The PRIMER study: Nudging patients with liver disease toward healthier habits, one step at a time.
The PRIMER study: Nudging patients with liver disease toward healthier habits, one step at a time.
复制标题
PRIMER 研究：一步一步地促使肝病患者养成更健康的习惯。
DOI：
10.1097/lvt.0000000000000235
复制
发表时间：
2024
期刊：
影响因子：
--
通讯作者：
Desai,ArchitaP
中科院分区：
文献类型：
--
作者：
Orman,EricS;Desai,ArchitaP
虚弱在肝硬化患者中非常常见，与各种不良结果相关，并且通常是许多患者寻求移植的障碍。在这一人群中，体育锻炼可以提高有氧能力、肌肉质量和功能，提高生活质量因此，在移植手术前改善身体功能的“预康复”概念已成为一种促进体弱患者移植的方法然而，在向这一人群提供运动干预方面存在挑战。大多数肝脏移植治疗是在远离患者家的大型医疗中心提供的，在那里，后勤障碍限制了医院监督锻炼的影响。无监督的肝硬化家庭锻炼缺乏维持坚持所需的结构和责任同样，基于应用程序的新颖、自我导向的项目也很难坚持下去。[4,5]这些行为干预的失败反映了慢性肝病患者缺乏准备和生活方式改变的重大障碍，强调了制定有针对性的肝硬化行为干预措施的重要性。在这一期的《肝移植》杂志上，Serper和他的同事报告了一项随机试验的结果，该试验评估了在肝移植患者中，激进性体育锻炼计划与更有限的生活方式干预的可行性和有效性所有参与者都收到了个性化的体育活动和饮食讲义。此外，干预组的参与者接受了更正式的家庭锻炼计划，包括(1)对完成步骤目标和参加每周电话检查的财务激励；(2)每天两次以短信为基础的提醒，以支持药物依从性。这种多管齐下的干预利用了决策心理学。行为科学家已经发展了人类如何做决定的理论，其中大多数描述了指导现实世界决策的认知系统（“系统1”和“系统2”）。这一理论和行为经济学领域因丹尼尔·卡尼曼的著作《思考，快与慢》而得到普及。[7]“系统1”思维是快速的、自动的、直觉的，而“系统2”思维是费力的、分析的，因此速度较慢。随着时间和注意力在我们的日常生活中变得越来越宝贵，许多决定（包括那些对我们的健康有巨大影响的决定）都是使用系统1做出的。重要的是，系统1依赖于启发式（捷径或经验法则）来产生快速决策，并受到做出决策的环境（心理、社会和物理）的严重影响。[7,8]行为经济学表明，我们可以通过改变决策环境来支持更健康的选择，从而利用这一特征这种改变被称为“助推”。推动的例子包括改变默认的选择（例如，要求器官捐赠的“选择退出”）和把想要的选择放在显眼的地方（例如，把更健康的食物放在自助餐厅食品队伍的前面，或者放在最容易接近的杂货店货架上）。通过环境的微小改变，轻推可以让一个人毫不费力地克服旧习惯，而不增加认知负担或需要有意识。PRIMER（预康复干预以最大化早期恢复）研究利用了几个这样的推动来改变研究参与者的环境，以促进身体活动。具体到体力活动目标，该研究采用了财务损失规避法（未达到目标的每一天扣除3美元）。损失厌恶促使人们利用大多数人……
Frailty is exceedingly common in individuals with cirrhosis, is associated with a variety of poor outcomes, and is often a barrier for many patients seeking transplant. In this population, physical exercise can improve aerobic capacity, muscle mass and function, and quality of life.[1] The concept of “prehabilitation” to improve physical function prior to transplant surgery has therefore become popular as a method to facilitate transplant for frail patients.[2] There are challenges, however, in delivering exercise interventions to this population. Most transplant hepatology care is provided in large medical centers far from the patients’ homes, where logistical barriers limit the impact of hospitalbased supervised exercise. Unsupervised home-based exercise in cirrhosis lacks the structure and accountability required to maintain adherence.[3] Similarly, novel app-based, self-directed programs also suffer from poor adherence.[4, 5] These failures of behavioral interventions reflect lack of readiness and significant barriers to lifestyle change in chronic liver disease, underscoring the importance of developing targeted behavioral interventions for cirrhosis. In this edition of Liver Transplantation, Serper and colleagues report the findings of a pilot randomized trial assessing the feasibility and efficacy of an incentivized physical activity program as compared with a more limited lifestyle intervention in individuals pursuing liver transplant.[6] All participants received personalized physical activity and diet handouts. Additionally, those in the intervention arm received a more formal at-home exercise program including (1) financial incentives for meeting step goals and for participating in weekly phone check-ins and (2) twice daily text-based reminders to support medication adherence. This multipronged intervention leverages the psychology of decision-making. Behavioral scientists have developed theories of how humans make decisions, with most describing 2 cognitive systems that guide real-world decision-making (“system 1” and “system 2”). This theory and the field of behavioral economics were popularized by Daniel Kahneman in his book Thinking, Fast and Slow.[7]“System 1” thinking is fast, automatic, and intuitive, while “system 2” thinking is effortful, analytic, and, thus, slower. With time and attention becoming increasingly at a premium in our day-to-day lives, many decisions (including those that have a tremendous impact on our health) are made using system 1. Importantly, system 1 relies on heuristics (shortcuts or rules of thumb) to produce fast decisions and is heavily influenced by the environment (mental, social, and physical) in which the decision is being made.[7, 8] Behavioral economics has shown that we can take advantage of this feature by modifying the decision-making environment to support healthier choices.[8] The modifications are known as nudges. Examples of nudges include changing the default choice (eg, requiring an “opt-out” for organ donation) and placing the desired choices in prominent areas (eg, healthier food earlier in the cafeteria food line or on the most accessible grocery store shelf). Through small changes in the environment, nudges can allow an individual to effortlessly overcome old habits without adding cognitive burden or requiring intentionality. The PRIMER (Prehabilitation Intervention to Maximize Early Recovery) study leverages several such nudges to modify the environment of the study participants to facilitate physical activity. Specific to the physical activity goal, the study employs financial loss aversion ($3 was deducted for each day the step goal was not met). Loss aversion nudges capitalize on the tendency of most individuals to …