institute for Neurological Disorders and Stroke (NINDS) and the Canadian Stroke Network (CSN) recommend a 5-minute cognitive screening protocol that has yet to be psychometrically evaluated in HF populations. The aim of this study was to conduct a secondary analysis of the sensitivity and specificity of the NINDS-CSN brief cognitive screening protocol in HF patients. METHODS: The Montreal Cognitive Assessment (MoCA) was administered to 221 HF patients. The NINDS-CSN screen comprises 3 MoCA items, with lower scores indicating poorer cognitive function. Receiver operator characteristic (ROC) curves were constructed, determining the sensitivity, specificity and appropriate cutoff scores of the NINDS-CSN screen. RESULTS: In an HF population aged 76 ± 12 years, 136 (62%) were characterized with cognitive impairment (MoCA <26). Scores on the NINDS-CSN screen ranged from 3-11. The area under the receiver operating characteristic curve indicated good accuracy in screening for cognitive impairment (0.88; P < .01; 95% CI 0.83-0.92). A cutoff score of ≤9 provided 89% sensitivity and 71% specificity. CONCLUSIONS: The NINDS-CSN protocol offers clinicians a feasible telephone method to screen for cognitive impairment in patients with HF. Future studies should include a neuropsychologic battery to more comprehensively examine the diagnostic accuracy of brief cognitive screening protocols.

Age-related similarities and differences in first impressions of trustworthiness.

Trust is a particularly under-studied aspect of social relationships in older age. In the current study, young (n = 35) and older adults (n = 35) completed a series of one-shot social economic trust games in which they invested real money with trustees. There were potential gains with each investment and also a risk of losing everything if the trustee was untrustworthy. The reputation and facial appearance of each trustee were manipulated to make them appear more or less trustworthy. Results revealed that young and older adults invest more money with trustees whose facial appearance and reputation indicate that they are trustworthy rather than untrustworthy. However, older adults were more likely than young to invest with trustees who had a reputation for being untrustworthy. We discuss whether age-related differences in responding to negative information may account for an age-related increase in trust, particularly when trusting someone with a reputation for being uncooperative.

An Investigation of Emotion Recognition and Theory of Mind in People with Chronic Heart Failure.

OBJECTIVES: Cognitive deficits are common in patients with chronic heart failure (CHF), but no study has investigated whether these deficits extend to social cognition. The present study provided the first empirical assessment of emotion recognition and theory of mind (ToM) in patients with CHF. In addition, it assessed whether each of these social cognitive constructs was associated with more general cognitive impairment. METHODS: A group comparison design was used, with 31 CHF patients compared to 38 demographically matched controls. The Ekman Faces test was used to assess emotion recognition, and the Mind in the Eyes test to measure ToM. Measures assessing global cognition, executive functions, and verbal memory were also administered. RESULTS: There were no differences between groups on emotion recognition or ToM. The CHF group's performance was poorer on some executive measures, but memory was relatively preserved. In the CHF group, both emotion recognition performance and ToM ability correlated moderately with global cognition (r = .38, p = .034; r = .49, p = .005, respectively), but not with executive function or verbal memory. CONCLUSION: CHF patients with lower cognitive ability were more likely to have difficulty recognizing emotions and inferring the mental states of others. Clinical implications of these findings are discussed.

PROspective MEmory Training to improve HEart failUre Self-care (PROMETHEUS): study protocol for a randomised controlled trial.

BACKGROUND: Cognitive impairment is seen in up to three quarters of heart failure (HF) patients and has a significant negative impact on patients' health outcomes. Prospective memory, which is defined as memory to carry out future intentions, is important for functional independence in older adults and involves application of multiple cognitive processes that are often impaired in HF patients. The objective of this study is to examine the effects of prospective memory training on patients' engagement in HF self-care and health outcomes, carer strain and quality of life. METHODS/DESIGN: The proposed study is a randomised, controlled trial in which 200 patients diagnosed with HF, and their carers will be recruited from 3 major hospitals across Melbourne. Eligible patients with HF will be randomised to receive either: 1) The Virtual Week Training Program - a computerised prospective memory (PM) training program (intervention) or 2) non-adaptive computer-based word puzzles (active control). HF patients' baseline cognitive function will be compared to a healthy control group (n = 60) living independently in the community. Patients will undergo a comprehensive assessment of PM, neuropsychological functioning, self-care, physical, and emotional functioning. Assessments will take place at baseline, 4 weeks and 12 months following intervention. Carers will complete measures assessing quality of life, strain, perceived control in the management of the patients' HF symptoms, and ratings of the patients' level of engagement in HF self-care behaviours. DISCUSSION: If the Virtual Week Training Program is effective in improving: 1) prospective memory; 2) self-care behaviours, and 3) wellbeing in HF patients, this study will enhance our understanding of impaired cognitive processes in HF and potentially is a mechanism to reduce healthcare costs. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry #366376; 27 May 2014. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366376&isClinicalTrial=False .

