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Shea JA, Silber JH, Desai SV, Dinges DF, Bellini LM, Tonascia J, Sternberg AL, Small DS, Shade DM, Katz JT, Basner M, Chaiyachati KH, Even-Shoshan O, Bates DW, Volpp KG, Asch DA. Development of the individualised Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial: a protocol summary of a national cluster-randomised trial of resident duty hour policies in internal medicine. BMJ Open 2018; 8:e021711. [PMID: 30244209 PMCID: PMC6157525 DOI: 10.1136/bmjopen-2018-021711] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Medical trainees' duty hours have received attention globally; restrictions in Europe, New Zealand and some Canadian provinces are much lower than the 80 hours per week enforced in USA. In USA, resident duty hours have been implemented without evidence simultaneously reflecting competing concerns about patient safety and physician education. The objective is to prospectively evaluate the implications of alternative resident duty hour rules for patient safety, trainee education and intern sleep and alertness. METHODS AND ANALYSIS 63 US internal medicine training programmes were randomly assigned 1:1 to the 2011 Accreditation Council for Graduate Medical Education resident duty hour rules or to rules more flexible in intern shift length and number of hours off between shifts for academic year 2015-2016. The primary outcome is calculated for each programme as the difference in 30-day mortality rate among Medicare beneficiaries with any of several prespecified principal diagnoses in the intervention year minus 30-day mortality in the preintervention year among Medicare beneficiaries with any of several prespecified principal diagnoses. Additional safety outcomes include readmission rates, prolonged length of stay and costs. Measures derived from trainees' and faculty responses to surveys and from time-motion studies of interns compare the educational experiences of residents. Measures derived from wrist actigraphy, subjective ratings and psychomotor vigilance testing compare the sleep and alertness of interns. Differences between duty hour groups in outcomes will be assessed by intention-to-treat analyses. ETHICS AND DISSEMINATION The University of Pennsylvania Institutional Review Board (IRB) approved the protocol and served as the IRB of record for 40 programmes that agreed to sign an Institutional Affiliation Agreement. Twenty-three programmes opted for a local review process. TRIAL REGISTRATION NUMBER NCT02274818; Pre-results.
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Mehta SJ, Troxel AB, Marcus N, Jameson C, Taylor D, Asch DA, Volpp KG. Participation Rates With Opt-out Enrollment in a Remote Monitoring Intervention for Patients With Myocardial Infarction. JAMA Cardiol 2018; 1:847-848. [PMID: 27603755 DOI: 10.1001/jamacardio.2016.2374] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Pandya A, Asch DA, Volpp KG, Sy S, Troxel AB, Zhu J, Weinstein MC, Rosenthal MB, Gaziano TA. Cost-effectiveness of Financial Incentives for Patients and Physicians to Manage Low-Density Lipoprotein Cholesterol Levels. JAMA Netw Open 2018; 1:e182008. [PMID: 30646152 PMCID: PMC6324619 DOI: 10.1001/jamanetworkopen.2018.2008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Financial incentives shared between physicians and patients were shown to significantly reduce low-density lipoprotein cholesterol (LDL-C) levels in a randomized clinical trial, but it is not known whether these health benefits are worth the added incentive and utilization costs required to achieve them. OBJECTIVE To evaluate the long-term cost-effectiveness of financial incentives on LDL-C level control. DESIGN, SETTING, AND PARTICIPANTS In this economic evaluation, a previously validated microsimulation computer model was parameterized using individual-level data from the randomized clinical trial on financial incentives, National Health and Nutrition Examination Surveys for model population inputs, and other published sources. The study was conducted from April 15, 2016, to March 29, 2018. INTERVENTIONS The following interventions were used: (1) usual care, (2) trial control strategy (increased cholesterol level monitoring and use of electronic pill bottles), (3) financial incentives for physicians, (4) financial incentives for patients, and (5) incentives shared between physicians and patients. MAIN OUTCOMES AND MEASURES Discounted costs (2017 US dollars), lifetime cardiovascular disease risk, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS The model population (n = 1 000 000 [30.7% women]) had similar mean (SD) age (61.5 [11.9] years) and LDL-C level (153.9 mg/dL) as the observed trial population (n = 1503 [42.7% women]; age, 62.0 [8.7] years; and LDL-C level, 160.6 mg/dL). Using base-case assumptions (including a 10-year waning period of LDL-C level reductions), the usual-care strategy was dominated (higher costs and lower QALYs) by all other strategies. Strategies for physician- or patient-only incentives were dominated by the shared-incentives strategy, which had an ICER of $60 000/QALY compared with the trial control strategy. In a sensitivity analysis regarding the duration of LDL-C level reductions, the shared-incentives strategy remained cost-effective (ICERs <$100 000/QALY and <$150 000/QALY) for scenarios with LDL-C level reductions lasting, with linear waning, at least 7 and 5 years, respectively. In the 1-way sensitivity analysis for the time horizon of the analysis, the ICER of the shared-incentives strategy exceeded $100 000/QALY at 11 years and $150 000/QALY at 8 years. In probabilistic sensitivity analysis, the shared-incentives intervention was cost-effective in 69% to 77% of iterations using cost-effectiveness thresholds of $100 000 to $150 000/QALY. Cost-effectiveness results were also sensitive to the duration of intervention costs. CONCLUSIONS AND RELEVANCE This study suggests that the financial incentives shared between patients and physicians for LDL-C level control meet conventional standards of cost-effectiveness, but these results appeared to be sensitive to assumptions about the durations of LDL-C level reductions and years of intervention costs included, as well as to the choice of time horizon.
