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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: 88] [Impact Index Per Article: 12.6] [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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Shea JA, Adejare A, Volpp KG, Troxel AB, Finnerty D, Hoffer K, Isaac T, Rosenthal M, Sequist TD, Asch DA. Patients' views of a behavioral intervention including financial incentives. THE AMERICAN JOURNAL OF MANAGED CARE 2017; 23:366-371. [PMID: 28817301 PMCID: PMC6171344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Clinical trials are increasingly testing the effectiveness of paying patients' financial incentives for achieving desired clinical outcomes. Some researchers and providers are concerned that patient financial incentives will harm the doctor-patient relationship. How patients feel about these approaches, and these trials, is largely unknown. This study examined patients' perceptions of a compound behavioral and financial incentive intervention used in a large multicenter trial to lower low-density lipoprotein cholesterol (LDL-C), including their perceptions of benefits and challenges and the study's effect on patients' relationship with their primary care physicians (PCPs). STUDY DESIGN Semi-structured telephone interviews with patients post intervention. METHODS PCPs from 3 primary care practices in the northeastern United States were randomized to 1 of 4 arms: physician financial incentives, patient financial incentives, shared incentives between physicians and patients, and a control arm. Within each arm, 10 high, 10 medium, and 10 low performers in LDL-C reduction were interviewed. Interviews targeted reasons for enrolling in the study, the specific intervention elements that helped them reach the goal (incentives, engagement, monitoring), challenges faced in reducing cholesterol, and the impact of study participation on their relationship with their PCP. RESULTS Patients reported positive experiences with the study: 65% described personal changes to improve health and 61% reported increased awareness. Views about financial incentives varied: 71% clearly found them motivating and 36% claimed they made no difference. Patients noted that changing lifestyle (36%) and diet (65%) was difficult. Patients who substantially lowered their LDL-C revealed themes similar to those who did not. CONCLUSIONS Overall, behavioral interventions with financial incentives appear to be socially acceptable to patients who participate in them. Both adherence monitoring and financial incentives were well received, with little effect on the physician-patient relationship.
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Basner M, Dinges DF, Shea JA, Small DS, Zhu J, Norton L, Ecker AJ, Novak C, Bellini LM, Volpp KG. Sleep and Alertness in Medical Interns and Residents: An Observational Study on the Role of Extended Shifts. Sleep 2017; 40:3045870. [PMID: 28329124 PMCID: PMC5806581 DOI: 10.1093/sleep/zsx027] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Study Objectives Fatigue from sleep loss is a risk to physician and patient safety, but objective data on physician sleep and alertness on different duty hour schedules is scarce. This study objectively quantified differences in sleep duration and alertness between medical interns working extended overnight shifts and residents not or rarely working extended overnight shifts. Methods Sleep-wake activity of 137 interns and 87 PGY-2/3 residents on 2-week Internal Medicine and Oncology rotations was assessed with wrist-actigraphy. Alertness was assessed daily with a brief Psychomotor Vigilance Test (PVT) and the Karolinska Sleepiness Scale. Results Interns averaged 6.93 hours (95% confidence interval [CI] 6.84-7.03 hours) sleep per 24 hours across shifts, significantly less than residents not working overnight shifts (7.18 hours, 95% CI 7.06-7.30 hours, p = .007). Interns obtained on average 2.19 hours (95% CI 2.02-2.36 hours) sleep during on-call nights (17.5% obtained no sleep). Alertness was significantly lower on mornings after on-call nights compared to regular shifts (p < .001). Naps between 9 am and 6 pm on the first day post-call were frequent (90.8%) and averaged 2.84 hours (95% CI 2.69-3.00 hours), but interns still slept 1.66 hours less per 24 hours (95% CI 1.56-1.76 hours) compared to regular shift days (p < .001). Sleep inertia significantly affected alertness in the 60 minutes after waking on-call. Conclusions Extended overnight shifts increase the likelihood of chronic sleep restriction in interns. Reduced levels of alertness after on-call nights need to be mitigated. A systematic comparison of sleep, alertness, and safety outcomes under current and past duty hour rules is encouraged.
