Patients More Likely to Take Medications When Refills are Synced
Penn Medicine News, 08/08/16

Conditions Worse Than Death as Rated by the Seriously Ill
The Economist; WHYY ; Fox News ; ; LDI Health Policy$ense ; Live Science, 08/08/16

Ordering Food in Advance Leads to Healthier Choices
New York Times ; Consumer Reports ; Science Alert ; New York Magazine, 07/25/16

Employee Exercise Increases with Competition and Financial Incentives
Penn Medicine News, 07/15/16

Using Science to Make Good Health Choices
NPR, 07/07/16
Kevin Volpp Comments on IBC Workplace Walking Study
Reuters, 07/07/16

Heather Schofield Study Shows Muslims Less Productive During Ramadan
The Economist,  07/02/16

Shivan Mehta Comments on Text Messaging Study
The Wall Street Journal, 06/30/16

What is the Financial Value of Wearable Devices?
Money Magazine, 06/22/16

"Traffic-light" and Numeric Calorie Labels Cut Calorie Consumption
Penn Medicine News ; US News & World Report ; Huffington Post ; CBS Philly ; Tech Times ; New Hampshire Voice , 06/17/16

CHIBE and CHOP Partner to Address Juvenile Diabetes through Way to Health Platform
Bench to Bedside (CHOP) , June/July 2016

Volpp and Asch Receive AcademyHealth Article of the Year Award for "Effect of Financial Incentives on Lipid Levels"
AcademyHealth, 06/14/16

Nudging Physicians Toward Value: Incentives in the Era of MACRA-Economics
Commonwealth Fund, 06/02/16

Making End-of-Life Care More Scientific
Philadelphia Inquirer, 05/22/16

CHIBE Partners with ideas42 for "Behavioral Insights for Health Innovation" Initiative
ideas42; , 05/17/16

Volpp, Asch and Halpern Lead New 'NEJM Catalyst' Advisory Committee
LDI eMagazine, 05/11/16

Changing EHR Default Options Increases Generic Prescribing
Medical Express, 05/09/16
Aufhauser DD Jr, Wang Z, Murken DR, Bhatti TR, Wang Y, Ge G, Redfield RR 3rd, Abt PL, Wang L, Svoronos N, Thomasson A, Reese PP, Hancock WW, Levine MH.  J Clin Invest. 2016. 126(5):1968-77.

Public Opinion Regarding Financial Incentives to Engage in Advance Care Planning and Complete Advance Directives.
Auriemma CL, Chen L, Olorunnisola M, Delman A, Nguyen CA, Cooney E, Gabler NB, Halpern SD. Am J Hosp Palliat Care. 2016. Epub ahead of print. 

Leveraging Behavioral Insights to Promote Vaccine Acceptance: One Year After Disneyland.  
Buttenheim AM, Asch DA.
JAMA Pediatr. 2016 Jul 1;170(7):635-6.

Obesity, Renin-Angiotensin System Blockade and Risk of Adverse Renal Outcomes: A Population-Based Cohort Study.
Cohen JB, Stephens-Shields AJ, Denburg MR, Anderson AH, Townsend RR, Reese PP. 
Am J Nephrol. 2016. 43(6):431-40.

Rationale and Design of the Randomized Evaluation of Default Access to Palliative Services (REDAPS) Trial. Courtright KR, Madden V, Gabler NB, Cooney E, Small DS, Troxel A, Casarett D, Ersek M, Cassel JB, Nicholas LH, Escobar G, Hill SH, O'Brien D, Vogel M, Halpern SD. Ann Am Thorac Soc. 2016. Epub ahead of print.   
mHealth for Tuberculosis Treatment Adherence: A Framework to Guide Ethical Planning, Implementation, and Evaluation. 
DiStefano MJ, Schmidt H. 
Glob Health Sci Pract. 2016. 4(2):211-21.

Calorie Underestimation When Buying High-Calorie Beverages in Fast-Food Contexts.  Franckle RL, Block JP, Roberto CA. Am J Public Health. 2016 Jul;106(7):1254-5. doi: 10.2105/AJPH.2016.303200.