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VanEpps EM, Troxel AB, Villamil E, Saulsgiver KA, Zhu J, Chin JY, Matson J, Anarella J, Roohan P, Gesten F, Volpp KG. Effect of Process- and Outcome-Based Financial Incentives on Weight Loss Among Prediabetic New York Medicaid Patients: A Randomized Clinical Trial. Am J Health Promot 2018; 33:372-380. [PMID: 30021451 DOI: 10.1177/0890117118783594] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To determine whether different financial incentives are effective in promoting weight loss among prediabetic Medicaid recipients. DESIGN Four-group, multicenter, randomized clinical trial. SETTING AND PARTICIPANTS Medicaid managed care enrollees residing in New York, aged 18 to 64 years, and diagnosed as prediabetic or high risk for diabetes (N = 703). INTERVENTION In a 16-week program, participants were randomly assigned to one of 4 arms: (1) control (no incentives), (2) process incentives for attending weekly Diabetes Prevention Program sessions, (3) outcome incentives for achieving weekly weight loss goals, and (4) combined process and outcome incentives. MEASURES Weight loss over a 16-week period; proportion who completed educational sessions; proportion who met weight loss goals. ANALYSIS AND RESULTS No intervention arm achieved greater reduction in weight than control (outcome incentive -6.6 lb [-9.1 to -4.1 lb], process incentive -7.3 lb [-9.5 to -5.1 lb], combined incentive -5.8 lb [-8.8 to -2.8 lb], control -7.9 lb [-11.1 to -4.7 lb]; all P > .29). Session attendance in the process incentive arm (50%) was significantly higher than control (31%; P < .0001) and combined incentive arms (28%; P < .0001), but not significantly higher than the outcome incentive arm (38%). CONCLUSION Process incentives increased session attendance, but when combined at half strength with outcome incentives did not achieve that effect. There were no significant effects of either process or outcomes incentives on weight loss.
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Patel MS, Kurtzman GW, Kannan S, Small DS, Morris A, Honeywell S, Leri D, Rareshide CAL, Day SC, Mahoney KB, Volpp KG, Asch DA. Effect of an Automated Patient Dashboard Using Active Choice and Peer Comparison Performance Feedback to Physicians on Statin Prescribing: The PRESCRIBE Cluster Randomized Clinical Trial. JAMA Netw Open 2018; 1:e180818. [PMID: 30646039 PMCID: PMC6324300 DOI: 10.1001/jamanetworkopen.2018.0818] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Statins are not prescribed to approximately 50% of patients who could benefit from them. OBJECTIVE To evaluate the effectiveness of an automated patient dashboard using active choice framing with and without peer comparison feedback on performance to nudge primary care physicians (PCPs) to increase guideline-concordant statin prescribing. DESIGN, SETTING, AND PARTICIPANTS This 3-arm cluster randomized clinical trial was conducted from February 21, 2017, to April 21, 2017, at 32 practice sites in Pennsylvania and New Jersey. Participants included 96 PCPs and 4774 patients not previously receiving statin therapy. Data were analyzed from April 25, 2017, to June 16, 2017. INTERVENTIONS Primary care physicians in the 2 intervention arms were emailed a link to an automated online dashboard listing their patients who met national guidelines for statin therapy but had not been prescribed this medication. The dashboard included relevant patient information, and for each patient, PCPs were asked to make an active choice to prescribe atorvastatin, 20 mg, once daily, atorvastatin at another dose, or another statin or not prescribe a statin and select a reason. The dashboard was available for 2 months. In 1 intervention arm, the email to PCPs also included feedback on their statin prescribing rate compared with their peers. Primary care physicians in the usual care group received no interventions. MAIN OUTCOMES AND MEASURES Statin prescription rates. RESULTS Patients had a mean (SD) age of 62.4 (8.3) years and a mean (SD) 10-year atherosclerotic cardiovascular disease risk score of 13.6 (8.2); 2625 (55.0%) were male, 3040 (63.7%) were white, and 1318 (27.6%) were black. In the active choice arm, 16 of 32 PCPs (50.0%) accessed the patient dashboard, but only 2 of 32 (6.3%) signed statin prescription orders. In the active choice with peer comparison arm, 12 of 32 PCPs (37.5%) accessed the patient dashboard and 8 of 32 (25.0%) signed statin prescription orders. Statins were prescribed in 40 of 1566 patients (2.6%) in the usual care arm, 116 of 1743 (6.7%) in the active choice arm, and 117 of 1465 (8.0%) in the active choice with peer comparison arm. In the main adjusted model, compared with usual care, there was a significant increase in statin prescribing in the active choice with peer comparison arm (adjusted difference in percentage points, 5.8; 95% CI, 0.9-13.5; P = .008), but not in the active choice arm (adjusted difference in percentage points, 4.1; 95% CI, -0.8 to 13.1; P = .11). CONCLUSIONS AND RELEVANCE An automated patient dashboard using both active choice framing and peer comparison feedback led to a modest but significant increase in guideline-concordant statin prescribing rates. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03021759.
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Halpern SD, Harhay MO, Saulsgiver K, Brophy C, Troxel AB, Volpp KG. A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation. N Engl J Med 2018; 378:2302-2310. [PMID: 29791259 DOI: 10.1056/nejmsa1715757] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether financial incentives, pharmacologic therapies, and electronic cigarettes (e-cigarettes) promote smoking cessation among unselected smokers is unknown. METHODS We randomly assigned smokers employed by 54 companies to one of four smoking-cessation interventions or to usual care. Usual care consisted of access to information regarding the benefits of smoking cessation and to a motivational text-messaging service. The four interventions consisted of usual care plus one of the following: free cessation aids (nicotine-replacement therapy or pharmacotherapy, with e-cigarettes if standard therapies failed); free e-cigarettes, without a requirement that standard therapies had been tried; free cessation aids plus $600 in rewards for sustained abstinence; or free cessation aids plus $600 in redeemable funds, deposited in a separate account for each participant, with money removed from the account if cessation milestones were not met. The primary outcome was sustained smoking abstinence for 6 months after the target quit date. RESULTS Among 6131 smokers who were invited to enroll, 125 opted out and 6006 underwent randomization. Sustained abstinence rates through 6 months were 0.1% in the usual-care group, 0.5% in the free cessation aids group, 1.0% in the free e-cigarettes group, 2.0% in the rewards group, and 2.9% in the redeemable deposit group. With respect to sustained abstinence rates, redeemable deposits and rewards were superior to free cessation aids (P<0.001 and P=0.006, respectively, with significance levels adjusted for multiple comparisons). Redeemable deposits were superior to free e-cigarettes (P=0.008). Free e-cigarettes were not superior to usual care (P=0.20) or to free cessation aids (P=0.43). Among the 1191 employees (19.8%) who actively participated in the trial (the "engaged" cohort), sustained abstinence rates were four to six times as high as those among participants who did not actively engage in the trial, with similar relative effectiveness. CONCLUSIONS In this pragmatic trial of smoking cessation, financial incentives added to free cessation aids resulted in a higher rate of sustained smoking abstinence than free cessation aids alone. Among smokers who received usual care (information and motivational text messages), the addition of free cessation aids or e-cigarettes did not provide a benefit. (Funded by the Vitality Institute; ClinicalTrials.gov number, NCT02328794 .).
