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Beidas RS, Volpp KG, Buttenheim AN, Marcus SC, Olfson M, Pellecchia M, Stewart RE, Williams NJ, Becker-Haimes EM, Candon M, Cidav Z, Fishman J, Lieberman A, Zentgraf K, Mandell D. Transforming Mental Health Delivery Through Behavioral Economics and Implementation Science: Protocol for Three Exploratory Projects. JMIR Res Protoc 2019; 8:e12121. [PMID: 30747719 PMCID: PMC6390186 DOI: 10.2196/12121] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/19/2018] [Accepted: 10/20/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Efficacious psychiatric treatments are not consistently deployed in community practice, and clinical outcomes are attenuated compared with those achieved in clinical trials. A major focus for mental health services research is to develop effective and cost-effective strategies that increase the use of evidence-based assessment, prevention, and treatment approaches in community settings. OBJECTIVE The goal of this program of research is to apply insights from behavioral economics and participatory design to advance the science and practice of implementing evidence-based practice (EBP) for individuals with psychiatric disorders across the life span. METHODS Project 1 (Assisting Depressed Adults in Primary care Treatment [ADAPT]) is patient-focused and leverages decision-making heuristics to compare ways to incentivize adherence to antidepressant medications in the first 6 weeks of treatment among adults newly diagnosed with depression. Project 2 (App for Strengthening Services In Specialized Therapeutic Support [ASSISTS]) is provider-focused and utilizes normative pressure and social status to increase data collection among community mental health workers treating children with autism. Project 3 (Motivating Outpatient Therapists to Implement: Valuing a Team Effort [MOTIVATE]) explores how participatory design can be used to design organizational-level implementation strategies to increase clinician use of EBPs. The projects are supported by a Methods Core that provides expertise in implementation science, behavioral economics, participatory design, measurement, and associated statistical approaches. RESULTS Enrollment for project ADAPT started in 2018; results are expected in 2020. Enrollment for project ASSISTS will begin in 2019; results are expected in 2021. Enrollment for project MOTIVATE started in 2018; results are expected in 2019. Data collection had begun for ADAPT and MOTIVATE when this protocol was submitted. CONCLUSIONS This research will advance the science of implementation through efforts to improve implementation strategy design, measurement, and statistical methods. First, we will test and refine approaches to collaboratively design implementation strategies with stakeholders (eg, discrete choice experiments and innovation tournaments). Second, we will refine the measurement of mechanisms related to heuristics used in decision making. Third, we will develop new ways to test mechanisms in multilevel implementation trials. This trifecta, coupled with findings from our 3 exploratory projects, will lead to improvements in our knowledge of what causes successful implementation, what variables moderate and mediate the effects of those causal factors, and how best to leverage this knowledge to increase the quality of care for people with psychiatric disorders. TRIAL REGISTRATION ClinicalTrials.gov NCT03441399; https://www.clinicaltrials.gov/ct2/show/NCT03441399 (Archived by WebCite at http://www.webcitation.org/74dRbonBD). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/12121.
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Affiliation(s)
- Rinad S Beidas
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Kevin G Volpp
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, United States.,Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, United States.,Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Alison N Buttenheim
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.,Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Steven C Marcus
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, United States
| | - Mark Olfson
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - Melanie Pellecchia
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Rebecca E Stewart
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Emily M Becker-Haimes
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Molly Candon
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Zuleyha Cidav
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Jessica Fishman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Annenberg School for Communication, University of Pennyslvania, Philadelphia, PA, United States
| | - Adina Lieberman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Kelly Zentgraf
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - David Mandell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Ma QH, Fang JH. International normalized ratio for the guidance of warfarin treatment in elderly patients after cardiac valve replacement. Exp Ther Med 2018; 17:1486-1491. [PMID: 30680032 DOI: 10.3892/etm.2018.7078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 09/13/2018] [Indexed: 11/06/2022] Open
Abstract
Thus far, the target value for international normalized ratio (INR) has remained to be determined. The current study aimed to further explore the INR value of the anti-coagulation drug warfarin after cardiac valve replacement. The clinical data of 213 patients who underwent cardiac valve replacement at Linyi Central Hospital (Linyi, China) between January 2010 and May 2013 were retrospectively analyzed. The warfarin dosage, prothrombin time (PT) and INR were compared among patients with hemorrhage or embolism, and those with no complications. A total of 31 cases (14.6%) developed adverse reactions and complications during the medication period, including 21 cases with hemorrhage (9.9%, hemorrhage group) and 10 cases with embolism (4.7%, embolism group), while 182 patients did not (85.4%, normal group). The average dosage of warfarin was 2.0±0.6, 3.1±0.7 and 1.7±0.6 mg/day in the normal, hemorrhage and embolism groups, respectively. The dosage of warfarin, the PT and the INR in the hemorrhage group were all significantly greater than those in the normal group and the embolism group (all P<0.05). INR monitoring is recommended to ensure the safety of the anti-coagulant drug warfarin, but further study is still required to determine a reasonable target INR value.
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Affiliation(s)
- Qing-Hua Ma
- Department of Cardiology, Linyi Central Hospital, Linyi, Shandong 276400, P.R. China
| | - Jian-Hai Fang
- Department of Cardiology, Linyi Central Hospital, Linyi, Shandong 276400, P.R. China
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Kaboli PJ, Howren MB, Ishani A, Carter B, Christensen AJ, Vander Weg MW. Efficacy of Patient Activation Interventions With or Without Financial Incentives to Promote Prescribing of Thiazides and Hypertension Control: A Randomized Clinical Trial. JAMA Netw Open 2018; 1:e185017. [PMID: 30646291 PMCID: PMC6324341 DOI: 10.1001/jamanetworkopen.2018.5017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Evidence-based guidelines recommend thiazide diuretics as a first-line therapy for uncomplicated hypertension; however, thiazides are underused, and hypertension remains inadequately managed. OBJECTIVE To test the efficacy of a patient activation intervention with financial incentives to promote thiazide prescribing. DESIGN, SETTING, AND PARTICIPANTS The Veterans Affairs Project to Implement Diuretics, a randomized clinical trial, was conducted at 13 Veterans Affairs primary care clinics from August 1, 2006, to July 31, 2008, with 12 months of follow-up. A total of 61 019 patients were screened to identify 2853 eligible patients who were not taking a thiazide and not at their blood pressure (BP) goal; 598 consented to participate. Statistical analysis was conducted from December 1, 2017, to September 12, 2018. INTERVENTIONS Patients were randomized to a control group (n = 196) or 1 of 3 intervention groups designed to activate patients to talk with their primary care clinicians about thiazides and hypertension: group A (n = 143) received an activation letter, group B (n = 128) received a letter plus a financial incentive, and group C (n = 131) received a letter, financial incentive, and a telephone call encouraging patients to speak with their primary care clinicians. MAIN OUTCOMES AND MEASURES Primary outcomes were thiazide prescribing and BP control. A secondary process measure was discussion between patient and primary care clinician about thiazides. RESULTS Among 598 participants (588 men and 10 women), the mean (SD) age for the combined intervention groups (n = 402) was 62.9 (8.8) years, and the mean baseline BP was 148.1/83.8 mm Hg; the mean (SD) age for the control group (n = 196) was 64.1 (9.2) years, and the mean baseline BP was 151.0/83.4 mm Hg. At index visits, the unadjusted rate of thiazide prescribing was 9.7% for the control group (19 of 196) and 24.5% (35 of 143) for group A, 25.8% (33 of 128) for group B, and 32.8% (43 of 131) for group C (P < .001). Adjusted analyses demonstrated an intervention effect on thiazide prescribing at the index visit and 6-month visit, which diminished at the 12-month visit. For BP control, there was a significant intervention effect at the 12-month follow-up for group C (adjusted odds ratio, 1.73; 95% CI, 1.06-2.83; P = .04). Intervention groups exhibited improved thiazide discussion rates in a dose-response fashion: group A, 44.1% (63 of 143); group B, 56.3% (72 of 128); and group C, 68.7% (90 of 131) (P = .004). CONCLUSIONS AND RELEVANCE This patient activation intervention about thiazides for hypertension resulted in two-thirds of patients having discussions and nearly one-third initiating a prescription of thiazide. Adding a financial incentive and telephone call to the letter resulted in incremental improvements in both outcomes. By 12 months, improved BP control was also evident. This low-cost, low-intensity intervention resulted in high rates of discussions between patients and clinicians and subsequent thiazide treatment and may be used to promote evidence-based guidelines and overcome clinical inertia. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00265538.
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Affiliation(s)
- Peter J. Kaboli
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City
| | - M. Bryant Howren
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Psychological and Brain Sciences, The University of Iowa College of Liberal Arts and Sciences, Iowa City
| | - Areef Ishani
- Center for Epidemiology and Clinical Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
- Section of Nephrology, Department of Medicine, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis
| | - Barry Carter
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Pharmacy Practice and Science, The University of Iowa College of Pharmacy, Iowa City
- Department of Family Medicine, The University of Iowa Carver College of Medicine, Iowa City
| | - Alan J. Christensen
- Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City
- Department of Psychological and Brain Sciences, The University of Iowa College of Liberal Arts and Sciences, Iowa City
| | - Mark W. Vander Weg
- Center for Comprehensive Access & Delivery Research & Evaluation, Veterans Affairs Iowa City Healthcare System, Iowa City, Iowa
- Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City
- Department of Psychological and Brain Sciences, The University of Iowa College of Liberal Arts and Sciences, Iowa City
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Improving medication adherence in stroke survivors: the intervention development process. BMC Health Serv Res 2018; 18:772. [PMID: 30309346 PMCID: PMC6182841 DOI: 10.1186/s12913-018-3572-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 09/27/2018] [Indexed: 11/13/2022] Open
Abstract
Background Medications targeting stroke risk factors have shown good efficacy, yet adherence is suboptimal. A lack of underlying theory may contribute to the ineffectiveness of eliciting or sustaining behaviour change in many existing interventions targeting medication adherence in stroke. Intervention effectiveness and implementation could be enhanced by consideration of evidence base and theory to drive development. The purpose of this study is to identify appropriate components for a theory-driven and evidence-based medication adherence intervention for stroke survivors. Methods The Behaviour Change Wheel (BCW), a guide to intervention development, informed our systematic process of intervention development. Our earlier systematic review had identified important determinants of medication adherence that were mapped into the Theoretical Domains Framework (TDF), with Knowledge, Beliefs about consequences and Emotions found to be more influential. Utilising the BCW facilitated selection of intervention options and behaviour change techniques (BCTs); the active ingredients within an intervention. To further refine BCT selection, APEASE criteria were employed, allowing evaluation of potential BCTs within context: The National Health Service (NHS), United Kingdom (UK). Results Five intervention functions (Education, Persuasion, Training, Environmental Restructuring and Enablement) and five policy categories (Communication/marketing, Guidelines, Regulation, Environmental/social planning and Service provision) were identified as potential intervention options, underpinned by our systematic review findings. Application of APEASE criteria led to an initial pool of 21 BCTs being reduced to 11 (e.g. Habit Formation, Information about Health Consequences and Action Planning) identified as potential intervention components that would both be feasible and directly target the underlying determinants of stroke survivors’ medication adherence. Conclusions Careful consideration of underlying evidence and theory to drive intervention design, facilitated by the BCW, enabled identification of appropriate intervention components. BCTs including Habit Formation, Information about Health Consequences and Self-monitoring of Behaviour were considered potentially effective and appropriate to deliver within the NHS. Having reduced the pool of potential intervention components to a manageable number, it will now be possible to explore the perceived acceptability of selected BCTs in interviews with stroke survivors and healthcare professionals. This approach to intervention development should be generalisable to other chronic conditions and areas of behaviour change (e.g. exercise adherence).