Default options in advance directives: study protocol for a randomised clinical trial.
Gabler NB, Cooney E, Small DS, Troxel AB, Arnold RM, White DB, Angus DC, Loewenstein G, Volpp KG, Bryce CL, Halpern SD.
BMJ Open. 2016. 6(6):e010628.

Patients with Hepatocellular Carcinoma Have Highest Rates of Wait-listing for Liver Transplantation Among Patients With End-stage Liver Disease.
Goldberg D, French B, Newcomb C, Liu Q, Sahota G, Wallace AE, Forde KA, Lewis JD, Halpern SD. Clin Gastroenterol Hepatol. 2016. Epub ahead of print.

Evaluating the Impact of U.S. Food and Drug Administration-Proposed Nutrition Facts Label Changes on Young Adults' Visual Attention and Purchase Intentions.
Graham DJ, Roberto CA. Health Educ Behav. 2016. 43(4):389-98.

Heterogeneity in the Effects of Reward- and Deposit-based Financial Incentives on Smoking Cessation.  Halpern SD, French B, Small DS, Saulsgiver K, Harhay MO, Audrain-McGovern J, Loewenstein G, Asch DA, Volpp KG. Am J Respir Crit Care Med. 2016. Epub ahead of print.

Second Primary Cancers After Intensity-Modulated vs 3-Dimensional Conformal Radiation Therapy for Prostate Cancer.  Journy NM, Morton LM, Kleinerman RA, Bekelman JE, Berrington de Gonzalez A. JAMA Oncol. 2016. Epub ahead of print.

Consequences of Influencing Physician Behavior--Reply.
Judson TJ, Volpp KG, Detsky AS. JAMA. 2016. 7;315(21):2351.

Differences in Terminal Hospitalization Care Between U.S. Men and Women.
Just E, Casarett DJ, Asch DA, Dai D, Feudtner C.
J Pain Symptom Manage. 2016. pii: S0885-3924(16)30101-4. Epub ahead of print.

Nighttime physician staffing improves patient outcomes: no.   
Kerlin MP, Halpern SD. Intensive Care Med. 2016 Jun 27. Epub ahead of print. 

Disparities in Absolute Denial of Modern Hepatitis C Therapy by Type of Insurance.   Lo Re V 3rd, Gowda C, Urick PN, Halladay JT, Binkley A, Carbonari DM, Battista K, Peleckis C, Gilmore J, Roy JA, Doshi JA, Reese PP, Reddy KR, Kostman JR. . Clin Gastroenterol Hepatol. 2016. 14(7):1035-43.

Believing that certain foods are addictive is associated with support for obesity-related public policies. Moran A, Musicus A, Soo J, Gearhardt AN, Gollust SE, Roberto CA. Prev Med. 2016. 90:39-46. Epub ahead of print.

Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial.  
Patel MS, Asch DA, Rosin R, Small DS, Bellamy SL, Eberbach K, Walters KJ, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Volpp KG. J Gen Intern Med. 2016 Jul;31(7):746-54.

Generic Medication Prescription Rates After Health System-Wide Redesign of Default Options Within the Electronic Health Record.  
Patel MS, Day SC, Halpern SD, Hanson CW, Martinez JR, Honeywell S Jr, Volpp KG. . JAMA Intern Med. 2016.

To spray or not to spray? Understanding participation in an indoor residual spray campaign in Arequipa, Peru.
Paz-Soldán VA, Bauer KM, Hunter GC, Castillo-Neyra R, Arriola VD, Rivera-Lanas D, Rodriguez GH, Toledo Vizcarra AM, Mollesaca Riveros LM, Levy MZ, Buttenheim AM. Glob Public Health. 2016. Epub ahead of print.

Yelp Reviews Of Hospital Care Can Supplement And Inform Traditional Surveys Of The Patient Experience Of Care.  
Ranard BL, Werner RM, Antanavicius T, Schwartz HA, Smith RJ, Meisel ZF, Asch DA, Ungar LH, Merchant RM. Health Aff (Millwood). 2016 Apr 1;35(4):697-705.