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Desai SV, Asch DA, Bellini LM, Chaiyachati KH, Liu M, Sternberg AL, Tonascia J, Yeager AM, Asch JM, Katz JT, Basner M, Bates DW, Bilimoria KY, Dinges DF, Even-Shoshan O, Shade DM, Silber JH, Small DS, Volpp KG, Shea JA. Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine. N Engl J Med 2018; 378:1494-1508. [PMID: 29557719 PMCID: PMC6101652 DOI: 10.1056/nejmoa1800965] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians. METHODS We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores. RESULTS There were no significant between-group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees' perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees' workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in-training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, -0.43; 95% CI, -2.38 to 1.52; P=0.06 for noninferiority). od Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818 .). CONCLUSIONS There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blo
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Patel MS, Volpp KG, Rosin R, Bellamy SL, Small DS, Heuer J, Sproat S, Hyson C, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Asch DA. A Randomized, Controlled Trial of Lottery-Based Financial Incentives to Increase Physical Activity Among Overweight and Obese Adults. Am J Health Promot 2018. [PMID: 29534597 DOI: 10.1177/0890117118758932] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the effect of lottery-based financial incentives in increasing physical activity. DESIGN Randomized, controlled trial. SETTING University of Pennsylvania Employees. PARTICIPANTS A total of 209 adults with body mass index ≥27. INTERVENTIONS All participants used smartphones to track activity, were given a goal of 7000 steps per day, and received daily feedback on performance for 26 weeks. Participants randomly assigned to 1 of the 3 intervention arms received a financial incentive for 13 weeks and then were followed for 13 weeks without incentives. Daily lottery incentives were designed as a "higher frequency, smaller reward" (1 in 4 chance of winning $5), "jackpot" (1 in 400 chance of winning $500), or "combined lottery" (18% chance of $5 and 1% chance of $50). MEASURES Mean proportion of participant days step goals were achieved. ANALYSIS Multivariate regression. RESULTS During the intervention, the unadjusted mean proportion of participant days that goal was achieved was 0.26 in the control arm, 0.32 in the higher frequency, smaller reward lottery arm, 0.29 in the jackpot arm, and 0.38 in the combined lottery arm. In adjusted models, only the combined lottery arm was significantly greater than control ( P = .01). The jackpot arm had a significant decline of 0.13 ( P < .001) compared to control. There were no significant differences during follow-up. CONCLUSIONS Combined lottery incentives were most effective in increasing physical activity.
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Song Z, Navathe AS, Emanuel EJ, Volpp KG. Incorporating value into physician payment and patient cost sharing. THE AMERICAN JOURNAL OF MANAGED CARE 2018; 24:126-128. [PMID: 29553274 PMCID: PMC6039972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The United States is simultaneously moving toward value-based payments for populations and precision medicine for individuals. During this evolution, innovations in payment and delivery that enhance tailoring of treatments to individuals while improving the value of care are needed. We propose one such innovation that would allow physician payment and patient cost sharing to better reflect the value of care by allowing the appropriateness of a service for a given patient in a given clinical situation to play a more meaningful role in the design of such incentives. We introduce the idea of a payment modifier, based on indication and appropriateness, and discuss its advantages and challenges to implementation.
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VanEpps EM, Troxel AB, Villamil E, Saulsgiver KA, Zhu J, Chin JY, Matson J, Anarella J, Roohan P, Gesten F, Volpp KG. Financial Incentives for Chronic Disease Management: Results and Limitations of 2 Randomized Clinical Trials With New York Medicaid Patients. Am J Health Promot 2018; 32:1537-1543. [PMID: 29390862 DOI: 10.1177/0890117117753986] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To identify whether financial incentives promote improved disease management in Medicaid recipients diagnosed with hypertension or diabetes, respectively. DESIGN Four-group, multicenter, randomized clinical trials. SETTING AND PARTICIPANTS Between 2013 and 2016, New York State Medicaid managed care members diagnosed with hypertension (N = 920) or with diabetes (N = 959). INTERVENTION Participants in each 6-month trial were randomly assigned to 1 of 4 arms: (1) process incentives-earned by attending primary care visits and/or receiving prescription medication refills, (2) outcome incentives-earned by reducing systolic blood pressure (hypertension) or hemoglobin A1c (HbA1c; diabetes) levels, (3) combined process and outcome incentives, and (4) control (no incentives). MEASURES Systolic blood pressure (hypertension) and HbA1c (diabetes) levels, primary care visits, and medication prescription refills. Analysis and Results: At 6 months, there were no statistically significant differences between intervention arms and the control arm in the change in systolic blood pressure, P = .531. Similarly, there were no significant differences in blood glucose control (HbA1c) between the intervention arms and control after 6 months, P = .939. The majority of participants had acceptable systolic blood pressure (<140 mm Hg) or blood glucose (<8.0%) levels at baseline and throughout the study. CONCLUSION Financial incentives-regardless of whether they were delivered based on disease-relevant outcomes, process activities, or a combination of the two-have a negligible impact on health outcomes for Medicaid recipients diagnosed with either hypertension or diabetes in 2 studies in which, among other design and operational limitations, the majority of recipients had relatively well-controlled diseases at the time of enrollment.
