Signing at the beginning versus at the end does not decrease dishonesty.

Honest reporting is essential for society to function well. However, people frequently lie when asked to provide information, such as misrepresenting their income to save money on taxes. A landmark finding published in PNAS [L. L. Shu, N. Mazar, F. Gino, D. Ariely, M. H. Bazerman, Proc. Natl. Acad. Sci. U.S.A. 109, 15197-15200 (2012)] provided evidence for a simple way of encouraging honest reporting: asking people to sign a veracity statement at the beginning instead of at the end of a self-report form. Since this finding was published, various government agencies have adopted this practice. However, in this project, we failed to replicate this result. Across five conceptual replications (n = 4,559) and one highly powered, preregistered, direct replication (n = 1,235) conducted with the authors of the original paper, we observed no effect of signing first on honest reporting. Given the policy applications of this result, it is important to update the scientific record regarding the veracity of these results.

Does Real Age Feedback Really Motivate Us to Change our Lifestyle? Results from an Online Experiment.

We set out to research the causal impact of Real Age feedback, a popular tool on health and lifestyle platforms, on health behaviors. We ran an online experiment where participants were randomly assigned a Real Age that differed in both direction (older or younger) and magnitude (much or slightly) from their passport age, or to a control condition where they received no Real Age feedback. We measured the impact of Real Age feedback on motivation to begin a healthier lifestyle, interest in taking a Real Age test, and percentage click-rate on an optional health link. We found that younger Real Age feedback was associated with higher interest. In addition, participants who received a slightly older Real Age were significantly less motivated to begin a healthier lifestyle compared to not only those who received a much younger or much older Real Age, but also to those in the control condition, suggesting a backfire effect. This effect remained even after accounting for participant health, demographics, and other psychological correlates to motivation. Real Age tests may backfire and demotivate people, and the positive effects they may have on psychological states may not outweigh the negative effects. Though promising, we caution using Real Age tests in their current form as stand-alone interventions to get people motivated.

The Association of Digital Health Application Use With Heart Failure Care and Outcomes: Insights From CONNECT-HF.

BACKGROUND: It is unknown whether digital applications can improve guideline-directed medical therapy (GDMT) and outcomes in heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS: Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure trial (CONNECT-HF) included an optional, prospective ancillary study of a mobile health application among patients hospitalized due to HFrEF. Digital users were matched to nonusers from the usual-care group. Coprimary outcomes included change in opportunity-based composite HF quality scores and HF rehospitalization or all-cause mortality. Among 2431 patients offered digital applications across the United States, 1526 (63%) had limited digital access or insufficient data, 425 (17%) were digital users, and 480 (20%) declined use. Digital users were similar in age to those who declined use (mean 58 vs 60 years; P = 0.031). Digital users (n = 368) vs matched nonusers (n = 368) had improved composite HF quality scores (48.0% vs 43.6%; + 4.76% [3.27-6.24]; P = 0.001) and composite clinical outcomes (33.0% vs 39.6%; HR 0.76 [0.59-0.97]; P = 0.027). CONCLUSIONS: Among participants in the CONNECT-HF trial, use of digital applications was modest but was associated with higher HF quality-of-care scores, including use of GDMT and better clinical outcomes. Although cause and effect cannot be determined from this study, the application of technology to guide GDMT use and dosing among patients with HFrEF warrants further investigation.

Effect of a Hospital and Postdischarge Quality Improvement Intervention on Clinical Outcomes and Quality of Care for Patients With Heart Failure With Reduced Ejection Fraction: The CONNECT-HF Randomized Clinical Trial.

