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Berardi V, Phillips CB, McEntee ML, Stecher C, Todd M, Adams MA. The Impact of Monetary Incentives on Delay Discounting Within a Year-Long Physical Activity Intervention. Ann Behav Med 2024; 58:341-352. [PMID: 38507617 PMCID: PMC11008587 DOI: 10.1093/abm/kaae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Delay discounting is the depreciation in a reward's perceived value as a function of the time until receipt. Monetary incentive programs that provide rewards contingent on meeting daily physical activity (PA) goals may change participants' delay discounting preferences. PURPOSE Determine if monetary incentives provided in close temporal proximity to meeting PA goals changed delay discounting, and if such changes mediated intervention effects. METHODS Inactive adults (n = 512) wore accelerometers during a 12-month intervention where they received proximal monetary incentives for meeting daily moderate-to-vigorous PA (MVPA) goals or delayed incentives for study participation. Delay discount rate and average MVPA were assessed at baseline, end of intervention, and a 24-month follow-up. Using structural equation modeling, we tested effects of proximal versus delayed rewards on delay discounting and whether any changes mediated intervention effects on MVPA. PA self-efficacy was also evaluated as a potential mediator, and both self-efficacy and delay discounting were assessed as potential moderators of intervention effects. RESULTS Proximal rewards significantly increased participants' delay discounting (β = 0.238, confidence interval [CI]: -0.078, 0.380), indicating greater sensitivity to reinforcement timing. This change did not mediate incentive-associated increases in MVPA at the end of the 12-month intervention (β = -0.016, CI: -0.053, 0.019) or at a 24-month follow-up (β = -0.020, CI: -0.059, 0.018). Moderation effects were not found. CONCLUSIONS Incentive-induced increases in delay discounting did not deleteriously impact MVPA. This finding may help assuage concerns about using monetary incentives for PA promotion, but further research regarding the consequences of changes in delay discounting is warranted.
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Affiliation(s)
- Vincent Berardi
- Department of Psychology, Chapman University, Orange, CA, USA
| | | | - Mindy L McEntee
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Chad Stecher
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Michael Todd
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA
| | - Marc A Adams
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
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Keyser HHD, Brinton JT, Bothwell S, Camacho M, Kempe A, Szefler SJ. Encouraging adherence in adolescents with asthma using financial incentives: An RCT. Pediatr Pulmonol 2023; 58:2823-2831. [PMID: 37449768 PMCID: PMC10538420 DOI: 10.1002/ppul.26594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/12/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Medication adherence in adolescents remains a significant management challenge and innovative strategies are needed to improve medication adherence. Financial incentives have been used to improve outcomes for health behaviors among adults, but have not been well-studied among adolescents. The objective of this study was to test if a modest financial incentive improved medication adherence in adolescents with asthma compared with a control group. METHODS Participants were randomized to either control (electronic medication monitoring [EMM] with App reminders/feedback for 4 months) or intervention (EMM + $1 per day for perfect medication adherence for 3 months [maximum $84] followed by 1 month of EMM only). A repeated measures mixed model, with a first order autoregressive correlation structure between errors, was used to test the null hypothesis for an interaction of treatment group and week. RESULTS Fifty-two participants were enrolled, and 48 completed primary analysis. Mean adherence rates declined in both groups over time, and there was no significant difference in the change in adherence rates between the groups (F-statistic = 0.72, ndf = 15, ddf = 625, p = 0.76). Adherence rates (during the 12 weeks when incentives were given) declined from 80% to 64% in the control group, and from 90% to 58% in the incentive group. There was no significant change in the slope of decline in the incentives group in the month following payment discontinuation. CONCLUSION A modest financial incentive did not lead to significantly different medication adherence rates in adolescents with asthma who were receiving a monitoring and reminder intervention. Further study is needed to determine viable interventions to optimize medication use in this group.