Prospective memory impairment in chronic heart failure.

Although cognitive deficits are common in patients with chronic heart failure (CHF), no study to date has investigated whether these deficits extend to the capacity to execute delayed intentions (prospective memory, PM). This is a surprising omission given the critical role PM plays in correctly implementing many important CHF self-care behaviors. The present study aimed to provide the first empirical assessment of PM function in people with CHF. The key dependent measure was a laboratory measure of PM that closely simulates PM tasks in daily life - Virtual Week. A group comparison design was used, with 30 CHF patients compared to 30 demographically matched controls. Background measures assessing executive functions, working memory, and verbal memory were also administered. The CHF group exhibited significant PM impairment, with difficulties generalizing across different types of PM tasks (event, time, regular, irregular). The CHF group also had moderate deficits on several of the background cognitive measures. Given the level of impairment remained consistent even on tasks that imposed minimal demands on memory for task content, CHF-related difficulties most likely reflects problems with the prospective component. However, exploratory analyses suggest that difficulties with retrospective memory and global cognition (but not executive control), also contribute to the PM difficulties seen in this group. The implications of these data are discussed, and in particular, it is argued that problems with PM may help explain why patient engagement in CHF self-care behaviors is often poor.

Prospective memory impairment in long-term opiate users.

RATIONALE: Opiate use is associated with a range of neurological and cognitive deficits. However, to date, no studies have assessed whether these cognitive deficits extend to the ability to perform intended actions in the future (i.e. prospective memory). Reduced ability in this area might be anticipated due to impaired executive functions and episodic memory associated with long-term opiate use. OBJECTIVES: The main objectives of this study are to assess the performance of long-term opiate users on a laboratory measure of prospective memory which closely simulates the types of prospective memory tasks encountered in everyday life ('Virtual Week') and to investigate the extent to which prospective memory performance is related to executive functions and episodic memory ability. METHODS: Twenty-six long-term heroin users enrolled in an opiate substitution program, and 30 controls with no previous history of drug use were tested on Virtual Week. Retrospective memory and executive functions were also assessed. RESULTS: Long-term opiate users were significantly impaired on prospective memory performance compared with controls (p = 0.002, η(2) p = 0.17), and these deficits did not vary as a function of prospective memory task type (regular, irregular, event, time). The findings also suggest that retrospective memory difficulties contribute to the prospective memory difficulties seen in opiate users (r s = 0.78, p < 0.001) but that executive dysfunction is less influential. CONCLUSIONS: Prospective memory is sensitive to long-term opiate use. Importantly, opiate users suffer from generalised deficits in prospective memory, regardless of the task demands, which may have significant implications for day-to-day functioning. These results may therefore contribute to the development of clinical intervention strategies to reduce the negative impact of prospective memory failures in daily life.

Development of the Heart Failure Screening Tool (Heart-FaST) to measure barriers that impede engagement in self-care.

