Kevin Volpp

Background: Physical activity is associated with a lower risk of major adverse cardiovascular events, but few individuals achieve guideline recommended levels of physical activity. Strategies informed by behavioral economics increase physical activity, but their longer-term effectiveness is uncertain. We sought to determine the effect of behaviorally-designed gamification, loss-framed financial incentives, or the combination on physical activity compared with attention control over 12-month intervention and 6-month post-intervention follow-up periods. Methods: Between May 2019 and January 2024, participants with clinical ASCVD or 10-year risk of myocardial infarction, stroke, or cardiovascular death ≥ 7.5% by the pooled cohort equation were enrolled in a pragmatic randomized clinical trial. Participants received a wearable device to track daily steps, established a baseline, selected a step goal increase, and were …

BackgroundThe use of financial incentives and environmental change strategies to encourage health behaviour change is increasingly prevalent. However, the experiences of participants in incentive interventions are not well characterised. Examination of participant perceptions of financial incentives and environmental strategies can offer insights about how these interventions are facilitating or failing to encourage behaviour change.ObjectiveThis study aimed to learn how participants in a randomised trial that tested financial incentives and environmental interventions to support weight loss perceived factors contributing to their success or failure in the trial.DesignQualitative study with one-time interviews of trial participants with high and low success in losing weight, supplemented by study records of incentive payments and weight loss.Participants24 trial participants (12 with substantial weight loss and 12 with no …

BackgroundFamilial hypercholesterolemia (FH) is a heritable disorder affecting 1.3 million individuals in the USA. Eighty percent of people with FH are undiagnosed, particularly minoritized populations including Black or African American people, Asian or Asian American people, and women across racial groups. Family cascade screening is an evidence-based practice that can increase diagnosis and improve health outcomes but is rarely implemented in routine practice, representing an important care gap. In pilot work, we leveraged best practices from behavioral economics and implementation science—including mixed-methods contextual inquiry with clinicians, patients, and health system constituents—to co-design two patient-facing implementation strategies to address this care gap:(a) an automated health system-mediated strategy and (b) a nonprofit foundation-mediated strategy with contact from a …

BackgroundIn patients with or at risk for atherosclerotic vascular disease, statins reduce the incidence of major adverse cardiovascular events, but the majority of U.S. adults with an indication for statin therapy are not prescribed statins at guideline-recommended intensity. Clinicians’ limited time to address preventative care issues is cited as one factor contributing to gaps in statin prescribing. Centralized pharmacy services can fulfill a strategic role for population health management through outreach, education, and statin prescribing for patients at elevated ASCVD risk, but best practices for optimizing referrals of appropriate patients are unknown.Study Design and ObjectivesSUPER LIPID (NCT05537064) is a program consisting of two pragmatic clinical trials testing the effect of nudges in increasing referrals of appropriate patients to a centralized pharmacy service for lipid management, conducted within 11 primary …

NEJM Catalyst Insights Council members say behavioral nudges are highly effective for a range of care delivery goals.

BackgroundHeart failure (HF) is one of the most common reasons for hospital admission and is a major cause of morbidity, mortality, and increasing health care costs. The EMPOWER study was a randomized trial that used remote monitoring technology to track patients’ weight and diuretic adherence and a state-of-the-art approach derived from behavioral economics to motivate adherence to the reverse monitoring technology.ObjectiveThe goal was to explore patient and clinician perceptions of the program and its impact on perceived health outcomes and better understand why some patients or clinicians did better or worse than others in response to the intervention.ApproachThis was a retrospective qualitative study utilizing semi-structured interviews with 43 patients and 16 clinicians to understand the trial’s processes, reflecting on successes and areas for improvement for future iterations of behavioral …

To reduce atherosclerotic cardiovascular disease (ASCVD) risk, the American College of Cardiology/American Heart Association recommends routinely assessing traditional cardiovascular risk factors and calculation of 10-year ASCVD risk for adults 40-75 years of age and traditional ASCVD risk factors for adults 20-39 years of age at least every 4-6 years. For many patients, the ASCVD risk can’t be calculated due to a missing comprehensive lipid panel. In our health system, 23% of adult patients had not had labs within the past 5 years. We aim to evaluate the effect of behavioral economic interventions on lipid screening uptake. We hypothesize that reducing effort for patients and clinicians through default bulk ordering and salient communication through outreach letters with PCP endorsement, time-limited components and physical lab orders will result in greater completion of lipid screening compared to usual …

Each year, there are nearly 400 000 out-of-hospital cardiac arrest (OHCA) events in the US. 1 The national survival to discharge rate was less than 10% in 2020, 2 and survival varies considerably between communities. 3 Survival rates from OHCA in the US are low since less than 40% receive bystander cardiopulmonary resuscitation (CPR) and much fewer receive use of an automated external defibrillator (AED) in the field before arrival by emergency medical services (EMS). EMS response times vary enormously based on geographic location, and often by the time of EMS arrival, the patient with OHCA has experienced overwhelming ischemic injury and no longer can be resuscitated. The availability of AEDs is a special challenge: availability is limited near the 70% of OHCAs that happen in private residences, many public locations do not have AEDs, even if there is an AED nearby a bystander may not be aware …

OBJECTIVEWe sought to evaluate the use of behavioral economics approaches to promote the carrying of epinephrine auto-injectors (EAIs) among adolescents with food allergies. We hypothesized that adolescents who receive frequent text message nudges (Intervention 1) or frequent text message nudges plus modest financial incentives (Intervention 2) would be more likely to carry their epinephrine than members of the usual care control group.METHODSWe recruited 131 adolescents ages 15 to 19 with a food allergy and a current prescription for epinephrine to participate in a cohort multiple randomized controlled trial. Participants were randomly assigned to participate in Intervention 1, Intervention 2, or to receive usual care. The primary outcome was consistency of epinephrine-carrying, measured as the proportion of checkpoints at which a participant could successfully demonstrate they were carrying their …

Peer comparison feedback is a promising strategy for reducing opioid prescribing and opioid-related harms. Such comparisons may be particularly impactful among underestimating clinicians who do not perceive themselves as high prescribers relative to their peers. But peer comparisons could also unintentionally increase prescribing among overestimating clinicians who do not perceive themselves as lower prescribers than peers. The objective of this study was to assess if the impact of peer comparisons varied by clinicians’ preexisting opioid prescribing self-perceptions. Subgroup analysis of a randomized trial of peer comparison interventions among emergency department and urgent care clinicians was used. Generalized mixed-effects models were used to assess whether the impact of peer comparisons, alone or combined with individual feedback, varied by underestimating or overestimating prescriber …

Connected healthcare is a form of health delivery that connects patients and providers through connected health devices, allowing providers to monitor patient behavior and proactively intervene before an adverse event occurs. Unlike the costs, the benefits of connected healthcare in improving patient behavior and health outcomes are usually difficult to determine. In this study, we examine the efficacy of a connected health system that aimed to reduce readmissions through improved medication adherence. Specifically, we study 975 patients with heart disease who received electronic pill bottles that tracked medication adherence. Patients who were nonadherent received active social support that involved different types of feedback, such as text messages and calls. By integrating data on adherence, intervention, and readmission, we aim to (1) investigate the efficacy of connected healthcare in promoting …

In response to the escalating global obesity crisis and its associated health and financial burdens, this paper presents a novel methodology for analyzing longitudinal weight loss data and assessing the effectiveness of financial incentives. Drawing from the Keep It Off trial—a three-arm randomized controlled study with 189 participants—we examined the potential impact of financial incentives on weight loss maintenance. Given that some participants choose not to weigh themselves because of small weight change or weight gains, which is a common phenomenon in many weight-loss studies, traditional methods, for example, the Generalized Estimating Equations (GEE) method tends to overestimate the effect size due to the assumption that data are missing completely at random. To address this challenge, we proposed a framework which can identify evidence of missing not at random and conduct bias correction …

Incentives are a useful tool in encouraging healthy behavior as part of public health initiatives. However, there remains concern about motivation crowd out—a decline in levels of motivation to undertake a behavior to below baseline levels after incentives have been removed—and few public health studies have assessed for motivation crowd out. Here, we assess the feasibility of identifying motivation crowd out following a lottery to promote participation in a Chagas disease vector control campaign. We look for evidence of crowd out in subsequent participation in the same behavior, a related behavior, and an unrelated behavior. We identified potential motivation crowd out for the same behavior, but not for related behavior or unrelated behaviors after lottery incentives are removed. Despite some limitations, we conclude that motivation crowd out is feasible to assess in large-scale trials of incentives.