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Affiliation(s)
- Heather H De Keyser
- Breathing Institute, Children's Hospital Colorado, Los Angeles, California, USA
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and The Childrens Hospital, Aurora, Colorado, USA
| | - John T Brinton
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Samantha Bothwell
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Megan Camacho
- Breathing Institute, Children's Hospital Colorado, Los Angeles, California, USA
| | - Allison Kempe
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and The Childrens Hospital, Aurora, Colorado, USA
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital Colorado, Los Angeles, California, USA
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and The Childrens Hospital, Aurora, Colorado, USA
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Bilger M, Shah M, Tan NC, Tan CYL, Bundoc FG, Bairavi J, Finkelstein EA. Process- and Outcome-Based Financial Incentives to Improve Self-Management and Glycemic Control in People with Type 2 Diabetes in Singapore: A Randomized Controlled Trial. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 14:555-567. [PMID: 33491116 PMCID: PMC8357673 DOI: 10.1007/s40271-020-00491-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sub-optimally controlled diabetes increases risks for adverse and costly complications. Self-management including glucose monitoring, medication adherence, and exercise are key for optimal glycemic control, yet, poor self-management remains common. OBJECTIVE The main objective of the Trial to Incentivize Adherence for Diabetes (TRIAD) study was to determine the effectiveness of financial incentives in improving glycemic control among type 2 diabetes patients in Singapore, and to test whether process-based incentives tied to glucose monitoring, medication adherence, and physical activity are more effective than outcome-based incentives tied to achieving normal glucose readings. METHODS TRIAD is a randomized, controlled, multi-center superiority trial. A total of 240 participants who had at least one recent glycated hemoglobin (HbA1c) being 8.0% or more and on oral diabetes medication were recruited from two polyclinics. They were block-randomized (blocking factor: current vs. new glucometer users) into the usual care plus (UC +) arm, process-based incentive arm, and outcome-based incentive arm in a 2:3:3 ratio. The primary outcome was the mean change in HbA1c at month 6 and was linearly regressed on binary variables indicating the intervention arms, baseline HbA1c levels, a binary variable indicating titration change, and other baseline characteristics. RESULTS Our findings show that the combined incentive arms trended toward better HbA1c than UC + , but the difference is estimated with great uncertainty (difference - 0.31; 95% confidence interval [CI] - 0.67 to 0.06). Lending credibility to this result, the proportion of participants who reduced their HbA1c is higher in the combined incentive arms relative to UC + (0.18; 95% CI 0.04, 0.31). We found a small improvement in process- relative to outcome-based incentives, but this was again estimated with great uncertainty (difference - 0.05; 95% CI - 0.42 to 0.31). Consistent with this improvement, process-based incentives were more effective at improving weekly medication adherent days (0.64; 95% CI - 0.04 to 1.32), weekly physically active days (1.37; 95% CI 0.60-2.13), and quality of life (0.04; 95% CI 0.0-0.07) than outcome-based incentives. CONCLUSION This study suggests that both incentive types may be part of a successful self-management strategy. Process-based incentives can improve adherence to intermediary outcomes, while outcome-based incentives focus on glycemic control and are simpler to administer.
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Affiliation(s)
- Marcel Bilger
- Health Economics and Policy, Vienna University of Business and Economics, Vienna, Austria.
| | - Mitesh Shah
- SingHealth Polyclinics, Singapore, Singapore
| | | | | | - Filipinas G Bundoc
- Health Services and Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Joann Bairavi
- Health Services and Systems Research Program, Duke-NUS Medical School, Singapore, Singapore
| | - Eric A Finkelstein
- Health Services and Systems Research Program, Duke-NUS Medical School, Singapore, Singapore.,Duke Global Health Institute, Duke University, Durham, USA
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Chepulis L, Morison B, Cassim S, Norman K, Keenan R, Paul R, Lawrenson R. Barriers to Diabetes Self-Management in a Subset of New Zealand Adults with Type 2 Diabetes and Poor Glycaemic Control. J Diabetes Res 2021; 2021:5531146. [PMID: 34136579 PMCID: PMC8177985 DOI: 10.1155/2021/5531146] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/02/2021] [Accepted: 05/21/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite the fact that there is an increasingly effective armoury of medications to treat diabetes, many people continue to have substantially elevated blood glucose levels. The purpose of this study was to explore what the barriers to diabetes management are in a cohort of people with diabetes and poor glycaemic control. METHODS Qualitative semistructured interviews were carried out with 10 people with diabetes who had known diabetes and a recent HbA1c of >11.3% (100 mmol/mol) to explore their experiences of barriers to diabetes self-management and glycaemic control. RESULTS Barriers to diabetes management were based around two key themes: biopsychosocial factors and knowledge about diabetes. Specifically, financial concerns, social stigma, medication side effects, and cognitive impairment due to hyperglycaemia were commonly reported as barriers to medication use. Other barriers included a lack of knowledge about their own condition, poor relationships with healthcare professionals, and a lack of relevant resources to support diet and weight loss. CONCLUSION People with diabetes with poor glycaemic control experience many of the same barriers as those reported elsewhere, but also experience issues specifically related to their severe hyperglycaemia. Management of diabetes could be improved via the increased use of patient education and availability of locally relevant resources.