Importance: Adoption of guideline-directed medical therapy for patients with heart failure is variable. Interventions to improve guideline-directed medical therapy have failed to consistently achieve target metrics, and limited data exist to inform efforts to improve heart failure quality of care. Objective: To evaluate the effect of a hospital and postdischarge quality improvement intervention compared with usual care on heart failure outcomes and care. Design, Setting, and Participants: This cluster randomized clinical trial was conducted at 161 US hospitals and included 5647 patients (2675 intervention vs 2972 usual care) followed up after a hospital discharge for acute heart failure with reduced ejection fraction (HFrEF). The trial was performed from 2017 to 2020, and the date of final follow-up was August 31, 2020. Interventions: Hospitals (n = 82) randomized to a hospital and postdischarge quality improvement intervention received regular education of clinicians by a trained group of heart failure and quality improvement experts and audit and feedback on heart failure process measures (eg, use of guideline-directed medical therapy for HFrEF) and outcomes. Hospitals (n = 79) randomized to usual care received access to a generalized heart failure education website. Main Outcomes and Measures: The coprimary outcomes were a composite of first heart failure rehospitalization or all-cause mortality and change in an opportunity-based composite score for heart failure quality (percentage of recommendations followed). Results: Among 5647 patients (mean age, 63 years; 33% women; 38% Black; 87% chronic heart failure; 49% recent heart failure hospitalization), vital status was known for 5636 (99.8%). Heart failure rehospitalization or all-cause mortality occurred in 38.6% in the intervention group vs 39.2% in usual care (adjusted hazard ratio, 0.92 [95% CI, 0.81 to 1.05). The baseline quality-of-care score was 42.1% vs 45.5%, respectively, and the change from baseline to follow-up was 2.3% vs -1.0% (difference, 3.3% [95% CI, -0.8% to 7.3%]), with no significant difference between the 2 groups in the odds of achieving a higher composite quality score at last follow-up (adjusted odds ratio, 1.06 [95% CI, 0.93 to 1.21]). Conclusions and Relevance: Among patients with HFrEF in hospitals randomized to a hospital and postdischarge quality improvement intervention vs usual care, there was no significant difference in time to first heart failure rehospitalization or death, or in change in a composite heart failure quality-of-care score. Trial Registration: ClinicalTrials.gov Identifier: NCT03035474.

Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure: Rationale and design of CONNECT-HF.

Many therapies have been shown to improve outcomes for patients with heart failure (HF) in controlled settings, but there are limited data available to inform best practices for hospital and post-discharge quality improvement initiatives. The CONNECT-HF study is a prospective, cluster-randomized trial of 161 hospitals in the United States with a 2×2 factorial design. The study is designed to assess the effect of a hospital and post-discharge quality improvement intervention compared with usual care (primary objective) on HF outcomes and quality-of-care, as well as to evaluate the effect of hospitals implementing a patient-level digital intervention compared with usual care (secondary objective). The hospital and post-discharge intervention includes audit and feedback on HF clinical process measures and outcomes for patients with HF with reduced ejection fraction (HFrEF) paired with education to sites and clinicians by a trained, nationally representative group of HF and quality improvement experts. The patient-level digital intervention is an optional ancillary study and includes a mobile application and behavioral tools that are intended to facilitate improved use of guideline-directed recommendations for self-monitoring and self-management of activity and medications for HFrEF. The effects of the interventions will be measured through an opportunity-based composite score on quality and time-to-first HF readmission or death among patients with HFrEF who present to study hospitals with acute HF and who consent to participate. The CONNECT-HF study is evaluating approaches for implementing HF guideline recommendations into practice and is one of the largest HF implementation science trials performed to date.

The Effect of a Priest-Led Intervention on the Choice and Preference of Soda Beverages: A Cluster-Randomized Controlled Trial in Catholic Parishes.

BACKGROUND: Latin America ranks among the regions with the highest level of intake of sugary beverages in the world. Innovative strategies to reduce the consumption of sugary drinks are necessary. PURPOSE: Evaluate the effect of a one-off priest-led intervention on the choice and preference of soda beverages. METHODS: We conducted a pragmatic cluster-randomized trial in Catholic parishes, paired by number of attendees, in Chimbote, Peru between March and June of 2017. The priest-led intervention, a short message about the importance of protecting one's health, was delivered during the mass. The primary outcome was the proportion of individuals that choose a bottle of soda instead of a bottle of water immediately after the service. Cluster-level estimates were used to compare primary and secondary outcomes between intervention and control groups utilizing nonparametric tests. RESULTS: Six parishes were allocated to control and six to the intervention group. The proportion of soda selection at baseline was ~60% in the intervention and control groups, and ranged from 56.3% to 63.8% in Week 1, and from 62.7% to 68.2% in Week 3. The proportion of mass attendees choosing water over soda was better in the priest-led intervention group: 8.2% higher at Week 1 (95% confidence interval 1.7%-14.6%, p = .03), and 6.2% higher at 3 weeks after baseline (p = .15). CONCLUSIONS: This study supports the proof-of-concept that a brief priest-led intervention can decrease sugary drink choice. CLINICAL TRIAL INFORMATION: ISRCTN, ISRCTN24676734. Registered 25 April 2017, https://www.isrctn.com/ISRCTN24676734.

