Information Avoidance and Image Concerns.

A rich literature finds that individuals avoid information and suggests that avoidance is driven by image concerns. This paper provides the first direct test of whether individuals avoid information because of image concerns. We build on a classic paradigm, introducing control conditions that make minimal changes to eliminate the role of image concerns while keeping other key features of the environment unchanged. Data from 6,421 experimental subjects shows that image concerns play a role in driving information avoidance, but a role that is substantially smaller than one might have expected.

A Randomized Trial of Theory-Informed Appeals for Organ Donor Registration Using Internet Advertisements.

INTRODUCTION: Many people do not register as organ donors. We developed 5 different brief appeals for organ donation that were disseminated online. The content was informed by theories of behavior change and studies of the specific cognitive barriers to organ donor registration. METHODS: One message was a persuasive narrative about a transplant recipient. Another message promoted the idea that organ donor registration is a social norm. The knowledge-based message communicated that 1 donor could improve the lives of 50 people. The message on reciprocity offered a free organ donation wristband, whether or not the participant registered as a donor. The message on control simply encouraged organ donation. Using Google AdWords, the messages were deployed randomly as banners of different sizes on diverse online sites and carried a link to an organ donor registration site. We measured clicks, page visits, and organ donor registrations. RESULTS: There were 5,156,048 impressions and 25,001 total clicks, a click-through rate of 0.49%. The messages on control and reciprocity both had the highest click-through rates of 0.51%. A total of 152 unique individuals requested wristbands and there were 52 total organ donor registration events. The message on reciprocity had the highest number of organ donor registrations (n = 18). CONCLUSION: Online organ donation messages rapidly generated substantial attention through clicks, but no message led to a meaningful number of organ donor registrations. Future research may focus on effectively capturing the attention of viewers through social networks or other convenient online venues with less competition for attention than Internet banners.

Forgoing earned incentives to signal pure motives.

Policy makers, employers, and insurers often provide financial incentives to encourage citizens, employees, and customers to take actions that are good for them or for society (e.g., energy conservation, healthy living, safe driving). Although financial incentives are often effective at inducing good behavior, they've been shown to have self-image costs: Those who receive incentives view their actions less positively due to the perceived incompatibility between financial incentives and intrinsic motives. We test an intervention that allows organizations and individuals to resolve this tension: We use financial rewards to kick-start good behavior and then offer individuals the opportunity to give up some or all of their earned financial rewards in order to boost their self-image. Two preregistered studies-an incentivized online experiment (n = 763) on prosocial behavior and a large field experiment (n = 17,968) on exercise-provide evidence that emphasizing the intrinsic rewards of a past action leads individuals to forgo or donate earned financial rewards. Our intervention allows individuals to retroactively signal that they acted for the right reason, which we call "motivation laundering." We discuss the implications of motivation laundering for the design of incentive systems and behavioral change.

Partners and Alerts in Medication Adherence: A Randomized Clinical Trial.

BACKGROUND: Poor medication adherence is common and limits the effectiveness of treatment. OBJECTIVE: To investigate how social supports, automated alerts, and their combination improve medication adherence. DESIGN: Four-arm, randomized clinical trial with a 6-month intervention. PARTICIPANTS: A total of 179 CVS health employees or adult dependents with CVS Caremark prescription coverage, a current daily statin prescription, a medication possession ratio less than 80%, and Internet access. INTERVENTIONS: Participants were randomly assigned to control, social support (partner), automated adherence alert messages (alert), or both social support and alerts (partner + alert). Participants in the social support arms were asked to name a medication adherence partner (MAP) to help them take their medication. Participants in the alert arms were sent emails, text messages, or automated phone calls if they had failed to adhere on the previous day and on one or both of the 2 days before that. In partner + alert, both participants and fully enrolled MAPs received alerts. MAIN MEASURES: Adherence measured by wireless pill bottle opening. KEY RESULTS: Compared to 36.0% adherence in control, adherence was significantly greater in the alert arm (52.9%, difference vs. control of 17.0%, 95% CI for difference 6.3 to 27.6%, P = 0.002) and the partner + alert arm (54.5%, difference vs. control of 18.6%, 95% CI for difference 6.6 to 30.5%, P = 0.003). Adherence in the partner arm was not statistically significantly greater than control (43.2%, difference vs. control of 7.2%, 95% CI of difference - 5.2% to 19.5%, P = 0.25). There were no statistically significant differences among the three treatment arms. Fewer participants invited a MAP in the partner + alert arm than the partner arm (P = 0.02). CONCLUSIONS: Automated alerts were effective at improving medication adherence. Assigning a medication adherence partner did not statistically significantly affect adherence rates. TRIAL REGISTRATION: ClinicalTrials.gov Number NCT01890018 [ https://clinicaltrials.gov /].

