September 2014

In This Issue
HeartStrong Study Uses Wireless Bottle Caps, Social Support for Drug Adherence.
Penn's New Prevention Research Center Targets Chronic Disease, Health Disparities
Decisions to Start Smoking and to Quit are Highly Variable and Defy Single Solutions
Researcher Spotlight: Karen Glanz, PhD, MPH
New Initiatives

Quick Links

CHIBE in the News


What Health Systems Can Learn From the ALS Ice Bucket Challenge 

Philadelphia Inquirer, 8/21/14


Vaccine Exemption Research Garners NICHD Funding 

Penn Nursing News, 8/20/14 


How to Boost Organ Donor Registrations? Research Says Just Keep Asking 

The Washington Post, 8/18/14


Why Fresh Starts Matter 

Strategy+Business, 8/8/14


Innovation in Medical Education

Penn Medicine News, WHYY Newsworks, 7/30/14 


Living Kidney Donation Does Not Increase Risk of Death or Heart Disease for Older Adult Donors 

Penn Medicine News, Philadelphia Inquirer, 7/9/14 


Do Monetary Incentives Alone Change Behavior? 

The Toronto Star, 6/29/14


Changing Roles of Physicians With MBA's 

Penn Medicine News, 6/26/14


HeartStrong Study Featured in The Wall Street Journal

The Wall Street Journal, 6/8/14


Recent Publications


Innovation in medical education.
Asch DA, Weinstein DF. 

Stability of end-of-life preferences: A systematic review of the evidence.

Auriemma CL, Nguyen CA, Bronheim R, Kent S, Nadiger S, Pardo D, Halpern SD.
JAMA Intern Med. 2014. 174(7):1085-92.  

Facilitators of an interprofessional approach to care in medical and mixed medical/surgical ICUs: A multicenter qualitative study.

Costa DK, Barg FK, Asch DA, Kahn JM.

Res Nurs Health. 2014. 37(4):326-35.

Economic burden of irritable bowel syndrome with constipation: A retrospective analysis of health care costs in a commercially insured population.
Doshi JA, Cai Q, Buono JL, Spalding WM, Sarocco P, Tan H, Stephenson JJ, Carson RT.

J Manag Care Pharm. 2014. 20(4):382-90.

Reframing the impact of combined heart-liver allocation on liver transplant waitlist candidates. 

Goldberg DS, Reese PP, Amaral S, Abt PL.

Liver Transpl. 2014 . Epub ahead of print.


Cross-coverage in the intensive care unit: more than meets the "i"?

Am J Respir Crit Care Med. 2014. 189(11):1297-8.

Potential effects of California's new vaccine exemption law on the prevalence and clustering of exemptions.

Jones M, Buttenheim A.
Am J Public Health. 2014. 104(9):e3-6. 

Promoting public health through public art in the digital age. Am J Public Health.

Kilaru AS, Asch DA, Sellers A, Merchant RM. 

Am J Public Health. 2014. 104(9):1633-5. 

Factors associated with antimicrobial drug use in medicaid programs.

Li P, Metlay JP, Marcus SC, Doshi JA. 
Emerg Infect Dis. 2014. 20(5):829-32.


A "placement of death" approach for studies of treatment effects on ICU length of stay. 

Lin W, Halpern SD, Prasad Kerlin M, Small DS.
Stat Methods Med Res. 2014.

Glucose control and medication adherence among veterans with diabetes and serious mental illness: does collocation of primary care and mental health care matter? 
Long JA, Wang A, Medvedeva EL, Eisen SV, Gordon AJ, Kreyenbuhl J, Marcus SC.
Diabetes Care. 2014. 37(8):2261-7.

Using reporting requirements to improve employer wellness incentives and their regulation.
Madison K, Schmidt H, Volpp, KG. 

J Health Polit Policy Law. 2014. Epub ahead of print.


Identifying a reliable boredom induction.

Markey A, Chin A, Vanepps EM, Loewenstein G. 

Percept Mot Skills. 2014. 119(1):237-53.