Leveraging Behavioral Economics to Improve Heart Failure Care and Outcomes.

Behavioral challenges are often present in human illness, so behavioral economics is increasingly being applied in healthcare settings to better understand why patients choose healthy or unhealthy behaviors. The application of behavioral economics to healthcare settings parallels recent shifts in policy and reimbursement structures that hold providers accountable for outcomes that are dependent on patient behaviors. Numerous studies have examined the application of behavioral economics principles to policy making and health behaviors, but there are limited data on applying these concepts to the management of chronic conditions, such as heart failure (HF). Given its increasing prevalence and high associated cost of care, HF is a paradigm case for studying novel approaches to improve health care; therefore, if we can better understand why patients with HF make the choices they do, then we may be more poised to help them manage their medications, influence daily behaviors, and encourage healthy decision making. In this article, we will give a brief explanation of the core behavioral economics concepts that apply to patients with HF. We will also examine how to craft these concepts into tools such as financial incentives and social networks that may improve the management of patients with HF. We believe that behavioral economics can help us understand barriers to change, encourage positive behaviors, and offer additional approaches to improving the outcomes of patients with HF.

Impact of Disgust on Intentions to Undergo Colorectal Surgery.

BACKGROUND: Surgeons present patients with complex information at the perioperative appointment. Emotions likely play a role in surgical decision-making, and disgust is an emotion of revulsion at a stimulus that can lead to avoidance. OBJECTIVE: The purpose of this study was to determine the impact of disgust on intention to undergo surgical resection for colorectal cancer and recall of perioperative instructions. DESIGN: This was a cross-sectional observational study conducted online using hypothetical scenarios with nonpatient subjects. SETTINGS: The study was conducted using Amazon's Mechanical Turk. PATIENTS: Survey respondents were living in the United States. MAIN OUTCOME MEASURES: Surgery intention and recall of perioperative instructions were measured. RESULTS: A total of 319 participants met the inclusion criteria. Participants in the experimental condition, who were provided with detailed information and pictures about stoma care, had significantly lower surgery intentions (mean ± SD, 4.60 ± 1.15) compared with the control condition with no stoma prompt (mean ± SD, 5.14 ± 0.91; p = 0.05) and significantly lower recall for preoperative instructions (mean ± SD, 13.75 ± 2.38) compared with the control condition (mean ± SD, 14.36 ± 2.19; p = 0.03). Those within the experimental conditions also reported significantly higher state levels of disgust (mean ± SD, 4.08 ± 1.74) compared with a control condition (mean ± SD, 2.35 ± 1.38; p < 0.001). State-level disgust was found to fully mediate the relationship between condition and recall (b = -0.31) and to partially mediate the effect of condition on surgery intentions (b = 0.17). LIMITATIONS: It is unknown whether these results will replicate with patients and the impact of competing emotions in clinical settings. CONCLUSIONS: Intentions to undergo colorectal surgery and recall of preoperative instructions are diminished in patients who experience disgust when presented with stoma information. Surgeons and care teams must account for this as they perform perioperative counseling to minimize interference with recall of important perioperative information. See Video Abstract at http://links.lww.com/DCR/A776.

Triadic treatment decision-making in advanced cancer: a pilot study of the roles and perceptions of patients, caregivers, and oncologists.

