A randomized controlled trial to evaluate a behavioral economic strategy for improving mobility in veterans with chronic pain.

Rates of chronic pain and daily opioid use are higher among veterans relative to civilian populations. Increasing physical activity can reduce pain severity and decrease opioid use among patients with chronic pain. Behavioral economic strategies can improve physical activity levels but have been undertested in veterans with chronic pain. The objective of this study was to evaluate if a financial incentive combined with a loss aversion component-a "regret lottery" in which veterans could win money if they met a set goal or told how much they could have won had they met their goal-would increase physical activity levels among veterans with chronic pain. A 12-week single-blinded randomized controlled trial (ClinicalTrials.gov: NCT04013529) was designed. Veterans with chronic pain (N = 40) receiving care at a specialty pain clinic were eligible for participation, and were randomly assigned (1:1) to either (a) activity trackers and daily text message reminders to increase physical activity ("control arm"), or (b) the same plus a weekly regret lottery ("intervention arm"). For those in the intervention arm, participants who met their activity goal, had a chance to win a small ($30) or large ($100) gift card incentive; those who did not meet their goals were informed of what they would have won had they met their goal. The primary outcome, physical activity, was measured using self-reported physical activity and step counts using activity trackers. Secondary outcomes included changes in physical function, chronic pain severity, depression and opioid use. The sample was primarily white, male and disabled, with an average age of 57 years. No between-arm differences were noted for physical activity, physical function, chronic pain severity, depression or opioid use. Regret lottery-based approaches may be ineffective at increasing physical activity levels in veterans with chronic pain. Trial Registry: NCT04013529.

Effect of Peer Mentors in Diabetes Self-management vs Usual Care on Outcomes in US Veterans With Type 2 Diabetes: A Randomized Clinical Trial.

Importance: Diabetes is a substantial public health issue. Peer mentoring is a low-cost intervention for improving glycemic control in patients with diabetes. However, long-term effects of peer mentoring and creation of sustainable models are not well studied. Objective: Assess the effects of a peer support intervention for improving glycemic control in patients with diabetes and evaluate a model in which former mentees serve as mentors. Design, Setting, and Participants: A randomized clinical trial was conducted from September 27, 2012, to March 21, 2018, at the Corporal Michael J. Crescenz Medical Center. US veterans with type 2 diabetes aged 30 to 75 years with hemoglobin A1C (HbA1c) greater than 8% received support over 6 months from peers with prior poor glycemic control but who had achieved HbA1c less than or equal to 7.5% (phase 1). Phase 1 mentees were then randomized to become a mentor or not to new randomly assigned participants in phase 2. Outcomes were assessed at 6 and 12 months. Data were analyzed from October 5, 2016, to September 4, 2018. Interventions: Mentors who received an initial training session and monthly reinforcement training were assigned 1 mentee and given $20 for each month they contacted their mentee at least weekly. Main Outcomes and Measures: Primary outcome was HbA1c change at 6 months. Secondary outcomes included HbA1c change at 12 months and change in low-density lipoprotein, blood pressure, diabetes quality of life, and depression symptoms at 6 and 12 months. Results: The study enrolled 365 participants into phase 1 and 122 participants into phase 2. Most participants were Black (341 [66%]) and male (454 [96%]), with a mean (SD) age of 60 (7.5) years. Mean phase 1 HbA1c change at 6 months for usual care was -0.20% (95% CI, -0.46% to 0.06%) vs -0.52% (95% CI, -0.76% to -0.29%) for mentees (P = .06). Mean phase 2 HbA1c change at 6 months for usual care was -0.46% (95% CI, -1.02% to 0.10%) vs 0.08% (95% CI, -0.42% to 0.57%) for mentees (P = .16). There were no differences in secondary outcomes or HbA1c levels at 12 months. There was no benefit to past mentees who became mentors. Conclusions and Relevance: In this randomized clinical trial, a peer mentor intervention did not improve 6-month HbA1c levels and did not have sustained benefits. Trial Registration: ClinicalTrials.gov Identifier: NCT01651117.

Insights Into Veterans' Perspectives on a Peer Support Program for Glycemic Management.

PURPOSE: The purpose of this study was to explore the mentor-mentee relationship in veterans with type 2 diabetes and gain insight into successful pairings. METHODS: Qualitative semistructured interviews were conducted as part of a peer mentoring randomized controlled trial to understand participants' experiences, their relationship with their partner, and how the intervention affected self-care behaviors. Purposive sampling was done to ensure adequate representation of mentees who made large strides in reaching their glycemic targets, those who made marginal improvements toward their glycemic goals, and those who got worse. All interviews were audio-recorded, transcribed, and analyzed for salient themes. RESULTS: The intervention was well received, with most participants describing it as valuable. Participants perceived the intervention to have a number of benefits, including accessible support, enhanced self-confidence, increased accountability, better self-efficacy, improved glycemic management, and a fulfilled sense of altruism. Participants did encounter barriers, including logistical, interpersonal, and individual obstacles. The more successful mentees tended to be more effusive in their description of their mentors, endorsed a stronger sense of connection to their mentor, described a more structured interaction with their mentor, and tended to be more complimentary of the intervention. CONCLUSIONS: Large peer support programs are appealing and well received. These programs can be optimized by selecting naturally inclined mentors, providing additional training to introduce more structure into mentorship interactions, and targeting mentees who are not struggling with overwhelming comorbidities.

Financial incentives for completion of fecal occult blood tests among veterans: a 2-stage, pragmatic, cluster, randomized, controlled trial.

BACKGROUND: Rates of patient completion of fecal occult blood tests (FOBTs) are often low. OBJECTIVE: To examine whether financial incentives increase rates of FOBT completion. DESIGN: A 2-stage, parallel-design, pragmatic, cluster, randomized, controlled trial with clustering by clinic day (ClinicalTrials.gov: NCT01516489). SETTING: Primary care clinic of the Philadelphia Veterans Affairs Medical Center. PATIENTS: 1549 patients who were prescribed an FOBT (unique samples of 713 patients for stage 1 and 836 patients for stage 2). INTERVENTION: In stage 1, patients were assigned to usual care or receipt of $5, $10, or $20 for FOBT completion. In stage 2, different patients were assigned to usual care or receipt of $5, a 1 in 10 chance of $50, or entry into a $500 raffle for FOBT completion. MEASUREMENTS: Primary outcome was FOBT completion within 30 days. Preplanned subgroup analyses examined 30-day FOBT completion by previous nonadherence to a prescribed FOBT. RESULTS: In stage 1, none of the incentives increased rates of FOBT completion. In stage 2, a 1 in 10 chance of $50 increased FOBT completion compared with usual care (between-group difference, 19.6% [95% CI, 10.7% to 28.6%]; P < 0.001) but a $5 fixed payment and entry into a raffle for $500 did not. None of the incentives were more effective among patients who had previously been nonadherent to an FOBT than among patients who had previously completed an FOBT. LIMITATIONS: Single Veterans Affairs medical center setting, short follow-up, use of 3-sample rather than 1-sample immunochemical FOBTs, limited power to detect small effects of incentives, inability to evaluate cost-effectiveness. CONCLUSION: A 1 in 10 chance of receiving $50 was effective at increasing rates of FOBT completion, but 5 other tested incentives were not. PRIMARY FUNDING SOURCE: Veterans Affairs Center for Health Equity Research and Promotion.