Food Insecurity, Neighborhood Food Access, and Food Assistance in Philadelphia. 
Mayer VL, Hillier A, Bachhuber MA, Long JA.  

J Urban Health. 2014. Epub ahead of print.

Donation after cardiac death liver transplantation is associated with increased risk of end-stage renal disease. 
Ruebner RL, Reese PP, Abt PL. 

Transpl Int. 2014. Epub ahead of print. 

Planning, implementing and evaluating the effectiveness and ethics of health incentives: key considerations.
Schmidt H.  

Eurohealth. 2014. 20(2):10-14. 


Simulating the new kidney allocation policy in the United States: modest gains and many unknowns. 

Schold JD, Reese PP. 

J Am Soc Nephrol. 2014 Aug;25(8):1617-9. 


Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy.

Shea JA, Bellini LM, Dinges DF, Curtis ML, Tao Y, Zhu J, Small DS, Basner M, Norton L, Novak C, Dine CJ, Rosen IM, Volpp KG.

J Grad Med Educ. 2014. 6(2):256-63.

An official American Thoracic Society/ American College of Chest Physicians policy statement: the choosing wisely top five list in adult pulmonary medicine.
Wiener RS, Ouellette DR, Diamond E, Fan VS, Maurer JR, Mularski RA, Peters JI, Halpern SD.

Chest. 2014. 145(6):1383-91.


A trial of in-hospital, electronic alerts for Acute Kidney Injury: Design and rationale. 
Wilson FP, Reese PP, Shashaty MG, Ellenberg SS, Gitelman Y, Bansal AD, Urbani R, Feldman HI, Fuchs B.
Clin Trials. 2014. Epub ahead of print. 

The experience of young adults on suggestions for improvement.

Wong CA, Asch DA, Vinoya CM, Ford CA, Baker T, Town R, Merchant RM. 
Ann Intern Med. 2014. 161(3):231-2.

Upcoming Events


CHIBE Work in Progress Seminars

9/18/14- 12:00pm
1319 Blockley Hall 
RWJF Classroom
10/16/14- 12:00pm
Blockley Hall 11th Floor Conference Rom

11/13/14- 12:00pm
Blockley Hall 11th Floor Conference Rom

12/11/14- 12:00pm

Blockley Hall 11th Floor Conference Rom

LDI/CHIBE Health Policy Seminar

Troy Brennan, MD, MPH, Executive Vice President and Chief Medical Officer of CVS Caremark: "Tobacco Sales & Retail Pharmacies"

10/30/14 - 12:00PM
Colonial Penn Center Auditorium
Registration required

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


Kevin Volpp and Scott Halpern  

Dear Colleague,


We hope you had a great summer! We are happy to present to you our September issue of the CHIBE newsletter which describes a lot of exciting new opportunities for our center.


Our first story describes the HeartStrong Study, one of CHIBE's flagship studies, aiming to improve medication adherence among heart attack patients, which was recently reported on in the Wall Street Journal.


We then report on the exciting new research center which will target chronic diseases and health disparities, made possible by a 4.35 million dollar grant from the CDC. The University of Pennsylvania Prevention Research Center (PRC) is designed to be highly complementary to the work CHIBE is already conducting.


In light of the Prevention Research Center grant, we turn the spotlight on one of the PRC co-directors, Karen Glanz, PhD, MPH, an affiliated faculty member of CHIBE and director of the Center for Health Behavior Research at Penn. She details the research the PRC will be conducting along with her research in many other areas.


Steven Schroeder, MD, a member of CHIBE's external advisory board and Director of the Smoking Cessation Leadership Center at the University of California, San Francisco, reflects on smokers he knew early in life compared to the population of smokers today and their motivations to quit.


We want to remind you that you can follow us on Twitter @PennCHIBE for instant updates on CHIBE research and news publications. Our website at is also frequently updated and provides information that you might find of interest.


We hope you enjoy reading this issue of the CHIBE newsletter!




Kevin Volpp, Director


Scott Halpern, Deputy Director

HeartStrong Study Uses Wireless Bottle

Caps, Social Support for Drug Adherence

Shivan Mehta, MD, MBA


University of Pennsylvania medical researchers, working with five major health insurers, are studying the use of wireless pill bottles, lottery incentives and social support to encourage heart attack patients to keep taking their medication after leaving the hospital.