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Patel MS, Asch DA, Troxel AB, Fletcher M, Osman-Koss R, Brady J, Wesby L, Hilbert V, Zhu J, Wang W, Volpp KG. Premium-Based Financial Incentives Did Not Promote Workplace Weight Loss In A 2013-15 Study. Health Aff (Millwood) 2017; 35:71-9. [PMID: 26733703 DOI: 10.1377/hlthaff.2015.0945] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Employers commonly use adjustments to health insurance premiums as incentives to encourage healthy behavior, but the effectiveness of those adjustments is controversial. We gave 197 obese participants in a workplace wellness program a weight loss goal equivalent to 5 percent of their baseline weight. They were randomly assigned to a control arm, with no financial incentive for achieving the goal, or to one of three intervention arms offering an incentive valued at $550. Two intervention arms used health insurance premium adjustments, beginning the following year (delayed) or in the first pay period after achieving the goal (immediate). A third arm used a daily lottery incentive separate from premiums. At twelve months there were no statistically significant differences in mean weight change either between the control group (whose members had a mean gain of 0.1 pound) and any of the incentive groups (delayed premium adjustment, -1.2 pound; immediate premium adjustment, -1.4 pound; daily lottery incentive, -1.0 pound) or among the intervention groups. The apparent failure of the incentives to promote weight loss suggests that employers that encourage weight reduction through workplace wellness programs should test alternatives to the conventional premium adjustment approach by using alternative incentive designs, larger incentives, or both.
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Doshi JA, Lim R, Li P, Young PP, Lawnicki VF, Troxel AB, Volpp KG. Synchronized prescription refills and medication adherence: a retrospective claims analysis. THE AMERICAN JOURNAL OF MANAGED CARE 2017; 23:98-104. [PMID: 28245653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Medication adherence is often suboptimal, especially among patients on multiple chronic medications. We examined the association between synchronized medication refill schedules-which typically reduce organizational effort and logistical demands-and adherence. STUDY DESIGN Retrospective study among patients enrolled in Medicare Advantage prescription drug plans. METHODS We used 2012 pharmacy, medical, and enrollment data linked with consumer meta-data for Medicare patients filling 2 or more maintenance prescriptions for antihypertensives, lipid-lowering agents, antidiabetic agents, antidepressants, and/or antiosteoporotic agents. Medication adherence for the year was measured using the proportion of days covered (PDC) at the drug class level. Patients were deemed adherent if drug class PDC was ≥0.80. Outcomes were compared between 1:1 propensity score-matched patients on synchronized versus nonsynchronized refill schedules for maintenance medications. RESULTS The synchronized refill group showed better adherence than the control group, although the magnitude of effects varied by drug class and specific outcome measure. Mean PDC scores ranged from 0.02 higher for antihypertensives to 0.07 higher for antidepressants in the synchronized refill group relative to the control group (P <.01). Further, compared with the control group, a larger proportion of synchronized refill group members were deemed adherent, ranging from 6 percentage points higher for antihypertensives to 15 percentage points higher for lipid-lowering agents (P <.01). Differences between the synchronized and control groups were larger among exclusive users of retail versus mail order pharmacies for maintenance medications. CONCLUSIONS Synchronized medication refill schedules were associated with better medication adherence, particularly for patients filling maintenance medications exclusively at retail pharmacies.
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Becker NV, Asch DA, Kullgren JT, Bellamy SL, Sen AP, Volpp KG. Stages of change and patient activation measure scores in the context of incentive-based health interventions. Am J Health Promot 2017; 30:133-5. [PMID: 26517587 DOI: 10.4278/ajhp.141001-quan-489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To determine if two widely used behavioral change measures-Stages of Change (SoC) and Patient Activation Measure (PAM)-correlate with each other, are affected by financial incentives, or predict positive outcomes in the context of incentive-based health interventions. DESIGN Secondary analysis of two randomized controlled trials of incentives for weight loss and for improved diabetes self-monitoring. SETTING Philadelphia, Pennsylvania; Newark, New Jersey. SUBJECTS A total of 132 obese and 75 diabetic adults enrolled in one of two trials. MEASURES . SoC and PAM scores; weight loss and usage rate of diabetes self-monitoring equipment. ANALYSIS Multiple regression; Kruskal-Wallis test. RESULTS We found no association between baseline SoC and PAM scores in either study (p = .30 and p = .89). Regression models showed no association between baseline PAM score and SoC and subsequent outcomes for either study (weight loss study: PAM: p = .14, SoC: p = .1; diabetes study: PAM: p = .45, SoC: p = .61). Change in PAM score and SoC among participants in the intervention groups did not differ by study arm or among participants with better outcomes. CONCLUSION . PAM score and SoC may not effectively predict success or monitor progress among individuals enrolled in incentive-based interventions.