BackgroundThe Diabetes Prevention Program (DPP) and metformin can prevent or delay the onset of type 2 diabetes mellitus (T2DM) among patients with prediabetes. Yet, even when these evidence-based strategies are accessible and affordable, uptake is low. Thus, there is a critical need for effective, scalable, and sustainable approaches to increase uptake and engagement in these interventions.MethodsIn this randomized controlled trial, we will test whether financial incentives and automated messaging to promote autonomous motivation for preventing T2DM can increase DPP participation, metformin use, or both among adults with prediabetes. Participants (n = 380) will be randomized to one of four study arms. Control Arm participants will receive usual care and educational text messages about preventing T2DM. Incentives Arm participants will receive the Control Arm intervention plus financial incentives …

IntroductionMultiple U.S. localities have introduced legislation requiring sugar-sweetened beverage (SSB) warnings. This study effects of different warning designs on beverage selections and perceptions.Study DesignThe study was an RCT.Setting/ParticipantsAn online virtual convenience store and survey were used with a nationally representative sample of primary caregivers of 6–11-year-olds (n=961). Data were collected in January 2020 and analyzed in May–July 2020.InterventionParticipants were randomized to view SSBs with 1 of 4 front-of-package label designs: (1) no-warning control, (2) health-related text warning, (3) sugar pictorial warning (image of beverage sugar content in cubes/teaspoons/packets with health-related warning text), or (4) health pictorial warning (image of possible health consequences of overconsuming SSBs with health-related warning text).Main outcome measuresOutcomes …

ImportanceTaxes on sweetened beverages are being implemented around the globe; an understanding of these taxes on individual-level behavior is necessary.ObjectiveTo evaluate the degree to which the sweetened beverage tax in Philadelphia, Pennsylvania, was associated with changes in beverage prices and individual-level purchasing over time at a national pharmacy chain in Philadelphia compared with Baltimore, Maryland.Design, Setting, and ParticipantsUsing a difference-in-differences approach and generalized linear mixed models, this cohort study examined beverage purchases made by loyalty cardholders at a national chain pharmacy retailer with stores in Philadelphia and Baltimore (control city) from before tax to after tax. Beverage sales (in US dollars) were linked by unique loyalty card numbers to enable longitudinal analyses. Data were collected from January 1, 2015, through December 31 …

The integration of coaches in an innovative care delivery team that supports a patient in setting goals, identifying and overcoming challenges, improving behaviors and choices, aligning social support inside and outside the physician’s office, and sustaining effort through to goal achievement, can enhance value-based care that improves processes and outcomes for patients, health plans, and the health care system.

Publisher Correction: Quantifying and correcting bias due to outcome dependent self-reported weights in longitudinal study of weight loss interventions - PMC Back to Top Skip to main content NIH NLM Logo Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation Search PMC Full-Text Archive Search in PMC Advanced Search User Guide Journal List Scientific Reports PMC10728146 Other Formats PDF (737K) Actions Cite Collections Share Permalink Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Journal List Scientific Reports PMC10728146 As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Logo of scirep Sci Rep. 2023; 13: 22546. Published online 2023 …

ObjectiveThe aim of this study was to evaluate the effectiveness of a digital health intervention plus community health worker (CHW) support on self-monitoring of blood glucose and glycosylated hemoglobin (HbA1c) among adult Medicaid beneficiaries with diabetes.DesignRandomized controlled trial. Setting: Urban outpatient clinic.ParticipantsAdult Medicaid beneficiaries living with diabetes and treated with insulin and who had a HbA1c ≥ 9%.InterventionParticipants were randomly assigned to one of three arms. Participants in the usual-care arm received a wireless glucometer if needed. Those in the digital arm received a lottery incentive for daily glucose monitoring. Those in the hybrid arm received the lottery plus support from a CHW if they had low adherence or high blood glucose levels.Main MeasuresThe primary outcome was the difference in adherence to daily glucose self-monitoring at 3 months …

Background Germline testing for prostate cancer is on the increase, with clinical implications for risk assessment, treatment, and management. Regardless of family history, NCCN recommends germline testing for patients with metastatic, regional, very-high-risk localized, and high-risk localized prostate cancer. Although African ancestry is a significant risk factor for aggressive prostate cancer, due to a lack of available data no testing criteria have been established for ethnic minorities. Patients and Methods Through deep sequencing, we interrogated the 20 most common germline testing panel genes in 113 Black South African males presenting with largely advanced prostate cancer. Bioinformatic tools were then used to identify the pathogenicity of the variants. Results After we identified 39 predicted deleterious variants (16 genes), further computational annotation classified 17 variants as potentially oncogenic (12 …

BackgroundHigher levels of physical activity are associated with improvements in cardiovascular health, and consensus guidelines recommend that individuals with or at risk for atherosclerotic cardiovascular disease (ASCVD) participate in regular physical activity. However, most adults do not achieve recommended levels of physical activity. Concepts from behavioral economics have been used to design scalable interventions that increase physical activity over short time periods, but the longer-term efficacy of these strategies is uncertain.Study Design and ObjectivesBE ACTIVE (NCT03911141) is a pragmatic, virtual, randomized controlled trial designed to evaluate the effectiveness of 3 strategies informed by behavioral economic concepts to increase daily physical activity in patients with established ASCVD or 10-year ASCVD risk > 7.5% who are seen in primary care and cardiology clinics affiliated with the …

Unhealthy diets are a major impediment to achieving a healthier population in the United States. Although there is a relatively clear sense of what constitutes a healthy diet, most of the US population does not eat healthy food at rates consistent with the recommended clinical guidelines. An abundance of barriers, including food and nutrition insecurity, how food is marketed and advertised, access to and affordability of healthy foods, and behavioral challenges such as a focus on immediate versus delayed gratification, stand in the way of healthier dietary patterns for many Americans. Food Is Medicine may be defined as the provision of healthy food resources to prevent, manage, or treat specific clinical conditions in coordination with the health care sector. Although the field has promise, relatively few studies have been conducted with designs that provide strong evidence of associations between Food Is Medicine …

Cardiovascular-kidney-metabolic health reflects the interplay among metabolic risk factors, chronic kidney disease, and the cardiovascular system and has profound impacts on morbidity and mortality. There are multisystem consequences of poor cardiovascular-kidney-metabolic health, with the most significant clinical impact being the high associated incidence of cardiovascular disease events and cardiovascular mortality. There is a high prevalence of poor cardiovascular-kidney-metabolic health in the population, with a disproportionate burden seen among those with adverse social determinants of health. However, there is also a growing number of therapeutic options that favorably affect metabolic risk factors, kidney function, or both that also have cardioprotective effects. To improve cardiovascular-kidney-metabolic health and related outcomes in the population, there is a critical need for (1) more clarity on the …