The problem researchers are wrestling with is significant. Within a year of their heart attacks, only about 40 percent of patients are still taking their prescribed medications, according to Dr. Shivan Mehta, Perelman School of Medicine assistant professor and one of the HeartStrong study investigators.


Adherence rates are suboptimal even among those who receive free medication, he said. Heart attack patients face risk of a repeat occurrence, especially in the year after hospital discharge, but medicines such as aspirin and beta blockers can lower that risk, noted Mehta, director of operations at the Penn Medicine Center for Health Care Innovation.


With funding from the U.S. Centers for Medicare & Medicaid Services, researchers have enrolled nearly 1,100 of the targeted 1,500 study participants from 42 states. Two-thirds of participants are randomly assigned to the program intervention group, while the rest are part of the control group.


"Many of the participants are very, very happy and engaged in this intervention so far," Mehta said, adding that researchers also have received good feedback from participating payors. Participants must be between 18 and 80 years old, taking at least two of four kinds of medications -- aspirin, beta blockers, statins and anti-platelet medicines - and must enroll within 60 days of hospital discharge after heart attack.


"So far we're seeing really encouraging results in terms of adherence," with fairly high rates among patients receiving the program intervention, HeartStrong Principal Investigator and CHIBE Director Dr. Kevin Volpp said.


One of the tools that HeartStrong uses is Vitality Inc.'s GlowCap, a prescription pill bottle cap with a chip that monitors when the container is opened and closed. The chip can wirelessly relay alerts through AT&T's mobile broadband network to the patient, health-care professional or supportive health buddy.


The bottle caps communicate with a web platform, Way to Health, developed by Volpp and Dr. David Asch, Penn professor and executive director of the Penn Medicine Center for Health Care Innovation.


For every day that they take their medications, patients are entered into a lottery in which they have a one in five chance to win $5 and a one in 100 chance to win $50, Volpp said. The HeartStrong program also involves identifying a friend or family member to serve as a social support to help keep the patient on track. A helper receives a text or email if a patient misses two or more doses, prompting a follow-up check on the family member or friend.


Patients also will be assigned to a program engagement adviser.  Social workers and program advisers will become involved only if a patient hasn't taken medication for at least four straight days or needs help that automated services can't resolve, Mehta said. The program is designed to be as automated and scalable as possible, and can be conducted from anywhere, he said, noting that Philadelphia researchers are providing the intervention to patients across the country.


The primary outcome measured in the study will be vascular events, including stroke, heart attack or heart failure, while secondary outcomes will include hospital readmissions, and cost of care and medication adherence as measured by pharmacy claims data.


This type of project is being used by CHIBE investigators to generate data that could be used in helping to shift the health financing model from one focused on treating sick people to one aimed at keeping people healthy, Volpp said. "This kind of initiative could become an important input for how to manage patient populations using technology and behavioral-economic type approaches," he said.


The Wall Street Journal reported on HeartStrong in June.


- Dinah Wisenberg Brin

Penn's New Prevention Research Center 

Targets Chronic Disease, Health Disparities 

Kevin Volpp, MD, PhD

A new $4.35 million U.S. Centers for Disease Control and Prevention grant is allowing the University of Pennsylvania to set up a research center focused on public health and behavioral economics strategies to reduce obesity, prevent chronic disease and curb health-care disparities.


A joint effort of Penn's LDI Center for Health Incentives and Behavioral Economics and the university's Center for Health Behavior Research, the interdisciplinary program is one of 26 Prevention Research Centers in the country awarded CDC grants for 2014 through 2019, and the first PRC to be funded in Philadelphia.


The core of Penn's PRC will be its work with three local employers -- - the Philadelphia city government, health insurer Independence Blue Cross and the Southeastern Pennsylvania Transportation Authority (SEPTA) -- to explore workplace approaches to help employees lose weight and avoid cardiovascular disease.


