January 2016

In This Issue
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CHIBE in the News

Recent Publications

The Hidden Economics of Telemedicine.
Asch DA. 
Intern Med. 2015. 63(10):801-2.

Mining the Social Mediome.
Asch DA, Rader DJ, Merchant RM.  
Trends Mol Med. 2015. 21(9):528-9.

Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels: A Randomized Clinical Trial.
Asch DA, Troxel AB, Stewart WF, Sequist TD, Jones JB, Hirsch AG, Hoffer K, Zhu J, Wang W, Hodlofski A, Frasch AB, Weiner MG, Finnerty DD, Rosenthal MB, Gangemi K, Volpp KG. 
JAMA. 2015. 314(18):1926-35.

Asking the Patient About Patient-Centered Medical Homes: A Qualitative Analysis. 
Aysola J, Werner RM, Keddem S, SoRelle R, Shea JA. 
J Gen Intern Med. 2015. 30(10):1461-7. 

Stages of Change and Patient Activation Measure Scores in the Context of Incentive-Based Health Interventions.
Becker NV, Asch DA, Kullgren JT, Bellamy SL, Sen AP, Volpp KG. 
Am J Health Promot. 2015. 30(2):133-5.

Nutrition and the Science of Disease Prevention: A Systems Approach To Support Metabolic Health.
Bennett BJ, Hall KD, Hu FB, McCartney AL, Roberto C.

A Behavioral Economics Intervention to Increase Pertussis Vaccination Among Infant Caregivers: A Randomized Feasibility Trial.
Buttenheim AM, Fiks AG, Burson Ii RC, Wang E, Coffin SE, Metlay JP, Feemster KA.
Vaccine. 2015. Epub ahead of print. 

Using Behavioral Economics to Design Physician Incentives That Deliver High-Value Care.
Emanuel EJ, Ubel PA, Kessler JB, Meyer G, Muller RW, Navathe AS, Patel P, Pearl R, Rosenthal MB, Sacks L, Sen AP, Sherman P, Volpp KG.
Ann Intern Med. 2015. Epub ahead of print.

Liver Transplant Center Variability in Accepting Organ Offers and its Impact on Patient Survival.
Goldberg DS, French B, Lewis JD, Scott FI, Mamtani R, Gilroy R, Halpern SD, Abt PL.
J Hepatol. 2015. pii: S0168-8278(15)00773-4. 

Are Patients With Cancer Less Willing to Share Their Health Information? Privacy, Sensitivity, and Social Purpose.
Grande D, Asch DA, Wan F, Bradbury AR, Jagsi R, Mitra N. 
J Oncol Pract. 2015. 11(5):378-83. 

Toward Evidence-Based End-of-Life Care.
Halpern SD. 
N Engl J Med. 2015. 19;373(21):2001-3. 

Thinking Forward: Future-oriented Thinking Among Patients with Tobacco-associated Thoracic Diseases and Their Surrogates.
Hart JL, Pflug E, Madden V, Halpern SD.

Harnessing the Right Combination of Extrinsic and Intrinsic Motivation to Change Physician Behavior.
Judson TJ, Volpp KG, Detsky AS. 

Quality of Health Insurance Coverage and Access to Care for Children in Low-Income Families.
Kreider AR, French B, Aysola J, Saloner B, Noonan KG, Rubin DM.

What Web Browsing Reveals About Your Health
Libert T, Grande D, Asch DA. 

Habit Formation in Children: Evidence From Incentives for Healthy Eating.
Loewenstein G, Price J, Volpp K.

ACA-mandated Elimination of Cost Sharing for Preventive Screening has had Limited Early Impact.
Mehta SJ, Polsky D, Zhu J, Lewis JD, Kolstad JT, Loewenstein G, Volpp KG

Linking Social Media and Medical Record Data: A Study of Adults Presenting to an Academic, Urban Emergency Department. 
Padrez KA, Ungar L, Schwartz HA, Smith RJ, Hill S, Antanavicius T, Brown DM, Crutchley P, Asch DA, Merchant RM. 

Put the Healthy Item First: Order of Ingredient Listing Influences Consumer Selection.
Policastro P, Smith Z, Chapman G. 

Premium-Based Financial Incentives Did Not Promote Workplace Weight Loss In A 2013-15 Study.
Patel MS, Asch DA, Troxel AB, Fletcher M, Osman-Koss R, Brady J, Wesby L, Hilbert V, Zhu J, Wang W, Volpp KG. 

New Solutions to Reduce Discard of Kidneys Donated for Transplantation. 
Reese PP, Harhay MN, Abt PL, Levine MH, Halpern SD. 

