Feedback and Financial Incentives for Reducing Cell Phone Use While Driving: A Randomized Clinical Trial.

Importance: Handheld phone use while driving is a major factor in vehicle crashes. Scalable interventions are needed to encourage drivers not to use their phones. Objective: To test whether interventions involving social comparison feedback and/or financial incentives can reduce drivers' handheld phone use. Design, Setting, and Participants: In a randomized clinical trial, interventions were administered nationwide in the US via a mobile application in the context of a usage-based insurance program (Snapshot Mobile application). Customers were eligible to be invited to participate in the study if enrolled in the usage-based insurance program for 30 to 70 days. The study was conducted from May 13 to June 30, 2019. Analysis was completed December 22, 2023. Interventions: Participants were randomly assigned to 1 of 6 trial arms for a 7-week intervention period: (1) control; (2) feedback, with weekly push notification about their handheld phone use compared with that of similar others; (3) standard incentive, with a maximum $50 award at the end of the intervention based on how their handheld phone use compared with similar others; (4) standard incentive plus feedback, combining interventions of arms 2 and 3; (5) reframed incentive plus feedback, with a maximum $7.15 award each week, framed as participant's to lose; and (6) doubled reframed incentive plus feedback, a maximum $14.29 weekly loss-framed award. Main Outcome and Measure: Proportion of drive time engaged in handheld phone use in seconds per hour (s/h) of driving. Analyses were conducted with the intention-to-treat approach. Results: Of 17 663 customers invited by email to participate, 2109 opted in and were randomized. A total of 2020 drivers finished the intervention period (68.0% female; median age, 30 [IQR, 25-39] years). Median baseline handheld phone use was 216 (IQR, 72-480) s/h. Relative to control, feedback and standard incentive participants did not reduce their handheld phone use. Standard incentive plus feedback participants reduced their use by -38 (95% CI, -69 to -8) s/h (P = .045); reframed incentive plus feedback participants reduced their use by -56 (95% CI, -87 to -26) s/h (P < .001); and doubled reframed incentive plus feedback participants reduced their use by -42 s/h (95% CI, -72 to -13 s/h; P = .007). The 5 active treatment arms did not differ significantly from each other. Conclusions and Relevance: In this randomized clinical trial, providing social comparison feedback plus incentives reduced handheld phone use while individuals were driving. Trial Registration: ClinicalTrials.gov Identifier: NCT03833219.

Pilot Study of a Mobile Phone Chatbot for Medication Adherence and Toxicity Management Among Patients With GI Cancers on Capecitabine.

PURPOSE: Capecitabine is an oral chemotherapy used to treat many gastrointestinal cancers. Its complex dosing and narrow therapeutic index make medication adherence and toxicity management crucial for quality care. METHODS: We conducted a pilot study of PENNY-GI, a mobile phone text messaging-based chatbot that leverages algorithmic surveys and natural language processing to promote medication adherence and toxicity management among patients with gastrointestinal cancers on capecitabine. Eligibility initially included all capecitabine-containing regimens but was subsequently restricted to capecitabine monotherapy because of challenges in integrating PENNY-GI with radiation and intravenous chemotherapy schedules. We used design thinking principles and real-time data on safety, accuracy, and usefulness to make iterative refinements to PENNY-GI with the goal of minimizing the proportion of text messaging exchanges with incorrect medication or symptom management recommendations. All patients were invited to participate in structured exit interviews to provide feedback on PENNY-GI. RESULTS: We enrolled 40 patients (median age 64.5 years, 52.5% male, 62.5% White, 55.0% with colorectal cancer, 50.0% on capecitabine monotherapy). We identified 284 of 3,895 (7.3%) medication-related and 13 of 527 (2.5%) symptom-related text messaging exchanges with incorrect recommendations. In exit interviews with 24 patients, participants reported finding the medication reminders reliable and user-friendly, but the symptom management tool was too simplistic to be helpful. CONCLUSION: Although PENNY-GI provided accurate recommendations in >90% of text messaging exchanges, we identified multiple limitations with respect to the intervention's generalizability, usefulness, and scalability. Lessons from this pilot study should inform future efforts to develop and implement digital health interventions in oncology.

