"Loss Incentive" Motivates Employees to Take More Steps
The New York Times, Forbes, TIME, Philadelphia Inquirer, Reuters, Fortune, Medpage Today, Newswise, STAT, ACSH, LDI Blog, Penn Medicine, 2/16/16; Penn Current, 3/24/16

High Out-of Pocket Costs Limits Access to Lifesaving Specialty Drugs
Penn Medicine News, 3/30/16

Drawing the Line between Paternalism and Patient-Centered Care

NEJM Catalyst, 3/25/16

Improving Patient Engagement
NEJM Catalyst, 3/7/16

When - and How - Can Incentives Actually Work?
NEJM Catalyst, 3/7/16

New York Times Op-Ed: Paying Employees to Lose Weight
The New York Times, 3/4/16

How Defaults Can be Used to Improve Cancer Care
Medscape, 3/3/16

NEJM Catalyst Patient Engagement Seminar
New England Journal of Medicine Catalyst, 2/25/16

Financial Incentives and Obesity
2ser Radio, 2/24/16

Kevin Volpp and Dan Polsky Lead New Big Data Initiative to Improve Health in Pennsylvania
Penn Medicine News, LDI News, 2/23/16

Jalpa Doshi Wins Patient Access Network (PAN) Foundation Challenge
Patient Access Network, 1/19/16

SUMR Scholar Alum Named to Forbes "30 Under 30"
Forbes, 1/16/16

Insurer Rewards Push Women Towards Mammograms

The New York Times, 1/18/16

Transforming Living Kidney Donation with a Comprehensive Strategy.
Allen MB, Reese PP. PLoS Med. 2016; 13(2):e1001948. 
Anesi GL, Halpern SD. Intensive Care Med. 2016. [Epub ahead of print]. 
Asch DA, Pauly MV, Muller RW. N Engl J Med. 2016; 374(7):606-8.  
Baumann BC, He J, Hwang WT, Tucker KN, Bekelman JE, Herr HW, Lerner SP, Guzzo TJ, Malkowicz SB, Christodouleas JP. Int J Radiat Oncol Biol Phys. 2016. [Epub ahead of print]. 

Comparison of Site of Death, Health Care Utilization, and Hospital Expenditures for Patients Dying With Cancer in 7 Developed Countries. Bekelman JE, Halpern SD, Blankart CR, Bynum JP, Cohen J, Fowler R, et al. (ICELR). JAMA. 2016; 315(3):272-83. 
Caspi CE, Tucker-Seeley RD, Adamkiewicz G, Roberto CA, Stoddard AM, Sorensen GC. 
J Immigr Minor Health. 2016. [Epub ahead of print]. 
Choudhury RA, Reese PP, Goldberg DS, Bloom RD, Sawinski DL, Abt PL. Transplantation. 2016. [Epub ahead of print].
Doshi JA, Takeshita J, Pinto L, Li P, Yu X, Rao P, Viswanathan HN, Gelfand JM. J Am Acad Dermatol. 2016. [Epub ahead of print].
Doshi JA, Hu T, Li P, Pettit AR, Yu X, Blum M. Arthritis Care Res (Hoboken). 2016. [Epub ahead of print].

Doshi JA, Li P, Ladage VP, Pettit AR, Taylor EA. Am J Manag Care. 2016; 22(3):188-97.

Griffis HM, Band RA, Ruther M, Harhay M, Asch DA, Hershey JC, Hill S, Nadkarni L, Kilaru A, Branas CC, Shofer F, Nichol G, Becker LB, Merchant RM. Am Heart J. 2016; 172:185-91. 
Hua M, Halpern SD, Gabler NB, Wunsch H. Intensive Care Med. 2016. [Epub ahead of print].

Toward A Scalable, Patient-Centered Community Health Worker Model: Adapting the IMPaCT Intervention for Use in the Outpatient Setting. Kangovi S, Carter T, Charles D, Smith RA, Glanz K, Long JA, Grande D. Popul Health Manag. 2016. [Epub ahead of print].
Lehmann BA, Chapman GB, Franssen FM, Kok G, Ruiter RA. Vaccine. 2016; 34(11):1389-92. Epub 2016. 
Leiman DA, Metz DC, Ginsberg GG, Howell JT, Mehta SJ, Ahmad NA. Clin Gastroenterol Hepatol. 2016; 14(3):333-337.e1.
Liao JM, Navathe AS. Lancet. 2016; 387(10022):936-7. 