Clinical impact of prolonged diagnosis to treatment interval (DTI) among patients with oropharyngeal squamous cell carcinoma. Sharma S, Bekelman J, Lin A, Lukens JN, Roman BR, Mitra N, Swisher-McClure S. Oral Oncol. 2016. 56:17-24. 

Stoler A, Kessler JB, Ashkenazi T, Roth AE, Lavee J.
Health Econ. 2016 Apr 29. Epub ahead of print.  
Troxel AB, Asch DA, Volpp KG.
Clin Trials. 2016.
Calorie Label Formats: Using Numeric and Traffic Light Calorie Labels to Reduce Lunch Calories.
VanEpps, EM; Downs, JS; Loewenstein, G.
Journal of Public Policy & Marketing. 2016. 35(1). 26-36.

Price Transparency: Not a Panacea for High Health Care Costs.
Volpp KG. JAMA. 2016. 315(17):1842-3.

Procedure-specific consent is the norm in United States intensive care units.   

Weiss EM, Kohn R, Madden V, Halpern S, Joffe S, Kerlin MP.
Intensive Care Med. 2016. Epub ahead of print.

Natural Language Processing to Assess Documentation of Features of Critical Illness in Discharge Documents of ARDS Survivors.  

Weissman GE, Harhay MO, Lugo RM, Fuchs BD, Halpern SD, Mikkelsen ME. Ann Am Thorac Soc. 2016. Epub ahead of print.
HP/CHIBE Work in Progress Seminars

Mitesh Patel, MD, MBA, MS, 
09/08/16 - 12:00pm
1104 Blockley Hall

Kit Delgado, MD, MS TBD 09/22/16 - 12:00 pm
1104 Blockley Hall

Mike Luca, PhD
10/13/16 - 12:00pm
1104 Blockley Hall

Ruben Amarasingham, MD, MBA 
TBD 11/10/16 - 12:00 pm
1104 Blockley Hall

Flora Or, MHS 
12/15/16 - 12:00 pm
1104 Blockley Hall 

Dear Colleague,

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

Our first story features a study conducted by Mitesh Patel, MD, Assistant Professor of Medicine and Health Care Management at the Perelman School of Medicine and CHIBE faculty member. The study, published recently in Health Affairs, tested the effectiveness of financial incentives in the form of premium adjustments. The results suggest these types of incentives are ineffective since they are hidden. "These incentives have to be salient and front of mind," Patel offered.

Our next story focuses on an article published in the Journal of Clinical Oncology, by lead author Eric Ojerholm, MD, a radiation oncology resident at Penn. The article suggests that default options could be used to improve the value and quality of treatment in cancer care, an idea that hasn't been widely embraced in that area. "We believe that defaults could be used across the continuum of cancer care. In particular, they may nudge patients and providers away from low-quality or low-value practices," the authors wrote.

Joanna Hart, MD, of the FIELDS program authors our "Musings" column to share how the principles of behavioral economics, which are usually focused on improving the daily behaviors of individuals to promote health, can also be used to approach complex shared medical decision making.

This issue also shares a spotlight on Kit Delgado, Assistant Professor of Emergency Medicine at Perelman School of Medicine and CHIBE grantee. Dr. Delgado discusses how he is using behavioral economic approaches for injury prevention in his research.

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

Kevin Volpp, Director
Scott Halpern, Deputy Director

Insurance Premium Breaks Don't Prompt Employee Weight Loss in Penn Study

Mitesh Patel, MD 
Employers who offer lower health insurance premiums as an incentive for workers to lose weight might do better to try an alternative approach, a University of Pennsylvania study suggests.
The 2013-15 study, published recently in
Health Affairs, found that an incentive valued at $550, whether offered in the form of a premium adjustment or a daily lottery unrelated to premiums, didn't lead obese employees to lose weight. 
More than 80 percent of large employers use financial incentives to promote better health, and while many use premium adjustments, that form of inducement hasn't been well evaluated, according to the study led by Mitesh Patel, MD, a CHIBE faculty member and assistant professor at Penn's Perelman and Wharton schools. Other members of the team included CHIBE faculty members Drs. Asch, Troxel and Volpp as well as CHIBE staff Lisa Wesby, Victoria Hilbert, Jingsan Zhu and Wenli Wang.

