Expertise, experience, and excellence. Twenty years of patient involvement in health technology assessment at NICE: an evolving story.

From its inception in 1999, the National Institute for Health and Care Excellence (NICE) committed to including the expertise, experiences, and perspectives of lay people, patients and carers, and patient organizations in its health technology assessments (HTAs). This is our story of patient involvement in HTA: from early methods designed for use when assessing medicines, widening to address the different requirements of HTAs for interventional procedures, medical technologies, and diagnostic technologies. We also chart the evolution and development of all our patient involvement methods over the past 20 years through regular evaluation and by responding to external challenge. However, we know that processes and methods alone are not enough. Through case studies we demonstrate the value of patient involvement in HTA and highlight the unique perspectives and experiences that patients bring to HTA committees. Finally, we discuss the underpinning principles and commitments that have made NICE a world leader in delivering meaningful and legitimate patient involvement.

Rapid qualitative evidence syntheses (rQES) in health technology assessment: experiences, challenges, and lessons.

Healthcare decision makers are increasingly demanding that health technology assessment (HTA) is patient focused, and considers data about patients' perspectives on and experiences with health technologies in their everyday lives. Related data are typically generated through qualitative research, and in HTA the typical approach is to synthesize primary qualitative research through the conduct of qualitative evidence synthesis (QES). Abbreviated HTA timelines often do not allow for the full 6-12 months it may take to complete a QES, which has prompted the Canadian Agency for Drugs and Technologies in Health (CADTH) to explore the concept of "rapid qualitative evidence synthesis" (rQES). In this paper, we describe our experiences conducting three rQES at CADTH, and reflect on challenges faced, successes, and lessons learned. Given limited methodological guidance to guide this work, our aim is to provide insight for researchers who may contemplate rQES. We suggest several lessons, including strategies to iteratively develop research questions and search for eligible studies, use search of filters and limits, and use of a single reviewer experienced in qualitative research throughout the review process. We acknowledge that there is room for debate, though believe rQES is a laudable goal and that it is possible to produce a quality, relevant, and useful product, even under restricted timelines. That said, it is vital to recognize what is lost in the name of rapidity. We intend our paper to advance the necessary debate about when rQES may be appropriate, and not, and enable productive discussions around methodological development.

Technology anxiety and resistance to change behavioral study of a wearable cardiac warming system using an extended TAM for older adults.

With advances in technology, wireless and sensor technologies represent a method for continuously recording people's biomedical signals, which may enhance the diagnosis and treatment of users' everyday health conditions. These technologies mostly target older adults. In this study, we examine a smart clothing system targeting clinically high-risk patients, including older adults with cardiovascular disease (31 outpatients) and older adults in general (81 participants), to obtain an understanding of the patients' perception of using wearable healthcare technologies. Given that technology anxiety has been shown to affect users' resistance to using new technology and that perceived ubiquity is considered a characteristic of wearable devices and other mobile wireless technologies, we included three external variables: i.e., technology anxiety, perceived ubiquity, and resistance to change, in addition to the traditional components of the technology acceptance model (TAM). The results of the hypothesized model showed that among older adults in general, technology anxiety had a negative effect on the perceived ease of use and perceived ubiquity. The perceived ubiquity construct affects both user groups' perceived ease of use and perceived usefulness of wearing smart clothes. Most relationships among the original constructs of the TAM were validated in older adults in general. Interestingly, we found that perceived usefulness had an indirect effect on behavioral intention through attitude. These results further confirm the validity of the extended TAM in determining older users' technology acceptance behavior.

On digital intimacy: redefining provider-patient relationships in remote monitoring.

Remote monitoring has often been thought to lead to a highly structured and standardised care process. Several studies have stressed that patient-provider communication could be hindered if mediated by technologies, leading to an impoverished relationship. We argue that while remote monitoring leads to a redefinition of the patient-provider relationship, it could also offer the opportunity to develop a more intimate acquaintance not possible via only routine visits. The study is part of a clinical trial aimed at assessing the acceptability of a remote monitoring platform for type 1 diabetes. Drawing on practice-based studies, we focused our analysis on the practice of text message exchange between patients and providers. The 396 conversations were coded with a template analysis, leading to the identification of two main categories: 'knowing the patient' and 'knowing about the patient'. The analysis reveals that the practice of messaging led to the development of a 'digital intimacy', a relationship characterised by a thorough familiarity made possible by electronic devices that extends to face-to-face encounters. Drawing on our case, we argue that remote monitoring can foster greater intimacy between patients and providers, which is made possible by the overall increase in the quantity and quality of communication between patients and providers.