Introduction Palliative care (PC) is a medical specialty focusing on providing relief from the symptoms and stress of serious illnesses such as cancer. Early outpatient specialty PC concurrent with cancer-directed treatment improves quality of life and symptom burden, decreases aggressive end-of-life care and is an evidence-based practice endorsed by national guidelines. However, nearly half of patients with advanced cancer do not receive specialty PC prior to dying. The objective of this study is to test the impact of an oncologist-directed default PC referral orders on rates of PC utilisation and patient quality of life.Methods and analysis This single-centre two-arm pragmatic randomised trial randomises four clinician-led pods, caring for approximately 250 patients who meet guideline-based criteria for PC referral, in a 1: 1 fashion into a control or intervention arm. Intervention oncologists receive a nudge consisting of …

IntroductionPalliative care (PC) is a medical specialty focusing on providing relief from the symptoms and stress of serious illnesses such as cancer. Early outpatient specialty PC concurrent with cancer-directed treatment improves quality of life and symptom burden, decreases aggressive end-of-life care and is an evidence-based practice endorsed by national guidelines. However, nearly half of patients with advanced cancer do not receive specialty PC prior to dying. The objective of this study is to test the impact of an oncologist-directed default PC referral orders on rates of PC utilisation and patient quality of life.Methods and analysisThis single-centre two-arm pragmatic randomised trial randomises four clinician-led pods, caring for approximately 250 patients who meet guideline-based criteria for PC referral, in a 1:1 fashion into a control or intervention arm. Intervention oncologists receive a nudge consisting of …

Hospital readmission prediction models often perform poorly, but most only use information collected until the time of hospital discharge. In this clinical trial, we randomly assigned 500 patients discharged from hospital to home to use either a smartphone or wearable device to collect and transmit remote patient monitoring (RPM) data on activity patterns after hospital discharge. Analyses were conducted at the patient-day level using discrete-time survival analysis. Each arm was split into training and testing folds. The training set used fivefold cross-validation and then final model results are from predictions on the test set. A standard model comprised data collected up to the time of discharge including demographics, comorbidities, hospital length of stay, and vitals prior to discharge. An enhanced model consisted of the standard model plus RPM data. Traditional parametric regression models (logit and lasso) were …

ImportanceFederal and state policymakers continue to pursue work requirements and premiums as conditions of Medicaid participation. Opinion polling should distinguish between general policy preferences and specific views on quotas, penalties, and other elements.ObjectiveTo identify views of adults in Kentucky regarding the design of Medicaid work requirements and premiums.Design, Setting, and ParticipantA cross-sectional survey was conducted via telephone and the internet from June 27 through July 11, 2019, of 1203 Kentucky residents 9 months before the state intended to implement Medicaid work requirements and mandatory premiums. Statistical analysis was performed from October 2019 to August 2023.Main Outcomes and MeasuresAgreement, disagreement, or neutral views on policy components were the main outcomes. Recruitment for the survey used statewide random-digit dialing and an …

Introduction: Statins substantially reduce cardiovascular risk, yet adherence is suboptimal. 90-day prescription fills are associated with better adherence than 30-day fills, though many prescriptions are not written for 90 days. We evaluated the effect of changing default prescription length to 90 days within the electronic health record (EHR) on the proportion of statin prescriptions written for 90 days. Methods: At a single academic health system, we changed the default duration for statin prescriptions written using the primary care preference list within the EHR to 90 pills with 3 refills, while still allowing providers to make a manual change. We compared the proportion of prescriptions written for 90 days over the 4 months before the change (pre-intervention) and 4 months after the change (post-intervention) using a chi-square test, along with need to change prescription dose or drug during the 90-day period after the …

ImportanceStatins reduce the risk of major adverse cardiovascular events, but less than one-half of individuals in America who meet guideline criteria for a statin are actively prescribed this medication.ObjectiveTo evaluate whether nudges to clinicians, patients, or both increase initiation of statin prescribing during primary care visits.Design, Setting, and ParticipantsThis cluster randomized clinical trial evaluated statin prescribing of 158 clinicians from 28 primary care practices including 4131 patients. The design included a 12-month preintervention period and a 6-month intervention period between October 19, 2019, and April 18, 2021.InterventionsThe usual care group received no interventions. The clinician nudge combined an active choice prompt in the electronic health record during the patient visit and monthly feedback on prescribing patterns compared with peers. The patient nudge was an interactive text …

PurposeTo evaluate if nudges delivered by text message prior to an upcoming primary care visit can increase influenza vaccination rates.DesignRandomized, controlled trial.SettingTwo health systems in the Northeastern US between September 2020 and March 2021.Subjects74,811 adults.InterventionsPatients in the 19 intervention arms received 1-2 text messages in the 3 days preceding their appointment that varied in their format, interactivity, and content.MeasuresInfluenza vaccination.AnalysisIntention-to-treat.ResultsParticipants had a mean (SD) age of 50.7 (16.2) years; 55.8% (41,771) were female, 70.6% (52,826) were White, and 19.0% (14,222) were Black. Among the interventions, 5 of 19 (26.3%) had a significantly greater vaccination rate than control. On average, the 19 interventions increased vaccination relative to control by 1.8 percentage points or 6.1% (P = .005). The top performing text message …

Encouraging vaccination is a pressing policy problem. To assess whether text-based reminders can encourage pharmacy vaccination and what kinds of messages work best, we conducted a megastudy. We randomly assigned 689,693 Walmart pharmacy patients to receive one of 22 different text reminders using a variety of different behavioral science principles to nudge flu vaccination or to a business-as-usual control condition that received no messages. We found that the reminder texts that we tested increased pharmacy vaccination rates by an average of 2.0 percentage points, or 6.8%, over a 3-mo follow-up period. The most-effective messages reminded patients that a flu shot was waiting for them and delivered reminders on multiple days. The top-performing intervention included two texts delivered 3 d apart and communicated to patients that a vaccine was “waiting for you.” Neither experts nor lay people …

Background Google and Apple’s Exposure Notifications System (ENS) was developed early in the COVID-19 pandemic to complement existing contact tracing efforts while protecting user privacy. An analysis by the Associated Press released in December 2020 estimated approximately 1 in 14 people had downloaded apps in states one was available. In this study, we assessed the motivation and experience of individuals who downloaded ENS apps from the Google Play and Apple App Stores. Methods We collected review text, star rating, and date of rating for all the reviews on ENS apps in the Google Play and Apple App stores. We extracted the relative frequency of single words and phrases from reviews and created an open vocabulary language, with themes categorized by the research team, to study the salient themes around reviews with high (3–5 stars), neutral (3 stars), and negative (1–2 stars) ratings using logistic regression. Results Of 7622 reviews obtained from 26 states between 04/07/2020 to 03/31/2021, 6364 were from Google Play Store, and 1258 were from Apple App Store. We obtained reviews for a total of 38 apps, with 25 apps from the Google Play Store and 13 apps from the Apple Play Store. 78% of the reviews are either 1 star or 5 stars. Positive reviews were driven by ease of use, support for the state government in creating the app, and encouragement for others to download, as well as engage in other COVID-19 precautions. Negative and neutral reviews focused on issues with app functionality (i.e., installation and tracking errors). Conclusions Uptake was the largest barrier to success for ENS apps, but states can …

ImportanceClose remote monitoring of patients following discharge for heart failure (HF) may reduce readmissions or death.ObjectiveTo determine whether remote monitoring of diuretic adherence and weight changes with financial incentives reduces hospital readmissions or death following discharge with HF.Design, Setting, and ParticipantsThe Electronic Monitoring of Patients Offers Ways to Enhance Recovery (EMPOWER) study, a 3-hospital pragmatic trial, randomized 552 adults recently discharged with HF to usual care (n = 280) or a compound intervention (n = 272) designed to inform clinicians of diuretic adherence and changes in patient weight. Patients were recruited from May 25, 2016, to April 8, 2019, and followed up for 12 months. Investigators were blinded to assignment but patients were not. Analysis was by intent to treat.InterventionsParticipants randomized to the intervention arm received …

This document is a technical summary of the Federal Highway Administration report, Comparative Effectiveness of Alternative Smartphone-Based Nudges to Reduce Cellphone Use While Driving: Final Report (FHWA-HRT-22-057).

