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Xu L, Tong Q, Zhang X, Yu T, Lian X, Yu T, Falter M, Scherrenberg M, Kaihara T, Kizilkilic SE, Kindermans H, Dendale P, Li F. Smartphone-based gamification intervention to increase physical activity participation among patients with coronary heart disease: A randomized controlled trial. J Telemed Telecare 2024; 30:1425-1436. [PMID: 36794484 DOI: 10.1177/1357633x221150943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Despite proven benefits, patients with coronary heart disease (CHD) typically fail to participate in sufficient physical activity (PA). Effective interventions should be implemented to help patients maintain a healthy lifestyle and modify their present behavior. Gamification is the use of game design features (such as points, leaderboards, and progress bars) to improve motivation and engagement. It shows the potential for encouraging patients to engage in PA. However, empirical evidence on the efficacy of such interventions among patients with CHD is still emerging. PURPOSE The aim of the study is to explore whether a smartphone-based gamification intervention could increase PA participation and other physical and psychological outcomes in CHD patients. METHODS Participants with CHD were randomly assigned to three groups (control group, individual group, and team group). The individual and team groups received gamified behavior intervention based on behavioral economics. The team group combined gamified intervention with social interaction. The intervention lasted for 12 weeks, and the follow-up was12 weeks. The primary outcomes included the change in daily steps and the proportion of patient days that step goals were achieved. The secondary outcomes included competence, autonomy, relatedness, and autonomous motivation. RESULTS For the individual group, smartphone-based gamification intervention significantly increased PA among CHD patients over the 12-week period (step count difference 988; 95% CI 259-1717; p < 0.01) and had a good maintenance effect during the follow-up period (step count difference 819; 95% CI 24-1613; p < 0.01). There are also significant differences in competence, autonomous motivation, body mass index (BMI), and waist circumference in 12 weeks between the control group and individual group. For the team group, gamification intervention with collaboration didn't result in significant increases in PA. But patients in this group had a significant increase in competence, relatedness, and autonomous motivation. CONCLUSION A smartphone-based gamification intervention was proven to be an effective way to increase motivation and PA engagement, with a substantial maintenance impact (Chinese Clinical Trial Registry Identifier: ChiCTR2100044879).
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Affiliation(s)
- Linqi Xu
- School of Nursing, Jilin University, Changchun, China
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
| | - Qian Tong
- Department of Cardiology, First Hospital of Jilin University, Changchun, China
| | - Xin Zhang
- School of Nursing, Jilin University, Changchun, China
| | - Tianzhuo Yu
- School of Nursing, Jilin University, Changchun, China
| | - Xiaoqian Lian
- School of Nursing, Jilin University, Changchun, China
| | - Tianyue Yu
- School of Nursing, Jilin University, Changchun, China
| | - Maarten Falter
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
- Faculty of Medicine, Department of Cardiology, KU Leuven, Leuven, Belgium
| | - Martijn Scherrenberg
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
- Faculty of Medicine and Health Sciences, Antwerp University, Leuven, Belgium
| | - Toshiki Kaihara
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
- Division of Cardiology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Japan
| | - Sevda Ece Kizilkilic
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
| | - Hanne Kindermans
- Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
| | - Paul Dendale
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
| | - Feng Li
- School of Nursing, Jilin University, Changchun, China
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Taj U, Grimani A, Read D, Vlaev I. Using Games to Simulate Medication Adherence and Nonadherence: Laboratory Experiment in Gamified Behavioral Simulation. JMIR Serious Games 2024; 12:e47141. [PMID: 39316506 PMCID: PMC11444231 DOI: 10.2196/47141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 02/15/2024] [Accepted: 03/17/2024] [Indexed: 09/26/2024] Open
Abstract
Background Medical nonadherence is a significant problem associated with worse clinical outcomes, higher downstream rehospitalization rates, and a higher use of resources. To improve medication adherence, it is vital for researchers and practitioners to have a solid theoretical understanding of what interventions are likely to work. To achieve this understanding, we propose that researchers should focus on creating small-scale laboratory analogs to the larger real-world setting and determine what interventions, such as nudges or incentives, work to change behavior in the laboratory. To do this, we took inspiration from the literature on serious games and gamification and experimental economics. We call our approach "gamified behavioral simulation." In this paper, we modeled everyday life as the state of being engaged in a simple but addictive game, illness as being interruptions to the functionality of that game, treatment as being a series of actions that can be taken to prevent or mitigate those interruptions, and adherence as sticking to a prescribed rule for the application of those actions. Objective This study carries out a behavioral diagnosis of the medication adherence problem through a theoretically informed framework and then develops the gamified behavioral modeling approach to simulate medication nonadherence. Methods A laboratory experiment was conducted using a modified popular and addictive open-source video game called "2048," which created an abstract model for the medication adherence behavior observed in real life. In total, 509 participants were assigned to the control and 4 intervention groups ("incentive" group, "reminder" group, "commitment device" group, and "elongated duration for symptoms" group). Results The results of the modeling experiment showed that having theoretically informed interventions can increase the likelihood for them to be successful. In particular, there is evidence that the use of reminders improves the medication adherence rates for patients, and the same result was found in the modeling experiment, as they improved adherence significantly by 23% (95% CI -33.97% to -11.72%; P<.001). However, providing an incentive did not improve the adherence rate. We also tested the use of commitment devices, which, in line with real-world evidence, did not improve adherence rates. The fourth treatment tested elongated duration for symptoms, which attempted to show the power of modeling experiments where we test a what-if scenario that is extremely difficult to test in a real setting. The results indicated that if symptoms last longer, people did not adhere more to their medication regimen. Conclusions Gamified behavioral simulation is a useful tool to explain real health behaviors and help in identifying which interventions are most likely to work in a randomized trial.
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Affiliation(s)
- Umar Taj
- Behavioural Science Group, Warwick Business School, University of Warwick, Scarman Road, Coventry, CV4 7AL, United Kingdom, 44 024-765-24498
| | - Aikaterini Grimani
- Behavioural Science Group, Warwick Business School, University of Warwick, Scarman Road, Coventry, CV4 7AL, United Kingdom, 44 024-765-24498
| | - Daniel Read
- Behavioural Science Group, Warwick Business School, University of Warwick, Scarman Road, Coventry, CV4 7AL, United Kingdom, 44 024-765-24498
| | - Ivo Vlaev
- Behavioural Science Group, Warwick Business School, University of Warwick, Scarman Road, Coventry, CV4 7AL, United Kingdom, 44 024-765-24498
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Pierce LJ, Were MC, Amaral S, Aliyu MH, Ezechi O, David A, Idigbe I, Musa AZ, Okonkwo P, Dowshen N, Ahonkhai AA. PEERNaija-a mobile health platform incentivizing medication adherence among youth living with HIV in Nigeria: study protocol for a randomized controlled trial. Pilot Feasibility Stud 2023; 9:179. [PMID: 37891681 PMCID: PMC10605971 DOI: 10.1186/s40814-023-01404-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Poor medication adherence is a major barrier to HIV control among youth living with HIV (Y-PLWH). The PEERNaija application (app) is an adapted smartphone app grounded in social cognitive and contigency management theories and designed to harness peer-based social incentives and conditional financial incentives to promote medication adherence. The app delivers a multifaceted medication adherence intervention including (1) peer-based social incentives, (2) financial incentives, (3) virtual peer social support, and (4) early clinic-based outreach for non-adherent Y-PLWH. A pilot trial of the app will be conducted in Nigeria, Africa's most populous country with the 4th largest HIV epidemic, and home to 10% of the world's four million Y-PLWH. METHODS In this randomized controlled trial, we will compare implementation outcomes (feasibility, acceptability, appropriateness measured via validated scales, enrollment and application installation rates, feedback surveys and focus group discussions with participants, and back-end application data), and preliminary efficacy (in improving medication adherence and viral suppression) of the PEERNaija app at 6 months. Participants in Arm 1 (PEERNaija) will receive daily medication reminders, peer-based social incentives, and virtual peer social support. Participants in Arm 2 (PEERNaija +) will additionally receive a conditional financial incentive based on their adherence performance. Eligibility for Y-PLWH includes (1) being aged 14-29 years, (2) being on ART, (3) owning a smartphone, (4) being willing to download an app, and (5) being able to read simple text in English. DISCUSSION This study will serve as the basis for a larger intervention trial evaluating the PEERNaija app (and the integration of mHealth, incentive, and peer-support-based strategies) to improve HIV outcomes in a critically important region of the world for Y-PLWH. TRIAL REGISTRATION ClinicalTrials.gov. NCT04930198. First submitted date: May 25, 2021. Study start: August 1, 2021, https://clinicaltrials.gov/ . PROTOCOL VERSION January 21, 2022.
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Affiliation(s)
- Leslie J Pierce
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Martin C Were
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandra Amaral
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Muktar H Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oliver Ezechi
- Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Agatha David
- Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Ifeoma Idigbe
- Nigerian Institute of Medical Research, Lagos, Nigeria
| | | | | | - Nadia Dowshen
- Craig-Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aima A Ahonkhai
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Medicine, Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA.
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, MA, USA.
- Harvard University Center for AIDS Research, Boston, MA, USA.
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Hospital MM, Contreras-Pérez ME, Alessi SM, Langwerden RJ, Morris SL, Wagner EF. Mindfulness as an early intervention for hazardous alcohol use among non-treatment seeking Latine emerging adults: A mini-review. Addict Behav 2023; 145:107759. [PMID: 37276788 DOI: 10.1016/j.addbeh.2023.107759] [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] [Received: 12/05/2022] [Revised: 05/17/2023] [Accepted: 05/24/2023] [Indexed: 06/07/2023]
Abstract
The age cohort referred to as emerging adults (ages 18-29 years old) demonstrates the most hazardous alcohol use in the United States (U.S.) Approximately one-third of emerging adults regularly engage in heavy episodic drinking (4/5 drinks in two hours females/males). Compared to their non-Latine White peers, Latine emerging adults in the U.S. report lower rates of heavy episodic drinking (HED) yet are at greater risk of developing a substance use disorder and experience more severe negative consequences from drinking alcohol. Despite their high-risk status, Latine emerging adults are less likely to seek treatment and have less access to innovative health-promoting resources, further exacerbating health inequities. Research has shown that practicing mindfulness can interrupt habituated cognitions, intrusive thinking, and automatic behaviors associated with hazardous drinking. However, Latine representation in MBI trials is minimal. This mini-review explores the potential value of mindfulness as an early intervention for hazardous alcohol use among Latine emerging adults. The review provides future directions for research, highlighting the need to design culturally and developmentally tailored MBIs that can provide a respectful, non-judgmental, and discrimination-free environment that appeals to Latine emerging adults. Additionally, conclusions are drawn regarding the possible benefits of pairing MBI with contingency management strategies to decrease attrition rates in MBI trials.
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Affiliation(s)
- Michelle M Hospital
- Community-Based Research Institute, Florida International University, Miami, FL 33199, USA; Research Center in a Minority Institution, Florida International University, Miami, FL 33199, USA; Department of Biostatistics, Florida International University, Miami, FL 33199, USA.
| | - María Eugenia Contreras-Pérez
- Community-Based Research Institute, Florida International University, Miami, FL 33199, USA; Research Center in a Minority Institution, Florida International University, Miami, FL 33199, USA; School of Social Work, Florida International University, Miami, FL 33199, USA.
| | - Sheila M Alessi
- Department of Medicine and the Calhoun Cardiology Center - Behavioral Health Division, University of Connecticut School of Medicine, Farmington, CT 06030-3944, USA.
| | - Robbert J Langwerden
- Community-Based Research Institute, Florida International University, Miami, FL 33199, USA; Research Center in a Minority Institution, Florida International University, Miami, FL 33199, USA.
| | - Staci Leon Morris
- Community-Based Research Institute, Florida International University, Miami, FL 33199, USA; Research Center in a Minority Institution, Florida International University, Miami, FL 33199, USA; School of Social Work, Florida International University, Miami, FL 33199, USA.
| | - Eric F Wagner
- Community-Based Research Institute, Florida International University, Miami, FL 33199, USA; Research Center in a Minority Institution, Florida International University, Miami, FL 33199, USA; School of Social Work, Florida International University, Miami, FL 33199, USA.
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Ebinger JE, Ghai I, Barajas D, Vallejo R, Blyler CA, Morales M, Garcia N, Joung S, Palimaru A, Linnemayr S. Behavioural Economics to Improve Antihypertensive Therapy Adherence (BETA): protocol for a pilot randomised controlled trial in Los Angeles. BMJ Open 2023; 13:e066101. [PMID: 36697048 PMCID: PMC9884869 DOI: 10.1136/bmjopen-2022-066101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Non-adherence to antihypertensive therapy is one of the major barriers to reducing the risk of cardiovascular disease. Several interventions have targeted higher medication adherence, yet most do not result in sustained adherence. Routinisation has emerged as a potential method for mitigating this problem, but requires high motivation during the relatively long habit formation phase. This pilot randomised controlled trial aims to test the feasibility, acceptability, and preliminary efficacy of behavioural economics-based incentives and text messages to support the routinisation of the medication-taking behaviour for promoting long-term medication adherence. METHODS AND ANALYSIS This study will recruit and randomly assign 60 adult patients seeking care for hypertension at the Cedars-Sinai Medical Center in Los Angeles to one of the three groups, Control (n=20), Messages (n=20) and Incentives (n=20) in a 1:1:1 ratio. All participants will receive information about the importance of routinisation and will select an existing behavioural routine ('anchor') to which they will tie their pill-taking to, and the corresponding time. Additionally, participants in the Messages group will receive daily text messages reminding them of the importance of routines, while those in the Incentives group will receive daily text messages and conditional prize drawings. The interventions will be delivered over three months. Participants will be followed for six months post-intervention to measure behavioural persistence. Surveys will be administered at baseline, month-3 and month-9 visits. Primary outcomes include: (1) electronically measured mean medication adherence during the intervention period and (2) post-intervention period; and (3) mean timely medication adherence based around the time of the participants' anchor during the intervention period, and (4) post-intervention period. ETHICS AND DISSEMINATION The study was approved by the Cedars-Sinai Institutional Review Board (Study ID: Pro00057764). Findings will be published in scientific peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04029883.