Factors influencing behavioural intention to use a smart shoe insole in regionally based adults with diabetes: a mixed methods study.

BACKGROUND: Smart insole technologies that provide biofeedback on foot health can support foot-care in adults with diabetes. However, the factors that influence patient uptake and acceptance of this technology are unclear. Therefore, the aim of this mixed-methods study was to use an established theoretical framework to determine a model of psychosocial factors that best predicts participant intention to use smart insoles. METHODS: Fifty-three adults with diabetes from regional Australia completed the validated Unified Theory of Acceptance and Use of Technology (UTAUT) questionnaire. Multiple regression analysis was used to determine the psychosocial factors that best predict behavioural intention to adopt a smart insole. Additionally, a focus group was conducted and thematic analysis was performed to explore barriers and enablers to adopting this technology. RESULTS: The multiple regression model that best predicted intention to adopt the smart insole (adjusted R2 = 0.51, p < 0.001) identified that self-efficacy (ß = 0.67, p = 0.001) and attitude (ß = 0.72, p < 0.001) were significant predictors of behavioural intention, while effort expectancy (ß = - 0.52, p = 0.003) and performance expectancy (ß = - 0.40, p = 0.040) were moderating factors. Thematic analysis illustrates the importance of attitude and self-efficacy on participants' behavioural intentions, influenced by participant's belief in the device's clinical efficacy and anticipated effort expectancy. CONCLUSIONS: This mixed-methods study demonstrates that attitude, self-efficacy, performance expectancy and effort expectancy combine to predict intention to adopt smart insole technology. Clinicians should consider these psychosocial factors when they prescribe and implement smart soles with patients at high risk of foot ulceration.

How to assess negative affective reactivity to daily life stress in depressed and nondepressed individuals?

Intensive longitudinal data studies on affective reactivity to daily life stress have used various dimensions of stress. Based on an evidence-based conceptual model of stress, the current study included unpredictability, uncontrollability and unpleasantness, and examined whether and how these predict affective reactivity in depressed and non-depressed individuals in daily life. Participants (27 depressed, 27 non-depressed) completed a diary 3 times a day for a period of 30 days. Multilevel analyses were performed to investigate unpleasantness, uncontrollability and unpredictability of daily events as univariate predictors of negative affect (NA). Multivariable models were composed to determine the optimal combination of stress dimensions, and whether the strength of the predictions differed between the depressed and non-depressed groups. Unpleasantness, uncontrollability and unpredictability each predicted subsequent NA independently. However, a combination of all three dimensions, together with an interaction between unpleasantness and uncontrollability, predicted subsequent NA best. The stress dimensions predicted NA more strongly in the depressed than the non-depressed group. This was mostly accounted for by an increased NA response to unpleasantness. Thus, unpleasantness seems to be the most important aspect of daily stress to distinguish depressed from non-depressed individuals. Nevertheless, for a comprehensive assessment of affective reactivity, a multidimensional model of event stressfulness is recommended.

A Mixed-Methods Study of Users' Journey Mapping Experience and Acceptance of Telehealthcare Technology in Taiwan.

Background: The integration of telehealthcare technologies into geriatric care has clear advantages, but poses challenges for key stakeholders, including the telehealthcare service industry, smart device developers, marketers and, of course, users. The purpose of this study was to gain insight into user experience and acceptance of telehealthcare technology in Taiwan. Materials and Methods: Taking an integrated mixed-methods approach, 51 participants-33 women (64.71%) and 18 men (35.29%) (mean age: 52.1 years)-were examined before, during, and after using a telehealthcare device. A questionnaire was used to assess users' acceptance of the technology. Interviews were conducted to gather feedback. Results: The quantitative analysis revealed that (1) effort expectancy and relatives significantly influenced users' behavior intentions, (2) error and memorability significantly affected users' satisfaction, and (3) intention and satisfaction significantly affected users' behavior. The qualitative analysis revealed two key implications. First, participants generally were not satisfied with the telehealthcare device. Second, participants suggested the redesign of the telehealthcare device to reduce operating errors and time consumption to meet users' needs. Conclusions: Contemporary telehealthcare devices do not meet users' needs. Participants were made to adapt to the equipment rather than the equipment tailored to meet their needs. Although there were key benefits from home telehealthcare, the systems require enhanced technology, improved usability, and an expanded scale of services backed by government before widespread implementation can successfully proceed.