Validation of an Automated Symptom-Based Triage Tool in Ophthalmology.

OBJECTIVES: Acute care ophthalmic clinics often suffer from inefficient triage, leading to suboptimal patient access and resource utilization. This study reports the preliminary results of a novel, symptom-based, patient-directed, online triage tool developed to address the most common acute ophthalmic diagnoses and associated presenting symptoms. METHODS: A retrospective chart review of patients who presented to a tertiary academic medical center's urgent eye clinic after being referred for an urgent, semi-urgent, or nonurgent visit by the ophthalmic triage tool between January 1, 2021 and January 1, 2022 was performed. Concordance between triage category and severity of diagnosis on the subsequent clinic visit was assessed. RESULTS: The online triage tool was utilized 1,370 and 95 times, by the call center administrators (phone triage group) and patients directly (web triage group), respectively. Of all patients triaged with the tool, 8.50% were deemed urgent, 59.2% semi-urgent, and 32.3% nonurgent. At the subsequent clinic visit, the history of present illness had significant agreement with symptoms reported to the triage tool (99.3% agreement, weighted kappa = 0.980, p < 0.001). The triage algorithm also had significant agreement with the severity of the physician diagnosis (97.0% agreement, weighted kappa = 0.912, p < 0.001). Zero patients were found to have a diagnosis on exam that should have corresponded to a higher urgency level on the triage tool. CONCLUSION: The automated ophthalmic triage algorithm was able to safely and effectively triage patients based on symptoms. Future work should focus on the utility of this tool to reduce nonurgent patient load in urgent clinical settings and to improve access for patients who require urgent medical care.

Development of a patient-centered text message-based platform for the self-management of interstitial cystitis/bladder pain syndrome symptoms.

OBJECTIVE: To develop a patient-centered text message-based platform that promotes self-management of symptoms of interstitial cystitis/bladder pain syndrome (IC/BPS). METHODS: Adult women with IC/BPS interested in initiating a first- or second-line treatments per American Urological Association guidelines (recategorized as "behavioral/non-pharmacologic treatments" and "oral medicines" in the 2022 version) participated in rapid cycle innovation consisting of iterative cycles of contextual inquiry, prototype design and development. We delivered treatment modules and supportive messages using an algorithm-driven interactive messaging prototype through a HIPAA-compliant texting platform. Patients provided feedback through narrative text messages and an exit interview. Feedback was analyzed qualitatively and used to iteratively revise the platform until engagement ≥ 85% and accuracy ≥ 80% were achieved. The final version consisted of four treatment module categories (patient education and behavioral modification, cognitive behavioral therapy, pelvic floor physical therapy, and guided mindfulness practices) and supportive messages delivered through an automated algorithm over 6 weeks. RESULTS: Thirty IC/BPS patients with moderate symptom bother (median IC Problem Index score 9, range 6-12) participated in five cycles of contextual inquiry. Qualitative analysis identified three overarching concepts that informed the development of the platform: preference for patient centered terms, desire to gain self-efficacy in managing symptoms, and need for provider support. Patients preferred the term "interstitial cystitis" to "bladder pain syndrome" which carried the stigma of chronic pain. Patients reported greater self-efficacy in managing symptoms through improved access to mind-body and behavioral treatment modules that helped them to gain insight into their motivations and behaviors. The concept of provider support was informed by shared decision making (patients could choose preferred treatment modules) and reduced sense of isolation (weekly check in messages to check on symptom bother). CONCLUSION: A patient centered text message-based platform may be clinically useful in the self-management of IC/BPS symptoms.

Effect of Text Messaging and Behavioral Interventions on COVID-19 Vaccination Uptake: A Randomized Clinical Trial.

