Fall 2015

In This Issue


Andrea B. Troxel, ScD: 
Samuel Martin Health Evaluation Sciences Research 

Recent Publications

Thinking Forward: Future-oriented Thinking Among Patients with Tobacco-associated Thoracic Diseases and Their Surrogates. 
Hart JL, Pflug E, Madden V, Halpern SD. 
Am J Respir Crit Care Med. 2015 Oct 5.

New Solutions to Reduce Discard of Kidneys Donated for Transplantation. 
Reese PP, Harhay MN, Abt PL, Levine MH, Halpern SD.
J Am Soc Nephrol. 2015 Sep 14. 

Asch DA, Rader DJ, Merchant RM. Trends in Molecular Medicine. 

The Hidden Economics of Telemedicine. 
Asch DA. 
Ann Intern Med. [Epub ahead of print 8 September 2015] 

The Ethics of Incentivizing Mammography Screening. 
Schmidt H. 
JAMA. 2015;314(10):995-996

Intensive care unit capacity strain and adherence to prophylaxis guidelines.
Weissman GE, Gabler NB, Brown SE, Halpern SD.
J Crit Care. 2015 Aug 22. pii: S0883-9441(15)00447-5. [Epub ahead of print] 

Innovation as Discipline, Not Fad. 
Asch DA, Rosin R:
N Engl J Med 2015; 2015 Aug 13. 373:592-594

An observational study of decision making by medical intensivists. 
McKenzie MS, Auriemma CL, Olenik J, Cooney E, Gabler NB, Halpern SD: Crit Care Med (2015) 43(8):1660-8

Allowing Physicians to Choose the Value of Compensation for Participation in a Web-Based Survey: Randomized Controlled Trial. 
Turnbull AE, O'Connor CL, Lau B, Halpern SD, Needham DM 
J Med Internet Res 2015;17 (7):e189. 

A Pilot Randomized Trial of Financial Incentives or Coaching to Lower Serum Phosphorus in Dialysis Patients. 
Reese PP, Mqbako O, Mussell A, Potluri V, Yekta Z, Bellamy S, Parikh CR, Shults J, Glanz K, Feldman HI, Volpp K: 
J Ren Nutr. 15: pii: S1051-2276(15)00120-X, July 2015. 

Defining the medical intensive care unit in the words of patients and family members: A freelisting analysis. 
Auriemma C, Lyon S, Strelec L, Kent S, Barg F, Halpern S: 
Am J Crit Care. 2015 Jul;24(4):e47-55. 

Identifying Patients with Depression Using Free-text Clinical Documents.
Zhou L, Baughman AW, Lei VJ, Lai KH, Navathe AS, Chang F, Sordo M, Topaz M, Zhong F, Murrali M, Navathe S, Rocha RA.
Stud Health Technol Inform. 2015;216:629-33.

Randomized Trial of Financial Incentives or Coaching to Lower Serum Phosphorus in Dialysis Patients.
Reese, Peter P. et al.
Journal of Renal Nutrition
J Ren Nutr. 15: pii: S1051-2276(15)00120-X, July 2015

Upcoming Events


CHIBE and PRC Research Seminar
11/11/15 - Noon 

HP/CHIBE Work-in-Progress  Research Seminar
11/12/15 - Noon
1104 Blockley Hall

HP/CHIBE Work-in-Progress Research Seminar
12/03/15 - Noon
1104 Blockley Hall

Annual UPENN LDI CHIBE Behavioral Economics and Health Symposium
Colloquium Hall, 8th Floor
Huntsman Hall 

Contact Us
Mailing Address:
University of Pennsylvania
423 Guardian Drive
Philadelphia, PA 19104-6021

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Dear Colleague,

We hope you are enjoying fall! We are happy to present to you our latest issue of the CHIBE newsletter which focuses on low value care and changing physician behavior.

Our first story describes a study conducted by CHIBE affiliated faculty member, Mitesh Patel which suggests that health systems should be able to significantly increase the likelihood that doctors will prescribe generic medications by using the default options in the electronic health records.

We then report on an article that was published in Health Affairs by Drs. David Asch and Peter Ubel. They discuss strategies to reduce physician resistance to de-innovation, including emphasizing evidence over clinical judgment, discouraging the premature use of treatments for unproven purposes, and asking providers to consider how their experiences may influence their interpretation of clinical data. 

