Jun 22, 2018

Stop and shop

The story

There's no amount of money you'd accept to do an extra 30-hour call, but you'd think long and hard before paying a co-resident to take an existing shift off your schedule. New research explores whether the fear of losing money can drive smokers to quit.

The background

Your fear of giving up cash is called loss aversion, and it's a powerful driver of human behavior. The strategy was first tested on the big stage in a 2015 trial that found that smokers were twice as likely to toss their lighters if they incurred financial penalties from smoking rather than positive rewards. The problem? The fear of loss is so distasteful that only 14% of smokers chose to participate, diluting the strategy's efficacy.

The frame

The same authors compared loss framing – redeemable deposits that had already been 'earned', but patients had to stop smoking not to lose them – to positive rewards for abstinence. Over 6,000 smokers at 54 companies were included regardless of whether or not they were interested in quitting. The loss framing group saw 6-month sustained abstinence rates of 2.9%, compared to 2.0% in the rewards group. Free cessation aids like nicotine patches and lozenges produced abstinence rates of 0.5%, and free e-cigarettes led to abstinence rates of 1.0%. Rates were 4 - 6x higher across the board in employees interested in quitting.

The takeaway

Employees who smoke on average cost their companies thousands of dollars per year in increased healthcare costs, so the $3,500 average cost per successful quit for redeemable deposits seems worth it. Free smoking cessation aids, an old standby of employee wellness programs, appear ineffective by comparison.

Say it on rounds

When the right note template makes copy forward a breeze

We're all looking for a one-time fix. Patients have trouble adhering to daily blood pressure control meds, and renal sympathetic artery denervation offers promise as a more permanent solution. In the latest entry in what has been a complicated literature, a multi-national RCT of 150 hypertensive patients found that endovascular ultrasound denervation reduced daytime ambulatory systolic BP by 6.3 mmHg compared to sham procedure. About 25% of the denervation group achieved BP control at 2 months compared to 3% in the control arm. Adverse events were minimal.

When a ball of stress leaves a pit in your stomach

Yep, they're related. A registry-based retrospective cohort of 100,000 Swedish patients with stress-related disorders like PTSD, acute stress disorder, or adjustment disorder found a 36% increased risk of developing an autoimmune disease over 32-year follow-up compared to unexposed individuals. PTSD conferred the highest risk, though early treatment with SSRIs appeared to help. The authors suggest that stress dysregulates immune function and can activate inflammation.

When your whole list has C. diff, but you swear you’re washing your hands

At least you're focused on prevention. A retrospective cohort study of 17,500 opioid overdose survivors in Massachusetts found that only 30% of patients received an opiate addiction medication – methadone, buprenorphine, or naltrexone – in the 12 months after their overdose. When prescribed, methadone maintenance treatment and buprenorphine substantially cut the risk of all-cause and opioid-related mortality. And while too few patients were given addiction meds, 34% of patients received further opioid prescriptions and 26% received scripts for benzos in the 12 months after their overdose.

Brush up

Chronic pancreatitis

Once thought to be limited to patients with alcohol abuse, chronic pancreatitis also affects heavy smokers and is increasingly idiopathic. Look for relapsing abdominal pain in the epigastric-to-back distribution. CT and MRI findings can be supportive, but imaging is often negative early in the disease course and false positives abound in high-risk populations. Management focuses on pain control and monitoring for complications like endocrine / exocrine insufficiency and pancreatic cancer.

What's the evidence

For pregabalin in chronic pancreatitis? A 2011 RCT found that patients who received three weeks of pregabalin in addition to their chronic pain regimen reported better pain control and improved perception of their health status compared with placebo. Low fat diets are often prescribed but lack prospective data, while celiac plexus blocks are generally ineffective.

What your business friends are talking about

Pals Jamie Dimon, Warren Buffett, and Jeff Bezos teamed up in January to announce a joint healthcare initiative. Details remain sparse, but this week Atul Gawande was brought into the fold as the venture's CEO.

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