Encouraging the Development of New Antibiotics: Are Financial Incentives the Right Way Forward? A Systematic Review and Case Study

Antibiotic resistance is an urgent public health threat that has received substantial attention from the world's leading health agencies and national governmental bodies alike. However, despite increasing rates of antibiotic resistance, pharmaceutical companies are reluctant to develop new antibiotics due to scientific, regulatory, and financial barriers. Nonetheless, only a handful of countries have addressed this by implementing or proposing financial incentive models to promote antibiotic innovation. This study is comprised of a systematic review that aimed to understand which antibiotic incentive strategies are most recommended within the literature and subsequently analyzed these incentives to determine which are most likely to sustainably revitalize the antibiotic pipeline. Through a case study of Canada, we apply our incentive analysis to the Canadian landscape to provide decision-makers with a possible path forward. Based on our findings, we propose that Canada support the ongoing efforts of other countries by implementing a fully delinked subscription-based market entry reward. This paper seeks to spark action in Canada by shifting the national paradigm to one where antibiotic research and development is prioritized as a key element to addressing antibiotic resistance.

What drives general practitioners in the UK to improve the quality of care? A systematic literature review

BACKGROUND

In the UK, the National Health Service has various incentivisation schemes in place to improve the provision of high-quality care. The Quality Outcomes Framework (QOF) and other Pay for Performance (P4P) schemes are incentive frameworks that focus on meeting predetermined clinical outcomes. However, the ability of these schemes to meet their aims is debated.

OBJECTIVES

(1) To explore current incentive schemes available in general practice in the UK, their impact and effectiveness in improving quality of care and (2) To identify other types of incentives discussed in the literature.

METHODS

This systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six databases were searched: Cochrane, PubMed, National Institute for Health and Care Excellence Evidence, Health Management Information Consortium, Embase and Health Management. Articles were screened according to the selection criteria, evaluated against critical appraisal checklists and categorised into themes.

RESULTS

35 articles were included from an initial search result of 22087. Articles were categorised into the following three overarching themes: financial incentives, non-financial incentives and competition.

DISCUSSION

The majority of the literature focused on QOF. Its positive effects included reduced mortality rates, better data recording and improved sociodemographic inequalities. However, limitations involved decreased quality of care in non-incentivised activities, poor patient experiences due to tick-box exercises and increased pressure to meet non-specific targets. Findings surrounding competition were mixed, with limited evidence found on the use of non-financial incentives in primary care.

CONCLUSION

Current research looks extensively into financial incentives, however, we propose more research into the effects of intrinsic motivation alongside existing P4P schemes to enhance motivation and improve quality of care.

Patients' Reactions to Being Offered Financial Incentives to Increase Colorectal Screening: A Qualitative Analysis

PURPOSE

To explore financial incentives as an intervention to improve colorectal cancer screening (CRCS) adherence among traditionally disadvantaged patients who have never been screened or are overdue for screening.

APPROACH

We used qualitative methods to describe patients' attitudes toward the offer of incentives, plans for future screening, and additional barriers and facilitators to CRCS.

SETTING

Kaiser Permanente Washington (KPWA).

PARTICIPANTS

KPWA patients who were due or overdue for CRCS.

METHOD

We conducted semi-structured qualitative interviews with 37 patients who were randomized to 1 of 2 incentives (guaranteed $10 or a lottery for $50) to complete CRCS. Interview transcripts were analyzed using a qualitative content approach.

RESULTS

Patients generally had positive attitudes toward both types of incentives, however, half did not recall the incentive offer at the time of the interview. Among those who recalled the offer, 95% were screened compared to only 25% among those who did not remember the offer. Most screeners stated that staying healthy was their primary motivator for screening, but many suggested that the incentive helped them prioritize and complete screening.

CONCLUSIONS

Incentives to complete CRCS may help motivate patients who would like to screen but have previously procrastinated. Future studies should ensure that the incentive offer is noticeable and shorten the deadline for completion of FIT screening.

