ArticlePDF Available

Automated Hovering in Health Care - Watching Over the 5000 Hours

June 2012
The New-England Medical Review and Journal 367(1):1-3

DOI:10.1056/NEJMp1203869

Source
PubMed

Authors:

University of Pennsylvania

The dominant form of health care financing in the United States supports a reactive, visit-based model in which patients are seen when they become ill, typically during hospitalizations and at outpatient visits. That care model falls short not just because it is expensive and often fails to proactively improve health, but also because so much of health is explained by individual behaviors,(1) most of which occur outside health care encounters. Indeed, even patients with chronic illness might spend only a few hours a year with a doctor or nurse, but they spend 5000 waking hours each year engaged in everything . . .

Content uploaded by Ralph W Muller

Content may be subject to copyright.

Perspective

The

NEW ENGLA ND JOURNA L

MEDICIN E

july 5, 2012

n engl j med 367;1 nejm.org july 5, 2012 1

outpatient visits. That care model

falls short not just because it is

expensive and often fails to pro-

actively improve health, but also

because so much of health is ex-

plained by individual behaviors,

most of which occur outside

health care encounters. Indeed,

even patients with chronic illness

might spend only a few hours a

year with a doctor or nurse, but

they spend 5000 waking hours

each year engaged in everything

else — including deciding wheth-

er to take prescribed medications

or follow other medical advice, de-

ciding what to eat and drink and

whether to smoke, and making

other choices about activities that

can profoundly affect their health.

The increasing attention being

paid to those 5000 hours takes

various forms. Employers are fo-

cusing more on employees’ well-

ness — how they eat, whether

they smoke, and how much they

exercise. Medication adherence has

become a more important goal,

thanks to growing recognition

that many people with chronic

conditions fail to take their medi-

cations regularly and therefore do

not get the benefits that health

care can provide. Home-based bio-

metric assessments of indicators

such as glucose level, blood pres-

sure, and weight are emerging as

part of longitudinal clinical care.

Transitional care models are be-

ing touted as a way of coordinat-

ing care beyond hospitalization.

And hospitals and health plans

are developing “hot-spotter” ap-

proaches, deploying tailored and

intensive attention to managing

the care of their most challeng-

ing patients.

All these activities

occur outside the conventional,

billable, clinical encounter — and

all reflect some sort of hovering

over people in their daily lives.

Conventional approaches to im-

proving patient engagement along

these dimensions have been per-

sonnel-intensive — using visiting

nurses or clinically staffed tele-

medicine services. Although re-

sults have been mixed, in general

these programs have not fulfilled

their promise. One problem is

that using personnel in hovering

is expensive and therefore diffi-

cult to scale up and to justify, ex-

cept for the very sickest patients,

some of whom might be too sick

to benefit. Another problem is

Automated Hovering in Health Care — Watching

Over the 5000 Hours

David A. Asch, M.D., M.B.A., Ralph W. Muller, M.A., and Kevin G. Volpp, M.D., Ph.D.

The dominant form of health care financing in

the United States supports a reactive, visit-

based model in which patients are seen when they

become ill, typically during hospitalizations and at

The New England Journal of Medicine

Downloaded from nejm.org on November 4, 2015. For personal use only. No other uses without permission.

PERSPECTIVE

n engl j med 367;1 nejm.org july 5, 2012

that initiating and maintaining

patient engagement is difficult.

A large multicenter trial of tele-

monitoring for patients with heart

failure showed no effect on the

primary outcomes of rehospital-

ization and death; moreover, 14%

of those assigned to the interven-

tion group would not use the

system at all, and nearly half of

those who did lost interest over

time. One challenge, therefore, is

finding a way to automate hover-

ing to reduce its cost. A related

challenge is figuring out how to

incorporate it into people’s lives

in ways that are not just accept-

able and convenient, but ideally

even welcomed.

Three recent developments sug-

gest that automated hovering may

offer promise. First are early ef-

forts at payment mechanisms that

support more accountability for

health outcomes — including

nonreimbursement for prevent-

able readmissions and bundling of

payments around the goals of care

rather than encounters. These

changes provide a financial en-

gine to support automated hover-

ing initiatives.

The second development is

our deepening understanding of

behavioral economics and the re-

ality that although most people

want better health and typically

know what it would take to

achieve it, the desires, distractions,

and urgencies of the moment of-

ten get in the way of pursuing

what’s in their own long-term

self-interest. Behavioral econom-

ics explains why people are pre-

dictably irrational and provides

tools for redirecting their behav-

ior with carefully deployed nudg-

es and financial incentives.

