Nudging to Change: Using Behavioral Economics Theory to Move People and Their Health Care Partners Toward Effective Type 2 Diabetes Prevention

Implementation of Session Zero as a Recruitment Strategy in the National Diabetes Prevention Program's Lifestyle Change Program

PURPOSE

The purpose of the study was to understand the extent to which organizations offering the Centers for Disease Control and Prevention's (CDC) National Diabetes Prevention Program (National DPP) lifestyle change program implement session zero (a pre-enrollment session designed to recruit, engage, and enroll participants in programs), the stated purpose(s) for offering session zero, the content of session zero, and best practices for using session zero for recruitment.

METHODS

Researchers conducted a survey of all organizations offering the National DPP lifestyle change program that were registered with the CDC's Diabetes Prevention Recognition Program and their affiliated delivery locations.

RESULTS

Most (79.5%) delivery locations reported implementing session zero; of these, most used session zero as a recruitment strategy (81.1%) and orientation session (72.8%), whereas few (17.7%) used session zero solely to complete participant enrollment paperwork. Most (60.7%) delivery locations that implement session zero offer all their sessions at the same location, offer one session per upcoming participant cohort (66.7%), and use a consistent agenda (83.0%). Out of a list of activities informed by behavior change theory, the most common was offering an opportunity to enroll in the year-long lifestyle change program at the end of session zero (71.1%).

CONCLUSIONS

Most National DPP delivery locations implement session zero as a recruitment and orientation session. Most delivery locations reported including some activities informed by behavior change theory, but delivery locations could offer more theoretically informed activities during their session zero. The findings provide practice-based considerations for implementing session zero for recruitment into lifestyle change programs.

Two decades of diabetes prevention efforts: A call to innovate and revitalize our approach to lifestyle change

The impact of global diabetes prevention efforts has been modest despite the promise of landmark diabetes prevention trials nearly twenty years ago. While national and regional initiatives show potential, challenges remain to adapt large-scale strategies in the real-world that fits individuals and their communities. Additionally, the sedentary lifestyle changes during the COVID-19 pandemic and guidelines that now call for earlier screening (e.g., US Preventative Task Force) will increase the pool of eligible adults worldwide. Thus, a more adaptable, person-centered approach that expands the current toolkit is urgently needed to innovate and revitalize our approach to diabetes prevention. This review identifies key priorities to optimize the population-level delivery of diabetes prevention based on a consensus-based evaluation of the current evidence among experts in global translational programs; key priorities identified include (1) participant eligibility, (2) intervention intensity, (3) delivery components, (4) behavioral economics, (5) technology, and (6) the role of pharmacotherapy. We offer a conceptual framework for a broader, person-centered approach to better address an individual's risk, readiness, barriers, and digital competency.

Evaluating efficiency of counties in providing diabetes preventive care using data envelopment analysis

For patients with diabetes, annual preventive care is essential to reduce the risk of complications. Local healthcare resources affect the utilization of diabetes preventive care. Our objectives were to evaluate the relative efficiency of counties in providing diabetes preventive care and explore potential to improve efficiencies. The study setting is public and private healthcare providers in US counties with available data. County-level demographics were extracted from the Area Health Resources File using data from 2010 to 2013, and individual-level information of diabetes preventive service use was obtained from the 2010 Behavioral Risk Factor Surveillance System. 1112 US counties were analyzed. Cluster analysis was used to place counties into three similar groups in terms of economic wellbeing and population characteristics. Group 1 consisted of metropolitan counties with prosperous or comfortable economic levels. Group 2 mostly consisted of non-metropolitan areas between distress and mid-tier levels, while Group 3 were mostly prosperous or comfortable counties in metropolitan areas. We used data enveopement analysis to assess efficiencies within each group. The majority of counties had modest efficiency in providing diabetes preventive care; 36 counties (57.1%), 345 counties (61.1%), and 263 counties (54.3%) were inefficient (efficiency scores < 1) in Group 1, Group 2, and Group 3, respectively. For inefficient counties, foot and eye exams were often identified as sources of inefficiency. Available health professionals in some counties were not fully utilized to provide diabetes preventive care. Identifying benchmarking targets from counties with similar resources can help counties and policy makers develop actionable strategies to improve performance.