We then hear from the Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, a signature program of our Center.  FIELDS investigators are currently conducting more than 20 projects in the US and Canada focusing on how to improve end-of-life care for terminally ill patients.  

This issue spotlights Amol Navathe, a CHIBE affiliated faculty and a new faculty member in the Division of Health Policy. He describes his work to improve healthcare delivery which lies at the intersection of advanced data analytics, technology, health policy, and clinical practice.

Please enjoy reading the fall 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
Study: Health Systems can Significantly Increase the Likelihood that Doctors will Prescribe Generic Medications by Using the Default Settings in Electronic Health Records.

Prompting physicians to prescribe generic medicines rather than the equivalent brand-name drugs could be one way for health systems to cut wasteful spending on so-called low-value medical services. By using the default options on their electronic health records, health systems should be able to significantly boost the odds that doctors will prescribe generics, according to University of Pennsylvania researchers.

After two experiments in which default prescription settings were changed on electronic health records at Penn medical facilities, the university in late 2014 adopted a system-wide settings change to promote generic prescriptions.

Unnecessary waste accounts for an estimated one-third of the more  than $2.8 trillion in annual U.S. health care costs, the researcher noted in a study published last year in an Annals of Internal Medicine supplement, citing outside statistics. Initiatives by medical societies and boards aim to reduce wasteful "low-value" services and promote "high-value care" that involves providing the best treatments while cutting unnecessary costs.

"Prescribing brand-name medications that have existing generic equivalents is a prime example of a low-value service. These medications are often more expensive than their generic equivalents, yet in most cases evidence suggests they are similar in effectiveness," said Dr. Mitesh S. Patel, assistant professor in Penn's Perelman School of Medicine and The Wharton School. Another study of 20 popular drugs found that Medicaid, in 2009, spent an extra $329 million that could have been saved by using generics instead of brand-name prescriptions, they noted.

In their first inquiry, a "quasi-experimental study" detailed in the  Annals piece, researchers studied a change in the default settings for the electronic health record in Penn internal medicine clinics from displaying both brand and generic medications to showing only generic beta-blockers, statins and proton-pump inhibitors. Physicians had the ability to opt out and prescribe brand name drugs if they chose.

Mitesh Patel, MD, MBA, MS
The internal medicine clinics' prescription rates were compared to those of Penn's family medicine clinics, which had a slightly higher
generic prescription rate before the experiment (roughly 81% to 86%
for family clinics and 75% to 80% for internal medicine clinics before
the study).

After changing the EHR default settings, generic prescribing
increased for beta blockers and statins for the internal medicine
clinics as compared to the family medicine clinics. "With such a rapid adoption of electronic health records throughout the United States...a lot of decisions that doctors are making are now happening through the electronic health records," Patel said in an interview.

The internal medicine clinics' prescription rates were compared to those of Penn's family medicine clinics, which had a slightly higher generic prescription rate before the experiment (roughly 81% to 86% for family clinics and 75% to 80% for internal medicine clinics before the study).

While the increase in generic prescription rates in the first experiment were significant, at about 4.0 to 10.5 percentage points, the researchers had hoped for stronger results, with prescriptions close to full generic prescribing, Patel said.

In a second, yet-to-be-published experiment, researchers studied the use of a stronger default designed differently from the first and saw more dramatic results, he said. That intervention requires doctors to go through a second step to opt out of the generic default. The physician sees a second screen that requires him or her to check "dispense as written" to prescribe the brand-name drug, according to Patel.

"The design of the default is very important," he said. The Annals report noted that small changes in the default settings "can substantially affect medical decision making and provider behavior."

With the second intervention, the Penn health system realized that generic prescription rates "were going through the roof," he said. The Penn system stuck with that default model, launching it for all clinics across the entire health system in November, Patel said.

"We were excited to see that the use of default spread from one division to the entire health system," he said. "It was a very low-cost intervention," and didn't disrupt the physicians' work flow, he said.

The study was funded by the U.S. Department of Veterans Affairs and the Robert Wood Johnson Foundation.

