[Show abstract][Hide abstract] ABSTRACT: Determination of comparative effectiveness in a randomized controlled trial requires consideration of an intervention’s comparative uptake (or acceptance) among randomized participants and the intervention’s comparative efficacy among participants who use their assigned intervention. If acceptance differs across interventions, then simple randomization of participants can result in post-randomization losses that introduce bias and limit statistical power.
We develop a novel preference-adaptive randomization procedure in which the allocation probabilities are updated based on the inverse of the relative acceptance rates among randomized participants in each arm. In simulation studies, we determine the optimal frequency with which to update the allocation probabilities based on the number of participants randomized. We illustrate the development and application of preference-adaptive randomization using a randomized controlled trial comparing the effectiveness of different financial incentive structures on prolonged smoking cessation.
Simulation studies indicated that preference-adaptive randomization performed best with frequent updating, accommodated differences in acceptance across arms, and performed well even if the initial values for the allocation probabilities were not equal to their true values. Updating the allocation probabilities after randomizing each participant minimized imbalances in the number of accepting participants across arms over time. In the smoking cessation trial, unexpectedly large differences in acceptance among arms required us to limit the allocation of participants to less acceptable interventions. Nonetheless, the procedure achieved equal numbers of accepting participants in the more acceptable arms, and balanced the characteristics of participants across assigned interventions.
Preference-adaptive randomization, coupled with analysis methods based on instrumental variables, can enhance the validity and generalizability of comparative effectiveness studies. In particular, preference-adaptive randomization augments statistical power by maintaining balanced sample sizes in efficacy analyses, while retaining the ability of randomization to balance covariates across arms in effectiveness analyses.
ClinicalTrials.gov, NCT01526265; https://clinicaltrials.gov/ct2/show/NCT01526265 31 January 2012
[Show abstract][Hide abstract] ABSTRACT: The experiences and behaviors revealed in our everyday lives provide as much insight into health and disease as any analysis of our genome could ever produce. These characteristics are not found in the genome, but may be revealed in our online activities, which make up our social mediome.
Published by Elsevier Ltd.
Trends in Molecular Medicine 07/2015; DOI:10.1016/j.molmed.2015.06.004 · 9.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Primary care provider (PCP) turnover is common and can disrupt patient continuity of care. Little is known about the effect of PCP turnover on patient care experience and quality of care.
To measure the effect of PCP turnover on patient experiences of care and ambulatory care quality.
Observational, retrospective cohort study of a nationwide sample of primary care patients in the Veterans Health Administration (VHA). We included all patients enrolled in primary care at the VHA between 2010 and 2012 included in 1 of 2 national data sets used to measure our outcome variables: 326 374 patients in the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) associated with 8441 PCPs and 184 501 patients in the External Peer Review Program (EPRP; used to measure ambulatory care quality) associated with 6973 PCPs.
Whether a patient experienced PCP turnover, defined as a patient whose provider (physician, nurse practitioner, or physician assistant) had left the VHA (ie, had no patient encounters for 12 months).
Five patient care experience measures (from SHEP) and 11 measures of quality of ambulatory care (from EPRP).
Nine percent of patients experienced a PCP turnover in our study sample. Primary care provider turnover was associated with a worse rating in each domain of patient care experience. Turnover was associated with a reduced likelihood of having a positive rating of their personal physician of 68.2% vs 74.6% (adjusted percentage point difference, -5.3; 95% CI, -6.0 to -4.7) and a reduced likelihood of getting care quickly of 36.5% vs 38.5% (adjusted percentage point difference, -1.1; 95% CI, -2.1 to -0.1). In contrast, PCP turnover was not associated with lower quality of ambulatory care except for a lower likelihood of controlling blood pressure of 78.7% vs 80.4% (adjusted percentage point difference, -1.44; 95% CI, -2.2 to -0.7). In 9 measures of ambulatory care quality, the difference between patients who experienced no PCP turnover and those who had a PCP turnover was less than 1 percentage point. These effects were moderated by the patients' continuity with their PCP prior to turnover, with a larger detrimental effect of PCP turnover among those with higher continuity prior to the turnover.
Primary care provider turnover was associated with worse patient experiences of care but did not have a major effect on ambulatory care quality.
JAMA Internal Medicine 05/2015; 175(7). DOI:10.1001/jamainternmed.2015.1853 · 13.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Financial incentives promote many health behaviors, but effective ways to deliver health incentives remain uncertain.
We randomly assigned CVS Caremark employees and their relatives and friends to one of four incentive programs or to usual care for smoking cessation. Two of the incentive programs targeted individuals, and two targeted groups of six participants. One of the individual-oriented programs and one of the group-oriented programs entailed rewards of approximately $800 for smoking cessation; the others entailed refundable deposits of $150 plus $650 in reward payments for successful participants. Usual care included informational resources and free smoking-cessation aids.