The third development is the

expanded reach of both sophisti-

cated and simple technologies —

cell phones, wireless devices, and

the Internet — that can help

health experts connect to people

during their everyday lives. Nei-

ther wireless devices nor behav-

ioral economics were part of the

disease-management programs

that have produced mixed results

in the past.

There is already considerable

evidence of the promise of auto-

mated hovering. One study of pa-

tients taking warfarin deployed a

home-based pill dispenser that

was electronically tethered to a

lottery system. Patients were au-

tomatically entered into a daily

random drawing, with a small

chance of winning $100 and a

larger chance of winning $10.

Each day, patients were electroni-

cally notified if their number had

come up — which it would do

about 1 day in 5 — but were eli-

gible for the prize only if they

had taken their warfarin the pre-

vious day, as signaled by the dis-

penser. The system provided daily

engagement, the chance of a prize,

and a sense of anticipated regret:

no one wants to receive news of

winning only to be disqualified

for nonadherence the previous day.

The expected value of the lottery

was less than $3 per day, but the

system reduced the rate of incor-

rect doses from 22% to about 3%

and reduced the rate of out-of-

range international normalized

ratios from 35% to 12%.

Such a

system could easily be deployed

to improve medication adherence

among patients discharged from

the hospital with congestive heart

failure or after being treated for

acute coronary syndromes. This

system uses technology with an

engagement strategy informed by

behavioral economics to hover

over patients.

In another clinical trial, pa-

tients with difficult-to-control di-

abetes were randomly assigned to

receive usual care or mentorship

from another patient who had

previously managed to tame his

or her own diabetes. The mentor

merely had to call the patient once

a week. The result at 6 months was

glycated hemoglobin levels more

than a full percentage point lower

than those in the control group,

created by a system requiring

minimal technology to produce

hovering that was “automatic”

from the clinician’s perspective.

This kind of hovering must be

targeted to the right clinical and

social circumstances. The biggest

savings will probably come from

reducing preventable hospitaliza-

tions or delaying entrance into

nursing homes, because that’s

where so much spending current-

ly occurs. However, cell-phone

mentors and automatic pill-bot-

tle reminders probably won’t of-

fer much to patients who are fre-

quently hospitalized owing to a

combination of severe illness and

challenging life circumstances.

These patients, at one end of the

spectrum of intensity of health

care needs, require a more per-

sonnel-intensive approach that fo-

cuses as much on social circum-

stances as on complex medical

care. The best targets for auto-

mated hovering are conditions

whose management depends sub-

stantially on individual patients’

behavior. Good targets are medi-

cation adherence in patients with

heart failure or acute coronary

syndromes and efforts to manage

diet, exercise, or weight. The

amount of hovering required to

engage patients in healthy behav-

iors during those 5000 hours will

depend critically on the intensity

of their needs, but automated

systems might be a cost-effective

solution for many patients.

There are potential concerns.

Some people might worry that

Auto mated Hover ing in He alth C are

The New England Journal of Medicine

Downloaded from nejm.org on November 4, 2015. For personal use only. No other uses without permission.

n engl j med 367;1 nejm.org july 5, 2012

PERSPECTIVE

too much hovering will erode pa-

tients’ sense of personal respon-

sibility or that hovering in one

area might distract providers or

patients from other important

health issues. Others may worry

that hovering is too intrusive or

paternalistic — though patients

could easily opt out, and it’s ar-

guably no more paternalistic than

traditional approaches to improv-

ing patient outcomes. It will be

important to ensure that new

hovering efforts are evaluated

carefully, with assessment of both

intended and potential unintend-

ed consequences.

And of course, there is a con-

siderable amount we don’t know

about these approaches: the kinds

of patients, conditions, or set-

tings for which they will be the

most useful; the organizations

(hospitals, employers, or insur-

ers) that should be the ones to

deploy them; and how to make

them heard over the din of every-

thing else that competes for atten-

tion while remaining unintrusive

enough that nudges don’t become

self-defeating nags. There are both

clinical and research opportunities

in pursuing an approach that is

just as rigorous as our approach

to other areas of medicine. Care-

ful iterative testing is essential

because these new forms of pa-

tient engagement, whatever shape

they take, will be central to im-

proving population health in our

future health care system.

Disclosure forms provided by the authors

are available with the full text of this article

at NEJM.org.