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Affiliation(s)
- Lynne Chepulis
- Medical Research Centre, University of Waikato, Hamilton, New Zealand
| | - Brittany Morison
- Medical Research Centre, University of Waikato, Hamilton, New Zealand
| | - Shemana Cassim
- Medical Research Centre, University of Waikato, Hamilton, New Zealand
| | - Kimberley Norman
- Medical Research Centre, University of Waikato, Hamilton, New Zealand
| | - Rawiri Keenan
- Medical Research Centre, University of Waikato, Hamilton, New Zealand
| | - Ryan Paul
- Medical Research Centre, University of Waikato, Hamilton, New Zealand
- Waikato District Health Board, Waikato, Hamilton, New Zealand
| | - Ross Lawrenson
- Medical Research Centre, University of Waikato, Hamilton, New Zealand
- Waikato District Health Board, Waikato, Hamilton, New Zealand
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O'Donnell A, Angus C, Hanratty B, Hamilton FL, Petersen I, Kaner E. Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time-series analysis. Addiction 2020; 115:49-60. [PMID: 31599022 DOI: 10.1111/add.14778] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/24/2019] [Accepted: 08/06/2019] [Indexed: 12/24/2022]
Abstract
AIM To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care. DESIGN Interrupted time-series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006-31 March 2008); (2) during the implementation of financial incentives (1 April 2008-31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015-31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points. SETTING England. PARTICIPANTS Newly registered patients (16+) in 500 primary care practices for 2006-16 (n = 4 278 723). MEASUREMENTS The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher-risk drinking; and (3) were reported as having received brief advice on alcohol consumption. FINDINGS There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21-3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87-14.23) per 1000 patients screening positive for higher-risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen-positive rates of 29.96 (95% CI = 19.56-40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51-2.77) per 1000. Screen-positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30-28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26-0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97-24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28-1.12) per 1000 per month. CONCLUSIONS Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme.
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Affiliation(s)
- Amy O'Donnell
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Colin Angus
- Sheffield Alcohol Research Group, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Barbara Hanratty
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona L Hamilton
- Primary Care and Population Health, University College London, London, UK
| | - Irene Petersen
- Primary Care and Population Health, University College London, London, UK
| | - Eileen Kaner
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Greene JC, Haun JN, French DD, Chambers SL, Roswell RH. Reduced Hospitalizations, Emergency Room Visits, and Costs Associated with a Web-Based Health Literacy, Aligned-Incentive Intervention: Mixed Methods Study. J Med Internet Res 2019; 21:e14772. [PMID: 31625948 PMCID: PMC6823604 DOI: 10.2196/14772] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The association between health literacy and health care costs, particularly for hospitalizations and emergency room services, has been previously observed. Health information interventions aimed at addressing the negative impacts of inadequate health literacy are needed. The MedEncentive Mutual Accountability and Information Therapy (MAIT) Program is a Web-based system designed to improve health and lower costs by aligning patient-doctor incentives. OBJECTIVE In this mixed methods study of a Web-based patient-doctor aligned-incentive, information therapy program conducted in an 1800-member employee health plan, we aimed to (1) determine the program's quantitative impact on hospitalization and emergency room utilization and costs, and (2) assess survey responses about the program's perceived value. METHODS We used a mixed methods, single within-group, pre-post, descriptive study design. We analyzed quantitative data using pre-post mean utilization and cost differences and summarized the data using descriptive statistics. We used open-ended electronic survey items to collect descriptive data and analyzed them using thematic content analysis. RESULTS Hospitalizations and emergency room visits per 1000 decreased 32% (26.5/82.4) and 14% (31.3/219.9), respectively, after we implemented the program in 2015-2017, relative to 2013-2014. Correspondingly, the plan's annual per capita expenditures declined US $675 (95% CI US $470-865), or 10.8% ($675/$6260), after program implementation in 2015-2017 (US $5585 in 2013-2014 dollars), relative to the baseline years of 2013-2014 (US $6260; P<.05). Qualitative findings suggested that respondents valued the program, benefiting from its educational and motivational aspects to better self-manage their health. CONCLUSIONS Analyses suggested that the reported reductions in hospitalizations, emergency room visits, and costs were associated with the program. Qualitative findings indicated that targeted users perceived value in participating in the MAIT Program. Further research with controls is needed to confirm these outcomes and more completely understand the health improvement and cost-containment capabilities of this Web-based health information, patient-doctor, aligned-incentive program.
