March 2015

In This Issue

CHIBE in the News


Smartphone Apps Just as Accurate as Wearable Devices for Tracking Physical Activity 

The New York Times, CNN, Reuters, Los Angeles Times, TIME, Self, Huffington Post, The Guardian, LDI News, Penn Medicine News, 2/11/15



The Atlantic, Philadelphia Magazine, Shape, NY Daily News, Penn News, 1/8/15


Shortened Shifts for Residents Not Associated with Patient Outcomes 

Reuters, Penn Medicine News, HealthDay, Physician's Digest, 12/10/14


Many Breast Cancer Patients Receive Unnecessarily Long Courses of Radiation

Penn Medicine News, The New York Times, TimeUSA TodayNBC News, 12/10/14


Using Behavioral Economics to Achieve Wellness Goals 

Harvard Business Review, 12/1/14

Recent Publications


Effectiveness of androgen-deprivation therapy and radiotherapy for older men with locally advanced prostate cancer.
Bekelman JE, Mitra N, Handorf EA, Uzzo RG, Hahn SA, Polsky D, Armstrong K.
J Clin Oncol. 2015. 1;33(7):716-22.

Uptake and Costs of Hypofractionated vs Conventional Whole Breast Irradiation After Breast Conserving Surgery in the United States, 2008-2013.
Bekelman JE, Sylwestrzak G, Barron J, Liu J, Epstein AJ, Freedman G, Malin J, Emanuel EJ.
JAMA. 2014. 312(23):2542-50.

Factors associated with increased specialty care access in an urban area: the roles of local workforce capacity and practice location.

Bisgaier J, Rhodes KV, Polsky D.

J Health Polit Policy Law. 2014. 39(6):1173-83.

Accuracy of smartphone applications and wearable devices for tracking physical activity data.

Case MA, Burwick HA, Volpp KG, Patel MS. 

JAMA. 2015 10;313(6):625-6.


Low Health Literacy Predicts Misperceptions of Diabetes Control in Patients With Persistently Elevated A1C.  

Ferguson MO, Long JA, Zhu J, Small DS, Lawson B, Glick HA, Schapira MM. 

Diabetes Educ. 2015. Epub ahead of print. 


Ethical guidance on the use of life-sustaining therapies for patients with ebola in developed countries. 

Halpern SD, Emanuel EJ. 

Ann Intern Med. 2015.162(4):304-5.


A Qualitative Evaluation of Patient-Perceived Benefits and Barriers to Participation in a Telephone Care Management Program.

Jubelt LE, Volpp KG, Gatto DE, Friedman JY, Shea JA.

Am J Health Promot. 2015 Epub ahead of print

Web-Based Access to Positive Airway Pressure Usage with or without an Initial Financial Incentive Improves Treatment Use in Patients with Obstructive Sleep Apnea.
Kuna ST, Shuttleworth D, Chi L, Schutte-Rodin S, Friedman E, Guo H, Dhand S, Yang L, Zhu J, Bellamy SL, Volpp KG, Asch DA. 
Sleep. 2015. Epub ahead of print.

Putting public health ethics into practice: a systematic framework.

Marckmann G, Schmidt H, Sofaer N, Strech D.

Front Public Health. 2015. 3:23.

Telemedicine's Potential Ethical Pitfalls.

Mehta SJ. 

Virtual Mentor. 2014. 16(12):1014-1017.

The Patient Diarist in the Digital Age. 
Padrez KA, Asch DA, Merchant RM.

J Gen Intern Med. 2014. Epub ahead of print. 

Wearable devices as facilitators, not drivers, of health behavior change.
Patel MS, Asch DA, Volpp KG. 

JAMA. 2015. 313(5):459-60. 

Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients. 

Patel MS, Volpp KG, Small DS, Hill AS, Even-Shoshan O, Rosenbaum L, Ross RN, Bellini L, Zhu J, Silber JH. 
JAMA. 2014. 312(22):2364-73.

Appointment availability after increases in Medicaid payments for primary care. 