From the Center for Health Equity Research

and Promotion, Philadelphia Veterans Af-

fairs Medical Center (D.A.A., K.G.V.), the

University of Pennsylvania Health System

Center for Innovations in Health Care Fi-

nancing (D.A.A., R.W.M., K.G.V.), the Penn

CMU Roybal P30 Center in Behavioral Eco-

nomics and Health (D. A.A., K.G.V.), the

Leonard Davis Institute of Health Econom-

ics, Center for Health Incentives and Behav-

ioral Economics (D.A.A., R.W.M., K.G.V.),

and the Perelman School and Wharton

School (D.A.A., K.G.V.), University of Penn-

sylvania — all in Philadelphia.

This article was published on June 20, 2012,

at NEJM.org.

1. McGinnis JM, Williams-Russo P, Knick-

man JR. The case for more active policy at-

tention to health promotion. Health Aff

(Millwood) 2002;21:78-93.

2. Gawande A. The hot spotters. The New

Yorker. January 24, 2011.

3. Volpp KG, Asch DA, Galvin R, Loewen-

stein G. Redesigning employee health incen-

tives — lessons from behavioral economics.

N Engl J Med 2011;365:388-90.

4. Volpp KG, Loewenstein G, Troxel A, et al.

A test of financial incentives to improve war-

farin adherence. BMC Health Serv Res 2008;

8:272.

5. Long JA , Jahnle EC, Richardson DM,

Loewenstein G, Volpp KG. Peer mentoring

and financial incentives to improve glucose

control in African American veterans: a ran-

domized trial. Ann Intern Med 2012;156:416-

24.

DOI: 10.1056/NEJMp1203869

Auto mated Hover ing in He alth C are

hree decades of research fo-

cused predominantly on

costs and the use of services

among Medicare beneficiaries

has repeatedly found wide re-

gional variations in health care

experiences and health system

performance.

Much less atten-

tion has been paid to variations

in access to care and their asso-

ciated implications for quality of

care and health outcomes. Our re-

cent Commonwealth Fund report,

“Rising to the Challenge: Results

from a Scorecard on Local Health

System Performance,”

shows that

when we look beyond state aver-

ages, there are staggeringly wide

gaps in people’s ability to gain ac-

cess to care in different commu-

nities around the country. We

also find a strong and persistent

association between access and

health care quality, including the

receipt of preventive care.

Simply put, where a person

lives matters — it influences the

ability to obtain health care, as

well as the probable quality of

care that will be received —

though it should not matter in an

equitable health care system. This

and other Scorecard findings have

important implications that are

relevant to national policy reforms

and to newly available resources

for improving access and quality

of care.

The Scorecard tracks 43 health

system performance measures

grouped into four dimensions:

access, prevention and treatment,

potentially avoidable hospital use

and cost, and healthy lives. The

analysis examined the range of

variation across all 306 hospital

referral regions (HRRs) — region-

al health care markets defined

with the use of patient-flow data

for the Dartmouth Atlas of Health

Care — and drew largely from

publicly available data, generally

from 2008 to 2010. (See the Sup-

plementary Appendix, available

Geographic Variation in Access to Care — The Relationship

with Quality

David C. Radley, Ph.D., M.P.H., and Cathy Schoen, M.S.

The New England Journal of Medicine

Downloaded from nejm.org on November 4, 2015. For personal use only. No other uses without permission.

Family cascade screening for equitable identification of familial hypercholesterolemia: study protocol for a hybrid effectiveness-implementation type III randomized controlled trial

Article

Full-text available

Apr 2024
IMPLEMENT SCI

Background Familial 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 foundation-employed care navigator. This trial will test the comparative effectiveness of these strategies on completion of cascade screening for relatives of individuals with FH, centering equitable reach. Methods We will conduct a hybrid effectiveness-implementation type III randomized controlled trial testing the comparative effectiveness of two strategies for implementing cascade screening with 220 individuals with FH (i.e., probands) per arm identified from a large northeastern health system. The primary implementation outcome is reach, or the proportion of probands with at least one first-degree biological relative (parent, sibling, child) in the USA who is screened for FH through the study. Our secondary implementation outcomes include the number of relatives screened and the number of relatives meeting the American Heart Association criteria for FH. Our secondary clinical effectiveness outcome is post-trial proband cholesterol level. We will also use mixed methods to identify implementation strategy mechanisms for implementation strategy effectiveness while centering equity. Discussion We will test two patient-facing implementation strategies harnessing insights from behavioral economics that were developed collaboratively with constituents. This trial will improve our understanding of how to implement evidence-based cascade screening for FH, which implementation strategies work, for whom, and why. Learnings from this trial can be used to equitably scale cascade screening programs for FH nationally and inform cascade screening implementation efforts for other genetic disorders. Trial registration ClinicalTrials.gov, NCT05750667. Registered 15 February 2023—retrospectively registered, https://clinicaltrials.gov/study/NCT05750667.