Controlling COVID-19 Outbreaks with Financial Incentives

In this paper, we consider controlling coronavirus disease 2019 (COVID-19) outbreaks with financial incentives. We use the recently developed susceptible-unidentified infected-confirmed (SUC) epidemic model. The unidentified infected population is defined as the infected people who are not yet identified and isolated and can spread the disease to susceptible individuals. It is important to quickly identify and isolate infected people among the unidentified infected population to prevent the infectious disease from spreading. Considering financial incentives as a strategy to control the spread of disease, we predict the effect of the strategy through a mathematical model. Although incentive costs are required, the duration of the disease can be shortened. First, we estimate the unidentified infected cases of COVID-19 in South Korea using the SUC model, and compute two parameters such as the disease transmission rate and the inverse of the average time for confirming infected individuals. We assume that when financial incentives are provided, there are changes in the proportion of confirmed patients out of unidentified infected people in the SUC model. We evaluate the numbers of confirmed and unidentified infected cases with respect to one parameter while fixing the other estimated parameters. We investigate the effect of the incentives on the termination time of the spread of the disease. The larger the incentive budget is, the faster the epidemic will end. Therefore, financial incentives can have the advantage of reducing the total cost required to prevent the spread of the disease, treat confirmed patients, and recover overall economic losses.

The Impact of Financial Incentives on Service Engagement Among Adults Experiencing Homelessness and Mental Illness: A Pragmatic Trial Protocol

Background: People experiencing homelessness and mental illness have poorer service engagement and health-related outcomes compared to the general population. Financial incentives have been associated with increased service engagement, but evidence of effectiveness is limited. This protocol evaluates the acceptability and impact of financial incentives on service engagement among adults experiencing homelessness and mental illness in Toronto, Canada. Methods: This study protocol uses a pragmatic field trial design and mixed methods (ClinicalTrials.gov Identifier: NCT03770221). Study participants were recruited from a brief multidisciplinary case management program for adults experiencing homelessness and mental illness following hospital discharge, and were randomly assigned to usual care or a financial incentives arm offering $20 for each week they attended meetings with a program provider. The primary outcome of effectiveness is service engagement, measured by the count of participant-provider health-care contacts over the 6-month period post-randomization. Secondary health, health service use, quality of life, and housing outcomes were measured at baseline and at 6-month follow-up. Quantitative data will be analyzed using descriptive statistics and inferential modeling including Poisson regression and generalized estimating equations. A subset of study participants and other key informants participated in interviews, and program staff in focus groups, to explore experiences with and perspectives regarding financial incentives. Qualitative data will be rigorously coded and thematically analyzed. Conclusions: Findings from this study will contribute high quality evidence to an underdeveloped literature base on the effectiveness and acceptability of financial incentives to improve service engagement and health-related outcomes among adults experiencing homelessness and mental illness.

A moneymaking scan: Dual reimbursement systems and supplier-induced demand for diagnostic imaging

In complex health systems with growing healthcare spending, combining reimbursement systems that incentivize cost-efficient healthcare provision within and across care sectors is key. This study investigates whether dual reimbursement systems lead hospitals to offset financial pressures in one care sector by inducing demand in another. We find that hospital imaging units induced demand for costly and unnecessary ambulatory imaging examinations reimbursed under fee-for-service, following a reform that introduced prospective payment and increased competition in the inpatient sector in Switzerland in 2012. Market structure, competitive pressures, and price regulations also influence demand inducement by varying the response to the reform. Reimbursement systems can influence supplier-induced demand in other care sectors within hospitals where revenue is tied to the intensity of care provision. In particular, the possibility to self-refer patients to high-margin diagnostic examinations bears negative consequences on healthcare expenditures and potentially patient health.

Stirring the pot: Switching from blended fee-for-service to blended capitation models of physician remuneration

In Canada's most populous province, Ontario, family physicians may choose between the blended fee-for-service (Family Health Group [FHG]) and blended capitation (Family Health Organization [FHO] payment models). Both models incentivize physicians to provide after-hours (AH) and comprehensive care, but FHO physicians receive a capitation payment per enrolled patient adjusted for age and sex, plus a reduced fee-for-service while FHG physicians are paid by fee-for-service. We develop a theoretical model of physician labor supply with multitasking to predict their behavior under FHG and FHO, and estimable equations are derived to test the predictions empirically. Using health administrative data from 2006 to 2014 and a two-stage estimation strategy, we study the impact of switching from FHG to FHO on the production of a capitated basket of services, after-hours services and nonincentivized services. Our results reveal that switching from the FHG to FHO reduces the production of capitated services to enrolled patients and services to nonenrolled patients by 15% and 5% per annum and increases the production of after-hours and nonincentivized services by 8% and 15% per annum.