ImportanceThe COVID-19 pandemic has claimed nearly 6 million lives globally as of February 2022. While pandemic control efforts, including contact tracing, have traditionally been the purview of state and local health departments, the COVID-19 pandemic outpaced health department capacity, necessitating actions by private health systems to investigate and control outbreaks, mitigate transmission, and support patients and communities.ObjectiveTo investigate the process of designing and implementing a volunteer-staffed contact tracing program at a large academic health system from April 2020 to May 2021, including program structure, lessons learned through implementation, results of case investigation and contact tracing efforts, and reflections on how constrained resources may be best allocated in the current pandemic or future public health emergencies.Design, Setting, and ParticipantsThis case series …

4. Greshock J, Naylor TL, Margolin A, Diskin S, Cleaver SH, Futreal PA, deJong PJ, Zhao S, Liebman M, Weber BL: 1-Mb resolution array-based comparative genomic hybridization using a BAC clone set optimized for cancer gene analysis. Genome Res 14 (1): 179-87, Jan 2004.

BackgroundInsulin-dependent diabetes is a challenging disease to manage and involves complex behaviors, such as self-monitoring of blood glucose. This can be especially challenging in the face of socioeconomic barriers and in the wake of the COVID-19 pandemic. Digital health self-monitoring interventions and community health worker support are promising and complementary best practices for improving diabetes-related health behaviors and outcomes. Yet, these strategies have not been tested in combination. This protocol paper describes the rationale and design of a trial that measures the combined effect of digital health and community health worker support on glucose self-monitoring and glycosylated hemoglobin.MethodsThe study population was uninsured or publicly insured; lived in high-poverty, urban neighborhoods; and had poorly controlled diabetes mellitus with insulin dependence. The study …

Consumers, public officials, and even managers of health care and insurance are unhappy about care quality, access, and costs. This book shows that is because efforts to do something about these problems often rely on hope or conjecture, not rigorous evidence of effectiveness. In this book, experts in the field separate the speculative from the proven with regard to how care is rendered, how patients can be in control, how providers should be paid, and how disparities can be reduced–and they also identify the issues for which evidence is currently missing. It provides an antidote to frustration and a clear-eyed guide for forward progress, helping health care and insurance innovators make better decisions on deciding whether to go ahead now based on current evidence, to seek and wait for additional evidence, or to move on to different ideas. It will be useful to practitioners in hospital systems, medical groups, and insurance organizations and can also be used in executive and MBA teaching.

To promote COVID-19 vaccination, many states in the US introduced financial incentives ranging from small, guaranteed rewards to lotteries that give vaccinated individuals a chance to win large prizes. There is limited evidence on the effectiveness of these programs and conflicting evidence from survey experiments and studies of individual states’ lotteries. To assess the effectiveness of COVID-19 vaccination incentive programs, we combined information on statewide incentive programs in the US with data on daily vaccine doses administered in each state. Leveraging variation across states in the daily availability of incentives, our difference-in-differences analyses showed that statewide programs were not associated with a significant change in vaccination rates. Furthermore, there was no significant difference in vaccination trends between states with and without incentives in any of the 14 days before or after incentives were introduced. Heterogeneity analyses indicated that neither lotteries nor guaranteed rewards were associated with significant change in vaccination rates.

Smoking burdens are greatest among underserved patients. Lung cancer screening (LCS) reduces mortality among individuals at risk for smoking-associated lung cancer. Although LCS programs must offer smoking cessation support, the interventions that best promote cessation among underserved patients in this setting are unknown. This stakeholder-engaged, pragmatic randomized clinical trial will compare the effectiveness of four interventions promoting smoking cessation among underserved patients referred for LCS. By using an additive study design, all four arms provide standard “ask–advise–refer” care. Arm 2 adds free or subsidized pharmacologic cessation aids, arm 3 adds financial incentives up to $600 for cessation, and arm 4 adds a mobile device–delivered episodic future thinking tool to promote attention to long-term health goals. We hypothesize that smoking abstinence rates will be higher with …

Statement of Purpose To compare the effectiveness of novel interventions aimed at building the habit of putting down one’s phone while driving, among drivers eligible for a smartphone telematics-based auto-insurance rate.Methods/Approach We enrolled 1,670 Progressive Snapshot usage-based auto insurance customers in a 10-week randomized trial (NCT04587609) to test the additive impact of interventions designed to reduce handheld phone use while driving. Arm 1 (control) educated participants about the risks of handheld use. Arm 2 also gave them a free phone mount. Arm 3 included goal commitment and habit tips. Arm 4 added gamification and social competition, and Arm 5 linked performance to financial incentives ($11 average/driver). Post-intervention, participants were monitored for 25–65 more days. Outcome differences were measured using fractional logistic regression with Holm adjustment for …

Lotteries have been shown to motivate behaviour change in many settings, but their value as a policy tool is relatively untested. We implemented a pre-registered, citywide experiment to test the effects of three high-pay-off, geographically targeted lotteries designed to motivate adult Philadelphians to get their COVID-19 vaccine. In each drawing, the residents of a randomly selected ‘treatment’ zip code received half the lottery prizes, boosting their chances of winning to 50×–100× those of other Philadelphians. The first treated zip code, which drew considerable media attention, may have experienced a small bump in vaccinations compared with the control zip codes: average weekly vaccinations rose by an estimated 61 per 100,000 people per week (+11%). After pooling the results from all three zip codes treated during our six-week experiment, however, we do not detect evidence of any overall benefits …

The overarching goal of the proposed project is to increase diagnosis and effective treatment of persons with Familial Hypercholesterolemia (FH). The proposed project aims to improve FH diagnosis by (1) using a validated machine learning tool in a large healthcare system (Penn Medicine) to flag individuals at high risk of having FH;(2) employing effective interventions based on implementation science (IS) and behavioral economics (BE) to engage the healthcare system, clinicians, and patients to ensure that the diagnosis of FH is appropriately made; and (3) to improve the uptake of, and adherence to, evidence-based practices (EBP) for these patients, resulting in a reduction in LDL-C and ultimately improved CV outcomes. The project initiated on July 1, 2021 and multiple work streams have been initiated to achieve specific goals of Aim 1 and Aim 2.