Importance: COVID-19 vaccine uptake among urban populations remains low. Objective: To evaluate whether text messaging with outbound or inbound scheduling and behaviorally informed content might increase COVID-19 vaccine uptake. Design, Setting, and Participants: This randomized clinical trial with a factorial design was conducted from April 29 to July 6, 2021, in an urban academic health system. The trial comprised 16 045 patients at least 18 years of age in Philadelphia, Pennsylvania, with at least 1 primary care visit in the past 5 years, or a future scheduled primary care visit within the next 3 months, who were unresponsive to prior outreach. The study was prespecified in the trial protocol, and data were obtained from the intent-to-treat population. Interventions: Eligible patients were randomly assigned in a 1:20:20 ratio to (1) outbound telephone call only by call center, (2) text message and outbound telephone call by call center to those who respond, or (3) text message, with patients instructed to make an inbound telephone call to a hotline. Patients in groups 2 and 3 were concurrently randomly assigned in a 1:1:1:1 ratio to receive different content: standard messaging, clinician endorsement (eg, "Dr. XXX recommends"), scarcity ("limited supply available"), or endowment framing ("We have reserved a COVID-19 vaccine appointment for you"). Main Outcomes and Measures: The primary outcome was the proportion of patients who completed the first dose of the COVID-19 vaccine within 1 month, according to the electronic health record. Secondary outcomes were the completion of the first dose within 2 months and completion of the vaccination series within 2 months of initial outreach. Additional outcomes included the percentage of patients with invalid cell phone numbers (wrong number or nontextable), no response to text messaging, the percentage of patients scheduled for the vaccine, text message responses, and the number of telephone calls made by the access center. Analysis was on an intention-to-treat basis. Results: Among the 16 045 patients included, the mean (SD) age was 36.9 (11.1) years; 9418 (58.7%) were women; 12 869 (80.2%) had commercial insurance, and 2283 (14.2%) were insured by Medicaid; 8345 (52.0%) were White, 4706 (29.3%) were Black, and 967 (6.0%) were Hispanic or Latino. At 1 month, 14 of 390 patients (3.6% [95% CI, 1.7%-5.4%]) in the outbound telephone call-only group completed 1 vaccine dose, as did 243 of 7890 patients (3.1% [95% CI, 2.7%-3.5%]) in the text plus outbound call group (absolute difference, -0.5% [95% CI, -2.4% to 1.4%]; P = .57) and 253 of 7765 patients (3.3% [95% CI, 2.9%-3.7%]) in the text plus inbound call group (absolute difference, -0.3% [95% CI, -2.2% to 1.6%]; P = .72). Among the 15 655 patients receiving text messaging, 118 of 3889 patients (3.0% [95% CI, 2.5%-3.6%]) in the standard messaging group completed 1 vaccine dose, as did 135 of 3920 patients (3.4% [95% CI, 2.9%-4.0%]) in the clinician endorsement group (absolute difference, 0.4% [95% CI, -0.4% to 1.2%]; P = .31), 100 of 3911 patients (2.6% [95% CI, 2.1%-3.1%]) in the scarcity group (absolute difference, -0.5% [95% CI, -1.2% to 0.3%]; P = .20), and 143 of 3935 patients (3.6% [95% CI, 3.0%-4.2%]) in the endowment group (absolute difference, 0.6% [95% CI, -0.2% to 1.4%]; P = .14). Conclusions and Relevance: There was no detectable increase in vaccination uptake among patients receiving text messaging compared with telephone calls only or behaviorally informed message content. Trial Registration: ClinicalTrials.gov Identifier: NCT04834726.

Crowdsourced Community Support Resources Among Patients Discharged From the Emergency Department During the COVID-19 Pandemic: Pilot Feasibility Study.