Field study of charitable giving reveals that reciprocity decays over time.

We examine how reciprocity changes over time by studying a large quasiexperiment in the field. Specifically, we analyze administrative data from a university hospital system. The data include information about over 18,000 donation requests made by the hospital system via mail to a set of its former patients in the 4 months after their first hospital visit. We exploit quasiexperimental variation in the timing of solicitation mailings relative to patient hospital visits and find that an extra 30-day delay between the provision of medical care and a donation solicitation decreases the likelihood of a donation by 30%. Our findings have important implications for models of economic behavior, which currently fail to incorporate reciprocity's sensitivity to time. The fact that reciprocal behavior decays rapidly as time passes also suggests the importance of capitalizing quickly on opportunities to benefit from a quid pro quo.

Incentivizing Organ Donor Registrations with Organ Allocation Priority.

How donor organs are allocated for transplant can affect their scarcity. In 2008, Israel's Parliament passed an Organ Transplantation Law granting priority on organ donor waiting lists to individuals who had previously registered as organ donors. Beginning in November 2010, public awareness campaigns advertised the priority policy to the public. Since April 2012, priority has been added to the routine medical criteria in organ allocation decisions. We evaluate the introduction of priority for registered organ donors using Israeli data on organ donor registration from 1992 to 2013. We find that registrations increased when information about the priority law was made widely available. We find an even larger increase in registration rates in the 2 months leading up to a program deadline, after which priority would only be granted with a 3-year delay. We also find that the registration rate responds positively to public awareness campaigns, to the ease of registration (i.e. allowing for registering online and by phone) and to an election drive that included placing registration opportunities in central voting locations. Copyright © 2016 John Wiley & Sons, Ltd.

Two Randomized Controlled Pilot Trials of Social Forces to Improve Statin Adherence among Patients with Diabetes.

BACKGROUND: Medication nonadherence is an important obstacle to cardiovascular disease management. OBJECTIVE: To improve adherence through real-time feedback based on theories of how social forces influence behavior. DESIGN: Two randomized controlled pilot trials called PROMOTE and SUPPORT. Participants stored statin medication in wireless-enabled pill bottles that transmitted adherence data to researchers. PARTICIPANTS: Adults with diabetes and a history of low statin adherence based on pharmacy refills (i.e., Medication Possession Ratio [MPR] <80% in the pre-randomization screening period). INTERVENTION: In PROMOTE, each participant was randomized to 1) weekly messages in which that participant's statin adherence was compared to that of other participants (comparison), 2) weekly summaries of that participant's statin adherence (summary), or 3) control. In SUPPORT, each participant identified another person (the Medication Adherence Partner [MAP]) to receive reports about that participant's adherence, and was randomized to 1) daily reports to MAP, 2) weekly reports to MAP, 3) reports to MAP only if dose was missed, or 4) control. MAIN OUTCOMES MEASURE: Adherence measured by pill bottle. KEY RESULTS: Among 45,000 health plan members contacted by mail, <1% joined the trial. Participants had low baseline MPRs (median = 60%, IQR 41-72%) but high pill-bottle adherence (90% in PROMOTE, 92% in SUPPORT) during the trial. In PROMOTE (n = 201) and SUPPORT (n = 200), no intervention demonstrated significantly better adherence vs. CONTROL: In a subgroup of PROMOTE participants with the lowest pre-study MPR, pill-bottle-measured adherence in the comparison arm (89%) was higher than the control (86%) and summary (76%) arms, but differences were non-significant (p = 0.10). CONCLUSIONS: Interventions based on social forces did not improve medication adherence vs. control over a 3-month period. Given the low percentage of invited individuals who enrolled, the studies may have attracted participants who required little encouragement to improve adherence other than study participation.

Using Behavioral Economics to Design Physician Incentives That Deliver High-Value Care.

Behavioral economics provides insights about the development of effective incentives for physicians to deliver high-value care. It suggests that the structure and delivery of incentives can shape behavior, as can thoughtful design of the decision-making environment. This article discusses several principles of behavioral economics, including inertia, loss aversion, choice overload, and relative social ranking. Whereas these principles have been applied to motivate personal health decisions, retirement planning, and savings behavior, they have been largely ignored in the design of physician incentive programs. Applying these principles to physician incentives can improve their effectiveness through better alignment with performance goals. Anecdotal examples of successful incentive programs that apply behavioral economics principles are provided, even as the authors recognize that its application to the design of physician incentives is largely untested, and many outstanding questions exist. Application and rigorous evaluation of infrastructure changes and incentives are needed to design payment systems that incentivize high-quality, cost-conscious care.