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Liu T, Asch DA, Volpp KG, Zhu J, Wang W, Troxel AB, Adejare A, Finnerty DD, Hoffer K, Shea JA. Physician attitudes toward participating in a financial incentive program for LDL reduction are associated with patient outcomes. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2016; 5:119-124. [PMID: 27932264 DOI: 10.1016/j.hjdsi.2016.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 08/03/2016] [Accepted: 09/14/2016] [Indexed: 10/20/2022]
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Gopalan A, Paramanund J, Shaw PA, Patel D, Friedman J, Brophy C, Buttenheim AM, Troxel AB, Asch DA, Volpp KG. Randomised controlled trial of alternative messages to increase enrolment in a healthy food programme among individuals with diabetes. BMJ Open 2016; 6:e012009. [PMID: 27903559 PMCID: PMC5168560 DOI: 10.1136/bmjopen-2016-012009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES We compared the effectiveness of diabetes-focused messaging strategies at increasing enrolment in a healthy food programme among adults with diabetes. METHODS Vitality is a multifaceted wellness benefit available to members of Discovery Health, a South Africa-based health insurer. One of the largest Vitality programmes is HealthyFood (HF), an incentive-based programme designed to encourage healthier diets by providing up to 25% cashback on healthy food purchases. We randomised adults with type 2 diabetes to 1 of 5 arms: (1) control, (2) a diabetes-specific message, (3) a message with a recommendation of HF written from the perspective of a HF member with diabetes, (4) a message containing a physician's recommendation of HF, or (5) the diabetes-specific message from arm 2 paired with an 'enhanced active choice'(EAC). In an EAC, readers are asked to make an immediate choice (in this case, to enrol or not enrol); the pros and cons associated with the preferred and non-preferred options are highlighted. HF enrolment was assessed 1 month following the first emailed message. RESULTS We randomised 3906 members. After excluding those who enrolled in HF or departed from the Vitality programme before the first intervention email, 3665 (94%) were included in a modified intent-to-treat analysis. All 4 experimental arms had significantly higher HF enrolment rates compared with control (p<0.0001 for all comparisons). When comparing experimental arms, the diabetes-specific message with the EAC had a significantly higher enrolment rate (12.6%) than the diabetes-specific message alone (7.6%, p=0.0016). CONCLUSIONS Messages focused on diabetes were effective at increasing enrolment in a healthy food programme. The addition of a framed active choice to a message significantly raised enrolment rates in this population. These findings suggest that simple, low-cost interventions can enhance enrolment in health promoting programmes and also be pragmatically tested within those programmes. TRIAL REGISTRATION NUMBER NCT02462057.
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Doshi JA, Volpp KG. Medication Adherence: The Authors Reply. Health Aff (Millwood) 2016; 35:2151. [DOI: 10.1377/hlthaff.2016.1239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Patel MS, Asch DA, Volpp KG. Framing Financial Incentives to Increase Physical Activity Among Overweight and Obese Adults. Ann Intern Med 2016; 165:600. [PMID: 27750316 DOI: 10.7326/l16-0280] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Troxel AB, Asch DA, Mehta SJ, Norton L, Taylor D, Calderon TA, Lim R, Zhu J, Kolansky DM, Drachman BM, Volpp KG. Rationale and design of a randomized trial of automated hovering for post-myocardial infarction patients: The HeartStrong program. Am Heart J 2016; 179:166-74. [PMID: 27595692 DOI: 10.1016/j.ahj.2016.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 06/06/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Coronary artery disease is the single leading cause of death in the United States, and medications can significantly reduce the rate of repeat cardiovascular events and treatment procedures. Adherence to these medications, however, is very low. METHODS HeartStrong is a national randomized trial offering 3 innovations. First, the intervention is built on concepts from behavioral economics that we expect to enhance its effectiveness. Second, the implementation of the trial takes advantage of new technology, including wireless pill bottles and remote feedback, to substantially automate procedures. Third, the trial's design includes an enhancement of the standard randomized clinical trial that allows rapid-cycle innovation and ongoing program enhancement. RESULTS Using a system involving direct data feeds from 6 insurance partners followed by mail, telephone, and email contact, we enrolled 1,509 patients discharged from the hospital with acute myocardial infarction in a 2:1 ratio of intervention:usual care. The intervention period lasts 1 year; the primary outcome is time to first fatal or nonfatal acute vascular event or revascularization, including acute myocardial infarction, unstable angina, stroke, acute coronary syndrome admission, or death. CONCLUSIONS Our randomized controlled trial of the HeartStrong program will provide an evaluation of a state-of-the-art behavioral economic intervention with a number of important pragmatic features. These include a tailored intervention responding to patient activity, streamlining of consent and implementation processes using new technologies, outcomes centrally important to patients, and the ability to implement rapid-cycle innovation.