Two Randomized Controlled Pilot Trials of Social Forces to Improve Statin Adherence among Patients with Diabetes.
Reese PP, Kessler JB, Doshi JA, Friedman J, Mussell AS, Carney C, Zhu J, Wang W, Troxel A, Young P, Lawnicki V, Rajpathak S, Volpp K. 

Public Health and Legal Arguments in Favor of a Policy to Cap the Portion Sizes of Sugar-Sweetened Beverages
Roberto CA, Pomeranz JL. 

The Influence of Sugar-Sweetened Beverage Health Warning Labels on Parents' Choices.
Roberto CA, Wong D, Musicus A,  Hammond D.

Comparing the Effectiveness of Individualistic, Altruistic, and Competitive Incentives in Motivating Completion of Mental Exercises.
Schofield H, Loewenstein G, Kopsic J, Volpp KG. 

A Randomized Controlled Trial of Negative Co-payments: The CHORD Trial.
Volpp KG, Troxel AB, Long JA, Ibrahim SA, Appleby D, Smith JO, Jaskowiak J, Helweg-Larsen M, Doshi JA, Kimmel SE. 

A Randomized Controlled Trial of Co-payment Elimination: The CHORD Trial. 
Volpp KG, Troxel AB, Long JA, Ibrahim SA, Appleby D, Smith JO, Jaskowiak J, Helweg-Larsen M, Doshi JA, Kimmel SE.

"Everybody Just Wants to Do What's Best For Their Child": Understanding How Pro-vaccine Parents Can Support a Culture of Vaccine Hesitancy.
Wang E, Baras Y, Buttenheim AM. 

Seeing Health Insurance and Through the Eyes of Young Adults.
Wong CA, Asch DA, Vinoya CM, Ford CA, Baker T, Town R, Merchant RM. 

Changes in Young Adult Primary Care Under the Affordable Care Act.
Wong CA, Ford CA, French B, Rubin DM.

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Dear Colleague,
We hope everyone had a happy and healthy holiday season! We are happy to present to you our winter issue of the CHIBE newsletter which focuses on exciting results from several recently published studies of medication adherence.
Our first story highlights a study conducted by Dr. David Asch, executive director of Penn's Center for Health Care Innovation, and CHIBE Director Dr. Kevin Volpp, on the effect of financial incentives on lipid levels. This study, recently published in JAMA, found that providing financial incentives to both primary care physicians and patients leads to a greater reduction in low-density lipoprotein (LDL) cholesterol in patients than paying only the physician or only the patient.  
We then focus on two studies led by Dr. Peter Reese, Penn medical school faculty member and physician, that were jointly published in Journal of General Internal Medicine . The two randomized pilot trials tested different ways to improve drug adherence through social influence. The studies demonstrated the feasibility of using social interventions to encourage healthy behavior and the promise of social interventions.
Wharton faculty member Dr. Iwan Barankay authors our "Musings" column to share how he embraces the rigorous methods of Michael Faraday to carefully measure and implement new tests, and advises other researchers to do the same.

This issue also shares a Spotlight on Christina Roberto, PhD, who leads the Psychology of Eating and Consumer Health, or PEACH Lab ( ) at Penn's Perelman School of Medicine where she is Assistant Professor of Medical Ethics and Health Policy. Her interdisciplinary work aims to address unhealthy eating behaviors by designing realistic interventions that improve eating habits and nutrition policy.

Please enjoy reading the winter 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: Shared Patient-Physician Incentives Seem to Help Lower LDL Cholesterol

Financial incentives for patients and physicians are emerging as tools to improve clinical health outcomes, but researchers haven't established the effectiveness of such inducements. A recent University of Pennsylvania-led study, however, suggests that health markers and behaviors improve significantly when doctors and patients share in monetary rewards.

David Asch,  MD, MBA
The clinical trial, led by Dr. David Asch, executive director of Penn's Center for Health Care Innovation, and CHIBE Director Dr. Kevin Volpp, divided patients into four groups, with a goal of lowering LDL cholesterol: those sharing financial incentives with their primary care physicians, those earning the reward for themselves exclusively, patients whose physicians received the entire inducement, and a
 control group with no financial incentives for doctors or patients.

Patients in all four groups improved levels of the so-called bad cholesterol after a year, but only those in the patient-physician incentive-sharing group realized statistically significant progress compared with the control group, according to results published in November in the Journal of the American Medical Association.
Even then, the difference between the patient-doctor incentive group and control-group patients was modest, researchers said, adding that more information is needed to determine whether the strategy represents "good value."