McConnell RA, Kerlin MP, Schweickert WD, Ahmad F, Patel MS, Fuchs BD. Respir Care. 2016. [Epub ahead of print].
Mehta SJ, Ahmad NA. Gastroenterology. 2016; 150(3):543-6. 
Moore KA, Rubin EB, Halpern SD. JAMA. 2016; 315(3):259-60. 
Ojerholm E, Halpern SD, Bekelman JE. J Clin Oncol. 2016. [Epub ahead of print].
Patel MS, Patel N, Small DS, Rosin R, Rohrbach JI, Stromberg N, Hanson CW, Asch DA. J Gen Intern Med. 2016. [Epub ahead of print].
Patel MS, Asch DA, Rosin R, Small DS, Bellamy SL, Heuer J, Sproat S, Hyson C, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Volpp KG. Ann Intern Med. 2016; 164(6):385-94. 
Potluri VS, Dember LM, Reese PP. JAMA Intern Med. 2016; 176(2):236-7. 

Roberto CA, Wong D, Musicus A, Hammond D. Pediatrics. 2016; 137(2):1-10.  
VanEpps EM, Roberto CA, Park S, Economos CD, Bleich SN. Curr Obes Rep. 2016; 5(1):72-80. 
Wong CA, Ostapovich G, Kramer-Golinkoff E, Griffis H, Asch DA, Merchant RM. Healthc (Amst). 2016; 4(1):15-21.
HP/CHIBE Work in Progress Seminars

Eric VanEpps, PhD  
"Implicit Information Provision: How Question Phrasing and Choice Structure Can Communicate Information."
4/28/16 - 12:00pm
1104 Blockley Hall

Mitesh Patel, MD, MBA, MS, 
5/26/16 - 12:00pm
1104 Blockley Hall

Joachim Marti, PhD
6/15/16 - 12:00pm
1104 Blockley Hall

Laura A. Petersen, MD, MPH, FACP
6/23/16 - 12:00pm
1104 Blockley Hall

Dear Colleague,

We are happy to present to you our spring issue of the CHIBE newsletter.

Our first story features a study conducted by Christina Roberto, Ph.D., assistant professor of medical ethics and health policy at Penn's Perelman School of Medicine. This study looks at the effects of sugary soft-drink labels on parents. The results suggest warning labels would decrease parents' likelihood of buying sugary drinks for their children, whereas calorie labeling did not have much of an effect.

We then focus on a study led by Carolyn Cannuscio, ScD, a social epidemiologist with Penn's Center for Public Health Initiatives and assistant professor of family medicine and community health at the Hospital of the University of Pennsylvania. The study incentivized adolescents and young adults with food allergies to consistently carry epinephrine, the emergency medication that could save their lives. The results suggested that young adults who received both financial incentives and text messages appeared to carry their epinephrine auto-injectors far more often than those who received only text messages.

CHIBE faculty member Mitesh Patel, MD, authors our "Musings" column to share how the "nudge unit" model, currently used in governments across the world, could be used to improve health care value and outcomes.

This issue also shares a Spotlight on Heather Schofield, PhD, Assistant Professor at the University of Pennsylvania Perlman School of Medicine in the Department of Medical Ethics and Health Policy and at the Wharton School. Dr. Schofield's areas of research include the role of health human capital (nutrition, pain management, adequate sleep) in economic productivity, cognitive function, and decision-making, and the role of financial and social incentives in promoting healthy behaviors.

Please enjoy reading the spring issue of the newsletter and be sure to check out our media citations and recent publications below. Also be sure to follow us on Twitter @PennCHIBE!


Kevin Volpp, Director
Scott Halpern, Deputy Director
Warning Label Dampens Parents' Interest in Buying Sugary Drinks 

Christina Roberto, PhD
Lawmakers in various states have proposed legislation to require health warnings on sugary soft drinks, although there has been little research on the likely effectiveness of such labels.

A recent study from CHIBE researchers led by Medical Ethics and Health Policy faculty member Christina Roberto, however, suggests that parents may be less likely to purchase sugar-laden sodas for their children if warned that the product contributes to health problems such as obesity, diabetes, heart disease and tooth decay.

"Health warning labels on (sugar-sweetened beverages) improved parents' understanding of health harms associated with overconsumption of such beverages and may reduce parents' purchase of (them) for their children," concluded Dr. Roberto's  study, published in the February edition of Pediatrics.