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Cotton P, Newhouse JP, Volpp KG, Fendrick AM, Oesterle SL, Oungpasuk P, Aggarwal R, Wilensky G, Sebelius K. Medicare Advantage: Issues, Insights, and Implications for the Future. Popul Health Manag 2017; 19:S1-S8. [PMID: 27834576 PMCID: PMC5107672 DOI: 10.1089/pop.2016.29013.pc] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Medicare Advantage: Issues, Insights, and Implications for the Future Paul Cotton, Joseph P. Newhouse, PhD, Kevin G. Volpp, MD, PhD, A. Mark Fendrick, MD, Susan Lynne Oesterle, Pat Oungpasuk, Ruchi Aggarwal, Gail Wilensky, PhD, and Kathleen Sebelius Editorial S-2 D.B. Nash, and A.Y. Schwartz The History, Impact, and Future of the Medicare Advantage Star Ratings System S-3 P. Cotton Medicare Advantage and Traditional Fee-For-Service Medicare S-4 J.P. Newhouse Behavioral Economics: Key to Effective Care Management Programs for Patients, Payers, and Providers S-5 K.G. Volpp Value-Based Insurance Design: A Promising Strategy for Medicare Advantage S-6 A.M. Fendrick, S.L. Oesterle, P. Oungpasuk, and R. Aggarwal Two Perspectives on the Future of Medicare Advantage S-7 G. Wilensky and K. Sebelius
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Terwiesch C, Asch DA, Volpp KG. Technology and Medicine: Reimagining Provider Visits as the New Tertiary Care. Ann Intern Med 2017; 167:814-815. [PMID: 29059692 DOI: 10.7326/m17-0597] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Rosenthal MB, Troxel AB, Volpp KG, Stewart WF, Sequist TD, Jones JB, Hirsch AG, Hoffer K, Zhu J, Wang W, Hodlofski A, Finnerty D, Huang JJ, Asch DA. Moderating Effects of Patient Characteristics on the Impact of Financial Incentives. Med Care Res Rev 2017; 76:56-72. [PMID: 29148344 DOI: 10.1177/1077558717707313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
While financial incentives to providers or patients are increasingly common as a quality improvement strategy, their impact on patient subgroups and health care disparities is unclear. To examine these patterns, we analyzed data from a randomized clinical trial of financial incentives to lower low-density lipoprotein (LDL) cholesterol levels in patients at risk for cardiovascular disease. Patients with higher baseline LDL experienced greater cholesterol reductions in the shared incentive arm (0.23 mg/dL per unit change in baseline LDL, 95% CI [-0.46, -0.00]) but were also less likely to have medication potency increases in the physician incentive arm ( OR = 0.98, 95% CI [0.97, 0.996]). Uninsured patients and those of race other than Black or White were less likely to have potency increases in the shared incentive arm ( OR = 0.15, 95% CI [0.03, 0.70] and OR = 0.09, 95% CI [0.01, 0.93], respectively). These findings suggest some differential response to incentives, particularly in the form of targeted medication changes.
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Mehta SJ, Feingold J, Vandertuyn M, Niewood T, Cox C, Doubeni CA, Volpp KG, Asch DA. Active Choice and Financial Incentives to Increase Rates of Screening Colonoscopy-A Randomized Controlled Trial. Gastroenterology 2017; 153:1227-1229.e2. [PMID: 28734830 PMCID: PMC5669820 DOI: 10.1053/j.gastro.2017.07.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 12/02/2022]
Abstract
Behavioral economic approaches could increase uptake for colorectal cancer screening. We performed a randomized controlled trial of 2245 employees to determine whether an email containing a phone number for scheduling (control), an email with the active choice to opt in or opt out (active choice), or the active choice email plus a $100 incentive (financial incentive) increased colonoscopy completion within 3 months. Higher proportions of participants in the financial incentive group underwent screening (3.7%) than in the control (1.6%) or active choice groups (1.5%) (P = .01 and P < .01). We found no difference in uptake of screening between the active choice and control groups (P = .88). The $100 conditional incentive modestly but significantly increased colonoscopy use. ClinicalTrials.gov no: NCT02660671.
