Enhancing Patient Navigation with Contingent Incentives to Improve Healthcare Behaviors and Viral Load Suppression of Persons with HIV and Substance Use.
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ABSTRACT:
SUBMITTER: Stitzer ML
PROVIDER: S-EPMC6034401 | biostudies-literature | 2018 Jul
REPOSITORIES: biostudies-literature
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Enhancing Patient Navigation with Contingent Incentives to Improve Healthcare Behaviors and Viral Load Suppression of Persons with HIV and Substance Use.
Stitzer Maxine L ML Hammond Alexis S AS Matheson Tim T Sorensen James L JL Feaster Daniel J DJ Duan Rui R Gooden Lauren L Del Rio Carlos C Metsch Lisa R LR
AIDS patient care and STDs 20180608 7
This secondary analysis compares health behavior outcomes for two groups of HIV+ substance users randomized in a 3-arm trial [1] to receive Patient Navigation with (PN+CM) or without (PN) contingent financial incentives (CM). Mean age of participants was 45 years; the majority was male (67%), African American (78%), unemployed (35%), or disabled (50%). Behaviors incentivized for PN+CM were (1) attendance at HIV care visits and (2) verification of an active HIV medication prescription. Incentives ...[more]
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Project description:Interventions are needed to improve viral suppression rates among persons with HIV and substance use. A 3-arm randomized multi-site study (Metsch et al. in JAMA 316:156-70, 2016) was conducted to evaluate the effect on HIV outcomes of usual care referral to HIV and substance use services (N = 253) versus patient navigation delivered alone (PN: N = 266) or together with contingency management (PN + CM; N = 271) that provided financial incentives targeting potential behavioral mediators of viral load suppression.This secondary analysis evaluates the effects of financial incentives on attendance at PN sessions and the relationship between session attendance and viral load suppression at end of the intervention.Frequency of sessions attended was analyzed over time and by distribution of individual session attendance frequency (PN vs PN + CM). Percent virally suppressed (?200 copies/mL) at 6 months was compared for low, medium and high rate attenders. In PN + CM a total of $220 could be earned for attendance at 11 PN sessions over the 6-month intervention with payments ranging from $10 to $30 under an escalating schedule.The majority (74%) of PN-only participants attended 6 or more sessions but only 28% attended 10 or more and 16% attended all eleven sessions. In contrast, 90% of PN + CM attended 6 or more visits, 69% attended 10 or more and 57% attended all eleven sessions (attendance distribution ?2[11] = 105.81; p < .0001). Overall (PN and PN + CM participants combined) percent with viral load suppression at 6-months was 15, 38 and 54% among those who attended 0-5, 6-9 and 10-11 visits, respectively (?2(2) = 39.07, p < .001).In this secondary post hoc analysis, contact with patient navigators was increased by attendance incentives. Higher rates of attendance at patient navigation sessions was associated with viral suppression at the 6-month follow-up assessment. Study results support use of attendance incentives to improve rates of contact between service providers and patients, particularly patients who are difficult to engage in care. Trial Registration clinicaltrials.govIdentifier: NCT01612169.