Using behavioral skills training to teach goal setting for health behaviors

Article

Jul 2024

Goal setting is a component of many behavior‐change interventions, with the Specific, Measurable, Attainable, Relevant, Time‐Bound (SMART) goal‐setting method being a commonly used strategy. The current study used a multiple‐baseline across participants design to evaluate the efficacy of behavioral skills training (BST) to teach individuals to set health‐related SMART goals in response to multiple hypothetical health scenarios. Participant attempts at goal setting were scored according to a task analysis encompassing each major element of SMART goals. Goal‐setting performance noticeably improved following an average of 1.25 h of BST, and participants rated the intervention and outcomes favorably.

Association of Smartwatch-Based Heart Rate and Physical Activity With Cardiorespiratory Fitness Measures in the Community: Cohort Study

Article

Jun 2024
J MED INTERNET RES

Background Resting heart rate (HR) and routine physical activity are associated with cardiorespiratory fitness levels. Commercial smartwatches permit remote HR monitoring and step count recording in real-world settings over long periods of time, but the relationship between smartwatch-measured HR and daily steps to cardiorespiratory fitness remains incompletely characterized in the community. Objective This study aimed to examine the association of nonactive HR and daily steps measured by a smartwatch with a multidimensional fitness assessment via cardiopulmonary exercise testing (CPET) among participants in the electronic Framingham Heart Study. Methods Electronic Framingham Heart Study participants were enrolled in a research examination (2016-2019) and provided with a study smartwatch that collected longitudinal HR and physical activity data for up to 3 years. At the same examination, the participants underwent CPET on a cycle ergometer. Multivariable linear models were used to test the association of CPET indices with nonactive HR and daily steps from the smartwatch. Results We included 662 participants (mean age 53, SD 9 years; n=391, 59% women, n=599, 91% White; mean nonactive HR 73, SD 6 beats per minute) with a median of 1836 (IQR 889-3559) HR records and a median of 128 (IQR 65-227) watch-wearing days for each individual. In multivariable-adjusted models, lower nonactive HR and higher daily steps were associated with higher peak oxygen uptake (VO2), % predicted peak VO2, and VO2 at the ventilatory anaerobic threshold, with false discovery rate (FDR)–adjusted P values <.001 for all. Reductions of 2.4 beats per minute in nonactive HR, or increases of nearly 1000 daily steps, corresponded to a 1.3 mL/kg/min higher peak VO2. In addition, ventilatory efficiency (VE/VCO2; FDR-adjusted P=.009), % predicted maximum HR (FDR-adjusted P<.001), and systolic blood pressure-to-workload slope (FDR-adjusted P=.01) were associated with nonactive HR but not associated with daily steps. Conclusions Our findings suggest that smartwatch-based assessments are associated with a broad array of cardiorespiratory fitness responses in the community, including measures of global fitness (peak VO2), ventilatory efficiency, and blood pressure response to exercise. Metrics captured by wearable devices offer a valuable opportunity to use extensive data on health factors and behaviors to provide a window into individual cardiovascular fitness levels.

TELEHEALTH TECHNOLOGY AND HEALTHCARE

Chapter

Mar 2024

Biotechnology is one of the emerging fields that can add new and better application in a wide range of sectors like health care, service sector, agriculture, and processing industry to name some. This book will provide an excellent opportunity to focus on recent developments in the frontier areas of Biotechnology and establish new collaborations in these areas. The book will highlight multidisciplinary perspectives to interested biotechnologists, microbiologists, pharmaceutical experts, bioprocess engineers, agronomists, medical professionals, sustainability researchers and academicians. This technical publication will provide a platform for potential knowledge exhibition on recent trends, theories and practices in the field of Biotechnology.

Protocol for a pragmatic stepped wedge cluster randomized clinical trial testing behavioral economic implementation strategies to increase supplemental breast MRI screening among patients with extremely dense breasts