"In many programs effectiveness has been assumed rather than tested," the study said. Employers offered rewards averaging $690 in 2015, according to the authors, who noted that other research has shown incentive effectiveness depends on reward size and "on how it is deployed and in what context."

Researchers in the Penn study gave the nearly 200 workplace-wellness program participants a goal of losing 5 percent of their weight. The employees, based on random group assignments, were offered either an immediate or delayed cut in their premiums or an equivalent incentive in the form of lottery chances, or were assigned to a control set with no incentives.

After a year, there were no statistically significant mean weight-loss differences between the control arm and any of the incentive groups, or among the incentive sets.

"This suggests that employers involved in widespread efforts to encourage employee weight loss would benefit by testing alternatives to a standard premium adjustment approach- such as alternative incentive designs, changes in incentive magnitude, or both," the authors wrote.
The result wasn't surprising, according to Patel, who said in an interview that the researchers had hypothesized premium adjustments were ineffective, considering health insurance payments are broken up in employee paychecks throughout the year.

"It's really a hidden incentive. These incentives have to be salient and front of mind" to be effective, he said, explaining that premium adjustments are paid in the future and bundled into larger payments. A $550 adjustment made over 26 paychecks amounts to about $20 a check, he noted.

"We should be thinking about more creative ways to deploy incentives," Patel said. He suggests unbundling financial incentives from premiums.

The researchers had hoped the lottery incentive would be more effective, but were unable to factor in regret aversion - letting participants know what they would have won had they weighed in and met their goal. Since employees had to weigh in at work and had varying schedules it was not possible to distinguish between when the participant didn't weigh in versus when they were just off work that day.

Patel suggests that programs work with newer technologies, like wireless scales, that allow people to weigh in at home rather than at work.

In previous studies, Penn researchers found that other behavioral economics approaches did prompt weight loss, Patel noted. These incentives included a daily regret-aversion lottery in which participants were told what they would have won if they had met their weight-loss goal.

Another successful approach tried previously involved participants making deposits that would be returned and matched, with potential bonuses, if they met weight-loss goals. Another study found weight-loss success via a group incentive -- $500 to be split among five members of a group if they met their monthly goals.

"We need to try to figure out ways to fit these intervention s within the lives of patients," Patel said.  
-Dinah Wisenberg Brin
Cancer Care a Good Area To Explore Default Options