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Patel MS, Benjamin EJ, Volpp KG, Fox CS, Small DS, Massaro JM, Lee JJ, Hilbert V, Valentino M, Taylor DH, Manders ES, Mutalik K, Zhu J, Wang W, Murabito JM. Effect of a Game-Based Intervention Designed to Enhance Social Incentives to Increase Physical Activity Among Families: The BE FIT Randomized Clinical Trial. JAMA Intern Med 2017; 177:1586-1593. [PMID: 28973115 PMCID: PMC5710273 DOI: 10.1001/jamainternmed.2017.3458] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Gamification, the application of game design elements such as points and levels in nongame contexts, is often used in digital health interventions, but evidence on its effectiveness is limited. OBJECTIVE To test the effectiveness of a gamification intervention designed using insights from behavioral economics to enhance social incentives within families to increase physical activity. DESIGN, SETTING, AND PARTICIPANTS The Behavioral Economics Framingham Incentive Trial (BE FIT) was a randomized clinical trial with a 12-week intervention period and a 12-week follow-up period. The investigation was a community-based study between December 7, 2015, and August 14, 2016. Participants in the modified intent-to-treat analysis were adults enrolled in the Framingham Heart Study, a long-standing cohort of families. INTERVENTIONS All participants tracked daily step counts using a wearable device or a smartphone, established a baseline, selected a step goal increase, and received daily individual feedback on goal performance by text message or email for 24 weeks. Families in the gamification arm could earn points and progress through levels based on physical activity goal achievement during the 12-week intervention. The game design was meant to enhance collaboration, accountability, and peer support. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of participant-days that step goals were achieved during the intervention period. Secondary outcomes included the proportion of participant-days that step goals were achieved during the follow-up period and the change in the mean daily steps during the intervention and follow-up periods. RESULTS Among 200 adults comprising 94 families, the mean age was 55.4 years, and 56.0% (n = 112) were female. During the intervention period, participants in the gamification arm achieved step goals on a significantly greater proportion of participant-days (0.53 vs 0.32; adjusted difference, 0.27; 95% CI, 0.20-0.33; P < .001) and had a significantly greater increase in the mean daily steps compared with baseline (1661 vs 636; adjusted difference, 953; 95% CI, 505-1401; P < .001) than the control arm. During the follow-up period, physical activity in the gamification arm declined but remained significantly greater than that in the control arm for the proportion of participant-days achieving step goals (0.44 vs 0.33; adjusted difference, 0.12; 95% CI, 0.05-0.19; P < .001) and the mean daily steps compared with baseline (1385 vs 798; adjusted difference, 494; 95% CI, 170-818; P < .01). CONCLUSIONS AND RELEVANCE Gamification designed to leverage insights from behavioral economics to enhance social incentives significantly increased physical activity among families in the community. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02531763.
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Cuellar A, Haviland AM, Richards-Shubik S, LoSasso AT, Atwood A, Wolfendale H, Shah M, Volpp KG. Boosting workplace wellness programs with financial incentives. THE AMERICAN JOURNAL OF MANAGED CARE 2017; 23:604-610. [PMID: 29087632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Using a large natural experiment among 39 employers, we examined the effect of adding financial incentives to workplace wellness programs. STUDY DESIGN The 39 study employers used the same national insurer to administer their wellness programs, allowing us to observe preventive and health-promoting behaviors before and after financial incentives were implemented. Fifteen treatment employers introduced financial incentives into their wellness programs over 3 years, providing variation in the start dates, whereas 24 employers did not introduce financial incentives. These incentives were attached to specific health actions, including annual preventive visits, biometric screening, and selected screening services for diabetes, heart disease, and cancer. METHODS Using multivariate regression, we examined employees and their adult dependents who had insurance coverage for at least 12 months and were offered a wellness program. Outcomes include utilization of annual preventive visits, low-density lipoprotein cholesterol testing, fasting blood sugar (FBS) testing, and breast, cervical, and colon cancer screens. RESULTS Financial incentives increased annual preventive visits by 7.7 percentage points, cholesterol testing by 7.9 percentage points, and FBS testing by 7.1 percentage points (P <.05 for each). Compared with baseline rates, these changes represent significant improvements of 21% to 29%. Increases for cancer screening were smaller: 2.7 percentage points for mammograms and 2.2 percentage points for colorectal cancer screening, which correspond to increases over baseline rates of 5.5% and 7.3%, respectively. We did not detect an impact on cervical cancer screening. CONCLUSIONS The addition of financial incentives to wellness programs increases their impact on selected preventive care services.