Article

Full-text available

Nov 2023
IMPLEMENT SCI

Background Increased breast density augments breast cancer risk and reduces mammography sensitivity. Supplemental breast MRI screening can significantly increase cancer detection among women with dense breasts. However, few women undergo this exam, and screening is consistently lower among racially minoritized populations. Implementation strategies informed by behavioral economics (“nudges”) can promote evidence-based practices by improving clinician decision-making under conditions of uncertainty. Nudges directed toward clinicians and patients may facilitate the implementation of supplemental breast MRI. Methods Approximately 1600 patients identified as having extremely dense breasts after non-actionable mammograms, along with about 1100 clinicians involved with their care at 32 primary care or OB/GYN clinics across a racially diverse academically based health system, will be enrolled. A 2 × 2 randomized pragmatic trial will test nudges to patients, clinicians, both, or neither to promote supplemental breast MRI screening. Before implementation, rapid cycle approaches informed by clinician and patient experiences and behavioral economics and health equity frameworks guided nudge design. Clinicians will be clustered into clinic groups based on existing administrative departments and care patterns, and these clinic groups will be randomized to have the nudge activated at different times per a stepped wedge design. Clinicians will receive nudges integrated into the routine mammographic report or sent through electronic health record (EHR) in-basket messaging once their clinic group (i.e., wedge) is randomized to receive the intervention. Independently, patients will be randomized to receive text message nudges or not. The primary outcome will be defined as ordering or scheduling supplemental breast MRI. Secondary outcomes include MRI completion, cancer detection rates, and false-positive rates. Patient sociodemographic information and clinic-level variables will be examined as moderators of nudge effectiveness. Qualitative interviews conducted at the trial’s conclusion will examine barriers and facilitators to implementation. Discussion This study will add to the growing literature on the effectiveness of behavioral economics-informed implementation strategies to promote evidence-based interventions. The design will facilitate testing the relative effects of nudges to patients and clinicians and the effects of moderators of nudge effectiveness, including key indicators of health disparities. The results may inform the introduction of low-cost, scalable implementation strategies to promote early breast cancer detection. Trial registration ClinicalTrials.gov NCT05787249. Registered on March 28, 2023.

Obesity Prevention at an Early Age: Progress, but a Long Way to Go

Article

Nov 2024
J Am Med Assoc

Kevin G Volpp

Willingness to use remote patient monitoring among cardiovascular patients in a resource-limited setting: a cross-sectional study

Article

Full-text available

Sep 2024

Introduction Currently, mortality by non-communicable diseases is increasing alarmingly. They account for approximately 35 million deaths each year, of which 14% are due to cardiovascular disease and 9.2% occur in Africa. Patients do not have access to healthcare services outside the healthcare setting, resulting in missed follow-ups and appointments and adverse outcomes. This study aimed to assess the willingness to use remote monitoring among cardiovascular patients in a resource-limited setting in Ethiopia. Method An institution-based cross-sectional study was conducted from April to June 2021 among cardiovascular patients at referral hospitals in Ethiopia. A structured interview questionnaire was used to collect the data. A systematic random sampling technique was used to select 397 study participants. Binary and multivariable logistic regression analyses were employed and a 95% confidence level with a p -value <0.05 was used to determine the level of association between variables. Result In total, 81.61% of the study participants were willing to use remote patient monitoring [95% confidence interval (CI) = 77.4%–85.1%]. Age [adjusted odds ratio (AOR) = 0.94; 95% CI: 0.90–0.98], having a mobile phone (AOR = 5.70; 95% CI: 1.86–17.22), and perceived usefulness (AOR = 1.50; 95% CI: 1.18–1.82) were significantly associated with willingness to use remote patient monitoring among cardiovascular patients. Conclusion Cardiovascular patients had a high willingness to use remote patient monitoring. Age, perceived usefulness of remote patient monitoring, and having a mobile phone were significantly associated with a willingness to use remote patient monitoring.

Effectiveness of the Self-Care Support Program for People with Acute Coronary Syndrome: A Quasi-experimental Study

Article

Full-text available

Sep 2024

Acute coronary syndrome is a chronic illness that influences physical and psychological health and well-being and requires continuous treatment and effective self-care. This two-group quasi-experimental study investigated the effectiveness of the Self-Care Support Program for People with Acute Coronary Syndrome. Sixty participants were purposively recruited from medical wards of a university-affiliated hospital in Bangkok, Thailand. A Self-Care Support Program based on Orem’s self-care theory was integrated with a motivational interviewing approach. The experimental group (n = 30) received the 4-week intervention program with the usual care, while the comparison group (n = 30) received only usual care. Instruments for data collection included a Demographic and Health Data Form, the Self-Care Behavior for Acute Coronary Syndrome Questionnaire, the Veterans Specific Activity Questionnaire, and the Rehospitalization Record Form. Data analysis was performed using descriptive statistics, Chi-square test, Fisher’s exact test, and two-way repeated measures analysis of variance. Results revealed that the experimental group had significantly improved self-care behavior and functional ability immediately and four weeks after program completion (week 8), compared to the comparison group. There was no difference in rehospitalization between the two groups. Nurses with advanced skills in motivational training can use this program to promote effective self-care practices, improve functional ability, and reduce rehospitalization. Further study using randomized controlled trials and other settings is needed before it can be widely used.

