Kevin G. Volpp

Financial Incentive Based Approaches for Weight Loss: A Randomized Trial

CONTEXT Identifying effective obesity treatment is both a clinical challenge and a public health priority due to the health consequences of obesity. OBJECTIVE To determine whether common decision errors identified by behavioral economists such as prospect theory, loss aversion, and regret could be used to design an effective weight loss intervention. DESIGN, SETTING, AND PARTICIPANTS Fifty-seven healthy participants aged 30-70 years with a body mass index of 30-40 were randomized to 3 weight loss plans: monthly weigh-ins, a lottery incentive program, or a deposit contract that allowed for participant matching, with a weight loss goal of 1 lb (0.45 kg) a week for 16 weeks. Participants were recruited May-August 2007 at the Philadelphia VA Medical Center in Pennsylvania and were followed up through June 2008. MAIN OUTCOME MEASURES Weight loss after 16 weeks. RESULTS The incentive groups lost significantly more weight than the control group (mean, 3.9 lb). Compared with the control group, the lottery group lost a mean of 13.1 lb (95% confidence interval [CI] of the difference in means, 1.95-16.40; P = .02) and the deposit contract group lost a mean of 14.0 lb (95% CI of the difference in means, 3.69-16.43; P = .006). About half of those in both incentive groups met the 16-lb target weight loss: 47.4% (95% CI, 24.5%-71.1%) in the deposit contract group and 52.6% (95% CI, 28.9%-75.6%) in the lottery group, whereas 10.5% (95% CI, 1.3%-33.1%; P = .01) in the control group met the 16-lb target. Although the net weight loss between enrollment in the study and at the end of 7 months was larger in the incentive groups (9.2 lb; t = 1.21; 95% CI, -3.20 to 12.66; P = .23, in the lottery group and 6.2 lb; t = 0.52; 95% CI, -5.17 to 8.75; P = .61 in the deposit contract group) than in the control group (4.4 lb), these differences were not statistically significant. However, incentive participants weighed significantly less at 7 months than at the study start (P = .01 for the lottery group; P = .03 for the deposit contract group) whereas controls did not. CONCLUSIONS The use of economic incentives produced significant weight loss during the 16 weeks of intervention that was not fully sustained. The longer-term use of incentives should be evaluated. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00520611.

Wearable Devices as Facilitators, Not Drivers, of Health Behavior Change

Several large technology companies including Apple, Google, and Samsung are entering the expanding market of population health with the introduction of wearable devices. This technology, worn in clothing or accessories, is part of a larger movement often referred to as the “quantified self.” The notion is that by recording and reporting information about behaviors such as physical activity or sleep patterns, these devices can educate and motivate individuals toward better habits and better health. The gap between recording information and changing behavior is substantial, however, and while these devices are increasing in popularity, little evidence suggests that they are bridging that gap. Only 1% to 2% of individuals in the United States have used a wearable device, but annual sales are projected to increase to more than

Accuracy of Smartphone Applications and Wearable Devices for Tracking Physical Activity Data

50 billion by 2018. 1 Some of these devices aim at individuals already motivated to change their health behaviors. Others are being considered by health care organizations, employers, insurers, and clinicians who see promise in using these devices to better engage less motivated individuals. Some of these devices may justify that promise, but less because of their technology and more because of the behavioral change strat

Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care

Accuracy of Smartphone Applications and Wearable Devices for Tracking Physical Activity Data Despite the potential of pedometers to increase physical activity and improve health,1 there is little evidence of broad adoption by the general population. In contrast, nearly twothirds of adults in the United States own a smartphone2 and technology advancements have enabled these devices to track health behaviors such as physical activity and provide convenient feedback.3 New wearable devices that may have more consumer appeal have also been developed. Even though these devices and applications might better engage individuals in their health, for example through workplace wellness programs,3 there has been little evaluation of their use.3-5 The objective of this study was to evaluate the accuracy of smartphone applications and wearable devices compared with direct observation of step counts, a metric successfully used in interventions to improve clinical outcomes.1

A test of financial incentives to improve warfarin adherence

IMPORTANCE Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear. OBJECTIVE To measure associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, one of the earliest and largest multipayer medical home pilots conducted in the United States, and changes in the quality, utilization, and costs of care. DESIGN, SETTING, AND PARTICIPANTS Thirty-two volunteering primary care practices participated in the pilot (conducted from June 1, 2008, to May 31, 2011). We surveyed pilot practices to compare their structural capabilities at the pilots beginning and end. Using claims data from 4 participating health plans, we compared changes (in each year, relative to before the intervention) in the quality, utilization, and costs of care delivered to 64,243 patients who were attributed to pilot practices and 55,959 patients attributed to 29 comparison practices (selected for size, specialty, and location similar to pilot practices) using a difference-in-differences design. EXPOSURES Pilot practices received disease registries and technical assistance and could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA). MAIN OUTCOMES AND MEASURES Practice structural capabilities; performance on 11 quality measures for diabetes, asthma, and preventive care; utilization of hospital, emergency department, and ambulatory care; standardized costs of care. RESULTS Pilot practices successfully achieved NCQA recognition and adopted new structural capabilities such as registries to identify patients overdue for chronic disease services. Pilot participation was associated with statistically significantly greater performance improvement, relative to comparison practices, on 1 of 11 investigated quality measures: nephropathy screening in diabetes (adjusted performance of 82.7% vs 71.7% by year 3, P < .001). Pilot participation was not associated with statistically significant changes in utilization or costs of care. Pilot practices accumulated average bonuses of

Failure-to-rescue: comparing definitions to measure quality of care.

92,000 per primary care physician during the 3-year intervention. CONCLUSIONS AND RELEVANCE A multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement.

A Randomized Controlled Trial of Financial Incentives for Smoking Cessation

BackgroundSub-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.MethodsVolunteers 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

Peer Mentoring and Financial Incentives to Improve Glucose Control in African American Veterans: A Randomized Trial

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

Impact of a Prescription Copayment Increase on Lipid-Lowering Medication Adherence in Veterans

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

Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation

10 and a 1 in 100 chance of winning