In contrast, the study found that a label which showed only the number of calories per bottle - a standard label currently used on soda bottles -- didn't do much to dissuade parents from turning to sugary drinks.

The results suggest warning labels would decrease parents' likelihood of buying sugary drinks for their children.
The research, which measured parents' intentions about hypothetical shopping choices, is one of the first studies, if not the first, to look at the effects of sugary soft-drink labels on a large cross section of parents, reported Dr. Roberto. She added that there has been virtually no data on how labeling would affect consumers.
In the study, nearly 2,400 parents from demographically and educationally diverse backgrounds participated in an online survey in which they were asked to choose a vending-machine beverage for their child, rate their perceptions of different drinks and indicate interest in receiving drink coupons.
The parents were randomly divided among six groups: a control group who saw no warning label, those seeing a calorie-only label, and those shown one of four text versions of a safety warning label indicating the health risks of drinking sugar-sweetened beverages.
Forty percent of the parents shown the health risk label chose the sugar-sweetened drinks compared with the 60 percent who saw no label and the 53 percent with the calorie label, the researchers found. Parents who saw the health-risk label also chose fewer coupons for sugary drinks, believed such drinks were less healthy for their child, and were less likely to plan to buy them, according to the study.
"The calorie labels really didn't impact purchase intentions or shift beliefs about these beverages," said Roberto, who noted worldwide interest in different labeling schemes.
Roberto said she was surprised to find that a majority of parents favored a warning-label strategy.  "That was true across party affiliations," she said.
The study noted that "l abeling strategies typically garner more public support than more controversial food policies," such as taxing soft drinks or limiting their portion size.
Roberto, principal investigator for the Psychology of Eating and Consumer Health lab, has been working on another study, not yet published, exploring adolescents' choices. "I think it's one thing for parents choosing for a kid," she said. "We are seeing some effects for adolescents but they're not as strong."

-Dinah Wisenberg Brin
Financial Incentives May Boost Young Adults' Epinephrine Auto-Injector Use

Carolyn Cannuscio, ScD, ScM
Few people with serious food allergies - particularly adolescents and young adults - consistently carry epinephrine, the emergency medication that could save their lives.

A University of Pennsylvania study indicates that financial incentives may prompt more young people to carry their epinephrine auto-injectors.

The trial, which enrolled 33 people from 18 to 30 years old, found that young adults who received both financial incentives and text messages appeared to carry their epinephrine auto-injectors far more often (at 54 percent of check-ins) than those who received only text messages (27 percent).

Prompt administration of epinephrine is critically important in case of anaphylaxis, a life-threatening allergic reaction that can include trouble breathing or swallowing.

"It is imperative for individuals at increased risk of anaphylaxis to carry their epinephrine auto-injectors with them at all times," the researchers noted in the study, published in the  Annals of Allergy, Asthma & Immunology .

"We were impressed by the effects of the incentives," said lead researcher and CHIBE faculty member Carolyn Cannuscio, a social epidemiologist with Penn's Center for Public Health Initiatives and assistant professor of family medicine and community health at the Hospital of the University of Pennsylvania.

Study participants received 40 text messages over 49 days with social support, information on managing food allergies and, on 10 occasions, prompts to send a photo of their auto-injectors with that day's password.

People in the incentive group could earn $10 per text check-in in which they were carrying their auto-injector, for a potential $100, while those who received only text messages received only  $20 at the end of the study.
In a short period there was a dramatic increase in carrying epinephrine in the financial incentive group, Cannuscio said in an interview. "This is a behavior that we can influence," she said, adding that researchers need to explore other methods as well.

There remained "ample room for improvement" in both groups "given the goal of consistent, uninterrupted epinephrine carriage by people with potentially life-threatening food allergies," the study noted.
To achieve constant epinephrine access now, people must be responsible for carrying their own auto-injectors, Cannuscio noted, adding that she hopes one day they'll be available in public places, as automated external defibrillators are now.

There is very limited research on improving food-allergy management, and no clear counseling guidelines or strategies to help families deal with food allergies, she said. Cannuscio cited various reasons why people with food allergies don't always carry their devices.

"When you think about a chronic illness like food allergies or a chronic disease like diabetes that requires constant vigilance, I think there's a certain fatigue that sets in," she said. "We have limited capacity to attend to these important health management behaviors."