Supporting Self-Management of Healthy Behaviors in Chronic Kidney Disease and Hypertension: The SMART-HABITS Pilot Randomized Trial

Article

Jul 2024
CLIN J AM SOC NEPHRO

Background Support programs for self-management are under-utilized among people with chronic kidney disease (CKD). We examined the feasibility of a smartphone-based intervention to support physical activity and blood pressure monitoring, Supporting Self-Management of Healthy Behaviors (SMART-HABITS), for individuals with CKD and hypertension. Methods SMART-HABITS was piloted in a 12-week randomized cross-over trial among people with CKD and hypertension. Participants were asked to monitor blood pressure ≥3-times/week and step counts ≥5-times/week. Participants were randomized to blood pressure communication approach–self-report through text message for six weeks vs. automatic reporting with a smartphone application (app) paired to a Bluetooth enabled blood pressure machine for the alternate six weeks. The approach to monitoring and reporting steps was the same during both phases. Primary outcomes were adoption (retention and use of SMART-HABITS dashboard), adherence (% of transmitted blood pressure and step counts), and acceptability as assessed with surveys and interviews. Secondary outcomes were reach, maintenance, CKD knowledge, digital health literacy, self-management, self-efficacy, quality of life, step counts and blood pressure values. Interviews were conducted at study end. Results Of the 47 randomized participants, 44 (94%) completed the Text phase and 43 (92%) completed the App phase. Median age was 63 years, 49% were female, and 45% were Black. Retention was 91%. Blood pressure adherence was 87% in the Text phase and 74% in the App phase, and step count adherence was 97%. Acceptability scores were high and interviews largely conveyed acceptance. CKD knowledge increased but remaining survey scores did not change. Mean step counts increased from the pre-study period similarly in both phases. Blood pressure did not change over time. Conclusion Implementing a smartphone support tool for self-management was feasible among people with CKD and hypertension. The approach can supplement clinic-based care and potentially lead to less cardiovascular disease and CKD progression.

Technology-Based Assessments of Frailty

Chapter

May 2024

Technology has become an integral part of healthcare and will be increasingly so over time. Technology could be a vehicle for expanding and scaling frailty assessments in older adults. Despite a large commercial technology market, the evidence base relating various technology measures to clinical frailty measures is in its infancy. Validation and implementation science studies are in great need. Prior to clinical integration, the barriers to technology use must also be addressed. This chapter will provide a high-level overview of the types of technology available for measuring frailty in the future, will provide examples from the literature in which a technology has been related to frailty and will outline key limitations and future research priorities.

A Test of Financial Incentives to Improve Warfarin Adherence

Article

Full-text available

Jan 2009
BMC HEALTH SERV RES

Sub-optimal adherence to warfarin places millions of patients at risk for stroke and bleeding complications each year. Novel methods are needed to improve adherence for warfarin. We conducted two pilot studies to determine whether a lottery-based daily financial incentive is feasible and improves warfarin adherence and anticoagulation control. Volunteers from the University of Pennsylvania Anticoagulation Management Center who had taken warfarin for at least 3 months participated in either a pilot study with a lottery with a daily expected value of

5 (N = 10) or a daily expected value of

3 (N = 10). All subjects received use of an Informedix Med-eMonitor System with a daily reminder feature. If subjects opened up their pill compartments appropriately, they were entered into a daily lottery with a 1 in 5 chance of winning

10 and a 1 in 100 chance of winning

100 (pilot 1) or a 1 in 10 chance of winning

10 and a 1 in 100 chance of winning

100 (pilot 2). The primary study outcome was proportion of incorrect warfarin doses. The secondary outcome was proportion of INR measurements not within therapeutic range. Within-subject pre-post comparisons were done of INR measurements with comparisons with either historic means or within-subject comparisons of incorrect warfarin doses. In the first pilot, the percent of out-of-range INRs decreased from 35.0% to 12.2% during the intervention, before increasing to 42% post-intervention. The mean proportion of incorrect pills taken during the intervention was 2.3% incorrect pills, compared with a historic mean of 22% incorrect pill taking in this clinic population. Among the five subjects who also had MEMS cap adherence data from warfarin use in our prior study, mean incorrect pill taking decreased from 26% pre-pilot to 2.8% in the pilot. In the second pilot, the time out of INR range decreased from 65.0% to 40.4%, with the proportion of mean incorrect pill taking dropping to 1.6%. A daily lottery-based financial incentive demonstrated the potential for significant improvements in missed doses of warfarin and time out of INR range. Further testing should be done of this approach to determine its effectiveness and potential application to both warfarin and other chronic medications.