- Dinah Wisenberg Brin 
Article: Medicaid Boost Tied to Better Physician Appointment Availability Penn, Duke Professors Suggest Ways to Weaken Resistance to 'De-Innovation'

Giving up outdated clinical practices is often more difficult for physicians than adopting new ones, even when research supports such a change. Controversies over recommended changes in breast and prostate cancer screenings, for example, arose partly from clinicians' psychological biases that deter "de-innovation," or dropping old regimens, according to an article by two University of Pennsylvania and Duke University medical and business school professors.

Medical institutions, however, could take several steps to reduce physician resistance to de-innovation, including emphasizing evidence over clinical judgment, discouraging the premature use of treatments for unproven purposes, and asking providers to consider how their experiences may influence their interpretation of clinical data, according to the February 2015  Health Affairs  article by Duke's Peter A. Ubel and Penn's David A. Asch, executive director of Penn's Center for Health Care Innovation.

Asch and Ubel cite a "pervasive asymmetry in human psychology" that makes it  hard to give up "old technologies and old ways of doing things," even when they're costly and no longer make sense, either because of new evidence or competing approaches.

In addition, they said, removing outdated practices involves different processes than simply reversing those used to initiate new innovations. "The stakeholders and the stakes may be different," the authors said. "People do not perceive gains and losses symmetrically, and many require different kinds of convincing when starting something new or stopping something old."

David Asch, MD, MBA
Asch, in an interview, compared the medical adoption and de-
adoption processes to refreshing closets. "It's always fun and exciting to adopt new things but cleaning out your closets is not fun. It's fun to get new clothing but it's not fun to get rid of old stuff, and they can't coexist or your closet will get too full," he said.

It's helpful for clinicians who want to do the best for their patients to be aware of their own blind spots, according to Asch, who said a book on the power of decluttering helped to influence his thinking. "It just taught me some ways to think about old practices that I realized I could do without."

Clinicians often use old and new technologies side by side, according to Asch and Ubel. Other researchers noted nearly 30 years ago that physicians were continuing to use nuclear medicine brain scans in addition to the computed tomography (CT) head scans "that should have completely replaced them," the authors wrote in the recent Health Affairs article.

" The problem wasn't that new innovations weren't adopted; it was that the old approaches weren't de-adopted," Asch and Ubel wrote.

The U.S. Preventive Services Task Force in 2012 recommended against use of the PSA test for prostate cancer screening, deciding that the harms outweighed the benefits. The American Urological Association initially criticized the task force for "doing men a great disservice by disparaging what is now the only widely available test for prostate cancer."

Radiologists objected when the task force concluded three years earlier that routine mammography isn't necessary before age 50, and sleep specialists haven't embraced home testing for sleep disorders, in spite of evidence that many patients would be well served by such testing, which is less expensive than overnight lab testing, Asch and Ubel wrote.

These controversies stem in part from scientific uncertainty, and also may be influenced by "America's market-oriented health care system, in which radiologists make money from mammography, urologists from performing prostate biopsies ...  and sleep specialists from conducting sleep tests," they wrote.

However, they added, these controversies "also persist because of several psychological phenomena that influence the way physicians perceive innovative medical interventions that no longer warrant the kind of enthusiasm they engendered when they first entered clinical practice. "

Experts looking at the same mammogram and PSA research may reach different conclusions because of "confirmation bias," a tendency to choose data that confirms prior beliefs, Asch and Ubel wrote. They also contend that physicians develop biases based on their clinical experiences.

Urologists may prefer PSA tests because they tend to see large numbers of patients with prostate cancer, including those whose cancers advanced because they didn't receive a screening; the urologists don't see patients who never were screened, remained healthy and weren't referred to a urologist, the authors note.

Among their other recommendations, the authors suggest that guideline development committees be comprised of experts with a wide range of experience, to help overcome bias issues.

About 30% of U.S. health care dollars are spent on no- or low-value services "so it's not a little issue," Asch told the CHIBE newsletter. "No one can entirely agree on which 30% that is but in some cases we do know."

- Dinah Wisenberg Brin 
Update: Fostering Improvement in End of Life Decision Science (FIELDS) Program

The Fostering Improvement in End-of-Life Decision Science (FIELDS) Program is a core program of the LDI Center for Health Incentives and Behavioral Economics. The team, directed by Dr. Scott Halpern, uses approaches from psychology, economics, epidemiology, and sociology to design programs that narrow the gap between the care patients want and the care they actually receive in their last months and years of life.