Associations between Governmental Policies to Improve the Nutritional Quality of Supermarket Purchases and Individual, Retailer, and Community Health Outcomes: An Integrative Review

Supermarkets are natural and important settings for implementing environmental interventions to improve healthy eating, and governmental policies could help improve the nutritional quality of purchases in this setting. This review aimed to: (1) identify governmental policies in the United States (U.S.), including regulatory and legislative actions of federal, tribal, state, and local governments, designed to promote healthy choices in supermarkets; and (2) synthesize evidence of these policies' effects on retailers, consumers, and community health. We searched five policy databases and developed a list of seven policy actions that meet our inclusion criteria: calorie labeling of prepared foods in supermarkets; increasing U.S. Department of Agriculture (USDA) Supplemental Nutrition Assistance Program (SNAP) benefits; financial incentives for the purchase of fruit and vegetables; sweetened beverage taxes; revisions to the USDA Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package; financial assistance for supermarkets to open in underserved areas; and allowing online purchases with SNAP. We searched PubMed, Econlit, PsycINFO, Web of Science, and Business Source Ultimate to identify peer-reviewed, academic, English-language literature published at any time until January 2020; 147 studies were included in the review. Sweetened beverage taxes, revisions to the WIC food package, and financial incentives for fruits and vegetables were associated with improvements in dietary behaviors (food purchases and/or consumption). Providing financial incentives to supermarkets to open in underserved areas and increases in SNAP benefits were not associated with changes in food purchasing or diet quality but may improve food security. More research is needed to understand the effects of calorie labeling in supermarkets and online SNAP purchasing.

Pilot feasibility trial of dual contingency management for cigarette smoking cessation and weight maintenance among weight-concerned female smokers

Many women who smoke cigarettes report that concern about weight gain is a barrier to quitting. Indeed, most quitters gain weight and some attribute relapses to weight gain concern. Contingency management (CM), which refers to reinforcing a target behavior with financial incentives, has been demonstrated effective for promoting smoking abstinence and weight management independently. We conducted a pilot trial to establish the feasibility of dual CM, in which both smoking cessation and weight maintenance were incentivized, as a smoking cessation intervention for female weight-concerned smokers. Participants (N = 10) received a 12-week intervention during which they earned financial incentives for smoking abstinence, verified by breath carbon monoxide (CO) testing, and for maintaining their weight (larger incentives for gaining less than five pounds, smaller incentives for 5-10 pound gain) while abstaining from smoking. They attended an end of intervention visit at week 13 and a follow-up visit at week 26. Total compensation was up to $550 ($255 for participation independent of smoking and weight, $145 for smoking abstinence incentives, and $150 for weight maintenance incentives). Results indicated that five of the 10 participants (50%) were continuously abstinent for at least 4 weeks and received at least 2 weight maintenance incentives. Three participants (33%) were abstinent at every visit they attended from quit date through week 26; 2 of these 3 had gained more than 10 pounds by week 26. Additional formative research to test alternative incentive schedules and modalities should be conducted before CM-W is evaluated in a larger trial. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Tailored Medication Adherence Incentives Using mHealth for Children With High-Risk Asthma (TAICAM): Protocol for a Randomized Controlled Trial

Background

Poor adherence to inhaled corticosteroid medications for children with high-risk asthma is both well documented and poorly understood. It has a disproportionate prevalence and impact on children of minority demographics in urban settings. Financial incentives have been shown to be a compelling method to engage those in a high-risk asthma population, but whether adherence can be maintained by offering financial incentives and how these incentives can be used to sustain high adherence are unknown.

Objective

The aim of this study is to determine the marginal effects of a financial incentive–based intervention on inhaled corticosteroid adherence, health care system use, and costs.

Methods

Participants include children aged 5 to 12 years who have had either at least two hospitalizations or one hospitalization and one emergency department visit for asthma in the year prior to their enrollment (and their caregivers). Participants are given an electronic inhaler sensor in order to track their medication use over a period of 7 months. After a 1-month period of observation, participants are randomized to 1 of 3 arms for a 3-month period. Participants in arm 1 receive daily text message reminders, feedback, and gain–framed, nominal financial incentives; participants in arm 2 receive daily text message reminders and feedback only, and participants in arm 3 receive no reminders, feedback, or incentives. All participants are subsequently observed for an additional 3-month period with no reminders, feedback, or incentives to assess whether any sustained effects are apparent.