Polsky D, Richards M, Basseyn S, Wissoker D, Kenney GM, Zuckerman S, Rhodes KV.

N Engl J Med. 2015. 372(6):537-45. 

Primary care appointment availability and preventive care utilization: evidence from an audit study. 

Saloner B, Polsky D, Friedman A, Rhodes K.  

 Med Care Res Rev. 2015. 72(2):149-67. 


Creating value in health by understanding and overcoming resistance to de-innovation. 

Ubel PA, Asch DA. 

Health Aff (Millwood). 2015. 34(2):239-44.


Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial.  

Wilson FP, Shashaty M, Testani J, Aqeel I, Borovskiy Y, Ellenberg SS, Feldman HI, Fernandez H, Gitelman Y, Lin J, Negoianu D, Parikh CR, Reese PP, Urbani R, Fuchs B. 

Lancet. 2015. Epub ahead of print. 

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Dear Colleague,


We hope you stayed warm and dry this winter season! The March 2015 issue of the CHIBE newsletter focuses on some exciting research that received a lot of media attention in the last few months. You can follow our media publications on our Twitter account @PennCHIBE or our website at


Our first story highlights recent findings related to wearable devices. A study published in JAMA found that smartphones are just as accurate at tracking steps as wearable devices, which is a "game changer," according to one of the lead authors, Mitesh Patel; since two-thirds of US adults own smart phones and only one to two percent own wearable devices. While these devices are increasing in popularity, little evidence suggests that they are changing behavior. Combining the use of wearable devices and proven behavioral economics concepts can help bridge that gap, according to an opinion piece published in JAMA by Mitesh Patel, David Asch and Kevin Volpp.


Another study that received a lot of media attention was Justin Bekelman's breast cancer treatment study, also published in JAMA. He found that a shorter "hypofractionated" treatment following lumpectomy can be equally effective, less expensive and no more toxic than the more traditional five to seven weeks of radiation. He describes hypofractionated treatment as a "win-win" since it is patient-centric and saves the healthcare system money.


Our guest column by McKinsey & Company examines consumer behavior in the first full year of public health insurance exchanges.


This issue spotlights Gretchen Chapman, CHIBE affiliated faculty member and Professor of Psychology in the School of Arts & Sciences at Rutgers University. She describes the work she does in the Medical Decision Making Lab which uses behavioral economics to explore ways to nudge people toward healthy behaviors like annual flu vaccination and healthy eating.


Please enjoy reading the March issue of the newsletter and be sure to check out our media citations and recent publications below.




Kevin Volpp, Director


Scott Halpern, Deputy Director

Wearable Devices Alone Won't Drive Healthier Behaviors

Annual sales of wearable devices that track physical activity are projected to exceed $50 billion by 2018, but there's no solid proof that these gadgets alone will drive people to adopt healthier habits, according to University of Pennsylvania researchers. Wearable devices, though, may be more effective when used in concert with broader strategies designed to sustain behavioral changes, they suggest.

What's more, researchers say, smartphone apps appear to be at least as accurate as wearable devices in tracking steps - a significant finding given that nearly two-thirds of U.S. adults already own smartphones and people tend to carry them anyway. Smartphone apps, they said, could aid those looking to make enduring changes in health habits.

The conclusions arise from research, recently discussed in the Journal of the American Medical Association,that explores the effectiveness and accuracy of wearable devices, including fitness bands and other digital pedometers.


"The challenge has been that there's no good evidence around how effective wearable devices are in getting individuals to change their behaviors," said Dr. Mitesh Patel, MD, MBA, an assistant professor of medicine at Penn's Perelman School of Medicine and of health care management at The Wharton School.

While armbands and other gadgets can facilitate the adoption of healthier habits, the Penn research indicates that for most people, "wearable devices are not enough to drive behavior change," said Patel, a CHIBE faculty member involved with the study.


Concepts from behavioral economics, however, could be employed to help engage individuals who use wearable devices, Patel and his colleagues wrote.