Feasibility of smart wristbands for continuous monitoring during pregnancy and one month after birth.

BACKGROUND: Smart wristbands enable the continuous monitoring of health parameters, for example, in maternity care. Understanding the feasibility and acceptability of these devices in an authentic context is essential. The aim of this study was to evaluate the feasibility of using a smart wristband to collect continuous activity, sleep and heart rate data from the beginning of the second trimester until one month postpartum. METHODS: The feasibility of a smart wristband was tested prospectively through pregnancy in nulliparous women (n = 20). The outcomes measured were the wear time of the device and the participants' experiences with the smart wristband. The data were collected from the wristbands, phone interviews, questionnaires, and electronic patient records. The quantitative data were analyzed with hierarchical linear mixed models for repeated measures, and qualitative data were analyzed using content analysis. RESULTS: Participants (n = 20) were recruited at a median of 12.9 weeks of gestation. They used the smart wristbands for an average of 182 days during the seven-month study period. The daily use of the devices was similar during the second (17.9 h, 95% CI 15.2 to 20.7) and third trimesters (16.7 h, 95% CI 13.8 to 19.5) but decreased during the postpartum period (14.4 h, 95% CI 11.4 to 17.4, p = 0.0079). Participants who could not wear smart wristbands at work used the device 300 min less per day than did those with no use limitations. Eight of the participants did not wear the devices or wore them only occasionally after giving birth. Nineteen participants reported that the smart wristband did not have any permanent effects on their behavior. Problems with charging and synchronizing the devices, perceiving the devices as uncomfortable, or viewing the data as unreliable, and the fear of scratching their babies with the devices were the main reasons for not using the smart wristbands. CONCLUSIONS: A smart wristband is a feasible tool for continuous monitoring during pregnancy. However, the daily use decreased after birth. The results of this study may support the planning of future studies and help with overcoming barriers related to the use of smart wristbands on pregnant women.

Schooling diabetes: Use of continuous glucose monitoring and remote monitors in the home and school settings.

BACKGROUND: Despite significant advances in type 1 diabetes (T1D) management, achieving targeted glycemic control in pediatric patients remains a struggle. Continuous glucose monitoring (CGM) with remote access holds the promise to address this challenge by allowing caregivers to monitor glucose, even when the child is not directly under their supervision. OBJECTIVE: To explore real-time and remote CGM practices in homes and schools, including caregiver expectations regarding this technology. SUBJECTS: Parents and daytime caregivers. METHODS: Respondents answered an anonymous survey assessing characteristics of CGM use. Cross-sectional data were collected and analyzed using quantitative and qualitative methods. RESULTS: Thirty-three parents and 17 daytime caregivers responded. Threshold alerts (alerts when patients reached certain pre-set high or low limits) were used most frequently, followed by rate of change alerts. Most parents and daytime caregivers responded to low- and high-threshold CGM alerts by confirming with a glucose meter prior to treatment; while about one-third endorsed treating lows without a confirmatory test. Most parents expected their child's daytime caregiver to respond to CGM alerts and daytime caregivers felt the parent's expectations of them were reasonable. All parents and most caregivers reported decreased overall worry/stress. Parents felt positive about CGM use and daytime caregivers felt comfortable with CGM. CONCLUSION: The positive and collaborative management reported by parents and daytime caregivers sets the stage for CGM to play an important role in the management of children with T1D both in the home and in the school settings.

Acceptance of Telemonitoring Among Patients with Obstructive Sleep Apnea Syndrome: How is the Perceived Interest by and for Patients?

BACKGROUND: Obstructive sleep apnea syndrome, a chronic respiratory disease, requires regular adherence to Continuous Positive Airway Pressure (CPAP) therapy. Telemonitoring may be relevant to support adherence, but nonetheless this raises ethical issues around the intrusive nature of the daily life of patients Objective: To explore the acceptance of telemonitoring by patients and the impact of this on adherence. MATERIALS AND METHODS: A prospective and observational study has been performed with 160 patients who initiated their CPAP therapy. The acceptability of telemonitoring was studied using an attitudes' scale of 8 items. A total of 160 patients (111 men, 49 women) responded to the questionnaire at 1 month upon treatment. The adoption of both telemonitoring and adherence behavior were observed at 10 months of therapy. RESULTS: A majority (78%) of patients expressed a favorable attitude toward telemonitoring, but nearly 40% consider this device like intrusive. However, at 10 months of treatment, 78% of patients are still telemonitored. We did not observe a significant difference between telemonitoring patients and nontelemonitoring patients with respect to the mean duration of use of CPAP therapy. However, the risk of stopping CPAP therapy is significantly more important in patients who refused telemonitoring. DISCUSSION AND CONCLUSION: It seems reductive to consider telemonitoring as a simple tool of surveillance to support adherence. It may be preferable to consider telemonitoring as a follow-up proposal. This will allow for more reactive management and close to the needs of the patients, in particular as telemonitoring is, in general, well accepted by patients.