BACKGROUND: Screening for self-care capacity is advocated before applying educational strategies. No screening tool has been specifically developed to assess barriers that impede engagement in self-care in people with heart failure. Earlier conceptual work (InCOGNITO) identified NYHA class, mild cognitive impairment and depressive symptoms as barriers that impede engagement in HF self-care. AIMS: Study aims were: 1) to develop the Heart Failure Screening Tool (Heart-FaST) as a means of assessing three critical barriers to self-care; 2) to assess the content validity of the Heart-FaST; and 3) to test the feasibility of implementing the Heart-FaST in clinical practice. METHODS: The Heart-FaST was developed from barriers identified in previous research (InCOGNITO) and from expert panel consensus. Content validity was assessed by examining the proportion of experts who scored each item as relevant. RESULTS: The InCOGNITO study indicated that four cognitive tasks, seven emotional questions and NYHA functional class were significantly correlated with the self-care scales: maintenance, management and confidence. These factors were used to create the Heart-FaST items. Consensus on wording and items to be included in the Heart-FaST was reached after two rounds of panel discussion. All items had an item-level content validity index ≥ 0.78. High scores on each barrier (physical, cognitive and emotional functioning) suggest poor self-care and the need for more intensive disease management efforts. CONCLUSION: The Heart-FaST measures three critical barriers that impede engagement in self-care. In clinical practice this tool may assist in individually tailoring educational and support strategies to promote effective heart failure self-care.

Prospective memory and chronic heart failure.

BACKGROUND: Patients with chronic heart failure (CHF) experience a number of debilitating symptoms, which impact on activities of daily living and result in poor quality of life. Prospective memory, which is defined as memory to carry out future intentions, has not been investigated in this group. However, emerging evidence suggests CHF patients have difficulties with cognitive processes related to prospective memory. Self-care, which partly relies on prospective memory, is essential in symptom management and preventing acute clinical deterioration. This study aims to measure prospective memory in CHF patients, and examine the relationship between prospective memory and CHF self-care. METHODS/DESIGN: A comprehensive neuropsychological assessment will be conducted to assess a range of cognitive functions and psychopathology. The primary focus will be an assessment of prospective memory using a well-established behavioral measure; Virtual Week. Thirty CHF patients attending a nurse-led management program will be recruited from three hospital sites in Melbourne, Australia and their self-care behaviors will be assessed using the Self-care Chronic Heart Failure Index (SCHFI), a validated self-report tool. An additional 30 healthy controls, matched on age, gender, and IQ will be recruited from the general community. DISCUSSION: This is a group comparison study that will provide an evaluation of the prospective memory abilities of CHF patients. The findings of this research will provide insight into whether prospective memory may be hindering patients' ability to perform adequate self-care.

The depression-executive dysfunction (DED) syndrome and response to antidepressants: a meta-analytic review.

BACKGROUND: The depression-executive dysfunction (DED) model predicts that cognitive impairment, particularly executive dysfunction, is associated with poor response to antidepressant medication. A meta-analysis was undertaken to assess the evidence for this hypothesis. METHODS: The PsycInfo and PubMed databases were searched to identify studies that examined response to antidepressant treatment in relation to pre-treatment cognitive performance. Systematic screening yielded 17 eligible publications, providing data for 1269 individuals. Ninety cognitive tests and subtests were used by these studies; 30 were used by more than one study. Weighted mean Cohen's d effect sizes, 95% confidence intervals and Fail Safe Ns were calculated for these 30 tests. RESULTS: Five cognitive tests provided good discrimination (d(w) > 0.5) between patients who ultimately responded to antidepressant medication and those who failed to respond. One was a test of executive function but the remainder assessed other cognitive domains. Due to the small number of studies the influence of methodological factors, such as participant age and treatment duration, could not be statistically examined. However, a supplementary analysis restricted to nine studies where SSRIs were the only class of antidepressant revealed a similar pattern of results. CONCLUSIONS: Performance on selected tests of executive function and non-executive cognitive functions is associated with response to anti-depressant medication in some populations. The available evidence does not provide strong support for the DED model.

Cognitive impairment predicts functional capacity in dementia-free patients with cardiovascular disease.