Overall, 2538 participants were enrolled. Of those assigned to reward-based programs, 90.0% accepted the assignment, as compared with 13.7% of those assigned to deposit-based programs (P<0.001). In intention-to-treat analyses, rates of sustained abstinence from smoking through 6 months were higher with each of the four incentive programs (range, 9.4 to 16.0%) than with usual care (6.0%) (P<0.05 for all comparisons); the superiority of reward-based programs was sustained through 12 months. Group-oriented and individual-oriented programs were associated with similar 6-month abstinence rates (13.7% and 12.1%, respectively; P=0.29). Reward-based programs were associated with higher abstinence rates than deposit-based programs (15.7% vs. 10.2%, P<0.001). However, in instrumental-variable analyses that accounted for differential acceptance, the rate of abstinence at 6 months was 13.2 percentage points (95% confidence interval, 3.1 to 22.8) higher in the deposit-based programs than in the reward-based programs among the estimated 13.7% of the participants who would accept participation in either type of program.
Reward-based programs were much more commonly accepted than deposit-based programs, leading to higher rates of sustained abstinence from smoking. Group-oriented incentive programs were no more effective than individual-oriented programs. (Funded by the National Institutes of Health and CVS Caremark; ClinicalTrials.gov number, NCT01526265.).
New England Journal of Medicine 05/2015; 372(22). DOI:10.1056/NEJMoa1414293 · 55.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective . To evaluate the use of behavioral economics to design financial incentives to promote health behavior change and to explore associations with demographic characteristics. Data Source . Studies performed by the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania published between January 2006 and March 2014. Study Inclusion and Exclusion Criteria . Randomized, controlled trials with available participant-level data. Studies that did not use financial incentives to promote health behavior change were excluded. Data Extraction . Participant-level data from seven studies were pooled. Data Synthesis . Meta-analysis on the pooled sample using a random-effects model with interaction terms to examine treatment effects and whether they varied by incentive structure or demographic characteristics. Results . The pooled study sample comprised 1403 participants, of whom 35% were female, 70% were white, 24% were black, and the mean age was 48 years (standard deviation 11.2 years). In the fully adjusted model, participants offered financial incentives had higher odds of behavior change (odds ratio [OR]: 3.96; p < .01) when compared to control. There were no significant interactions between financial incentives and gender, age, race, income, or education. When further adjusting for incentive structure, blacks had higher odds than whites of achieving behavior change (OR: 1.67; p < .05) with a conditional payment. Compared to lower-income participants, higher-income participants had lower odds of behavior change (OR: 0.46; p = .01) with a regret lottery. Conclusion . Financial incentives designed using concepts from behavioral economics were effective for promoting health behavior change. There were no large and consistent relationships between the effectiveness of financial incentives and observable demographic characteristics. Second-order examinations of incentive structure suggest potential relationships among the effectiveness of financial incentives, incentive structure, and the demographic characteristics of race and income.
American journal of health promotion: AJHP 05/2015; 29(5):314-23. DOI:10.4278/ajhp.140714-LIT-333 · 2.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: As hard as it may be for clinicians to adopt new practices, it is often harder for them to "de-innovate," or give up old practices, even when new evidence reveals that those practices offer little value. In this article we explore recent controversies over screening for breast and prostate cancer and testing for sleep disorders. We show that these controversies are not caused solely by a lack of clinical data on the harms and benefits of these tests but are also influenced by several psychological biases that make it difficult for clinicians to de-innovate. De-innovation could be fostered by making sure that advisory panels and guideline committees include experts who have competing biases; emphasizing evidence over clinical judgment; resisting "indication creep," or the premature extension of innovations into unproven areas; and encouraging clinicians to explicitly consider how their experiences bias their interpretations of clinical evidence.
Project HOPE—The People-to-People Health Foundation, Inc.
Health Affairs 02/2015; 34(2):239-44. DOI:10.1377/hlthaff.2014.0983 · 4.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: William Howard Taft was obsessed with his health—an observation many will find surprising given that he is remembered as the nation’s most obese president. But Taft kept a detailed diary of his diet, exercise, reflux symptoms, and bowel movements. He shared his logs with his personal physician, who used the information to provide feedback and, with this support, Taft lost nearly sixty pounds.1Now, close to 70 % of Americans track some form of health-related behavior.2 The traditional leather-bound diaries of Taft’s era are less common, but personal journals are more popular than ever in the form of blogs, social media posts, and other online activities. A growing number of sensors, including wearable devices and smartphone apps, collect biometric data passively or with minimal inputs from users, supporting what is called “the quantified self,” with assessments of blood sugar, heart rhythm, or peak respiratory flow.3 The majority of these platforms and devices are never intended to be s ...
Journal of General Internal Medicine 12/2014; 30(6). DOI:10.1007/s11606-014-3145-x · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Adoption of electronic health record systems has increased the availability of patient-level electronic health information.
To examine public support for secondary uses of electronic health information under different consent arrangements.
