Search

Decision-making errors such as present bias (PB) can have important consequences for health behaviors, but have been largely studied in the financial domain. We conducted a mixed-method study on PB in the context of ART adherence among clinic-enrolled adults in Uganda (n = 39). Specifically, we quantified PB by asking about preferences between medication available sooner to minimize headaches versus available later to cure headaches. We describe demographic similarities among PB participants and qualitatively explored how participants reflected on their PB (or absence thereof) in the context of health. Participants reporting PB were predominantly male, single/unmarried, older, had higher levels of education and income and more advanced HIV progression. Three common reasons for more present-biased choices provided were: (1) wanting to avoid pain, (2) wanting to return to work, and (3) fear of one's health worsening if s/he did not address their illness immediately. While PB in the financial domain often suggests that poorer individuals are more likely to prefer immediate rewards over their wealthier counterparts, our results suggest poor health is potentially a driving factor of PB. Further research is needed to build on these finding and inform how programs can frame key messages regarding ART adherence to patients displaying PB.Trial registration: ClinicalTrials.gov identifier: NCT03494777.

Supplemental Digital Content is Available in the Text., Introduction: Recent studies project thousands of additional AIDS-related deaths because of COVID-19–related disruptions in HIV care. However, the extent to which disruptions in care have materialized since the start of the pandemic is not well understood. Methods: We use electronic health records to investigate how the pandemic has affected clinic visits, patients' antiretroviral therapy (ART) supply, and viral suppression for a cohort of 14,632 HIV clients from a large HIV clinic in Kampala, Uganda. We complement this with an analysis of electronically measured longitudinal ART adherence data from a subcohort of 324 clients. Results: Clinic visits decreased by more than 50% after a national lockdown started. The risk of patients running out of ART on a given day increased from 5% before the lockdown to 25% 3 months later (Relative Risk Ratio of 5.11, 95% confidence interval: 4.99 to 5.24) and remained higher than prelockdown 6 months later at 13% (Relative Risk Ratio of 2.60; 95% confidence interval: 2.52 to 2.70). There was no statistically significant change in electronically measured adherence or viral suppression. Conclusion: We document substantial gaps in HIV care after the start of the COVID-19 pandemic in Uganda. This suggests that measures to improve access should be explored as the pandemic persists. However, ART adherence was unaffected for the subcohort for whom we measured electronic adherence. This suggests that some clients may have stockpiles of ART tablets from previous prescriptions that allowed them to keep taking their medication even when they could not visit the clinic for ART refills.

Community health workers (CHWs) are a vital part of the health infrastructure in Uganda and in many other low- and middle-income countries. While the need for CHWs is clear, it is less clear how they should dispense health products to maximize the health benefits to their community. In this study, we assess the cost-effectiveness of several competing CHW distribution strategies in the context of treatment for child diarrhoea. We used data from a four-armed cluster-randomized controlled trial to assess the cost-effectiveness of (1) free distribution of oral rehydration salts (ORS) via home deliveries prior to diarrhoea onset (free delivery arm), (2) free distribution via vouchers where households retrieved the treatment from a central location (voucher arm), (3) a door-to-door sales model (home sales arm) and (4) a control arm where CHWs carried out their activities as normal. We assessed the cost-effectiveness from the implementor’s perspective and a societal perspective in terms of cost per case treated with ORS and cost per disability-adjusted life year (DALY) averted. Free delivery was the most effective strategy and the cheapest from a societal perspective. Although implementor costs were highest in this arm, cost savings comes from households using fewer resources to seek treatment outside the home (transport, doctor fees and treatment costs). From the implementors’ perspective, free delivery costs $2.19 per additional case treated and $56 per DALY averted relative to the control. Free delivery was also extremely cost-effective relative to home sales and vouchers, but there was a large degree of uncertainty around the comparison with vouchers. Free distribution of ORS by CHWs prior to diarrhoea onset is extremely cost-effective compared to other CHW distribution models. Implementers of CHW programmes should consider free home delivery of ORS.

The health and economic threats posed by the COVID-19 pandemic can be sources of great distress among people living with HIV, which in turn can impact the management of their HIV disease. We examined change in depression from pre- to post-lockdown restrictions and correlates of elevated depressive symptoms, including antiretroviral therapy (ART) adherence. Participants enrolled in a randomized controlled trial of an ART adherence intervention in Uganda. The month-12 follow-up assessment was fully administered just prior to the start of the pandemic-related lockdown in March 2020; at the conclusion of the lockdown three months later, we administered a mixed-methods phone-based assessment. ART adherence was electronically monitored throughout the study period, including during and after the lockdown. Depression was assessed with the 8-item Patient health questionnaire (PHQ-8), on which scores > 9 signify a positive screen for elevated depressive symptoms. A sample of 280 participants completed both the month-12 and post-lockdown assessments. Rates of elevated depressive symptoms nearly tripled from month 12 (n = 17, 6.1%) to the post-lockdown assessment (n = 50, 17.9%; McNemar test

The unmet need for modern contraception remains high around the world, particularly for youth. While some of this unmet need is driven by limited health infrastructure and method mix availability, many adolescents who visit family planning providers still do not receive methods that fit their needs. This suggests that providers may be biased against youth and that interventions to change provider behavior could help close this gap. However, it is unclear if this bias is a result of age or other characteristics common among young women such as not being married and not having children. We use a discrete choice experiment in Burkina Faso, Pakistan, and Tanzania to disentangle the effects of age on providers' decisions to provide contraception from the effects of other potential confounding factors. We find that, although young women may experience the most bias, age is not the main driver. Rather, marital status and parity seem to influence provider decisions to offer services or counsel on modern methods. These findings suggest that interventions to reduce provider bias should focus on changing behavior towards unmarried and nulliparous women, regardless of their age.