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Affiliation(s)
- Joseph E Ebinger
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ishita Ghai
- Frederick S. Pardee RAND Graduate School, RAND Corporation, Santa Monica, California, USA
| | - Denisse Barajas
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Rocío Vallejo
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ciantel A Blyler
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle Morales
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nairy Garcia
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sandy Joung
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Dodson JA, Schoenthaler A, Fonceva A, Gutierrez Y, Shimbo D, Banco D, Maidman S, Olkhina E, Hanley K, Lee C, Levy NK, Adhikari S. Study design of BETTER-BP: Behavioral economics trial to enhance regulation of blood pressure. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2022; 15:200156. [PMID: 36573193 PMCID: PMC9789360 DOI: 10.1016/j.ijcrp.2022.200156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/19/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
Background Nonadherence to antihypertensive medications remains a persistent problem that leads to preventable morbidity and mortality. Behavioral economic strategies represent a novel way to improve antihypertensive medication adherence, but remain largely untested especially in vulnerable populations which stand to benefit the most. The Behavioral Economics Trial To Enhance Regulation of Blood Pressure (BETTER-BP) was designed in this context, to test whether a digitally-enabled incentive lottery improves antihypertensive adherence and reduces systolic blood pressure (SBP). Design BETTER-BP is a pragmatic randomized trial conducted within 3 safety-net clinics in New York City: Bellevue Hospital Center, Gouveneur Hospital Center, and NYU Family Health Centers - Park Slope. The trial will randomize 435 patients with poorly controlled hypertension and poor adherence (<80% days adherent) in a 2:1 ratio (intervention:control) to receive either an incentive lottery versus passive monitoring. The incentive lottery is delivered via short messaging service (SMS) text messages that are delivered based on (1) antihypertensive adherence tracked via a wireless electronic monitoring device, paired with (2) a probability of lottery winning with variable incentives and a regret component for nonadherence. The study intervention lasts for 6 months, and ambulatory systolic blood pressure (SBP) will be measured at both 6 and 12 months to evaluate immediate and durable lottery effects. Conclusions BETTER-BP will generate knowledge about whether an incentive lottery is effective in vulnerable populations to improve antihypertensive medication adherence. If successful, this could lead to the implementation of this novel strategy on a larger scale to improve outcomes.
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Affiliation(s)
- John A. Dodson
- NYU Langone Medical Center, New York, NY, USA
- Corresponding author. New York University Grossman School of Medicine, 227 East 30th Street, TRB 851, New York, NY, 10016, USA.
| | | | - Ana Fonceva
- NYU Langone Medical Center, New York, NY, USA
| | | | - Daichi Shimbo
- Columbia University Irving Medical Center, New York, NY, USA
| | - Darcy Banco
- NYU Langone Medical Center, New York, NY, USA
| | | | | | | | - Carson Lee
- NYU Langone Medical Center, New York, NY, USA
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Stecher C, Ghai I, Lunkuse L, Wabukala P, Odiit M, Nakanwagi A, Linnemayr S. INcentives and ReMINDers to Improve Long-term Medication Adherence (INMIND): Protocol for a Pilot Randomized Controlled Trial in Uganda (Preprint). JMIR Res Protoc 2022; 11:e42216. [DOI: 10.2196/42216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 09/20/2022] [Accepted: 09/24/2022] [Indexed: 11/13/2022] Open
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Tran S, Smith L, El-Den S, Carter S. The Use of Gamification and Incentives in Mobile Health Apps to Improve Medication Adherence: Scoping Review. JMIR Mhealth Uhealth 2022; 10:e30671. [PMID: 35188475 PMCID: PMC8902658 DOI: 10.2196/30671] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/19/2021] [Accepted: 12/13/2021] [Indexed: 12/24/2022] Open
Abstract
Background Emerging health care strategies addressing medication adherence include the use of direct-to-patient incentives or elements adapted from computer games. However, there is currently no published evidence synthesis on the use of gamification or financial incentives in mobile apps to improve medication adherence. Objective The aim of this scoping review is to synthesize and appraise the literature pertaining to the use of mobile apps containing gamification or financial incentives for medication adherence. There were two objectives: to explore the reported effectiveness of these features and to describe and appraise the design and development process, including patient involvement. Methods The following databases were searched for relevant articles published in English from database inception to September 24, 2020: Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science. The framework by Arksey and O’Malley and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist guided this scoping review. Using a systematic screening process, studies were included if incentives or game features were used within mobile apps to specifically address medication adherence. An appraisal using risk of bias tools was also applied to their respective study design. Results A total of 11 studies from the initial 691 retrieved articles were included in this review. Across the studies, gamification alone (9/11, 82%) was used more than financial incentives (1/11, 9%) alone or a combination of the two (1/11, 9%). The studies generally reported improved or sustained optimal medication adherence outcomes; however, there was significant heterogeneity in the patient population, methodology such as outcome measures, and reporting of these studies. There was considerable variability in the development process and evaluation of the apps, with authors opting for either the waterfall or agile methodology. App development was often guided by a theory, but across the reviewed studies, there were no common theories used. Patient involvement was not commonly evident in predevelopment phases but were generally reserved for evaluations of feasibility, acceptance, and effectiveness. Patient perspectives on gamified app features indicated a potential to motivate positive health behaviors such as medication adherence along with critical themes of repetitiveness and irrelevance of certain features. The appraisal indicated a low risk of bias in most studies, although concerns were identified in potential confounding. Conclusions To effectively address medication adherence via gamified and incentivized mobile apps, an evidence-based co-design approach and agile methodology should be used. This review indicates some adoption of an agile approach in app development; however, patient involvement is lacking in earlier stages. Further research in a generalized cohort of patients living with chronic conditions would facilitate the identification of barriers, potential opportunities, and the justification for the use of gamification and financial incentives in mobile apps for medication adherence.
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Affiliation(s)
- Steven Tran
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Lorraine Smith
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Sarira El-Den
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Stephen Carter
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Xu L, Li J, Zhang X, Pang Y, Yu T, Lian X, Yu T, Zhu L, Tong Q, Li F. Mobile health-based gamification intervention to increase physical activity participation among patients with coronary heart disease: study protocol of a randomised controlled trial. BMJ Open 2022; 12:e054623. [PMID: 35105640 PMCID: PMC8808393 DOI: 10.1136/bmjopen-2021-054623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Despite proven benefits, physical activity participation remains low in patients with coronary heart disease (CHD). Scientific evidence suggests that mobile health (mHealth)-based gamification interventions could increase physical activity levels. However, several systematic reviews demonstrated that most gamification intervention designs do not appropriately leverage theories from health behaviour models, and empirical evidence on the efficacy of such interventions among patients with CHD is still emerging. This study embeds the principles of behavioural economics into a gamification intervention based on a smartphone app (WeChat applet) to explore whether a mHealth-based gamification intervention can improve participation in physical activity and other related physical and psychological outcomes in patients with CHD. METHODS We propose a single-blinded three-arm randomised controlled trial with 108 patients with CHD, who will be randomly divided into three groups (Control group: WeChat applet+step goal setting; Individual group: WeChat applet+step goal setting+gamification; Team group: WeChat applet+step goal setting+gamification+collaboration). The interventions will last for 12 weeks and follow-up for 12 weeks. All patients will receive only WeChat applet-based step goal setting in the follow-up period. The primary outcome is physical activity participation, which includes a change in daily steps and self-reported physical activity from the baseline to 12 and 24 weeks, and the proportion of patient-days that step goals achieved in 12 and 24 weeks. The secondary outcomes include biomedical and lifestyle-related risk factors, intrinsic motivation, enjoyment, competence, autonomy and relatedness, social support and mental health and patients' satisfaction, perceptions and intervention experience. ETHICS AND DISSEMINATION The Human Research Ethics Committee of the School of Nursing, Jilin University (HREC 2020122401) approved this. The results will be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER ChiCTR2100044879; Pre-results.
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Affiliation(s)
- Linqi Xu
- School of Nursing, Jilin University, Changchun, Jilin, China
| | - Jinwei Li
- School of Nursing, Jilin University, Changchun, Jilin, China
| | - Xin Zhang
- School of Nursing, Jilin University, Changchun, Jilin, China
| | - Yue Pang
- School of Nursing, Jilin University, Changchun, Jilin, China
| | - Tianzhuo Yu
- School of Nursing, Jilin University, Changchun, Jilin, China
| | - Xiaoqian Lian
- School of Nursing, Jilin University, Changchun, Jilin, China
| | - Tianyue Yu
- School of Nursing, Jilin University, Changchun, Jilin, China
| | - Lanyu Zhu
- School of Nursing, Jilin University, Changchun, Jilin, China
- School of Nursing, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Qian Tong
- Department of Cardiology, Bethune First Hospital Of Jilin University, Changchun, Jilin, China
| | - Feng Li
- School of Nursing, Jilin University, Changchun, Jilin, China
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Barber A, West J. Conditional cash lotteries increase COVID-19 vaccination rates. JOURNAL OF HEALTH ECONOMICS 2022; 81:102578. [PMID: 34986437 PMCID: PMC8685289 DOI: 10.1016/j.jhealeco.2021.102578] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/14/2021] [Accepted: 12/14/2021] [Indexed: 06/13/2023]
Abstract
Conditional cash lotteries (CCLs) provide people with opportunities to win monetary prizes only if they make specific behavioral changes. We conduct a case study of Ohio's Vax-A-Million initiative, the first CCL targeting COVID-19 vaccinations. Forming a synthetic control from other states, we find that Ohios incentive scheme increases the vaccinated share of state population by 1.5 percent (0.7 pp), costing sixty-eight dollars per person persuaded to vaccinate. We show this causes significant reductions in COVID-19, preventing at least one infection for every six vaccinations that the lottery had successfully encouraged. These findings are promising for similar CCL public health initiatives.
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Lee C, Chung KM. A Pilot Study for Testing the Effectiveness and Cost-Efficiency of Lottery Incentive in mHealth App that Promotes Walking. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2022; 59:469580221091398. [PMID: 35621321 PMCID: PMC9150245 DOI: 10.1177/00469580221091398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This is a pilot study that investigated differences in effectiveness, maintenance of effectiveness, cost-efficiency, satisfaction, and usability of a lottery incentive via mobile devices to promote walking, depending on the chance of winning the lottery, the amount of the prize, and gender. Sixty-six college students (male = 26) were randomly assigned to 3 groups: 10% chance of a big prize (10% + B), 50% chance of a medium prize (50% + M), and 100% chance of a small prize (100% + S). Step counts were collected through mobile devices before and after the intervention, as well as at the 2-month follow-up. The results showed significant increases in the step counts among males after the intervention in the 10% + B and the 50% + M groups, and females in the 100% + S group. Only males in the 50% + M group exhibited maintenance in effectiveness during follow-up. With regard to cost-efficiency, the 10% + B and the 50% + M male groups, which showed significant differences in effectiveness, were compared, and no significant difference was found. With regard to intervention satisfaction, satisfaction of the 10% + B group was lower than that of the 100% + S group. There were no significant interactions or main effects regarding the usability of the intervention. The results suggest that a lottery incentive is effective only for men to promote walking when a medium size prize is given with a 50% of chance of winning the lottery.