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Buttenheim AM, Paz-Soldán VA, Castillo-Neyra R, Toledo Vizcarra AM, Borrini-Mayori K, McGuire M, Arevalo-Nieto C, Volpp KG, Small DS, Behrman JR, Naquira-Verlarde C, Levy MZ. Increasing participation in a vector control campaign: a cluster randomised controlled evaluation of behavioural economic interventions in Peru. BMJ Glob Health 2018; 3:e000757. [PMID: 30271624 PMCID: PMC6157568 DOI: 10.1136/bmjgh-2018-000757] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 07/30/2018] [Accepted: 08/03/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To assess the efficacy of strategies informed by behavioural economics for increasing participation in a vector control campaign, compared with current practice. DESIGN Pragmatic cluster randomised controlled trial. SETTING Arequipa, Peru. PARTICIPANTS 4922 households. INTERVENTIONS Households were randomised to one of four arms: advanced planning, leader recruitment, contingent group lotteries, or control. MAIN OUTCOME MEASURES Participation (allowing the house to be sprayed with insecticide) during the vector control campaign. RESULTS In intent-to-treat analyses, none of the interventions increased participation compared with control (advanced planning adjusted OR (aOR) 1.07 (95% CI 0.87 to 1.32); leader recruitment aOR 0.95 (95% CI 0.78 to 1.15); group lotteries aOR 1.12 (95% CI 0.89 to 1.39)). The interventions did not improve the efficiency of the campaign (additional minutes needed to spray house from generalised estimating equation regressions: advanced planning 1.08 (95% CI -1.02 to 3.17); leader recruitment 3.91 (95% CI 1.85 to 5.97); group lotteries 3.51 (95% CI 1.38 to 5.64)) nor did it increase the odds that houses would be sprayed in an earlier versus a later stage of the campaign cycle (advanced planning aOR 0.94 (95% CI 0.76 to 1.25); leader recruitment aOR 0.68 (95% CI 0.55 to 0.83); group lotteries aOR 1.19 (95% CI 0.96 to 1.47)). A post hoc analysis suggested that advanced planning increased odds of participation compared with control among households who had declined to participate previously (aOR 2.50 (95% CI 1.41 to 4.43)). CONCLUSIONS Achieving high levels of household participation is crucial for many disease prevention efforts. Our trial was not successful in improving participation compared with the existing campaign. The trial highlights persistent challenges to field experiments as well as lessons about the intervention design process, particularly understanding barriers to participation through a behavioural lens. TRIAL REGISTRATION NUMBER American Economic Association AEARCTR-0000620.
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Affiliation(s)
- Alison M Buttenheim
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Valerie A Paz-Soldán
- Global Community Health and Behavioral Sciences, Tulane University, New Orleans, Louisiana, USA
| | - Ricardo Castillo-Neyra
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Amparo M Toledo Vizcarra
- Zoonotic Disease Research Lab, OneHealth Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Arequipa, Peru
| | - Katty Borrini-Mayori
- Zoonotic Disease Research Lab, OneHealth Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Arequipa, Peru
| | - Molly McGuire
- Global Community Health and Behavioral Sciences, Tulane University, New Orleans, Louisiana, USA
| | - Claudia Arevalo-Nieto
- Zoonotic Disease Research Lab, OneHealth Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Arequipa, Peru
| | - Kevin G Volpp
- Medical Ethics and Health Policy, School of Medicine, University of Pennsylvania Perelman, Philadelphia, Pennsylvania, USA
| | - Dylan S Small
- Department of Statistics, University of Pennsylvania Wharton School, Philadelphia, Pennsylvania, USA
| | - Jere R Behrman
- Department of Economics School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Michael Z Levy
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Every-Palmer S, Huthwaite MA, Elmslie JL, Grant E, Romans SE. Long-term psychiatric inpatients' perspectives on weight gain, body satisfaction, diet and physical activity: a mixed methods study. BMC Psychiatry 2018; 18:300. [PMID: 30227840 PMCID: PMC6145113 DOI: 10.1186/s12888-018-1878-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 09/05/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Obesity is a significant problem for people with serious mental illness. We aimed to consider body size from the perspective of long-stay psychiatric inpatients, focussing on: weight gain and its causes and impacts; diet and physical activity; and the perceived ability to make meaningful change in these domains. METHOD A mixed methods study with 51 long-term psychiatric forensic and rehabilitation inpatients using semi-structured interviews combined with biometric and demographic data. RESULTS 94% of participants were overweight or obese (mean BMI 35.3, SD 8.1). They were concerned about their weight, with 75% of them attempting to lose weight. Qualitative responses indicated low personal effectiveness and self-stigmatisation. Participants viewed their weight gain as something 'done to them' through medication, hospitalisation and leave restrictions. A prevailing theme was that institutional constraints made it difficult to live a healthy life (just the way the system is). Many had an external locus of control, viewing weight loss as desirable but unachievable, inhibited by environmental factors and requiring a quantum of motivation they found hard to muster. Despite this, participants were thoughtful and interested, had sound ideas for weight loss, and wished to be engaged in a shared endeavour to achieve better health outcomes. Consulting people as experts on their experiences, preferences, and goals may help develop new solutions, remove unidentified barriers, and improve motivation. CONCLUSIONS The importance of an individualised, multifactorial approach in weight loss programmes for this group was clear. Patient-led ideas and co-design should be key principles in programme and environmental design.
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Affiliation(s)
- Susanna Every-Palmer
- Department of Psychological Medicine, University of Otago Wellington, PO Box 7343, Wellington, 6242 New Zealand
- Capital and Coast District Health Board, Wellington, New Zealand
| | - Mark A. Huthwaite
- Department of Psychological Medicine, University of Otago Wellington, PO Box 7343, Wellington, 6242 New Zealand
- Capital and Coast District Health Board, Wellington, New Zealand
| | | | - Eve Grant
- Capital and Coast District Health Board, Wellington, New Zealand
| | - Sarah E. Romans
- Department of Psychological Medicine, University of Otago Wellington, PO Box 7343, Wellington, 6242 New Zealand
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Cohen J, Saran I. The impact of packaging and messaging on adherence to malaria treatment: Evidence from a randomized controlled trial in Uganda. JOURNAL OF DEVELOPMENT ECONOMICS 2018; 134:68-95. [PMID: 30177864 PMCID: PMC6088513 DOI: 10.1016/j.jdeveco.2018.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 04/19/2018] [Accepted: 04/25/2018] [Indexed: 05/07/2023]
Abstract
Despite substantial public and private costs of non-adherence to infectious disease treatments, patients often do not finish their medication. We explore adherence to medication for malaria, a major cause of morbidity and health system costs in Africa. We conducted a randomized trial in Uganda testing specialized packaging and messaging, designed to increase antimalarial adherence. We find that stickers with short, targeted messages on the packaging increase adherence by 9% and reduce untaken pills by 29%. However, the currently used method of boosting adherence through costly, specialized packaging with pictorial instructions had no significant impacts relative to the standard control package. We develop a theoretical framework of the adherence decision, highlighting the role of symptoms, beliefs about being cured, and beliefs about drug effectiveness to help interpret our results. Patients whose symptoms resolve sooner are substantially less likely to adhere, and the sticker interventions have the strongest impact among these patients.
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Affiliation(s)
- Jessica Cohen
- Harvard T.H. Chan School of Public Health and J-PAL, Building 1, Room 1209, 665 Huntington Avenue, Boston, MA 02115, USA
| | - Indrani Saran
- Harvard T.H. Chan School of Public Health, Building 1, 665 Huntington Avenue, Boston, MA 02115, USA
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Cash incentives versus defaults for HIV testing: A randomized clinical trial. PLoS One 2018; 13:e0199833. [PMID: 29979742 PMCID: PMC6034801 DOI: 10.1371/journal.pone.0199833] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 06/14/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tools from behavioral economics have been shown to improve health-related behaviors, but the relative efficacy and additive effects of different types of interventions are not well established. We tested the influence of small cash incentives, defaults, and both in combination on increasing patient HIV test acceptance. METHODS AND FINDINGS We conducted a randomized clinical trial among patients aged 13-64 receiving care in an urban emergency department. Patients were cross-randomized to $0, $1, $5, and $10 incentives, and to opt-in, active-choice, and opt-out test defaults. The primary outcome was the proportion of patients who accepted an HIV test. 4,831 of 8,715 patients accepted an HIV test (55.4%). Those offered no monetary incentive accepted 51.6% of test offers. The $1 treatment did not increase test acceptance (increase 1%; 95% confidence interval [CI] -2.0 to 3.9); the $5 and $10 treatments increased test acceptance rates by 10.5 and 15 percentage points, respectively (95% CI 7.5 to 13.4 and 11.8 to 18.1). Compared to opt-in testing, active-choice testing increased test acceptance by 11.5% (95% CI 9.0 to 14.0), and opt-out testing increased acceptance by 23.9 percentage points (95% CI 21.4 to 26.4). CONCLUSIONS Small incentives and defaults can both increase patient HIV test acceptance, though when used in combination their effects were less than additive. These tools from behavioral economics should be considered by clinicians and policymakers. How patient groups respond to monetary incentives and/or defaults deserves further investigation for this and other health behaviors.
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Stitzer ML, Hammond AS, Matheson T, Sorensen JL, Feaster DJ, Duan R, Gooden L, del Rio C, Metsch LR. Enhancing Patient Navigation with Contingent Incentives to Improve Healthcare Behaviors and Viral Load Suppression of Persons with HIV and Substance Use. AIDS Patient Care STDS 2018; 32:288-296. [PMID: 29883190 DOI: 10.1089/apc.2018.0014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This secondary analysis compares health behavior outcomes for two groups of HIV+ substance users randomized in a 3-arm trial [1] to receive Patient Navigation with (PN+CM) or without (PN) contingent financial incentives (CM). Mean age of participants was 45 years; the majority was male (67%), African American (78%), unemployed (35%), or disabled (50%). Behaviors incentivized for PN+CM were (1) attendance at HIV care visits and (2) verification of an active HIV medication prescription. Incentives were associated with shorter time to treatment initiation and higher rates of behaviors during the 6-month intervention with exception of month 6 HIV care visits. Median HIV care visits were 3 (IQR 2-4) for PN+CM versus 1.5 (IQR 0-3) for PN (Wilcoxon p < 0.001); median validated medication checks were 4 (IQR 2-6) for PN+CM versus 1 (IQR 0-3) for PN (Wilcoxon p < 0.001). Viral suppression rates at end of treatment were not significantly different for the two groups but were directly related to the number of behaviors completed for both care visits (χ2(1) = 7.69, p = 0.006) and validated medication (χ2(1) = 8.49, p = 0.004). Results support use of incentives to increase performance of key healthcare behaviors. Adjustments to the incentive program may be needed to achieve greater rates of sustained health behavior change that result in improved viral load outcomes.
