Search strategies improve with practice, but not with time pressure or financial incentives.
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ABSTRACT:
SUBMITTER: Nowakowska A
PROVIDER: S-EPMC8388182 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:PURPOSE OF REVIEW:We reviewed recent literature on conditional and unconditional financial incentives for their impact on improving movement through the HIV care cascade and HIV prevention. RECENT FINDINGS:Concepts from behavioral economics may help improve engagement in HIV care by addressing upstream structural risk factors for HIV, such as poverty, or providing conditional rewards for immediate, measurable outcomes related to HIV care. Incentives have been shown to increase uptake of HIV testing. Yet, few studies to date focus on linkage to care: one large USA-based randomized trial failed to show an effect of incentives; and a smaller trial showed improved linkage to care among drug users, but no difference in virologic suppression. Several small USA-based studies have shown an impact of financial incentives on antiretroviral therapy adherence, but without durability beyond the incentive period. HIV prevention has the most robust evidence for decreasing HIV risk-taking behavior among adolescents and may serve as a model for research on the care cascade. SUMMARY:Financial incentives show promise for improving engagement in HIV testing, care, and prevention. Understanding the durability, scalability, ease of implementation, and cost-effectiveness of these different approaches will be critical for maximizing the impact of incentives in curtailing the HIV epidemic.
| S-EPMC4699403 | biostudies-literature
Project description:ObjectivesTo evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary value-based payment reforms.Data sources/study settingPublicly available data from Medicare's Physician Compare (n = 1,278; January 2012 to November 2013) and nationally representative physician practice data from the National Survey of Physician Organizations 3 (NSPO3; n = 907,538; 2013).Study designWe used regression analysis to examine practice-level relationships between prior exposure to performance incentives and participation in key Medicare value-based payment reforms: accountable care organization (ACO) programs, the Physician Quality Reporting System ("Physician Compare"), and the Meaningful Use of Health Information Technology program ("Meaningful Use"). Prior experience and success with financial incentives were measured as (1) the percentage of practices' revenue from financial incentives for quality or efficiency; and (2) practices' exposure to public reporting of quality measures.Data collection/extraction methodsWe linked physician participation data from Medicare's Physician Compare to the NSPO3 survey.Principal findingsThere was wide variation in practices' exposure to performance incentives, with 64 percent exposed to financial incentives, 45 percent exposed to public reporting, and 2.2 percent of practice revenue coming from financial incentives. For each percentage-point increase in financial incentives, there was a 0.9 percentage-point increase in the probability of participating in ACOs (standard error [SE], 0.1, p < .001) and a 0.8 percentage-point increase in the probability of participating in Meaningful Use (SE, 0.1, p < .001), controlling for practice characteristics. Financial incentives were not associated with participation in Physician Compare. Among ACO participants, a 1 percentage-point increase in incentives was associated with a 0.7 percentage-point increase in the probability of being "very well" prepared to utilize cost and quality data (SE, 0.1, p < .001).ConclusionsPhysicians organizations' prior experience and success with performance incentives were related to participation in Medicare ACO arrangements and participation in the meaningful use criteria but not to participation in Physician Compare. We conclude that Medicare must complement financial incentives with additional efforts to address the needs of practices with less experience with such incentives to promote value-based payment on a broader scale.
| S-EPMC6056599 | biostudies-literature
Project description:Background: Given the increase in financial-incentive programs nationwide, many physicians and physician groups are concerned about potential unintended consequences of providing financial incentives to improve quality of care. However, few studies examine whether actual unintended consequences result from providing financial incentives to physicians. We sought to document the extent to which the unintended consequences discussed in the literature were observable in a randomized clinical trial (RCT) of financial incentives.Methods: We conducted a qualitative observational study nested within a larger RCT of financial incentives to improve hypertension care. We conducted 30-minute telephone interviews with primary care personnel at facilities participating in the RCT housed at12 geographically dispersed Veterans Affairs Medical Centers nationwide. Participants answered questions about unintended effects, clinic team dynamics, organizational impact on care delivery, study participation. We employed a blend of inductive and deductive qualitative techniques for analysis.Participants: Sixty-five participants were recruited from RCT enrollees and personnel not enrolled in the larger RCT, plus one primary care leader per site.Results: Emergent themes included possible patient harm, emphasis on documentation over improving care, reduced professional morale, and positive spillover. All discussions of unintended consequences involving patient harm were only concerns, not actual events. Several unintended consequences concerned ancillary initiatives for quality improvement (e.g., practice guidelines and performance measurement systems) rather than financial incentives.Conclusions: Many unintended consequences of financial incentives noted were either only concerns or attributable to ancillary quality-improvement initiatives. Actual unintended consequences included improved documentation of care without necessarily improving actual care, and positive unintended consequences.Trial registration: Clinicaltrials.gov Identifier: NCT00302718.