Results

Study enrollment began in September 2019 with a target sample size of N=125 children. As of June 2020, 61 children have been enrolled. Data collection is estimated to be completed in June 2022, and analyses will be completed by June 2023.

Conclusions

This study will provide data that will help to determine whether a financial incentive–based mobile health intervention for promoting inhaled corticosteroid use can be effective in patients with high-risk asthma over longer periods.

Trial Registration

Clinicaltrial.gov NCT03907410; https://clinicaltrials.gov/ct2/show/NCT03907410

International Registered Report Identifier (IRRID)

DERR1-10.2196/16711

Individual breastfeeding support with contingent incentives for low-income mothers in the USA: the 'BOOST (Breastfeeding Onset & Onward with Support Tools)' randomised controlled trial protocol

INTRODUCTION

National breastfeeding rates have improved in recent years, however, disparities exist by socioeconomic and psychosocial factors. Suboptimal breastfeeding overburdens the society by increasing healthcare costs. Existing breastfeeding supports including education and peer support have not been sufficient in sustaining breastfeeding rates especially among low-income women. The preliminary outcomes of contingent incentives for breastfeeding in addition to existing support show promising effects in sustaining breastfeeding among mothers in the Special Supplemental Nutrition Programme for women, infants and children (WIC).

METHODS AND ANALYSIS

This trial uses a parallel randomised controlled trial. This trial is conducted at two sites in separate states in the USA. Mothers who were enrolled in WIC and initiated breastfeeding are eligible. Participants (n=168) are randomised into one of the two study groups: (1) standard care control (SC) group consisting of WIC breastfeeding services plus home-based individual support or (2) SC plus breastfeeding incentives (SC +BFI) contingent on demonstrating successful breastfeeding. All participants receive standard breastfeeding services from WIC, home-based individual support and assessments. Participants in SC receive financial compensation based on the number of completed monthly home visits, paid in a lump sum at the end of the 6-month intervention period. Participants in SC +BFI receive an escalating magnitude of financial incentives contingent on observed breastfeeding, paid monthly during the intervention period, as well as bonus incentives for selecting full breastfeeding food packages at WIC. The primary hypothesis is that monthly incentives contingent on breastfeeding in SC +BFI will significantly increase rates of any breastfeeding compared with SC. The primary outcome is the rate of any breastfeeding over 12 months. Randomisation is completed in an automated electronic system. Staff conducting home visits for support and assessments are blinded to study groups.

ETHICS AND DISSEMINATION

The Advarra Institutional Review Board has approved the study protocol (Pro00033168). Findings will be disseminated to our participants, scientific communities, public health officials and any other interested community members.

TRIAL REGISTRATION NUMBER

NCT03964454.

A Secondary Data Analysis Examining Young Adults' Performance in an Internet Weight Loss Program with Financial Incentives

OBJECTIVE

In traditional behavioral weight loss (BWL) programs, young adults fare worse than older adults with respect to engagement, retention, and weight loss, but money and use of technology have been cited as program factors that might improve outcomes for this population. This study evaluated young adult performance in internet-based BWL (IBWL) offering financial incentives for self-monitoring and weight loss.

METHODS

Participants (N = 180; BMI = 33.2 ± 6.0 kg/m² ) were randomly assigned to a 12-week IBWL or IBWL + incentives (IBWL + $) group. This secondary data analysis compared young adults (ages 18-35) in IBWL (n = 16) with young adults in IBWL + $ (n = 12) on percent weight loss, engagement, and retention. Young adults (n = 28) were also compared with older adults (ages 36-70; n = 152) on these outcomes.

RESULTS

Young adult weight loss was -2.8% ± 5.2% in IBWL and -5.4% ± 5.7% in IBWL + $ (P = 0.23, partial η²  = 0.06). A greater proportion of young adults in IBWL + $ achieved a 10% weight loss compared with IBWL (42% vs. 6%, P = 0.02). Compared with older adults, young adults were less engaged, but there were no differences for retention or weight loss (P values > 0.05).