PURPOSE: The research on cancer treatment decision-making focuses on dyads; the full "triad" of patients, oncologists, and caregivers remains largely unstudied. We investigated how all members of this triad perceive and experience decisions related to treatment for advanced cancer. METHODS: At an academic cancer center, we enrolled adult patients with advanced gastrointestinal or hematological malignancies, their caregivers, and their oncologists. Triad members completed a semi-structured qualitative interview and a survey measuring decisional conflict and perceived influence of the other triad members on treatment decisions. RESULTS: Seventeen patients, 14 caregivers, and 10 oncologists completed the study. Patients and caregivers reported little decisional regret and voiced high satisfaction with their decisions, but levels of decisional conflict were high. We found sizeable disagreement among triad members' perceptions and preferences. For example, patients and oncologists disagreed about the caregiver's influence on the decision 56% of the time. In addition, many patients and caregivers preferred to defer to their oncologist about treatment decisions, felt like no true decision existed, and disagreed with their oncologist about how many treatment options had been presented. CONCLUSIONS: Patients, caregivers, and oncologists have discordant perceptions of the cancer treatment decision-making process, and bring different preferences about how they want to make decisions. These data suggest that oncologists should assess patients' and caregivers' decisional preferences, explicitly signal that a decision needs to be made whenever approaching an important crossroads in treatment and ensure that patients and caregivers understand the full range of presented options.

Naïve models of dietary splurges: Beliefs about caloric compensation and weight change following non-habitual overconsumption.

The mechanisms that lead to overeating and the consumption of tempting, unhealthy foods have been studied extensively, but the compensatory actions taken afterwards have not. Here we describe the naïve models individuals hold around dietary splurges (single bouts of overeating) and associated weight changes. Across six online experiments, we found that, following a hypothetical dietary splurge, participants did not plan to adequately adjust calorie consumption to account for the additional calories consumed (Studies 1 and 2), and this pattern was worse following hypothetical splurges characterized by a large amount of food consumed in a single bout (Study 3). Participants expected weight changes to happen faster than they do in reality (Study 4) and they expected that weight gained from a dietary splurge would disappear on its own without explicit compensation attempts through diet or exercise (Study 5). Similarly, participants expected that when compensation attempts were made through calorie restriction, the rate of weight loss would be faster following a dietary splurge compared to normal eating (Study 6). This research contributes novel data demonstrating an important mechanism that likely contributes to weight gain and failed weight loss attempts.

Can You Have Your Vigorous Exercise and Enjoy It Too? Ramping Intensity Down Increases Postexercise, Remembered, and Forecasted Pleasure.

There is a paucity of methods for improving the affective experience of exercise. We tested a novel method based on discoveries about the relation between exercise intensity and pleasure, and lessons from behavioral economics. We examined the effect of reversing the slope of pleasure during exercise from negative to positive on pleasure and enjoyment, remembered pleasure, and forecasted pleasure. Forty-six adults were randomly assigned to a 15-min bout of recumbent cycling of either increasing intensity (0-120% of watts corresponding to the ventilatory threshold) or decreasing intensity (120-0%). Ramping intensity down, thereby eliciting a positive slope of pleasure during exercise, improved postexercise pleasure and enjoyment, remembered pleasure, and forecasted pleasure. The slope of pleasure accounted for 35-46% of the variance in remembered and forecasted pleasure from 15 min to 7 days postexercise. Ramping intensity down makes it possible to combine exposure to vigorous and moderate intensities with a pleasant affective experience.

Neural substrates underlying the tendency to accept anger-infused ultimatum offers during dynamic social interactions.

In managing our way through interpersonal conflict, anger might be crucial in determining whether the dispute escalates to aggressive behaviors or resolves cooperatively. The Ultimatum Game (UG) is a social decision-making paradigm that provides a framework for studying interpersonal conflict over division of monetary resources. Unfair monetary UG-offers elicit anger and while accepting them engages regulatory processes, rejecting them is regarded as an aggressive retribution. Ventro-medial prefrontal-cortex (vmPFC) activity has been shown to relate to idiosyncratic tendencies in accepting unfair offers possibly through its role in emotion regulation. Nevertheless, standard UG paradigms lack fundamental aspects of real-life social interactions in which one reacts to other people in a response contingent fashion. To uncover the neural substrates underlying the tendency to accept anger-infused ultimatum offers during dynamic social interactions, we incorporated on-line verbal negotiations with an obnoxious partner in a repeated-UG during fMRI scanning. We hypothesized that vmPFC activity will differentiate between individuals with high or low monetary gains accumulated throughout the game and reflect a divergence in the associated emotional experience. We found that as individuals gained more money, they reported less anger but also more positive feelings and had slower sympathetic response. In addition, high-gain individuals had increased vmPFC activity, but also decreased brainstem activity, which possibly reflected the locus coeruleus. During the more angering unfair offers, these individuals had increased dorsal-posterior Insula (dpI) activity which functionally coupled to the medial-thalamus (mT). Finally, both vmPFC activity and dpI-mT connectivity contributed to increased gain, possibly by modulating the ongoing subjective emotional experience. These ecologically valid findings point towards a neural mechanism that might nurture pro-social interactions by modulating an individual's dynamic emotional experience.