Eric Ojerholm, MD
As researchers look for ways to improve medical care, one avenue they've explored is the use of default options to help influence certain health choices. Default options have been employed to boost vaccination rates and generic drug prescriptions, for example.
An article written by Dr. Eric Ojerholm and CHIBE faculty members Drs. Scott Halpern and Justin Bekelman, published in the Journal of Clinical Oncology, suggests that default options could be used to improve the value and quality of treatment in another area - cancer care.
"It hasn't been an idea that's been widely embraced in cancer care," lead author Eric Ojerholm, MD, a radiation oncology resident at Penn, said in an interview. The researchers were surprised by the number of oncology scenarios in which default options might be suitable, he said.
"In the setting of finite health care resources, we believe that consciously constructing defaults to promote high-quality, high-value care is an appropriate and important effort," they wrote.
A default option goes into effect if a patient or physician doesn't make an alternative choice, the researchers noted.
In a study led by FIELDS Director Dr. Scott Halpern, for example, patients with life-limiting illnesses took home advance directive information that described their choices for life-extending treatment or comfort-oriented care. Patients received a form on which one option -- a default -- had already been checked, and were told either to confirm the choice or pick an alternative.
The default option profoundly influenced patients' choice . A large majority of patients in a comfort-oriented default group, 77 percent, chose that form of care, while only 43 percent of people in the life-extending default group chose comfort-oriented care.
Defaults may strike the right balance of choice and effectiveness when it comes to interventions that promote high-value healthcare practices or minimize low-value practices.
Providing information to educate healthcare providers on treatment guidelines, for instance, is "a very non-intrusive way of trying to influence behavior, but it may not be effective," Ojerholm said. On the other end of the spectrum, a hospital prohibiting certain procedures is "very effective, but it's also very intrusive." The default option "sits somewhere in the middle," he said, as it gives people the ability to choose an alternative with minimal effort.
"If guidelines have not been effective and stakeholders wish to gently influence behavior while preserving choice, defaults can be considered. Although it is paternalistic to intentionally design defaults toward a particular outcome, the key feature of this 'soft' or 'libertarian' paternalism is that it maintains the option to choose otherwise with minimal effort," the article said.
In cancer treatment, a default might be employed when there are more cost-effective alternatives to expensive cancer drug therapies, the researchers noted.
Among other possibilities, defaults programmed into an electronic prescription ordering system also might address the problems of over- or under-treating chemotherapy patients with anti-nausea drugs, the researchers said.
The article also suggested defaults might encourage prescription of short-course radiotherapy, which has been shown to be just as effective, but is lower cost and more convenient than a traditional treatment course for certain cancers.
"We believe that defaults could be used across the continuum of cancer care. In particular, they may nudge patients and providers away from low-quality or low-value practices," they wrote.
The researchers did note some concerns with defaults, such as the potential for negative unintended consequences, and the fact that a default program might work in one clinical context but not another. Cancer-specific evidence is needed, they said.
So-called smart defaults, Ojerholm noted, take into account patient- and disease-specific details.
The article suggested further research be conducted on defaults in cancer care, examining which defaults successfully change behavior, measuring the size of the effect and determining the best implementation method.
"I'd be excited if people would run with these ideas and test them, and test them rigorously," Ojerholm said.

- Dinah Wisenberg Brin
Musings of a Behavioral Economist
Joanna Hart, MD 
"Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue."
-Paul Kalanithi, MD in
When Breath Becomes Air
Metastatic non-small cell lung cancer is an incurable disease. Despite this, over 2/3 of patients with this cancer who are receiving palliative chemotherapy, which is intended to reduce symptoms and improve quality of life, report that they believe such treatment may cure their cancer. Similar predictive errors can be found across a wide range of health care decision makers, including asthmatics, family members of critically ill patients, and patients undergoing high-risk surgeries. These unrealistic expectations impair decision makers' abilities to weigh the relative risks and benefits of health care choices, thus degrading the decision making process. This is particularly worrisome in our current health care culture that places shared decision making at its foundation. Insights from behavioral economics may help identify the mechanisms leading to the formation of these errors and, ultimately, enable us to develop ways to overcome these misunderstandings.
Patients' engagement in health-promoting behaviors is often driven by their expectations of potential health outcomes. Errors in their expectations may reflect poor physician-patient communication, psychological self-protection as patients or their family members confront a health threat, or both. The difficulties of predicting future mortality, illness burden, and accompanying emotions limit patients' abilities to make decisions that promote health. Optimism is the typical direction of these predictive errors, reflecting unrealistic hopes. Such optimism, such as believing palliative chemotherapy can cure cancer, may lead to preventable patient distress when foreseeable, yet unforeseen, poor outcomes occur. A patient with metastatic lung cancer who believes a cure is possible is less likely to make choices which acknowledge and prepare for his or her impending decline in function and, ultimately, death. These neglected preparations may include those related to emotional, financial, or legal matters in addition to the health care choices made along the way. As such, optimistic patients are failing to be fiduciaries to their future selves.
While much of the clinical research using behavioral economics to date focuses on improving the daily behaviors of individuals to promote health (e.g., smoking cessation, eating and exercise habits, medication adherence), the same principles can also be used to approach complex shared decision making. For example, patients with lung cancer are often current or former heavy smokers. We know from prior work that heavy smokers are likely to have steep delay discounting rates. When facing lung cancer, this present bias is likely to change the way that these patients form expectations of future health states and the benefits of offered treatments, thus changing the way they make health care decisions. Therefore, clinicians need to provide information in a way that allows patients to select options that are matched to their true preferences. This first requires acknowledging that information alone does not overcome bounded rationality.
In the era of shared decision making and patient-centered care, we need to provide support to patients and family members making high-stakes decisions that are imbued with uncertainty. Prior attempts to develop and test supportive interventions have generally failed. At least in part, this is likely due to a failure to sufficiently incorporate the lessons behavioral economics has to teach. Extending the reach of behavioral economics to these complex health decisions will undoubtedly improve shared decision making. This is especially needed in those situations where shared decision making is at highest risk of failing to fulfill its promise of patient-centeredness: those in which patients and families experience extreme emotions and stress. In the face of suffering, a deft hand is required when communicating scientific evidence in a way that respects important aspects of our humanness such as hope and fear. Behavioral economics can provide the foundation for improving the quality of these decisions if we, as a community, are able to educate and advocate for its use among clinicians unaccustomed to the principles of decision theory.
- Joanna Hart, MD 
Researcher Spotlight:
M. Kit Delgado, MD, MS