BACKGROUND: The COVID-19 pandemic has placed strains on communities. During this public health crisis, health systems have created remote methods of monitoring symptom progression and delivering care virtually. OBJECTIVE: Using an SMS text message-based system, we sought to build and test a remote model to explore community needs, connect individuals to curated resources, and facilitate community health worker intervention when needed during the pandemic. The primary aims of this pilot study were to establish the feasibility (ie, engagement with the text line) and acceptability (ie, participant ratings of resources and service) of delivering automated well-being resources via smartphone technology. METHODS: Eligible patients (aged 18 years or older, having a cell phone with SMS text messaging capability, and recently visited the emergency department) were identified using the electronic health record. The patients were consented to enroll and begin receiving COVID-19-related information and links to community resources. We collected open-ended and close-ended resource and mood ratings. We calculated the frequencies and conducted a thematic review of the open-ended responses. RESULTS: In 7 weeks, 356 participants were enrolled; 13,917 messages were exchanged including 333 resource ratings (mean 4) and 673 well-being scores (mean 6.8). We received and coded 386 open-ended responses, most of which elaborated upon their self-reported mood score (29%). Overall, 77% (n=274) of our participants rated the platform as a service they would highly recommend to a family member or friend. CONCLUSIONS: This approach is designed to broaden the reach of health systems, tailor to community needs in real time, and connect at-risk individuals with robust community health support.

Sustained Implementation of a Multicomponent Strategy to Increase Emergency Department-Initiated Interventions for Opioid Use Disorder.

STUDY OBJECTIVE: There is strong evidence supporting emergency department (ED)-initiated buprenorphine for opioid use disorder, but less is known about how to implement this practice. Our aim was to describe implementation, maintenance, and provider adoption of a multicomponent strategy for opioid use disorder treatment in 3 urban, academic EDs. METHODS: We conducted a retrospective analysis of electronic health record data for adult patients with opioid use disorder-related visits before (March 2017 to November 2018) and after (December 2018 to July 2020) implementation. We describe patient characteristics, clinical treatment, and process measures over time and conducted an interrupted time series analysis using a patient-level multivariable logistic regression model to assess the association of the interventions with buprenorphine use and other outcomes. Finally, we report provider-level variation in prescribing after implementation. RESULTS: There were 2,665 opioid use disorder-related visits during the study period: 28% for overdose, 8% for withdrawal, and 64% for other conditions. Thirteen percent of patients received medications for opioid use disorder during or after their ED visit overall. Following intervention implementation, there were sustained increases in treatment and process measures, with a net increase in total buprenorphine of 20% in the postperiod (95% confidence interval 16% to 23%). In the adjusted patient-level model, there was an immediate increase in the probability of buprenorphine treatment of 24.5% (95% confidence interval 12.1% to 37.0%) with intervention implementation. Seventy percent of providers wrote at least 1 buprenorphine prescription, but provider-level buprenorphine prescribing ranged from 0% to 61% of opioid use disorder-related encounters. CONCLUSION: A combination of strategies to increase ED-initiated opioid use disorder treatment was associated with sustained increases in treatment and process measures. However, adoption varied widely among providers, suggesting that additional strategies are needed for broader uptake.

A Mobile, Electronic Health Record-Connected Application for Managing Team Workflows in Inpatient Care.

BACKGROUND: Clinical workflows require the ability to synthesize and act on existing and emerging patient information. While offering multiple benefits, in many circumstances electronic health records (EHRs) do not adequately support these needs. OBJECTIVES: We sought to design, build, and implement an EHR-connected rounding and handoff tool with real-time data that supports care plan organization and team-based care. This article first describes our process, from ideation and development through implementation; and second, the research findings of objective use, efficacy, and efficiency, along with qualitative assessments of user experience. METHODS: Guided by user-centered design and Agile development methodologies, our interdisciplinary team designed and built Carelign as a responsive web application, accessible from any mobile or desktop device, that gathers and integrates data from a health care institution's information systems. Implementation and iterative improvements spanned January to July 2016. We assessed acceptance via usage metrics, user observations, time-motion studies, and user surveys. RESULTS: By July 2016, Carelign was implemented on 152 of 169 total inpatient services across three hospitals staffing 1,616 hospital beds. Acceptance was near-immediate: in July 2016, 3,275 average unique weekly users generated 26,981 average weekly access sessions; these metrics remained steady over the following 4 years. In 2016 and 2018 surveys, users positively rated Carelign's workflow integration, support of clinical activities, and overall impact on work life. CONCLUSION: User-focused design, multidisciplinary development teams, and rapid iteration enabled creation, adoption, and sustained use of a patient-centered digital workflow tool that supports diverse users' and teams' evolving care plan organization needs.