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Affiliation(s)
- Changseok Lee
- Department of Psychology, Yonsei University, Seoul, South Korea
| | - Kyong-Mee Chung
- Department of Psychology, Yonsei University, Seoul, South Korea
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12
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Pal P, Sambhakar S, Dave V, Paliwal SK, Paliwal S, Sharma M, Kumar A, Dhama N. A review on emerging smart technological innovations in healthcare sector for increasing patient's medication adherence. GLOBAL HEALTH JOURNAL 2021. [DOI: 10.1016/j.glohj.2021.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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13
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Belli HM, Troxel AB, Blecker SB, Anderman J, Wong C, Martinez TR, Mann DM. A Behavioral Economics-Electronic Health Record Module to Promote Appropriate Diabetes Management in Older Adults: Protocol for a Pragmatic Cluster Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e28723. [PMID: 34704959 PMCID: PMC8581753 DOI: 10.2196/28723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/28/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
Background The integration of behavioral economics (BE) principles and electronic health records (EHRs) using clinical decision support (CDS) tools is a novel approach to improving health outcomes. Meanwhile, the American Geriatrics Society has created the Choosing Wisely (CW) initiative to promote less aggressive glycemic targets and reduction in pharmacologic therapy in older adults with type 2 diabetes mellitus. To date, few studies have shown the effectiveness of combined BE and EHR approaches for managing chronic conditions, and none have addressed guideline-driven deprescribing specifically in type 2 diabetes. We previously conducted a pilot study aimed at promoting appropriate CW guideline adherence using BE nudges and EHRs embedded within CDS tools at 5 clinics within the New York University Langone Health (NYULH) system. The BE-EHR module intervention was tested for usability, adoption, and early effectiveness. Preliminary results suggested a modest improvement of 5.1% in CW compliance. Objective This paper presents the protocol for a study that will investigate the effectiveness of a BE-EHR module intervention that leverages BE nudges with EHR technology and CDS tools to reduce overtreatment of type 2 diabetes in adults aged 76 years and older, per the CW guideline. Methods A pragmatic, investigator-blind, cluster randomized controlled trial was designed to evaluate the BE-EHR module. A total of 66 NYULH clinics will be randomized 1:1 to receive for 18 months either (1) a 6-component BE-EHR module intervention + standard care within the NYULH EHR, or (2) standard care only. The intervention will be administered to clinicians during any patient encounter (eg, in person, telemedicine, medication refill, etc). The primary outcome will be patient-level CW compliance. Secondary outcomes will measure the frequency of intervention component firings within the NYULH EHR, and provider utilization and interaction with the BE-EHR module components. Results Study recruitment commenced on December 7, 2020, with the activation of all 6 BE-EHR components in the NYULH EHR. Conclusions This study will test the effectiveness of a previously developed, iteratively refined, user-tested, and pilot-tested BE-EHR module aimed at providing appropriate diabetes care to elderly adults, compared to usual care via a cluster randomized controlled trial. This innovative research will be the first pragmatic randomized controlled trial to use BE principles embedded within the EHR and delivered using CDS tools to specifically promote CW guideline adherence in type 2 diabetes. The study will also collect valuable information on clinician workflow and interaction with the BE-EHR module, guiding future research in optimizing the timely delivery of BE nudges within CDS tools. This work will address the effectiveness of BE-inspired interventions in diabetes and chronic disease management. Trial Registration ClinicalTrials.gov NCT04181307; https://clinicaltrials.gov/ct2/show/NCT04181307 International Registered Report Identifier (IRRID) DERR1-10.2196/28723
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Affiliation(s)
- Hayley M Belli
- Division of Biostatistics, Department of Population Health, Grossman School of Medicine, New York University, New York, NY, United States
| | - Andrea B Troxel
- Division of Biostatistics, Department of Population Health, Grossman School of Medicine, New York University, New York, NY, United States
| | - Saul B Blecker
- Division of Healthcare Delivery Science, Department of Population Health, Grossman School of Medicine, New York University, New York, NY, United States.,Department of Medicine, Grossman School of Medicine, New York University, New York, NY, United States
| | - Judd Anderman
- Medical Center Information Technology, New York University Langone Health, New York, NY, United States
| | - Christina Wong
- Medical Center Information Technology, New York University Langone Health, New York, NY, United States
| | - Tiffany R Martinez
- Division of Healthcare Delivery Science, Department of Population Health, Grossman School of Medicine, New York University, New York, NY, United States
| | - Devin M Mann
- Division of Healthcare Delivery Science, Department of Population Health, Grossman School of Medicine, New York University, New York, NY, United States.,Department of Medicine, Grossman School of Medicine, New York University, New York, NY, United States.,Medical Center Information Technology, New York University Langone Health, New York, NY, United States
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Abstract
PURPOSE OF REVIEW Behavioral economics represents a promising set of principles to inform the design of health-promoting interventions. Techniques from the field have the potential to increase quality of cardiovascular care given suboptimal rates of guideline-directed care delivery and patient adherence to optimal health behaviors across the spectrum of cardiovascular care delivery. RECENT FINDINGS Cardiovascular health-promoting interventions have demonstrated success in using a wide array of principles from behavioral economics, including loss framing, social norms, and gamification. Such approaches are becoming increasingly sophisticated and focused on clinical cardiovascular outcomes in addition to health behaviors as a primary endpoint. Many approaches can be used to improve patient decisions remotely, which is particularly useful given the shift to virtual care in the context of the COVID-19 pandemic. Numerous applications for behavioral economics exist in the cardiovascular care delivery space, though more work is needed before we will have a full understanding of ways to best leverage such applications in each clinical context.
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Incentives for Uptake of and Adherence to Outpatient Stroke Rehabilitation Services: A 3-Arm Randomized Controlled Trial. Arch Phys Med Rehabil 2021; 103:1-7.e4. [PMID: 34516998 DOI: 10.1016/j.apmr.2021.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/11/2021] [Accepted: 08/15/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine if rehabilitation uptake and adherence can be increased by providing coordinated transportation (increased convenience) and eliminating out-of-pocket costs (reduced expense). DESIGN Three-arm randomized controlled trial. SETTING Stroke units of 2 Singapore tertiary hospitals. PARTICIPANTS Singaporeans or permanent residents 21 years or older who were diagnosed as having stroke and were discharged home with physician's recommendation to continue outpatient rehabilitation (N=266). INTERVENTIONS A Transportation Incentives arm (T), which provides free transportation services, a Transportation & Sessions Incentives arm (T&S), offering free transportation and prescribed stroke rehabilitation sessions, and a control arm, Education (E), consisting of a stroke rehabilitation educational program. MAIN OUTCOME MEASURES The primary study outcome was uptake of outpatient rehabilitation services (ORS) among patients poststroke and key predefined secondary outcomes being number of sessions attended and adherence to prescribed sessions. RESULTS Uptake rate of ORS was 73.0% for E (confidence interval [CI], 63.8%-82.3%), 81.8% for T (CI, 73.8%-89.8%), and 84.3% for T&S (CI, 76.7%-91.8%). Differences of T and T&S vs E were not statistically significant (P=.22 and P=.10, respectively). However, average number of rehabilitation sessions attended were significantly higher in both intervention arms: 5.50±7.65 for T and 7.51±9.52 for T&S vs 3.26±4.22 for control arm (E) (T vs E: P=.017; T&S vs E: P<.001). Kaplan-Meier analysis indicated that persistence was higher for T&S compared with E (P=.029). CONCLUSIONS This study has demonstrated a possibility in increasing the uptake of and persistence to stroke ORS with free transportation and sessions. Incentivizing survivors of stroke to take up ORS is a new strategy worthy of further exploration for future policy change in financing ORS or other long-term care services.
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16
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Jeminiwa R, Hohmann NS, Hastings TJ, Hansen R, Qian J, Garza KB. Individuals' preference for financial over social incentives for medication adherence. J Am Pharm Assoc (2003) 2021; 62:134-141.e1. [PMID: 34561192 DOI: 10.1016/j.japh.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/26/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with chronic conditions continue to face financial and system-related barriers to medication adherence. Pharmacy, provider, and payer-based financial and social incentive-based interventions may reduce these barriers and improve adherence. However, it is unclear how patient demographics and clinical characteristics influence the type of incentives preferred by patients. OBJECTIVES To examine individuals' preference for financial versus social incentives and to explore the association between patient demographic and clinical characteristics with preferences for financial or social incentives. METHODS A cross-sectional survey of a nationally representative sample of patients was conducted with Qualtrics panelists (N = 909). U.S. adults taking at least 1 prescription medication for a chronic condition were included. Survey items elicited participants' demographic characteristics, preference for financial or social incentives, self-reported medication adherence, number of prescribed medications, and number of chronic conditions. Bivariate associations between patient characteristics and incentive preferences were tested using t and chi-square tests. Logistic regression was performed to determine patient characteristics associated with participants' preference for incentives. RESULTS When compared with those who were adherent to medications, individuals who were nonadherent were less likely to prefer financial incentives over social incentives (adjusted odds ratio [OR] 0.55 [95% CI 0.31-0.98]). Patient income, sex, and ethnicity were also associated with preferences for financial incentives. Those earning less than $50,000 per year were less likely to prefer financial incentives compared with social incentives (adjusted OR 0.44 [0.24-0.79]). Females were more likely to prefer financial incentives (adjusted OR 1.98 [1.16-3.37]). Hispanic/Latinos were less likely to prefer financial incentives compared to non-Hispanics/non-Latinos (adjusted OR 0.51 [0.29-0.89]). CONCLUSION Preferences for medication adherence incentives differed on the basis of adherence status and patients' demographic characteristics. Findings have implications for how incentive-based interventions can be structured to target certain patient groups.
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17
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Glasgow RE, Knoepke CE, Magid D, Grunwald GK, Glorioso TJ, Waughtal J, Marrs JC, Bull S, Ho PM. The NUDGE trial pragmatic trial to enhance cardiovascular medication adherence: study protocol for a randomized controlled trial. Trials 2021; 22:528. [PMID: 34380527 PMCID: PMC8356469 DOI: 10.1186/s13063-021-05453-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 07/13/2021] [Indexed: 11/30/2022] Open
Abstract
Background Nearly half of patients do not take their cardiovascular medications as prescribed, resulting in increased morbidity, mortality, and healthcare costs. Mobile and digital technologies for health promotion and disease self-management offer an opportunity to adapt behavioral “nudges” using ubiquitous mobile phone technology to facilitate medication adherence. The Nudge pragmatic clinical trial uses population-level pharmacy data to deliver nudges via mobile phone text messaging and an artificial intelligent interactive chat bot with the goal of improving medication adherence and patient outcomes in three integrated healthcare delivery systems. Methods The Theory of mHealth, the Expanded RE-AIM/PRISM, and the PRECIS-2 frameworks were used for program planning, implementation, and evaluation, along with a focus on dissemination and cost considerations. During the planning phase, the Nudge study team developed and piloted a technology-based nudge message and chat bot of optimized interactive content libraries for a range of diverse patients. Inclusion criteria are very broad and include patients in one of three diverse health systems who take medications to treat hypertension, atrial fibrillation, coronary artery disease, diabetes, or hyperlipidemia. A target of approximately 10,000 participants will be randomized to one of 4 study arms: usual care (no intervention), generic nudge (text reminder), optimized nudge, and optimized nudge plus interactive AI chat bot. The PRECIS-2 tool indicated that the study protocol is very pragmatic, although there is variability across PRECIS-2 dimensions. Discussion The primary effectiveness outcome is medication adherence defined by the proportion of days covered (PDC) using pharmacy refill data. Implementation outcomes are assessed using the RE-AIM framework, with a particular focus on reach, consistency of implementation, adaptations, cost, and maintenance/sustainability. The project has limitations including limited power to detect some subgroup effects, medication complications (bleeding), and longer-term outcomes (myocardial infarction). Strengths of the study include the diverse healthcare systems, a feasible and generalizable intervention, transparent reporting using established pragmatic research and implementation science frameworks, strong stakeholder engagement, and planning for dissemination and sustainment. Trial registration ClinicalTrials.govNCT03973931. Registered on 4 June 2019. The study was funded by the NIH; grant number is 4UH3HL144163-02 issued 4/5/19. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05453-9.
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Affiliation(s)
- Russell E Glasgow
- Department of Family Medicine, University of Colorado Denver - Anschutz Medical Campus, Denver, USA. .,Dissemination and Implementation Science Program of ACCORDS (Adult and Child Consortium for Health Outcomes Research and Delivery Science), Aurora, USA.
| | - Christopher E Knoepke
- Department of Medicine, Division of Cardiology, University of Colorado Denver - Anschutz Medical Campus, Denver, USA.,ACCORDS (Adult and Child Consortium for Health Outcomes Research and Delivery Science), Aurora, USA
| | - David Magid
- University of Colorado Denver - Anschutz, Denver, USA
| | - Gary K Grunwald
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Denver, USA.,U.S. Department of Veterans Affairs, Washington, DC, USA
| | | | - Joy Waughtal
- mHealth Impact Laboratory Colorado School of Public Health, Aurora, USA
| | - Joel C Marrs
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Sheana Bull
- mHealth Impact Laboratory Colorado School of Public Health, Aurora, USA.,Department of Community and Behavioral Health, Aurora, USA.,Digital Education, Denver, USA
| | - P Michael Ho
- Department of Medicine, University of Colorado School of Medicine, Aurora, USA.,VA Eastern Colorado Health Care System, Aurora, USA
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Strother M, Koepsell K, Song L, Faerber J, Bernard J, Malkowicz SB, Guzzo T, Tasian G. Financial incentives and wearable activity monitors to increase ambulation after cystectomy: A randomized controlled trial. Urol Oncol 2021; 39:434.e31-434.e38. [PMID: 33308975 PMCID: PMC8184881 DOI: 10.1016/j.urolonc.2020.11.035] [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] [Received: 10/05/2020] [Revised: 11/05/2020] [Accepted: 11/22/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Financial incentive programs are effective in increasing physical activity for overweight, ambulatory adults. We sought to determine the potential effect size and direction of financial incentives on ambulation after radical cystectomy. MATERIALS AND METHODS We performed a pilot randomized controlled trial of daily financial incentives to meet postoperative step goals among adults with Eastern Cooperative Oncology Group performance status ≤2 who underwent radical cystectomy for bladder cancer at a single center. Step counts were measured over a 3- to 14-day preoperative period and 30-day postoperative period using a wearable activity monitor. Postoperative daily step goals of 10%, 25%, 40%, and 55% of mean preoperative daily step counts were set for postoperative weeks 1 through 4, respectively. The primary outcome was the number of postoperative days on which the step goals were met. Secondary outcomes included the number of daily postoperative steps taken and the length of stay. Participants randomized to the intervention arm received $1.50 for every day the goal was met with a 20% chance of a $100 reward if the step goal was met on >75% of the first 30 postoperative days. Questionnaires assessing self-reported physical activity, disability, and social support were administered preoperatively at 30 days postoperatively. RESULTS Thirty-three patients were analyzed, 11 in the control and 22 in the intervention arms. There were no statistically significant differences between incentive and control arms for the primary outcome (4.5/30 days vs. 9/30 days, P = 0.53). Results after adjusting for differences in baseline characteristics were similar (RR 1.00, 95% CI 0.24-4.19, P = 1.00). There were also no differences in average daily postoperative steps (median 979 vs. 1191, 95% CI -810 to 1,400, P = 0.59), length of stay (7.5 vs. 7, 95% CI -2.7 to 5.1, P = 0.56), or self-reported measures of disability, activity, and social support. CONCLUSIONS While this trial was a pilot study and not powered to detect a difference between groups, there was no suggestion of any clinically important impact of this financial incentive on postoperative ambulation. While a fully-powered trial is feasible, given the small range of plausible benefit, such a trial would be unlikely to influence clinical practice.