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Affiliation(s)
| | - Jolie N Haun
- College of Public Health, University of South Florida, Tampa, FL, United States
| | - Dustin D French
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Susan L Chambers
- Oklahoma City Gynecology & Obstetrics, Oklahoma City, OK, United States
| | - Robert H Roswell
- University of Oklahoma College of Medicine, Health Administration and Policy, University of Oklahoma College of Public Health, Oklahoma City, OK, United States
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Vlaev I, King D, Darzi A, Dolan P. Changing health behaviors using financial incentives: a review from behavioral economics. BMC Public Health 2019; 19:1059. [PMID: 31391010 PMCID: PMC6686221 DOI: 10.1186/s12889-019-7407-8] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 07/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Incentives are central to economics and are used across the public and private sectors to influence behavior. Recent interest has been shown in using financial incentives to promote desirable health behaviors and discourage unhealthy ones. MAIN TEXT If we are going to use incentive schemes to influence health behaviors, then it is important that we give them the best chance of working. Behavioral economics integrates insights from psychology with the laws of economics and provides a number of robust psychological phenomena that help to better explain human behavior. Individuals' decisions in relation to incentives may be shaped by more subtle features - such as loss aversion, overweighting of small probabilities, hyperbolic discounting, increasing payoffs, reference points - many of which have been identified through research in behavioral economics. If incentives are shown to be a useful strategy to influence health behavior, a wider discussion will need to be had about the ethical dimensions of incentives before their wider implementation in different health programmes. CONCLUSIONS Policy makers across the world are increasingly taking note of lessons from behavioral economics and this paper explores how key principles could help public health practitioners design effective interventions both in relation to incentive designs and more widely.
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Affiliation(s)
- Ivo Vlaev
- Warwick Business School, University of Warwick, Coventry, UK.
| | - Dominic King
- Centre for Health Policy, Imperial College London, London, UK.
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Paul Dolan
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
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Kim DD, Cohen JT, Wong JB, Mohit B, Fendrick AM, Kent DM, Neumann PJ. Targeted Incentive Programs For Lung Cancer Screening Can Improve Population Health And Economic Efficiency. Health Aff (Millwood) 2019; 38:60-67. [PMID: 30615528 DOI: 10.1377/hlthaff.2018.05148] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Because an intervention's clinical benefit depends on who receives it, a key to improving the efficiency of lung cancer screening with low-dose computed tomography (LDCT) is to incentivize its use among the current or former smokers who are most likely to benefit from it. Despite its clinical advantages and cost-effectiveness, only 3.9 percent of the eligible population underwent LDCT screening in 2015. Using individual lung cancer mortality risk, we developed a policy simulation model to explore the potential impact of implementing risk-targeted incentive programs, compared to either implementing untargeted incentive programs or doing nothing. We found that compared to the status quo, an untargeted incentive program that increased overall LDCT screening from 3,900 (baseline) to 10,000 per 100,000 eligible people would save 12,300 life-years and accrue a net monetary benefit (NMB) of $771 million over a lifetime horizon. Increasing screening by the same amount but targeting higher-risk people would yield an additional 2,470-6,600 life-years and an additional $210-$560 million NMB, depending on the extent of the risk-targeting. Risk-targeted incentive programs could include provider-level bonuses, health plan premium subsidies, and smoking cessation programs to maximize their impact. As clinical medicine becomes more personalized, targeting and incentivizing higher-risk people will help enhance population health and economic efficiency.