On the practical side, the epinephrine auto injector "is a bulky clunky device" that's larger than a big Magic Marker she said. They can be awkward and inconvenient and can't easily fit in a pocket, a particular problem for men who don't carry backpacks or other bags.

Some adolescents have a holster around their leg, under a pant leg, she added, "but it takes a certain amount of ingenuity and a great deal of commitment."  With adolescents, who typically seek peer approval, "I think carrying that bulky auto-injector also influences that behavior," said Roxanne Dupuis, a Penn researcher who worked on the study.

Adverse events don't happen to a person every day, so people can get lulled into a false sense of security that anaphylaxis won't happen to them that day, in that place, said Cannuscio. Adverse food allergy reactions, however, are common overall, amounting to about 90,000 emergency room visits for anaphylaxis annually in the United States, she said.

Since a large portion of food allergy adverse events happen in schools to children with no known food allergies, researchers emphasized to participants that "by carrying your own epinephrine you not only help yourself, you may help another human being who has no known food allergy," according to Cannuscio.

Her next study will look at adolescents and auto-injectors.

"Adolescents and young adults have the highest rate of adverse events from food allergies," with a high fatality rate, she said. When children move from elementary to middle school, school support for those with food allergies tends to drop off, according to Cannuscio, who said it's a difficult transition to navigate.

"We have learned that in very active situations, sporting events or socializing, going out to nightclubs," said Cannuscio, "those are times when people really need to have their auto-injectors present."

- Dinah Wisenberg Brin
Musings of a Behavioral Economist
Mitesh Patel, MD, MBA, MS
In September 2015, President Obama signed an executive order directing federal agencies in the United States to focus on incorporating behavioral sciences into their efforts and policies.  This initiative first began in 2014 when the US formed a multidisciplinary team of experts called the Social and Behavioral Sciences Team.  The move followed an earlier decision by Prime Minister David Cameron to form the UK Behavioral Insights Team which found that small changes to choice architecture and the way information was framed could generate gains in tax revenues and significant improvements in the welfare of the population.  These teams now exist within governments across the world and have come to be known as "Nudge Units."

Medical decision-making is heavily influenced by how choices are presented and information is framed.  Many forms of medical decision-making are shifting from pen and paper to digital formats.  As this shift occurs, these environments must be carefully designed to optimize the balance between the risks and benefits of health care decisions in the present and future.  Systematic errors in decision-making - from what providers do (or fail to do) to choices patients make - often hinder our ability to deliver high value care.  While there are a growing number of examples of how nudges can be used to improve medical decision-making, the systematic application and testing of these interventions through nudge units have not been well utilized within health care systems. 

There are several opportunities to improve health care value and outcomes by better embracing the nudge unit model.  First, while changing behavior is a priority for many interventions, most are not designed to take into account predictable barriers to behavior change.  For example, education on why generics should be prescribed when available instead of brand names seems like it should work, but most physicians already understand these benefits and still prescribe brand name medications more than they should.  Instead there's evidence that health systems can achieve more success by simply changing the prescription ordering system to default to generic.  Nudge units can help health care leadership and clinical stakeholders properly apply these types of behavioral interventions within their programs.

Second, changes to choice architecture within digital environments such as the electronic health record or patient portals, is a fluid process with continual changes.  However, many of these changes are not evaluated and health systems are left wondering what worked and what didn't.  Nudge units can be leveraged to systematically test and evaluate these changes to identify opportunities to scale interventions that work and change ones that don't.

Third, opportunities to address barriers and challenges within the health system are often best understood by the individuals on the front lines such as providers that deliver care, pharmacy or radiology staff that see consistent trends of inappropriate orders, or the patients themselves who are left to deal with the consequences of these decisions.  Nudge units can serve as a mechanism to structure identification of these issues, prioritize how to align goals of multiple stakeholders, and then work with clinical partners to design and evaluate appropriate interventions.     

Suboptimal healthcare decisions occur far too often.  Nudge units within health care systems could provide a new model to think more systematically about how choice architecture is designed and information is framed to move us towards better outcomes and higher value care. Based on this thinking we have decided to create the world's first health system-based Nudge Unit within Penn Medicine - we will tell you more about this in a subsequent issue of this newsletter.