CONCLUSIONS

Findings suggest that technology-based BWL has the potential to eliminate weight loss disparities observed between young adults and older adults in in-person BWL trials. Moreover, adding financial incentives holds promise for promoting clinically meaningful weight loss for young adults.

Can financial rewards complement altruism to raise deceased organ donation rates?

BACKGROUND

Organ supply-demand in developing countries worldwide has continued to widen. Hence, using a large survey (n ¼ 10,412), this study seeks to investigate whether human psychology could be used to inculcate philanthropy to raise deceased organ donation rates.

METHODS

Three models were constructed to examine multidimensional relationships among the variables. Structural equation modeling was applied to estimate the direct and indirect influence of altruism, financial incentives, donation perception, and socioeconomic status simultaneously on willingness to donate deceased organs.

ETHICAL CONSIDERATIONS

The study was approved by the University of Malaya ethics committee.

RESULTS

The results show that altruism amplifies the impact of socioeconomic status and donation perception on willingness to donate. Also, the results show that financial incentives cannot complement altruism to raise organ donation rates. Hence, investing in education and public awareness enhances altruism in people, which then increases the propensity to donate.

CONCLUSION

Evidence suggests that governments should allocate resources to increase public awareness about organ donation. Awareness programs about the importance of philanthropic donations and the participation of medical consultants at hospitals in the processes form the foundation of such a presumptive approach.

Adolescent and parent perspectives on the acceptability of financial incentives to promote self-care in adolescents with type 1 diabetes

BACKGROUND

An understanding of acceptability among potential intervention participants is critical to the design of successful real-world financial incentive (FI) programs. The purpose of this qualitative study was to explore adolescent and parent perspectives on the acceptability of using FI to promote engagement in diabetes self-care in adolescents with type 1 diabetes (T1D).

METHODS

Focus groups with 46 adolescents with T1D (12-17 years old) and 39 parents of adolescents with T1D were conducted in the Seattle metropolitan area. Semistructured questions addressed participants' current use of incentives to promote change in diabetes self-care and receptivity to a theoretical incentive program administered by a third-party. Qualitative data were analyzed and emergent themes identified.

RESULTS

Three thematic categories informed participant views about the acceptability of FI programs: (a) the extent to which using FIs in the context of diabetes management fit comfortably into a family's value system, (b) the perceived effectiveness for FIs to promote improved diabetes self-care, and (c) the urgent need for improved self-care due to the threat of diabetes-related health complications. These factors together led most parents and adolescents to be open to FI program participation.

CONCLUSIONS

The results from this qualitative study suggest that well-designed FI programs to support diabetes management are acceptable to families with adolescents with T1D. Additionally, the use of FIs may have the potential to support adolescents with T1D in developing strong self-care habits and ease the often-turbulent transition to independent self-care.

Cost-effectiveness and cost-utility analysis of a work-place smoking cessation intervention with and without financial incentives

AIMS

To perform an economic evaluation of a work-place smoking cessation group training programme with incentives compared with a training programme without incentives.

DESIGN

A trial-based cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) from a societal perspective and an employer's perspective.

SETTING

Sixty-one companies in the Netherlands.

PARTICIPANTS

A total of 604 tobacco-smoking employees.

INTERVENTION AND COMPARATOR

A 7-week work-place smoking cessation group training programme. The intervention group earned gift vouchers of €350 for 12 months' continuous abstinence. The comparator group received no incentives.

MEASUREMENTS

Online questionnaires were administered to assess quality of life (EQ-5D-5 L) and resource use during the 14-month follow-up period (2-month training period plus 12-month abstinence period). For the CEA the primary outcome measure was carbon monoxide (CO)-validated continuous abstinence; for the CUA the primary outcome was quality-adjusted life years (QALY). Bootstrapping and sensitivity analyses were performed to account for uncertainty. Incremental cost-effectiveness ratio (ICER) tables were used to determine cost-effectiveness from a life-time perspective.

FINDINGS

Of the participants in the intervention group, 41.1% had quit smoking compared with 26.4% in the control group. From a societal perspective with a 14-month follow-up period, the ICER per quitter for an intervention with financial incentives compared with no incentives was €11 546. From an employer's perspective, the ICER was €5686. There was no significant difference in QALYs between the intervention and control group within the 14-month follow-up period. The intervention was dominated by the comparator in the primary analysis at a threshold of €20 000 per QALY. In the sensitivity analysis, these results were uncertain. A life-time perspective showed an ICER of €1249 (95% confidence interval = €850-2387) per QALY.