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Affiliation(s)
- Marshall Strother
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA.
| | - Kristen Koepsell
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lihai Song
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer Faerber
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joshua Bernard
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - S Bruce Malkowicz
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Thomas Guzzo
- Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Gregory Tasian
- Division of Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Urology, Department of Surgery, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
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19
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Reback CJ, Kisler KA, Fletcher JB. A Novel Adaptation of Peer Health Navigation and Contingency Management for Advancement Along the HIV Care Continuum Among Transgender Women of Color. AIDS Behav 2021; 25:40-51. [PMID: 31187355 PMCID: PMC6904539 DOI: 10.1007/s10461-019-02554-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Transgender women, particularly racial/ethnic minority transgender women, evidence disproportionately high rates of untreated HIV infection and disproportionately low rates of HIV viral suppression. The Alexis Project was a combined peer health navigation (PHN) and contingency management (CM) intervention that targeted HIV milestones associated with advancement along the HIV care continuum. From February 2014 through August 2016, 139 transgender women of color (TWOC) enrolled and received unlimited PHN sessions and an escalating CM rewards schedule for confirmed achievement of both behavioral (e.g., HIV care visits) and biomedical (e.g., viral load reductions and achieved/sustained viral suppression) HIV milestones. Results demonstrated that increased attendance to PHN sessions was associated with significant achievement of both behavioral (coef. range 0.12-0.38) and biomedical (coef. = 0.10) HIV milestones (all p ≤ 0.01); 85% were linked to HIV care, and 83% who enrolled detectable and achieved the minimum 1 log viral load reduction advanced to full viral suppression. The combined PHN and CM intervention successfully promoted advancement along the HIV Care Continuum, with particularly robust effects for behavioral HIV milestones.
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Affiliation(s)
- Cathy J Reback
- Friends Research Institute, Inc, 6910 Santa Monica Boulevard, Los Angeles, CA, 90038, USA.
- Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA.
- Center for HIV Identification, Prevention and Treatment Services, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Kimberly A Kisler
- Friends Research Institute, Inc, 6910 Santa Monica Boulevard, Los Angeles, CA, 90038, USA
| | - Jesse B Fletcher
- Friends Research Institute, Inc, 6910 Santa Monica Boulevard, Los Angeles, CA, 90038, USA
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Hastings TJ, Hohmann NS, Jeminiwa R, Hansen RA, Qian J, Garza KB. Perceived appropriateness of medication adherence incentives. J Manag Care Spec Pharm 2021; 27:772-778. [PMID: 34057397 PMCID: PMC10391207 DOI: 10.18553/jmcp.2021.27.6.772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: 50% of prescriptions dispensed in the United States are not taken as prescribed, leading to approximately 125,000 deaths and 10% of hospitalizations per year. Incentives are effective in improving medication adherence; however, information about patient perceptions regarding incentives is lacking. OBJECTIVES: To (1) explore perceived appropriateness of incentives among patients prescribed at least 1 medication for chronic hypertension, hyperlipidemia, heart disease, diabetes, and/or asthma/chronic obstructive pulmonary disease and (2) examine associations between perceived appropriateness and patient characteristics. METHODS: A cross-sectional online survey was administered via Qualtrics Panels to US adults taking at least 1 prescription medication for a chronic condition. The results describe patient preference for financial or social recognition-based incentive, perceived appropriateness of adherence incentives (5-point Likert scale), self-reported adherence (Medometer), and demographics. Analyses included descriptive statistics with chi-square and independent t-tests comparing characteristics between participants who perceived incentives as being appropriate or inappropriate and logistic regression to determine predictors of perceived appropriateness. RESULTS: 1,009 individuals completed the survey. Of the 1,009 total survey participants, 933 (92.5%) preferred to receive a financial (eg, cash, gift card, or voucher) rather than a social recognition-based incentive (eg, encouraging messages, feedback, individual recognition, or team competition) for medication adherence. 740 participants (73%) perceived medication adherence incentives as being appropriate or acceptable as a reward given for taking medications at the right time each day, whereas 95 (9%) perceived incentives as being inappropriate. Remaining participants were neutral. Hispanic ethnicity (OR = 0.57; 95% CI = 0.37-0.89); income under $75,000 (OR = 0.48; 95% CI = 0.28-0.84); no college degree (OR = 0.60; 95% CI = 0.37-0.96); and adherence (OR = 0.99; 95% CI = 0.98-0.99) were significant predictors. CONCLUSIONS: The majority of patients perceived incentives as appropriate and preferred financial incentives over social recognition-based incentives. Perceived appropriateness for medication adherence incentives was less likely among certain groups of patients, such as those with Hispanic ethnicity, lower annual income, no college degree, and higher levels of adherence. These characteristics should be taken into account when structuring incentives. DISCLOSURES: This study was funded by the Auburn University's Intramural Grants Program. Hansen, Qian, and Garza are affiliated with Auburn University. Hansen has provided expert testimony for Daiichi Sankyo and Takeda on unrelated matters. The other authors have no potential conflicts of interest to declare. This study was presented as a poster presentation at the American Association of Colleges of Pharmacy Annual Meeting held July 2018 in Boston, MA.
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Affiliation(s)
- Tessa J Hastings
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia
| | - Natalie S Hohmann
- Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, AL
| | - Ruth Jeminiwa
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA
| | - Richard A Hansen
- Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University, Auburn, AL
| | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University, Auburn, AL
| | - Kimberly B Garza
- Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University, Auburn, AL
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21
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Bien-Gund CH, Ho JI, Bair EF, Marcus N, Choi RJ, Szep Z, Althoff A, Momplaisir FM, Thirumurthy H. Brief Report: Financial Incentives and Real-Time Adherence Monitoring to Promote Daily Adherence to HIV Treatment and Viral Suppression Among People Living With HIV: A Pilot Study. J Acquir Immune Defic Syndr 2021; 87:688-692. [PMID: 33470727 PMCID: PMC8026510 DOI: 10.1097/qai.0000000000002628] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/11/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Interventions to promote medication adherence and viral suppression are needed among HIV-positive individuals. We aimed to determine the feasibility, acceptability, and preliminary impact of daily financial incentives linked to real-time adherence monitoring among treatment-experienced individuals. METHODS At an HIV clinic in Philadelphia, we conducted a pilot randomized trial among treatment-experienced HIV-positive adults with unsuppressed viral loads (>400 copies/mL). Participants randomized to the intervention group were eligible for daily lottery-based financial rewards dependent on antiretroviral therapy (ART) adherence, measured by a wireless-enabled electronic pill bottle. Participants also received a financial incentive for achieving viral suppression at 3 months. The control group received the standard of care. We measured acceptance and feasibility through follow-up survey at 3 months, viral suppression at 3 months, and adherence. RESULTS Among 29 participants, 28 (93%) completed 3-month follow-up, and 24 (83%) completed a 3-month laboratory visit. Electronic pill bottles were highly acceptable to participants, with most strongly agreeing that they worked well, were reliable, and easy to use. Among those who received the intervention, 77% were very satisfied with their experience. Among those who completed the 3-month laboratory visit, viral suppression was achieved by 40% in the intervention group and 29% in the control group. ART adherence ≥80% was achieved by 36% and 25% in the intervention and control groups, respectively. CONCLUSIONS Daily financial incentives coupled with real-time adherence monitoring are a promising strategy to support ART adherence among HIV-positive individuals who are not virally suppressed. This novel approach warrants testing in a larger trial.
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Affiliation(s)
- Cedric H Bien-Gund
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joshua I Ho
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth F Bair
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and
| | - Noora Marcus
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and
| | - Rebekah Ji Choi
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and
| | - Zsofia Szep
- Partnership Comprehensive Care Practice, Drexel University College of Medicine, Philadelphia, PA
| | - Amy Althoff
- Partnership Comprehensive Care Practice, Drexel University College of Medicine, Philadelphia, PA
| | - Florence M Momplaisir
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and
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22
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Luong P, Glorioso TJ, Grunwald GK, Peterson P, Allen LA, Khanna A, Waughtal J, Sandy L, Ho PM, Bull S. Text Message Medication Adherence Reminders Automated and Delivered at Scale Across Two Institutions: Testing the Nudge System: Pilot Study. Circ Cardiovasc Qual Outcomes 2021; 14:e007015. [PMID: 33993727 PMCID: PMC8153195 DOI: 10.1161/circoutcomes.120.007015] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 03/24/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Medication refill behavior in patients with cardiovascular diseases is suboptimal. Brief behavioral interventions called Nudges may impact medication refill behavior and can be delivered at scale to patients using text messaging. METHODS Patients who were prescribed and filled at least one medication for hypertension, hyperlipidemia, diabetes, atrial fibrillation, and coronary artery disease were identified for the pilot study. Patients eligible for the pilot (N=400) were enrolled with an opportunity to opt out. In phase I of the pilot, we tested text message delivery to 60 patients. In phase II, we tested intervention feasibility by identifying those with refill gap of ≥7 days and randomized them to intervention or control arms. Patients were texted Nudges and assessed whether they refilled their medications. RESULTS Of 400 patients sent study invitations, 56 (14%) opted out. In phase I, we successfully delivered text messages to 58 of 60 patients and captured patient responses via text. In phase II, 207 of 286 (72.4%) patients had a medication gap ≥7 days for one or more cardiovascular medications and were randomized to intervention or control. Enrolled patients averaged 61.7 years old, were primarily male (69.1%) and White (72.5%) with hypertension being the most prevalent qualifying condition (78.7%). There was a trend towards intervention patients being more likely to refill at least 1 gapping medication (30.6% versus 18.0%; P=0.12) and all gapping medications (17.8% versus 10.0%; P=0.27). CONCLUSIONS It is possible to set up automated processes within health care delivery systems to identify patients with gaps in medication adherence and send Nudges to facilitate medication refills. Text message Nudges could potentially be a feasible and effective method to facilitate medication refills. A large multi-site randomized trial to determine the impact of text-based Nudges on overall CVD morbidity and mortality is now underway to explore this further. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03973931.
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Affiliation(s)
- Phat Luong
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
| | - Thomas J Glorioso
- Veteran Affairs Eastern Colorado Health Care System, Aurora, CO (T.J.G., G.K.G., P.M.H.)
| | - Gary K Grunwald
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
- Veteran Affairs Eastern Colorado Health Care System, Aurora, CO (T.J.G., G.K.G., P.M.H.)
| | - Pamela Peterson
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
- Denver Health and Hospital System, Denver, CO (P.P.)
| | - Larry A Allen
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
| | - Amber Khanna
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
| | - Joy Waughtal
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
| | - Lisa Sandy
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
| | - P Michael Ho
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
- Veteran Affairs Eastern Colorado Health Care System, Aurora, CO (T.J.G., G.K.G., P.M.H.)
| | - Sheana Bull
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
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23
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Hohmann NS, Hastings TJ, Jeminiwa RN, Qian J, Hansen RA, Ngorsuraches S, Garza KB. Patient preferences for medication adherence financial incentive structures: A discrete choice experiment. Res Social Adm Pharm 2021; 17:1800-1809. [PMID: 33608244 DOI: 10.1016/j.sapharm.2021.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 11/24/2020] [Accepted: 01/31/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medication adherence for chronic conditions continues to be a challenge for patients. Patient incentives for medication adherence may help. Financial incentives delivered at the point of care may act as cues for medication-taking behavior. OBJECTIVES The purpose of this study was to investigate patient preferences for specific structures of financial medication adherence incentives that could feasibly be delivered at the point of care. METHODS A discrete choice experiment (DCE) was performed using a national online survey. Study participants were adults who self-reported taking at least one prescription medication for one or more chronic conditions. Following an orthogonal design generated in SAS, the DCE included 32 paired-choice tasks. Data were analyzed using mixed logit models and stratified on participants' income level. RESULTS In the full cohort (n = 933), form of financial reward (such as gift-card or cash) was 1.02 times as important to participants as the probability of incentive receipt, 1.58 times as important as monetary value, and 1.93 times as important as timing of receipt. Participants were willing to give up $31.04 of an incentive's monetary value (95% CI = $27.11-$34.98) to receive the incentive 5 months sooner (1-month vs. 6-month time-lag); $60.79 (95% CI = $53.19-$68.39) for probability of receipt to increase from a 1 out of 100 chance to a 1 out of 20 chance; and $10.52 (95% CI = $6.46-$14.58) to receive an incentive in the form of a Visa® gift-card instead of grocery store voucher. These patterns of trade-offs between attributes were generally consistent among participants with lower and higher income. CONCLUSIONS Regardless of socioeconomic status, patient preferences for financial medication adherence incentives delivered at the point of care may be most heavily influenced by incentive form and probability of receipt. This has implications for designing medication adherence programs in terms of incentive sustainability, patient engagement, plan star ratings, and patient outcomes.