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Affiliation(s)
- David D Kim
- David D. Kim ( ) is an assistant professor of medicine in the School of Medicine, Tufts University, and an investigator in the Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, in Boston, Massachusetts
| | - Joshua T Cohen
- Joshua T. Cohen is a research associate professor of medicine in the School of Medicine, Tufts University, and deputy director of the Center for the Evaluation of Value and Risk in Health, Tufts Medical Center
| | - John B Wong
- John B. Wong is a professor of medicine in the School of Medicine, Tufts University, and chief of the Division of Clinical Decision Making, Tufts Medical Center
| | - Babak Mohit
- Babak Mohit is a postdoctoral research fellow in the Center for the Evaluation of Value and Risk in Health, Tufts Medical Center
| | - A Mark Fendrick
- A. Mark Fendrick is a professor in the Department of Internal Medicine, University of Michigan, in Ann Arbor
| | - David M Kent
- David M. Kent is a professor of medicine in the School of Medicine, Tufts University, and director of the Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center
| | - Peter J Neumann
- Peter J. Neumann is a professor of medicine in the School of Medicine, Tufts University, and director of the Center for the Evaluation of Value and Risk in Health, Tufts Medical Center
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Pantell MS, Prather AA, Downing JM, Gordon NP, Adler NE. Association of Social and Behavioral Risk Factors With Earlier Onset of Adult Hypertension and Diabetes. JAMA Netw Open 2019; 2:e193933. [PMID: 31099868 PMCID: PMC6537925 DOI: 10.1001/jamanetworkopen.2019.3933] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE The National Academy of Medicine has recommended incorporating information on social and behavioral factors associated with health, such as educational level and exercise, into electronic health records, but questions remain about the clinical value of doing so. OBJECTIVE To examine whether National Academy of Medicine-recommended social and behavioral risk factor domains are associated with earlier onset of hypertension and/or diabetes in a clinical population. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study used data collected from April 1, 2005, to December 31, 2016, from a population-based sample of 41 745 patients from 4 cycles of Kaiser Permanente Northern California's Adult Member Health Survey, administered to members at 19 Kaiser Permanente Northern California medical center service populations. The study used Kaplan-Meier survival tables and Cox proportional hazards regression analysis to estimate the onset of hypertension and diabetes among patients with no indication of disease at baseline. Data analysis was performed from June 2, 2017, to March 26, 2019. EXPOSURES Race/ethnicity, educational level, financial worry, partnership status, stress, intimate partner violence, concentrated neighborhood poverty, depressive symptoms, infrequent exercise, smoking, heavy alcohol consumption, and cumulative social and behavioral risk. MAIN OUTCOMES AND MEASURES Onset of hypertension and diabetes during the 3.5 years after survey administration. RESULTS The study included 18 133 people without baseline hypertension (mean [SD] age, 48.1 [15.3] years; 10 997 [60.7%] female; and 11 503 [63.4%] white) and 35 788 people without baseline diabetes (mean [SD] age, 56.2 [16.9] years; 20 191 [56.4%] female; and 24 351 [68.0%] white). There was a dose-response association between the number of social and behavioral risk factors and likelihood of onset of each condition. Controlling for age, sex, race/ethnicity, body mass index, and survey year, hazard ratios (HRs) comparing those with 3 or more risk factors with those with 0 risk factor were 1.41 (95% CI, 1.17-1.71) for developing hypertension and 1.53 (95% CI, 1.29-1.82) for developing diabetes. When the same covariates were adjusted for, having less than a high school educational level (hazard ratio [HR], 1.84; 95% CI, 1.40-2.43), being widowed (HR, 1.38; 95% CI, 1.11-1.71), concentrated neighborhood poverty (HR, 1.26; 95% CI, 1.00-1.59), infrequent exercise (HR, 1.22; 95% CI, 1.08-1.38), and smoking (HR, 1.35; 95% CI, 1.10-1.67) were significantly associated with hypertension onset. Having less than a high school educational level (HR, 1.58; 95% CI, 1.26-1.97), financial worry (HR, 1.29; 95% CI, 1.13-1.46), being single or separated (HR, 1.24; 95% CI, 1.08-1.42), high stress (HR, 1.28; 95% CI, 1.09-1.51), intimate partner violence (HR, 1.68; 95% CI, 1.14-2.48), concentrated neighborhood poverty (HR, 1.31; 95% CI, 1.07-1.60), depressive symptoms (HR, 1.28; 95% CI, 1.10-1.50), and smoking (HR, 1.53; 95% CI, 1.27-1.86) were significantly associated with diabetes onset, although heavy alcohol consumption was associated with protection (HR, 0.75; 95% CI, 0.66-0.85) rather than risk. CONCLUSIONS AND RELEVANCE Independent of traditional risk factors, individual and cumulative social and behavioral risk factor exposures were associated with onset of hypertension and diabetes within 3.5 years in a clinical setting. The findings support the value of assessing social and behavioral risk factors to help identify high-risk patients and of providing targets for intervention.