An initial opioid prescription with a greater number of pills is associated with a greater risk for future long-term opioid use, yet few interventions have reliably influenced individual clinicians’ prescribing. Our objective was to evaluate the effect of feedback interventions for clinicians in reducing opioid prescribing. The interventions included feedback on a clinician’s outlier prescribing (individual audit feedback), peer comparison, and both interventions combined. We conducted a four-arm factorial pragmatic cluster randomized trial at forty-eight emergency department (ED) and urgent care (UC) sites in the western US, including 263 ED and 175 UC clinicians with 294,962 patient encounters. Relative to usual care, there was a significant decrease in pills per prescription both for peer comparison feedback (−0.8) and for the combination of peer comparison and individual audit feedback (−1.2). This decrease was …

Introduction. Pragmatic clinical trials test interventions in patients representative of real-world medical practice and reduce data collection costs by using data recorded in the electronic health record (EHR) during usual care. We describe our experience using the EHR to measure the primary outcome of a pragmatic trial, hospital readmissions, and important clinical covariates. Methods. The trial enrolled patients recently discharged from the hospital for treatment of heart failure to test whether automated daily monitoring integrated into the EHR could reduce readmissions. The study team used data from the EHR and several data systems that drew on the EHR, supplemented by the hospital admissions files of three states. Results. Almost three-quarters of enrollees’ readmissions over the 12-mo trial period were captured by the EHRs of the study hospitals. State data, which took 7 mo to more than 2 y from first contact …

Introduction Little is known about the impact of cumulative workdays on medical residents' alertness. The purpose of this study was to examine changes in alertness over consecutive workdays following a day off for internal medicine interns. Methods This is a secondary report of a randomized non-inferiority trial of 12 internal-medicine residency programs assigned to either standard duty-hour (80h workweek/16h shifts) or flexible (80h workweek/no shift-length limit) policies. Interns were followed for 2 weeks during inpatient rotations. Each morning, alertness (number of Brief Psychomotor Vigilance Test [PVT-B] lapses) was assessed, and interns selected the type of shift worked (day-off, days, nights, beginning/ending extended overnights, or other). Sleep duration (actigraphy) was averaged each 24h day. For this analysis, interns were included if they had ≥1 day-off followed by …

Incentives for Immunity Some state governments and businesses in the United States are starting to pay people to get vaccinated against Covid-19. But even if incentives can produce a short-term bump in vaccination, multiple strategies will be necessary to increase population immunity.

ImportanceModest weight loss can lead to meaningful risk reduction in adults with obesity. Although both behavioral economic incentives and environmental change strategies have shown promise for initial weight loss, to date they have not been combined, or compared, in a randomized clinical trial.ObjectiveTo test the relative effectiveness of financial incentives and environmental strategies, alone and in combination, on initial weight loss and maintenance of weight loss in adults with obesity.Design, Setting, and ParticipantsThis randomized clinical trial was conducted from 2015 to 2019 at 3 large employers in Philadelphia, Pennsylvania. A 2-by-2 factorial design was used to compare the effects of lottery-based financial incentives, environmental strategies, and their combination vs usual care on weight loss and maintenance. Interventions were delivered via website, text messages, and social media. Participants …

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 …

Policy-makers are increasingly turning to behavioural science for insights about how to improve citizens’ decisions and outcomes. Typically, different scientists test different intervention ideas in different samples using different outcomes over different time intervals. The lack of comparability of such individual investigations limits their potential to inform policy. Here, to address this limitation and accelerate the pace of discovery, we introduce the megastudy—a massive field experiment in which the effects of many different interventions are compared in the same population on the same objectively measured outcome for the same duration. In a megastudy targeting physical exercise among 61,293 members of an American fitness chain, 30 scientists from 15 different US universities worked in small independent teams to design a total of 54 different four-week digital programmes (or interventions) encouraging exercise …

Many Americans fail to get life-saving vaccines each year, and the availability of a vaccine for COVID-19 makes the challenge of encouraging vaccination more urgent than ever. We present a large field experiment (N= 47,306) testing 19 nudges delivered to patients via text message and designed to boost adoption of the influenza vaccine. Our findings suggest that text messages sent prior to a primary care visit can boost vaccination rates by an average of 5%. Overall, interventions performed better when they were (a) framed as reminders to get flu shots that were already reserved for the patient and (b) congruent with the sort of communications patients expected to receive from their healthcare provider (ie, not surprising, casual, or interactive). The best-performing intervention in our study reminded patients twice to get their flu shot at their upcoming doctor’s appointment and indicated it was reserved for them. This successful script could be used as a template for campaigns to encourage the adoption of life-saving vaccines, including against COVID-19.

METHODSThis study was approved by the University of Pennsylvania institutional review board and data was obtained from an ongoing randomized clinical trial evaluating the use of gamification and financial incentives to increase physical activity (NCT03911141). Participants were adults with either an atherosclerotic cardiovascular disease (ASCVD) condition or a 10-year ASCVD risk score of≥ 7.5% who used a Charge 3 (Fitbit) wearable to monitor activity. 3

ImportanceGamification is increasingly being used to promote healthy behaviors. However, it has not been well tested among patients with chronic conditions and over longer durations.ObjectiveTo test the effectiveness of behaviorally designed gamification interventions to enhance support, collaboration, or competition to promote physical activity and weight loss among adults with uncontrolled type 2 diabetes.Design, Setting, and ParticipantsA 4-arm randomized clinical trial with a 1-year intervention was conducted from January 23, 2017, to January 27, 2020, with remotely monitored intervention. Analyses were conducted between February 10 and October 6, 2020. Participants included 361 adults with type 2 diabetes with hemoglobin A1clevels greater than or equal to 8% and body mass index greater than or equal to 25.InterventionsAll participants received a wearable device, smart weight scale, and laboratory …

Background Routine screening reduces colorectal cancer mortality, but screening rates fall below national targets and are particularly low in underserved populations. Objective To compare the effectiveness of a single text message outreach to serial text messaging and mailed fecal home test kits on colorectal cancer screening rates. Design A two-armed randomized clinical trial. Participants An urban community health center in Philadelphia. Adults aged 50–74 who were due for colorectal cancer screening had at least one visit to the practice in the previously year, and had a cell phone number recorded. Interventions Participants were randomized (1:1 ratio). Individuals in the control arm were sent a simple text message reminder as per usual practice …

BackgroundOral health care use remains low among adult Medicaid recipients, despite the Patient Protection and Affordable Care Act’s expansion increasing access to care in many states. It remains unclear the extent to which low use reflects either low demand for care or barriers to accessing care. The authors aimed to examine factors associated with low oral health care use among adults enrolled in Medicaid.MethodsThe authors conducted a survey from May through September 2018 among able-bodied (n = 9,363) Medicaid recipients who were aged 19 through 65 years and nondisabled childless adults in Kentucky. The survey included questions on perceived oral health care use. Semistructured interviews were also conducted from May through November 2018 among a subset of participants (n = 127).ResultsMore than one-third (37.8%) of respondents reported fair or poor oral health, compared with 26.2 …

Importance Incentivizing research participation is controversial and variably regulated because of uncertainty regarding whether financial incentives serve as undue inducements by diminishing peoples’ sensitivity to research risks or unjust inducements by preferentially increasing enrollment among underserved individuals. Objective To determine whether incentives improve enrollment in real randomized clinical trials (RCTs) or serve as undue or unjust inducements. Design, Setting, and Participants Two RCTs of incentives that were embedded in 2 parent RCTs, 1 comparing smoking cessation interventions (conducted at smoking cessation clinics in 2 health systems) and 1 evaluating an ambulation intervention (conducted across wards of the Hospital of the University of Pennsylvania) included all persons eligible for the parent trials who did not have prior knowledge of the incentives trials. Recruitment occurred …

Digital contact tracing smartphone applications (apps) can mitigate the spread of COVID-19 through exposure notification. 1-4 However, their success requires widespread use. We examined the effectiveness of low-cost behavioral interventions (ie, nudges) in increasing downloads of Pennsylvania’s COVID Alert PA app. Specifically, we explored the effectiveness of 2 nudges5, 6 on 39 937 individuals, one nudge displaying a descriptive social norm (vs not) and another framing the benefit of downloading for others (vs self).