Ultimately, the PRC aims to translate its findings into public health programs that can be duplicated and used in the wider community.


"It's designed to be very complementary to what we are already doing and to build on that," said CHIBE Director and PRC Co-Director Dr. Kevin Volpp, a professor at Penn's Perelman School of Medicine and The Wharton School. "It's an exciting opportunity to be at the table with the CDC in one of the agency's flagship health-improvement programs," he said.

Karen Glanz, PhD, MPH


The workplace weight-loss study will compare a behavioral economics approach and environmental strategies, according to PRC Co-Director Karen Glanz, a Penn nursing and epidemiology professor and director of the Center for Health Behavior Research. The PRC doesn't aim to change the workplace environment per se, she said, but rather to give employees tools to support healthy behavioral changes.


That could mean showing employees how to pack more physical activity into their day or how to find a healthy lunch truck, "and how to really look at your environment and use it to your advantage," said Glanz.


Workplace study participants will be assigned to one of four groups - one looking at environmental change management, another examining financial incentives, another assessing a combination of the two, and a control group with no intervention -- according to Glanz, who previously directed the Emory University PRC.


Penn's grant, awarded earlier this year, starts this fall and makes the university eligible for several supplementary financial awards that could add five or six other projects at the outset.


Program leaders aim to pull together people with expertise in areas such as chronic disease prevention, behavioral economics, business organizational behavior, communications, policy implementation and nursing, and use the center as a catalyst to build new programs, said Glanz. The center, for example, expects to connect with other experts to lay the groundwork for establishing evidenced-based programs, she said.


In addition to Penn's medical and nursing schools and Wharton, leadership at the PRC will come from the university's Annenberg Public Policy Center and Children's Hospital of Philadelphia. The Annenberg center's associate director, Amy Jordan, is slated to help to lead a section focused on disseminating research to academic and scientific communities and to local health organizations and news media.

- Dinah Wisenberg Brin 

Decisions to Start Smoking and to Quit are Highly Variable and Defy Single Solutions

Steven Schroeder, MD

Despite the well known fact that cigarette smoking is the single largest source of preventable illness and death, we remain ignorant about the fundamental reasons to start smoking and to quit. Since I direct the Smoking Cessation Leadership Center at UCSF, I will focus on decisions to quit. We know that there are now more ex-smokers than current ones, and that it can take from 8 to 14 unsuccessful attempts before quitting successfully. Beyond that however, it is a bit of a mystery.  While our Center works with organizations and groups, I want to tell some stories about people in my life who did quit.

Like many of my generation (born in 1939) both my parents smoked. Dad called me up at age 52 to announce that he had just quit. He had awakened that morning wheezing, and said to himself, "Who is in charge here Schroeder, old man tobacco or you?" He quit cold turkey, never looked back, and lived to age 99, though with persistent pulmonary symptoms. His incentive? To prevent further health damage and to retain control. Mom smoked a lot longer. At age 73, she got pneumonia, and her recovery was slow. She complained to me, and I responded that I wouldn't give her any sympathy until she quit smoking. This was not the first such message I had given her, and a decade earlier her unextinguished cigarette almost burned down their house. But this time it worked. Why? Probably a combination of health concerns and maternal obligation. Mom lived to age 91, although there is now evidence that smoking may have contributed to her Alzheimer's Disease.

In college, I asked a young woman to be my girlfriend, contingent on quitting smoking. She accepted, but when we broke up about 8 months later she went back to a two pack per day habit. I am not sure whether she thought the bargain was worth it, but it did do the trick, although not permanently. 

A good friend from medical school, medical residency and thereafter was a fiercely addicted smoker who tried many times to quit. Each time he resumed smoking it was because of a perceived stressful period in his life. For him, the incentive to relieve stress trumped his health incentive to quit. Ultimately he was able to quit, but not without sustaining considerable lung damage.

Former Secretary of HEW (now HHS) Joseph Califano likes to tell the story of how he quit. His son, Joe Jr., was approaching his 12th birthday and was asked what he wanted as a present. To his father's surprise, the son asked if dad would quit smoking. For a three pack a day smoker that was not an easy gift to give. But he did it.

