No abstract

BACKGROUND: Smoking is the leading preventable cause of premature death in the United States. Previous studies of financial incentives for smoking cessation in work settings have not shown that such incentives have significant effects on cessation rates, but these studies have had limited power, and the incentives used may have been insufficient.

burned. Underlying differences in device accuracy may be compounded in these measures.Our study is limited by being conducted with young, healthy volunteers in a controlled setting with a convenience sample of a small number of applications and devices. Results should be confirmed in other settings and with other devices.Increased physical activity facilitated by these devices could lead to clinical benefits not realized by low adoption of pedometers. Our findings may help reinforce individuals' trust in using smartphone applications and wearable devices to track health behaviors, which could have important implications for strategies to improve population health. Role of the Funder/Sponsor: The National Institute on Aging, the US Department of Veteran Affairs, and the Robert Wood Johnson Foundation had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Meredith COMMENT & RESPONSE Treating Chronic Knee Pain With AcupunctureTo the Editor In the randomized clinical trial of acupuncture for chronic knee pain, 1 the acupuncture treatment design appeared flawed. Specifically, the acupuncture points were nonstandardized and the study lacked the details necessary to ascertain whether the provided interventions were representative of acupuncture sessions appropriate for chronic knee pain. First, the acupuncture regimen was not consistent in the study, with some patients receiving less than 1 treatment per week, some patients receiving 1 treatment per week, and others receiving 2 treatments per week for 12 weeks. Dr Hinman and colleagues failed to report how many patients received 1 or 2 treatments per week. The commonly used frequency of acupuncture treatments for chronic knee pain due to osteoarthritis is 2 treatments per week for 8 weeks, followed by 2 weeks of 1 treatment per week, then 4 weeks of 1 treatment every other week, and finally 12 weeks of 1 treatment per month.2 Furthermore, no details were provided regarding depth of insertion or whether subjective deqi sensation was experienced by the patient. Deqi has been shown to be important to differential neurophysiological analgesic mechanisms in responders vs nonresponders to acupuncture.3 Hinman and colleagues also did not provide acupuncture with electrical stimulation, which not only has a dose-dependent effect on the degree of analgesia but also induces differential neurotransmitter responses depending on the electrical frequency used. 2,4The only conclusion that can be drawn from this study is that unsystematic acupuncture regimens did not result in significant clinical benefit to patients with chronic knee pain.

No abstract

SignificanceDepression is disabling and treatable, but underdiagnosed. In this study, we show that the content shared by consenting users on Facebook can predict a future occurrence of depression in their medical records. Language predictive of depression includes references to typical symptoms, including sadness, loneliness, hostility, rumination, and increased self-reference. This study suggests that an analysis of social media data could be used to screen consenting individuals for depression. Further, social media content may point clinicians to specific symptoms of depression.

Background Financial incentive designs to increase physical activity have not been well-examined. Objective To test the effectiveness of 3 methods to frame financial incentives to increase physical activity among overweight and obese adults. Design Randomized, controlled trial. (ClinicalTrials.gov: NCT 02030119) Setting University of Pennsylvania. Participants 281 adult employees (body mass index ≥27 kg/m2). Intervention 13-week intervention. Participants had a goal of 7000 steps per day and were randomly assigned to a control group with daily feedback or 1 of 3 financial incentive programs with daily feedback: a gain incentive ($1.40 given each day the goal was achieved), lottery incentive (daily eligibility [expected value approximately $1.40] if goal was achieved), or loss incentive ($42 allocated monthly upfront and $1.40 removed each day the goal was not achieved). Participants were followed for another 13 weeks with daily performance feedback but no incentives. Measurements Primary outcome was the mean proportion of participant-days that the 7000-step goal was achieved during the intervention. Secondary outcomes included the mean proportion of participant-days achieving the goal during follow-up and the mean daily steps during intervention and follow-up. Results The mean proportion of participant-days achieving the goal was 0.30 (95% CI, 0.22 to 0.37) in the control group, 0.35 (CI, 0.28 to 0.42) in the gain-incentive group, 0.36 (CI, 0.29 to 0.43) in the lottery-incentive group, and 0.45 (CI, 0.38 to 0.52) in the loss-incentive group. In adjusted analyses, only the loss-incentive group had a significantly greater mean proportion of participant-days achieving the goal than control (adjusted difference, 0.16 [CI, 0.06 to 0.26]; P = 0.001), but the adjusted difference in mean daily steps was not significant (861 [CI, 24 to 1746]; P = 0.056). During follow-up, daily steps decreased for all incentive groups and were not different from control. Limitation Single employer. Conclusion Financial incentives framed as a loss were most effective for achieving physical activity goals. Primary Funding Source National Institute on Aging.