During fall 2020, many US kindergarten through grade 12 (K–12) schools closed campuses and instituted remote learning because of concerns that significant in-school transmission of SARS-CoV-2 was not preventable.

Background Identifying individuals at risk for future hospitalization or death has been a major priority of population health management strategies. High-risk individuals are a heterogeneous group, and existing studies describing heterogeneity in high-risk individuals have been limited by data focused on clinical comorbidities and not socioeconomic or behavioral factors. We used machine learning clustering methods and linked comorbidity-based, sociodemographic, and psychobehavioral data to identify subgroups of high-risk Veterans and study long-term outcomes, hypothesizing that factors other than comorbidities would characterize several subgroups. Methods and findings In this cross-sectional study, we used data from the VA Corporate Data Warehouse, a national repository of VA administrative claims and electronic health data. To identify high-risk Veterans, we used the Care Assessment Needs (CAN) score, a routinely-used VA model that predicts a patient’s percentile risk of hospitalization or death at one year. Our study population consisted of 110,000 Veterans who were randomly sampled from 1,920,436 Veterans with a CAN score≥75th percentile in 2014. We categorized patient-level data into 119 independent variables based on demographics, comorbidities, pharmacy, vital signs, laboratories, and prior utilization. We used a previously validated density-based clustering algorithm to identify 30 subgroups of high-risk Veterans ranging in size from 50 to 2,446 patients. Mean CAN score ranged from 72.4 to 90.3 among subgroups. Two-year mortality ranged from 0.9% to 45.6% and was highest in the home-based care and …

ImportanceFinancial incentives may improve health by rewarding patients for focusing on present actions—such as medication regimen adherence—that provide longer-term health benefits.ObjectiveTo identify barriers to improving statin therapy adherence and control of cholesterol levels with financial incentives and insights for the design of future interventions.Design, Setting, and ParticipantsThis qualitative study involved retrospective interviews with participants in a preplanned secondary analysis of a randomized clinical trial of financial incentives for statin therapy adherence. A total of 636 trial participants from several US insurer or employer populations and an academic health system were rank ordered by change in low-density lipoprotein cholesterol (LDLC) levels. Participants with the most LDLC level improvement (high-improvement group) and those with LDLC levels that did not improve …

As health care leaders give voice and commit resources to diversity, equity, and inclusiveness initiatives, an external community-focused strategy will fail without an honest look inside their own organizations and their own ideas of what leadership is and what it looks like.

Research Objective Prescribing opioids, particularly the number of pills, is associated with greater likelihood of patients developing longer‐term opioid dependence. Nudges targeted to clinicians are a low‐cost strategy that could reduce unnecessary opioid prescribing. In particular, clinician‐focused peer comparison feedback has been effective in influencing prescribing for other medications. However, peer comparison feedback has not been well‐tested for opioid prescribing, alone or compared against other feedback approaches such as individual audit feedback. Study Design We conducted a pragmatic, four‐arm factorial cluster randomized clinical trial among 48 emergency department (ED) and urgent care (UC) practice sites within Sutter Health System including a 6‐month pre‐intervention period and a 6‐month intervention. 438 clinicians were cluster randomized by practice site. Interventions were …

Objective We describe the design, implementation, and validation of an online, publicly available tool to algorithmically triage patients experiencing severe acute respiratory syndrome coronavirus (SARS-CoV-2)-like symptoms. Methods We conducted a chart review of patients who completed the triage tool and subsequently contacted our institution's phone triage hotline to assess tool- and clinician-assigned triage codes, patient demographics, SARS-CoV-2 (COVID-19) test data, and health care utilization in the 30 days post-encounter. We calculated the percentage of concordance between tool- and clinician-assigned triage categories, down-triage (clinician assigning a less severe category than the triage tool), and up-triage (clinician assigning a more severe category than the triage tool) instances. Results From May 4, 2020 through January 31, 2021, the triage tool was completed 30,321 times by 20,930 …

ImportanceHealth promotion efforts commonly communicate goals for healthy behavior, but the best way to design goal setting among high-risk patients has not been well examined.ObjectiveTo test the effectiveness of different ways to set and implement goals within a behaviorally designed gamification intervention to increase physical activity.Design, Setting, and ParticipantsEvaluation of the Novel Use of Gamification With Alternative Goal-setting Experiences was conducted from January 15, 2019, to June 1, 2020. The 24-week randomized clinical trial included a remotely monitored 8-week introductory intervention period, 8-week maintenance intervention period, and 8-week follow-up period. A total of 500 adults from lower-income neighborhoods in and around Philadelphia, Pennsylvania, who had either an atherosclerotic cardiovascular disease (ASCVD) condition or a 10-year ASCVD risk score greater than or …

Behavioral interventions involving electronic devices, financial incentives, gamification, and specially trained staff to encourage healthy behaviors are becoming increasingly prevalent and important in health innovation and improvement efforts. Although considerations of cost are key to their wider adoption, cost information is lacking because the resources required cannot be costed using standard administrative billing data. Pragmatic clinical trials that test behavioral interventions are potentially the best and often only source of cost information but rarely incorporate costing studies. This article provides a guide for researchers to help them collect and analyze, during the trial and with little additional effort, the information needed to inform potential adopters of the costs of adopting a behavioral intervention. A key challenge in using trial data is the separation of implementation costs, the costs an adopter would incur …

We partnered with Walmart to test 22 nudges designed to boost vaccination rates in their pharmacies. Nudges were delivered via text message to over 650,000 Walmart pharmacy patients in the fall of 2020 and encouraged patients to visit Walmart for a flu vaccine. We demonstrate that behaviorally informed messages increase pharmacy vaccination rates by an average of 6.7% over a roughly three-month follow-up period. The most effective messages in our field experiment matched the tone of typical pharmacy communications and reminded patients that a flu shot was waiting for them. These insights suggest that carefully crafted messages informed by the results of this study could nudge the adoption of other vaccines for other infectious diseases, including COVID-19.

Objective Many patients with advanced illness are unrealistically optimistic about their prognosis. We test for the presence of several cognitive biases, including optimism bias, illusion of superiority, self‐deception, misattribution, and optimistic update bias, that could explain unrealistically optimistic prognostic beliefs among advanced cancer patients and quantifies the extent to which hope exacerbates these biases. Methods A cross‐sectional survey was administered to 200 advanced cancer patients with physician‐estimated prognoses of one year or less. Hope was measured using the Herth Hope Index (HHI). Hypotheses were tested using linear and logistic regressions and a structural‐equation model. Results Results are consistent with the presence of optimism bias, illusion of superiority, self‐deception, and misattribution. All of these biases are amplified by higher levels of hope. Each 1‐point higher HHI is …

The lessons learned during the development of PennOpen Pass — an early warning system to detect symptoms and exposures concerning for Covid-19 — will help advance innovations in health care long after the pandemic.