My first "real" job was on the faculty of the George Washington Medical School. A neighbor and good friend, who worked as a lawyer for the DC government, occasionally asked me to drive him to work, which was on my way. But I would not let him smoke in my VW Beetle. We have stayed friends, he did eventually stop smoking, but it was not because of my travel restrictions.

In reciting these stories, I realize that the smokers who I knew earlier in my life do not resemble the smoking population today. My wife and I do not know anyone socially who smokes, and neither do my two physician sons and their wives. Smoking has become concentrated among the less fortunate-those with mental health conditions, substance use disorders, the poor, incarcerated persons, and  the homeless-as well as the LGBT community and some young "immortals" who  tend to smoke episodically rather than compulsively. None of my earlier contacts who quit did so because of financial pressures or incentives.  

Today, of course, cigarettes are more costly, especially for those who are financially challenged, the case for most current smokers. Thus, financial incentives may now be more important. In addition to the cost of cigarettes themselves, penalties such as the fact that smokers can be charged more for health insurance and that employers may refuse to hire smokers can also serve to stimulate behavior change.   That said, my earlier experience leaves me with the sense that quitting smoking is a highly personal decision. Financial incentives may be important for some, but as the stories I recited imply, there are many other reasons as well. Here in California perhaps the strongest incentive relates to social norms. Smoking rates among men in Asia are very high, often around 50%. Yet Asian immigrants who come to California, as well as other parts of the country, have very low smoking rates. This does not reflect selective immigration of non-smokers, but rather the desire of new immigrants to assimilate within a non-smoking culture.


What does all this mean for CHIBE? It is not that incentives don't matter, but that because personal change is so individualistic, formulaic approaches may fall short of desired goals. Ideally, clinicians, public health workers, and policy makers will have a full arsenal of cessation incentives at their disposal, and be able to deploy them successfully as indicated.


-Steven Schroeder, MD 

Researcher Spotlight: Karen Glanz, PhD, MPH

Karen Glanz, PhD, MPH


Karen Glanz, PhD, MPH is the George A. Weiss University Professor, Penn Integrates Knowledge (PIK) Professor, Professor of Epidemiology and Nursing, and Director of the Center for Health Behavior Research at the University of Pennsylvania. She is also a Senior Fellow at the Leonard Davis Institute, and Affiliated Faculty Member at CHIBE. 


Dr. Glanz's work integrates theory and research methods from the social and behavioral sciences with public health and medicine to explore short- and long-term applications for improving community health, health care, and public health services, primarily in the areas of preventive medicine. She began her career investigating ways to increase medication adherence for patients with hypertension. Almost a decade ago she developed internationally used tools to measure nutrition environments. She has also tested and disseminated effective multi-level cancer prevention strategies and refined measurement and methods, including validating self-report measures of sun exposure and protection. 


Dr. Glanz was recently elected to the Institute of Medicine (IOM) and is a member of the Task Force on Community Preventive Services, a federally appointed task force that oversees the Community Guide evidence reviews. Dr. Glanz has published more than 400 journal articles and book chapters and she is the senior editor of Health Behavior and Health Education: Theory, Research, and Practice, a widely used text now in its fourth edition. 


How did you become affiliated with CHIBE?


I had my very first academic position at Temple University before moving on to other tenured posts, first at the University of Hawaii and then at Emory University in Atlanta. The PIK Professorship, with the opportunity to cut across disciplines and work with leading investigators from Penn's faculty, lured me back to Philadelphia. For example, soon after arriving on campus, I worked as an advisor to Kevin Volpp, MD, PhD, David Asch, MD, MBA, and others on The Way to Health project, an interdisciplinary collaboration that blended behavioral sciences, medicine and technology to build a research tool that will help to improve health behaviors. Around the same time, I also became an affiliated faculty member at CHIBE. More recently, Kevin and I received notice that our application as Co-Directors of a new CDC-supported $4.35 million Penn Prevention Research Center will be funded at the end of September, which is another opportunity for us to work together.


What is the aim of the Prevention Research Center?