IMPORTANCEIt is unknown how much the mortality of patients with coronavirus disease 2019 (COVID-19) depends on the hospital that cares for them, and whether COVID-19 hospital mortality rates are improving.OBJECTIVE To identify variation in COVID-19 mortality rates and how those rates have changed over the first months of the pandemic. DESIGN, SETTING, AND PARTICIPANTSThis cohort study assessed 38 517 adults who were admitted with COVID-19 to 955 US hospitals from January 1, 2020, to June 30, 2020, and a subset of 27 801 adults (72.2%) who were admitted to 398 of these hospitals that treated at least 10 patients with COVID-19 during 2 periods (January 1 to April 30, 2020, and May 1 to June 30, 2020).EXPOSURES Hospital characteristics, including size, the number of intensive care unit beds, academic and profit status, hospital setting, and regional characteristics, including COVID-19 case burden. MAIN OUTCOMES AND MEASURESThe primary outcome was the hospital's risk-standardized event rate (RSER) of 30-day in-hospital mortality or referral to hospice adjusted for patient-level characteristics, including demographic data, comorbidities, community or nursing facility admission source, and time since January 1, 2020. We examined whether hospital characteristics were associated with RSERs or their change over time. RESULTSThe mean (SD) age among participants (18 888 men [49.0%]) was 70.2 (15.5) years. The mean (SD) hospital-level RSER for the 955 hospitals was 11.8% (2.5%). The mean RSER in the worst-performing quintile of hospitals was 15.65% compared with 9.06% in the best-performing quintile (absolute difference, 6.59 percentage points; 95% CI, 6.38%-6.80%; P < .001). Mean RSERs in all but 1 of the 398 hospitals improved; 376 (94%) improved by at least 25%. The overall mean (SD) RSER declined from 16.6% (4.0%) to 9.3% (2.1%). The absolute difference in rates of mortality or referral to hospice between the worst-and best-performing quintiles of hospitals decreased from 10.54 percentage points (95% CI, 10.03%-11.05%; P < .001) to 5.59 percentage points (95% CI, 5.33%-5.86%; P < .001). Higher county-level COVID-19 case rates were associated with worse RSERs, and case rate declines were associated with improvement in RSERs. CONCLUSIONS AND RELEVANCEOver the first months of the pandemic, COVID-19 mortality rates in this cohort of US hospitals declined. Hospitals did better when the prevalence of COVID-19 in their surrounding communities was lower.

BACKGROUND Financial incentives promote many health behaviors, but effective ways to deliver health incentives remain uncertain. METHODS We randomly assigned CVS Caremark employees and their relatives and friends to one of four incentive programs or to usual care for smoking cessation. Two of the incentive programs targeted individuals, and two targeted groups of six participants. One of the individual-oriented programs and one of the group-oriented programs entailed rewards of approximately $800 for smoking cessation; the others entailed refundable deposits of $150 plus $650 in reward payments for successful participants. Usual care included informational resources and free smoking-cessation aids. RESULTS Overall, 2538 participants were enrolled. Of those assigned to reward-based programs, 90.0% accepted the assignment, as compared with 13.7% of those assigned to deposit-based programs (P<0.001). In intention-to-treat analyses, rates of sustained abstinence from smoking through 6 months were higher with each of the four incentive programs (range, 9.4 to 16.0%) than with usual care (6.0%) (P<0.05 for all comparisons); the superiority of reward-based programs was sustained through 12 months. Group-oriented and individual-oriented programs were associated with similar 6-month abstinence rates (13.7% and 12.1%, respectively; P = 0.29). Reward-based programs were associated with higher abstinence rates than deposit-based programs (15.7% vs. 10.2%, P<0.001). However, in instrumental-variable analyses that accounted for differential acceptance, the rate of abstinence at 6 months was 13.2 percentage points (95% confidence interval, 3.1 to 22.8) higher in the deposit-based programs than in the reward-based programs among the estimated 13.7% of the participants who would accept participation in either type of program. CONCLUSIONS Reward-based programs were much more commonly accepted than deposit-based programs, leading to higher rates of sustained abstinence from smoking. Group-oriented incentive programs were no more effective than individual-oriented programs. (Funded by the National Institutes of Health and CVS Caremark; ClinicalTrials.gov number, NCT01526265.)