The study aimed to lower LDL cholesterol levels among patients at significant risk of developing cardiovascular disease, the leading cause of death in the United States. Roughly 1,500 patients aged 18 to 80 were enrolled. All patients participating in the study received Internet-connected pill bottles containing cholesterol-lowering statins.

After one year, those in the control and patient-only incentive groups lowered their LDL cholesterol by an average 25.1 mg/dL , while patients whose physicians were the only ones who could earn incentives reduced LDL by 27.9 mg/dL, the study says. In contrast, patients who shared financial incentives with their doctors reduced LDL by 33.6 mg/dL.

Volpp said he was surprised that the patient-only and doctor-onlyincentive groups didn't do better relative to the control group.

Kevin Volpp, MD, PhD
"A combination of provider and patient engagement is reallyimportant in these contexts," Volpp said, explaining that only the shared-incentive study group experienced both more appropriate treatment intensification and better patient adherence. "It is important to note that at baseline more than half of these high-risk patients with poorly controlled lipids weren't on statins; in the provider incentive arm we saw higher rates of treatment initiation and intensification; in the patient incentive arm we saw higher rates of medication adherence. Only in the shared incentive arm did we see both."

Researchers, however, had expected a bigger difference in lowered LDL levels between the control group and the shared-incentive patients, he said.

Studies show that statins used to lower cholesterol cut the risk of heart attack by about 30 percent, the researchers noted. In spite of statins' benefits and relative affordability, their effectiveness across the population has been limited in part because doctors under-prescribe them or neglect to intensify treatment when needed, the authors wrote. In addition, half of patients, including those who have survived severe cardiac syndromes, stop using statins within a year, they noted.

"Poor adherence is associated with worse outcomes, higher hospitalization and mortality rates, and increased health care costs among patients" with cardiovascular disease, the authors said.
Patients already using statins at the trial's start showed significantly increased adherence if they received incentives, suggesting that the inducements weren't effective at getting people to start using statins but worked well at improving compliance for those already on the medication, according to the report.

Volpp and a team of other investigators including Asch and Troxel are now preparing to test in partnership with Blue Cross Blue Shield of Hawaii a shared physician-patient incentives model  for patients  in Hawaii  with poorly controlled diabetes.
- Dinah Wisenberg Brin
Penn Study: T apping Social Forces for Drug Adherence Promising but Outcomes Not Much Improved Vs Control

University of Pennsylvania researchers recently explored the way social forces might be harnessed to improve patients' adherence to prescription statins, as growing evidence suggests links between a person's social environment and health behavior.

Patient failure to stick with medication regimens is a major problem in managing cardiovascular disease, so researchers conducted two randomized pilot trials aimed at improving drug adherence through social influence. Study subjects were diabetic adults who, based on their pharmacy refill insurance claims, appeared to have a history of low compliance with their prescriptions for cholesterol-lowering statins.

Peter Reese, MD, MSCE
In the study, led by Penn medical school faculty member and physician Dr. Peter Reese, patients kept their statins in wireless-enabled pill bottles that tracked their drug usage. They participated in one of two trials. In the PROMOTE trial, intervention patients received reports that compared their adherence to the adherence of other participants. The idea was that comparison to others might motivate patients to take their statins. In the SUPPORT trial, each participant chose a "medication adherence partner" who received reports about the participant's adherence.  The medication adherence partners would have opportunities to encourage participants to take their statins.

These social interventions didn't significantly improve statin adherence compared with control group patients over the three-month trials; all patient groups, including controls, showed high compliance rates. The researchers suggested that the patients already may have been fairly compliant in taking their medications.

"We think that we wound up with a biased (patient) sample," said Reese, CHIBE affiliated faculty and a senior fellow at Penn's Leonard Davis Institute of Health Economics. "Participants took their statins pretty consistently from the beginning of the study. That observation suggests that they needed minimal encouragement to become adherent with their medications. I think we didn't recruit the population that we hoped to recruit."

Fewer than 1 percent of 45,000 Humana health plan members contacted by mail enrolled in the trials, according to the study article, published in November in the Journal of General Internal Medicine. Even though prior prescription refill claims indicated poor adherence, pill-bottle tracking showed high compliance among both PROMOTE and SUPPORT patients.

"The high pill-bottle adherence rates-found even in the control arms-were unexpected. This finding may be related to the low enrollment rate among individuals invited to join the trials," the researchers wrote. "It is possible that participants were individuals with existing interest in improving their medication adherence and that trial enrollment and pill bottle usage, even  for control arm participants, provided sufficient encouragement to make this improvement. "

The adherence improvement also might be explained by a "Hawthorne effect," in which behavior under observation changes substantially, the researchers wrote. They added that it's possible the participants had higher adherence than suggested by their previous prescription refill rate; several study participants acknowledged receiving statins without submitting pharmacy benefit claims.