M. Kit Delgado, MD, MS
M. Kit Delgado, MD, MS, is an emergency physician investigator and a CHIBE grantee. His research seeks to improve emergency care overall and to prevent injury in the first place. He has analyzed large existing datasets and used decision analytic modeling to guide policy aimed at improving trauma and emergency care. He is also developing a novel research program leveraging smartphones, connected devices, and insights from behavioral economics for injury prevention.
Why did you choose Emergency Medicine as a specialty?
Emergency medicine is a fun specialty to practice and it provides a unique lens to identify failures in public health prevention and in the health care system in general, which is appealing to me as someone who studied public policy as an undergraduate. The emergency department is the safety net of the health care system. We treat anyone who comes through the door, regardless of ability to pay.
You conduct health services research around improving emergency room trauma care, what are you working on?
Trauma is the number one cause death among people between the ages of 1 and 46 and it is the number one cause of potential years of life before the age of 75 - more than heart disease or cancer. The economic toll of trauma is estimated to be over $670 billion per year. Despite the huge public health and economic significance of trauma, there's relatively little science on how to take care of injured patients relative to other conditions.

Much of my work in health services research has focused on optimizing the triage, transport, and regionalization strategies for injured patients. I have looked into disparities in access to trauma care and have found that those with insurance are less likely to be transferred to designated trauma centers, which puts them at greater risk for mortality. I have also studied when it is cost-effective to use air medical evacuation and the cost-effectiveness of alternative field triage criteria. I recently received an NIH R03 award to extend this work to injured older adults. My colleagues at Rutgers University and I will analyze data from over 30,000 injured New Jersey residents ages 55 years and older. We'll use linked prehospital emergency medical service electronic records, hospital data, and death certificates to determine the effect triage and transport to a trauma center on 60-day mortality in this population. Hopefully, this work will enable smarter decision making in trauma care.

