The effect of executive function on adherence with a cardiac secondary prevention program and its interaction with an incentive-based intervention

Diann E. Gaalema, Sarahjane Dube, Alexandra Potter, Rebecca J. Elliott, Katharine Mahoney, Stacey C. Sigmon, Stephen T. Higgins, Philip A. Ades

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


Participation in secondary prevention programs such as cardiac rehabilitation (CR) reduces morbidity, mortality, and hospitalizations while improving quality of life. Executive function (EF) is a complex set of cognitive abilities that control and regulate behavior. EF predicts many health-related behaviors, but how EF interacts with interventions to improve treatment adherence is not well understood. The objective of this study is to examine if EF predicts CR treatment adherence and how EF interacts with an intervention to improve adherence. Data were collected from 2013 to 2018 in Vermont, USA. 130 Medicaid-enrolled individuals who had experienced a qualifying cardiac event were enrolled in a controlled clinical trial and randomized 1:1 to receive financial incentives for completing secondary prevention sessions or to usual care. In this secondary analysis, effects of EF on CR adherence (defined as completing ≥30/36 sessions) were examined in 112 participants (57 usual care, 55 intervention) who completed an EF battery. Delay-discounting, a measure of impulsivity, predicted CR adherence (p = 0.01) and interacted with the incentive intervention, such that those who exhibited greater discounting of future rewards benefitted more from the intervention than those who discounted less (F(1, 104) = 5.23, p = 0.02). Better cognitive flexibility, measured with the trail-making-task, also predicted CR adherence (p = 0.02). While EF has been associated with adherence to a variety of treatment regimens, this interaction between an incentive-based intervention to promote treatment adherence and EF is novel. This work illustrates the value of considering individual differences in EF when designing and implementing interventions to promote health-related behavior change.

Original languageEnglish (US)
Article number105865
JournalPreventive Medicine
StatePublished - Nov 2019
Externally publishedYes


  • Contingency management
  • Executive function
  • Incentives
  • Socioeconomic status
  • Treatment adherence

ASJC Scopus subject areas

  • Epidemiology
  • Public Health, Environmental and Occupational Health


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