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Affiliation(s)
- Maxine L. Stitzer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Alexis S. Hammond
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Tim Matheson
- San Francisco Department of Public Health, San Francisco, California
| | - James L. Sorensen
- UCSF Department of Psychiatry, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Daniel J. Feaster
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Rui Duan
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Lauren Gooden
- Department of Sociomedical Sciences Mailman School of Public Health, Columbia University, New York, New York
| | - Carlos del Rio
- Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, Georgia
| | - Lisa R. Metsch
- Department of Sociomedical Sciences Mailman School of Public Health, Columbia University, New York, New York
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Williams AM, Liu PJ, Muir KW, Waxman EL. Behavioral economics and diabetic eye exams. Prev Med 2018; 112:76-87. [PMID: 29626555 DOI: 10.1016/j.ypmed.2018.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 03/09/2018] [Accepted: 04/02/2018] [Indexed: 01/09/2023]
Abstract
Diabetic retinopathy is a common microvascular complication of diabetes mellitus and is the leading cause of new blindness among working-age adults in the United States. Timely intervention to prevent vision loss is possible with early detection by regular eye examinations. Unfortunately, adherence to recommended annual diabetic eye exams is poor. Public health interventions have targeted traditional barriers to care, such as cost and transportation, with limited success. Behavioral economics provides an additional framework of concepts and tools to understand low screening rates and to promote regular diabetic eye exams for populations at risk. In particular, behavioral economics outlines biases and heuristics that affect decision-making and underlie pervasive barriers to care, such as not viewing diabetic eye exams as a priority or perceiving oneself as too healthy to need an examination. In this review, we examine the literature on the use of behavioral economics interventions to promote regular diabetic eye exams. From the results of the included studies, we outline how concepts from behavioral economics can improve eye examination rates. In particular, the default bias, present bias, and self-serving bias play a significant role in precluding regular diabetic eye examinations. Potential tools to mitigate these biases include leveraging default options, using reminder messages, providing behavioral coaching, applying commitment contracts, offering financial incentives, and personalizing health messages. When combined with traditional public health campaigns, insights from behavioral economics can improve understanding of pervasive barriers to care and offer additional strategies to promote regular preventive eye care for patients with diabetes.
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Affiliation(s)
- Andrew M Williams
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Peggy J Liu
- Department of Marketing and Business Economics, Katz Graduate School of Business, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kelly W Muir
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA; Durham VA Medical Center, Health Services Research and Development, Durham, NC, USA
| | - Evan L Waxman
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Witman A, Acquah J, Alva M, Hoerger T, Romaire M. Medicaid Incentives for Preventing Chronic Disease: Effects of Financial Incentives for Smoking Cessation. Health Serv Res 2018; 53:5016-5034. [PMID: 29896800 DOI: 10.1111/1475-6773.12994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To test the effectiveness of financial incentives for smoking cessation in the Medicaid population. DATA SOURCES Secondary data from the Medicaid Incentives for Prevention of Chronic Disease (MIPCD) program and Medicaid claims/encounter data from 2010 to 2015 for five states. STUDY DESIGN Beneficiaries were randomized into receipt or no receipt of financial incentives. We ran multivariate regression models testing the impact of financial incentives on the use of counseling services, smoking behavior, and Medicaid expenditures and utilization. DATA EXTRACTION Participating states provided Medicaid eligibility, claims and encounters, program enrollment, and incentivized service use data. PRINCIPAL FINDINGS Participants who received incentives were more likely to call the Quitline and complete counseling sessions. Incentive receipt was positively associated with self-reported quit attempts, self-reported quits, or passing cotinine tests of smoking cessation in most programs, although results were only statistically significant in a subset. There was no systematic evidence that incentives affected health care use or spending. CONCLUSIONS Financial incentives are a promising policy lever to motivate behavioral change in the Medicaid population, but more evidence is needed regarding optimal incentive size, effectiveness of process-versus outcome-based incentives, targeting of incentives, and long-run cost-effectiveness.
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Insights From Behavioral Economics to Design More Effective Incentives for Improving Chronic Health Behaviors, With an Application to Adherence to Antiretrovirals. J Acquir Immune Defic Syndr 2018; 72:e50-2. [PMID: 26918543 DOI: 10.1097/qai.0000000000000972] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kohl Malone S, Ziporyn T, Buttenheim AM. Applying behavioral insights to delay school start times. Sleep Health 2017; 3:483-485. [PMID: 29157644 PMCID: PMC5728679 DOI: 10.1016/j.sleh.2017.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/10/2017] [Accepted: 07/24/2017] [Indexed: 10/18/2022]
Abstract
Healthy People 2020 established a national objective to increase the proportion of 9th-to-12th-grade students reporting sufficient sleep. A salient approach for achieving this objective is to delay middle and high school start times. Despite decades of research supporting the benefits of delayed school start times on adolescent sleep, health, and well-being, progress has been slow. Accelerating progress will require new approaches incorporating strategies that influence how school policy decisions are made. In this commentary, we introduce four strategies that influence decision-making processes and demonstrate how they can be applied to efforts aimed at changing school start time policies.
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Affiliation(s)
- Susan Kohl Malone
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, 3624 Market St, Philadelphia, PA 19104; Rory Meyers College of Nursing, New York University, 433 First Ave, New York, NY 10010.
| | - Terra Ziporyn
- Start School Later, PO Box 6105, Annapolis, MD 21401
| | - Alison M Buttenheim
- School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA 19104
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McNairy ML, Lamb MR, Gachuhi AB, Nuwagaba-Biribonwoha H, Burke S, Mazibuko S, Okello V, Ehrenkranz P, Sahabo R, El-Sadr WM. Effectiveness of a combination strategy for linkage and retention in adult HIV care in Swaziland: The Link4Health cluster randomized trial. PLoS Med 2017; 14:e1002420. [PMID: 29112963 PMCID: PMC5675376 DOI: 10.1371/journal.pmed.1002420] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 09/29/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Gaps in the HIV care continuum contribute to poor health outcomes and increase HIV transmission. A combination of interventions targeting multiple steps in the continuum is needed to achieve the full beneficial impact of HIV treatment. METHODS AND FINDINGS Link4Health, a cluster-randomized controlled trial, evaluated the effectiveness of a combination intervention strategy (CIS) versus the standard of care (SOC) on the primary outcome of linkage to care within 1 month plus retention in care at 12 months after HIV-positive testing. Ten clusters of HIV clinics in Swaziland were randomized 1:1 to CIS versus SOC. The CIS included point-of-care CD4+ testing at the time of an HIV-positive test, accelerated antiretroviral therapy (ART) initiation for treatment-eligible participants, mobile phone appointment reminders, health educational packages, and noncash financial incentives. Secondary outcomes included each component of the primary outcome, mean time to linkage, assessment for ART eligibility, ART initiation and time to ART initiation, viral suppression defined as HIV-1 RNA < 1,000 copies/mL at 12 months after HIV testing among patients on ART ≥6 months, and loss to follow-up and death at 12 months after HIV testing. A total of 2,197 adults aged ≥18 years, newly tested HIV positive, were enrolled from 19 August 2013 to 21 November 2014 (1,096 CIS arm; 1,101 SOC arm) and followed for 12 months. The median participant age was 31 years (IQR 26-39), and 59% were women. In an intention-to-treat analysis, 64% (705/1,096) of participants at the CIS sites achieved the primary outcome versus 43% (477/1,101) at the SOC sites (adjusted relative risk [RR] 1.52, 95% CI 1.19-1.96, p = 0.002). Participants in the CIS arm versus the SOC arm had the following secondary outcomes: linkage to care regardless of retention at 12 months (RR 1.08, 95% CI 0.97-1.21, p = 0.13), mean time to linkage (2.5 days versus 7.5 days, p = 0.189), retention in care at 12 months regardless of time to linkage (RR 1.48, 95% CI 1.18-1.86, p = 0.002), assessment for ART eligibility (RR 1.20, 95% CI 1.07-1.34, p = 0.004), ART initiation (RR 1.16, 95% CI 0.96-1.40, p = 0.12), mean time to ART initiation from time of HIV testing (7 days versus 14 days, p < 0.001), viral suppression among those on ART for ≥6 months (RR 0.97, 95% CI 0.88-1.07, p = 0.55), loss to follow-up at 12 months after HIV testing (RR 0.56, 95% CI 0.40-0.79, p = 0.002), and death (N = 78) within 12 months of HIV testing (RR 0.80, 95% CI 0.46-1.35, p = 0.41). Limitations of this study include a small number of clusters and the inability to evaluate the incremental effectiveness of individual components of the combination strategy. CONCLUSIONS A combination strategy inclusive of 5 evidence-based interventions aimed at multiple steps in the HIV care continuum was associated with significant increase in linkage to care plus 12-month retention. This strategy offers promise of enhanced outcomes for HIV-positive patients. TRIAL REGISTRATION ClinicalTrials.gov NCT01904994.
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Affiliation(s)
- Margaret L. McNairy
- ICAP at Columbia University, New York, New York, United States of America
- Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
- * E-mail:
| | - Matthew R. Lamb
- ICAP at Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Averie B. Gachuhi
- ICAP at Columbia University, New York, New York, United States of America
| | - Harriet Nuwagaba-Biribonwoha
- ICAP at Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Sean Burke
- ICAP at Columbia University, New York, New York, United States of America
| | | | - Velephi Okello
- Ministry of Health, Kingdom of Swaziland, Mbabane, Swaziland
| | - Peter Ehrenkranz
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Ruben Sahabo
- ICAP at Columbia University, New York, New York, United States of America
| | - Wafaa M. El-Sadr
- ICAP at Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
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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: 37] [Impact Index Per Article: 5.3] [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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Affiliation(s)
- Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania; Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jordyn Feingold
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew Vandertuyn
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania
| | - Tess Niewood
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine Cox
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin G Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania; Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - David A Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania; Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
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Marti J, Bachhuber M, Feingold J, Meads D, Richards M, Hennessy S. Financial incentives to discontinue long-term benzodiazepine use: a discrete choice experiment investigating patient preferences and willingness to participate. BMJ Open 2017; 7:e016229. [PMID: 28988167 PMCID: PMC5640034 DOI: 10.1136/bmjopen-2017-016229] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Investigate the acceptability of financial incentives for initiating a medically supervised benzodiazepine discontinuation programme among people with long-term benzodiazepine use and to identify programme features that influence willingness to participate. METHODS We conducted a discrete choice experiment in which we presented a variety of incentive-based programs to a sample of older adults with long-term benzodiazepine use identified using the outpatient electronic health record of a university-owned health system. We studied four programme variables: incentive amount for initiating the programme, incentive amount for successful benzodiazepine discontinuation, lottery versus certain payment and whether partial payment was given for dose reduction. Respondents reported their willingness to participate in the programmes and additional information was collected on demographics, history of use and anxiety symptoms. RESULTS The overall response rate was 28.4%. Among the 126 respondents, all four programme variables influenced stated preferences. Respondents strongly preferred guaranteed cash-based incentives as opposed to a lottery, and the dollar amount of both the starting and conditional incentives had a substantial impact on choice. Willingness to participate increased with the amount of conditional incentive. Programme participation also varied by gender, duration of use and income. CONCLUSIONS Participation in an incentive-based benzodiazepine discontinuation programme might be relatively low, but is modifiable by programme variables including incentive amounts. These results will be helpful to inform the design of future trials of benzodiazepine discontinuation programmes. Further research is needed to assess the financial viability and potential cost-effectiveness of such economic incentives.