Organ Allocation Policy and the Decision to Donate.

Organ donations from deceased donors provide the majority of transplanted organs in the United States, and one deceased donor can save numerous lives by providing multiple organs. Nevertheless, most Americans are not registered organ donors despite the relative ease of becoming one. We study in the laboratory an experimental game modeled on the decision to register as an organ donor and investigate how changes in the management of organ waiting lists might impact donations. We find that an organ allocation policy giving priority on waiting lists to those who previously registered as donors has a significant positive impact on registration.

Role of intravenous urogram in investigation of urinary tract infection: an observational study.

OBJECTIVES: To examine the value of an intravenous urogram (i.v.U) in patients with abnormal differential (99m)Tc dimercaptosuccinic acid (DMSA) uptake without scarring or ultrasound abnormality. STUDY DESIGN: Forty patients (age 0-19 years) were identified over a two year period in whom the differential renal uptake was >10%, who had smooth renal outlines, and had no evidence of scarring. All patients had an ultrasound examination. Two had marked urological abnormalities on ultrasound and eight had a duplex system in the kidney with greater DMSA uptake. In 18 patients where no explanation was apparent for the discrepant DMSA uptake, an i.v.U was performed. RESULTS: Eight patients had a normal i.v.U. In the remaining 10 patients, six had duplex systems without scarring and four had appearances of scarring in the kidney with reduced DMSA uptake. CONCLUSIONS: In this small selected group an i.v.U will identify a significant number of patients with normal kidneys, unrecognised simple duplex systems, or scarring where the DMSA scan has been inconclusive. This will help in planning long term follow up.

A method comparison study to assess the reliability of urine collection pads as a means of obtaining urine specimens from non-toilet-trained children for microbiological examination.

BACKGROUND: In young, non-toilet-trained children, the collection of a urine sample for microbiology can be challenging, with the application of a urine bag being the main method of collection. However, recent research has shown that absorbent pads can be used yielding similar results to bag specimens. However, weaknesses in study design erode confidence in research findings. Therefore, improvements in research design are required to fully evaluate the reliability of pad collection. AIMS OF THE STUDY: This pilot study sought to test the feasibility of a technique for the collection of concurrent bag/pad urine samples from non-toilet-trained children, and to assess the reliability of urine pads over bags as a collection method for urine specimens for microbiological evaluation. DESIGN: A pilot, method comparison study. METHODS: Twenty concurrent bag and pad specimens were collected from non-toilet-trained children, following parental consent. Urine specimens were analysed for presence or absence of white cell count (WBC), and bacterial growth, using standard laboratory methods. DATA ANALYSIS: The Kappa (kappa) statistics and confidence interval (CI) estimation were used to assess agreement between the two collection methods. RESULTS: Despite concurrent samples there was a lack of agreement between bag and pad specimens on both main outcome measures. Agreement between bag and pad specimens for the presence of WBC yielded a kappa=0.10 (95% CI: 0.19, 0.39), indicating poor agreement, while a kappa of 0.5 (95% CI: 0.12, 0.88) was calculated for the degree of agreement in bacterial growth reflecting moderate agreement. Differences in proportions of the presence of WBC between bag and pad did not quite reach significance at the 5% level 0.2 (95% CI: 0.00, 0.42, P=0.062). For cultures the difference was calculated as 0.15 (95% CI: 0.05, 0.35, P=0.125). CONCLUSION: The pilot study demonstrates that concurrent urine samples can be obtained without difficulty. Despite poor to moderate agreement on outcome measures the level of agreement is greater than reported in those other studies, that use non-current methods of urine collection, suggesting an advantage of the concurrent technique. It is recommended that larger scale studies be undertaken using the concurrent collection technique to assess reliability of these findings.

C-terminal peptide of thrombospondin-1 induces platelet aggregation through the Fc receptor gamma-chain-associated signaling pathway and by agglutination.