In the study, PROMOTE patients received either weekly messages that compared their statin adherence to that of other participants or weekly summaries of their own compliance, or they were placed in the control group. SUPPORT patients' medication adherence partners received either daily reports, weekly reports, or reports only in cases of a missed dose; other patients were assigned to the control group.

The study demonstrated the feasibility of such interventions, according to Reese.  "We think this  area is very promising," he said, noting that CHIBE and the Leonard Davis Institute are studying other social force interventions.

Social pressure in the form of encouragement or discouragement to take certain actions "is a powerful social force that can influence individual behavior," the researchers wrote. Evidence is mounting of strong associations between a patient's social environment and health behavior, they said.

"Harnessing social forces could be an effective approach for promoting health behaviors, because patients typically only engage with their physicians and nurses during occasional health system visits a few hours a year, but they interact with their social networks much more frequently," the authors said.

Reese is writing up another social intervention study with a positive result, involving kidney transplant patients whose physicians received reports of low adherence to immunosuppression therapy. Patient reminders plus physician notification was the most effective adherence tool, followed by patient reminders only. 

- Dinah Wisenberg Brin
Researcher Spotlight: Christina Roberto, PhD
Christina Roberto, PhD
Christina Roberto, PhD leads the Psychology of Eating AndConsumer Health (PEACH) Lab at Penn's Perelman School of Medicine where she is Assistant Professor of Medical Ethics and Health Policy. A psychologist and epidemiologist by training, in her research Dr. Roberto aims to identify and understand social, environmental and psychological factors that promote unhealthy eating behaviors and to design policy interventions to improve eating habits. She was recruited to the Department of Medical Ethics and Healthy Policy and CHIBE from the Harvard School of Public Health in July of 2015. 

What inspired you to focus on eating behaviors and shaping policy?
I majored in psychology as an undergraduate. After graduation I worked at Columbia University's Center for Eating Disorders and became involved in clinical trials testing behavioral techniques and drug therapy for the treatment of anorexia nervosa and bulimia nervosa. Later, when I got to graduate school at Yale and began collaborating with mentors at the Rudd Center for Food Policy and Obesity, I became interested in the intersection of public health and policy in relation to food. It was at Rudd that I was fortunate to be mentored by Kelly Brownell, PhD who introduced me to the idea of strategic science and the approach of co-creating research. My work at Rudd taught me the value of interdisciplinary collaboration, which informs the operations at the PEACH Lab.

How does being at the University of Pennsylvania affect the work of the PEACH Lab?
Penn and PEACH are a great fit. Our research aims to address unhealthy eating behaviors by designing realistic interventions that improve eating habits and nutrition policy. It's interdisciplinary work and Penn is a perfect place to find collaborators. PEACH is based at the Clinical Translational Research Center at Presbyterian Hospital, which aligns well with our goals to develop effective patient interventions. Faculty across Penn, including the medical and nursing schools, Wharton, and the Annenberg School for Communication work in areas relevant to PEACH. Plus, our health policy focus at PEACH also overlaps with many of the amazing Centers at Penn including CHIBE, The Leonard Davis Institute, the Center for Public Health Initiatives, the Prevention Research Center, and the Center for Health Behavior Research. I discover new connections all the time. It has been easy to attend talks and meet other faculty, and people have been very welcoming and generous with their time. 

What drew you to join the CHIBE faculty?
Being at CHIBE and working with Kevin Volpp, MD, PhD and other faculty who are conducting innovative work around health behavior change provides an ideal context for my research because I am able to tap expertise in the fields of psychology, marketing, behavioral economics, and population health, which are critical to answering my research questions around nutrition policy. Obesity is one of our most pressing public health issues and there is growing interest from policymakers in doing something about it. At CHIBE, I plan to continue studying emerging food policy ideas to encourage healthier eating and to work with regulators to ask and answer timely, policy-relevant questions. 

Can you talk about the methods you use in your policy-related work?
My colleagues and I call our approach to studies linked to potential policy changes "Strategic Science." Strategic Science means we co-create research questions with people in positions to enact change and we communicate scientific evidence in an actionable way to those who can use it. This process encourages a two-way bridge between investigators and policy makers. It helps to ensure research addresses policy-relevant issues and that those findings are communicated in real-time to policy makers who often have to act quickly. 

Your dissertation research on the effects of calorie information helped to shape FDA menu labeling regulations, what are you really excited about now?
Right now I'm most excited about some of the Strategic Science research we are doing on understanding the impact of placing warning labels on sugary drinks, messaging to increase the influence of calorie labels on restaurant menus, and the effects of limiting the portion size of sugary drinks in restaurants. 