Background: Prior studies on disparities in postoperative opioid prescribing have focused primarily on in-hospital opioid administration or long-term opioid use, with fewer studies examining discharge opioid prescribing for adults, and no studies looking across different surgical subspecialties or service lines. We sought to examine racial and ethnic disparities in postoperative opioid prescribing to test the hypothesis that racial and ethnic minority groups receive opioid prescriptions at postoperative discharge with lower morphine milligram equivalents (MME) than non-Hispanic whites (NHW). Methods: We utilized electronic health records (EHR) data across 24 hospitals from a healthcare delivery system in northern California from January 1, 2015 to February 2, 2020 (study period). The sample included adult patients undergoing a procedure during the study period, discharged to home with an opioid prescription. Cross-sectional, secondary data analyses were conducted to examine differences by race and ethnicity in opioid prescribing, measured as MME, among patients who underwent select, but commonly performed, surgical procedures. Linear regression models included adjustment for factors that would likely influence prescribing decisions and race and ethnicity-specific propensity weights. Opioid prescribing, overall and by race and ethnicity, was also compared to postoperative opioid guidelines. Results: Among 61,564 patients, on adjusted regression analysis, non-Hispanic Black (NHB) patients received prescriptions with higher mean MME than NHW patients (+6.4% [95% confidence interval: 4.4%, 8.3%]), whereas Hispanic and non-Hispanic Asian patients received lower mean MME (-4.2% [-5.1%, -3.2%] and -3.6% [-4.8%, -2.3%], respectively). Nevertheless, 72.8% of all patients received prescriptions above guidelines, ranging from 71.0% to 80.3% by race and ethnicity. Disparities in prescribing were eliminated among Hispanic and NHB patients versus NHW patients when prescriptions were written within guideline recommendations. Conclusions: Racial and ethnic disparities in opioid prescribing exist in the postoperative setting, yet all groups received prescriptions above guideline recommendations. Policies encouraging guideline-based postoperative prescribing can reduce disparities and overall excess prescribing.

There are two salient facts about health care in low and middle-income countries; (1) the private sector plays an important role and (2) the care provided is often of poor quality. Despite these facts we know little about what drives quality of care in the private sector and why patients seek care from poor quality providers. We use two field studies in India that provide insight into this issue. First, we use a discrete choice experiment to show that patients strongly value technical quality. Second, we use standardized patients to show that better quality providers are not able to charge higher prices. Instead providers are able to charge higher prices for elements of quality that the patient can observe, which are less important for health outcomes. Future research should explore whether accessible information on technical quality of local providers can shift demand to higher quality providers and improve health outcomes.

COVID-19 measures that restrict movement may negatively impact access to HIV care and treatment. To contribute to the currently limited evidence, we used telephone interviews with quantitative and qualitative questions to examine how clients perceived COVID-19 and its effect on their HIV care and ART adherence. One hundred (n = 100) Ugandan adults on ART from an existing study were randomly selected and enrolled. Interviews were recorded, transcribed, and analyzed using descriptive statistics and rapid content analyses. 76% of clients indicated that COVID-19 negatively impacted travel to HIV clinics; 54% perceived that coming to the clinic increased their risk of acquiring COVID-19; and 14% said that COVID-19 had negatively impacted their ART adherence. Qualitative feedback suggests that fear of COVID-19 infection discouraged clinic attendance while stay-at-home orders helped routinize ART adherence and employ new community-based approaches for HIV care. Addressing negative unintended consequences of COVID-19 lockdowns on HIV care is urgently needed.

International audience

Objectives To determine the public health surveillance severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing volume needed, both for acute infection and seroprevalence. Methods Required testing volumes were developed using standard statistical methods based on test analytical performance, disease prevalence, desired precision, and population size. Results Widespread testing for individual health management cannot address surveillance needs. The number of people who must be sampled for public health surveillance and decision making, although not trivial, is potentially in the thousands for any given population or subpopulation, not millions. Conclusions While the contributions of diagnostic testing for SARS-CoV-2 have received considerable attention, concerns abound regarding the availability of sufficient testing capacity to meet demand. Different testing goals require different numbers of tests and different testing strategies; testing strategies for national or local disease surveillance, including monitoring of prevalence, receive less attention. Our clinical laboratory and diagnostic infrastructure are capable of incorporating required volumes for many local, regional, and national public health surveillance studies into their current and projected testing capacity. However, testing for surveillance requires careful design and randomization to provide meaningful insights.

