Do smoking abstinence periods among pregnant smokers improve birth weight? A secondary analysis of a randomised, controlled trial.

OBJECTIVES: Maternal smoking during pregnancy is associated with low birth weight (LBW). Reduction of cigarette consumption does not seem to improve birth weight but it is not known whether implementation of periods of smoking abstinence improves it. We assessed whether the number of 7-day periods of smoking abstinence during pregnancy may help reduce the number of newborns with LBW. DESIGN AND SETTING: Secondary analysis of a randomised, controlled, multicentre, smoking cessation trial among pregnant smokers. PARTICIPANTS: Pregnant women were included at <18 weeks of gestational age and assessed at face-to-face, monthly visits. Data of 407 singleton live births were analysed. PRIMARY OUTCOME MEASURE: Newborns with low birth weight. RESULTS: 40 and 367 newborns were born with and without LBW, respectively. Adjusted for all available confounders, 3 or more periods of at least 7 days' smoking abstinence during pregnancy was associated with reduced likelihood of LBW compared with no abstinence periods (OR = 0.124, 95% CI 0.03 to 0.53, p = 0.005). Reduction of smoking intensity by at least 50% was not associated with birth weight. CONCLUSION: Aiming for several periods of smoking abstinence among pregnant smokers unable to remain continuously abstinent from smoking may be a better strategy to improve birth weight than reducing cigarette consumption. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02606227.

The effects of multi-disciplinary integrated care on healthcare utilization: Evidence from a natural experiment in the UK.

Better integration is a priority for most international health systems. However, multiple interventions are often implemented simultaneously, making evaluation difficult and providing limited evidence for policy makers about specific interventions. We evaluate a common integrated care intervention, multi-disciplinary group (MDG) meetings for discussion of high-risk patients, introduced in one socio-economically deprived area in the UK in spring 2015. Using data from multiple waves of the national GP Patient Survey and Hospital Episode Statistics, we estimate its effects on primary and secondary care utilization and costs, health status and patient experience. We use triple differences, exploiting the targeting at people aged 65 years and over, parsing effects from other population-level interventions implemented simultaneously. The intervention reduced the probability of visiting a primary care nurse by three percentage points and decreased length of stay by 1 day following emergency care admission. However, since planned care use increased, overall costs were unaffected. MDG meetings are presumably fulfilling public health objectives by decreasing length of stay and detecting previously unmet needs. However, the effect of MDGs on health system cost is uncertain and health remains unchanged. Evaluations of specific integrated care interventions may be more useful to public decision makers facing budget constraints.

Financial incentives for smoking cessation in pregnancy: multicentre randomised controlled trial.

OBJECTIVE: To evaluate the efficacy of financial incentives dependent on continuous smoking abstinence on smoking cessation and birth outcomes among pregnant smokers. DESIGN: Single blind, randomised controlled trial. SETTING: Financial Incentive for Smoking Cessation in Pregnancy (FISCP) trial in 18 maternity wards in France. PARTICIPANTS: 460 pregnant smokers aged at least 18 years who smoked ≤5 cigarettes/day or ≤3 roll-your-own cigarettes/day and had a pregnancy gestation of <18 weeks were randomised to a financial incentives group (n=231) or a control group (n=229). INTERVENTIONS: Participants in the financial incentives group received a voucher equivalent to €20 (£17; $23), and further progressively increasing vouchers at each study visit if they remained abstinent. Participants in the control group received no financial incentive for abstinence. All participants received a €20 show-up fee at each of six visits. MAIN OUTCOME MEASURES: The main outcome measure was continuous smoking abstinence from the first post-quit date visit to visit 6, before delivery. Secondary outcomes in the mothers were point prevalence abstinence, time to smoking relapse, withdrawal symptoms, blood pressure, and alcohol and cannabis use in past 30 days. Secondary outcomes in the babies were gestational age at birth, birth characteristics (birth weight, length, head circumference, Apgar score), and a poor neonatal outcome-a composite measure of transfer to the neonatal unit, congenital malformation, convulsions, or perinatal death. RESULTS: Mean age was 29 years. In the financial incentives and control groups, respectively, 137 (59%) and 148 (65%) were employed, 163 (71%) and 171 (75%) were in a relationship, and 41 (18%) and 31 (13%) were married. The participants had smoked a median of 60 cigarettes in the past seven days. The continuous abstinence rate was significantly higher in the financial incentives group (16%, 38/231) than control group (7%, 17/229): odds ratio 2.45 (95% confidence interval 1.34 to 4.49), P=0.004). The point prevalence abstinence rate was higher (4.61, 1.41 to 15.01, P=0.011), the median time to relapse was longer (visit 5 (interquartile range 3-6) and visit 4 (3-6), P<0.001)), and craving for tobacco was lower (ß=-1.81, 95% confidence interval -3.55 to -0.08, P=0.04) in the financial incentives group than control group. Financial incentives were associated with a 7% reduction in the risk of a poor neonatal outcome: 4 babies (2%) in the financial incentives group and 18 babies (9%) in the control group: mean difference 14 (95% confidence interval 5 to 23), P=0.003. Post hoc analyses suggested that more babies in the financial incentives group had birth weights ≥2500 g than in the control group: unadjusted odds ratio 1.95 (95% confidence interval 0.99 to 3.85), P=0.055; sex adjusted odds ratio 2.05 (1.03 to 4.10), P=0.041; and sex and prematurity adjusted odds ratio 2.06 (0.90 to 4.71), P=0.086. As these are post hoc analyses, the results should be interpreted with caution. CONCLUSIONS: Financial incentives to reward smoking abstinence compared with no financial incentives were associated with an increased abstinence rate in pregnant smokers. Financial incentives dependent on smoking abstinence could be implemented as a safe and effective intervention to help pregnant smokers quit smoking. TRIAL REGISTRATION: ClinicalTrials.gov NCT02606227.