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Affiliation(s)
| | - Aric A. Prather
- Department of Psychiatry, University of California, San Francisco
| | - Jae M. Downing
- Department of Health Management and Policy, School of Public Health, Oregon Health & Science University, Portland
- Department of Health Systems & Policy, School of Public Health, Oregon Health & Science University, Portland
| | - Nancy P. Gordon
- Kaiser Permanente Division of Research, Kaiser Permanente Northern California, Oakland
| | - Nancy E. Adler
- Department of Pediatrics, University of California, San Francisco
- Department of Psychiatry, University of California, San Francisco
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10
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Humphries B, Irwin A, Zoratti M, Xie F. How do financial (dis)incentives influence health behaviour and costs? Protocol for a systematic literature review of randomised controlled trials. BMJ Open 2019; 9:e024694. [PMID: 31023752 PMCID: PMC6501998 DOI: 10.1136/bmjopen-2018-024694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION In this era of rising healthcare costs, there is a growing interest in understanding how funding policies can be used to improve health and healthcare efficiency. Financial incentives (eg, vouchers or access to health insurance) or disincentives (eg, fines or out-of-pocket costs) affect behaviours. To date, reviews have explored the effects of financial (dis)incentives on patient health and behaviour by focusing on specific behaviours or geographical areas. The objective of this systematic review is to provide a comprehensive overview on the use of financial (dis)incentives as a means of influencing health-related behaviour and costs in randomised trials. METHODS AND ANALYSIS We will search electronic databases, clinical trial registries and websites of health economic organisations for randomised controlled trials. The initial searches, which were conducted on 13 January 2018, will be updated every 12 months until the completion of data analysis. The reference lists of included studies will be manually screened to identify additional eligible studies. Two researchers will independently review titles, abstracts and full texts to determine eligibility according to a set of predetermined inclusion criteria. Data will be extracted from included studies using a form developed and piloted by the research team. Discrepancies will be resolved through discussion with a third reviewer. Risk of bias will be assessed using the Cochrane Collaboration tool. ETHICS AND DISSEMINATION Ethics approval is not required since this is a review of published data. Results will be disseminated through publication in peer-reviewed journals and presentations at relevant conferences. PROSPERO REGISTRATION NUMBER CRD42018097140.
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Affiliation(s)
- Brittany Humphries
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Irwin
- Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York City, New York, USA
| | - Michael Zoratti
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Canada
- Program for Health Economics and Outcome Measures (PHENOM), McMaster University, Hamilton, Ontario, Canada
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van der Tol A, Lameire N, Morton RL, Van Biesen W, Vanholder R. An International Analysis of Dialysis Services Reimbursement. Clin J Am Soc Nephrol 2019. [PMID: 30545819 DOI: 10.2215/cjn.0815071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND AND OBJECTIVES The prevalence of patients with ESKD who receive extracorporeal kidney replacement therapy is rising worldwide. We compared government reimbursement for hemodialysis and peritoneal dialysis worldwide, assessed the effect on the government health care budget, and discussed strategies to reduce the cost of kidney replacement therapy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Cross-sectional global survey of nephrologists in 90 countries to assess reimbursement for dialysis, number of patients receiving hemodialysis and peritoneal dialysis, and measures to prevent development or progression of CKD, conducted online July to December of 2016. RESULTS Of the 90 survey respondents, governments from 81 countries (90%) provided reimbursement for maintenance dialysis. The prevalence of patients per million population being treated with long-term dialysis in low- and middle-income countries increased linearly with Gross Domestic Product per capita (GDP per capita), but was substantially lower in these countries compared with high-income countries where we did not observe an higher prevalence with higher GDP per capita. The absolute expenditure for dialysis by national governments showed a positive association with GDP per capita, but the percent of total health care budget spent on dialysis showed a negative association. The percentage of patients on peritoneal dialysis was low, even in countries where peritoneal dialysis is better reimbursed than hemodialysis. The so-called peritoneal dialysis-first policy without financial incentive seems to be effective in increasing the utilization of peritoneal dialysis. Few countries actively provide CKD prevention. CONCLUSIONS In low- and middle-income countries, reimbursement of dialysis is insufficient to treat all patients with ESKD and has a disproportionately high effect on public health expenditure. Current reimbursement policies favor conventional in-center hemodialysis.