| S-EPMC5608267 | biostudies-literature
Project description:ObjectivesNarrative review of the impact of pay-for-performance (P4P) and public reporting (PR) on health care outcomes, including spillover effects and impact on disparities.Principal findingsThe impact of P4P and PR is dependent on the underlying payment system (fee-for-service, salary, capitation) into which these schemes are introduced. Both have the potential to improve care, but they can also have substantial unintended consequences. Evidence from the behavioral economics literature suggests that individual physicians will vary in how they respond to incentives. We also discuss issues to be considered when including patient-reported outcome measures (PROMs) or patient-reported experience measures into P4P and PR schemes.ConclusionWe provide guidance to payers and policy makers on the design of P4P and PR programs so as to maximize their benefits and minimize their unintended consequences. These include involving clinicians in the design of the program, taking into account the payment system into which new incentives are introduced, designing the structure of reward programs to maximize the likelihood of intended outcomes and minimize the likelihood of unintended consequences, designing schemes that minimize the risk of increasing disparities, providing stability of incentives over some years, and including outcomes that are relevant to patients' priorities. In addition, because of the limitations of PR and P4P as effective interventions in their own right, it is important that they are combined with other policies and interventions intended to improve quality to maximize their likely impact.
| S-EPMC5338201 | biostudies-literature
Project description:BackgroundHypertension is prevalent in Singapore and is a major risk factor for cardiovascular morbidity and mortality and increased health care costs. Strategies to lower blood pressure include lifestyle modifications and home blood pressure monitoring. Nonetheless, adherence to home blood pressure monitoring remains low. This protocol details an algorithm for remote management of primary care patients with hypertension.ObjectiveThe objective of this study was to determine whether wireless home blood pressure monitoring with or without financial incentives is more effective at reducing systolic blood pressure than nonwireless home blood pressure monitoring (usual care).MethodsThis study was designed as a randomized controlled open-label superiority study. A sample size of 224 was required to detect differences of 10 mmHg in average systolic blood pressure. Participants were to be randomized, in the ratio of 2:3:3, into 1 of 3 parallel study arms :(1) usual care, (2) wireless home blood pressure monitoring, and (3) wireless home blood pressure monitoring with financial incentives. The primary outcome was the mean change in systolic blood pressure at month 6. The secondary outcomes were the mean reduction in diastolic blood pressure, cost of financial incentives, time taken for the intervention, adherence to home blood pressure monitoring, effectiveness of the framing of financial incentives in decreasing nonadherence to blood pressure self-monitoring and the adherence to antihypertensive medication at month 6.ResultsThis study was approved by SingHealth Centralised Institutional Review Board and registered. Between January 24, 2018 and July 10, 2018, 42 participants (18.75% of the required sample size) were enrolled, and 33 participants completed the month 6 assessment by January 31, 2019.ConclusionsDue to unforeseen events, the study was stopped prematurely; therefore, no results are available. Depending on the blood pressure information received from the patients, the algorithm can trigger immediate blood pressure advice (eg, Accident and Emergency department visit advice for extremely high blood pressure), weekly feedback on blood pressure monitoring, medication titration, or skipping of routine follow-ups. The inclusion of financial incentives framed as health capital provides a novel idea on how to promote adherence to remote monitoring, and ultimately, improve chronic disease management.Trial registrationClinicalTrials.gov NCT03368417; https://clinicaltrials.gov/ct2/show/NCT03368417.International registered report identifier (irrid)DERR1-10.2196/27496.
| S-EPMC8262550 | biostudies-literature
Project description:ObjectivesSevere mental illness (SMI) is associated with premature cardiovascular disease, prompting the UK primary care payment-for-performance system (Quality and Outcomes Framework, QOF) to incentivise annual physical health reviews. This study aimed to assess the QOF's impact on detection and treatment of cardiovascular risk factors in people with SMI.MethodsA retrospective open cohort study of UK general practice was conducted between 1996 and 2014, using segmented logistic regression with 2004 and 2011 as break points, reflecting the introduction of relevant QOF incentives in these years. 67239 SMI cases and 359951 randomly-selected unmatched controls were extracted from the Clinical Practice Research Datalink (CPRD).ResultsThere was strong evidence (p≤0.015) the 2004 QOF indicator (general health) resulted in an immediate increase in recording of elevated cholesterol (odds ratio 1.37 (95% confidence interval 1.24 to 1.51)); obesity (OR 1.21 (1.06 to 1.38)); and hypertension (OR 1.19 (1.04 to 1.38)) in the SMI group compared with the control group, which was sustained in subsequent years. Similar findings were found for diabetes, although the evidence was weaker (p = 0.059; OR 1.21 (0.99 to 1.49)). There was evidence (p<0.001) of a further, but unsustained, increase in recording of elevated cholesterol and obesity in the SMI group following the 2011 QOF indicator (cardiovascular specific). There was no clear evidence that the QOF indicators affected the prescribing of lipid modifying medications or anti-diabetic medications.ConclusionIncentivising general physical health review for SMI improves identification of cardiovascular risk factors, although the additional value of specifically incentivising cardiovascular risk factor assessment is unclear. However, incentives do not affect pharmacological management of these risks.