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Affiliation(s)
- Natalie S Hohmann
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, 1202F Walker Building, Auburn, AL, USA.
| | - Tessa J Hastings
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, 715 Sumter St, CLS 311E, Columbia, SC, USA.
| | - Ruth N Jeminiwa
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, 4306 Walker Building, Auburn, AL, 36849, USA.
| | - Richard A Hansen
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, 4306 Walker Building, Auburn, AL, 36849, USA.
| | - Surachat Ngorsuraches
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, 4306 Walker Building, Auburn, AL, 36849, USA.
| | - Kimberly B Garza
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, 4306 Walker Building, Auburn, AL, 36849, USA.
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24
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Egede LE, Campbell JA, Walker RJ, Dawson AZ, Williams JS. Financial incentives to improve glycemic control in African American adults with type 2 diabetes: a pilot randomized controlled trial. BMC Health Serv Res 2021; 21:57. [PMID: 33435969 PMCID: PMC7803385 DOI: 10.1186/s12913-020-06029-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/17/2020] [Indexed: 11/24/2022] Open
Abstract
Background Financial incentives is emerging as a viable strategy for improving clinical outcomes for adults with type 2 diabetes. However, there is limited data on optimal structure for financial incentives and whether financial incentives are effective in African Americans with type 2 diabetes. This pilot study evaluated impact of three financial incentive structures on glycemic control in this population. Methods Sixty adults with type 2 diabetes were randomized to one of three financial incentive structures: 1) single incentive (Group 1) at 3 months for Hemoglobin A1c (HbA1c) reduction, 2) two-part equal incentive (Group 2) for home testing of glucose and HbA1c reduction at 3 months, and 3) three-part equal incentive (Group 3) for home testing, attendance of weekly telephone education classes and HbA1c reduction at 3 months. The primary outcome was HbA1c reduction within each group at 3 months post-randomization. Paired t-tests were used to test differences between baseline and 3-month HbA1c within each group. Results The mean age for the sample was 57.9 years and 71.9% were women. Each incentive structure led to significant reductions in HbA1c at 3 months with the greatest reduction from baseline in the group with incentives for multiple components: Group 1 mean reduction = 1.25, Group 2 mean reduction = 1.73, Group 3 mean reduction = 1.74. Conclusion Financial incentives led to significant reductions in HbA1c from baseline within each group. Incentives for multiple components led to the greatest reductions from baseline. Structured financial incentives that reward home monitoring, attendance of telephone education sessions, and lifestyle modification to lower HbA1c are viable options for glycemic control in African Americans with type 2 diabetes. Trial registration Trial registration: NCT02722499. Registered 23 March 2016, url.
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Affiliation(s)
- Leonard E Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, 701 Watertown Plank Rd, Milwaukee, WI, 53226-3596, USA. .,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Jennifer A Campbell
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, 701 Watertown Plank Rd, Milwaukee, WI, 53226-3596, USA.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, 701 Watertown Plank Rd, Milwaukee, WI, 53226-3596, USA.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aprill Z Dawson
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, 701 Watertown Plank Rd, Milwaukee, WI, 53226-3596, USA.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joni S Williams
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, 701 Watertown Plank Rd, Milwaukee, WI, 53226-3596, USA.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
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25
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Marquez-Padilla F. When less is more: Can reduced health monitoring improve medication adherence? JOURNAL OF HEALTH ECONOMICS 2021; 75:102387. [PMID: 33190015 DOI: 10.1016/j.jhealeco.2020.102387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 05/10/2023]
Abstract
As the prevalence of chronic diseases rises, improving self-management has become an important determinant of the productivity of healthcare delivery. Recently, Mexico's largest healthcare provider began issuing automatic-refill prescriptions to stable hypertensive patients, thus reducing the frequency of health monitoring from 30- to 90-day intervals. Exploiting this change, I find that less monitoring implies no drawbacks in health outcomes and actually improves self-management of disease by increasing medication adherence when baseline monitoring is relatively frequent. The number of days when patients are out of medication between fillings falls by 2.2 days-an improvement in adherence of 6.4%. Furthermore, patients appear to value being on a low-frequency regime as they improve adherence in order to remain on it, suggesting that lower monitoring could be used as a "reward" to promote medication adherence or, potentially, other health behaviors. Finally, I find evidence of positive spillovers on adherence, as clinic congestion falls.
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26
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Boonmanunt S, Pattanaprateep O, Ongphiphadhanakul B, McKay G, Attia J, Thakkinstian A. Evaluation of the effectiveness of behavioural economic incentive programmes for the promotion of a healthy diet and physical activity: a protocol for a systematic review and network meta-analysis. BMJ Open 2020; 10:e046035. [PMID: 33371052 PMCID: PMC7754655 DOI: 10.1136/bmjopen-2020-046035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Obesity and being overweight are major risk factors for metabolic syndrome and non-communicable diseases. Despite the recommendation that a healthy diet and physical activity can reduce the severity of these diseases, many fail to adhere to these measures. From a behavioural economic perspective, adherence to such measures can be encouraged through financial incentives. However, additional related behavioural economic approaches may improve the effectiveness of an incentive programme. As such, we have developed a protocol for a systematic review and network meta-analysis to summarise the current evidence from financial incentive programmes with and without behavioural economic insights for promoting healthy diet and physical activity. METHODS AND ANALYSIS Previous systematic reviews, meta-analyses and individual studies were identified from Medline and Scopus in June 2020 and will be updated until December 2020. Individual studies will be selected and data extracted by two reviewers. Disagreement will be resolved by consensus or adjudicated by a third reviewer. A descriptive analysis will summarise the effectiveness of behavioural economic incentive programmes for promoting healthy diet and physical activity. Moreover, individual studies will be pooled using network meta-analyses where possible. I2 statistics and Cochran's Q test will be used to assess heterogeneity. Risk of bias and publication bias, if appropriate, will be evaluated, as well as the overall strength of the evidence. ETHICS AND DISSEMINATION Ethics approval for a systematic review and meta-analysis is not required. The findings will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42020198024.
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Affiliation(s)
- Suparee Boonmanunt
- Department of Clinical Epidemiology and Biostatistics, Mahidol University, Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Mahidol University, Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
| | | | - Gareth McKay
- Centre for Public Health, Queen's University Belfast Faculty of Medicine Health and Life Sciences, Belfast, UK
| | - John Attia
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Mahidol University, Faculty of Medicine Ramathibodi Hospital, Bangkok, Thailand
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27
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Hawking MKD, Robson J, Taylor SJC, Swinglehurst D. Adherence and the Moral Construction of the Self: A Narrative Analysis of Anticoagulant Medication. QUALITATIVE HEALTH RESEARCH 2020; 30:2316-2330. [PMID: 32856537 PMCID: PMC7649927 DOI: 10.1177/1049732320951772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
In this article, we examine illness narratives to illuminate the discursive work that patients undertake to construct themselves as "good" and adherent. Biographical narrative interviews were undertaken with 17 patients receiving anticoagulation for stroke prevention in atrial fibrillation, from five English hospitals (May 2016-June 2017). Through pluralistic narrative analysis, we highlight the discursive tensions narrators face when sharing accounts of their medicine-taking. They undertake challenging linguistic and performative work to reconcile apparently paradoxical positions. We show how the adherent patient is co-constructed through dialogue at the intersection of discourses including authority of doctors, personal responsibility for health, scarcity of resources, and deservingness. We conclude that the notion of medication adherence places a hidden moral and discursive burden of treatment on patients which they must negotiate when invited into conversations about their medications. This discursive work reveals, constitutes, and upholds medicine-taking as a profoundly moral practice.
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Affiliation(s)
- Meredith K. D. Hawking
- Queen Mary University of London, London, United Kingdom
- Meredith K. D. Hawking, Institute of Population Health Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London E1 2AB, UK.
| | - John Robson
- Queen Mary University of London, London, United Kingdom
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28
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Scales CD, Desai AC, Harper JD, Lai HH, Maalouf NM, Reese PP, Tasian GE, Al-Khalidi HR, Kirkali Z, Wessells H. Prevention of Urinary Stones With Hydration (PUSH): Design and Rationale of a Clinical Trial. Am J Kidney Dis 2020; 77:898-906.e1. [PMID: 33212205 DOI: 10.1053/j.ajkd.2020.09.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 09/15/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Although maintaining high fluid intake is an effective low-risk intervention for the secondary prevention of urinary stone disease, many patients with stones do not increase their fluid intake. STUDY DESIGN We describe the rationale and design of the Prevention of Urinary Stones With Hydration (PUSH) Study, a randomized trial of a multicomponent behavioral intervention program to increase and maintain high fluid intake. Participants are randomly assigned (1:1 ratio) to the intervention or control arm. The target sample size is 1,642 participants. SETTING & PARTICIPANTS Adults and adolescents 12 years and older with a symptomatic stone history and low urine volume are eligible. Exclusion criteria include infectious or monogenic causes of urinary stone disease and comorbid conditions precluding increased fluid intake. INTERVENTIONS All participants receive usual care and a smart water bottle with smartphone application. Participants in the intervention arm receive a fluid intake prescription and an adaptive program of behavioral interventions, including financial incentives, structured problem solving, and other automated adherence interventions. Control arm participants receive guideline-based fluid instructions. OUTCOMES The primary end point is recurrence of a symptomatic stone during 24 months of follow-up. Secondary end points include changes in radiographic stone burden, 24-hour urine output, and urinary symptoms. LIMITATIONS Periodic 24-hour urine volumes may not fully reflect daily behavior. CONCLUSIONS With its highly novel features, the PUSH Study will address an important health care problem. FUNDING National Institute of Diabetes and Digestive and Kidney Diseases. TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT03244189.
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Affiliation(s)
- Charles D Scales
- Urologic Surgery and Population Health Science, Duke Surgical Center for Outcomes Research, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
| | - Alana C Desai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Jonathan D Harper
- Department of Urology, University of Washington School of Medicine, Seattle, WA
| | - H Henry Lai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Naim M Maalouf
- Department of Internal Medicine and Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Gregory E Tasian
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Division of Pediatric Urology, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Ziya Kirkali
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Hunter Wessells
- Department of Urology, University of Washington School of Medicine, Seattle, WA
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29
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Belli HM, Chokshi SK, Hegde R, Troxel AB, Blecker S, Testa PA, Anderman J, Wong C, Mann DM. Implementation of a Behavioral Economics Electronic Health Record (BE-EHR) Module to Reduce Overtreatment of Diabetes in Older Adults. J Gen Intern Med 2020; 35:3254-3261. [PMID: 32885374 PMCID: PMC7661670 DOI: 10.1007/s11606-020-06119-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 08/06/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Intensive glycemic control is of unclear benefit and carries increased risk for older adults with diabetes. The American Geriatrics Society's (AGS) Choosing Wisely (CW) guideline promotes less aggressive glycemic targets and reduction in pharmacologic therapy for older adults with type II diabetes. Meanwhile, behavioral economic (BE) approaches offer promise in influencing hard-to-change behavior, and previous studies have shown the benefits of using electronic health record (EHR) technology to encourage guideline adherence. OBJECTIVE This study aimed to develop and pilot test an intervention that leverages BE with EHR technology to promote appropriate diabetes management in older adults. DESIGN A pilot study within the New York University Langone Health (NYULH) EHR and Epic system to deliver BE-inspired nudges at five NYULH clinics at varying time points from July 12, 2018, through October 31, 2019. PARTICIPANTS Clinicians across five practices in the NYULH system whose patients were older adults (age 76 and older) with type II diabetes. INTERVENTIONS A BE-EHR module comprising six nudges was developed through a series of design workshops, interviews, user-testing sessions, and clinic visits. BE principles utilized in the nudges include framing, social norming, accountable justification, defaults, affirmation, and gamification. MAIN MEASURES Patient-level CW compliance. KEY RESULTS CW compliance increased 5.1% from a 16-week interval at baseline to a 16-week interval post intervention. From February 14 to June 5, 2018 (prior to the first nudge launch in Vanguard clinics), CW compliance for 1278 patients was mean (95% CI)-16.1% (14.1%, 18.1%). From July 3 to October 22, 2019 (after BE-EHR module launch at all five clinics), CW compliance for 680 patients was 21.2% (18.1%, 24.3%). CONCLUSIONS The BE-EHR module shows promise for promoting the AGS CW guideline and improving diabetes management in older adults. A randomized controlled trial will commence to test the effectiveness of the intervention across 66 NYULH clinics. NIH TRIAL REGISTRY NUMBER NCT03409523.