In a Jan. 8 opinion piece in JAMA, Patel, with Dr. David Asch, MD, MBA, executive director of Penn's Center for Health Care Innovation, and CHIBE Director Dr. Kevin Volpp, MD, Ph.D., noted that only 1% to 2% of people in the United States have used a wearable device, although sales are growing. Health care organizations, insurers and employers are considering the devices as a way to engage individuals in adopting healthier behaviors, they wrote.

Devices Could Work Better with Behavioral Economics


Mitesh Patel, MD, MBA
"The notion is that by recording and reporting information about behaviors such as physical activity or sleep patterns, these devices can educate and motivate individuals toward better habits and better health. The gap between recording information and changing behavior is substantial, however, and while these devices are increasing in popularity, little evidence suggests that they are bridging that gap," they wrote.


If wearable devices fulfill expectations, the researchers suggest, it will be less because of the technology and more because of behavioral-change strategies that incorporate them. Sustained behavior change is a major challenge and many mobile health applications have not yet leveraged principles from theories of health behavior, they said.


Workplace wellness programs may provide the right context for deploying interventions that combine use of wearable devices and proven behavioral-economics concepts, they write. Teams that provide peer support and promote accountability, using wearable devices to measure achievements, is one possible approach. The teams could win a prize in a drawing, for example, but must have achieved the previous day's goal to collect it.


Wearable devices seem to appeal to those who need them the least - younger, more affluent technology early adopters - reported the researchers which included medical student Meredith Case, summer intern Holly Burwick from Amherst College, Kevin Volpp and Mitesh Patel.


Smartphone Apps May Be the Answer


The JAMA paper cited a survey showing that more than half of people who bought a wearable device stopped using it, many within six months, and noted possible obstacles to adoption and effective use, including cost; the need to wear, recharge and, in some cases, synchronize data; and the need for data to be presented in a way that motivates sustained change.


"One potential solution might be to better leverage smartphones; most people with these phones carry them often," the team wrote. "Although smartphones are expensive, many people already have them, and the reach of these devices is increasing."


In a Feb. 10 research letter in JAMA, Patel, Volpp and two other researchers reported on a step-counting study they conducted which showed that many smartphones and wearable devices are accurate in tracking step counts. They recruited volunteers to wear or carry 10 devices and apps while walking on a treadmill, as an observer watched with a tally counter.


Smartphone data differed only slightly from observed step counts, but could be nearly 7% lower or roughly 6% higher, they reported. Wearable devices differed more, and one reported step counts nearly 23% lower than those observed.


The idea that people can use smartphones to track steps accurately, Patel said in an interview, "is a game changer."


Patel and colleagues have been conducting trials on behavioral strategies to get people to engage in more activity, aided by smartphone apps. 

 - Dinah Wisenberg Brin

Penn Researchers Find Slow Acceptance of High-Value Breast Cancer Treatment

Two-thirds of U.S. women diagnosed with early stage breast cancer unnecessarily receive the conventional five to seven weeks of radiation therapy following lumpectomy, even though a shorter, "hypofractionated" treatment has been shown to be equally effective, less expensive and no more toxic, according to University of Pennsylvania researchers.


The researchers looked at claims data from 14 U.S. commercial health plans for insights into women with early-stage breast cancer who, from 2008 to 2013, were treated with lumpectomy and whole breast irradiation. The patients were classified into one of two groups: those for whom three-week, hypofractionated whole breast irradiation was endorsed and those for whom it was permitted.


Justin Bekelman, MD

Hypofractionated WBI received the

endorsement of a radiationoncology society in 2011 for patients age 50 and older meeting certain other criteria, based on evidence from randomized trials, the Penn researchers noted in the Dec. 17 issue of the Journal of the American Medical Association. The group's guidelines also permit the shorter therapy for other early breast cancer patients.


While hypofractionated WBI increased for both groups from 2008 to 2013, "only 34.5% of patients with hypofractionation-endorsed and 21.2% with hypofractionation-permitted early-stage breast cancer received hypofractionated WBI in 2013," according to researchers led by Dr. Justin Bekelman, MD, assistant professor of radiation oncology at the Hospital of the University of Pennsylvania and CHIBE affiliated faculty.