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Affiliation(s)
- Joachim Marti
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Marcus Bachhuber
- Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Michael Richards
- Department of Health Policy, Vanderbilt University, Nashville, Tennessee, USA
| | - Sean Hennessy
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
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Pirnia B, Moradi AR, Pirnia K, Kolahi P, Roshan R. A Novel Therapy for cocaine dependence during abstinence: A randomized clinical trial. Electron Physician 2017; 9:4862-4871. [PMID: 28894547 PMCID: PMC5587005 DOI: 10.19082/4862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 02/02/2017] [Indexed: 01/22/2023] Open
Abstract
Background Topiramate is an anticonvulsant drug and an ideal candidate for reducing the craving in people relying on cocaine. Contingency management is one of the common therapies in the domain of addiction. Objective The present study aimed to evaluate and compare three medication methods of Topiramate (TPM), Contingency Management (CM) and the combined TPM treatment and cash intervention on craving during abstinence. Methods This randomized clinical trial was conducted at Bijan Center for Substance Abuse Treatment in Tehran, Iran, from December 15, 2014 to November 20, 2015. One hundred males (Age range=18–34; SD=4.11) undergoing abstinence were assigned randomly to four groups (n=25) of Topiramate (TPM), Contingency Management (CM) and the Combined Method plus a placebo control group. Treatment was provided for twelve weeks for the experiment groups, and only the control group received the placebo. Participants in the Cash-based and CM Condition had an identical 12-week escalating schedule of reinforcement (cash-based incentives worth $0, $20, $40, and $80). Also, in the Topiramate group, participants’ dosage ranged between 25–300 mg/day in escalating doses) 25, 50, 100, 150, 200, 250, 300). In addition, all subjects received brief behavioral compliance enhancement treatment (BBCET). Participants took a urine test twice a week, with a given threshold of > 300 ng/ml, and indicators of cocaine craving (response rate= 91%) was evaluated in two phases of pre-test and post-test. We used Chi square, ANCOVA Univariate Model and Scheffe’s post hoc to analyze the primary and secondary outcomes. Also, the qualitative data resulted from demographic evaluations were coded and analyzed by the instrument of analysis of qualitative data i.e. Atlas.ti, Version 5.2. Results The results showed that all three types of treatment played a significant efficacy in reducing the craving. The mean (95% CI) scores of craving was 12.04 (p=0.05) with TPM, 13.89 (p=0.05) with CM, 10.92 (p=0.01) with Mix and 16.89 (p>0.05) with control. Moreover, the highest variance explaining the changes in craving was assigned to the combined treatment (p<0.01). Conclusions The findings of this study, while having applicable aspects in this domain, can be helpful in planning supplementary remedial procedures. Trial registration The trial was registered at the Thai Clinical Trial Registration Center with the TCR ID: TCTR20170112001. Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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Affiliation(s)
- Bijan Pirnia
- Ph.D. Student of Clinical Psychology, Department of Psychology, Faculty of Humanities, University of Science and Culture, Tehran, Iran
| | - Ali Reza Moradi
- Ph.D. of Psychology, Professor, Department of Psychology, Faculty of Humanities, Kharazmi University, Tehran, Iran
| | - Kambiz Pirnia
- M.D., Internal disease specialist, Technical Assistant in Bijan Center for Substance Abuse Treatment, Tehran, Iran
| | - Parisa Kolahi
- Ph.D. Student of Psychology, Department of Psychology, Islamic Azad University, Central Tehran Branch, Tehran, Iran
| | - Rasool Roshan
- Ph.D. of Psychology, Professor, Department of Psychology, Faculty of Humanities, Shahed University, Tehran, Iran
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Kullgren JT, Hafez D, Fedewa A, Heisler M. A Scoping Review of Behavioral Economic Interventions for Prevention and Treatment of Type 2 Diabetes Mellitus. Curr Diab Rep 2017; 17:73. [PMID: 28755061 PMCID: PMC5619648 DOI: 10.1007/s11892-017-0894-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW The purpose of this paper was to review studies of behavioral economic interventions (financial incentives, choice architecture modifications, or commitment devices) to prevent type 2 diabetes mellitus (T2DM) among at-risk patients or improve self-management among patients with T2DM. RECENT FINDINGS We found 15 studies that used varied study designs and outcomes to test behavioral economic interventions in clinical, workplace, or health plan settings. Of four studies that focused on prevention of T2DM, two found that financial incentives increased weight loss and completion of a fasting blood glucose test, and two choice architecture modifications had mixed effects in encouraging completion of tests to screen for T2DM. Of 11 studies that focused on improving self-management of T2DM, four of six tests of financial incentives demonstrated increased engagement in recommended care processes or improved biometric measures, and three of five tests of choice architecture modifications found improvements in self-management behaviors. Though few studies have tested behavioral economic interventions for prevention or treatment of T2DM, those that have suggested such approaches have the potential to improve patient behaviors and such approaches should be tested more broadly.
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Affiliation(s)
- Jeffrey T Kullgren
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI, USA.
- Department of Internal Medicine, University of Michigan Medical School, 3101 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA.
- University of Michigan Institute for Healthcare Policy and Innovation, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.
| | - Dina Hafez
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, 3101 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, 2800 Plymouth Road, Building 10, Room G016, Ann Arbor, MI, 48109, USA
| | - Allison Fedewa
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, 2800 Plymouth Road, Building 10, Room G016, Ann Arbor, MI, 48109, USA
| | - Michele Heisler
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, 3101 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
- University of Michigan Institute for Healthcare Policy and Innovation, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
- Department of Health Behavior and Health Education, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA
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Chang LL, DeVore AD, Granger BB, Eapen ZJ, Ariely D, Hernandez AF. Leveraging Behavioral Economics to Improve Heart Failure Care and Outcomes. Circulation 2017; 136:765-772. [DOI: 10.1161/circulationaha.117.028380] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Leslie L. Chang
- From Duke Clinical Research Institute, Durham, NC (L.L.C., A.D.D., Z.J.E., A.F.H.); and School of Medicine (L.L.C., A.D.D., Z.J.E., A.F.H.), School of Nursing (B.B.G.), and Fuqua School of Business (D.A.), Duke University, Durham, NC
| | - Adam D. DeVore
- From Duke Clinical Research Institute, Durham, NC (L.L.C., A.D.D., Z.J.E., A.F.H.); and School of Medicine (L.L.C., A.D.D., Z.J.E., A.F.H.), School of Nursing (B.B.G.), and Fuqua School of Business (D.A.), Duke University, Durham, NC
| | - Bradi B. Granger
- From Duke Clinical Research Institute, Durham, NC (L.L.C., A.D.D., Z.J.E., A.F.H.); and School of Medicine (L.L.C., A.D.D., Z.J.E., A.F.H.), School of Nursing (B.B.G.), and Fuqua School of Business (D.A.), Duke University, Durham, NC
| | - Zubin J. Eapen
- From Duke Clinical Research Institute, Durham, NC (L.L.C., A.D.D., Z.J.E., A.F.H.); and School of Medicine (L.L.C., A.D.D., Z.J.E., A.F.H.), School of Nursing (B.B.G.), and Fuqua School of Business (D.A.), Duke University, Durham, NC
| | - Dan Ariely
- From Duke Clinical Research Institute, Durham, NC (L.L.C., A.D.D., Z.J.E., A.F.H.); and School of Medicine (L.L.C., A.D.D., Z.J.E., A.F.H.), School of Nursing (B.B.G.), and Fuqua School of Business (D.A.), Duke University, Durham, NC
| | - Adrian F. Hernandez
- From Duke Clinical Research Institute, Durham, NC (L.L.C., A.D.D., Z.J.E., A.F.H.); and School of Medicine (L.L.C., A.D.D., Z.J.E., A.F.H.), School of Nursing (B.B.G.), and Fuqua School of Business (D.A.), Duke University, Durham, NC
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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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Affiliation(s)
- Kevin G Volpp
- Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia.,Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania.,Health Care Management, Wharton School of the University of Pennsylvania, Philadelphia.,Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia.,LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Andrea B Troxel
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia.,Division of Biostatistics, New York University, New York
| | - Shivan J Mehta
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia.,Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania.,Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia.,LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Laurie Norton
- Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia.,LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia.,LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Raymond Lim
- Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia.,LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Wenli Wang
- University of Pennsylvania Health System, Philadelphia
| | - Noora Marcus
- Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia.,LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Christian Terwiesch
- Operations and Information Management, Wharton School of the University of Pennsylvania, Philadelphia
| | - Kristen Caldarella
- Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia.,LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | | | | | - Nathan Negin
- Horizon Blue Cross Blue Shield, Newark, New Jersey
| | | | | | | | - Brian Drachman
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Daniel Kolansky
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - David A Asch
- Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia.,Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania.,Health Care Management, Wharton School of the University of Pennsylvania, Philadelphia.,Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia.,LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
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The Effects of Providing Fixed Compensation and Lottery-Based Rewards on Uptake of Medical Male Circumcision in Kenya: A Randomized Trial. J Acquir Immune Defic Syndr 2017; 72 Suppl 4:S299-305. [PMID: 27404012 PMCID: PMC5054965 DOI: 10.1097/qai.0000000000001045] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Effective demand creation strategies are needed to increase uptake of medical male circumcision and reduce new HIV infections in eastern and southern Africa. Building on insights from behavioral economics, we assessed whether providing compensation for opportunity costs of time or lottery-based rewards can increase male circumcision uptake in Kenya. METHODS Uncircumcised men aged 21-39 years were randomized in 1:1:1 ratio to 2 intervention groups or a control group. One intervention group was offered compensation of US $12.50 conditional on circumcision uptake. Compensation was provided in the form of food vouchers. A second intervention group was offered the opportunity to participate in a lottery with high-value prizes on undergoing circumcision. The primary outcome was circumcision uptake within 3 months. RESULTS Among 903 participants enrolled, the group that received compensation of US $12.50 had the highest circumcision uptake (8.4%, 26/308), followed by the lottery-based rewards group (3.3%, 10/302), and the control group (1.3%, 4/299). Logistic regression analysis showed that compared with the control group, the fixed compensation group had significantly higher circumcision uptake [adjusted odds ratio 7.1; 95% CI: 2.4 to 20.8]. The lottery-based rewards group did not have significantly higher circumcision uptake than the control group (adjusted odds ratio 2.5; 95% CI: 0.8 to 8.1). CONCLUSIONS Providing compensation was effective in increasing circumcision uptake among men over a short period. The results are consistent with studies showing that such interventions can modify health behaviors by addressing economic barriers and behavioral biases in decision making. Contrary to findings from studies of other health behaviors, lottery-based rewards did not significantly increase circumcision uptake. TRIAL REGISTRATION Registry for International Development Impact Evaluations: RIDIE-STUDY-ID-530e60df56107.