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Affiliation(s)
- Hayley M Belli
- Division of Biostatistics, Department of Population Health, New York University School of Medicine, New York, NY, USA.
| | - Sara K Chokshi
- Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, NY, USA
| | | | - Andrea B Troxel
- Division of Biostatistics, Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Saul Blecker
- Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, NY, USA.,Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Paul A Testa
- Medical Center Information Technology, NYU Langone Health, New York, NY, USA.,Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
| | - Judd Anderman
- Medical Center Information Technology, NYU Langone Health, New York, NY, USA
| | - Christina Wong
- Medical Center Information Technology, NYU Langone Health, New York, NY, USA
| | - Devin M Mann
- Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, NY, USA.,Department of Medicine, New York University School of Medicine, New York, NY, USA.,Medical Center Information Technology, NYU Langone Health, New York, NY, USA
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30
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Barankay I, Reese PP, Putt ME, Russell LB, Loewenstein G, Pagnotti D, Yan J, Zhu J, McGilloway R, Brennan T, Finnerty D, Hoffer K, Chadha S, Volpp KG. Effect of Patient Financial Incentives on Statin Adherence and Lipid Control: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2019429. [PMID: 33034639 PMCID: PMC7547367 DOI: 10.1001/jamanetworkopen.2020.19429] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Financial incentives can improve medication adherence and cardiovascular disease risk, but the optimal design to promote sustained adherence after incentives are discontinued is unknown. OBJECTIVE To determine whether 6-month interventions involving different financial incentives to encourage statin adherence reduce low-density lipoprotein cholesterol (LDL-C) levels from baseline to 12 months. DESIGN, SETTING, AND PARTICIPANTS This 4-group, randomized clinical trial was conducted from August 2013 to July 2018 among several large US insurer or employer populations and the University of Pennsylvania Health System. The study population included adults with elevated risk of cardiovascular disease, suboptimal LDL-C control, and evidence of imperfect adherence to statin medication. Data analysis was performed from July 2017 to June 2019. INTERVENTIONS The interventions lasted 6 months during which all participants received daily medication reminders and an electronic pill bottle. Statin adherence was measured by opening the bottle. For participants randomized to the 3 intervention groups, adherence was rewarded with financial incentives. The sweepstakes group involved incentives for daily adherence. In the deadline sweepstakes group, incentives were reduced if participants were adherent only after a reminder. The sweepstakes plus deposit contract group split incentives between daily adherence and a monthly deposit reduced for each day of nonadherence. MAIN OUTCOMES AND MEASURES The primary outcome was change in LDL-C level from baseline to 12 months. RESULTS Among 805 participants randomized (199 in the simple daily sweepstakes group, 204 in the deadline sweepstakes group, 201 in the sweepstakes plus deposit contract group, and 201 in the control group), the mean (SD) age was 58.5 (10.3) years; 519 participants (64.5%) were women, 514 (63.9%) had diabetes, and 273 (33.9%) had cardiovascular disease. The mean (SD) baseline LDL-C level was 143.2 (42.5) mg/dL. Measured adherence at 6 months (defined as the proportion of 180 days with electronic pill bottle opening) in the control group (0.69; 95% CI, 0.66-0.72) was lower than that in the simple sweepstakes group (0.84; 95% CI, 0.81-0.87), the deadline sweepstakes group (0.86; 95% CI, 0.83-0.89), and the sweepstakes plus deposit contract group (0.87; 95% CI, 0.84-0.90) (P < .001 for each incentive group vs control). LDL-C levels were measured for 636 participants at 12 months. Mean LDL-C level reductions from baseline to 12 months were 33.6 mg/dL (95% CI, 28.4-38.8 mg/dL) in the control group, 32.4 mg/dL (95% CI, 27.3-37.6 mg/dL) in the sweepstakes group, 33.2 mg/dL (95% CI, 28.1-38.3 mg/dL) in the deadline sweepstakes group, and 36.5 mg/dL (95% CI, 31.3-41.7 mg/dL) in the sweepstakes plus deposit contract group (adjusted P > .99 for each incentive group vs control). CONCLUSIONS AND RELEVANCE Compared with the control group, different financial incentives improved measured statin adherence but not LDL-C levels. This result points to the importance of directly measuring health outcomes, rather than simply adherence, in trials aimed at improving health behaviors. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01798784.
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Affiliation(s)
- Iwan Barankay
- Department of Management, The Wharton School, University of Pennsylvania, Philadelphia
- Department of Business Economics and Public Policy, The Wharton School, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
| | - Peter P. Reese
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mary E. Putt
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Louise B. Russell
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - George Loewenstein
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - David Pagnotti
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jiali Yan
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ryan McGilloway
- Department of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Troyen Brennan
- Department of Health Policy and Management, T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- CVS Health, Woonsocket, Rhode Island
| | - Darra Finnerty
- Department of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Karen Hoffer
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia
- Department of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Kevin G. Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medicine and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Mehta SJ, Oyalowo A, Reitz C, Dean O, McAuliffe T, Asch DA, Doubeni CA. Text messaging and lottery incentive to improve colorectal cancer screening outreach at a community health center: A randomized controlled trial. Prev Med Rep 2020; 19:101114. [PMID: 32477853 PMCID: PMC7251946 DOI: 10.1016/j.pmedr.2020.101114] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 04/28/2020] [Accepted: 05/03/2020] [Indexed: 12/11/2022] Open
Abstract
Efforts to boost colorectal cancer (CRC) screening rates in underserved populations have been limited by effectiveness and scalability. We evaluate the impact of adding a lottery-based financial incentive to a text messaging program that asks patients to opt-in to receive mailed fecal immunochemical testing (FIT). This is a two-arm pragmatic randomized controlled trial at a community health center in Southwest Philadelphia from April to July 2017. We included CRC screening-eligible patients between ages 50-74 years who had a mobile phone, active health insurance, and at least one visit to the clinic in the past 12 months. Patients received a text message about CRC screening with the opportunity to opt-in to receive mailed FIT. They were randomized 1:1 to the following: (1) text messaging outreach alone (text), or (2) text messaging with lottery for a 1-in-5 chance of winning $100 after FIT completion (text + lottery). The primary outcome was the percentage of patients completing the mailed FIT within 3 months of initial outreach. 281 patients were included in the intent-to-treat analysis. The FIT completion rate was 12.1% (95% CI, 6.7%-17.5%) in the text message arm and 12.1% (95% CI, 6.7%-17.5%) in the lottery arm, with no statistical difference between arms. The majority of post-intervention interview respondents found text messaging to be acceptable and convenient. Opt-in text messaging is a feasible option to promote the uptake of mailed FIT screening, but the addition of a lottery-based incentive did not improve completion rates. Trial Registration: clinicaltrials.gov (NCT03072095).
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Center for Health Care Innovation, University of Pennsylvania, United States
| | - Akinbowale Oyalowo
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - Owen Dean
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - Timothy McAuliffe
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Center for Health Care Innovation, University of Pennsylvania, United States
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, United States
| | - Chyke A. Doubeni
- Center for Health Equity and Community Engagement Research, Mayo Clinic, United States
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Roseleur J, Harvey G, Stocks N, Karnon J. Behavioral Economic Insights to Improve Medication Adherence in Adults with Chronic Conditions: A Scoping Review. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 12:571-592. [PMID: 31332723 DOI: 10.1007/s40271-019-00377-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Medication adherence is poor in patients with chronic conditions. Behavioral economic interventions may reduce biases that are associated with poor adherence. The objective of this review is to map the available evidence on behavioral economic interventions to improve medication adherence in adults with chronic conditions in high-income settings. METHODS We conducted a scoping review and reported the study using the Joanna Briggs Institute Reviewers' Manual and the PRISMA Extension for Scoping Review checklist. We searched PubMed, EMBASE, SCOPUS, PsycINFO, EconLit, and CINAHL from database inception to 29 August, 2018 for peer-reviewed studies and included a search of the gray literature. Data on study characteristics, study design, and study outcomes were extracted by one reviewer. Twenty-five percent of the studies were verified by a second reviewer. RESULTS Thirty-four studies, targeting diabetes mellitus, human immunodeficiency virus, and cardiovascular and renal diseases met our inclusion criteria. All but two studies were from the USA. The majority of interventions used financial incentives, often in conjunction with other behavioral economic concepts. Non-financial interventions included framing, social influences, reinforcement, and feedback. The effectiveness of interventions was mixed. CONCLUSIONS Behavioral economic informed interventions show promise in terms of improving medication adherence. However, there is no single simple intervention. This review highlighted the importance of targeting non-adherent patients, understanding their reasons for non-adherence, providing reminders and feedback to patients and physicians, and measuring clinical outcomes in addition to medication adherence. Further research in settings that differ from the US health system is needed.
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Affiliation(s)
- Jacqueline Roseleur
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.
| | - Gillian Harvey
- Adelaide Nursing School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jonathan Karnon
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Wiecek E, Torres-Robles A, Cutler RL, Benrimoj SI, Garcia-Cardenas V. Impact of a Multicomponent Digital Therapeutic Mobile App on Medication Adherence in Patients with Chronic Conditions: Retrospective Analysis. J Med Internet Res 2020; 22:e17834. [PMID: 32784183 PMCID: PMC7450368 DOI: 10.2196/17834] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/15/2020] [Accepted: 06/03/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Strategies to improve medication adherence are widespread in the literature; however, their impact is limited in real practice. Few patients persistently engage long-term to improve health outcomes, even when they are aware of the consequences of poor adherence. Despite the potential of mobile phone apps as a tool to manage medication adherence, there is still limited evidence of the impact of these innovative interventions. Real-world evidence can assist in minimizing this evidence gap. OBJECTIVE The objective of this study was to analyze the impact over time of a previously implemented digital therapeutic mobile app on medication adherence rates in adults with any chronic condition. METHODS A retrospective observational study was performed to assess the adherence rates of patients with any chronic condition using Perx Health, a digital therapeutic that uses multiple components within a mobile health app to improve medication adherence. These components include gamification, dosage reminders, incentives, educational components, and social community components. Adherence was measured through mobile direct observation of therapy (MDOT) over 3-month and 6-month time periods. Implementation adherence, defined as the percentage of doses in which the correct dose of a medication was taken, was assessed across the study periods, in addition to timing adherence or percentage of doses taken at the appropriate time (±1 hour). The Friedman test was used to compare differences in adherence rates over time. RESULTS We analyzed 243 and 130 patients who used the app for 3 months and 6 months, respectively. The average age of the 243 patients was 43.8 years (SD 15.5), and 156 (64.2%) were female. The most common medications prescribed were varenicline, rosuvastatin, and cholecalciferol. The median implementation adherence was 96.6% (IQR 82.1%-100%) over 3 months and 96.8% (IQR 87.1%-100%) over 6 months. Nonsignificant differences in adherence rates over time were observed in the 6-month analysis (Fr(2)=4.314, P=.505) and 3-month analysis (Fr(2)=0.635, P=.728). Similarly, the timing adherence analysis revealed stable trends with no significant changes over time. CONCLUSIONS Retrospective analysis of users of a medication adherence management mobile app revealed a positive trend in maintaining optimal medication adherence over time. Mobile technology utilizing gamification, dosage reminders, incentives, education, and social community interventions appears to be a promising strategy to manage medication adherence in real practice.
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Affiliation(s)
- Elyssa Wiecek
- Graduate School of Health, University of Technology Sydney, Sydney, Australia
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Howren MB, Vander Weg MW, Christensen AJ, Kaboli PJ. Association of patient preferences on medication discussion in hypertension: Results from a randomized clinical trial. Soc Sci Med 2020; 262:113244. [PMID: 32750626 DOI: 10.1016/j.socscimed.2020.113244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/26/2020] [Accepted: 07/20/2020] [Indexed: 12/31/2022]
Abstract
Patient-centered care has received significant attention and is an integral component of high-quality healthcare. While it is often assumed that most prefer a patient-centered role orientation, such preferences exist along a continuum with some patients preferring a more provider-centered role. The present study examines patient preference data from a randomized clinical trial designed to test the efficacy of a patient activation intervention to promote thiazide prescribing for veteran patients with uncontrolled hypertension. Patient preferences for involvement in healthcare were assessed using the 9-item Sharing subscale of the Patient-Practitioner Orientation Scale (PPOS). The primary aim was to examine differences in discussion of thiazide use in the clinical encounter by those scoring high versus low on the PPOS. Five hundred ninety-five veteran patients were randomized to either one of three intervention groups or a usual care control group. The adjusted odds ratios (OR) for the three intervention groups relative to the control group indicated that thiazide discussion increased as a function of intervention intensity across both high and low PPOS groups. ORs for the most intensive intervention group were 3.72 (95% CI = 1.61-8.65, p < .01) for high PPOS patients and 6.71 (95% CI = 2.59-10.67, p < .001) for low PPOS patients. Results suggest that this patient activation intervention is effective for veteran patients representing a range of preferred involvement. Consideration of such preferences may be useful in tailoring future interventions in the healthcare context.
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Affiliation(s)
- M Bryant Howren
- Center for Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA, USA; Department of Behavioral Sciences & Social Medicine, College of Medicine, Florida State University, Tallahassee, FL, USA.
| | - Mark W Vander Weg
- Center for Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA, USA; Division of General Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA, USA; Department of Psychological & Brain Sciences, The University of Iowa, Iowa City, IA, USA
| | | | - Peter J Kaboli
- Center for Access Delivery Research & Evaluation (CADRE), VA Iowa City Healthcare System, Iowa City, IA, USA; Division of General Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Mehta SJ, Volpp KG, Asch DA, Goldberg LR, Russell LB, Norton LA, Iannotte LG, Troxel AB. Rationale and Design of EMPOWER, a Pragmatic Randomized Trial of Automated Hovering in Patients With Congestive Heart Failure. Circ Cardiovasc Qual Outcomes 2020; 12:e005126. [PMID: 30939922 DOI: 10.1161/circoutcomes.118.005126] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Congestive heart failure is a major cause of morbidity, mortality, and cost. Disease management programs have shown promise but lack firm evidence of effectiveness and scalability. We describe the motivation, design, and planned analyses of EMPOWER (Electronic Monitoring of Patients Offers Ways to Enhance Recovery), a randomized clinical trial of an innovative intervention incorporating behavioral economic principles with remote monitoring technology embedded within a healthcare system. METHODS AND RESULTS EMPOWER is an ongoing, pragmatic, randomized clinical trial comparing usual care to an automated hovering intervention that includes patient-level incentives for daily weight monitoring and diuretic adherence combined with automated feedback into the clinical care pathway, enabling real-time response to concerning clinical symptoms. Identification of eligible patients began in May 2016, and implementation of the intervention is feasible. Trial processes are embedded into existing clinical pathways. The primary outcome is time to readmission for any cause. Cost-effectiveness analyses are planned to evaluate the healthcare costs and health outcomes of the approach. CONCLUSIONS The EMPOWER trial incorporates leading-edge approaches in human motivation, derived from behavioral economics, with contemporary technology to provide scale and exception handling at low cost. The trial is also implemented within the naturalized environment of a health system, as much as possible taking advantage of the existing journeys of patients and workflows of clinicians. A goal of this pragmatic design is to limit resource utilization and also to test an intervention that would need minimal modification to be translated from research into a new way of practice. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT02708654.