The Case For More Active Policy Attention To Health Promotion

Article

Full-text available

Mar 2002

Until recently, when anthrax triggered a concern about preparedness in the public health infrastructure, U.S. health policy and health spending had been dominated by a focus on payment for medical treatment. The fact that many of the conditions driving the need for treatment are preventable ought to draw attention to policy opportunities for promoting health. Following a brief review of the determinants of population health-genetic predispositions, social circumstances, environmental conditions, behavioral patterns, and medical care-this paper explores some of the factors inhibiting policy attention and resource commitment to the nonmedical determinants of population health and suggests approaches for sharpening the public policy focus to encourage disease prevention and health promotion.

The hot spotters

Article

Jan 2011
New Yorker

A. Gawande

Endoscopic Treatment of Primary Vesicoureteral Reflux REPLY

Article

Mar 2012
NEW ENGL J MED

A 7-year-old girl with a history of recurrent urinary tract infection since the age of 3 years is known to have bilateral, moderately severe (grade III) vesicoureteral reflux. Renal scintigraphy with technetium-99-labeled dimercaptosuccinic acid has revealed bilateral scarring in the upper poles of her kidneys, with more severe scarring on the left kidney than on the right. Despite ongoing antimicrobial prophylaxis, she has recently had another febrile urinary tract infection, which responded well to antibiotic treatment. Radionuclide cystography reveals persistent bilateral, moderately severe vesicoureteral reflux. The patient has no history of constipation or dysfunctional voiding. She is referred to a pediatric urologist, who discusses with the patient and her parents the various treatment options, including endoscopic correction.

Redesigning Employee Health Incentives - Lessons from Behavioral Economics

Article

Aug 2011
NEW ENGL J MED

Redesigning Employee Health Incentives Starting in 2014, employers will be able to use a portion of employees' health insurance premiums to provide outcome-based wellness incentives to try to cut health care costs. But evidence that such programs work is scant. Lessons from behavioral economics might help.

Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children

Article

Sep 2010
J UROLOGY

The American Urological Association established the Vesicoureteral Reflux Guideline Update Committee in July 2005 to update the management of primary vesicoureteral reflux in children guideline. The Panel defined the task into 5 topics pertaining to specific vesicoureteral reflux management issues, which correspond to the management of 3 distinct index patients and the screening of 2 distinct index patients. This report summarizes the existing evidence pertaining to children with diagnosed reflux including those young or older than 1 year without evidence of bladder and bowel dysfunction and those older than 1 year with evidence of bladder and bowel dysfunction. From this evidence clinical practice guidelines were developed to manage the clinical scenarios insofar as the data permit. The Panel searched the MEDLINE(R) database from 1994 to 2008 for all relevant articles dealing with the 5 chosen guideline topics. The database was reviewed and each abstract segregated into a specific topic area. Exclusions were case reports, basic science, secondary reflux, review articles and not relevant. The extracted article to be accepted should have assessed a cohort of children with vesicoureteral reflux and a defined care program that permitted identification of cohort specific clinical outcomes. The reporting of meta-analysis of observational studies elaborated by the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) group was followed. The extracted data were analyzed and formulated into evidence-based recommendations. A total of 2,028 articles were reviewed and data were extracted from 131 articles. Data from 17,972 patients were included in this analysis. This systematic meta-analysis identified increasing frequency of urinary tract infection, increasing grade of vesicoureteral reflux and presence of bladder and bowel dysfunction as unique risk factors for renal cortical scarring. The efficacy of continuous antibiotic prophylaxis could not be established with current data. However, its purported lack of efficacy, as reported in selected prospective clinical trials, also is unproven owing to significant limitations in these studies. Reflux resolution and endoscopic surgical success rates are dependent upon bladder and bowel dysfunction. The Panel then structured guidelines for clinical vesicoureteral reflux management based on the goals of minimizing the risk of acute infection and renal injury, while minimizing the morbidity of testing and management. These guidelines are specific to children based on age as well as the presence of bladder and bowel dysfunction. Recommendations for long-term followup based on risk level are also included. Using a structured, formal meta-analytic technique with rigorous data selection, conditioning and quality assessment, we attempted to structure clinically relevant guidelines for managing vesicoureteral reflux in children. The lack of robust prospective randomized controlled trials limits the strength of these guidelines but they can serve to provide a framework for practice and set boundaries for safe and effective practice. As new data emerge, these guidelines will necessarily evolve.