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Navathe AS, Sen AP, Rosenthal MB, Pearl RM, Ubel PA, Emanuel EJ, Volpp KG. New strategies for aligning physicians with health system incentives. THE AMERICAN JOURNAL OF MANAGED CARE 2016; 22:610-612. [PMID: 27662223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Doshi JA, Lim R, Li P, Young PP, Lawnicki VF, State JJ, Troxel AB, Volpp KG. A Synchronized Prescription Refill Program Improved Medication Adherence. Health Aff (Millwood) 2016; 35:1504-12. [DOI: 10.1377/hlthaff.2015.1456] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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VanEpps EM, Volpp KG, Halpern SD. A nudge toward participation: Improving clinical trial enrollment with behavioral economics. Sci Transl Med 2016; 8:348fs13. [PMID: 27440726 PMCID: PMC6134397 DOI: 10.1126/scitranslmed.aaf0946] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 06/29/2016] [Indexed: 11/02/2022]
Abstract
Interventions informed by behavioral economics can address barriers to patient enrollment in clinical trials and improve recruitment efforts.
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Patel MS, Volpp KG, Rosin R, Bellamy SL, Small DS, Fletcher MA, Osman-Koss R, Brady JL, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Asch DA. A Randomized Trial of Social Comparison Feedback and Financial Incentives to Increase Physical Activity. Am J Health Promot 2016; 30:416-24. [PMID: 27422252 PMCID: PMC6029434 DOI: 10.1177/0890117116658195] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To compare the effectiveness of different combinations of social comparison feedback and financial incentives to increase physical activity. DESIGN Randomized trial (Clinicaltrials.gov number, NCT02030080). SETTING Philadelphia, Pennsylvania. PARTICIPANTS Two hundred eighty-six adults. INTERVENTIONS Twenty-six weeks of weekly feedback on team performance compared to the 50th percentile (n = 100) or the 75th percentile (n = 64) and 13 weeks of weekly lottery-based financial incentive plus feedback on team performance compared to the 50th percentile (n = 80) or the 75th percentile (n = 44) followed by 13 weeks of only performance feedback. MEASURES Mean proportion of participant-days achieving the 7000-step goal during the 13-week intervention. ANALYSIS Generalized linear mixed models adjusting for repeated measures and clustering by team. RESULTS Compared to the 75th percentile without incentives during the intervention period, the mean proportion achieving the 7000-step goal was significantly greater for the 50th percentile with incentives group (0.45 vs 0.27, difference: 0.18, 95% confidence interval [CI]: 0.04 to 0.32; P = .012) but not for the 75th percentile with incentives group (0.38 vs 0.27, difference: 0.11, 95% CI: -0.05 to 0.27; P = .19) or the 50th percentile without incentives group (0.30 vs 0.27, difference: 0.03, 95% CI: -0.10 to 0.16; P = .67). CONCLUSION Social comparison to the 50th percentile with financial incentives was most effective for increasing physical activity.