| S-EPMC5485550 | biostudies-literature
Project description:ImportanceSubstance use is a major driver of the HIV epidemic and is associated with poor HIV care outcomes. Patient navigation (care coordination with case management) and the use of financial incentives for achieving predetermined outcomes are interventions increasingly promoted to engage patients in substance use disorders treatment and HIV care, but there is little evidence for their efficacy in improving HIV-1 viral suppression rates.ObjectiveTo assess the effect of a structured patient navigation intervention with or without financial incentives to improve HIV-1 viral suppression rates among patients with elevated HIV-1 viral loads and substance use recruited as hospital inpatients.Design, setting, and participantsFrom July 2012 through January 2014, 801 patients with HIV infection and substance use from 11 hospitals across the United States were randomly assigned to receive patient navigation alone (n = 266), patient navigation plus financial incentives (n = 271), or treatment as usual (n = 264). HIV-1 plasma viral load was measured at baseline and at 6 and 12 months.InterventionsPatient navigation included up to 11 sessions of care coordination with case management and motivational interviewing techniques over 6 months. Financial incentives (up to $1160) were provided for achieving targeted behaviors aimed at reducing substance use, increasing engagement in HIV care, and improving HIV outcomes. Treatment as usual was the standard practice at each hospital for linking hospitalized patients to outpatient HIV care and substance use disorders treatment.Main outcomes and measuresThe primary outcome was HIV viral suppression (≤200 copies/mL) relative to viral nonsuppression or death at the 12-month follow-up.ResultsOf 801 patients randomized, 261 (32.6%) were women (mean [SD] age, 44.6 years [10.0 years]). There were no differences in rates of HIV viral suppression versus nonsuppression or death among the 3 groups at 12 months. Eighty-five of 249 patients (34.1%) in the usual-treatment group experienced treatment success compared with 89 of 249 patients (35.7%) in the navigation-only group for a treatment difference of 1.6% (95% CI, -6.8% to 10.0%; P = .80) and compared with 98 of 254 patients (38.6%) in the navigation-plus-incentives group for a treatment difference of 4.5% (95% CI -4.0% to 12.8%; P = .68). The treatment difference between the navigation-only and the navigation-plus-incentives group was -2.8% (95% CI, -11.3% to 5.6%; P = .68).Conclusions and relevanceAmong hospitalized patients with HIV infection and substance use, patient navigation with or without financial incentives did not have a beneficial effect on HIV viral suppression relative to nonsuppression or death at 12 months vs treatment as usual. These findings do not support these interventions in this setting.Trial registrationclinicaltrials.gov Identifier: NCT01612169.
| S-EPMC5339876 | biostudies-literature
Project description:IntroductionIndividuals with substance use disorders (SUDs) experience increased smoking-related morbidity and mortality but severely compromised smoking treatment benefits. Residential SUD treatment settings may be particularly positioned to target smoking, with ever-increasing smoking bans and culture shifts, but most smokers continue smoking. This study examined the effects of contingency management (CM) for increasing smoking abstinence in residential patients.MethodsSmokers interested in quitting were recruited from a residential SUD program for men and were randomized to frequent smoking monitoring with behavioral support (monitoring; n = 21) or that plus smoking abstinence-contingent (expired carbon monoxide [CO] ≤ 6 ppm; urinary cotinine ≤ 30ng/ml) incentives (CM, n = 24) for 4 weeks. After setting a quit date, procedures included daily behavioral support and smoking self-reports, 2 CO samples (a.m./p.m.) Monday through Friday, and cotinine tests on Mondays. CM participants received escalating draws for prizes ($1, $20, and $100 values) for negative tests; positive and missed samples reset draws. Follow-ups involved samples, self-reported smoking, and self-efficacy (weeks 4, 8, 12, and 24).ResultsPercent days CO-negative was higher with CM (median [interquartile range] 51.7% [62.8%]) compared to monitoring (0% [32.1%]) (p = .002). Cigarettes per day declined and point-prevalence abstinence increased through follow-up (p < .01), without significant group by time effects (p > .05). Abstinence self-efficacy increased overall during the intervention and more with CM compared to monitoring and was associated with abstinence across conditions through follow-up.ConclusionsCM improved some measures of response to smoking treatment in residential SUD patients.