Participation and weight loss in online National Diabetes Prevention Programs: a comparison of age and gender subgroups

Early onset diabetes has adverse transgenerational effects, yet in-person National Diabetes Prevention Programs (NDPPs) have low reach among adults of peak reproductive age. We examined participation and weight loss with online NDPPs for younger versus older adults. Solera Health, Inc., collected data from 12,966 adults who enrolled in a yearlong online NDPP from 2015 to 2018. We used general linear models and logistic regression to assess differences between younger and older adults (<45 vs. ≥45 years) in session initiation (logging in), session completion (activities approximating intensity of in-person classes), and weight loss, overall and according to engagement thresholds. Almost all (N = 12,497, 96%) individuals who enrolled initiated ≥1 session(s), but fewer (N = 2,408, 19%) completed ≥4 sessions over ≥9 months, achieving 4.5% weight loss on average. Among all enrollees with ≥2 weights (N = 10,161), younger men and women lost less weight (1.8% and 1.7%, respectively) than older men (3.3%) and women (2.7%; all p < .05). Among all enrollees who completed ≥4 sessions over ≥9 months, weight loss did not differ between older men (4.3%), older women (4.0%), and younger men (3.5%), but younger women achieved less weight loss (3.0%) than older adults (all p < .001). Online programming supports NDPP reach and weight loss, although younger adults completed fewer sessions and young women achieved less weight loss than older adults. Efforts to increase ongoing engagement among younger adults are needed to prevent early onset of diabetes and adverse transgenerational effects.

It's how you say it: Systematic A/B testing of digital messaging cut hospital no-show rates

Failure to attend hospital appointments has a detrimental impact on care quality. Documented efforts to address this challenge have only modestly decreased no-show rates. Behavioral economics theory has suggested that more effective messages may lead to increased responsiveness. In complex, real-world settings, it has proven difficult to predict the optimal message composition. In this study, we aimed to systematically compare the effects of several pre-appointment message formats on no-show rates. We randomly assigned members from Clalit Health Services (CHS), the largest payer-provider healthcare organization in Israel, who had scheduled outpatient clinic appointments in 14 CHS hospitals, to one of nine groups. Each individual received a pre-appointment SMS text reminder five days before the appointment, which differed by group. No-show and advanced cancellation rates were compared between the eight alternative messages, with the previously used generic message serving as the control. There were 161,587 CHS members who received pre-appointment reminder messages who were included in this study. Five message frames significantly differed from the control group. Members who received a reminder designed to evoke emotional guilt had a no-show rates of 14.2%, compared with 21.1% in the control group (odds ratio [OR]: 0.69, 95% confidence interval [CI]: 0.67, 0.76), and an advanced cancellation rate of 26.3% compared with 17.2% in the control group (OR: 1.2, 95% CI: 1.19, 1.21). Four additional reminder formats demonstrated significantly improved impact on no-show rates, compared to the control, though not as effective as the best performing message format. Carefully selecting the narrative of pre-appointment SMS reminders can lead to a marked decrease in no-show rates. The process of a/b testing, selecting, and adopting optimal messages is a practical example of implementing the learning healthcare system paradigm, which could prevent up to one-third of the 352,000 annually unattended appointments in Israel.

Evidence and Challenges for Translation and Population Impact of the Diabetes Prevention Program

PURPOSE OF REVIEW

Type 2 diabetes is common, burdensome, and preventable. Landmark trials such as the Diabetes Prevention Program (DPP) demonstrated that resource-intensive lifestyle support interventions resulting in modest weight loss via healthy diet changes and physical activity can lower the rate of diabetes development by 58%. We performed a review of efforts to translate and implement DPP-like programs throughout the USA to identify challenges and opportunities for improvement.

RECENT FINDINGS

For more than a decade, multiple stakeholders have worked to translate evidence-based principles of diabetes prevention to reach 84 million Americans with prediabetes. DPP-like programs have been delivered by over 1500 organizations, reaching almost 300,000 people, but this number represents less than 1% of the target population. Research has uncovered large gaps in efforts to diagnose, raise awareness, and provide access to DPP-like programs for adults with prediabetes, requiring further stakeholder engagement and coordination to resolve. Efforts to address prevailing gaps in diabetes prevention must address distinct and sometimes conflicting priorities and concerns of stakeholders. Our review recommends several areas of further research and action to improve type 2 diabetes prevention on a population scale.