- Mitesh Patel, MD, MBA, MS
Researcher Spotlight: Heather Schofield, PhD

Heather Schofield, PhD
Heather Schofield, Ph.D., is Assistant Professor at the University of Pennsylvania Perlman School of Medicine in the Department of Medical Ethics and Health Policy and in the Department of Operations, Information, and Decisions at the Wharton School. She is also a CHIBE and LDI affiliated faculty member. An economist with a degree in public health, Dr. Schofield studies development, health, and behavioral economics, primarily in low-income countries. Her areas of research include the role of health human capital (nutrition, pain management, adequate sleep) in economic productivity, cognitive function, and decision-making, and the role of financial and social incentives in promoting healthy behaviors. Dr. Schofield completed her Ph.D. in Business Economics, M.S. in Global Health and Population, and B.A. in Economics at Harvard University. 

How did you come to be on the CHIBE faculty?
I have been aware of CHIBE for awhile. While completing my dissertation I had an opportunity to work with Kevin Volpp, MD, Ph.D. and George Loewenstein, Ph.D., on a behavioral economics study examining the impact of financial and social incentives for engagement with healthy behaviors among the elderly. I presented some of our findings at the Penn/CMU Roybal Center faculty retreat in 2011. Following a post-doc year at the Center for Global Development in Washington D.C., I began my position at Penn, which enabled me to join CHIBE. My research interests in development, health, and behavioral economics are a great fit for CHIBE. There is a wealth of expertise in health and behavioral economics here and it is highly motivating to be a part of such an innovative group.
How does being at Penn in the Department of Medical Ethics and Health Policy affect your work?
As a new faulty member, I've been excited to spend time meeting people in the department and have been kept busy with research and teaching Managerial Economics at Wharton. Being in an interdisciplinary department at a larger university is a perfect environment for my work, since my research spans many disciplines and areas of knowledge. For example, I'm working on a study related to the economic, cognitive, and decision-making consequences of sleep deprivation in India and have gotten excellent advice from my colleagues here in the department, preeminent sleep researchers from the medical school, economists in Business Economics and Public Policy, and decision-scientists in Operations Information and Decisions at Wharton. It's rare to find an atmosphere that is so supportive of work spanning many disciplines and I've been really enjoying settling into the department. 
What research are you excited about now?
I'm particularly excited about ongoing work examining the economic, cognitive, and decision-making consequences of a number of factors associated with poverty in the developing world including malnutrition, chronic pain, and sleep deprivation. All of these studies are randomized controlled trials taking place in a lab I co-founded in Chennai, India, with Frank Schilbach, Ph.D. in partnership with The Institute for Financial Management and Research (IFMR). The lab has been growing quickly and we are moving forward with a number of new studies.
How does the lab in Chennai work?
The lab is centrally located with good access to potential participant pools, which allows us to interact with participants frequently over long time periods, while also providing a controlled setting to conduct rigorous studies. We have been expanding rapidly and currently have four studies running concurrently from three offices with about 35 staff, many of whom have been working at the lab for years.
What research does the lab support?
As an example of the types of questions we study, I recently completed a project examining the impact of low caloric intake on labor market outcomes and cognitive function among cycle-rickshaw drivers in Chennai. It was a five-week randomized controlled trial in which the control group received a small amount of cash and the treatment group a combination of equivalent value, consisting of cash plus 700 additional calories of food. The lab made it possible for participants to come daily to collect their cash and/or food and answer surveys, as well as complete a battery of assessments at the beginning and end of the study. By the last week of the study, treated individuals showed significant improvements in both physical and cognitive tasks in the lab and they were able to work more, increasing their income by approximately 10 percent by the final week of the study. This research helps us empirically understand the economic effects of low caloric intake, which, while not a common topic here in the U.S., affects roughly one-seventh of the world's population.   
How did you come to do research in India?
India is an incredibly diverse and interesting place to conduct research in development and health economics. With one of the fastest growing economies in the world and a population of 1.3 billion, the country has many opportunities to explore the intersection of human capital, health, and development.
What kind of impact can your research have for people in India?
I consider myself an academic and think it is important to ground my work in theory, but hope that my research will provide insights to policy makers. We know that a population's individual and collective health status affects a nation's economic development and performance, so work in the area of health human capital is highly policy relevant. For example, providing information about the economic and cognitive costs of poor health may provide an economic as well as humanitarian argument to tackle these issues and hopefully guide policy in a direction that helps to lift people out of poverty.
- Christine Weeks
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