Flash Glucose Measurements in Children with Type 1 Diabetes in Real-Life Settings: To Trust or Not to Trust?

BACKGROUND AND AIMS: To evaluate the clinical accuracy of a flash glucose monitoring device FreeStyle Libre (FSL) among children with type 1 diabetes in real-world settings during a summer camp. MATERIALS AND METHODS: During a summer camp, children with type 1 diabetes (n = 79, aged 8-18 years) were provided with FSLs for 12 days. On days 3, 7, and 11 of the study, they underwent supervised glucose testing at 8 timepoints. Glycemia was estimated by using FSL and measured with a personal glucometer within a period of 2 min. The glucose trend arrows were recorded. RESULTS: The study was completed by 78 children (median: age 12.8 years, diabetes duration 5.8 years, HbA1c 58.5 mmol/mol). Mean absolute relative difference (MARD) between the FSL and the glucometer was 13.5% ± 12.9%. FSL was the most accurate in stable glycemic conditions: MARD 11.4% ± 10.4%, less accurate when glycemia was falling >2 mg/(dL·min) [0.111 mmol/(L·min)-MARD 22.6% ± 18.6%; P < 0.001 vs. stable conditions] and when the device could not determine the glucose trends (16.5% ± 16.3%, P = 0.01 vs. stable conditions). The FSL demonstrated lower accuracy during the day than the night [MARD 14.9% ± 14% vs. 11.2% ± 10.6%, P < 0.0001]. Out of 1655 data pairs of glucometer and FSL, using the Surveillance Error Grid methodology we determined that 80.36% of FSL readings were associated with no clinical risk, 18.73% with slight risk and only one high-risk measurement was detected. CONCLUSION: FSL is accurate in children, but its accuracy depends on the glucose trend. Results flagged by the rapid fall flag and "trend undetermined" should be verified by blood glucose measurements.

A Qualitative Analysis of Real-Time Continuous Glucose Monitoring Data Sharing with Care Partners: To Share or Not to Share?

BACKGROUND: Little research exists regarding how real-time continuous glucose monitoring (RT-CGM) data sharing plays a role in the relationship between patients and their care partners. OBJECTIVE: To (1) identify the benefits and challenges related to RT-CGM data sharing from the patient and care partner perspective and (2) to explore the number and type of individuals who share and follow RT-CGM data. METHODS: This qualitative content analysis was conducted by examining publicly available blogs focused on RT-CGM and data sharing. A thematic analysis of blogs and associated comments was conducted. RESULTS: A systematic appraisal of personal blogs examined 39 blogs with 206 corresponding comments. The results of the study provided insight about the benefits and challenges related to individuals with diabetes sharing their RT-CGM data with a care partner(s). The analysis resulted in three themes: (1) RT-CGM data sharing enhances feelings of safety, (2) the need to communicate boundaries to avoid judgment, and (3) choice about sharing and following RT-CGM data. RT-CGM data sharing occurred within dyads (n = 46), triads (n = 15), and tetrads (n = 2). CONCLUSIONS: Adults and children with type 1 diabetes and their care partners are empowered by the ability to share and follow RT-CGM data. Our findings suggest that RT-CGM data sharing between an individual with diabetes and their care partner can complicate relationships. Healthcare providers need to engage patients and care partners in discussions about best practices related to RT-CGM sharing and following to avoid frustrations within the relationship.

Fear of hypoglycemia: Influence on glycemic variability and self-management behavior in young adults with type 1 diabetes.