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Kullgren JT, Troxel AB, Loewenstein G, Norton LA, Gatto D, Tao Y, Zhu J, Schofield H, Shea JA, Asch DA, Pellathy T, Driggers J, Volpp KG. A Randomized Controlled Trial of Employer Matching of Employees' Monetary Contributions to Deposit Contracts to Promote Weight Loss. Am J Health Promot 2016; 30:441-52. [PMID: 27445325 PMCID: PMC6134401 DOI: 10.1177/0890117116658210] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To test whether employer matching of employees' monetary contributions increases employees' (1) participation in deposit contracts to promote weight loss and (2) weight loss. DESIGN A 36-week randomized trial. SETTING Large employer in the northeast United States. PARTICIPANTS One hundred thirty-two obese employees. INTERVENTIONS Over 24 weeks, participants were asked to lose 24 pounds and randomized to monthly weigh-ins or daily weigh-ins with monthly opportunities to deposit $1 to $3 per day that was not matched, matched 1:1, or matched 2:1. Deposits and matched funds were returned to participants for each day they were below their goal weight. MEASURES Rates of making ≥1 deposit, weight loss at 24 weeks (primary outcome), and 36 weeks. ANALYSIS Deposit rates were compared using χ(2) tests. Weight loss was compared using t tests. RESULTS Among participants eligible to make deposits, 29% made ≥1 deposit and matching did not increase participation. At 24 weeks, control participants gained an average of 1.0 pound, whereas 1:1 match participants lost an average of 5.3 pounds (P = .005). After 36 weeks, control participants gained an average of 2.1 pounds, whereas no match participants lost an average of 5.1 pounds (P = .008). CONCLUSION Participation in deposit contracts to promote weight loss was low, and matching deposits did not increase participation. For deposit contracts to impact population health, ongoing participation will need to be higher.
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Patel MS, Asch DA, Rosin R, Small DS, Bellamy SL, Eberbach K, Walters KJ, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Volpp KG. Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial. J Gen Intern Med 2016; 31:746-54. [PMID: 26976287 PMCID: PMC4907949 DOI: 10.1007/s11606-016-3627-0] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 11/16/2015] [Accepted: 02/01/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND More than half of adults in the United States do not attain the minimum recommended level of physical activity to achieve health benefits. The optimal design of financial incentives to promote physical activity is unknown. OBJECTIVE To compare the effectiveness of individual versus team-based financial incentives to increase physical activity. DESIGN Randomized, controlled trial comparing three interventions to control. PARTICIPANTS Three hundred and four adult employees from an organization in Philadelphia formed 76 four-member teams. INTERVENTIONS All participants received daily feedback on performance towards achieving a daily 7000 step goal during the intervention (weeks 1- 13) and follow-up (weeks 14- 26) periods. The control arm received no other intervention. In the three financial incentive arms, drawings were held in which one team was selected as the winner every other day during the 13-week intervention. A participant on a winning team was eligible as follows: $50 if he or she met the goal (individual incentive), $50 only if all four team members met the goal (team incentive), or $20 if he or she met the goal individually and $10 more for each of three teammates that also met the goal (combined incentive). MAIN MEASURES Mean proportion of participant-days achieving the 7000 step goal during the intervention. KEY RESULTS Compared to the control group during the intervention period, the mean proportion achieving the 7000 step goal was significantly greater for the combined incentive (0.35 vs. 0.18, difference: 0.17, 95 % confidence interval [CI]: 0.07-0.28, p <0.001) but not for the individual incentive (0.25 vs 0.18, difference: 0.08, 95 % CI: -0.02-0.18, p = 0.13) or the team incentive (0.17 vs 0.18, difference: -0.003, 95 % CI: -0.11-0.10, p = 0.96). The combined incentive arm participants also achieved the goal at significantly greater rates than the team incentive (0.35 vs. 0.17, difference: 0.18, 95 % CI: 0.08-0.28, p < 0.001), but not the individual incentive (0.35 vs. 0.25, difference: 0.10, 95 % CI: -0.001-0.19, p = 0.05). Only the combined incentive had greater mean daily steps than control (difference: 1446, 95 % CI: 448-2444, p ≤ 0.005). There were no significant differences between arms during the follow-up period (weeks 14- 26). CONCLUSIONS Financial incentives rewarded for a combination of individual and team performance were most effective for increasing physical activity. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02001194.
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Abstract
BACKGROUND Randomized clinical trials provide gold-standard evidence for the efficacy of interventions, but have limitations, including highly selected populations that make inference on effectiveness difficult and a lack of ability to adapt and change midstream. METHODS We propose two innovations for pragmatic trial design. RESULTS Evidence-based evolutionary testing, a framework that allows adaptation of interventions and rapid-cycle innovation, preserves the power of randomization while acknowledging the need for adaptation and learning. An opt-out consent framework increases the fraction of the target population who participate in trials, but may lead to dampening of effect sizes. CONCLUSION Pragmatic trials offer numerous advantages in the evaluation of behavioral interventions in health. Statistical innovations, including evidence-based evolutionary testing and opt-out framing of consent and enrollment processes, can enhance the power of pragmatic trials and lead to more rapid progress.
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