The study also found that hypofractionated WBI saved 10% in average total healthcare costs per patient in the year after diagnosis, although patients' out-of-pocket costs didn't differ much. Each hypofractionated radiation dose is higher than each dose delivered during each treatment in the longer, conventional treatment, but studies have shown equal effectiveness and comparable long-term side effects.


"The reason we focused on this is because breast cancer is a highly prevalent cancer in the United States and lumpectomy followed by radiation is one of the most common treatments for it," with 160,000 lumpectomies performed every year, Bekelman said in an interview. "This is an important area of understanding the value of cancer care. "While health insurers saved money when patients used the shorter treatment, the new method provides an important advantage for patients as well, Bekelman noted.


"Women with breast cancer have said it's very meaningful for them to have a shorter treatment schedule" of three to four weeks versus seven weeks of daily treatment, he said. "It's a burden for patients." Hypofractionated WBI is a "win-win" because it's patient-centric and saves the healthcare system money, Bekelman said.


There are several possible explanations for the relatively low uptake of the shorter therapy.


Translating research evidence into medical practice generally takes time, and "there are special challenges related to de-adopting treatments rather than adopting treatments," Bekelman said. The current health payment system "doesn't help us with it," as it emphasizes length of care rather than value, he said.


"In fee-for-service reimbursement, the more treatment, the more providers are reimbursed. ...I don't think that's the whole story here, but it could be part of it," Bekelman said. The findings come at a time when the government, health insurers and other health-care players consider new payment strategies that incentivize high-value care.


Bekelman and Penn colleagues have a research program to identify areas of low-value cancer care and to understand ways to increase high-value radiation and chemotherapy for breast, lung and prostate cancer.


"This is where CHIBE as an organization can have a very big impact," Bekelman said. "One of the center's objectives is to explore how behavioral economics and other types of interventions can reduce low-value and increase high-value medical care."


Health insurer Anthem Inc. and the National Cancer Institute funded the study. Anthem had no role in designing or conducting the research, or in managing or analyzing the data.


- Dinah Wisenberg Brin 

Consumer Behavior on the Public Health Insurance Exchanges


As we examine the first full year of consumer behavior on the public health exchanges, we are beginning to learn about motivations, choice, and ultimately, selection. Three characteristics in particular have characterized consumer evaluation and purchasing behavior: 1) the number of choices available to consumers increased considerably; 2) a large majority, or plurality, of subscribers believed premium price was the most important factor influencing plan selection; and 3) many consumers indicated they made their decision in the absence of more in-depth knowledge or comprehensive evaluation of the benefit design.


Choice of Health Insurance Products Increased Considerably in 2014 


Between 2013 and 2014, the number of individual health insurance carriers remained essentially constant, but the number of products offered on the public exchanges relative to those in the 2013 individual market increased substantially. There was a disproportionate proliferation of narrower network products, but there were additional broad network products as well (1). Additionally, carriers were required statutorily to offer only silver and gold-tier products, yet 100% of the public also had access to bronze products and 75% to platinum (2).


Consumer Preferences and Behavior


In a survey of 701 individuals who had enrolled in a qualified 2014 health plan, 67% of previously insured respondents claimed the lowest-price premium was the most important factor influencing their purchase decision, and 55% claimed other out-of-pocket costs (i.e., deductible, co-pay) were most important. However, only 44% claimed having access to a preferred physician was most important and only 13% thought having access to a preferred hospital was most important (3).

Among those previously without insurance, the numbers suggest even more price sensitivity as 81% claimed that the lowest-price premium was most important.

When we evaluated actual enrollment, we learned that 64% of all enrollees (on the Federally Facilitated Exchanges) reported that they had selected the lowest, or second lowest, price product available (4). So, while not an exact match, it appears in this case that actual behavior was pretty consistent with expressed buying factors.