Neuromarketing: the hope and hype of neuroimaging in business.

The application of neuroimaging methods to product marketing - neuromarketing - has recently gained considerable popularity. We propose that there are two main reasons for this trend. First, the possibility that neuroimaging will become cheaper and faster than other marketing methods; and second, the hope that neuroimaging will provide marketers with information that is not obtainable through conventional marketing methods. Although neuroimaging is unlikely to be cheaper than other tools in the near future, there is growing evidence that it may provide hidden information about the consumer experience. The most promising application of neuroimaging methods to marketing may come before a product is even released - when it is just an idea being developed.

Signing at the beginning makes ethics salient and decreases dishonest self-reports in comparison to signing at the end.

Many written forms required by businesses and governments rely on honest reporting. Proof of honest intent is typically provided through signature at the end of, e.g., tax returns or insurance policy forms. Still, people sometimes cheat to advance their financial self-interests-at great costs to society. We test an easy-to-implement method to discourage dishonesty: signing at the beginning rather than at the end of a self-report, thereby reversing the order of the current practice. Using laboratory and field experiments, we find that signing before-rather than after-the opportunity to cheat makes ethics salient when they are needed most and significantly reduces dishonesty.

In pain thou shalt bring forth children: the peak-and-end rule in recall of labor pain.

Childbirth is usually the most painful event of a mother's life, and resonates in individual and collective memory for years. The current study examined the relationship between the experience of labor pain and its recollection 2 days and 2 months after delivery. We found that despite the exceptional physical and emotional experiences of childbirth, the memory of the pain involved in labor was biased toward the average of the peak pain and the end pain, whereas the duration of the delivery had a relatively negligible effect on the recollected intensity of pain. A comparison of mothers whose labor ended with or without epidural analgesia corroborated previous findings that the level of pain toward the end of an experience greatly influences the way the overall experience is remembered. Although both short- and long-term retention of memories of labor exhibited the peak-and-end effect, having given birth before weakened the effect 2 months after delivery.

Healthier by precommitment.

We tested a voluntary self-control commitment device to help grocery shoppers make healthier food purchases. Participants, who were already enrolled in a large-scale incentive program that discounts the price of eligible groceries by 25%, were offered the chance to put their discount on the line. Agreeing households pledged that they would increase their purchases of healthy food by 5 percentage points above their household baseline for each of 6 months. If they reached that goal, their discount was awarded as usual; otherwise, their discount was forfeited for that month. Thirty-six percent of households that were offered the binding commitment agreed; they subsequently showed an average 3.5-percentage-point increase in healthy grocery items purchased in each of the 6 months; households that declined the commitment and control-group households that were given a hypothetical option to precommit did not show such an increase. These results suggest that self-aware consumers will seize opportunities to create restrictive choice environments for themselves, even at some risk of financial loss.

Temporal view of the costs and benefits of self-deception.

Researchers have documented many cases in which individuals rationalize their regrettable actions. Four experiments examine situations in which people go beyond merely explaining away their misconduct to actively deceiving themselves. We find that those who exploit opportunities to cheat on tests are likely to engage in self-deception, inferring that their elevated performance is a sign of intelligence. This short-term psychological benefit of self-deception, however, can come with longer-term costs: when predicting future performance, participants expect to perform equally well-a lack of awareness that persists even when these inflated expectations prove costly. We show that although people expect to cheat, they do not foresee self-deception, and that factors that reinforce the benefits of cheating enhance self-deception. More broadly, the findings of these experiments offer evidence that debates about the relative costs and benefits of self-deception are informed by adopting a temporal view that assesses the cumulative impact of self-deception over time.