Does retirement affect secondary preventive care use? Evidence from breast cancer screening.

This paper examines the causal impact of retirement on preventive care use by focusing on breast cancer screening. It contributes to a better understanding of the puzzling results in the literature reporting mixed effects on health care consumption at retirement. We use five waves of data from the Eurobarometer surveys conducted between 1996 and 2006, covering 25 different European countries. We address the endogeneity of retirement by using age thresholds for pension eligibility as instrumental variables in a bivariate probit model. We find that retirement reduces mammography use and other secondary preventive care use. Our results suggest that health status, income, and knowledge on cancer prevention and treatment contribute little to our understanding of the effects of retirement. Instead, our evidence suggests important effect heterogeneity based on the generosity of the social health insurance system and organized screening programs.

Does prevention-focused integration lead to the triple aim? An evaluation of two new care models in England.

OBJECTIVES: To examine the effectiveness of two integrated care models ('vanguards') in Salford and South Somerset in England, United Kingdom, in relation to patient experience, health outcomes and costs of care (the 'triple aim'). METHODS: We used difference-in-differences analysis combined with propensity score weighting to compare the two care model sites with control ('usual care') areas in the rest of England. We estimated combined and separate annual effects in the three years following introduction of the new care model, using the national General Practice Patient Survey (GPPS) to measure patient experience (inter-organisational support with chronic condition management) and generic health status (EQ-5D); and hospital episode statistics (HES) data to measure total costs of secondary care. As secondary outcomes we measured proxies for improved prevention: cost per user of secondary care (severity); avoidable emergency admissions; and primary care utilisation. RESULTS: Both intervention sites showed an increase in total costs of secondary care (approximately £74 per registered patient per year in Salford, £45 in South Somerset) and cost per user of secondary care (£130-138 per person per year). There were no statistically significant effects on health status or patient experience of care. There was a more apparent short-term negative effect on measured outcomes in South Somerset, in terms of increased costs and avoidable emergency admissions, but these reduced over time. CONCLUSION: New care models such as those implemented within the Vanguard programme in England might lead to unintended secondary care cost increases in the short to medium term. Cost increases appeared to be driven by average patient severity increases in hospital. Prevention-focused population health management models of integrated care, like previous more targeted models, do not immediately improve the health system's triple aim.

Health information provision, health knowledge and health behaviours: Evidence from breast cancer screening.

Many public health interventions aim to provide individuals with health information on the consequences of behaviours such as smoking, alcohol consumption or preventive care use, with the intention of changing health behaviour through better health knowledge. This paper examines whether the provision of health information in organised breast cancer screening programs affects mammography utilisation via changes in health knowledge. We use unique data on 10,610 European women from the Eurobarometer survey collected in 1997/1998, and we exploit variation in the availability and coverage of organised breast cancer screening programs for causal identification in a difference-in-differences design. We find that health information provision improves health knowledge. Yet, these changes in health knowledge had little to no effects on mammography utilisation in the overall population. Our findings imply that health information provision contributes little to health behaviour change. Although screening programs are effective at increasing preventive care use, their effect can be attributed almost entirely to factors other than health knowledge.

The effect of organized breast cancer screening on mammography use: Evidence from France.