Choice in the Absence of Full Information


Many of our respondents acknowledged, however, that they made decisions largely on the basis of price in the absence of more complete information about the plans they were purchasing. For instance, 26% of our respondents claimed they were unaware of the hospital networks attached to their plans. This lack of awareness was highest among previously uninsured respondents; they were more than twice as likely as previously insured respondents to be unaware of network breadth (41% versus 21%, respectively) (1).

When we separately estimated the total annual premium and out-of-pocket expenses for individuals with various health statuses in certain geographies, we found that many whose income was above ~250% FPL, and were expected to consume as little as $2,500 in annual health services, would be best off economically in the market's lowest cost platinum tier product (5). Nationwide, however, only 5% of all subscribers enrolled in platinum plans. We suspect that many more would have benefited from them (4). This suggests any of a number of explanations: the subscribers did not fully understand the total personal economic impact of the products being offered, or they did not believe they would spend as much on health services as their health status would imply, or perhaps that they would not actually be obliged to cover their deductibles should they actually consume health services. All three of these could also be a function of a bias against parting with the money up front in the form of a premium.

We also observe a similar lack of understanding of plan design among consumers who did not enroll. The same survey found that 71% of the respondents who reported shopping but not enrolling indicated that they would have been more likely to enroll if they had had more information about the design and cost of different plans (including out-of-pocket maximums and expected out-of-pocket total cost).


Some Implications

From these data, there are a number of potential implications and we note three of them below:

■ Like many other sectors where the product is complicated (i.e. financial services, advanced consumer electronics), it will take several years before the consumer matures enough in his knowledge of the alternative offerings to truly "optimize", and therefore, in the short term, the most visible "benchmark" for evaluative purposes is likely to be the net premium price.

■ Health insurance, with all of its variables in benefit design, may remain too complicated for most consumers to optimize their true objective functions regardless of how much time passes, and we will continue to observe new intermediaries entering the competitive fray to "guide" consumers through what are difficult and complex tradeoffs.

■ Alternatively, we may have reached the point where health insurance has become such a significant percentage of the median American household's income that premium price sensitivity will be the dominant factor influencing consumer selection for an extended period of time. If true, we will continue to see the success of lower cost, heavily-managed, narrow network products in the market. And, given that this is the consumer's own money at stake, and that it is the consumer's choice to enroll in such plans, we will not resume the backlash directed against employers for forcing employees to enroll in similar plans in the 1990s.

Regardless of these potential implications, there will be real value in understanding the consumer behavior associated with purchasing health insurance as the sector continues to move much more toward a retail posture.


1. Noam Bauman, Erica Coe, Jessica Ogden, Ashish Parikh. Rivera. Hospital networks: Updated national view of configurations on the exchanges. June 2014. 
2. Ananya Banarjee, Erica Coe, Jim Oatman. Exchanges go live: Early trends in exchange dynamics. October 2013. 
3. Amit Bhardwaj, Erica Coe, Jenny Cordina, Ruchira Saha. Individual market: Insights into consumer behavior at the end of open enrollment. May 2014.

4. Amy Burke, Arpit Misra, Steven Sheingold. Premium Affordability, Competition, and Choice in the Health Insurance Marketplace, 2014. June 2014. 

5.  Erica Coe, Jim Oatman, Mahi Rayasam, Tom Bowen Wright. Exchange product benefit design: Consumer responsibility and value consciousness. March 2014.


Data Sources

1. McKinsey Center for U.S. Health System Reform Exchange Offering Database 

2. McKinsey Center for U.S. Health System Reform Open Enrollment Consumer Survey


- Paul Mango and Erica Hutchins Coe, McKinsey & Company

Researcher Spotlight: Gretchen Chapman, Ph.D.

Gretchen Chapman, PhD


Gretchen Chapman, Ph.D. is Professor of Psychology in the School of Arts & Sciences, Rutgers University and a CHIBE Affiliated Faculty Member. Her research uses judgment and decision-making theory and health psychology to examine the decision processes underlying preventive health behaviors. 


What sparked your interest in psychology and decision making in preventive health?  