A peptide from the C-terminal domain of thrombospondin-1 (Arg-Phe-Tyr-Val-Val-Met-Trp-Lys; known as 4N1-1) has been reported to induce platelet aggregation and to bind to the integrin-associated protein (IAP), which is also known as CD47. In this study, it was discovered that 4N1-1 or its derivative peptide, 4N1K, induces rapid phosphorylation of the Fc receptor (FcR) gamma chain, Syk, SLP-76, and phospholipase C gamma2 in human platelets. A specific inhibitor of Src family kinases, 4-amino-4-(4-methylphenyl)-7-(t-butyl) pyrazola[3,4-d]pyrimidine, prevented phosphorylation of these proteins, abolished platelet secretion, and reduced aggregation by approximately 50%. A similar inhibition of aggregation to 4N1-1 was obtained in the presence of Arg-Gly-Asp-Ser in mouse platelets deficient in FcR gamma chain or SLP-76 and in patients with type I Glanzmann thrombasthenia. These results show that 4N1-1 signals through a pathway similar to that used by the collagen receptor glycoprotein (GP) VI. The alphaIIbbeta3-independent aggregation induced by 4N1-1 was also observed in fixed platelets and platelets from patients with Bernard-Soulier syndrome, which are deficient in GPIbalpha. Surprisingly, the ability of 4N1-1 to stimulate aggregation and tyrosine phosphorylation was not altered in platelets pretreated with anti-IAP antibodies and in IAP-deficient mice. These results show that the C-terminal peptide of thrombospondin induces platelet aggregation through the FcR gamma-chain signaling pathway and through agglutination. The latter pathway is independent of signaling events and does not use GPIbalpha or alphaIIbbeta3. Neither of these pathways is mediated by IAP.

The role of the adapter molecule SLP-76 in platelet function.

Following vascular injury, one of the most critical initial events is activation of platelets followed by formation of a hemostatic plug. Platelets are capable of responding to a diverse array of agonists resulting in adhesion and granule release. The biochemical events underlying platelet activation are just beginning to be understood. One class of molecules shown to play important roles in this process is adapters. Adapter molecules contain distinct modular domains which mediate protein-protein or protein-lipid interactions giving these proteins the ability to nucleate signal transduction complexes. In this review we will discuss the function of the hematopoietic cell specific adapter molecule, SLP-76 in both platelet activation and hemostasis. Because many parallels exist between signal transduction pathways in platelets and lymphocytes, we will also review the function of SLP-76 in coordinating signal transduction pathways following antigen bind to the T cell receptor.

Hypercalciuria in ex-preterm children, aged 7-8 years.

In a previous study, 8 of 28 ex-preterm infants, aged 4-5 years, had increased urinary calcium excretion. The aim of this study was to confirm this finding and to determine if raised urinary calcium excretion is associated with reduced bone mineralisation. Forty-six ex-preterm children, aged 7-9 years, and 40 age- and sex-matched controls were recruited. The calcium excretion measured from 3 separate 24-h urine collections was recorded and a dietary assessment made from a diary record. Data were retrieved from the neonatal case notes and included aminoglycoside usage. Dual energy X-ray absorptiometry was used to measure bone mineral content and bone mineral density (BMD) in all children. The mean maximum 24-h urinary calcium was significantly higher in the preterm group than the term group (P=0.01). Increased calcium excretion was associated with raised neonatal aminoglycoside levels (P=0.0013). Height standard deviation score and hip BMD were significantly lower in the 21 preterm children with a 24-h urinary calcium above 4 mg/kg per day than term controls (P=0.04 and P=0.004, respectively). Urinary calcium excretion had a negative relationship with hip BMD in the preterm group (P=0.004). This difference in BMD was not observed in the 25 preterm children with normocalciuria. In the 10 preterm girls with hypercalciuria, hip BMD was lower than in control females (P=0.01). This difference in hip BMD between the 11 preterm boys with hypercalciuria and term boys was not significant (P=0.05). In conclusion, preterm children are shorter and have a lower hip BMD than those with normocalciuria. Further prospective studies are required to assess this risk and its influence on subsequent impaired bone mineralisation.

Identification of respiratory vagal feedback in awake normal subjects using pseudorandom unloading.

Evidence of the Hering-Breuer reflex has been found in humans during anesthesia and sleep but not during wakefulness. Cortical influences, present during wakefulness, may mask the effects of this reflex in awake humans. We hypothesized that, if lung volume were increased in awake subjects unaware of the stimulus, vagal feedback would modulate breathing on a breath-to-breath basis. To test this hypothesis, we employed proportional assist ventilation in a pseudorandom sequence to unload the respiratory system above and below the perceptual threshold in 17 normal subjects. Tidal volume, integrated respiratory muscle pressure per breath, and inspiratory time were recorded. Both sub- and suprathreshold stimulation evoked a significant increase in tidal volume and inspiratory flow rate, but a significant decrease in inspiratory time was present only during the application of a subthreshold stimulus. We conclude that vagal feedback modulates respiratory timing on a breath-by-breath basis in awake humans, as long as there is no awareness of the stimulus.