In 2004, France introduced a national program of organized breast cancer screening. The national program built on preexisting local programs in some, but not all, départements. Using data from multiple waves of a nationally representative biennial survey of the French population, we estimate the effect of organized screening on the percentage of women obtaining a mammogram. The analysis uses difference-in-differences methods to exploit the fact that the program was targeted at women in a specific age group: 50 to 74 years old. We find that organized screening significantly raised mammography rates among women in the target age range. Just above the lower age threshold, the percentage of women reporting that they had a mammogram in the past 2 years increased by over 10 percentage points after the national program went into effect. Mammography rates increased even more among women in their 60s. Estimated effects are particularly large for women with less education and lower incomes, suggesting that France's organized screening program has reduced socioeconomic disparities in access to mammography.

Increasing breast-cancer screening uptake: A randomized controlled experiment.

Early screening increases the likelihood of detecting cancer, thereby improving survival rates. National screening programs have been established in which eligible women receive a letter containing a voucher for a free screening. Even so, mammography use is often considered as remaining too low. We test four behavioral interventions in a large-scale randomized experiment involving 26,495 women. Our main assumption is that, due to biases in decision-making, women may be sensitive to the content and presentation of the invitation letter they receive. None of our treatments had any significant impact on mammography use. Sub-sample analysis suggests that this lack of a significant impact holds also for women invited for the first time and low-income women.

Public acceptability of financial incentives to reward pregnant smokers who quit smoking: a United Kingdom-France comparison.

A substantial amount of research has been conducted on financial incentives to increase abstinence from smoking among pregnant smokers. If demonstrated to be effective, financial incentives could be proposed as part of health care interventions to help pregnant smokers quit. Public acceptability is important; as such interventions could be publicly funded. Concerns remain about the acceptability of these interventions in the general population. We aimed to assess the acceptability of financial incentives to reward pregnant smokers who stop smoking using a survey conducted in the UK and then subsequently in France, two developed countries with different cultural and social backgrounds. More French than British respondents agreed with financial incentives for rewarding quitting smoking during pregnancy, not smoking after delivery, keeping a smoke-free household, health service payment for meeting target and the maximum amount of the reward. However, fully adjusted models showed significant differences only for the two latter items. More British than French respondents were neutral toward financial incentives. Differences between the representative samples of French and British individuals demonstrate that implementation of financial incentive policies may not be transferable from one country to another.

Contributions of risk preference, time orientation and perceptions to breast cancer screening regularity.

Disparities in breast cancer screening are often explained by socioeconomic factors, although a growing body of papers show that risk preference, time orientation and perceptions may explain mammography use. The aim of this paper is to estimate the relative contribution of socioeconomic factors, risk preference, time orientation and perceptions to disparities in breast cancer screening regularity. These determinants are elicited in an experimental laboratory from 178 women aged between 50 and 75 years in France in 2013. The results reveal that risk aversion accounts for 30% of the variance in screening regularity, which is greater than that attributable to socioeconomic determinants (20%), perceptions (11.5%) or time orientation (2%). These results suggest that further investigation on the relationship between risk aversion and screening behaviors is needed to design more comprehensive public health interventions.

Protocol for study of financial incentives for smoking cessation in pregnancy (FISCP): randomised, multicentre study.

INTRODUCTION: Maternal smoking during pregnancy is associated with adverse perinatal and postnatal health outcomes. The efficacy of nicotine replacement therapies in helping pregnant smokers to quit is not clearly demonstrated; therefore new interventions should be proposed and assessed. Financial incentives rewarding abstinence from tobacco smoking is one of the promising options. OBJECTIVE: To assess the efficacy of financial incentives on smoking abstinence among French pregnant smokers. PARTICIPANTS: pregnant smokers aged ≥18 years, smoking at least five manufactured or three roll-your-own cigarettes per day, and pregnant for <18 weeks of amenorrhoea (WA). SETTING: participants will be recruited, included and followed-up at monthly face-to-face visits in 16 maternity wards in France. INTERVENTIONS: participants will be randomised to a control or an intervention group. After a predefined quit date, participants in the control group will receive €20 vouchers at the completion of each visit but no financial incentive for smoking abstinence. Participants in the intervention group will be rewarded for their abstinence by vouchers on top of the €20 show-up fee. The amount of reward for abstinence will increase as a function of duration of abstinence to stimulate longer periods of abstinence. MAIN OUTCOME MEASURE: complete abstinence from quit date to the last predelivery visit. SECONDARY OUTCOME MEASURES: point prevalence abstinence, time to relapse to smoking, birth weight, fetal growth restriction, preterm birth. Main data analysis: outcomes will be analysed on an intention-to-treat (ITT) basis. The ITT population is defined as all randomised smoking pregnant women. ETHICS AND DISSEMINATION: The research protocol was approved by the ethics committee (Comité de Protection des Personnes, CPP) of the Pitié-Salpêtrière Hospital on 15 May 2015, and Amendment No 1 was approved on 13 July 2015. Results will be presented at scientific meetings and published. TRIAL REGISTRATION NUMBER: NCT02606227; Pre-results.