The Program was established in 2012 with development funding from the Otto Haas Charitable Trust. During the past three years the Program has expanded to include more than 35 members including faculty, trainees, and staff and received eleven external grants totaling nearly $8,000,000 to support specific research projects.

FIELDS investigators are currently conducting more than 20 projects in the US and Canada. Many FIELDS studies focus on advance care planning, specifically, the completion of advance directives (ADs). Building on the program's seminal work on defaults in advance directives, FIELDS researchers are striving to understand how ADs might be better structured to improve patient outcomes. The team is also testing several scalable interventions to increase advance directive completion among individuals who would likely benefit from having an AD. Other related studies include a systematic review of the literature to determine how many and which types of Americans complete ADs, and an assessment of public opinion regarding the use of financial incentives for patients or physicians to promote AD completion or other types of advance care planning.

One particularly exciting FIELDS study, which will be launched in October 2015, is the  Randomized Evaluation of Default Access to Palliative Services (REDAPS) trial,. The REDAPS trial examines the effectiveness of inpatient palliative care .  Palliative care is care designed to relieve patients from the symptoms, pain, and stress of a serious illness-whatever the diagnosis or prognosis. Hospitals worldwide are investing in inpatient palliative care consultative services (IPCS) to improve care for seriously ill patients. However, experimental evidence is lacking regarding the effectiveness and costs of IPCS, the types of services that are most beneficial, and the types of patients most likely to benefit. To answer these important questions, FIELDS investigators are partnering with Ascension Health, the nation's largest not-for-profit health system, to conduct a 5-year, NIH-funded randomized trial. The 11 participating hospitals will switch from the current system, whereby patients or providers must actively request palliative care consultation, to a system in which such services are ordered by default for selected seriously ill patients. The team will then compare clinical and economic outcomes, and patient-centered processes of care between the usual care and default palliative care approaches.

The FIELDS Program's work has yielded roughly 30 publications in peer-reviewed journals to date, and more than 10 invited editorials and commentaries. Further, reflecting the FIELDS program's founding commitment to train future scholars committed to improving care for seriously ill patients and their families, FIELDS trainees have received numerous career development awards from the NIH, have earned a dozen prestigious awards for their research, and have given many podium presentations at prominent research conferences.

Looking ahead, the FIELDS Program is continuing to explore emerging areas in behavioral economics and end-of-life decision making. Upcoming initiatives will develop ways to (1) reduce undue variability among physicians' end-of-life care practices, (2) improve clinician prognostication, (3) leverage electronic health records to improve end-of-life care delivery, and (4) use "big data" to enable early identification of patients at risk for poor outcomes near the end-of-life. 

- Elizabeth Cooney
Researcher Spotlight: 
Amol Navathe, MD, PhD
Amol Navathe, MD, PhD
Amol Navathe, MD, PhD is Assistant Professor of Medicine and Assistant Professor of Medical Ethics and Health Policy at the Perelman School of Medicine at the University of Pennsylvania (Penn). Dr. Navathe is a physician, health economist, and engineer. His research seeks to improve healthcare delivery and lies at the intersection of advanced data analytics, technology, health policy, and clinical practice.

How did you come to the University of Pennsylvania and CHIBE?

I went to medical school at Penn and while I worked toward my PhD in health economics at Wharton, Kevin Volpp, MD, PhD was a mentor, so in some ways I feel I never left Locust Walk. My interest in comparative effectiveness and patient outcomes research started here and that training allowed me to be a part of significant health policy developments around The American Recovery and Reinvestment Act (ARRA) of 2009 and The Affordable Care Act.

What was your role?
ARRA appropriated $1.1 billion to the Department of Health and Human Services (HHS) for Comparative Effectiveness Research. As a Medical Officer and Senior Program Manager for HHS, my job was to develop a Comparative Effectiveness Research (CER) program that would identify the optimal modalities for the prevention, diagnoses, treatment, and monitoring of health conditions. It was exciting work that combined my interests in technology, data, and health policy but I knew that I wanted to care for patients, so when the time was right, I left Washington to complete the rest of my clinical training at Harvard Medical School's Brigham and Women's Hospital. Now, I treat patients at the Philadelphia VA Medical Center, where I had my first clinical experiences during medical school.