CONCLUSIONS

Financial incentives may be cost-effective in increasing quitting smoking, particularly from a life-time perspective.

Reducing Tobacco Smoke Exposure in High-Risk Infants: A Randomized, Controlled Trial

OBJECTIVE

To evaluate a hospital-initiated intervention to reduce tobacco smoke exposure in infants in the neonatal intensive care unit.

STUDY DESIGN

A randomized, controlled trial compared motivational interviewing plus financial incentives with conventional care on infant urine cotinine at 1 and 4 months' follow-up. Mothers of infants in the neonatal intensive care unit (N = 360) who reported a smoker living in the home were enrolled. Motivational interviewing sessions were delivered in both the hospital and the home. Financial incentives followed session attendance and negative infant cotinine tests postdischarge.

RESULTS

The intervention effect on infant cotinine was not significant, except among mothers who reported high baseline readiness/ability to protect their infant (P ≤ .01) and mothers who completed the study within 6 months postdischarge (per protocol; P ≤ .05). Fewer mothers in the motivational interviewing plus financial incentives condition were smoking postdischarge (P ≤ .01). More mothers in the motivational interviewing plus financial incentives group reported a total home and car smoking ban at follow-up (P ≤ .05).

CONCLUSIONS

Motivational interviewing combined with financial incentives reduced infant tobacco smoke exposure in a subset of women who were ready/able to protect their infant. The intervention also resulted in less maternal smoking postpartum. More robust interventions that include maternal and partner/household smoking cessation are likely needed to reduce the costly effects of tobacco smoke exposure on children and their families.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01726062.

Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time-series analysis

AIM

To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care.

DESIGN

Interrupted time-series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006-31 March 2008); (2) during the implementation of financial incentives (1 April 2008-31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015-31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points.

SETTING

England.

PARTICIPANTS

Newly registered patients (16+) in 500 primary care practices for 2006-16 (n = 4 278 723).

MEASUREMENTS

The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher-risk drinking; and (3) were reported as having received brief advice on alcohol consumption.

FINDINGS

There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21-3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87-14.23) per 1000 patients screening positive for higher-risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen-positive rates of 29.96 (95% CI = 19.56-40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51-2.77) per 1000. Screen-positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30-28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26-0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97-24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28-1.12) per 1000 per month.

CONCLUSIONS

Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme.

Delay Discount Rate Moderates a Physical Activity Intervention Testing Immediate Rewards

Financial incentives can increase physical activity (PA), but differences in the immediacy of reward delivery and individual differences in delay discount rates (i.e., higher discount values associated with less tolerance for delayed rewards) may explain differential responding. The current study tested whether delay discount rate moderated the relative effectiveness of immediate financial rewards on increasing daily PA. Inactive, overweight adults (ages 18-60, N = 96) were randomized to receive either smaller, immediate goal-contingent rewards or larger, delayed rewards for participation. Delay discount rates were derived for those who completed the Monetary Choice Questionnaire (N = 85). Linear mixed models tested interactions between discount rate and intervention arm on changes in mean daily Fitbit-measured steps from baseline to intervention phases, and rates of change during the intervention phase. Across all groups, participants increased by 2258 steps/day on average from baseline to intervention and declined by 9 steps/day across the 4-month intervention phase. The mean increase in daily steps was greater for immediate reward-arm participants across all discount rates. Descriptive exploration of reward effects by delay discount rate suggested that the magnitude of reward effects decreased at higher discount rates. During the 4-month intervention phase, rates of decline in daily steps were similar in both reward arms, but declines became more pronounced at higher discount rates. Overall, intervention efficacy decreased with less tolerance for delays. The importance of financial reward immediacy for increasing PA appears to increase with greater delay discount rates.

