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Agarwal AK, Waddell KJ, Small DS, Evans C, Harrington TO, Djaraher R, Oon AL, Patel MS. Effect of Gamification With and Without Financial Incentives to Increase Physical Activity Among Veterans Classified as Having Obesity or Overweight: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2116256. [PMID: 34241628 PMCID: PMC8271358 DOI: 10.1001/jamanetworkopen.2021.16256] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Gamification is increasingly being used for health promotion but has not been well tested with financial incentives or among veterans. OBJECTIVE To test the effectiveness of gamification with social support, with and without a loss-framed financial incentive, to increase physical activity among veterans classified as having overweight and obesity. DESIGN, SETTING, AND PARTICIPANTS This 3-group randomized clinical trial had a 12-week intervention period and an 8-week follow-up period. Participants included veterans with a body mass index greater than or equal to 25 who were receiving care from a single site in Philadelphia, Pennsylvania. Participants underwent a remotely monitored intervention from March 19, 2019, to August 9, 2020. Data analyses were conducted between October 1, 2020, and November 14, 2020. INTERVENTIONS All participants received a wearable device to track step counts and selected a step goal. The control group received feedback from their devices only. Participants in the 2 gamification groups were entered into a 12-week game with points and levels designed using behavioral economic principles and selected a support partner to receive weekly updates. Participants in the loss-framed financial incentive group had $120 allocated to a virtual account and lost $10 if weekly goals were not achieved. MAIN OUTCOMES AND MEASURES The primary outcome was the change in mean daily steps from baseline during the intervention. Secondary outcomes include proportion of days goals were achieved and changes during follow-up. RESULTS A total of 180 participants were randomized, 60 to the gamification with social support group, 60 to the gamification with social support and loss-framed financial incentives group, and 60 to the control group. The participants had a mean (SD) age of 56.5 (12.9) years and a mean (SD) body mass index of 33.0 (5.6); 71 participants (39.4%) were women, 90 (50.0%) were White, and 67 (37.2%) were Black. During the intervention period, compared with control group participants, participants in the gamification with financial incentives group had a significant increase in mean daily steps from baseline (adjusted difference, 1224 steps; 95% CI, 451 to 1996 steps; P = .005), but participants in the gamification without financial incentives group did not (adjusted difference, 433 steps; 95% CI, -337 to 1203 steps; P = .81). The increase for the gamification with financial incentives group was not sustained during the follow-up period, and the step count was not significantly different than that of the control group (adjusted difference, 564 steps; 95% CI, -261 to 1389 steps; P = .37). Compared with the control group, participants in the intervention groups had a significantly higher adjusted proportion of days meeting their step goal during the main intervention and follow-up period (gamification with social support group, adjusted difference from control, 0.21 participant-day; 95% CI, 0.18-0.24 participant-day; P < .001; gamification with social support and loss-framed financial incentive group, adjusted difference from control, 0.34 participant-day; 95% CI, 0.31-0.37 participant-day; P < .001). CONCLUSIONS AND RELEVANCE Among veterans classified as having overweight and obesity, gamification with social support combined with loss-framed financial incentives was associated with a modest increase in physical activity during the intervention period, but the increase was not sustained during follow-up. Gamification without incentives did not significantly change physical activity. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03563027.
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Affiliation(s)
- Anish K. Agarwal
- Department of Emergency Medicine, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia
| | - Kimberly J. Waddell
- The Penn Medicine Nudge Unit, The University of Pennsylvania, Philadelphia
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Dylan S. Small
- Statistics Department,The Wharton School, The University of Pennsylvania, Philadelphia
| | - Chalanda Evans
- Department of Emergency Medicine, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia
- The Penn Medicine Nudge Unit, The University of Pennsylvania, Philadelphia
| | - Tory O. Harrington
- Department of Emergency Medicine, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia
- The Penn Medicine Nudge Unit, The University of Pennsylvania, Philadelphia
| | - Rachel Djaraher
- Department of Emergency Medicine, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia
- The Penn Medicine Nudge Unit, The University of Pennsylvania, Philadelphia
| | - Ai Leen Oon
- Department of Emergency Medicine, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia
- The Penn Medicine Nudge Unit, The University of Pennsylvania, Philadelphia
| | - Mitesh S. Patel
- Department of Emergency Medicine, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia
- The Penn Medicine Nudge Unit, The University of Pennsylvania, Philadelphia
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Health Care Management Department, The Wharton School, The University of Pennsylvania, Philadelphia
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Jazowski SA, Bosworth HB, Goldstein KM, White-Clark C, McCant F, Gierisch JM, Zullig LL. Implementing a Population Health Management Intervention to Control Cardiovascular Disease Risk Factors. J Gen Intern Med 2020; 35:1931-1933. [PMID: 32016698 PMCID: PMC7280426 DOI: 10.1007/s11606-020-05679-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Shelley A Jazowski
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA. .,Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA. .,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA. .,School of Nursing, Duke University, Durham, NC, USA. .,Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA.
| | - Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Courtney White-Clark
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Felicia McCant
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Jennifer M Gierisch
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Leah L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
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Padula CB, Weitlauf JC, Rosen AC, Reiber G, Cochrane BB, Naughton MJ, Li W, Rissling M, Yaffe K, Hunt JR, Stefanick ML, Goldstein MK, Espeland MA. Longitudinal Cognitive Trajectories of Women Veterans from the Women's Health Initiative Memory Study. THE GERONTOLOGIST 2016; 56:115-25. [PMID: 26615021 PMCID: PMC4906317 DOI: 10.1093/geront/gnv663] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 10/05/2015] [Indexed: 12/17/2022] Open
Abstract
PURPOSE OF THE STUDY A comparison of longitudinal global cognitive functioning in women Veteran and non-Veteran participants in the Women's Health Initiative (WHI). DESIGN AND METHODS We studied 7,330 women aged 65-79 at baseline who participated in the WHI Hormone Therapy Trial and its ancillary Memory Study (WHIMS). Global cognitive functioning (Modified Mini-Mental State Examination [3MSE]) in Veterans (n = 279) and non-Veterans (n = 7,051) was compared at baseline and annually for 8 years using generalized linear modeling methods. RESULTS Compared with non-Veterans, Veteran women were older, more likely to be Caucasian, unmarried, and had higher rates of educational and occupational attainment. Results of unadjusted baseline analyses suggest 3MSE scores were similar between groups. Longitudinal analyses, adjusted for age, education, ethnicity, and WHI trial assignment revealed differences in the rate of cognitive decline between groups over time, such that scores decreased more in Veterans relative to non-Veterans. This relative difference was more pronounced among Veterans who were older, had higher educational/occupational attainment and greater baseline prevalence of cardiovascular risk factors (e.g., smoking) and cardiovascular disease (e.g., angina, stroke). IMPLICATIONS Veteran status was associated with higher prevalence of protective factors that may have helped initially preserve cognitive functioning. However, findings ultimately revealed more pronounced cognitive decline among Veteran relative to non-Veteran participants, likely suggesting the presence of risks that may impact neuropathology and the effects of which were initially masked by Veterans' greater cognitive reserve.
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Affiliation(s)
- Claudia B Padula
- VA Palo Alto Health Care System, Sierra Pacific MIRECC and Department of Psychiatry & Behavioral Sciences, Stanford University, Palo Alto, California.
| | - Julie C Weitlauf
- VA Palo Alto Health Care System, Sierra Pacific MIRECC and Department of Psychiatry & Behavioral Sciences, Stanford University, Palo Alto, California. VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, California
| | - Allyson C Rosen
- VA Palo Alto Health Care System, Sierra Pacific MIRECC and Department of Psychiatry & Behavioral Sciences, Stanford University, Palo Alto, California
| | - Gayle Reiber
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
| | | | - Michelle J Naughton
- Division of Population Sciences, College of Medicine, The Ohio State University, Columbus
| | - Wenjun Li
- Department of Medicine, University of Massachusetts Medical School, Worcester. Department of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester
| | - Michelle Rissling
- Durham VA Medical Center, Mid-Atlantic MIRECC, Durham, North Carolina
| | - Kristine Yaffe
- UCSF Department of Psychiatry, Neurology and Epidemiology and Biostatistics, San Francisco VA Medical Center, Sierra Pacific MIRECC, California
| | - Julie R Hunt
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Marcia L Stefanick
- Department of Medicine (Stanford Center for Prevention Research), Stanford University School of Medicine, California. Department of Obstetrics & Gynecology, Stanford University School of Medicine, California
| | - Mary K Goldstein
- VA Palo Alto Health Care System, GRECC, Stanford University School of Medicine, Department of Medicine, Center for Primary Care & Outcomes Research, Palo Alto, California
| | - Mark A Espeland
- Wake Forest School of Medicine, Department of Biostatistical Sciences, One Medical Center Blvd, Winston-Salem, North Carolina