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Affiliation(s)
- Arjan van der Tol
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium; and
| | - Norbert Lameire
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium; and
| | - Rachael L Morton
- National Health and Medical Research Council Clinical Trials Centre, Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Wim Van Biesen
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium; and
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium; and
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van der Tol A, Lameire N, Morton RL, Van Biesen W, Vanholder R. An International Analysis of Dialysis Services Reimbursement. Clin J Am Soc Nephrol 2018; 14:84-93. [PMID: 30545819 PMCID: PMC6364535 DOI: 10.2215/cjn.08150718] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 10/07/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The prevalence of patients with ESKD who receive extracorporeal kidney replacement therapy is rising worldwide. We compared government reimbursement for hemodialysis and peritoneal dialysis worldwide, assessed the effect on the government health care budget, and discussed strategies to reduce the cost of kidney replacement therapy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Cross-sectional global survey of nephrologists in 90 countries to assess reimbursement for dialysis, number of patients receiving hemodialysis and peritoneal dialysis, and measures to prevent development or progression of CKD, conducted online July to December of 2016. RESULTS Of the 90 survey respondents, governments from 81 countries (90%) provided reimbursement for maintenance dialysis. The prevalence of patients per million population being treated with long-term dialysis in low- and middle-income countries increased linearly with Gross Domestic Product per capita (GDP per capita), but was substantially lower in these countries compared with high-income countries where we did not observe an higher prevalence with higher GDP per capita. The absolute expenditure for dialysis by national governments showed a positive association with GDP per capita, but the percent of total health care budget spent on dialysis showed a negative association. The percentage of patients on peritoneal dialysis was low, even in countries where peritoneal dialysis is better reimbursed than hemodialysis. The so-called peritoneal dialysis-first policy without financial incentive seems to be effective in increasing the utilization of peritoneal dialysis. Few countries actively provide CKD prevention. CONCLUSIONS In low- and middle-income countries, reimbursement of dialysis is insufficient to treat all patients with ESKD and has a disproportionately high effect on public health expenditure. Current reimbursement policies favor conventional in-center hemodialysis.
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Affiliation(s)
- Arjan van der Tol
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium; and
| | - Norbert Lameire
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium; and
| | - Rachael L Morton
- National Health and Medical Research Council Clinical Trials Centre, Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Wim Van Biesen
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium; and
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium; and
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13
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Killeen Á, Geoghegan R, Flaherty G. Documentation and follow-up of anthropometric measurements of hospitalised patients. Eur J Prev Cardiol 2018; 27:1004-1006. [PMID: 30354742 DOI: 10.1177/2047487318809496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Á Killeen
- School of Medicine, National University of Ireland Galway, Ireland.,National Institute for Preventive Cardiology, Ireland
| | - R Geoghegan
- School of Medicine, National University of Ireland Galway, Ireland
| | - G Flaherty
- School of Medicine, National University of Ireland Galway, Ireland.,National Institute for Preventive Cardiology, Ireland
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A Quality Improvement Bundle Including Pay for Performance for the Standardization of Order Set Use in Moderate Asthma. Pediatr Emerg Care 2018; 34:740-742. [PMID: 30281577 DOI: 10.1097/pec.0000000000001627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE In order to standardize use of our hospital's computerized asthma order set, which was developed based on an asthma clinical practice guideline, for moderately ill children presenting for care of asthma, we developed a quality improvement bundle, including a time-limited pay-for-performance component, for pediatric emergency department and pediatric urgent care faculty members. METHODS Following baseline measurement, we used a run-in period for education, feedback, and improvement of the asthma order set. Then, faculty members earned 0.1% of salary during each of 10 successive months (evaluation period) in which the asthma order set was used in managing 90% or more of eligible patients. RESULTS At baseline, the asthma order set was used in managing 60.5% of eligible patients. Order set use rose sharply during the run-in period. During the 10-month evaluation period, use of the asthma order set was significantly above baseline, with a mean of 91.6%; faculty earned pay-for-performance bonuses during 8 of 10 possible months. Following completion of the evaluation period, asthma order set use remained high. CONCLUSIONS A quality improvement bundle, including a time-limited pay-for-performance component, was associated with a sustained increase in the use of a computerized asthma order set for managing moderately ill asthmatic children.