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Skinner J, Volpp KG. Behavioral Economics and Health Insurance Reform-Reply. JAMA 2017; 318:965. [PMID: 28898374 DOI: 10.1001/jama.2017.10556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Volpp KG, Troxel AB, Mehta SJ, Norton L, Zhu J, Lim R, Wang W, Marcus N, Terwiesch C, Caldarella K, Levin T, Relish M, Negin N, Smith-McLallen A, Snyder R, Spettell CM, Drachman B, Kolansky D, Asch DA. Effect of Electronic Reminders, Financial Incentives, and Social Support on Outcomes After Myocardial Infarction: The HeartStrong Randomized Clinical Trial. JAMA Intern Med 2017; 177:1093-1101. [PMID: 28654972 PMCID: PMC5710431 DOI: 10.1001/jamainternmed.2017.2449] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Adherence to medications prescribed after acute myocardial infarction (AMI) is low. Wireless technology and behavioral economic approaches have shown promise in improving health behaviors. OBJECTIVE To determine whether a system of medication reminders using financial incentives and social support delays subsequent vascular events in patients following AMI compared with usual care. DESIGN, SETTING, AND PARTICIPANTS Two-arm, randomized clinical trial with a 12-month intervention conducted from 2013 through 2016. Investigators were blinded to study group, but participants were not. Design was a health plan-intermediated intervention for members of several health plans. We recruited 1509 participants from 7179 contacted AMI survivors (insured with 5 large US insurers nationally or with Medicare fee-for-service at the University of Pennsylvania Health System). Patients aged 18 to 80 years were eligible if currently prescribed at least 2 of 4 study medications (statin, aspirin, β-blocker, antiplatelet agent), and were hospital inpatients for 1 to 180 days and discharged home with a principal diagnosis of AMI. INTERVENTIONS Patients were randomized 2:1 to an intervention using electronic pill bottles combined with lottery incentives and social support for medication adherence (1003 patients), or to usual care (506 patients). MAIN OUTCOMES AND MEASURES Primary outcome was time to first vascular rehospitalization or death. Secondary outcomes were time to first all-cause rehospitalization, total number of repeated hospitalizations, medication adherence, and total medical costs. RESULTS A total of 35.5% of participants were female (n = 536); mean (SD) age was 61.0 (10.3) years. There were no statistically significant differences between study arms in time to first rehospitalization for a vascular event or death (hazard ratio, 1.04; 95% CI, 0.71 to 1.52; P = .84), time to first all-cause rehospitalization (hazard ratio, 0.89; 95% CI, 0.73 to 1.09; P = .27), or total number of repeated hospitalizations (hazard ratio, 0.94; 95% CI, 0.60 to 1.48; P = .79). Mean (SD) medication adherence did not differ between control (0.42 [0.39]) and intervention (0.46 [0.39]) (difference, 0.04; 95% CI, -0.01 to 0.09; P = .10). Mean (SD) medical costs in 12 months following enrollment did not differ between control ($29 811 [$74 850]) and intervention ($24 038 [$66 915]) (difference, -$5773; 95% CI, -$13 682 to $2137; P = .15). CONCLUSIONS AND RELEVANCE A compound intervention integrating wireless pill bottles, lottery-based incentives, and social support did not significantly improve medication adherence or vascular readmission outcomes for AMI survivors. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01800201.
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Halpern SD, French B, Small DS, Saulsgiver K, Harhay MO, Audrain-McGovern J, Loewenstein G, Asch DA, Volpp KG. Heterogeneity in the Effects of Reward- and Deposit-based Financial Incentives on Smoking Cessation. Am J Respir Crit Care Med 2017; 194:981-988. [PMID: 27064456 DOI: 10.1164/rccm.201601-0108oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Targeting different smoking cessation programs to smokers most likely to quit when using them could reduce the burden of lung disease. OBJECTIVES To identify smokers most likely to quit using pure reward-based financial incentives or incentive programs requiring refundable deposits to become eligible for rewards. METHODS We conducted prespecified secondary analyses of a randomized trial in which 2,538 smokers were assigned to an $800 reward contingent on sustained abstinence from smoking, a refundable $150 deposit plus a $650 reward, or usual care. MEASUREMENTS AND MAIN RESULTS Using logistic regression, we identified characteristics of smokers that were most strongly associated with accepting their assigned intervention and ceasing smoking for 6 months. We assessed modification of the acceptance, efficacy, and effectiveness of reward and deposit programs by 11 prospectively selected demographic, smoking-related, and psychological factors. Predictors of sustained smoking abstinence differed among participants assigned to reward- versus deposit-based incentives. However, greater readiness to quit and less steep discounting of future rewards were consistently among the most important predictors. Deposit-based programs were uniquely effective relative to usual care among men, higher-income participants, and participants who more commonly failed to pay their bills (all interaction P values < 0.10). Relative to rewards, deposits were more effective among black persons (P = 0.022) and those who more commonly failed to pay their bills (P = 0.082). Relative to rewards, deposits were more commonly accepted by higher-income participants, men, white persons, and those who less commonly failed to pay their bills (all P < 0.05). CONCLUSIONS Heterogeneity among smokers in their acceptance and response to different forms of incentives suggests potential benefits of targeting behavior-change interventions based on patient characteristics. Clinical trial registered with www.clinicaltrials.gov (NCT 01526265).