The Swedish Reflux Trial in children: IV. Renal damage

Article

Jul 2010
J UROLOGY

We compared the development of new renal damage in small children with dilating vesicoureteral reflux randomly allocated to antibiotic prophylaxis, endoscopic treatment or surveillance as the control group. Included in the study were 128 girls and 75 boys 1 to younger than 2 years with grade III-IV reflux. Voiding cystourethrography and dimercapto-succinic acid scintigraphy were done before randomization and after 2 years. Febrile urinary tract infections were recorded during followup. Data analysis was done by the intent to treat principle. New renal damage in a previously unscarred area was seen in 13 girls and 2 boys. Eight of the 13 girls were on surveillance, 5 received endoscopic therapy and none were on prophylaxis (p = 0.0155). New damage was more common in children with than without febrile recurrence (11 of 49 or 22% vs 4 of 152 or 3%, p <0.0001). In boys the rate of new renal damage was low. It was significantly higher in girls and most common in the control surveillance group. There was also a strong association between recurrent febrile UTIs and new renal damage in girls.

Long-term outcome in women who underwent anti-reflux surgery in childhood

Article

Jun 2007

The purpose of ureterocystoneostomy to correct vesicoureteral reflux is to thereby prevent recurrent febrile urinary tract infections (UTIs). The objective of this study was to determine the frequency of UTI in adult women who underwent reimplantation as children, with the emphasis on infections during pregnancy. Included in the study were women over 20 years of age who underwent surgery for primary reflux between 1969 and 2004. A total of 392 patients were identified and information on their case history, surgery and follow-up was collected from the medical records. A questionnaire, requesting information on their present state of health, and occurrences of lower or upper UTI since the age of 16 and during any pregnancies, was sent to 337 of these patients. In all, 242 (84%) of the questionnaires were returned. UTIs had occurred in 42% of the women before they had any sexual activity; thereafter the frequency increased to 61%. In 113 of the 282 women, 242 pregnancies were recorded. UTI occurred during 59 pregnancies (24%): 19% lower, 5% upper. Risk factors for UTI during pregnancy were infections as adults or decreased differential renal function (< or = 30%). There is an ongoing risk of UTI in adult women after anti-reflux surgery in childhood. During pregnancy, these women represent a population at risk who should be observed very closely.

Prevalence of hypertension in children with primary vescioureteral reflux

Article

Nov 1993
J Pediatr

This study was undertaken to determine the prevalence of hypertension in children with primary, uncomplicated vesicoureteral reflux (VUR) and to evaluate the relationship between blood pressure (BP), grade and duration of reflux, and renal scarring. Subjects were identified retrospectively during a 17-year period; of 146 subjects who agreed to participate, 129 (88.4%) were female. Mean age at diagnosis was 5.0 years (range, 1 month to 16 years), and at follow-up was 14.4 years (range, 5 months to 21 years). Mean duration of follow-up was 9.6 years. Renal scarring was detected in 34.3% of patients by intravenous pyelogram, ultrasonography, or both. The BP at diagnosis was linearly related to the grade of reflux, but values were not higher than expected norms for age. At follow-up, mean systolic and diastolic BP were at the 41.6 percentile and the 18.7 percentile, respectively. No patient's BP was above the 55th percentile. After a mean follow-up period of 10 years, we conclude that primary, uncomplicated VUR, regardless of the number of documented urinary tract infections, duration and severity of reflux, modality of therapy, presence of renal scarring, and duration of follow-up, is not associated with the development of hypertension. Hypertension does not appear to be a complication of VUR and urinary tract infection unless there is preexisting dysplasia.

Severe vesicoureteral reflux and chronic renal failure: a condition peculiar to male gender? Data from the ItalKid Project

Article

Jun 2004
J Pediatr

Primary vesicoureteral reflux (VUR), one of the principal causes of chronic renal failure (CRF), occurs as a result of two distinct and sex-related mechanisms: congenital renal hypoplasia, which is prevalent in males, and acquired renal scarring in females. We used data from the ItalKid Project, a prospective population-based CRF registry of patients undergoing conservative treatment, to evaluate the gender distribution and severity of primary VUR, the age at diagnosis, and the diagnostic and therapeutic methods adopted in children with CRF. The prevalence of males (77.5%), the severity of VUR (grade IV-V), and the early age at diagnosis (18% prenatally) seem to suggest that congenital renal damage is the major cause of pediatric CRF.