Design, Implementation, and Validation of an Automated, Algorithmic COVID-19 Triage Tool.

OBJECTIVE: We describe the design, implementation, and validation of an online, publicly available tool to algorithmically triage patients experiencing severe acute respiratory syndrome coronavirus (SARS-CoV-2)-like symptoms. METHODS: We conducted a chart review of patients who completed the triage tool and subsequently contacted our institution's phone triage hotline to assess tool- and clinician-assigned triage codes, patient demographics, SARS-CoV-2 (COVID-19) test data, and health care utilization in the 30 days post-encounter. We calculated the percentage of concordance between tool- and clinician-assigned triage categories, down-triage (clinician assigning a less severe category than the triage tool), and up-triage (clinician assigning a more severe category than the triage tool) instances. RESULTS: From May 4, 2020 through January 31, 2021, the triage tool was completed 30,321 times by 20,930 unique patients. Of those 30,321 triage tool completions, 51.7% were assessed by the triage tool to be asymptomatic, 15.6% low severity, 21.7% moderate severity, and 11.0% high severity. The concordance rate, where the triage tool and clinician assigned the same clinical severity, was 29.2%. The down-triage rate was 70.1%. Only six patients were up-triaged by the clinician. 72.1% received a COVID-19 test administered by our health care system within 14 days of their encounter, with a positivity rate of 14.7%. CONCLUSION: The design, pilot, and validation analysis in this study show that this COVID-19 triage tool can safely triage patients when compared with clinician triage personnel. This work may signal opportunities for automated triage of patients for conditions beyond COVID-19 to improve patient experience by enabling self-service, on-demand, 24/7 triage access.

Insourcing and scaling a telemedicine solution in under 2 weeks: Lessons for the digital transformation of health care.

The Covid-19 pandemic required rapid scale of telemedicine as well as other digital workflows to maintain access to care while reducing infection risk. Both patients and clinicians who hadn't used telemedicine before were suddenly faced with a multi-step setup process to log into a virtual meeting. Unlike in-person examination rooms, locking a virtual meeting room was more error-prone and posed a risk of multiple patients joining the same online session. There was administrative burden on the practice staff who were generating and manually sending links to patients, and educating patients on device set up was time-consuming and unsustainable. A solution had to be deployed rapidly system-wide, without the usual roll out across months. Our answer was to design and implement a novel EHR-integrated web application called the Switchboard, in just two weeks. The Switchboard leverages a commercial, cloud-based video meeting platform and facilitates an end-to-end virtual care encounter workflow, from pre-visit reminders to post-visit SMS text message-based measurement of patient experience, with tools to extend contact-less workflows to in-person appointments. Over the first 11 months of the pandemic, the in-house platform has been adopted across 6 hospitals and >200 practices, scaled to 8,800 clinicians who at their peak conducted an average of 30,000 telemedicine appointments/week, and enabled over 10,000-20,000 text messages/day to be exchanged through the platform. Furthermore, it enabled our organization to convert from an average of 75% of telehealth visits being conducted via telephone to 75% conducted via video within weeks.

Comparing the Effects of Design Thinking and A3 Problem-Solving on Resident Attitudes Toward Systems Change.