Describe how behavioral economics applies to your work.
A huge portion of the patients I see on a shift are in the emergency department due to the consequences of unhealthy, impulsive, and risky behaviors. After seeing the often tragic consequences of these behaviors, it's hard not to be motivated to prevent them in the first place. The work of other CHIBE investigators demonstrating behavioral change in adults reveals a huge opportunity to translate principles of behavioral economics to injury prevention, particularly in adolescents and young adults. The vast majority of serious injuries in these populations are caused by preventable risky behaviors and persistent cognitive decision errors that are amenable to behavioral economic interventions. For example, recurrent cell phone use while driving is an impulsive behavior that leads to serious injury, and it's driven by present-biased preferences. Everyone knows it's dangerous, but people keep doing it. I admit that I've picked up my phone in the middle of a drive when a notification pings, even though I know that I'm four to eight times more likely to crash my car during that instant.
What specific research are you doing around curbing cell phone use while driving?
With pilot funding from CHIBE, my colleagues and I are conducting two trials of interventions to reduce cell phone use while driving. Our tools include a windshield-mounted in-vehicle device (like an EZ Pass), smartphone apps that can measure cell phone use while driving, silence notifications, and block phone use while the car is in motion, plus behavioral engagement strategies informed by behavioral economics.
In the first trial, which is nearly complete, we are enrolling new teen drivers, the highest-risk group for serious crashes due to inexperience and distraction, and testing three different approaches against a monitor-only control group. The first approach is an "opt-in" blocking mode, where the teens have to remember to turn on the app each time they drive, akin to turning on Airplane mode when flying. The second approach is an "opt-out" blocking mode which comes on automatically when the car is in motion, and can be overridden The third approach, is an "opt-out" blocking approach combined with the disincentive of an email to the parent each time the blocking is overridden.
In the second trial, which will start enrolling in September, teen-parent dyads will be enrolled together. We found that in previous survey work, that 77% of teens who admit to texting while driving watch their parents do the same. We wanted to get around the "do as I say, and not as I do phenomenon." We also recognized that teens are on the same insurance plan as their parents and, given that these type of in-vehicle devices and smartphone apps are increasingly being deployed for usage based auto insurance, we saw an opportunity for incentivizing intrafamily behavioral strategies that reduce this risky behavior. In one study arm, teens and parents will both have "opt-out" cellphone blocking, but only the parents will be notified if their teens overrides the blocking. In the second study arm, the parents will be notified if their teens override the blocking and the teens will be notified if their parents override the blocking, thereby also keeping their parents accountable.
What other information has the technology you are using in the cellphone study enabled you to access?
In addition to assessing the effect of our interventions to reduce cellphone use while driving, we're conducting a number of secondary epidemiologic analyses using the 4-week baseline data we've collected in this population. We will describe for the first time the speed at which teens unlock their phones, and by linking the GPS and timestamp data to publically available spatial datasets, we will also be able to record the time of day, proximity to high-risk features such as intersections, street poles, bike lanes, and crosswalks. We will be better able to determine the correlation between behavioral characteristics such as present-bias, impulsivity, and cellphone addiction with use in high-risk situations. Additionally, we were recently approached to explore applying this work to commercial drivers and fleet-level interventions to incentivize safer driving.
How else can principles of behavioral economics be brought into research around emergency medicine?
Emergency physicians are tasked with making hundreds to thousands of decisions during a shift in a high stress environment with high stakes. Decision fatigue, a reliance on heuristics, and what Daniel Kahneman calls Type 1 thinking often occurs in these situations. Additionally, a study by my colleague Tiffani Johnson has shown that implicit bias in pediatric emergency physicians increases when the emergency department is overcrowded. Leveraging electronic medical records is one way to overcome these cognitive biases. For example, implementing default order sets for acute conditions may reduce treatment variability and, possibly, racial and ethnic disparities. The new Penn Medicine Nudge Unit has recently decided to implement my suggested "Big Idea" to leverage emergency medical record order defaults to safely reduce the quantity supplied for opioid prescriptions.
What other behavioral economic research are you excited about now?
We have received funding for pilot studies from CHIBE and the Penn Injury Science Center for research using smartphones to reduce risky drinking and drinking and driving. This spring we will be launching a randomized trial using smartphone-paired breathalyzers, financial incentives, and rideshare credits for reducing drinking and driving among high-risk adults. We will also be conducting pilot tests of newly developed wearable alcohol biosensor technology that will be a game changer in the field of remote alcohol monitoring and contingency management.
What's next for you?

In terms of behavioral economics, my long-term vision is to develop and sustain a research program leveraging smartphones and connected devices for injury prevention. I'm working on turning these pilot trials of interventions for cellphone use and drinking and driving into the bigger grants needed to sustain such a program.

- Christine Weeks