National experimental survey to examine perceptions of uses of electronic health information according to patient consent (obtained vs. not obtained), use (research vs. marketing), and framing of the findings (abstract description without results vs. specific results).
Nationally representative survey.
3064 African American, Hispanic, and non-Hispanic white persons (response rate, 65%).
Appropriateness of health information use described in vignettes on a scale of 1 (not at all appropriate) to 10 (very appropriate).
Mean ratings ranged from a low of 3.81 for a marketing use when consent was not obtained and specific results were presented to a high of 7.06 for a research use when consent was obtained and specific results were presented. Participants rated scenarios in which consent was obtained as more appropriate than when consent was not obtained (difference, 1.01 [95% CI, 0.69 to 1.34]; P < 0.001). Participants rated scenarios in which the use was marketing as less appropriate than when the use was research (difference, -2.03 [CI, -2.27 to -1.78]; P < 0.001). Unconsented research uses were rated as more appropriate than consented marketing uses (5.65 vs. 4.52; difference, 1.13 [CI, 0.87 to 1.39]).
Participants rated hypothetical scenarios. Results could be vulnerable to nonresponse bias despite the high response rate.
Although approaches to health information sharing emphasize consent, public opinion also emphasizes purpose, which suggests a need to focus more attention on the social value of information use.
National Human Genome Research Institute.
Annals of internal medicine 12/2014; 161(12):855-62. DOI:10.7326/M14-1118 · 17.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Use of social media has become widespread across the United States. Although businesses have invested in social media to engage consumers and promote products, less is known about the extent to which hospitals are using social media to interact with patients and promote health.
The aim was to investigate the relationship between hospital social media extent of adoption and utilization relative to hospital characteristics.
We conducted a cross-sectional review of hospital-related activity on 4 social media platforms: Facebook, Twitter, Yelp, and Foursquare. All US hospitals were included that reported complete data for the Centers for Medicare and Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Systems survey and the American Hospital Association Annual Survey. We reviewed hospital social media webpages to determine the extent of adoption relative to hospital characteristics, including geographic region, urban designation, bed size, ownership type, and teaching status. Social media utilization was estimated from user activity specific to each social media platform, including number of Facebook likes, Twitter followers, Foursquare check-ins, and Yelp reviews.
Adoption of social media varied across hospitals with 94.41% (3351/3371) having a Facebook page and 50.82% (1713/3371) having a Twitter account. A majority of hospitals had a Yelp page (99.14%, 3342/3371) and almost all hospitals had check-ins on Foursquare (99.41%, 3351/3371). Large, urban, private nonprofit, and teaching hospitals were more likely to have higher utilization of these accounts.
Although most hospitals adopted at least one social media platform, utilization of social media varied according to several hospital characteristics. This preliminary investigation of social media adoption and utilization among US hospitals provides the framework for future studies investigating the effect of social media on patient outcomes, including links between social media use and the quality of hospital care and services.
Journal of Medical Internet Research 11/2014; 16(11):e264. DOI:10.2196/jmir.3758 · 3.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In October 2013, multiple United States (US) federal health departments and agencies posted on Twitter, "We're sorry, but we will not be tweeting or responding to @replies during the shutdown. We'll be back as soon as possible!" These "last tweets" and the millions of responses they generated revealed social media's role as a forum for sharing and discussing information rapidly. Social media are now among the few dominant communication channels used today. We used social media to characterize the public discourse and sentiment about the shutdown. The 2013 shutdown represented an opportunity to explore the role social media might play in events that could affect health. (Am J Public Health. Published online ahead of print October 16, 2014: e1-e3. doi:10.2105/AJPH.2014.302118).
American Journal of Public Health 10/2014; 104(12):e1-e3. DOI:10.2105/AJPH.2014.302118 · 4.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives:
We sought to explore the feasibility of using a crowdsourcing study to promote awareness about automated external defibrillators (AEDs) and their locations.
The Defibrillator Design Challenge was an online initiative that asked the public to create educational designs that would enhance AED visibility, which took place over 8 weeks, from February 6, 2014, to April 6, 2014. Participants were encouraged to vote for AED designs and share designs on social media for points. Using a mixed-methods study design, we measured participant demographics and motivations, design characteristics, dissemination, and Web site engagement.
Over 8 weeks, there were 13 992 unique Web site visitors; 119 submitted designs and 2140 voted. The designs were shared 48 254 times on Facebook and Twitter. Most designers-voters reported that they participated to contribute to an important cause (44%) rather than to win money (0.8%). Design themes included: empowerment, location awareness, objects (e.g., wings, lightning, batteries, lifebuoys), and others.
The Defibrillator Design Challenge engaged a broad audience to generate AED designs and foster awareness. This project provides a framework for using design and contest architecture to promote health messages.
American Journal of Public Health 10/2014; 104(12):e1-e7. DOI:10.2105/AJPH.2014.302211 · 4.55 Impact Factor