BACKGROUND: Quality improvement (QI) is a required component of graduate medical education. Many medical educators struggle to foster an improvement mindset within residents. OBJECTIVE: We conducted a mixed-methods study to compare a Design Thinking (DT) approach to QI education with a Lean, A3 problem-solving approach. We hypothesized that a DT approach would better promote a mentality of continuous improvement, measured by residents' resistance to change. METHODS: Thirty-eight postgraduate year 2 internal medicine residents were divided into 4 cohorts during the 2017-2018 academic year. One cohort participated in an experimental QI curriculum utilizing DT while 3 control cohorts participated in the existing curriculum based on Lean principles. Participants voluntarily completed a quantitative Resistance to Change (RTC) scale pre- and post-curriculum. To inform our understanding of these results, we also conducted semistructured interviews for qualitative thematic analysis. RESULTS: The effect size on the overall RTC score (response rate 92%) was trivial in both groups. Three major themes emerged from the qualitative data: factors influencing the QI learning experience, factors influencing creativity, and general attitudes toward QI. Each contained several subthemes with minimal qualitative differences between groups. CONCLUSIONS: This study found similar results in terms of their effect on attitudes toward systems change, ability to promote creative change agency, and educational experience. Despite positive educational experiences, many residents still did not view systems-based problem-solving as part of their professional identity.

Framing Social Comparison Feedback With Financial Incentives for Physical Activity Promotion: A Randomized Trial.

BACKGROUND: Social comparison feedback is often used in physical activity interventions but the optimal design of feedback is unknown. METHODS: This 4-arm, randomized trial consisted of a 13-week intervention period and 13-week follow-up period. During the intervention, 4-person teams were entered into a weekly lottery valued at about $1.40/day and contingent on the team averaging ≥7000 steps per day. Social comparison feedback on performance was delivered weekly for 26 weeks, and varied by reference point (50th vs 75th percentile) and forgiveness in use of activity data (all 7 d or best 5 of 7 d). The primary outcome was the mean proportion of participant-days achieving the 7000-step goal. RESULTS: During the intervention period, the unadjusted mean proportion of participant-days that the goal was achieved was 0.47 (95% confidence interval [CI]: 0.38 to 0.56) in the 50th percentile arm, 0.38 (95% CI: 0.30 to 0.37) in the 75th percentile arm, 0.40 (95% CI: 0.31 to 0.49) in the 50th percentile with forgiveness arm, and 0.47 (95% CI: 0.38 to 0.55) in the 75th percentile with forgiveness arm. In adjusted models during the intervention and follow-up periods, there were no significant differences between arms. CONCLUSIONS: Changing social comparison feedback did not impact physical activity.

Telemedicine in Liver Disease and Beyond: Can the COVID-19 Crisis Lead to Action?

Evidence strongly supports that access to specialty gastroenterology or hepatology care in cirrhosis is associated with higher adherence to guideline-recommended care and improves clinical outcomes. Presently, only about one half of acute care hospitalizations for cirrhosis-related complications result in inpatient specialty care, and the current hepatology workforce cannot meet the demand of patients with liver disease nationwide, particularly in less densely populated areas and in community-based practices not affiliated with academic centers. Telemedicine, defined as the delivery of health care services at a distance using electronic means for diagnosis and treatment, holds tremendous promise to increase access to broadly specialty care. The technology is cheap and easy to use, although it is presently limited in scale by interstate licensing restrictions and reimbursement barriers. The outbreak of severe acute respiratory syndrome coronavirus 2 and coronavirus disease 2019 has, in the short term, accelerated the growth of telemedicine delivery as a public health and social distancing measure. Herein, we examine whether this public health crisis can accelerate the national conversation about broader adoption of telemedicine for routine medical care in non-crisis situations, using a case series from our telehepatology program as a pragmatic example.

Capturing Real-Time Emergency Department Sentiment: A Feasibility Study Using Touch-Button Terminals.