Penn's Prevention Research Center or PRC, is one of 26 in the nation. We will conduct public health and disease management research aimed at preventing chronic disease and reducing health disparities in Southeastern Pennsylvania. Through our work we hope to strengthen public and private sector community partnerships; improve understanding of how behavioral economics and public health strategies can reduce health risks and improve health; and extend collaborative training, education, and communication in high-risk and underserved populations. For Penn, the grant is a unique opportunity to create a hub for interdisciplinary chronic disease prevention research, training, and dissemination on campus and it supports the University's commitment to reducing disparities and improving the health of our communities.


What research will the PRC be conducting?


Among other initiatives, the PRC will conduct a workplace weight loss study to evaluate environmental change strategies and incentives for decreasing obesity and preventing cardiovascular disease among employees of the City of Philadelphia, Independence Blue Cross, and the Southeastern Pennsylvania Transportation Authority (SEPTA). We're working on understanding how to transform an external motivation like incentives, to a lasting internal motivation for healthier behaviors. What is the right formula for success? How can we modify the environment? What are the optimal time intervals and the best feedback to create lasting impact? Because the PRC is composed of an interdisciplinary team, we have a menu of strategies and approaches to test and deep expertise to draw upon.


What other research will you be working on?


I am particularly energized by the improvements technology has brought to the behavioral sciences and to the research I do. I want to build on a Robert Wood Johnson Pioneer Program-funded project with Jason Karlawish that used the Way to Health platform. We found that, in a population over the age of 65, altruism is a motivator for daily exercise and an incentive in the form of a donation to a social cause of the participants' choosing worked just as well as giving them money directly. Also, I am collaborating with Annenberg colleagues using their eye tracking and heart rate measurement technology to do message testing around prevention. We just learned that we will receive a supplement to the PRC center grant to use these and other methods to test communication strategies for skin cancer prevention. In another project, I am working with a group using real time measurements in combination with spatial analysis to evaluate tobacco and alcohol use among young adults and looking into home and community solutions for kidney disease treatment adherence. Additionally, I am going to continue my nutrition-related work, having recently received an R01 based on a pilot project that found that place- and promotion-based strategies in the retail food setting, i.e., supermarkets, can change purchasing patterns. 


Do you have any thoughts for younger researchers?


Even with all of the powerful technology we have, people and methodology matter more to the success of a project. Learn from other people around you because often there is more than one way to do something. And above all, have fun with what you're doing.   


- Christine Weeks

New Initiatives  

CDC Prevention Research Center
Directors: Karen Glanz, PhD, MPH; Kevin Volpp, MD, PhD
A five-year, $4,350,000 grant from the Centers for Disease Control and Prevention has established a Prevention Research Center (PRC) at the University of Pennsylvania. The PRC, one of 26 in the nation, will conduct innovative public health and disease management research aimed at preventing chronic disease and reducing health disparities in Southeastern Pennsylvania. This will be the first PRC in Philadelphia.

Among other initiatives, the PRC will conduct a workplace weight loss study to evaluate environmental change strategies and incentives for decreasing obesity and preventing cardiovascular disease in employees of the City of Philadelphia, Independence Blue Cross, and the Southeastern Pennsylvania Transportation Authority (SEPTA).


The PRC will strengthen public and private sector community partnerships; improve understanding of how behavioral economics and public health strategies can reduce health risks and improve health in social-environmental contexts; and extend collaborative training, education, and communication in high-risk and underserved populations in Southeastern Pennsylvania.


Funded by: Centers for Disease Control and Prevention


Roybal Center Grant Renewal

Directors:  Kevin Volpp, MD, PhD George Loewenstein, PhD


Our Roybal Center grant was renewed for another 5 year grant period. The Penn Roybal Center in Behavioral Economics and Health will tackle major public health challenges such as obesity, sedentary lifestyles, a national shortage of organ donors, and medication non-adherence utilizing concepts and tools from behavioral economics, a network of social scientists and physicians centered at the University of Pennsylvania, and collaborating organizations which have access to large populations and an infrastructure for communicating with them.


Funded by:  National Institute on Aging