| S-EPMC5466340 | biostudies-literature
Project description:Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory.To test the effect of explicit financial incentives to reward guideline-recommended hypertension care.Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists).Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports.Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension.Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout.Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these findings.clinicaltrials.gov Identifier: NCT00302718.
| S-EPMC4165573 | biostudies-literature
Project description:BACKGROUND:Compared with white persons, African Americans have a greater incidence of diabetes, decreased control, and higher rates of microvascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes. OBJECTIVE:To determine whether peer mentors or financial incentives are superior to usual care in helping African American veterans decrease their hemoglobin A(1c) (HbA(1c)) levels. DESIGN:A 6-month randomized, controlled trial. (ClinicalTrials.gov registration number: NCT01125956) SETTING:Philadelphia Veterans Affairs Medical Center. PATIENTS:African American veterans aged 50 to 70 years with persistently poor diabetes control. INTERVENTION:118 patients were randomly assigned to 1 of 3 groups: usual care, a peer mentoring group, and a financial incentives group. Usual care patients were notified of their starting HbA(1c) level and recommended goals for HbA(1c). Those in the peer mentoring group were assigned a mentor who formerly had poor glycemic control but now had good control (HbA(1c) level ?7.5%). The mentor was asked to talk with the patient at least once per week. Peer mentors were matched by race, sex, and age. Patients in the financial incentive group could earn $100 by decreasing their HbA(1c) level by 1% and $200 by decreasing it by 2% or to an HbA(1c) level of 6.5%. MEASUREMENTS:Change in HbA(1c) level at 6 months. RESULTS:Mentors and mentees talked the most in the first month (mean calls, 4; range, 0 to 30), but calls decreased to a mean of 2 calls (range, 0 to 10) by the sixth month. Levels of HbA(1c) decreased from 9.9% to 9.8% in the control group, from 9.8% to 8.7% in the peer mentor group, and from 9.5% to 9.1% in the financial incentive group. Mean change in HbA(1c) level from baseline to 6 months relative to control was -1.07% (95% CI, -1.84% to -0.31%) in the peer mentor group and -0.45% (CI, -1.23% to 0.32%) in the financial incentive group. LIMITATION:The study included only veterans and lasted only 6 months. CONCLUSION:Peer mentorship improved glucose control in a cohort of African American veterans with diabetes. PRIMARY FUNDING SOURCE:National Institute on Aging Roybal Center.
| S-EPMC3475415 | biostudies-literature
Project description:ObjectiveMost persons who undergo total knee replacement (TKR) do not increase their physical activity following surgery. We assessed whether financial incentives and health coaching would improve physical activity in persons undergoing TKR.MethodsWe designed a factorial randomized controlled trial among persons undergoing TKR for osteoarthritis. Subjects underwent normal perioperative procedures, including postoperative physical therapy, and were assigned to 1 of 4 arms: attention control, telephonic health coaching (THC), financial incentives (FI), or THC + FI. We objectively measured step counts and minutes of physical activity using a commercial accelerometer (Fitbit Zip) and compared the changes from pre-TKR to 6 months post-TKR across the 4 study arms.ResultsOf the 202 randomized subjects, 150 (74%) provided both pre-TKR and 6 months post-TKR accelerometer data. Among completers, the mean ± SE daily step count at 6 months ranged from 5,619 ± 381 in the THC arm to 7,152 ± 407 in the THC + FI arm (adjusting for baseline values). Daily step count 6 months post-TKR increased by 680 (95% confidence interval [95% CI] -94, 1,454) in the control arm, 274 (95% CI -473, 1,021) in the THC arm, 826 (95% CI 89, 1,563) in the FI arm, and 1,808 (95% CI 1,010, 2,606) in the THC + FI arm. Weekly physical activity increased by mean ± SE 14 ± 10, 14 ± 10, 16 ± 10, and 39 ± 11 minutes in the control, THC, FI, and THC + FI arms, respectively.ConclusionA dual THC + FI intervention led to substantial improvements in step count and physical activity following TKR.
| S-EPMC6334288 | biostudies-literature
Project description:There is a significant gender imbalance on financial trading floors. This motivated us to investigate gender differences in financial risk taking under pressure. We used a well-established approach from behavior economics to analyze a series of risky monetary choices by male and female participants with and without time pressure. We also used second to fourth digit ratio (2D:4D) and face width-to-height ratio (fWHR) as correlates of pre-natal exposure to testosterone. We constructed a structural model and estimated the participants' risk attitudes and probability perceptions via maximum likelihood estimation under both expected utility (EU) and rank-dependent utility (RDU) models. In line with existing research, we found that male participants are less risk averse and that the gender gap in risk attitudes increases under moderate time pressure. We found that female participants with lower 2D:4D ratios and higher fWHR are less risk averse in RDU estimates. Males with lower 2D:4D ratios were less risk averse in EU estimations, but more risk averse using RDU estimates. We also observe that men whose ratios indicate a greater prenatal exposure to testosterone exhibit a greater optimism and overestimation of small probabilities of success.
| S-EPMC5736567 | biostudies-literature