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73
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Harkins KA, Kullgren JT, Bellamy SL, Karlawish J, Glanz K. A Trial of Financial and Social Incentives to Increase Older Adults' Walking. Am J Prev Med 2017; 52:e123-e130. [PMID: 28062271 DOI: 10.1016/j.amepre.2016.11.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 10/21/2016] [Accepted: 11/07/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Despite evidence that regular physical activity confers health benefits, physical activity rates among older adults remain low. Both personal and social goals may enhance older adults' motivation to become active. This study tested the effects of financial incentives, donations to charity, and the combined effects of both interventions on older adults' uptake and retention of increased levels of walking. STUDY DESIGN RCT comparing three interventions to control. Data collection occurred from 2012 to 2013. Analyses were conducted in 2013-2016. PARTICIPANTS Ninety-four adults aged ≥65 years from Philadelphia-area retirement communities. INTERVENTION All participants received digital pedometers, walking goals of a 50% increase in daily steps, and weekly feedback on goal attainment. Participants were randomized to one of four groups: (1) Control: received weekly feedback only; (2) Financial Incentives: received payment of $20 each week walking goals were met; (3) Social Goals: received donation of $20 to a charity of choice each week walking goals were met; and (4) Combined: received $20 each week walking goals were met that could be received by participant, donated to a charity of choice, or divided between the participant and charity. MAIN OUTCOME MEASURES Mean proportion of days walking goals were met during the 16-week intervention and 4-week follow-up period. RESULTS After adjusting for baseline walking, the proportion of days step goals were met during the 16-week intervention period was higher in all intervention groups versus controls (relative risk, 3.71; 95% CI=1.37, 10.01). During the 4-week follow up period, the proportion of days step goals were met did not differ in intervention groups compared to control (relative risk, 2.91; 95% CI=0.62, 13.64). CONCLUSIONS Incentive schemes that use donations to a charity of choice, personal financial incentives, or a combination of the two can each increase older adults' initial uptake of increased levels of walking. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT01643538.
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Affiliation(s)
- Kristin A Harkins
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey T Kullgren
- VA Center for Clinical Management Research and University of Michigan Medical School, Ann Arbor, Michigan
| | - Scarlett L Bellamy
- Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Jason Karlawish
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen Glanz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania.
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74
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Helm ME. Value-Based Insurance Design Pharmacy Benefits for Children and Youth With Special Health Care Needs: Principles and Opportunities. Pediatrics 2017; 139:S117-S126. [PMID: 28562309 DOI: 10.1542/peds.2016-2786f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 11/24/2022] Open
Abstract
Value-based insurance design (VBID) represents an innovative approach to health insurance coverage. In the context of pharmacy benefits, the goal of VBID is to minimize access barriers to the most effective and appropriate treatments for specific medical conditions. Both private and public insurance programs have explored VBID pharmacy projects primarily for medical conditions affecting adults. To date, evidence for VBID pharmacy programs for children and youth with special health care needs (CYSHCN) appears lacking. There appears to be potential for VBID concepts to be applied to pharmacy coverage benefiting CYSHCN. An overview of VBID pharmacy principles and guiding principles are presented. Opportunities for the creation of pharmacy programs with a value-based orientation and challenges to the redesign of pharmacy benefits are identified. VBID pharmacy coverage principles may be helpful to improve medication use and important clinical outcomes while lowering barriers to medication use for the population of CYSHCN. Pilot projects of VBID pharmacy benefits for children and youth should be explored. However, many questions remain.
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Affiliation(s)
- Mark E Helm
- Childhood Health Associates of Salem, Salem, Oregon
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75
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Medicare Spending and Evidence-Based Approach in Surgical Treatment of Thumb Carpometacarpal Joint Arthritis: 2001 to 2010. Plast Reconstr Surg 2017; 137:980e-989e. [PMID: 27219267 DOI: 10.1097/prs.0000000000002156] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Despite equivalent outcomes among surgical treatments of thumb carpometacarpal arthritis, little is known about the variation in spending. Because of its complexities, the authors hypothesized that trapeziectomy with ligament reconstruction and tendon interposition incurs the greatest cost to Medicare compared with other surgical procedures. METHODS Using a random 5 percent sample of Medicare beneficiaries diagnosed with thumb carpometacarpal joint arthritis, the authors examined total and out-of-pocket spending for 3530 patients who underwent a surgical treatment between 2001 and 2010. The authors used generalized linear regression models, controlling for patient characteristics and place of surgery, to examine variations in spending. RESULTS Eighty-nine percent of patients who underwent surgery received trapeziectomy with ligament reconstruction and tendon interposition, with total and out-of-pocket spending of $2576 (95 percent CI, $2333 to $2843; p < 0.001) and $436 (95 percent CI, $429 to $531; p < 0.001), respectively. Simple complete trapeziectomy was the least expensive procedure, performed in 5 percent of patients, with total and out-of-pocket spending of $1268 (95 percent CI, $1089 to $1476; p < 0.001) and $236 (95 percent CI, $180 to $258; p < 0.001), respectively. Because of increasingly higher facility costs, performing the same procedure in a hospital outpatient setting compared with an ambulatory center would increase Medicare spending by more than two-fold (p < 0.001). CONCLUSIONS With a consistent rise in health care spending, adherence to an evidence-based approach in medicine is more important than ever. Most surgeons continue to perform trapeziectomy with ligament reconstruction and tendon interposition, the most expensive surgical option. Medicare could potentially save $7.4 million annually if simple complete trapeziectomy was the procedure of choice.
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Abstract
OBJECTIVE Fixed incentives have been largely unsuccessful in improving adherence to antiretroviral medication. Therefore, we evaluate whether small incentives based on behavioral economic theory can increase adherence to antiretroviral medication among treatment-mature adults in Kampala, Uganda. DESIGN A randomized control trial design tests whether providing small incentives based on either attending timely clinic visits (intervention group 1) or achieving high medication adherence (intervention group 2) can increase antiretroviral adherence. Antiretroviral adherence is measured by medical event monitoring system (MEMS) caps. METHODS Overall, 155 HIV-infected men and women age 19-78 were randomized into one of two intervention groups and received small prizes of US $1.50 awarded through a drawing conditional on either attending scheduled clinic appointments or achieving at least 90% antiretroviral adherence. The control group received the usual standard of care. RESULTS Preliminary results based on pooling the intervention groups showed individuals receiving incentives were 23.7 percentage points more likely to achieve 90% antiretroviral adherence compared with the control group [95% confidence interval (CI), 6.7-40.7%]. Specifically, 63.3% (95% CI, 52.9-72.8%) of participants in the pooled intervention groups maintained at least 90% mean adherence during the first 9 months of the intervention, compared with 39.6% (95% CI, 25.8-54.7%) in the control group. CONCLUSION Small prize incentives resulted in a statistically significant increase in antiretroviral adherence. Although more traditional fixed incentives have not produced the desired results, these findings suggest that small incentives based on behavioral economic theory may be more effective in motivating long-term adherence among treatment-mature adults.
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77
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Kranker K. The Efficacy of Using Financial Incentives to Change Unhealthy Behaviors Among a Rural Chronically Ill and Uninsured Population. Am J Health Promot 2017; 32:301-311. [PMID: 28279086 DOI: 10.1177/0890117117696621] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To measure the effects of weight loss, medication compliance, and physical activity financial incentives delivered by health providers to uninsured patients. DESIGN Full factorial (orthogonal) randomized design. SETTING Primary care clinic in rural Mississippi. PARTICIPANTS A total of 544 uninsured adult patients with diabetes or hypertension. All patients were enrolled in the clinic's care management program. INTERVENTION Patients randomly received 0, 1, 2, or 3 financial incentives. Incentives for weight loss, medication compliance, and physical activity were awarded quarterly over 1 year. MEASURES Weight loss, medication compliance, physical activity, and 6 clinical measures related to diabetes and hypertension. ANALYSIS Cross-section and panel data regression models were used to compare outcomes for those who received incentives to those who did not receive incentives and to measure interaction effects. RESULTS Effects of the weight loss incentive were positive but statistically insignificant (-3.7 lb; P = .106), while medication compliance was high in both the treatment and control groups (+2.37 percentage points; P = .411), and physical activity take-up was very limited. Effects on clinical outcomes, as well as interaction effects between incentives, were mixed and generally statistically insignificant. CONCLUSION This study found little to no evidence that these financial incentives had beneficial effects on the incentivized behaviors in this setting. Likewise, the study found no effects on clinical outcomes nor any systematic evidence of interaction effects between 2 and 3 incentives.
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Affiliation(s)
- Keith Kranker
- 1 Mathematica Policy Research Inc, Princeton, NJ, USA
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78
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Reddy A, Huseman TL, Canamucio A, Marcus SC, Asch DA, Volpp K, Long JA. Patient and Partner Feedback Reports to Improve Statin Medication Adherence: A Randomized Control Trial. J Gen Intern Med 2017; 32:256-261. [PMID: 27612487 PMCID: PMC5330995 DOI: 10.1007/s11606-016-3858-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 07/22/2016] [Accepted: 08/24/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Simple nudges such as reminders and feedback reports to either a patient or a partner may facilitate improved medication adherence. OBJECTIVE To test the impact of a pill bottle used to monitor adherence, deliver a daily alarm, and generate weekly medication adherence feedback reports on statin adherence. DESIGN Three-month, three-arm randomized clinical trial (ClinicalTrials.gov identifier: NCT02480530). PARTICIPANTS One hundred and twenty-six veterans with known coronary artery disease and poor adherence (medication possession ratio <80 %). INTERVENTION Patients were randomized to one of three groups: (1) a control group (n = 36) that received a pill-monitoring device with no alarms or feedback; (2) an individual feedback group (n = 36) that received a daily alarm and a weekly medication adherence feedback report; and (3) a partner feedback group (n = 54) that received an alarm and a weekly feedback report that was shared with a friend, family member, or a peer. The intervention continued for 3 months, and participants were followed for an additional 3 months after the intervention period. MAIN MEASURES Adherence as measured by pill bottle. Secondary outcomes included change in LDL (mg/dl), patient activation, and social support. KEY RESULTS During the 3-month intervention period, medication adherence was higher in both feedback arms than in the control arm (individual feedback group 89 %, partner feedback group 86 %, control group 67 %; p < 0.001 and = 0.001). At 6 months, there was no difference in medication adherence between either of the feedback groups and the control (individual feedback 60 %, partner feedback 52 %, control group 54 %; p = 0.75 and 0.97). CONCLUSIONS Daily alarms combined with individual or partner feedback reports improved statin medication adherence. While neither an individual feedback nor partner feedback strategy created a sustainable medication adherence habit, the intervention itself is relatively easy to implement and low cost.
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Affiliation(s)
- Ashok Reddy
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA.
- UW Medicine Center for Scholarship in Patient Care Quality and Safety, Seattle, WA, USA.
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Suite BB1240, Box: 356526, Seattle, WA, 98195-6526, USA.
| | - Tiffany L Huseman
- VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Anne Canamucio
- VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Steven C Marcus
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin Volpp
- VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Judith A Long
- VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Pitt MB, Furnival RA, Zhang L, Weber-Main AM, Raymond NC, Jacob AK. Positive Peer-Pressured Productivity (P-QUAD): Novel Use of Increased Transparency and a Weighted Lottery to Increase a Division's Academic Output. Acad Pediatr 2017; 17:218-221. [PMID: 27888166 DOI: 10.1016/j.acap.2016.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/11/2016] [Accepted: 10/09/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Evaluate a dual incentive model combining positive peer pressure through increased transparency of peers' academic work with a weighted lottery where entries are earned based on degree of productivity. METHODS We developed a dual-incentive peer mentoring model, Positive Peer-Pressured Productivity (P-QUAD), for faculty in the Pediatric Hospital Medicine Division at the University of Minnesota Masonic Children's Hospital. This model provided relative value-based incentives, with points assigned to different scholarly activities (eg. 1 point for abstract submission, 2 points for poster presentation, 3 points for oral presentation, etc.). These points translated into to lottery tickets for a semi-annual drawing for monetary prizes. Productivity was compared among faculty for P-QUAD year to the preintervention year. RESULTS Fifteen (83%) of 18 eligible faculty members participated. Overall annual productivity per faculty member as measured by total P-QUAD score increased from a median of 3 (interquartile range [IQR] 0-14) in the preintervention year to 4 (IQR 0-27) in the P-QUAD year (P = .051). Submissions and acceptances increased in all categories except posters which were unchanged. Annual abstract submissions per faculty member significantly increased from a median of 1 (IQR 0-2) to 2 (IQR 0-2; P = .047). Seventy-three percent (8 of 11) of post-survey respondents indicated that the financial incentive motivated them to submit academic work; 100% indicated that increased awareness of their peers' work was a motivator. CONCLUSIONS The combination of increased awareness of peers' academic productivity and a weighted lottery financial incentive appears to be a useful model for stimulating academic productivity in early-career faculty.