PURPOSE: The purpose of this study was to examine how fear of hypoglycemia (FOH) is associated with glycemic variability (GV) and self-management behavior in young adults (aged 18-35) with type 1 diabetes (T1DM). PROCEDURES: Using a prospective repeated-measures design, in 35 young adults, within- and between-person and temporal associations of FOH, specific self-management behaviors, and GV were measured. The data were collected using questionnaires and real-time measures using daily diaries, insulin pump downloads, actigraphy, and continuous glucose monitoring. FINDINGS: FOH was associated with greater glycemic variability. Significant temporal associations emerged. Concurrent day (glucose SD, p=.011) and previous-evening fear levels were associated with GV (glucose SD, p=.007). FOH was also associated with greater calorie intake (r=.492, p=.003) and less physical activity (light activity, r=-.341, p=.045). CONCLUSIONS: The significant associations of FOH with GV, dietary patterns, and physical activity provide evidence for FOH as an important psychological factor associated with diabetes care.

What impact do anxiety, depression, perceived control and technology capability have on whether patients with chronic heart failure take-up or continue to use home tele-monitoring services? Study design of ADaPT-HF.

BACKGROUND: Home tele-monitoring (HTM) is used to monitor the clinical signs and symptoms of patients with chronic heart failure (CHF) in order to reduce unplanned hospital admissions. However, not all patients who are referred will agree to use HTM, and some patients choose to withdraw early from its use. AIMS: ADaPT-HF will investigate whether depression, anxiety, low perceived control, reduced technology capability, level of education, age or the severity or complexity of a patient's illness can predict refusal of, or early withdrawal from, HTM in patients with CHF. METHODS: The study will recruit 288 patients who have been recently admitted to hospital with heart failure who have been referred for HTM. At the time of referral, patients will complete depression (nine-item Patient Health Questionnaire), anxiety (seven-item Generalised Anxiety Disorder questionnaire), perceived control (eight-item revised Controlled Attitudes Scale) and technology capability (ten-item Technology Readiness Index 2.0) screening questionnaires. In addition, data on demographics, diagnosis, clinical examination, socio-economic status, history of comorbidities, medication, biochemistry and haematology will be recorded. The primary outcome will be a composite of refusal of or early withdrawal from HTM. The principle analysis will be made using logistic regression. CONCLUSION: By establishing which factors influence a patient's decision to refuse or withdraw early from HTM, it may be possible to redesign HTM referral processes. It may be that patients with CHF who also have depression, anxiety, low control and poor technology skills should not be referred until they receive appropriate support or that they should be managed differently when they do receive HTM. The results of ADAPT-HF may provide a way of making more efficient and cost-effective use of HTM services.

Implementation and Validation of Engagement Monitoring in an Engagement Enhancing Rehabilitation System.

Enhancing engagement of patients during stroke rehabilitation exercises are in the focus of current research. Various methods and computer supported tools have been developed for this purpose, which try to avoid mundane exercising that is prone to become a routine or even boring for the patients and leads to ineffective training. This paper introduces an engagement enhancing cyber-physical stroke rehabilitation system (CP-SRS) aiming at enhancing the patient's engagement during rehabilitation training exercises. This paper focuses on introducing the implementation and validation of the engagement monitoring subsystem (EMS) in the CP-SRS. The EMS is expected to evaluate the patient's actual engagement levels in motor, perceptive, cognitive and emotional aspects. Experiments in these four aspects were conducted separately, in order to characterize the range and accuracy of the engagement indicators by influencing the subjects into different engaged states. During the experiments, different setups were created to mimic the situations in which the subject was engaged or not engaged. The subjects involved in the experiments were healthy subjects. Results showed that the measurement in motor, perceptive, cognitive, and emotional aspects can represent the corresponding engagement level. More experiments will be conducted in the future to validate the efficiency of the CP-SRS in enhancing the engagement with stroke patients.

Cardiac patients show high interest in technology enabled cardiovascular rehabilitation.

BACKGROUND: Cardiac rehabilitation (CR) can slow or reverse the progression of cardiovascular disease (CVD). However, uptake of community-based CR is very low. E-cardiology, e-health and technology solutions for physical activity uptake and monitoring have evolved rapidly and have potential in CVD management. However, it is unclear what the current technology usage is of CVD patients, and their needs and interests for technology enabled CR. METHODS: A technology usage questionnaire was developed and completed by patients from a supervised ambulatory CR program and an adult congenital heart disease clinic and from two community-based CR programs. Results were described and related with age, gender and educational level by Spearman correlations. RESULTS: Of 310 patients, 298 patients (77 % male; mean age 61,7 ± 14,5 years) completed at least 25 questions of the survey and were included in the analysis (completion rate 96 %). Most (97 %) patients had a mobile phone and used the internet (91 %). Heart rate monitors were used by 35 % and 68 % reported to find heart rate monitoring important when exercising at home. Physical activity monitoring was reported by 12 % of the respondents. Respondents were interested in CR support through internet (77 %) and mobile phone (68 %). Many patients reported interest in game-based CR (67 %) and virtual rehabilitation (58 %). At least medium interest in technology enabled CR was reported by 75 % of the patients. Interest decreased with increasing age (r = -0.16; p = 0.005). CONCLUSIONS: CVD patients show interest for technology enabled home-based CR. Our results could guide the design of a technology-based, virtual CR intervention.