Support and unmet needs of patients undergoing multidrug-resistant tuberculosis (MDR-TB) treatment in southern Nigeria

Multidrug-resistant tuberculosis (MDR-TB) is presently a major public health threat. MDR-TB patients face diverse financial and psychosocial difficulties. Researchers conducted in-depth interviews based on interview guides with 42 participants. Data were analyzed using categorization, coding, generation of themes, and thematic memo writing. The key findings were as follows: Out of the 42 patients, 30 (71.4%) were males and 12 (28.6%) were females. All patients received financial stipends for transport and monthly social support. The patients however needed more financial support than they received (suggesting high unmet financial needs). Patients suffered depressive mood before and during treatment but received inadequate mental health/psychosocial care and treatment. Patients developed hearing impairment as a major adverse drug reaction, but the care and treatment they received were inadequate. In conclusion, the programmatic support provided for MDR-TB patients' financial and mental health/psychosocial needs and auditory drug side effects fell short of their need. Programmes for control of MDR-TB should increase budgetary allocations and ramp up mechanisms for provision of mental health/psychosocial support and care/treatment for drug side effects.

Implementation of Financial Incentives for Successful Smoking Cessation in Real-Life Company Settings: A Qualitative Needs Assessment among Employers

Randomized studies have shown that financial incentives can significantly increase the effect of smoking cessation treatment in company settings. Evidence of effectiveness alone is, however, not enough to ensure that companies will offer this intervention. Knowledge about the barriers and facilitators for implementation in the workplace is needed, in order to develop an implementation strategy. We performed a qualitative needs assessment among 18 employers working in companies with relatively many employees with a low educational level, and our study revealed priority actions that aim to improve the implementation process in these types of workplaces. First, employers need training and support in how to reach their employees and convince them to take part in the group training. Second, employers need to be convinced that their non-smoking employees will not consider the incentives unfair, or they should be enabled to offer alternative incentives that are considered less unfair. Third, the cost-effectiveness of smoking cessation group trainings including financial incentives should be explained to employers. Finally, smoking cessation should become a standard part of workplace-based health policies.

Physician practices in Accountable Care Organizations are more likely to collect and use physician performance information, yet base only a small proportion of compensation on performance data

IMPORTANCE

It is critical to develop a better understanding of the strategies provider organizations use to improve the performance of frontline clinicians and whether ACO participation is associated with differential adoption of these tools.

OBJECTIVES

Characterize the strategies that physician practices use to improve clinician performance and determine their association with ACOs and other payment reforms.

DATA SOURCES

The National Survey of Healthcare Organizations and the National Survey of ACOs fielded 2017-2018 (response rates = 47 percent and 48 percent).

STUDY DESIGN

Descriptive analysis for practices participating and not participating in ACOs among 2190 physician practice respondents. Linear regressions to examine characteristics associated with counts of performance domains for which a practice used data for feedback, quality improvement, or physician compensation as dependent variables. Logistic and fractional regression to examine characteristics associated with use of peer comparison and shares of primary care and specialist compensation accounted for by performance bonuses, respectively.

PRINCIPAL FINDINGS

ACO-affiliated practices feed back clinician-level information and use it for quality improvement and compensation on more performance domains than non-ACO-affiliated practices. Performance measures contribute little to physician compensation irrespective of ACO participation.

CONCLUSION

ACO-affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.

Production of physician services under fee-for-service and blended fee-for-service: Evidence from Ontario, Canada

We examine family physicians' responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003-2008, a period during which family physicians could choose between the traditional fee for service (FFS) and blended FFS known as the Family Health Group (FHG) model. Under FHG, FFS physicians are incentivized to provide comprehensive care and after-hours services. A two-stage estimation strategy teases out the impact of switching from FFS to FHG on service production. We account for the selection into FHG using a propensity score matching model, and then we use panel-data regression models to account for observed and unobserved heterogeneity. Our results reveal that switching from FFS to FHG increases comprehensive care, after-hours, and nonincentivized services by 3%, 15%, and 4% per annum. We also find that blended FFS physicians provide more services by working additional total days as well as the number of days during holidays and weekends. Our results are robust to a variety of specifications and alternative matching methods. We conclude that switching from FFS to blended FFS improves patients' access to after-hours care, but the incentive to nudge service production at the intensive margin is somewhat limited.

Mobile telephone-delivered contingency management interventions promoting behaviour change in individuals with substance use disorders: a meta-analysis

BACKGROUND/AIMS

Contingency management (CM) interventions have gained considerable interest due to their success in the treatment of addiction. However, their implementation can be resource-intensive for clinical staff. Mobile telephone-based systems might offer a low-cost alternative. This approach could facilitate remote monitoring of behaviour and delivery of the reinforcer and minimize issues of staffing and resources. This systematic review and meta-analysis assessed the evidence for the effectiveness of mobile telephone-delivered CM interventions to promote abstinence (from drugs, alcohol and tobacco), medication adherence and treatment engagement among individuals with substance use disorders.