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Ludwig A, Lucero-Obusan C, Schirmer P, Winston C, Holodniy M. Acute cardiac injury events ≤30 days after laboratory-confirmed influenza virus infection among U.S. veterans, 2010-2012. BMC Cardiovasc Disord 2015; 15:109. [PMID: 26423142 PMCID: PMC4589211 DOI: 10.1186/s12872-015-0095-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 09/14/2015] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Cardiac injury is a known potential complication of influenza infection. Because U.S. veterans cared for at the U.S. Department of Veterans Affairs are older and have more cardiovascular disease (CVD) risk factors than the general U.S. population, veterans are at risk for cardiac complications of influenza infection. We investigated biomarkers of cardiac injury characteristics and associated cardiac events among veterans who received cardiac biomarker testing ≤30 days after laboratory-confirmed influenza virus infection. METHODS Laboratory-confirmed influenza cases among veterans cared for at U.S. Department of Veterans Affairs' facilities for October 2010-December 2012 were identified using electronic medical records (EMRs). Influenza confirmation was based on respiratory specimen viral culture or antigen or nucleic acid detection. Acute cardiac injury (ACI) was defined as an elevated cardiac biomarker (troponin I or creatinine kinase isoenzyme MB) >99 % of the upper reference limit occurring ≤30 days after influenza specimen collection. EMRs were reviewed for demographics, CVD history and risk factors, and ACI-associated cardiac events. RESULTS Among 38,197 patients with influenza testing results, 4,469 (12 %) had a positive result; 600 of those patients had cardiac biomarker testing performed ≤30 days after influenza testing, and 143 (24 %) had one or more elevated cardiac biomarkers. Among these 143, median age was 73 years (range 44-98 years), and 98 (69 %) were non-Hispanic white. All patients had one or more CVD risk factors, and 98 (69 %) had a history of CVD. Eighty-six percent of ACI-associated events occurred within 3 days of influenza specimen collection date. Seventy patients (49 %) had documented or probable acute myocardial infarction, 8 (6 %) acute congestive heart failure, 6 (4 %) myocarditis, and 4 (3 %) atrial fibrillation. Eleven (8 %) had non-cardiac explanations for elevated cardiac biomarkers, and 44 (31 %) had no documented explanation. Sixty-eight (48 %) patients had received influenza vaccination during the related influenza season. CONCLUSION Among veterans with laboratory-confirmed influenza infection and cardiac biomarker testing ≤30 days after influenza testing, approximately 25 % had evidence of ACI, the majority within 3 days. Approximately half were myocardial infarctions. Our findings emphasize the importance of considering ACI associated with influenza infection among patients at high risk, including this older population with prevalent CVD risk factors.
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Affiliation(s)
- Alison Ludwig
- Centers for Disease Control and Prevention, assigned to Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA. .,Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA.
| | - Cynthia Lucero-Obusan
- Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA.
| | - Patricia Schirmer
- Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA.
| | - Carla Winston
- Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA.
| | - Mark Holodniy
- Veterans Affairs Office of Public Health Surveillance and Research, 3801 Miranda Avenue (132), Palo Alto, CA, 94304, USA. .,Division of Infectious Diseases and Geographic Medicine, Stanford University, Palo Alto, CA, 94303, USA.
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Melnyk SD, Zullig LL, McCant F, Danus S, Oddone E, Bastian L, Olsen M, Stechuchak KM, Edelman D, Rakley S, Morey M, Bosworth HB. Telemedicine cardiovascular risk reduction in veterans. Am Heart J 2013; 165:501-8. [PMID: 23537965 DOI: 10.1016/j.ahj.2012.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 08/13/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Patients with co-occurrence of hypertension, hyperlipidemia, and diabetes have an increased risk of cardiovascular disease (CVD) events. Comprehensive programs addressing both tailored patient self-management and pharmacotherapy are needed to address barriers to optimal cardiovascular risk reduction. We are examining a Clinical pharmacy specialist-, telephone-administered intervention, relying on home monitoring, with a goal of providing tailored medication and behavioral intervention to Veterans with CVD risk. METHODS Randomized controlled trial including patients with hypertension (blood pressure >150/100 mm Hg) or elevated low density liporotein (>130 mg/dL). Longitudinal changes in CVD risk profile and improvement in health behaviors over time will be examined. CONCLUSION Given the national prevalence of CVD and the dismal rates of risk factor control, intensive but easily disseminated interventions are required to treat this epidemic. This study will be an important step in testing the effectiveness of a behavioral and medication intervention to improve CVD control among Veterans.
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