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Anesi GL, Halpern SD, Harhay MO, Volpp KG, Saulsgiver K. Time to selected quit date and subsequent rates of sustained smoking abstinence. J Behav Med 2017. [PMID: 28639106 DOI: 10.1007/s10865-017-9868-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In efforts to combat tobacco dependence, most smoking cessation programs offer individuals who smoke the choice of a target quit date. However, it is uncertain whether the time to the selected quit date is associated with participants' chances of achieving sustained abstinence. In a pre-specified secondary analysis of a randomized clinical trial of four financial-incentive programs or usual care to encourage smoking cessation (Halpern et al. in N Engl J Med 372(22):2108-2117, doi: 10.1056/NEJMoa1414293 , 2015), study participants were instructed to select a quit date between 0 and 90 days from enrollment. Among those who selected a quit date and provided complete baseline data (n = 1848), we used multivariable logistic regression to evaluate the association of the time to the selected quit date with 6- and 12-month biochemically-confirmed abstinence rates. In the fully adjusted model, the probability of being abstinent at 6 months if the participant selected a quit date in weeks 1, 5, 10, and 13 were 39.6, 22.6, 10.9, and 4.3%, respectively.
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Gamble T, Branson B, Donnell D, Hall HI, King G, Cutler B, Hader S, Burns D, Leider J, Wood AF, G Volpp K, Buchacz K, El-Sadr WM. Design of the HPTN 065 (TLC-Plus) study: A study to evaluate the feasibility of an enhanced test, link-to-care, plus treat approach for HIV prevention in the United States. Clin Trials 2017. [PMID: 28627929 PMCID: PMC5639958 DOI: 10.1177/1740774517711682] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background/Aims HIV continues to be a major public health threat in the United States, and mathematical modeling has demonstrated that the universal effective use of antiretroviral therapy among all HIV-positive individuals (i.e. the “test and treat” approach) has the potential to control HIV. However, to accomplish this, all the steps that define the HIV care continuum must be achieved at high levels, including HIV testing and diagnosis, linkage to and retention in clinical care, antiretroviral medication initiation, and adherence to achieve and maintain viral suppression. The HPTN 065 (Test, Link-to-Care Plus Treat [TLC-Plus]) study was designed to determine the feasibility of the “test and treat” approach in the United States. Methods HPTN 065 was conducted in two intervention communities, Bronx, NY, and Washington, DC, along with four non-intervention communities, Chicago, IL; Houston, TX; Miami, FL; and Philadelphia, PA. The study consisted of five components: (1) exploring the feasibility of expanded HIV testing via social mobilization and the universal offer of testing in hospital settings, (2) evaluating the effectiveness of financial incentives to increase linkage to care, (3) evaluating the effectiveness of financial incentives to increase viral suppression, (4) evaluating the effectiveness of a computer-delivered intervention to decrease risk behavior in HIV-positive patients in healthcare settings, and (5) administering provider and patient surveys to assess knowledge and attitudes regarding the use of antiretroviral therapy for prevention and the use of financial incentives to improve health outcomes. The study used observational cohorts, cluster and individual randomization, and made novel use of the existing national HIV surveillance data infrastructure. All components were developed with input from a community advisory board, and pragmatic methods were used to implement and assess the outcomes for each study component. Results A total of 76 sites in Washington, DC, and the Bronx, NY, participated in the study: 37 HIV test sites, including 16 hospitals, and 39 HIV care sites. Between September 2010 and December 2014, all study components were successfully implemented at these sites and resulted in valid outcomes. Our pragmatic approach to the study design, implementation, and the assessment of study outcomes allowed the study to be conducted within established programmatic structures and processes. In addition, it was successfully layered on the ongoing standard of care and existing data infrastructure without disrupting health services. Conclusion The HPTN 065 study demonstrated the feasibility of implementing and evaluating a multi-component “test and treat” trial that included a large number of community sites and involved pragmatic approaches to study implementation and evaluation.
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