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Affiliation(s)
- Michael B Pitt
- Department of Pediatrics, University of Minnesota School of Medicine & Masonic Children's Hospital, Minneapolis, Minn.
| | - Ronald A Furnival
- Department of Pediatrics, University of Minnesota School of Medicine & Masonic Children's Hospital, Minneapolis, Minn
| | - Lei Zhang
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minn
| | - Anne M Weber-Main
- Department of Medicine and Office of Faculty Affairs, University of Minnesota School of Medicine, Minneapolis, Minn
| | - Nancy C Raymond
- Department of Psychiatry, University of Minnesota School of Medicine & Masonic Children's Hospital, Minneapolis, Minn
| | - Abraham K Jacob
- Department of Pediatrics, University of Minnesota School of Medicine & Masonic Children's Hospital, Minneapolis, Minn
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80
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Gardiner CK, Bryan AD. Monetary Incentive Interventions Can Enhance Psychological Factors Related to Fruit and Vegetable Consumption. Ann Behav Med 2017; 51:599-609. [DOI: 10.1007/s12160-017-9882-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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81
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Pirnia B, Tabatabaei SKR, Tavallaii A, Soleimani AA, Pirnia K. The Efficacy of Contingency Management on Cocaine Craving, using Prize-based Reinforcement of Abstinence in Cocaine Users. Electron Physician 2017; 8:3214-3221. [PMID: 28070254 PMCID: PMC5217813 DOI: 10.19082/3214] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/25/2016] [Indexed: 01/23/2023] Open
Abstract
Introduction Contingency management (CM) is one of the most common therapies in the domain of drug addiction. This study has been carried out with the purpose of evaluating the efficacy of contingency management intervention. Method In an experimental design, between December 15, 2014 and November 20, 2015, fifty men (between 18 and 31 with an average age of 24.6) with a history of cocaine use, were selected voluntarily and were randomly assigned into two groups of CM and control group. The CM group were awarded coupons for negative urine tests, over a period of twelve weeks. The urine tests were taken from the participants twice per week, with cutoff concentrations for positive set at 300 ng/ml and self-reporting index of cocaine craving (response rate = 96%) were evaluated in two phase, through pretest and posttest measures. The data were analyzed by parametric covariance test. Additionally, the qualitative data, resulted from demographic measures, were coded and were analyzed with the help of an analysis instrument of qualitative data i.e. ATLAS.ti-5.2. Results The primary outcome was the number of negative urine tests and the secondary outcome included the cocaine usage craving index over twelve weeks. The mean of (95% of confidence) number of negative cocaine urine tests was 15.4 (13.1–17.8) in the CM group and 19.7 (17.7–21.6) in the control group (P = 0.049). Also, results showed that CM has a significant effect on reducing craving (p<0.01). Conclusion The findings of this study, while having practical aspects in this domain, can be valuable in planning remedial procedures.
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Affiliation(s)
- Bijan Pirnia
- PhD. Student of Clinical Psychology, Department of Psychology, Faculty of Humanities, University of Science and Culture, Tehran, Iran
| | | | - Abbas Tavallaii
- M.D., Psychiatric, Associate Professor, Department of Psychiatry, Faculty of Medicine, Behavioral Research Center, Baqyiatallah University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Soleimani
- Ph.D. of Psychology, Assistant Professor, Department of Psychology, Faculty of Humanities, University of Science and Culture, Tehran, Iran
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Abstract
Prophylactic clotting-factor regimens reduce the occurrence of bleeding episodes and maintain joint health in individuals with moderate and severe hemophilia. However, these outcomes are only achieved with adherence to prescribed prophylaxis regimens. There are several types of barriers to adherence related to key patient, condition, treatment, health-care system, and/or socioeconomic variables. Notably, health-care professionals may not prescribe prophylaxis if they perceive that a patient will be nonadherent. Prophylactic treatment strategies should be developed with the patient and family, focused on individualized treatment goals. Personalized strategies are needed to reinforce the importance of and encourage confidence in administering the regular infusions required for prophylactic therapy. These strategies may include verbal and written information delivered by health-care professionals, peers, and inter-active media. The advent of extended half-life clotting factors requiring less frequent infusion may improve adherence.
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Affiliation(s)
- Courtney D Thornburg
- Hemophilia and Thrombosis Treatment Center, Rady Children’s Hospital, San Diego, CA
- Correspondence: Courtney D Thornburg, Rady Children’s Hospital, 3020 Children’s Way – MC 5035, San Diego, CA 92123, USA, Tel +1 858 966 5811, Email
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83
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DiStefano MJ. Wearable Biometric Technologies and Public Health. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:79-81. [PMID: 27996903 DOI: 10.1080/15265161.2016.1251643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Michael J DiStefano
- a Johns Hopkins Berman Institute of Bioethics and Bloomberg School of Public Health
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84
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Mental health care among low-income pregnant women with depressive symptoms: facilitators and barriers to care access and the effectiveness of financial incentives for increasing care. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2016; 42:484-92. [PMID: 24898613 DOI: 10.1007/s10488-014-0562-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Access to mental health care is suboptimal for low-income pregnant women. Using in-depth interviews, we examined barriers and facilitators to accessing care among 42 low income pregnant women with depressive symptoms. To pilot whether financial incentives would increase utilization during pregnancy, half the women were randomized to receive $10 gift cards after mental health visits. Women reported external and internal barriers to accessing mental health care, and internal and interpersonal facilitators. Financial incentives did not impact how often the women visited mental health providers, suggesting that small incentives are not sufficient to catalyze mental health care use for this population.
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85
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Reese PP, Bloom RD, Trofe-Clark J, Mussell A, Leidy D, Levsky S, Zhu J, Yang L, Wang W, Troxel A, Feldman HI, Volpp K. Automated Reminders and Physician Notification to Promote Immunosuppression Adherence Among Kidney Transplant Recipients: A Randomized Trial. Am J Kidney Dis 2016; 69:400-409. [PMID: 27940063 DOI: 10.1053/j.ajkd.2016.10.017] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 10/10/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Immunosuppression nonadherence increases the risk for kidney transplant loss after transplantation. Wireless-enabled pill bottles have created the opportunity to monitor medication adherence in real time. Reminders may help patients with poor memory or organization. Provision of adherence data to providers may motivate patients to improve adherence and help providers identify adherence barriers. STUDY DESIGN Randomized controlled trial. SETTING & PARTICIPANTS Kidney transplant recipients (n=120) at a single center. INTERVENTION Participants were provided wireless pill bottles to store tacrolimus and record bottle openings. Participants were randomly assigned 1:1:1 to adherence monitoring with customized reminders (including alarms, texts, telephone calls, and/or e-mails), monitoring with customized reminders plus provider notification (every 2 weeks, providers received notification if adherence decreased to <90% during that period), or wireless pill bottle use alone (control). OUTCOMES The main outcome was bottle-measured tacrolimus adherence during the last 90 days of the 180-day trial. A secondary outcome was tacrolimus whole-blood concentrations at routine clinical visits. MEASUREMENTS Adherence for the primary outcome was assessed via wireless pill bottle openings. RESULTS Mean participant age was 50 years; 60% were men, and 40% were black. Mean adherence was 78%, 88%, and 55% in the reminders, reminders-plus-notification, and control arms (P<0.001 for comparison of each intervention to control). Mean tacrolimus levels were not significantly different between groups. LIMITATIONS The study did not assess clinical end points. Participants and study coordinators were not blinded to intervention arm. CONCLUSIONS Provider notification and customized reminders appear promising in helping patients achieve better medication adherence, but these strategies require evaluation in trials powered to detect differences in clinical outcomes.
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Affiliation(s)
- Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA.
| | - Roy D Bloom
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jennifer Trofe-Clark
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Adam Mussell
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Daniel Leidy
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Simona Levsky
- School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA
| | - Jingsan Zhu
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Lin Yang
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Wenli Wang
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Andrea Troxel
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Harold I Feldman
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Kevin Volpp
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Department of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, Philadelphia, PA; Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia, PA; Center for Health Equity Research and Promotion, Cresencz Philadelphia Veterans Affairs Medical Center, Philadelphia, PA
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86
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Kimmel SE, Troxel AB, French B, Loewenstein G, Doshi JA, Hecht TEH, Laskin M, Brensinger CM, Meussner C, Volpp K. A randomized trial of lottery-based incentives and reminders to improve warfarin adherence: the Warfarin Incentives (WIN2) Trial. Pharmacoepidemiol Drug Saf 2016; 25:1219-1227. [PMID: 27592594 DOI: 10.1002/pds.4094] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND Previous research has suggested that daily lottery incentives could improve medication adherence. Such daily incentives include implicit reminders. However, the comparative effectiveness of reminders alone versus daily incentives has not been tested. METHODS A total of 270 patients on warfarin were enrolled in a four-arm, multi-center, randomized controlled trial comparing a daily lottery-based incentive, a daily reminder, and a combination of the two against a control group (usual care). RESULTS Participants in the reminder group had the lowest percentage of time out of target international normalized ratio (INR) range, the primary outcome, with an adjusted odds of an out-of-range INR 36% lower than among those in the control group, 95%CI [7%, 55%]. No other group had a statistically significant improvement in anticoagulation control relative to the control group or to each other. The only group that had significant improvement in incorrect adherence was the lottery group (incorrect adherence: 12.1% compared with 23.7% in the control group, difference of -7.4% 95%CI [-14%, -0.3%]). However, there was no relationship between changes in adherence and anticoagulation control in the lottery group. CONCLUSIONS Automated reminders led to the largest improvements in anticoagulation control, although without impacting measured adherence. Lottery-based reminders improved measured adherence but did not lead to improved anticoagulation control. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Stephen E Kimmel
- Center for Therapeutic Effectiveness Research, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Andrea B Troxel
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin French
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - George Loewenstein
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Jalpa A Doshi
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Todd E H Hecht
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mitchell Laskin
- Department of Pharmacy Service, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen M Brensinger
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Meussner
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Health Care Management, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
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87
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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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Affiliation(s)
- Andrea B Troxel
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - David A Asch
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Shivan J Mehta
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Laurie Norton
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Devon Taylor
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Tirza A Calderon
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Raymond Lim
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jingsan Zhu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Daniel M Kolansky
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Brian M Drachman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kevin G Volpp
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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88
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DiStefano MJ, Schmidt H. mHealth for Tuberculosis Treatment Adherence: A Framework to Guide Ethical Planning, Implementation, and Evaluation. GLOBAL HEALTH: SCIENCE AND PRACTICE 2016; 4:211-21. [PMID: 27353615 PMCID: PMC4982246 DOI: 10.9745/ghsp-d-16-00018] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/14/2016] [Indexed: 11/15/2022]
Abstract
Promising mHealth approaches for TB treatment adherence include: Video observation Patient- or device-facilitated indirect monitoring Direct monitoring through embedded sensors or metabolite testing
To mitigate ethical concerns, our framework considers accuracy of monitoring technologies, stigmatization and intrusiveness of the technologies, use of incentives, and the balance of individual and public good.