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O’Leary JF, Howe J, Rich J, Melnick G. Lessons from the Real World: Financial Incentives to Improve Glycemic Control in Patients with Type 2 Diabetes. Health (London) 2018. [DOI: 10.4236/health.2018.102014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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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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Frail CK, Cooper S, Gallagher T, Sarkis J, Topor L, Bruzek RJ. A technology-supported collaboration between a health plan and a community pharmacy to improve blood pressure control. J Am Pharm Assoc (2003) 2017; 57:630-634. [PMID: 28712738 DOI: 10.1016/j.japh.2017.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 04/28/2017] [Accepted: 05/30/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To assess the impact of a health plan and community pharmacy partnership to improve blood pressure control. SETTING A midwestern health plan and a regional community pharmacy chain. PRACTICE INNOVATION Health plan members with a hypertension diagnosis and attributed to the pharmacy chain based on prescription claims were invited to participate. Interested patients enrolled in the program at their pharmacies and were assigned a "smart card" for use with a blood pressure kiosk in the pharmacy. When the card was used at the kiosk, individual patient readings were linked directly to their electronic pharmacy record and an online patient portal. Pharmacists intervened with patients and prescribers as necessary to address adherence issues and adjust therapy as needed. EVALUATION Before and after blood pressure readings were assessed to determine the impact of patient self-monitoring and pharmacist intervention for patients with 1) uncontrolled blood pressure at first reading and 2) multiple readings throughout the pilot period. RESULTS Fifty-six of 276 eligible patients (20%) were enrolled in the program. Fourteen patients qualified for before and after assessments, having uncontrolled blood pressure on initial reading and multiple readings throughout the pilot. These patients demonstrated a mean reduction in systolic blood pressure of 12 mm Hg and diastolic blood pressure of 8 mm Hg. Nine of 16 eligible pharmacy locations enrolled patients at their sites. Challenges faced in the initiative included gaining adequate pharmacist and patient engagement. CONCLUSION The pilot demonstrated promising early results in a model that has potential to improve blood pressure monitoring and management in a community pharmacy setting.
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Barnard LS, Wexler DJ, DeWalt D, Berkowitz SA. Material need support interventions for diabetes prevention and control: a systematic review. Curr Diab Rep 2015; 15:574. [PMID: 25620406 DOI: 10.1007/s11892-014-0574-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Unmet material needs, such as food insecurity and housing instability, are associated with increased risk of diabetes and worse outcomes among diabetes patients. Healthcare delivery organizations are increasingly held accountable for health outcomes that may be related to these "social determinants," which are outside the scope of traditional medical intervention. This review summarizes the current literature regarding interventions that provide material support for income, food, housing, and other basic needs. In addition, we propose a conceptual model of the relationship between unmet needs and diabetes outcomes and provide recommendations for future interventional research.
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Affiliation(s)
- Lily S Barnard
- Tufts University Biology and Community Health Programs, Medford, MA, USA
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Gopalan A, Tahirovic E, Moss H, Troxel AB, Zhu J, Loewenstein G, Volpp KG. Translating the hemoglobin A1C with more easily understood feedback: a randomized controlled trial. J Gen Intern Med 2014; 29:996-1003. [PMID: 24567202 PMCID: PMC4061357 DOI: 10.1007/s11606-014-2810-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 10/17/2013] [Accepted: 02/04/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Previous work has indicated that for patients with diabetes, there is value in understanding glycemic control. Despite these findings, patient understanding of the hemoglobin A1C value (A1C) is notably poor. In this study, we test the effect of two alternative communication formats of the A1C on improving glycemic control among patients with poorly controlled diabetes. METHODS 177 patients with poorly controlled diabetes were randomized to one of three study arms that varied in the information they received: (1) a "diabetes report card" containing individualized information about glycemic control for each participant with letter grades ranging from A to F; (2) a "report card" containing a face whose emotion reflected current glycemic control; or (3) a "report card" with glycemic control expressed with the A1C value (standard arm). The primary study outcome was change in A1C at 6 months. Secondary outcomes included changes in participant perceptions of their glycemic control. RESULTS The average A1C for enrolled participants was 9.9 % (S.D. 1.7) and did not differ significantly among study arms. We noted no significant differences in change in A1C at 6 months between the standard and experimental arms. Using multiple imputation to account for missing A1C values, the changes in A1C for the letter grade, face, and standard arms were -0.55 % (-1.15, 0.05), -0.89 % (-1.49, -0.29), and -0.74 % (-1.51, 0.029), respectively (p = 0.67 for control vs. grade, p = 0.76 for control vs. face). DISCUSSION Feedback to patients with poorly controlled diabetes in the form of letter grades and faces did not differentially impact glycemic control at 6 months or participant perceptions of current control. These efforts to improve communication and patient understanding of disease management targets need further refinement to significantly impact diabetes outcomes. CLINICAL TRIAL ID NCT01143870.
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Affiliation(s)
- Anjali Gopalan
- The Philadelphia VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA,
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