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Affiliation(s)
- Shivan J Mehta
- Departments of Medicine and Health Policy and Medical Ethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (S.J.M., K.G.V., D.A.A., L.R.G., L.B.R., L.A.N., L.G.I.).,The Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA (S.J.M., K.G.V., D.A.A.)
| | - Kevin G Volpp
- Departments of Medicine and Health Policy and Medical Ethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (S.J.M., K.G.V., D.A.A., L.R.G., L.B.R., L.A.N., L.G.I.).,The Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA (S.J.M., K.G.V., D.A.A.)
| | - David A Asch
- Departments of Medicine and Health Policy and Medical Ethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (S.J.M., K.G.V., D.A.A., L.R.G., L.B.R., L.A.N., L.G.I.).,The Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA (S.J.M., K.G.V., D.A.A.)
| | - Lee R Goldberg
- Departments of Medicine and Health Policy and Medical Ethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (S.J.M., K.G.V., D.A.A., L.R.G., L.B.R., L.A.N., L.G.I.)
| | - Louise B Russell
- Departments of Medicine and Health Policy and Medical Ethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (S.J.M., K.G.V., D.A.A., L.R.G., L.B.R., L.A.N., L.G.I.)
| | - Laurie A Norton
- Departments of Medicine and Health Policy and Medical Ethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (S.J.M., K.G.V., D.A.A., L.R.G., L.B.R., L.A.N., L.G.I.)
| | - Lauren G Iannotte
- Departments of Medicine and Health Policy and Medical Ethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (S.J.M., K.G.V., D.A.A., L.R.G., L.B.R., L.A.N., L.G.I.)
| | - Andrea B Troxel
- Division of Biostatistics, Department of Population Health, New York University School of Medicine, New York, NY (A.B.T.)
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Waddell KJ, Shah PD, Adusumalli S, Patel MS. Using Behavioral Economics and Technology to Improve Outcomes in Cardio-Oncology. JACC CardioOncol 2020; 2:84-96. [PMID: 34396212 PMCID: PMC8352113 DOI: 10.1016/j.jaccao.2020.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/03/2020] [Indexed: 12/20/2022] Open
Abstract
Patients with cancer are often at elevated risk for cardiovascular disease due to overlapping risk factors and cardiotoxic anticancer treatments. Their cancer diagnoses may be the predominant focus of clinical care, with less of an emphasis on concurrent cardiovascular risk management. Widely adopted technology platforms, including electronic health records and mobile devices, can be leveraged to improve the cardiovascular outcomes of these patients. These technologies alone may be insufficient to change behavior and may have greater impact if combined with behavior change strategies. Behavioral economics is a scientific field that uses insights from economics and psychology to help explain why individuals are often predictably irrational. Combining insights from behavioral economics with these scalable technology platforms can positively impact medical decision-making and sustained healthy behaviors. This review focuses on the principles of behavioral economics and how "nudges" and scalable technology can be used to positively impact clinician and patient behaviors.
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Affiliation(s)
- Kimberly J. Waddell
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Payal D. Shah
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Srinath Adusumalli
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mitesh S. Patel
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
- Penn Medicine Nudge Unit, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial. J Gen Intern Med 2020; 35:70-78. [PMID: 31515735 PMCID: PMC6958561 DOI: 10.1007/s11606-019-05269-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 06/07/2019] [Accepted: 07/17/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Uncontrolled hypertension contributes to disparities in cardiovascular outcomes. Patient intervention strategies informed by behavioral economics and social psychology could improve blood pressure (BP) control in disadvantaged minority populations. OBJECTIVE To assess the impact on BP control of an intervention combining short-term financial incentives with promotion of intrinsic motivation among highly disadvantaged patients. DESIGN Randomized controlled trial. PARTICIPANTS Two hundred seven adults (98% African American or Latino) aged 18 or older with uncontrolled hypertension attending Federally Qualified Health Centers. INTERVENTION Six-month intervention, combining financial incentives for measuring home BP, recording medication use, BP improvement, and achieving target BP values with counseling linking hypertension control efforts to participants' personal reasons to stay healthy. MAIN MEASURES Primary outcomes: percentage achieving systolic BP (SBP) < 140 mmHg, percentage achieving diastolic BP (DBP) < 90 mmHg, and changes in SBP and DBP, all after 6 months. Priority secondary outcomes were SBP < 140 mmHg, DBP < 90 mmHg, and BP change at 12 months, 6 months after the intervention ended. KEY RESULTS After 6 months, rates of achieving target BP values for intervention and control subjects respectively was 57.1% vs. 40.2% for SBP < 140 mmHg (adjusted odds ratio (AOR) 2.53 (1.13-5.70)), 79.8% vs 70.1% for DBP < 90 mmHg (AOR 2.50 (0.84-7.44)), and 53.6% vs 40.2% for achieving both targets (AOR 2.04 (0.92-4.52)). However, at 12 months, the groups did not differ significantly in these 3 measures: 39.5% vs 35.0% for SBP (AOR 1.20 (0.51-2.83)), 68.4% vs 75.0% for DBP (AOR 0.70 (0.24-2.09)), and 35.5% vs 33.8% for both (AOR 1.03 (0.44-2.42)). Change in absolute SBP and DBP did not differ significantly between the groups at 6 or 12 months. Exploratory post hoc analysis revealed intervention benefit only occurred among individuals whose providers intensified their regimens, but not among those with intensification but no intervention. CONCLUSIONS The intervention achieved short-term improvement in SBP control in a highly disadvantaged population. Despite attempts to enhance intrinsic motivation, the effect was not sustained after incentives were withdrawn. Future research should evaluate combined patient/provider strategies to enhance such interventions and sustain their benefit. TRIAL REGISTRATION NCT01402453; http://clinicaltrials.gov/show/NCT01402453.
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Sadness, but not all negative emotions, heightens addictive substance use. Proc Natl Acad Sci U S A 2019; 117:943-949. [PMID: 31888990 DOI: 10.1073/pnas.1909888116] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Do negative feelings in general trigger addictive behavior, or do specific emotions play a stronger role? Testing these alternative accounts of emotion and decision making, we drew on the Appraisal Tendency Framework to predict that sadness, specifically, rather than negative mood, generally, would 1) increase craving, impatience, and actual addictive substance use and 2) do so through mechanisms selectively heightened by sadness. Using a nationally representative, longitudinal survey, study 1 (n = 10,685) revealed that sadness, but not other negative emotions (i.e., fear, anger, shame), reliably predicted current smoking as well as relapsing 20 years later. Study 2 (n = 425) used an experimental design, and found further support for emotion specificity: Sadness, but not disgust, increased self-reported craving relative to a neutral state. Studies 3 and 4 (n = 918) introduced choice behavior as outcome variables, revealing that sadness causally increased impatience for cigarette puffs. Moreover, study 4 revealed that the effect of sadness on impatience was more fully explained by concomitant appraisals of self-focus, which are specific to sadness, than by concomitant appraisals of negative valence, which are general to all negative emotions. Importantly, study 4 also examined the topography of actual smoking behavior, finding that experimentally induced sadness (as compared to neutral emotion) causally increased the volume and duration of cigarette puffs inhaled. Together, the present studies provide support for a more nuanced model regarding the effects of emotion on tobacco use, in particular, as well as on addictive behavior, in general.
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Zwakala Ndoda: a cluster and individually randomized trial aimed at improving testing, linkage, and adherence to treatment for hard-to reach men in KwaZulu-Natal, South Africa. Trials 2019; 20:798. [PMID: 31888701 PMCID: PMC6937627 DOI: 10.1186/s13063-019-3908-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 11/15/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Men in sub-Saharan Africa are less likely than women to get tested for HIV, less likely to present for treatment, less likely to be maintained in treatment, more likely to have detectable viral load, more likely to transmit HIV with unprotected intercourse, and more likely to progress to AIDS and die sooner from HIV. The ultimate objective of this research is to provide evidence-based strategies to improve HIV testing and treatment of HIV-infected men. METHODS This study is being conducted in the Greater Edendale Area and Vulindlela region in KwaZulu-Natal, South Africa. It is a two-stage design of a cluster-randomized trial and an individual randomized trial to test how structural and individual-level interventions address the demand-side factors that affect HIV testing and treatment for hard-to reach, high-risk men. It combines male-focused mobilization, community-based mobile HIV testing services, and a small incentive to determine if the strategies singly and in combination can result in more men diagnosed with HIV, and more men linked to and maintained in care with undetectable viral load. DISCUSSION A priority for sub-Sahara Africa is developing and evaluating novel and cost-effective strategies for identifying hard-to-reach groups such as men, linking them to HIV testing and care services, and maintaining them in care to the point of viral suppression. We propose a combination prevention intervention that addresses men's individual, interpersonal, and structural barriers to testing and care. This includes male-led mobilization to encourage uptake of testing and treatment, male-focused testing venues, male-only counselors, developing counseling models that are flexible and responsive to men, and strategies for adhering to clinic visits without missing work and navigating the healthcare system. By thoughtfully combining male-focused mobilization, and testing and addressing some of the barriers to male engagement with health facilities, this study hopes to add to the growing evidence base about how to reach, test, link, and maintain a hard-to-reach group such as men in HIV treatment and care services. TRIAL REGISTRATION ClinicalTrials.gov, NCT03794245. Registered on 4 January 2019.
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McConnell M, Rogers W, Simeonova E, Wilson IB. Architecting Process of Care: A randomized controlled study evaluating the impact of providing nonadherence information and pharmacist assistance to physicians. Health Serv Res 2019; 55:136-145. [PMID: 31835278 PMCID: PMC6981078 DOI: 10.1111/1475-6773.13243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To test the impact of connecting physicians, pharmacists, and patients to address medication nonadherence, and to compare different physician choice architectures. DATA SOURCES AND STUDY SETTING The study was conducted with 90 physicians and 2602 of their patients on medications treating chronic illness. STUDY DESIGN In this cluster randomized controlled trial, physicians were randomly assigned to an arm where the physician receives notification of patient nonadherence derived from real-time claims data, an arm where they receive this information and a pharmacist may contact patients either by default or by physician choice, and a control group. The primary outcome was resolving nonadherence within 30 days. We also considered physician engagement outcomes including viewing information about nonadherence and utilizing a pharmacist. DATA COLLECTION Physician engagement was constructed from metadata from the study website; adherence outcomes were constructed from medication claims. PRINCIPAL FINDINGS We see no differences between the treatment arms and control for the primary adherence outcome. The pharmacist intervention was 42 percentage points (95% CI: 28 pp-56 pp) more likely when it was triggered by default. CONCLUSIONS Access to a pharmacist and real-time nonadherence information did not improve patient adherence. Physician process of care was sensitive to choice architecture.
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Affiliation(s)
- Margaret McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - William Rogers
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | | | - Ira B Wilson
- Brown University School of Public Health, Providence, Rhode Island
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Affiliation(s)
- Mark Skopec
- Department of Primary Care and Public Health, Imperial College London
| | - Hamdi Issa
- Institute of Global Health Innovation, Imperial College London
| | - Matthew Harris
- Department of Primary Care and Public Health, Imperial College London
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Electronic Pill Bottles or Bidirectional Text Messaging to Improve Hypertension Medication Adherence (Way 2 Text): a Randomized Clinical Trial. J Gen Intern Med 2019; 34:2397-2404. [PMID: 31396815 PMCID: PMC6848522 DOI: 10.1007/s11606-019-05241-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/30/2019] [Accepted: 07/17/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Poor medication adherence contributes to inadequate control of hypertension. However, the value of adherence monitoring is unknown. OBJECTIVE To evaluate the impact of monitoring adherence with electronic pill bottles or bidirectional text messaging on improving hypertension control. DESIGN Three-arm pragmatic randomized controlled trial. PATIENTS One hundred forty-nine primary care patients aged 18-75 with hypertension and text messaging capabilities who were seen at least twice in the prior 12 months with at least two out-of-range blood pressure (BP) measurements, including the most recent visit. INTERVENTIONS Patients were randomized in a 1:2:2 ratio to receive (1) usual care, (2) electronic pill bottles for medication adherence monitoring (pill bottle), and (3) bidirectional text messaging for medication adherence monitoring (bidirectional text). MAIN MEASURES Change in systolic BP during the final 4-month visit compared with baseline. KEY RESULTS At the 4-month follow-up visit, mean (SD) change values in systolic blood pressure were - 4.7 (23.4) mmHg in usual care, - 4.3 (21.5) mmHg in the pill bottle arm, and - 4.6 (19.8) mmHg in the text arm. There was no significant change in systolic blood pressure between control and the pill bottle arm (p = 0.94) or the text messaging arm (p = 1.00), and the two intervention arms did not differ from each other (p = 0.93). CONCLUSIONS Despite good measured adherence, neither feedback with electronic pill bottles nor bidirectional text messaging about medication adherence improved blood pressure control. Adherence to prescribed medications was not improved enough to affect BP control or it was not the primary driver of poor control. TRIAL REGISTRATION clinicaltrials.gov (NCT02778542).