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Affiliation(s)
- Michael J DiStefano
- University of Pennsylvania, Department of Medical Ethics and Health Policy, Philadelphia, PA, USA
| | - Harald Schmidt
- University of Pennsylvania, Department of Medical Ethics and Health Policy, Center for Health Incentives and Behavioral Economics, Philadelphia, PA, USA
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Kurti AN, Davis DR, Redner R, Jarvis BP, Zvorsky I, Keith DR, Bolivar HA, White TJ, Rippberger P, Markesich C, Atwood G, Higgins ST. A Review of the Literature on Remote Monitoring Technology in Incentive-Based Interventions for Health-Related Behavior Change. TRANSLATIONAL ISSUES IN PSYCHOLOGICAL SCIENCE 2016; 2:128-152. [PMID: 27777964 DOI: 10.1037/tps0000067] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Use of technology (e.g., Internet, cell phones) to allow remote implementation of incentives interventions for health-related behavior change is growing. To our knowledge, there has yet to be a systematic review of this literature reported. The present report provides a systematic review of the controlled studies where technology was used to remotely implement financial incentive interventions targeting substance use and other health behaviors published between 2004 and 2015. For inclusion in the review, studies had to use technology to remotely accomplish one of the following two aims alone or in combination: (a) monitor the target behavior, or (b) deliver incentives for achieving the target goal. Studies also had to examine financial incentives (e.g., cash, vouchers) for health-related behavior change, be published in peer-reviewed journals, and include a research design that allowed evaluation of the efficacy of the incentive intervention relative to another condition (e.g., non-contingent incentives, treatment as usual). Of the 39 reports that met inclusion criteria, 18 targeted substance use, 10 targeted medication adherence or home-based health monitoring, and 11 targeted diet, exercise, or weight loss. All 39 (100%) studies used technology to facilitate remote monitoring of the target behavior, and 26 (66.7%) studies also incorporated technology in the remote delivery of incentives. Statistically significant intervention effects were reported in 71% of studies reviewed. Overall, the results offer substantial support for the efficacy of remotely implemented incentive interventions for health-related behavior change, which have the potential to increase the cost-effectiveness and reach of this treatment approach.
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90
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Sung J. Fighting the oral disease epidemic: a call for more behavioral economics research. Perspect Public Health 2016; 136:125-6. [PMID: 27161272 DOI: 10.1177/1757913916638234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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91
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Judah G, Vlaev I, Gunn L, King D, King D, Valabhji J, Darzi A, Bicknell C. Incentives in Diabetic Eye Assessment by Screening (IDEAS): study protocol of a three-arm randomized controlled trial using financial incentives to increase screening uptake in London. BMC Ophthalmol 2016; 16:28. [PMID: 26993471 PMCID: PMC4797200 DOI: 10.1186/s12886-016-0206-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetes is an increasing public health problem in the UK and globally. Diabetic retinopathy is a microvascular complication of diabetes, and is one of the leading causes of blindness in the UK working age population. The diabetic eye screening programme in England aims to invite all people with diabetes aged 12 or over for retinal photography to screen for the presence of diabetic retinopathy. However, attendance rates are only 81 %, leaving many people at risk of preventable sight loss. METHODS This is a three arm randomized controlled trial to investigate the impact of different types of financial incentives (based on principles from behavioral economics) on increasing attendance at diabetic eye screening appointments in London. Eligible participants will be aged 16 or over, and are those who have been invited to screening appointments annually, but who have not attended, or telephoned to rearrange an appointment, within the last 24 months. Eligible participants will be randomized to one of three conditions: 1. Control condition (usual invitation letter) 2. Fixed incentive condition (usual invitation letter, including a voucher for £10 if they attend their appointment) 3. Probabilistic incentive condition (invitation letter, including a voucher for a 1 in 100 chance of winning £1000 if they attend their appointment). Participants will be sent invitation letters, and the primary outcome will be whether or not they attend their appointment. One thousand participants will be included in total, randomized with a ratio of 1.4:1:1. In order to test whether the incentive scheme has a differential impact on patients from different demographic or socio-economic groups, information will be recorded on age, gender, distance from screening center, socio-economic status and length of time since they were last screened. A cost-effectiveness analysis will also be performed. DISCUSSION This study will be the first trial of financial incentives for improving uptake of diabetic eye screening. If effective, the intervention may suggest a cost-effective way to increase screening rates, thus reducing unnecessary blindness. TRIAL REGISTRATION ISRCTN14896403, 25 February 2016.
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Affiliation(s)
- Gaby Judah
- />Department of Surgery and Cancer, Imperial College London, St. Mary’s Campus, Praed Street, London, W2 1NY UK
| | - Ivo Vlaev
- />Warwick Business School, University of Warwick, Scarman Road, Coventry, CV4 7AL Coventry, UK
| | - Laura Gunn
- />Department of Integrative Health Science, Stetson University, 421 North Woodland Blvd., DeLand, Florida 32723 USA
| | - Dominic King
- />Department of Surgery and Cancer, Imperial College London, St. Mary’s Campus, Praed Street, London, W2 1NY UK
| | - Derek King
- />Personal Social Services Research Unit, London School of Economics & Political Science, Houghton Street, London, WC2A 2AE UK
| | - Jonathan Valabhji
- />Imperial College Healthcare NHS Trust, St. Mary’s Hospital, Praed Street, London, W2 1NY UK
| | - Ara Darzi
- />Department of Surgery and Cancer, Imperial College London, St. Mary’s Campus, Praed Street, London, W2 1NY UK
| | - Colin Bicknell
- />Department of Surgery and Cancer, Imperial College London, St. Mary’s Campus, Praed Street, London, W2 1NY UK
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Bishop TF, Ryan AM, Chen MA, Mendelsohn J, Gottlieb D, Shih S, Desai P, Wolff EA, Casalino LP. A Randomized, Controlled Trial of a Shared Panel Management Program for Small Practices. Health Serv Res 2016; 51:1796-813. [PMID: 26846591 DOI: 10.1111/1475-6773.12455] [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: 11/30/2022] Open
Abstract
OBJECTIVES To determine whether a shared panel management program was effective at improving quality of care for patients with uncontrolled chronic disease. DATA SOURCES Data were extracted from electronic health records. STUDY DESIGN Randomized controlled trial of a panel management program initiated by New York City Department of Health and Mental Hygiene. Patients from 20 practices with an uncontrolled chronic disease and a lapse in care were assigned to the intervention (a phone call requesting that the patient schedule a physician appointment) or usual care. Outcomes were visits to physician practices, body mass index measurement, blood pressure measurement and control, use of antithrombotics, and low-density lipoprotein measurement and control. PRINCIPAL FINDINGS Panel managers were able to successfully speak with 1,676 patients (14.7 percent of the intervention group). There were no significant differences in outcomes between the intervention and usual care groups. Successfully contacted patients were more likely to have an office visit within 1 year of randomization (45.6 percent [95 percent CI: 22.8, 26.9] vs. 38.1 percent [95 percent CI: 36.8, 39.3]) and more likely to be on antithrombotics (24.4 percent [95 percent CI: 17.7, 31.0]) versus those in the usual care group (17.0 percent [95 percent CI: 13.9, 20.0]) but had no other difference in quality. CONCLUSIONS A shared, low-intensity panel management program run by a city health department did not improve quality of care for patients with chronic illnesses and lapses in care.
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Affiliation(s)
- Tara F Bishop
- Division of Healthcare Policy and Economics, Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY. .,Department of Medicine, Weill Cornell Medical College, New York, NY.
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Anna Arbor, MI
| | - Melinda A Chen
- Division of Healthcare Policy and Economics, Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY
| | | | - Daniel Gottlieb
- Bureau of the Primary Care Information Project, New York City Department of Health and Mental Hygiene, Long Island City, NY
| | - Sarah Shih
- Bureau of the Primary Care Information Project, New York City Department of Health and Mental Hygiene, Long Island City, NY
| | | | | | - Lawrence P Casalino
- Division of Healthcare Policy and Economics, Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY
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Asch DA, Troxel AB, Stewart WF, Sequist TD, Jones JB, Hirsch AG, Hoffer K, Zhu J, Wang W, Hodlofski A, Frasch AB, Weiner MG, Finnerty DD, Rosenthal MB, Gangemi K, Volpp KG. Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels: A Randomized Clinical Trial. JAMA 2015; 314:1926-35. [PMID: 26547464 PMCID: PMC5509443 DOI: 10.1001/jama.2015.14850] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Financial incentives to physicians or patients are increasingly used, but their effectiveness is not well established. OBJECTIVE To determine whether physician financial incentives, patient incentives, or shared physician and patient incentives are more effective than control in reducing levels of low-density lipoprotein cholesterol (LDL-C) among patients with high cardiovascular risk. DESIGN, SETTING, AND PARTICIPANTS Four-group, multicenter, cluster randomized clinical trial with a 12-month intervention conducted from 2011 to 2014 in 3 primary care practices in the northeastern United States. Three hundred forty eligible primary care physicians (PCPs) were enrolled from a pool of 421. Of 25,627 potentially eligible patients of those PCPs, 1503 enrolled. Patients aged 18 to 80 years were eligible if they had a 10-year Framingham Risk Score (FRS) of 20% or greater, had coronary artery disease equivalents with LDL-C levels of 120 mg/dL or greater, or had an FRS of 10% to 20% with LDL-C levels of 140 mg/dL or greater. Investigators were blinded to study group, but participants were not. INTERVENTIONS Primary care physicians were randomly assigned to control, physician incentives, patient incentives, or shared physician-patient incentives. Physicians in the physician incentives group were eligible to receive up to $1024 per enrolled patient meeting LDL-C goals. Patients in the patient incentives group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. Physicians and patients in the shared incentives group shared these incentives. Physicians and patients in the control group received no incentives tied to outcomes, but all patient participants received up to $355 each for trial participation. MAIN OUTCOMES AND MEASURES Change in LDL-C level at 12 months. RESULTS Patients in the shared physician-patient incentives group achieved a mean reduction in LDL-C of 33.6 mg/dL (95% CI, 30.1-37.1; baseline, 160.1 mg/dL; 12 months, 126.4 mg/dL); those in physician incentives achieved a mean reduction of 27.9 mg/dL (95% CI, 24.9-31.0; baseline, 159.9 mg/dL; 12 months, 132.0 mg/dL); those in patient incentives achieved a mean reduction of 25.1 mg/dL (95% CI, 21.6-28.5; baseline, 160.6 mg/dL; 12 months, 135.5 mg/dL); and those in the control group achieved a mean reduction of 25.1 mg/dL (95% CI, 21.7-28.5; baseline, 161.5 mg/dL; 12 months, 136.4 mg/dL; P < .001 for comparison of all 4 groups). Only patients in the shared physician-patient incentives group achieved reductions in LDL-C levels statistically different from those in the control group (8.5 mg/dL; 95% CI, 3.8-13.3; P = .002). CONCLUSIONS AND RELEVANCE In primary care practices, shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a statistically significant difference in reduction of LDL-C levels at 12 months. This reduction was modest, however, and further information is needed to understand whether this approach represents good value. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01346189.