BackgroundCardiac interventions account for a significant share of overall healthcare spending and have been the focus of several large-scale interventions to develop effective bundled payments. To date, however, none have proven successful in commercially insured populations. In 2018, we worked with Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, to design a novel commercial bundled payment for percutaneous coronary interventions, the Percutaneous Coronary Intervention Episode Payment Model (PCI EPM).MethodsDescriptive analysis of HMSA's PCI EPM, including its inclusion criteria, contents of the bundle, target prices, shared savings model, and incentivized quality metrics. We also compare HMSA's PCI EPM to Medicare's Bundled Payment for Care Improvement programs and the cancelled Cardiac Care Model.ResultsHMSA's PCI EPM was designed through an …

Background Medical interns are at risk for sleep deprivation from long and often rotating work schedules. However, the effects of specific rotations on sleep are less clear. Objective To examine differences in sleep duration and alertness among internal medicine interns during inpatient intensive care unit (ICU) compared to general medicine (GM) rotations. Methods This secondary analysis compared interns during a GM or ICU rotation from a randomized trial (2015–2016) of 12 internal medicine residency programs assigned to different work hour limit policies (standard 16-hour shifts or no shift-length limits). The primary outcome was sleep duration/24-hour using continuous wrist actigraphy over a 13-day period. Secondary outcomes assessed each morning during the concomitant actigraphy period were sleepiness (Karolinska Sleepiness Scale [KSS …

Rationale: A trial of four financial incentive programs, conducted at CVS Caremark, a large employer, documented their effectiveness in promoting sustained abstinence from smoking, but their cost-effectiveness is unknown, and the significant up-front cost of the incentives is a deterrent to their adoption. Objectives: To determine the cost-effectiveness of these incentives from the healthcare sector and employer perspectives. Methods: This study examines a decision model built with trial data, supplemented by data from the literature. Life-expectancy gains for quitters were projected on the basis of U.S. life tables. The two individual-oriented programs paid $800 for smoking cessation at 6 months; one required participants to deposit $150 at baseline. Payments in the two group-oriented programs varied with the group’s success; again, one required participants to deposit $150. Results: Life-years, quality-adjusted life …

ImportanceStatin therapy is underused for many patients who could benefit.ObjectiveTo evaluate the effect of passive choice and active choice interventions in the electronic health record (EHR) to promote guideline-directed statin therapy.Design, Setting, and ParticipantsThree-arm randomized clinical trial with a 6-month preintervention period and 6-month intervention. Randomization conducted at the cardiologist level at 16 cardiology practices in Pennsylvania and New Jersey. The study included 82 cardiologists and 11 693 patients. Data were analyzed between May 8, 2019, and January 9, 2020.InterventionsIn passive choice, cardiologists had to manually access an alert embedded in the EHR to select options to initiate or increase statin therapy. In active choice, an interruptive EHR alert prompted the cardiologist to accept or decline guideline-directed statin therapy. Cardiologists in the control group were …

Methods| Electronic health records identified patients with depression (International Statistical Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] codes F33 and

Many workplaces and insurers sponsor programs to increase employees’ physical activity, but these programs often fail to create healthy behaviors or else work only temporarily. They typically offer financial incentives without considering cognitive biases that influence whether people will join the programs and remain committed to exercising. We argue that interventions should leverage both insights from behavioral economics and the availability of remote-monitoring technologies, such as automatic step trackers, to be more effective. In this article, we summarize relevant insights from behavioral economics, highlight research findings that show the value of combining behaviorally informed program design with remote monitoring, and suggest strategies for selecting interventions and remote-monitoring devices.

Many Americans fail to get life-saving vaccines each year, and the availability of a vaccine for COVID-19 makes the challenge of encouraging vaccination more urgent than ever. We present a large field experiment (N = 47,306) testing 19 nudges delivered to patients via text message and designed to boost adoption of the influenza vaccine. Our findings suggest that text messages sent prior to a primary care visit can boost vaccination rates by an average of 5%. Overall, interventions performed better when they were 1) framed as reminders to get flu shots that were already reserved for the patient and 2) congruent with the sort of communications patients expected to receive from their healthcare provider (i.e., not surprising, casual, or interactive). The best-performing intervention in our study reminded patients twice to get their flu shot at their upcoming doctor’s appointment and indicated it was reserved for them. This …

Background & Aims Financial incentives might increase participation in prevention such as screening colonoscopy. We studied whether incentives informed by behavioral economics increase participation in risk assessment for colorectal cancer (CRC) and completion of colonoscopy for eligible adults. Methods Employees of a large academic health system (50–64 y old; n= 1977) were randomly assigned to groups that underwent risk assessment for CRC screening and direct access colonoscopy scheduling (control), or risk assessment, direct access colonoscopy scheduling, a $10 loss-framed incentive to complete risk assessment, and a $25 unconditional incentive for colonoscopy completion (incentive). The primary outcome was the percentage of participants who completed screening colonoscopy within 3 months of initial outreach. Secondary outcomes included the percentage of participants who scheduled …

ImportanceFinancial incentives may improve health behaviors. It is unknown whether incentives are more effective if they target a key process (eg, medication adherence), an outcome (eg, low-density lipoprotein cholesterol [LDL-C] levels), or both.ObjectiveTo determine whether financial incentives awarded daily for process (adherence to statins), awarded quarterly for outcomes (personalized LDL-C level targets), or awarded for process plus outcomes induce reductions in LDL-C levels compared with control.Design, Setting, and ParticipantsA randomized clinical trial was conducted from February 12, 2015, to October 3, 2018; data analysis was performed from October 4, 2018, to May 27, 2021, at the University of Pennsylvania Health System, Philadelphia. Participants included 764 adults with an active statin prescription, elevated risk of atherosclerotic cardiovascular disease, suboptimal LDL-C level, and …

Lotteries have been shown to motivate behavior change in many settings. However, the value of large-scale, geographically-targeted lotteries as a policy tool for changing the behaviors of entire populations is a matter of heated debate. In mid-2021, we implemented a pre-registered, city-wide experiment in Philadelphia to test the effects of three, high-payoff (up to $50,000) geographically-targeted lotteries designed to motivate adult residents of Philadelphia to get vaccinated against COVID-19. All Philadelphia residents ages 18 and older were eligible for inclusion in each drawing but, if selected, could not accept a prize unless they had received at least one dose of a COVID-19 vaccine. In each drawing, residents of a randomly selected “treatment” zip code received half of the 12 lottery prizes (boosting their chances of a win to 50-100x those of other Philadelphians). This experimental design makes possible a causal estimate of the impact of vastly increasing people’s odds of winning a vaccine lottery. We estimate that the first treated zip code, which drew considerable media attention, may have experienced a small bump in vaccinations compared to control zip codes: vaccinations rose by an estimated 61 per 100,000 people (an 11% increase). Pooling results from all three zip codes treated over the course of our six-week experiment, however, we do not detect any overall benefits. This unsustained effect may be because media attention waned, salience of the lottery declined, or attitudes about vaccination became increasingly entrenched over time. Further, our 95% confidence interval provides an upper bound on the overall benefits of …

The use of wearables is increasing and data from these devices could improve the prediction of changes in glycemic control. We conducted a randomized trial with adults with prediabetes who were given either a waist-worn or wrist-worn wearable to track activity patterns. We collected baseline information on demographics, medical history, and laboratory testing. We tested three models that predicted changes in hemoglobin A1c that were continuous, improved glycemic control by 5% or worsened glycemic control by 5%. Consistently in all three models, prediction improved when (a) machine learning was used vs. traditional regression, with ensemble methods performing the best; (b) baseline information with wearable data was used vs. baseline information alone; and (c) wrist-worn wearables were used vs. waist-worn wearables. These findings indicate that models can accurately identify changes in glycemic …