STUDY OBJECTIVE: Providing care in emergency departments (EDs) affects patients and providers. Providers experience high rates of work-related stress. Little is known about the feasibility of measuring real-time sentiment within busy clinical environments. We test the feasibility of measuring sentiment with touch-button terminals in an academic, urban ED. METHODS: Terminals offered a choice of 4 sentiment buttons (very positive, positive, negative, and very negative). They were placed central to physician workstations, nursing workstations, and the patient exit. Pearson correlation coefficients (r) were calculated to estimate correlation between sentiment and volume metrics (arrivals, length of stay, waiting patients, and number of boarding patients) over time. RESULTS: A total of 13,849 sentiments were recorded (June 2018 to October 2018); 9,472 came from providers (52.6% nursing) and 4,377 from patients. The majority of provider sentiments were negative (58.7%). Negative provider sentiment was associated with increasing number of patients waiting to be seen (r=0.45) and boarding (r=0.68). Positive provider sentiment was associated with increasing numbers of patients who left without being seen (r=0.48). Increased boarding was associated with more recorded sentiments (r=0.73). Negative patient sentiment was associated with increasing number waiting (r=0.55), boarding (r=0.67), and leaving without being seen (r=0.46). CONCLUSION: This study demonstrates the feasibility of a novel approach to measuring "on-shift" sentiment in real time and provides a sample comparison to traditional volume metrics.

A Randomized, Controlled Trial of Lottery-Based Financial Incentives to Increase Physical Activity Among Overweight and Obese Adults.

PURPOSE: To evaluate the effect of lottery-based financial incentives in increasing physical activity. DESIGN: Randomized, controlled trial. SETTING: University of Pennsylvania Employees. PARTICIPANTS: A total of 209 adults with body mass index ≥27. INTERVENTIONS: All participants used smartphones to track activity, were given a goal of 7000 steps per day, and received daily feedback on performance for 26 weeks. Participants randomly assigned to 1 of the 3 intervention arms received a financial incentive for 13 weeks and then were followed for 13 weeks without incentives. Daily lottery incentives were designed as a "higher frequency, smaller reward" (1 in 4 chance of winning $5), "jackpot" (1 in 400 chance of winning $500), or "combined lottery" (18% chance of $5 and 1% chance of $50). MEASURES: Mean proportion of participant days step goals were achieved. ANALYSIS: Multivariate regression. RESULTS: During the intervention, the unadjusted mean proportion of participant days that goal was achieved was 0.26 in the control arm, 0.32 in the higher frequency, smaller reward lottery arm, 0.29 in the jackpot arm, and 0.38 in the combined lottery arm. In adjusted models, only the combined lottery arm was significantly greater than control ( P = .01). The jackpot arm had a significant decline of 0.13 ( P < .001) compared to control. There were no significant differences during follow-up. CONCLUSIONS: Combined lottery incentives were most effective in increasing physical activity.

Association of Rideshare-Based Transportation Services and Missed Primary Care Appointments: A Clinical Trial.

Importance: Transportation barriers contribute to missed primary care appointments for patients with Medicaid. Rideshare services have been proposed as alternatives to nonemergency medical transportation programs because of convenience and lower costs. Objective: To evaluate the association between rideshare-based medical transportation and missed primary care appointments among Medicaid patients. Design, Setting, and Participants: In a prospective clinical trial, 786 Medicaid beneficiaries who resided in West Philadelphia and were established primary care patients at 1 of 2 academic internal medicine practices located within the same building were included. Participants were allocated to being offered complimentary ride-sharing services (intervention arm) or usual care (control arm) based on the prescheduled day of their primary care appointment reminder. Those scheduled on even-numbered weekdays were in the intervention arm and on odd-numbered weekdays, the control arm. The primary study outcome was the rate of missed appointments, estimated using an intent-to-treat approach. All individuals receiving a phone call reminder were included in the study sample, regardless of whether they answered their phone. The study was conducted between October 24, 2016, and April 20, 2017. Interventions: A model of providing rideshare-based transportation was designed. As part of usual care, patients assigned to both arms received automated appointment phone call reminders. As part of the study protocol, patients assigned to both arms received up to 3 additional appointment reminder phone calls from research staff 2 days before their scheduled appointment. During these calls, patients in the intervention arm were offered a complimentary ridesharing service. Research staff prescheduled rides for those interested in the service. After their appointment, patients phoned research staff to initiate a return trip home. Main Outcomes and Measures: Missed appointment rate (no shows and same-day cancellations) in the intervention compared with control arm. Results: Of the 786 patients allocated to the intervention or control arm, 566 (72.0%) were women; mean (SD) age was 46.0. (12.5) years. Within the intervention arm, 85 among 288 (26.0%) participants who answered the phone call used ridesharing. The missed appointment rate was 36.5% (144 of 394) for the intervention arm and 36.7% (144 of 392) for the control arm (P = .96). Conclusions and Relevance: The uptake of ridesharing was low and did not decrease missed primary care appointments. Future studies trying to reduce missed appointments should explore alternative delivery models or targeting populations with stronger transportation needs. Trial Registration: clinicaltrials.gov Identifier: NCT02955433.