I started out exploring animal behavior. In fact, my eighth grade science project included mice, a maze, and a Lashley jumping stand. I continued my scientific explorations using animal models throughout undergraduate school and in my first few years of graduate work at the University of Pennsylvania with Professor Robert Rescorla Ph.D. When my animal research did not yield consistent results, I turned to my back-up plan, which revolved around associative models of animal learning and human judgments about predictive relationships. During that time, I took a class with Professor Jon Baron, Ph.D. on judgment and decision making. The field clicked for me and became my professional home. A post-doctorate program with the decision sciences group at Wharton working with Eric J. Johnson, Ph.D. followed. Two years later, on my first job, I learned to apply decision theory to medicine with Professor Arthur Elstein, Ph.D. at the University of Illinois at Chicago in work on how people discount delayed health outcomes. Now, I am at Rutgers and have the ability to investigate and collaborate on all aspects of decision making around human health in the Medical Decision Making Lab.


What kind of research are you doing in the lab?


In my work I use field studies to deploy what we know about the psychology of decision making to try to help people improve behaviors related to preventive health. The Medical Decision Making Lab provides a home (A humble one at that, it's really a room.) for my research and that of interested graduate students. A few lab members are exploring prosocial behaviors, such as cooperation in games, gift giving, and environmental behavior, while others are looking into intertemporal choice and policy decisions. Some of my recent work has used findings from judgment and decision making and behavioral economics to explore ways to nudge people toward annual flu vaccination and healthy eating.


Vaccination is a hot news topic right now, what have you investigated?


In a series of studies I have explored factors associated with the decision to receive a flu shot, including perceived risks and benefits, anticipated emotions, social factors such as perceived norms and job role, and interpersonal factors such as altruistic benefits of vaccinating. Most recently, I investigated whether changing default options related to appointments could increase uptake of seasonal flu vaccine.  In this work, we used a representative sample of patients from a health clinic. Control patients were left alone. Meanwhile, one group of patients received a mailed invitation to get a flu shot for which they had to call to set the appointment, and another group received a letter indicating that an appointment had been set for them with instructions on how to cancel it. Half of the patients cancelled the preset appointment; however, this opt-out group was still significantly more likely to get vaccinated than the opt-in and control groups. It should be noted that the clinic called to remind everyone who had an appointment, which is a powerful prompt. Nonetheless, we found that having an appointment, regardless of who schedules it, is a good predictor of getting a flu shot. A subtle change in the choice architecture, in this case a new default option, influenced patients to be more proactive about their health.


How else can choice architecture affect health behaviors?


Recently I have been working with Peggy Policastro, MS, RD, who is the Director of the Rutgers Healthy Dining Team, on projects to promote healthy eating.  We've had success influencing dietary choices among students by manipulating menu displays, though sometimes it doesn't work out exactly as expected. One night each week the dining hall offers a custom hoagie option that requires students to fill out a slip indicating what they want on their sandwiches. We varied the wording of that menu slip over an eight-week interval. During four randomly selected weeks the menu slip was redesigned so healthy ingredients were listed first and starred to make them more salient. For the remaining four weeks we used the usual slip.  At the end, we evaluated the completed menu slips to measure the impact of our changes. Students who ordered from the redesigned slip were two-to-three percent more likely to pick the healthy options, with one exception: mayonnaise. When students ordered vegetables and skipped cheese, they added mayo, resulting in no net calorie savings. So, there is another effect complicating our findings, which means we have more to explore.


What is next for you?


I'm interested in altruism and how it influences behavior, so Ms. Policastro and I are going back to the dining hall to investigate if a donation to charity motivates healthier food and beverage choices. Specifically, we're testing if we can nudge students to opt for a half order of French fries instead of a whole order, and water over soda. Initial research indicates that a charitable donation will do better than nutrition information in influencing people to choose the smaller amount of fries and the water because people like to feel altruistic. In addition, I am continuing to examine issues related to vaccination and am also looking into ideas for a CHIBE pilot project.


Do you have any advice for researchers who are just starting out?


Studies don't always work out the way you think they will. In research it's always a good idea to have back-up plan. 


-Christine Weeks