| S-EPMC4271087 | biostudies-literature
Project description:BackgroundAbout 35 % of non-elderly U.S. adult Medicaid enrollees have a behavioral health condition, such as anxiety, mood disorders, substance use disorders, and/or serious mental illness. Individuals with serious mental illness, in particular, have mortality rates that are 2 to 3 times higher as the general population, which are due to multiple factors including inactivity, poor nutrition, and tobacco use. 61 % of Medicaid beneficiaries with behavioral health conditions also have multiple other co-occurring chronic physical health conditions, which further contributes to morbidity and mortality. The Wellness Incentives and Navigation (WIN) project is one of 10 projects under the Centers for Medicare and Medicaid Services "Medicaid Incentives for the Prevention of Chronic Diseases" Initiative, to "test the effectiveness of providing incentives directly to Medicaid beneficiaries of all ages who participate in prevention programs, and change their health risks and outcomes by adopting healthy behaviors."Methods/designWIN is a three-year randomized pragmatic clinical trial designed to examine the comparative effectiveness of the combined use of personal navigators, motivational interviewing, and a flexible wellness account on cardiovascular risk reduction among individuals in Medicaid with co-occurring physical and mental health conditions or serious mental illness alone relative to the usual care provided within Medicaid Managed Care. 1250 individuals, identified through Medicaid claims data, were recruited and randomly assigned to an intervention group or control group with outcomes tracked annually. A comparison group was also recruited to help assess the study's internal validity.DiscussionThe primary outcomes are physical and mental health related quality-of-life as measured by the SF-12, and BMI, blood pressure, LDL-C, and Hba1c results for those who are diabetic measured clinically. The purpose of this paper is to present the unique design of the WIN trial prior to results becoming available in hopes of assisting other researchers in conducting community-based randomized pragmatic trials. Outcomes will be assessed through the linkage of patient reported outcomes, health care claims, and electronic health record data.Trial registrationNCT02440906.
| S-EPMC4696169 | biostudies-literature
Project description:Among persons with human immunodeficiency virus (HIV) infection, illegal drug use and hazardous alcohol use are hypothesized to be strong risk factors for failure to achieve or maintain a suppressed HIV viral load, but accurate quantification of this association is difficult because of challenges involved in measuring substance use as part of routine clinical care. We estimated the associations of recent cocaine use, opioid/heroin use, and hazardous alcohol use with unsuppressed viral load among 1,554 persons receiving care at the John G. Bartlett Specialty Practice (Baltimore, Maryland) between 2013 and 2017. We accounted for measurement error in substance use using Bayesian models and prior estimates of the sensitivity and specificity of 2 imperfect measures of substance use derived from a previous analysis in this cohort. The prevalence difference for unsuppressed viral load associated with recent cocaine use was 11.3% (95% credible interval (CrI): 6.4, 17.0); that associated with recent opioid/heroin use was 13.2% (95% CrI: 6.6, 20.7); and that associated with recent hazardous alcohol use was 8.5% (95% CrI: 3.2, 14.4). Failure to account for measurement error resulted in clinically meaningful underestimates of the prevalence difference. Time-varying substance use is prevalent and difficult to measure in routine care; here we demonstrate a method that improves the utility of imperfect data by accounting for measurement error.
| S-EPMC6768806 | biostudies-literature
Project description:BACKGROUND:Individuals' perceptions of the importance of earning financial incentives for smoking cessation may influence the effectiveness of contingency management interventions. This study prospectively explored the perceived importance of earning financial incentives for smoking cessation and its association with smoking cessation within a contingency management intervention among socioeconomically disadvantaged adults. METHODS:This study is a secondary analysis of data from a randomized clinical trial that recruited socioeconomically disadvantaged adults from a safety-net hospital in Dallas County, Texas, from 2011 to 2013. Participants, who were randomly assigned to receive small financial incentives for smoking abstinence (N?=?75), rated the importance of earning abstinence-contingent financial incentives one day after their scheduled quit day and one-week post-quit day. Self-reported smoking abstinence was biochemically confirmed weekly through the fourth week post-quit day and at the twelfth week post-quit day. Participants were considered continuously abstinent if self-reported abstinence since the quit date was biochemically confirmed. RESULTS:Greater perceived importance of earning abstinence contingent incentives for smoking cessation was associated with a higher likelihood of achieving continuous abstinence during the four-week intervention period (OR?=?3.95 [95% CI?=?1.64, 9.53]) and through 12?weeks post-quit day (OR?=?4.71 [95% CI?=?1.56, 14.26]). CONCLUSIONS:Findings suggest that the perceived importance of earning abstinence-contingent incentives early in a quit attempt predicts smoking cessation among socioeconomically disadvantaged adults and may indicate whether an individual will be responsive to the magnitude of incentives offered.