Rideshare-Based Medical Transportation for Medicaid Patients and Primary Care Show Rates: A Difference-in-Difference Analysis of a Pilot Program.

BACKGROUND: Transportation to primary care is a well-documented barrier for patients with Medicaid, despite access to non-emergency medical transportation (NEMT) benefits. Rideshare services, which offer greater convenience and lower cost, have been proposed as an NEMT alternative. OBJECTIVE: To evaluate the impact of rideshare-based medical transportation on the proportion of Medicaid patients attending scheduled primary care appointments. DESIGN: In one of two similar practices, all eligible Medicaid patients were offered rideshare-based transportation ("rideshare practice"). A difference-in-difference analytical approach using logistic regression with robust standard errors was employed to compare show rate changes between the rideshare practice and the practice where rideshare was not offered ("control practice"). PARTICIPANTS: Our study population included residents of West Philadelphia who were insured by Medicaid and were established patients at two academic general internal medicine practices located in the same building. INTERVENTION: We designed a rideshare-based transportation pilot intervention. Patients were offered the service during their reminder call 2 days before the appointment, and rides were prescheduled by research staff. Patients then called research staff to schedule their return trip home. MAIN MEASURES: We assessed the effect of offering rideshare-based transportation on appointment show rates by comparing the change in the average show rate for the rideshare practice, from the baseline period to the intervention period, with the change at the control practice. KEY RESULTS: At the control practice, the show rate declined from 60% (146/245) to 51% (34/67). At the rideshare practice, the show rate improved from 54% (72/134) to 68% (41/60). In the adjusted model, controlling for patient demographics and provider type, the odds of showing up for an appointment before and after the intervention increased 2.57 (1.10-6.00) times more in the rideshare practice than in the control practice. CONCLUSIONS: Results of this pilot program suggest that offering a rideshare-based transportation service can increase show rates to primary care for Medicaid patients.

Effect of Outreach Messages on Medicaid Enrollment.

OBJECTIVES: To measure the impact of different outreach messages on health insurance enrollment among Medicaid-eligible adults. METHODS: Between March 2015 and April 2016, we conducted a series of experiments using mail-based outreach that encouraged individuals to enroll in Pennsylvania's expanded Medicaid program. Recipients were randomized to receive 1 of 4 different messages describing the benefits of health insurance. The primary outcome was the response rate to each letter. RESULTS: We mailed outreach letters to 32 993 adults in Philadelphia. Messages that emphasized the dental benefits of insurance were significantly more likely to result in a response than messages emphasizing the health benefits (odds ratio = 1.33; 95% confidence interval = 1.10, 1.61). CONCLUSIONS: Medicaid enrollment outreach messages that emphasized the dental benefits of insurance were more effective than those that emphasized the health-related benefits. Public Health Implications. Although the structure and eligibility of the Medicaid program are likely to change, testing and identifying successful outreach and enrollment strategies remains important. Outreach messages that emphasize dental benefits may be more effective at motivating enrollment among individuals of low socioeconomic status.