BACKGROUND AND RESEARCH OBJECTIVE: A high proportion of elderly people with cardiovascular diseases and risk factors have mild forms of cognitive impairment, the functional impact of which is poorly understood. The aim of this study was to determine whether subtle cognitive impairment contributes to limitations in instrumental activities of daily living in this group and whether this association is independent of physical comorbidity and other potentially confounding factors. SUBJECTS AND METHODS: Two hundred and nineteen nondemented patients were recruited from cardiovascular and diabetic hospital outpatient clinics. Functional dependence was assessed using the self-report version of the instrumental activities of daily living scale. Cognitive ability was assessed using the Montreal Cognitive Assessment (MoCA). Demographic and clinical information was collected via interview and a review of hospital records. Standard logistic regression was performed to identify factors independently associated with functional status. RESULTS: Five variables (sex, cardiovascular disease burden, non-cardiovascular disease burden, cognitive status, and age) were independently associated with an increased likelihood of requiring assistance with 1 or more everyday activities. The likelihood of needing assistance increased 2.05 times (95% confidence interval [CI], 1.59-2.79) for each additional cardiovascular diagnosis present and 1.12 times (95% CI, 1.01-1.27) for every point lower on MoCA. Thus, in comparison to a person with a perfect MoCA score, a person who scored in the cognitively impaired range (<23) was 7.7 (CI, 7.07-8.89) times more likely to report that he/she required assistance with an everyday activity. CONCLUSION: Cognitive impairments appear to reduce the ability to independently carry out routine daily tasks in patients with cardiovascular diseases and risk factors. Cognition should therefore be considered along with physical symptoms when assessing and responding to the support needs of this group.

Interventions to prevent back pain and back injury in nurses: a systematic review.

A systematic literature review was undertaken to assess the effectiveness of interventions that aim to prevent back pain and back injury in nurses. Ten relevant databases were searched; these were examined and reference lists checked. Two reviewers applied selection criteria, assessed methodological quality and extracted data from trials. A qualitative synthesis of evidence was undertaken and sensitivity analyses performed. Eight randomised controlled trials and eight non-randomised controlled trials met eligibility criteria. Overall, study quality was poor, with only one trial classified as high quality. There was no strong evidence regarding the efficacy of any interventions aiming to prevent back pain and injury in nurses. The review identified moderate level evidence from multiple trials that manual handling training in isolation is not effective and multidimensional interventions are effective in preventing back pain and injury in nurses. Single trials provided moderate evidence that stress management programs do not prevent back pain and limited evidence that lumbar supports are effective in preventing back injury in nurses. There is conflicting evidence regarding the efficacy of exercise interventions and the provision of manual handling equipment and training. This review highlights the need for high quality randomised controlled studies to examine the effectiveness of interventions to prevent back pain and injury in nursing populations. Implications for future research are discussed.

Prolonged effects of a home-based intervention in patients with chronic illness.

BACKGROUND: Data on the long-term benefits of nonspecific disease management programs are limited. We performed a long-term follow-up of a previously published randomized trial. METHODS: We compared all-cause mortality and recurrent hospitalization during median follow-up of 7.5 years in a heterogeneous cohort of patients with chronic illness initially exposed to a multidisciplinary, home-based intervention (HBI) (n = 260) or to usual postdischarge care (n = 268). RESULTS: During follow-up, HBI had no impact on all-cause mortality (relative risk, 1.04; 95% confidence interval, 0.80-1.35) or event-free survival from death or unplanned hospitalization (relative risk, 1.03; 95% confidence interval, 0.86-1.24). Initial analysis suggested that HBI had only a marginal impact in reducing unplanned hospitalization, with 677 readmissions vs 824 for the usual care group (mean +/- SD rate, 0.72 +/- 0.96 vs 0.84 +/- 1.20 readmissions/patient per year; P = .08). When accounting for increased hospital activity in HBI patients with chronic obstructive pulmonary disease during follow-up for 2 years, post hoc analyses showed that HBI reduced readmissions by 14% within 2 years in patients without this condition (mean +/- SD rate, 0.54 +/- 0.72 vs 0.63 +/- 0.88 readmission/patient per year; P = .04) and by 21% in all surviving patients within 3 to 8 years (mean +/- SD rate, 0.64 +/- 1.26 vs 0.81 +/- 1.61 readmissions/patient per year; P = .03). Overall, recurrent hospital costs were significantly lower (14%) in the HBI group (mean +/- SD, 823 dollars +/- 1642 dollars vs 960 dollars +/- 1376 dollars per patient per year; P = .045). CONCLUSION: This unique study suggests that a nonspecific HBI provides long-term cost benefits in a range of chronic illnesses, except for chronic obstructive pulmonary disease.