| S-EPMC6545141 | biostudies-literature
Project description:Mosquitoes spread deadly diseases that impact millions of people every year. Understanding mosquito physiology and behavior is vital for public health and disease prevention. However, many important questions remain unanswered in the field of mosquito neuroethology, particularly in our understanding of the larval stage. In this study, we investigate the innate exploration behavior of six different species of disease vector mosquito larvae. We show that these species exhibit strikingly different movement paths, corresponding to a wide range of exploration behaviors. We also investigated the response of each species to an appetitive food cue, aversive cue or neutral control. In contrast to the large differences in exploration behavior, all species appeared to gather near preferred cues through random aggregation rather than directed navigation, and exhibited slower speeds once encountering food patches. Our results identify key behavioral differences among important disease vector species, and suggest that navigation and exploration among even closely related mosquito species may be much more distinct than previously thought.
| S-EPMC7132834 | biostudies-literature
Project description:Navigation requires animals to adjust ongoing movements in response to pertinent features of the environment and select between competing target cues. The neurobiological basis of navigational behavior in vertebrates is hard to analyze, partly because underlying neural circuits are experience dependent. Phototaxis in zebrafish is a hardwired navigational behavior, performed at a stage when larvae swim by using a small repertoire of stereotyped movements. We established conditions to elicit robust phototaxis behavior and found that zebrafish larvae deploy directional orienting maneuvers and regulate forward swimming speed to navigate toward a target light. Using genetic analysis and targeted laser ablations, we show that retinal ON and OFF pathways play distinct roles during phototaxis. The retinal OFF pathway controls turn movements via retinotectal projections and establishes correct orientation by causing larvae to turn away from nontarget areas. In contrast, the retinal ON pathway activates the serotonergic system to trigger rapid forward swimming toward the target. Computational simulation of phototaxis with an OFF-turn, ON-approach algorithm verifies that our model accounts for key features of phototaxis and provides a simple and robust mechanism for behavioral choice between competing targets.
| S-EPMC3412192 | biostudies-literature
Project description:Gun-related violence is a public health concern. This study synthesizes findings on associations between substance use and gun-related behaviors. Searches through PubMed, Embase, and PsycINFO located 66 studies published in English between 1992 and 2014. Most studies found a significant bivariate association between substance use and increased odds of gun-related behaviors. However, their association after adjustment was mixed, which could be attributed to a number of factors such as variations in definitions of substance use and gun activity, study design, sample demographics, and the specific covariates considered. Fewer studies identified a significant association between substance use and gun access/possession than other gun activities. The significant association between nonsubstance covariates (e.g., demographic covariates and other behavioral risk factors) and gun-related behaviors might have moderated the association between substance use and gun activities. Particularly, the strength of association between substance use and gun activities tended to reduce appreciably or to become nonsignificant after adjustment for mental disorders. Some studies indicated a positive association between the frequency of substance use and the odds of engaging in gun-related behaviors. Overall, the results suggest a need to consider substance use in research and prevention programs for gun-related violence.
| S-EPMC4762249 | biostudies-literature
Project description:We study the design of provider incentives in the post-acute care setting - a high-stakes but under-studied segment of the healthcare system. We focus on long-term care hospitals (LTCHs) and the large (approximately $13,500) jump in Medicare payments they receive when a patient s stay reaches a threshold number of days. Discharges increase substantially after the threshold, with the marginal discharged patient in relatively better health. Despite the large financial incentives and behavioral response in a high mortality population, we are unable to detect any compelling evidence of an impact on patient mortality. To assess provider behavior under counterfactual payment schedules, we estimate a simple dynamic discrete choice model of LTCH discharge decisions. When we conservatively limit ourselves to alternative contracts that hold the LTCH harmless, we find that an alternative contract can generate Medicare savings of about $2,100 per admission, or about 5% of total payments. More aggressive payment reforms can generate substantially greater savings, but the accompanying reduction in LTCH profits has potential out-of-sample consequences. Our results highlight how improved financial incentives may be able to reduce healthcare spending, without negative consequences for industry profits or patient health.
| S-EPMC6529222 | biostudies-literature