National efforts to develop a coronavirus disease 2019 (COVID-19) vaccine at “warp speed” will likely yield a safe and effective vaccine by early 2021. However, this importantmilestoneisonlythefirststepinanequallyimportant challenge: getting a majority of the US public vaccinated. InaSeptember2020surveyof10093USadults, only51% indicatedthattheyweredefinitelyorprobablywillingtobe vaccinated with a novel COVID-19 vaccine, 25% reported thattheywereprobablynotwillingtogetthevaccine, and 24% reported that it is unlikely that they would be vaccinated. 1 Thissurveyfurtherrevealedthatacceptance wasloweramongBlackindividuals (32%, 263of822); those with lower educational attainment (47%, 676 of 1438 amongthosewithhighschoolorlesseducation) compared withcollegegraduates (56%, 1673of2988) orthosewith apostgraduateeducation (63%, 1693of2668); andamong Republican voters (44%, 1817 of 4129 …

Low-value services are a major problem in the US health care system. We believe that the coronavirus disease 2019 pandemic's unprecedented impact on the health system, and society writ large, offers an opportunity to reshape the conversation and incentives around low-value services. This article explores current barriers to and opportunities for accelerating progress toward high-value care delivery. We examine how financial and nonfinancial incentives, uncertainty in clinical decision-making, and insufficient partnering with patients and families contribute to the delivery of low-value care. We then explore potential solutions, including making it easier for clinicians to forgo low-value services and providing them with actionable information to make those decisions, expanding payer efforts to develop" value report cards," developing measures that map the adverse health and economic effects of low-value services …

Ohio Gov. Mike DeWine's announcement last week that his state would use a lottery to persuade more people to get vaccinated breaks new ground in the struggle to reach the vaccine hesitant. Starting May 26, five people will take home $1 million over five consecutive weeks; anyone with at least one shot will be eligible. What's more, five vaccinated Ohioans under the age of 18 will get a four-year college scholarship, doled out in a parallel drawing.DeWine, a Republican, is anxious to open his state-he's dropping almost all restrictions on June 2-and has settled on a psychologically interesting approach to get shots into arms, one that is likely to have more of an impact than programs that are offering free drinks to vaccinated residents, or West Virginia's $100 gift cards or savings bonds for people ages 18 to 34.

ImportanceFinancial incentives can improve medication adherence and cardiovascular disease risk, but the optimal design to promote sustained adherence after incentives are discontinued is unknown.ObjectiveTo 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 ParticipantsThis 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.InterventionsThe interventions lasted 6 months during …

ImportanceHip and knee arthroplasty are the most common inpatient surgical procedures for Medicare beneficiaries in the US, with substantial variation in cost and quality. Whether remote monitoring incorporating insights from behavioral science might help improve outcomes and increase value of care remains unknown.ObjectiveTo evaluate the effect of activity monitoring and bidirectional text messaging on the rate of discharge to home and clinical outcomes in patients receiving hip or knee arthroplasty.Design, Setting, and ParticipantsRandomized clinical trial conducted between February 7, 2018, and April 15, 2019. The setting was 2 urban hospitals at an academic health system. Participants were patients aged 18 to 85 years scheduled to undergo hip or knee arthroplasty with a Risk Assessment and Prediction Tool score of 6 to 8.InterventionsEligible patients were randomized evenly to receive usual care (n …

BACKGROUND/OBJECTIVE Risk‐stratification tools for cardiac complications after noncardiac surgery based on preoperative risk factors are used to inform postoperative management. However, there is limited evidence on whether risk stratification can be improved by incorporating data collected intraoperatively, particularly for low‐risk patients. METHODS We conducted a retrospective cohort study of adults who underwent noncardiac surgery between 2014 and 2018 at four hospitals in the United States. Logistic regression with elastic net selection was used to classify in‐hospital major adverse cardiovascular events (MACE) using preoperative and intraoperative data (“perioperative model”). We compared model performance to standard risk stratification tools and professional society guidelines that do not use intraoperative data. RESULTS Of 72,909 patients, 558 (0.77%) experienced MACE. Those with …

Introduction In a five-arm randomized clinical trial (RCT) with stratified randomization across 54 sites, we encountered low primary outcome event proportions, resulting in multiple sites with zero events either overall or in one or more study arms. In this paper, we systematically evaluated different statistical methods of accounting for center in settings with low outcome event proportions. Methods We conducted a simulation study and a reanalysis of a completed RCT to compare five popular methods of estimating an odds ratio for multicenter trials with stratified randomization by center: (i) no center adjustment, (ii) random intercept model, (iii) Mantel–Haenszel model, (iv) generalized estimating equation (GEE) with an exchangeable correlation structure, and (v) GEE with small sample correction (GEE-small sample correction). We varied the number of total participants (200, 500, 1000, 5000), number of centers (5, 50 …

We examine the effect of a value‐based insurance design (VBID) program implemented at a large public employer in the state of Oregon. The program substantially increased cost‐sharing for several healthcare services likely to be of low value for most patients: diagnostic services (e.g., imaging services) and surgeries (e.g., spinal surgeries for pain). Using a difference‐in‐differences design coupled with granular, administrative health insurance claims data over the period 2008–2012, we estimate the change in low‐value service use among beneficiaries before and after program implementation relative to a comparison group not exposed to the VBID. Our findings suggest that the VBID significantly reduced the use of targeted services, with an implied elasticity of demand of −0.22. We find no evidence that the VBID led to substitution to non‐targeted services or increased overall healthcare costs. However, we also …

Background Suicide is a global health issue. There are a number of evidence-based practices for suicide screening, assessment, and intervention that are not routinely deployed in usual care settings. The goal of this study is to develop and test implementation strategies to facilitate evidence-based suicide screening, assessment, and intervention in two settings where individuals at risk for suicide are especially likely to present: primary care and specialty mental health care. We will leverage methods from behavioral economics, which involves understanding the many factors that influence human decision making, to inform strategy development. Methods We will identify key mechanisms that limit implementation of evidence-based suicide screening, assessment, and intervention practices in primary care and specialty mental health through contextual …

In the literature on behavior change it has commonly been assumed that sustained changes in behavior means that habits have been formed and that sustained behavior change is achieved through the formation of habits. In this paper we argue that habit formation is often confused with a variety of alternative mechanisms through which sustained changes in behavior can be achieved. These include: learning, information acquisition, status quo bias, taste discovery, technology, commitment devices, social influences, and concomitant changes to choice environments. Understanding these mechanisms is important for determining why specific interventions work or don’t work and for aiding in the design of more effective mechanisms for inducing sustained behavior change.

Section 1115 demonstration waivers provide a mechanism for states to implement changes to their Medicaid programs. While such waivers are mandated to include evaluations of their impact, randomization – the gold standard for assessing causality – has not typically been a consideration. In a critical departure, the Commonwealth of Kentucky opted to pursue a two-arm randomized controlled trial (RCT) for their controversial 2018 Medicaid Demonstration waiver, which included work requirements as a condition for the subset of beneficiaries deemed able-bodied to maintain eligibility for benefits. Beneficiaries were randomized 9:1 to the new waiver program or a control group who would retain their current benefits as part of the existing Medicaid expansion program. To address potential bias from differential attrition from the Medicaid program that would accrue from solely analyzing administrative data, our team …

Simply urging people to choose healthy behavior will never be enough to make the U.S. healthier, increase our life expectancy, or reduce our healthcare spending, because technology and the structure of our modern world all but force us into unhealthy behavior and make healthy choices difficult or impossible. We must embrace structural changes to make healthier living an easy choice.