Meanings and experiences of assistive technologies in everyday lives of older citizens: a meta-interpretive review.

PURPOSE: The purpose of this study was to synthesize the available qualitative studies on the meaning of assistive technologies (AT) in elderly people's everyday lives in order to identify central concepts, themes, and findings from existing research. METHOD: A systematic search of the literature was conducted, using predetermined search strategies. Exclusion criteria were, in accordance with the meta-interpretive approach, developed iteratively during the reading of abstracts and articles. Interpretations from the studies were used as data for thematic analysis and synthesis of findings. RESULTS: Review of these studies show that older people not only have positive attitude towards AT, but also that acceptance of technologies is a potentially stressful process where trust towards technologies and other people are of importance. Older people have ambivalent experiences with technology, as it gives rise to possibilities as well as constraints, and safety as well as worries. AT enact sometimes conflicting values related to self and society. CONCLUSIONS: Although AT seem to support societal discourses on active aging, the empirical studies in this field show that the technologies enter older people's lives in complex ways, enacting social values and ambivalences and interact with caretakers, relatives and other actors, within specific institutional settings. Implications for rehabilitation In implementing AT, attention should be paid to ambivalences and conflicting values enacted by AT in older people's lives In implementing AT, attention should be paid not only to independency but also to the eventually dependencies, created by the use of AT.

Involvement of older people in the development of fall detection systems: a scoping review.

BACKGROUND: The involvement of users is recommended in the development of health related technologies, in order to address their needs and preferences and to improve the daily usage of these technologies. The objective of this literature review was to identify the nature and extent of research involving older people in the development of fall detection systems. METHODS: A scoping review according to the framework of Arksey and O'Malley was carried out. A key term search was employed in eight relevant databases. Included articles were summarized using a predetermined charting form and subsequently thematically analysed. RESULTS: A total of 53 articles was included. In 49 of the 53 articles, older people were involved in the design and/or testing stages, and in 4 of 53 articles, they were involved in the conceptual or market deployment stages. In 38 of the 53 articles, the main focus of the involvement of older people was technical aspects. In 15 of the 53 articles, the perspectives of the elderly related to the fall detection system under development were determined using focus groups, single interviews or questionnaires. CONCLUSIONS: Until presently, involvement of older people in the development of fall detection systems has focused mainly on technical aspects. Little attention has been given to the specific needs and views of older people in the context of fall detection system development and usage.

Transdermal alcohol concentration data collected during a contingency management program to reduce at-risk drinking.

BACKGROUND: Recently, we demonstrated that transdermal alcohol monitors could be used in a contingency management procedure to reduce problematic drinking; the frequency of self-reported heavy/moderate drinking days decreased and days of no to low drinking increased. These effects persisted for three months after intervention. In the current report, we used the transdermal alcohol concentration (TAC) data collected prior to and during the contingency management procedure to provide a detailed characterization of objectively measured alcohol use. METHODS: Drinkers (n=80) who frequently engaged in risky drinking behaviors were recruited and participated in three study phases: a 4-week Observation phase where participants drank as usual; a 12-week Contingency Management phase where participants received $50 each week when TAC did not exceed 0.03g/dl; and a 3-month Follow-up phase where self-reported alcohol consumption was monitored. Transdermal monitors were worn during the first two phases, where each week they recived $105 for visiting the clinic and wearing the monitor. Outcomes focused on using TAC data to objectively characterize drinking and were used to classify drinking levels as either no, low, moderate, or heavy drinking as a function of weeks and day of week. RESULTS: Compared to the Observation phase, TAC data indicated that episodes of heavy drinking days during the Contingency Management phase were reduced and episodes of no drinking and low to moderate drinking increased. CONCLUSIONS: These results lend further support for linking transdermal alcohol monitoring with contingency management interventions. Collectively, studies to date indicate that interventions like these may be useful for both abstinence and moderation-based programs.