Are you teaching at Penn?
I'm thrilled to be able to teach a course on the Science and Politics of Food as part of Penn's MPH program. The class is designed to introduce students to the many forces that shape what we eat. These include psychological, political, biological, legal, economic, and social influences. We discuss and critically evaluate scientific research on food policies designed to improve the world's diet and the class has a strong focus on the communication of health information.

Given your interest in food, do you have any restaurant recommendations?
Philadelphia is rich in restaurants and there are plenty to choose from, but my favorite place to eat is Barbuzzo.

- Christine Weeks
What Michael Faraday Taught Me About Running Health RCTs
One of my all-time superheroes in the history of science is Michael Faraday (1791 - 1867). Despite his limited formal education, he made numerous fundamental discoveries that still affect us today. Blimey, there is even a unit, the farad (F), named after him - how cool is that!  One of the things he wrote completely blew my mind and is a daily inspiration for me.

Michael Faraday
In 1833 he wrote a little passage in a chapter entitled "On Conducting Power Generally" in his book Experimental Researches in Electricity:  "I have lately met with an extraordinary case [...] which is in direct contrast with the influence of heat upon metallic bodies [...] On applying a lamp [...] the conducting power rose rapidly with the heat [...] On removing the lamp and allowing the heat to fall, the effects were reversed."

Now, I did not come across these lines by accident - even my nerdiness has limits. This is considered to be the first description of one of the core principles underlying the functioning of semi-conductors. Simply put, without this discovery, you could not read these lines on your computer or smartphone.

Why do I write about him? Because what is remarkable here is his method, which was rigorously scientific, passionate, yet humble.  This was a discovery at odds with everything he knew. He could not explain it and no one else could either, because to make sense of it, you need to employ quantum mechanics, which was only formally conceptualized some sixty years later by the likes of Boltzman, Planck, and Einstein. Nevertheless, he carefully described what he found and how he found it so that he and others can replicate it.

It is my firm belief that we again are at the cusp of history of making another fundamental discovery, this time around human nature. All of us at CHIBE can learn from Faraday's methods today in our quest to better understand ways to modify health behavior.

We are all involved in some way with testing one of the many behavioral ideas floating around in the social sciences. Take for instance, financial incentives for weight loss: many times they work, but other times we fail to replicate the effect. Why? Even with all our theories, I think it is quite possible that there is something fundamental about human nature that defies our comprehension.  Yet to uncover this mystery, we need to be rigorous and careful in describing what we find and what process we use. This should permeate every small detail of our work.

Take for instance, recruitment and retention of study participants - a perpetual challenge for RCTs and a core project risk. Rather than rely on some gut feeling or adopting approaches used by others, my co-researchers Peter Reese, Kevin Volpp and I embrace these challenges to test, whenever we can, new approaches to improve recruitment using RCTs and event studies. Over the last few years, we measured and probed effects to solidify our understanding of behavior modification in the context of health.

Even for such a trivial task like recruitment, it turns out that our understanding is surprisingly limited. We were humbled to find that many ideas around framing failed to raise recruitment, but other approaches like simple human interaction are more promising. Still, Faraday is with us every Friday afternoon in our team meetings as we make new plans to carefully measure and implement new tests.

May this be an inspiration for you to do the same!

- Iwan Barankay, PhD
New Research Initiatives
Smarter Big Data for a Healthy Pennsylvania: Changing the Paradigm of Healthcare
Principal Investigators: Daniel Polsky, PhD, MPP; Kevin Volpp, MD, PhD
The goal of this project is to improve the health of Pennsylvanians at an individual, community, and population level by changing the paradigm of medical care and health care delivery to predicting and preventing onset, exacerbation, and advancement of disease rather than principally reacting to clinical events with expensive treatments. Using medical record data with linkages to administrative claims, wearable monitor data, and social media data, we will develop algorithms to better predict clinical events in the hospital, at home, and in the community. The proposed project will expand an established and highly successful minority health services research training program to provide opportunities for training in big-data research to support the career development of under-represented minorities within the Commonwealth of Pennsylvania.
Funder: Commonwealth of Pennsylvania

Transforming Provider Payments
Principal Investigators: Zeke Emanuel, MD, PhD; Kevin Volpp, MD, PhD
The goal of this partnership is to provide guidance and to conduct research for the roll-out of a new HMSA provider payment initiative that will fundamentally change the way primary care providers are paid in Hawaii.
Funder: Hawaii Medical Services Association