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The effectiveness of financial intervention strategies for reducing caesarean section rates: a systematic review. BMC Public Health 2019; 19:1080. [PMID: 31399068 PMCID: PMC6688325 DOI: 10.1186/s12889-019-7265-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 06/30/2019] [Indexed: 01/08/2023] Open
Abstract
Background The increasing trend of Caesarean section (CS) in childbirth has become a global public health challenge. Previous studies have proposed financial intervention strategies for reducing CS rates by limiting caesarean delivery on maternal request (CDMR). This study synthesizes such strategies while evaluating their effectiveness. Methods The sources of data for this study are Cochrane Library, PubMed, EMBASE, and CINAHL. The publication period included in this study is from January 1991 to November 2018. The financial intervention strategies are divide into two categories: healthcare provider interventions and patient interventions. Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) was employed to assess the risk of bias of included studies. The outcome of each study was evaluated with Grades of Recommendation, Assessment, Development and Evaluation (GRADE) through the GRADEpro Guideline Development Tool software. Results Nine studies were included in this systematic review: five with high certainty evidence (HCE), three with moderate certainty evidence (MCE), and one with low certainty evidence (LCE). Of the nine studies, seven are centered on the effect of provider-side interventions. Three of the HCE studies found that the diagnosis-related group payment system, risk-adjusted capitation, and equalizing fee for both facilities and physicians were effective intervention strategies. One HCE and one MCE study showed that only equalizing facility fees between vaginal and CS deliveries in healthcare service settings had no significant effect on reducing the CS rate. The MCE study showed that case payment had a negative effect on reducing the CS rates. One LCE study revealed that the effect of a global budget system was uncertain, and one HCE and one MCE study focused on combining both provider and patient-side interventions. However, equalizing fees for vaginal and CS deliveries and a co-payment policy for CDMRs failed to reduce the CS rate. Conclusions The effectiveness of risk-adjusted payment methods appears promising and should be the subject of further research. Financial interventions should consider stakeholders’ characteristics, especially the personal interests of doctors. Finally, high-quality randomized control trials and comparative studies on different financial intervention methods are needed to confirm or refute previous studies’ outcomes. Electronic supplementary material The online version of this article (10.1186/s12889-019-7265-4) contains supplementary material, which is available to authorized users.
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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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Hogle LF. Accounting for accountable care: Value-based population health management. SOCIAL STUDIES OF SCIENCE 2019; 49:556-582. [PMID: 31122142 DOI: 10.1177/0306312719840429] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Accountable Care Organizations (ACOs) are exemplars of so-called value-based care in the US. In this model, healthcare providers bear the financial risk of their patients' health outcomes: ACOs are rewarded for meeting specific quality and cost-efficiency benchmarks, or penalized if improvements are not demonstrated. While the aim is to make providers more accountable to payers and patients, this is a sea-change in payment and delivery systems, requiring new infrastructures and practices. To manage risk, ACOs employ data-intensive sourcing and big data analytics to identify individuals within their populations and sort them using novel categories, which are then utilized to tailor interventions. The article uses an STS lens to analyze the assemblage involved in the enactment of population health management through practices of data collection, the creation of new metrics and tools for analysis, and novel ways of sorting individuals within populations. The processes and practices of implementing accountability technologies thus produce particular kinds of knowledge and reshape concepts of accountability and care. In the process, account-giving becomes as much a procedural ritual of verification as an accounting for health outcomes.
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Affiliation(s)
- Linda F Hogle
- Department of Medical History & Bioethics, University of Wisconsin-Madison, Madison, WI, USA
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46
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Husain SA, Diaz K, Schwartz JE, Parsons FE, Burg MM, Davidson KW, Kronish IM. Behavioral economics implementation: Regret lottery improves mHealth patient study adherence. Contemp Clin Trials Commun 2019; 15:100387. [PMID: 31198881 PMCID: PMC6555893 DOI: 10.1016/j.conctc.2019.100387] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 05/22/2019] [Accepted: 05/27/2019] [Indexed: 11/28/2022] Open
Abstract
Background Nonadherence to study protocols reduces the generalizability, validity, and statistical power of longitudinal studies. Purpose To determine whether an automated electronically-delivered regret lottery would improve adherence to an intensive mHealth self-monitoring protocol as part of a longitudinal observational study. Methods We enrolled 77 adults into a 52-week study requiring five daily ecologic momentary assessments (EMA) of stress and daily accelerometer use. We performed a pre/post single-arm study to evaluate the efficacy of a lottery intervention in improving adherence to this protocol. Midway through the study, participants were invited to enter a weekly regret lottery ($50 prize, expected value <$1) in which prize collection was contingent upon meeting adherence thresholds for the prior week. Study protocol adherence before and after lottery initiation were compared using mixed models repeated measures analysis of variance. Results 62 participants consented to lottery participation. In the 12 weeks prior to lottery initiation, weekly adherence was declining (slope −1.4%/week). The weekly per-participant probability of adherence was higher after lottery initiation when comparing the 4-week (32% pre-lottery vs 50% post-lottery, p < 0.001), 8-week (37% vs 49%, p < 0.001), and 12-week periods (39% vs 45%, p = 0.001) before and after lottery initiation. However, the rate of decline in adherence over time was unchanged. Conclusion The implementation of an automated, electronically-delivered weekly regret lottery improved adherence with an intensive self-monitoring study protocol. Regret lotteries may represent a cost-effective tool to improve adherence and reduce bias caused by dropout or nonadherence.
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Affiliation(s)
- S Ali Husain
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA.,Division of Nephrology, Columbia University Medical Center, New York, NY, USA
| | - Keith Diaz
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA
| | - Joseph E Schwartz
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA.,Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, NY, USA
| | - Faith E Parsons
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA
| | - Matthew M Burg
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Karina W Davidson
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA.,NewYork-Presbyterian Hospital, New York, NY, USA
| | - Ian M Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA
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Chaiyachati KH, Roy J, Asch DA, Dine CJ, Desai S, Bellini LM, Shea JA. Improving Longitudinal Survey Participation Among Internal Medicine Residents: Incorporating Behavioral Economic Techniques and Avoiding Friday or Saturday Invitations. J Gen Intern Med 2019; 34:823-824. [PMID: 30729415 PMCID: PMC6544584 DOI: 10.1007/s11606-019-04836-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Krisda H Chaiyachati
- The Department of Medicine, University of Pennsylvania Perelman School of Medicine, 423 Guardian Drive, 13th Floor Blockley Hall, Philadelphia, PA, 19104, USA. .,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA.
| | - Jason Roy
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | - David A Asch
- The Department of Medicine, University of Pennsylvania Perelman School of Medicine, 423 Guardian Drive, 13th Floor Blockley Hall, Philadelphia, PA, 19104, USA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - C Jessica Dine
- The Department of Medicine, University of Pennsylvania Perelman School of Medicine, 423 Guardian Drive, 13th Floor Blockley Hall, Philadelphia, PA, 19104, USA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
| | - Sanjay Desai
- The Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lisa M Bellini
- The Department of Medicine, University of Pennsylvania Perelman School of Medicine, 423 Guardian Drive, 13th Floor Blockley Hall, Philadelphia, PA, 19104, USA
| | - Judy A Shea
- The Department of Medicine, University of Pennsylvania Perelman School of Medicine, 423 Guardian Drive, 13th Floor Blockley Hall, Philadelphia, PA, 19104, USA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
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Roseleur J, Harvey G, Stocks N, Karnon J. Behavioral economic insights to improve medication adherence in adults with chronic conditions: a scoping review protocol. ACTA ACUST UNITED AC 2019; 17:1915-1923. [PMID: 31145189 DOI: 10.11124/jbisrir-2017-003971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The objective of this review is to map the evidence on the use of behavioral economic insights to improve medication adherence in adults with chronic conditions. INTRODUCTION Medication non-adherence is a barrier to effectively managing chronic conditions, leading to poorer patient outcomes and placing an additional financial burden on healthcare systems. As the population ages and the prevalence of chronic disease increases, new ways to influence patient behavior are needed. Approaches that use insights from behavioral economics may help improve medication adherence, thus reducing morbidity, mortality and financial costs of unmanaged chronic diseases. INCLUSION CRITERIA Eligible studies will include adults taking medication for a chronic condition. All interventions relevant to high-income settings using insights from behavioral economics to improve medication adherence in adults will be considered. Contexts may include, but are not limited to, primary health care, corporate wellness programs and health insurance schemes. Any study design published in English will be considered. Studies in facilities where medication is administered to patients will be excluded. METHODS PubMed, Embase, Scopus, PsycINFO, EconLit and CINAHL will be searched from database inception to present. Gray literature will be searched using Google Scholar, OpenGrey and the Grey Literature Report. One reviewer will review titles, and then two reviewers will independently review abstracts to identify eligible studies. One reviewer will extract data on study characteristics, study design and study outcomes. A second reviewer will validate 25% of the extracted information. The results of the data extraction will be presented in a table, and a narrative summary will be presented.
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Affiliation(s)
- Jacqueline Roseleur
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - Gillian Harvey
- Adelaide Nursing School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, NHMRC Centre of Research Excellence to Reduce Inequality in Heart Disease, The University of Adelaide, Adelaide, Australia
| | - Jonathan Karnon
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
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Nisa CF, Bélanger JJ, Schumpe BM. Parts greater than their sum: randomized controlled trial testing partitioned incentives to increase cancer screening. Ann N Y Acad Sci 2019; 1449:46-55. [PMID: 31111509 DOI: 10.1111/nyas.14115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 03/31/2019] [Accepted: 04/12/2019] [Indexed: 01/03/2023]
Abstract
Promoting healthy behavior is a challenge for public health officials, especially in the context of asking patients to participate in preventive cancer screenings. Small financial incentives are sometimes used, but there is a little scientific basis to support a compelling description of the best-practice implementation of such incentives. We present a simple behavioral strategy based on mental accounting from prospect theory that maximizes the impact of incentives with no additional cost. We show how the partition of one incentive into two smaller incentives of equivalent total amount produces substantial behavioral changes, demonstrated in the context of colorectal cancer screening. In a randomized controlled trial, eligible patients aged 50-74 (n = 1652 patients) were allocated to receive either one €10 incentive (upon completion of screening) or two €5 incentives (at the beginning and at the end of screening). We show that cancer screening rates were dramatically increased by partitioning the financial incentive (61.1%), compared with a single installment at the end (41.4%). These results support the hedonic editing hypothesis from prospect theory, and underline the importance of implementing theoretically grounded healthcare interventions. Our results suggest that, when patient incentives are feasible, healthcare procedures should be framed as multistage events with smaller incentives offered at multiple points in time.
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Affiliation(s)
- Claudia F Nisa
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Jocelyn J Bélanger
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Birga M Schumpe
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
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50
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Liu T, Volpp KG, Asch DA, Zhu J, Wang W, Wu R, Troxel AB, Finnerty DD, Hoffer K, Shea JA. The association of financial incentives for low density lipoprotein cholesterol reduction with patient activation and motivation. Prev Med Rep 2019; 14:100841. [PMID: 30911461 PMCID: PMC6416647 DOI: 10.1016/j.pmedr.2019.100841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/24/2019] [Accepted: 03/02/2019] [Indexed: 11/29/2022] Open
Abstract
There is growing interest in using financial incentives for patients to improve medication adherence, but few studies have evaluated whether financial incentives are associated with patients' activation and motivation. We analyzed survey data collected as part of a randomized clinical trial conducted from 2011 to 2014 of four financial incentive interventions to reduce low density lipoprotein cholesterol (LDL-C) among patients at risk for atherosclerotic cardiovascular disease. The main trial included 1503 patients aged 18–80 and recruited from primary care practices affiliated with three health systems. Participants were randomized into four groups: patient financial incentives, primary care physicians (PCPs) incentives, patients and PCPs shared incentives, or no incentives for LDL-C control. Patient Activation Measure (PAM) and Treatment Self Regulation Questionnaire (TSRQ) surveys were administered at baseline and 12 months. Clinical outcomes were change in LDL-C at 12 and 15 months and average medication adherence as measured by electronic pill bottle opening. Mean changes in PAM and TSRQ scores were compared between patients eligible and not eligible for incentives. Clinical outcomes were tested against baseline and change in psychosocial measures using bivariate and multivariate regression. Change in PAM score and TSRQ autonomous subscore did not differ significantly between patients eligible and not eligible for incentives. Lower baseline and greater increase in TSRQ autonomous subscore were predictive of greater 15-month decrease in LDL-C. A financial incentive intervention to improve LDL-C control was not associated with changes in patients' activation or autonomous motivation. Increases in patient autonomous motivation are predictive of long-term LDL-C control. Financial incentives for lipid control were not associated with changes in activation or motivation. Participants had high activation and motivation levels at baseline. Increases in autonomous motivation were associated with better lipid control at 15 months.
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Affiliation(s)
- Tianyu Liu
- University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, United States of America
| | - Kevin G Volpp
- University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, United States of America.,Department of Veterans Affairs, 3900 Woodland Avenue, Philadelphia, PA 19104, United States of America
| | - David A Asch
- University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, United States of America.,Department of Veterans Affairs, 3900 Woodland Avenue, Philadelphia, PA 19104, United States of America
| | - Jingsan Zhu
- University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, United States of America
| | - Wenli Wang
- University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, United States of America
| | - Ruoming Wu
- University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, United States of America
| | - Andrea B Troxel
- University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, United States of America
| | - Darra D Finnerty
- University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, United States of America
| | - Karen Hoffer
- University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, United States of America
| | - Judy A Shea
- University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, United States of America
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