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Affiliation(s)
- David A Asch
- University of Pennsylvania, Philadelphia2Department of Veterans Affairs, Philadelphia, Pennsylvania
| | | | | | - Thomas D Sequist
- Partners Healthcare System, Boston, Massachusetts5Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | - Wenli Wang
- University of Pennsylvania, Philadelphia
| | | | | | - Mark G Weiner
- Temple University School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Kevin G Volpp
- University of Pennsylvania, Philadelphia2Department of Veterans Affairs, Philadelphia, Pennsylvania
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Garza KB, Owensby JK, Braxton Lloyd K, Wood EA, Hansen RA. Pilot Study to Test the Effectiveness of Different Financial Incentives to Improve Medication Adherence. Ann Pharmacother 2015; 50:32-8. [PMID: 26447193 DOI: 10.1177/1060028015609354] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Medication nonadherence affects health care costs, morbidity, and mortality. Concepts from behavioral economics can guide the development of interventions to improve medication adherence. OBJECTIVE To measure the relative effectiveness of 2 behavioral economic-based incentive structures to improve medication adherence. METHODS This randomized controlled trial compared adherence among participants taking antihypertensive or antihyperlipidemic medications randomized to usual care (UC), guaranteed pay-out (GPO) incentives, or lottery incentives. Daily adherence was measured over a 90-day period using electronic caps (Medication Event Monitoring System [MEMS]). The GPO group received $30 up-front in a virtual account, with $0.50 deducted for each missed dose. Lottery group participants were eligible for a weekly $50 drawing, but only if they had taken their medication as prescribed all week. An electronic survey assessed self-reported adherence. Statistical analysis included descriptive statistics, paired t tests, ANOVA, and Pearson's correlations. RESULTS In all, 36 participants were randomized (UC, n = 11; GPO, n = 14; lottery, n = 11). Mean percentage (±SD) of days adherent during the incentive period was highest in the lottery group (96% ± 5%), followed by the GPO group (94% ± 9%) and the UC group (94% ± 9%). There were no statistically significant differences among groups (P > 0.05). MEMS-measured adherence was not significantly correlated with a patient's self-reported adherence (P > 0.05) at baseline but was correlated at 90-day follow-up (P < 0.001). CONCLUSIONS Although no statistically significant differences in adherence were demonstrated in this small sample of highly adherent participants, larger studies in a more diverse population or with other medications might show otherwise.
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Kurti AN. HOT THOUGHTS, COLD THOUGHTS, AND HARNESSING SELF-CONTROL: WALTER MISCHEL’S THE MARSHMALLOW TEST AND THE OTHER HALF OF THE EQUATION. AMERICAN JOURNAL OF PSYCHOLOGY 2015. [DOI: 10.5406/amerjpsyc.128.3.0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Hurley JC, Hollingshead KE, Todd M, Jarrett CL, Tucker WJ, Angadi SS, Adams MA. The Walking Interventions Through Texting (WalkIT) Trial: Rationale, Design, and Protocol for a Factorial Randomized Controlled Trial of Adaptive Interventions for Overweight and Obese, Inactive Adults. JMIR Res Protoc 2015; 4:e108. [PMID: 26362511 PMCID: PMC4704955 DOI: 10.2196/resprot.4856] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/06/2015] [Accepted: 08/11/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Walking is a widely accepted and frequently targeted health promotion approach to increase physical activity (PA). Interventions to increase PA have produced only small improvements. Stronger and more potent behavioral intervention components are needed to increase time spent in PA, improve cardiometabolic risk markers, and optimize health. OBJECTIVE Our aim is to present the rationale and methods from the WalkIT Trial, a 4-month factorial randomized controlled trial (RCT) in inactive, overweight/obese adults. The main purpose of the study was to evaluate whether intensive adaptive components result in greater improvements to adults' PA compared to the static intervention components. METHODS Participants enrolled in a 2x2 factorial RCT and were assigned to one of four semi-automated, text message-based walking interventions. Experimental components included adaptive versus static steps/day goals, and immediate versus delayed reinforcement. Principles of percentile shaping and behavioral economics were used to operationalize experimental components. A Fitbit Zip measured the main outcome: participants' daily physical activity (steps and cadence) over the 4-month duration of the study. Secondary outcomes included self-reported PA, psychosocial outcomes, aerobic fitness, and cardiorespiratory risk factors assessed pre/post in a laboratory setting. Participants were recruited through email listservs and websites affiliated with the university campus, community businesses and local government, social groups, and social media advertising. RESULTS This study has completed data collection as of December 2014, but data cleaning and preliminary analyses are still in progress. We expect to complete analysis of the main outcomes in late 2015 to early 2016. CONCLUSIONS The Walking Interventions through Texting (WalkIT) Trial will further the understanding of theory-based intervention components to increase the PA of men and women who are healthy, insufficiently active and are overweight or obese. WalkIT is one of the first studies focusing on the individual components of combined goal setting and reward structures in a factorial design to increase walking. The trial is expected to produce results useful to future research interventions and perhaps industry initiatives, primarily focused on mHealth, goal setting, and those looking to promote behavior change through performance-based incentives. TRIAL REGISTRATION ClinicalTrials.gov NCT02053259; https://clinicaltrials.gov/ct2/show/NCT02053259 (Archived by WebCite at http://www.webcitation.org/6b65xLvmg).
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Affiliation(s)
- Jane C Hurley
- Exercise Science and Health Promotion, School of Nutrition and Health Promotion, Arizona State University, Phoenix, AZ, United States
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Meeker D, Thompson C, Strylewicz G, Knight TK, Doctor JN. Use of Insurance Against a Small Loss as an Incentive Strategy. DECISION ANALYSIS 2015; 12:122-129. [PMID: 26966422 PMCID: PMC4782799 DOI: 10.1287/deca.2015.0314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The success of extended warranties and buyer protection plans suggests that insurance against a small loss has high decision utility. We explore whether the behavioral insight that people are highly averse to small chances of loss can be used to create a powerful incentive that has very low expected value. We compare decisions of individuals offered fixed payments for healthy choices to those offered insurance in exchange for healthy choices. We test the prediction that aversion to small losses will result in very high rates of health behavior uptake in exchange for insurance. Three hundred participants endowed with a $2 bonus randomly received one of two incentives for completing a scheduled health risk assessment: (1) an insurance guarantee against the 1% risk of losing the $2 bonus or (2) a fixed payment at the expected value of the insurance. Relative to the fixed payment condition, participants in the insurance intervention were 70% more likely to meet their health risk assessment appointment (p < 0.01). Fixed payments of $2.59 were needed for every $1 spent on insurance to achieve the same behavioral effect. Loss aversion, probability weighting, and the certainty effect may account for this result. Incentive design may benefit from utilizing an insurance paradigm.
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Affiliation(s)
- Daniella Meeker
- University of Southern California, Los Angeles, California 90033; and RAND Corporation, Santa Monica, California 90401
| | | | | | - Tara K. Knight
- University of Southern California, Los Angeles, California 90033
| | - Jason N. Doctor
- University of Southern California, Los Angeles, California 90033
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Münscher R, Vetter M, Scheuerle T. A Review and Taxonomy of Choice Architecture Techniques. JOURNAL OF BEHAVIORAL DECISION MAKING 2015. [DOI: 10.1002/bdm.1897] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Robert Münscher
- Centre for Social Investment; Heidelberg University; Heidelberg Germany
| | - Max Vetter
- Centre for Social Investment; Heidelberg University; Heidelberg Germany
| | - Thomas Scheuerle
- Centre for Social Investment; Heidelberg University; Heidelberg Germany
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Morewedge CK, Yoon H, Scopelliti I, Symborski CW, Korris JH, Kassam KS. Debiasing Decisions. ACTA ACUST UNITED AC 2015. [DOI: 10.1177/2372732215600886] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
From failures of intelligence analysis to misguided beliefs about vaccinations, biased judgment and decision making contributes to problems in policy, business, medicine, law, education, and private life. Early attempts to reduce decision biases with training met with little success, leading scientists and policy makers to focus on debiasing by using incentives and changes in the presentation and elicitation of decisions. We report the results of two longitudinal experiments that found medium to large effects of one-shot debiasing training interventions. Participants received a single training intervention, played a computer game or watched an instructional video, which addressed biases critical to intelligence analysis (in Experiment 1: bias blind spot, confirmation bias, and fundamental attribution error; in Experiment 2: anchoring, representativeness, and social projection). Both kinds of interventions produced medium to large debiasing effects immediately (games ≥ −31.94% and videos ≥ −18.60%) that persisted at least 2 months later (games ≥ −23.57% and videos ≥ −19.20%). Games that provided personalized feedback and practice produced larger effects than did videos. Debiasing effects were domain general: bias reduction occurred across problems in different contexts, and problem formats that were taught and not taught in the interventions. The results suggest that a single training intervention can improve decision making. We suggest its use alongside improved incentives, information presentation, and nudges to reduce costly errors associated with biased judgments and decisions.
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Reese PP, Mgbako O, Mussell A, Potluri V, Yekta Z, Levsky S, Bellamy S, Parikh CR, Shults J, Glanz K, Feldman HI, Volpp K. A Pilot Randomized Trial of Financial Incentives or Coaching to Lower Serum Phosphorus in Dialysis Patients. J Ren Nutr 2015; 25:510-7. [PMID: 26231324 DOI: 10.1053/j.jrn.2015.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 05/19/2015] [Accepted: 06/05/2015] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Among chronic hemodialysis patients, hyperphosphatemia is common and associated with mortality. Behavioral economics and complementary behavior-change theories may offer valuable approaches to achieving phosphorus (PO4) control. The aim was to determine feasibility of implementing financial incentives and structured coaching to improve PO4 in the hemodialysis setting. DESIGN AND METHODS This pilot randomized controlled trial was conducted in 3 urban dialysis units for 10 weeks among 36 adults with elevated serum PO4 (median >5.5 mg/dL over 3 months). INTERVENTIONS Twelve participants each were randomized to: (1) financial incentives for lowering PO4, (2) coaching about dietary and medication adherence, or (3) usual care. PO4 was measured during routine clinic operations. Each incentives arm participant received the equivalent of $1.50/day if the PO4 was ≤5.5 mg/dL or >5.5 mg/dL but decreased ≥0.5 mg/dL since the prior measurement. The coach was instructed to contact coaching arm participants at least 3 times per week. MAIN OUTCOME MEASURES The outcome measures included: (1) enrollment rate, (2) dropout rate, and (3) change in PO4 from beginning to end of 10-week intervention period. RESULTS Of 66 eligible patients, 36 (55%) enrolled. Median age was 53 years, 83% were black race, and 78% were male. Median baseline PO4 was 6.0 (interquartile range 5.6, 7.5). Using stratified generalized estimation equation analyses, the monthly decline in PO4 was -0.32 mg/dL (95% CI -0.60, -0.04) in the incentives arm, -0.40 mg/dL (-0.60, -0.20) in the coaching arm, and -0.24 mg/dL (-0.60, 0.08) in the usual care arm. No patients dropped out. All intervention arm participants expressed interest in receiving similar support in the future. CONCLUSIONS This pilot trial demonstrated good feasibility in enrollment and implementation of novel behavioral health strategies to reduce PO4 in dialysis patients.
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Affiliation(s)
- Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | | | - Adam Mussell
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Zahra Yekta
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Simona Levsky
- School of Arts & Sciences, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scarlett Bellamy
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chirag R Parikh
- Program of Applied Translational Research, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut; Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Justine Shults
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen Glanz
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harold I Feldman
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin Volpp
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
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