DESIGN

A systematic search of databases (PsychINFO, CINAHL, MEDLINE PubMed, CENTRAL, Embase) for randomized controlled trials and within-subject design studies (1995-2019). The review was conducted in accordance with the PRISMA statement. The protocol was registered on PROSPERO.

SETTING

All included studies originated in the United states.

PARTICIPANTS

Seven studies were found, including 222 participants; two targeted alcohol abstinence among frequent drinkers and four targeted smoking cessation (in homeless veterans and those with post-traumatic stress disorder). One targeted medication adherence.

MEASURES

The efficacy of CM to increase alcohol and nicotine abstinence was compared with control using several outcomes; percentage of negative samples (PNS), quit rate (QR) and longest duration abstinent (LDA) at the end of the intervention.

FINDINGS

The random-effects meta-analyses produced pooled effect sizes of; PNS [d = 0.94, 95% confidence interval (CI) = 0.63-1.25], LDA (d = 1.08, 95% CI = 0.69-1.46) and QR (d = 0.46, 95% CI = 0.27-0.66), demonstrating better outcomes across the CM conditions. Most of the studies were rated as of moderate quality. 'Fail-safe N' computations for PNS indicated that 50 studies would be needed to produce a non-significant overall effect size. None could be calculated for QR and LDA due to insufficient number of studies.

CONCLUSION

Mobile telephone-delivered contingency management performs significantly better than control conditions in reducing tobacco and alcohol use among adults not in treatment for substance use disorders.

The Association of Peer Smoking Behavior and Social Support with Quit Success in Employees Who Participated in a Smoking Cessation Intervention at the Workplace

The current study investigated whether quit success among employees who participated in a smoking cessation intervention at the workplace was associated with social support from, and the smoking behavior of, people in their environment. Tobacco-smoking employees (n = 604) from 61 companies participated in a workplace group smoking cessation program. Participants completed questionnaires assessing social support from, and the smoking behavior of, people in their social environment. They were also tested for biochemically validated continuous abstinence directly after finishing the training and after 12 months. The data were analyzed using mixed-effects logistic regression analyses. Social support from colleagues was positively associated with 12-month quit success (odds ratio (OR) = 1.85, 95% confidence interval (CI) = 1.14-3.00, p = 0.013). Support from a partner was positively associated with short-term quit success (OR = 2.01, 95% CI = 1.23-3.30, p = 0.006). Having a higher proportion of smokers in the social environment was negatively associated with long-term abstinence (OR = 0.81, 95% CI = 0.71-0.92, p = 0.002). Compared to having a non-smoking partner, long-term quit success was negatively associated with having no partner (OR = 0.48, 95% CI = 0.26-0.88, p < 0.019), with having a partner who smokes (OR = 0.40, 95% CI = 0.24-0.66, p < 0.001), and with having a partner who used to smoke (OR = 0.47, 95% CI = 0.26-0.86, p = 0.014). In conclusion, people in a smoker's social environment, particularly colleagues, were strongly associated with quit success. The workplace may, therefore, be a favorable setting for smoking cessation interventions.

The price of a woman: Re-examining the use of financial incentives for women's health in India

The use of financial incentives is a common instrument to advance women's health across low and middle-income countries. Since the 1990s, the conditional cash transfer (CCT) for health has been generally lauded by researchers, policy makers and international financial institutions due to demonstrated improvements in access to health services and a range of health outcomes. Some scholars, however, have cautioned that CCTs should be further scrutinised to assess potential unintended consequences and moral concerns in a variety of contexts. In this article, I re-examine Janani Suraksha Yojana (JSY), a cash incentive programme that aims to promote institutional deliveries in order to reduce high levels of home deliveries and maternal deaths in India. I adopt a critical perspective, focusing on the specific instrument of dowry through the lens of capitalist patriarchy (Mies, M. (1986). Patriarchy and accumulation on a world scale. London: Zed Books). Global and national health policy experts and policy makers require a greater awareness of the dowry system, since this system may hamper the use of financial incentives by reinforcing the commodification of women.