How does patient care inform your research?

My research is very technical and data driven, but the questions are motivated by how health care delivery affects patients. Most of the time I use claims and clinical data to measure the costs, quality, and appropriateness of care as it relates to health system performance and policy design. Treating and interacting with patients offers a change of pace from sitting in front of a computer and it is fulfilling on a very basic level. In addition, practicing medicine enriches my research and keeps me in touch with how things work in the clinic.  

What research are you working on right now?

I am working on two lines of research right now. One area of focus uses informatics techniques to better answer health services questions. For example, identifying high-need and high-cost patient populations is now a major policy priority. I am leading a project that utilizes the data in physician narrative notes to improve the identification of vulnerable populations such as homeless patients and those with poor social support systems. In my other research line I am studying provider incentives at the intersection of neoclassical and behavioral economics. We are exploring how to best use incentives to encourage value-driven healthcare delivery without compromising the joy of clinical practice or crowding out internal motivations and altruistic behaviors.

What are you looking forward to?

I am beginning a project with Drs. Kevin Volpp and Ezekiel Emanuel on designing incentive programs for physicians that align with the best possible care for patients. We've been using the blunt instrument of "pay for performance" to try and change physician behaviors for years, yet it has not dramatically improved outcomes for patients because incentive programs do not conform with how physicians think and practice. On the other hand, evidence from behavioral economics suggests that we could create a decision architecture that takes heuristics and biases into account, and help physicians make better treatment decisions. As a physician and someone who cares deeply about healthcare delivery and policy that possibility is something I can get excited about.

Do you miss policy work in Washington DC?

The research being conducted by me and other faculty at CHIBE has the potential to influence policy; plus, I don't really have time to miss Washington. In addition to my work at Penn and some extramural work with hospitals and insurers, I started the Foundation for Healthcare Innovation, a nonprofit organization working toward better health, better healthcare delivery, and lower costs through innovation. Our mission is to create opportunities that grow the ecosystem of healthcare innovators and to support national learning and diffusion of innovative works.  I am also a co-editor of Health Care: The Journal of Delivery Science and Innovation with Sachin H. Jain, MD, MBA. The journal is focused on disseminating information about leading-edge research in healthcare innovation, including improvements in systems, processes, management, payment, and applied information technology.
New Research Initiatives

Randomized control trial of automated hovering for congestive heart failure
Principal Investigators: Drs. David Asch and Kevin Volpp
The objective of this study is to conduct a pragmatic randomized controlled trial testing a new approach to chronic disease management combining wireless monitoring devices and behavioral economic engagement incentives to reduce rehospitalization rates among patients with Congestive Heart Failure (CHF) recently hospitalized at the University of Pennsylvania Health System (UPHS). This has the potential to serve as a foundation for further UPHS efforts around clinical deployment using clinical expertise, remote monitoring technology, and insights from behavioral science.
Behavioral economics in provider incentive design
Principal Investigators: Drs. Amol Navathe and Zeke Emanuel
Payers and provider groups are in need of novel approaches to structure provider incentives-both financial and non-financial-to better promote the delivery of quality, cost-effective care. In this project, we will study how behavioral economic principles can improve the effectiveness of physician incentives to deliver higher quality and lower cost care. We will test the application of specific behavioral economic principles including loss aversion; physician versus non-physician incentives; and variation in physician organization relationships in incentive design and implementation.
Funder: The Commonwealth Fund
Incentives for participation in a randomized control trial
Principal Investigator: Dr. Scott Halpern
Paying patients to enroll in randomized clinical trials could dramatically improve the pace and scientific validity with which new interventions for cancer and other diseases are tested, but the practice raises important ethical concerns. To inform the regulation of research incentives and reduce undue variability in their use, we will conduct a randomized trial of 3 real incentives for patients with lung cancer to participate in a real trial comparing two forms of radiation therapy. The trial's innovative design will enable definitive tests of how patients make research decisions in the face of money, and will provide the best possible evidence regarding the scientific and ethical pros and cons of incentives for research participation.
Funder: NIH/NCI