Ninety-nine percent of global maternal deaths occur in low- and middle-income countries. The high mortality rates are often attributed to a large portion of births occurring outside of formal healt...

BackgroundStudies report serious adherence problems among youth (individuals age 15–24 years of age) in Uganda. Recent growth in mobile phone ownership has highlighted the potential of using text-based interventions to improve antiretroviral treatment (ART) adherence among Ugandan youth. We piloted a randomized controlled trial of a text-based intervention providing weekly real-time antiretroviral adherence feedback, based on information from a smart pill box, to HIV-positive Ugandan youth. In this paper, we report the acceptability, feasibility, and preliminary impact of the intervention.MethodsWe randomized participants to a control group, or to receive messages with information on either their own adherence levels (Treatment 1 - T1), or their own adherence and peer adherence levels (Treatment 2 – T2). We conducted six focus groups from December 2016 to March 2017 with providers and youth ages 15–24, double coded 130 excerpts, and achieved a pooled Cohen’s Kappa of 0.79 and 0.80 based on 34 randomly selected excerpts.ResultsThe quantitative and qualitative data show that the intervention was deemed acceptable and feasible. After controlling for baseline adherence, the T1 group had 3.8 percentage point lower adherence than the control group (95% CI -9.9, 2.3) and the T2 group had 2.4 percentage points higher adherence than the control group (95% CI -3.0, 7.9). However, there was an increasing treatment effect over time for the T2 group with the largest effect towards the end of the study; a 2.5 percentage point increase in the initial 9-weeks that grows steadily to 9.0 percentage points by the last 9-weeks of the study. We find negative treatment effects for T1 in 3 of the 4 9-week intervals. This pilot study was not designed to detect statistically significant differences.ConclusionsImproving youth’s adherence by supplementing information about their adherence with information about the adherence of peers is a promising new strategy that should be further evaluated in a fully-powered study. Providing one’s own adherence information alone appears to have less potential.Trial registrationNCT0251435607/30/2015.

Background Many HIV-positive patients do not appropriately adhere to their antiretroviral medication (ART). This leads to higher viral loads and greater probability of HIV transmission. Present bias—a tendency to give in to short-term temptations at the expense of long-term outcomes—is a potential driver of low adherence. In this study we test a novel intervention rooted in behavioral economics that is designed to overcome present bias and increase ART adherence. Methods/design We will enroll 330 HIV-positive patients at Mildmay Hospital in Kampala, Uganda, into a 2-year randomized controlled trial. Participants will be randomized to one of three groups. The first intervention group (T1, n = 110) will be eligible for small lottery prizes based on timely clinic visits and demonstration of viral suppression. Group 2 (T2, n = 110) will be eligible for the same lottery prizes conditional on high adherence measured by a medication event management system (MEMS) cap. The control group (n = 110) will receive the usual standard of care. Adherence will be measured continuously throughout the intervention period and for 12 months post-intervention to evaluate effect persistence. Surveys will be conducted at baseline and then every 6 months. Viral loads will be measured annually. Primary outcomes are whether the viral load is detectable and MEMS-measured adherence. Secondary outcomes are the log-transformed viral load as a continuous measure and a binary measure for whether the person took at least 90% of their ART pills. Discussion Our study is one of the first to investigate the effectiveness of lottery incentives for improving ART adherence, and in addition, it compares the relative efficacy of using electronically measured adherence versus viral load to determine lottery eligibility. MEMS caps are relatively costly, whereas viral load testing is now part of routine clinical care in Uganda. BEST will test whether directly incentivizing viral suppression (which can be implemented using readily available clinic data) is as effective as incentivizing electronically measured adherence. Cost-effectiveness analyses of the two implementation modes will also be performed. Trial registration ClinicalTrials.gov, NCT03494777. Registered on 11 April 2018.

IntroductionSurgical patients are commonly prescribed more opioids at discharge than needed to manage their postoperative pain. These excess opioids increase the risks of new persistent opioid use, opioid-induced ventilatory impairment and opioid diversion. This study tests the effectiveness of two behavioural nudges, one based on peer behaviour and one based on best practice guidelines, in reducing excessive postoperative opioid prescriptions.Methods and analysisThe study will be conducted at 19 hospitals within a large healthcare delivery system in northern California, USA. Three surgical specialties (general surgery, orthopaedic surgery and obstetric/gynaecological surgery) at each hospital will be randomised either to a control group or to one of two active intervention arms. One intervention is grounded in the theory of injunctive norms, and provides feedback to surgeons on their postoperative opioid prescribing relative to prescribing guidelines endorsed by their institution. The other intervention draws from the theory of descriptive norms, and provides feedback similar to the first intervention but using peers’ behaviour rather than guidelines as the benchmark for the surgeon’s prescribing behaviour. The interventions will be delivered by a monthly email. Both interventions will be active for twelve months. The effects of each intervention relative to the control group and to each other will be tested using a four-level hierarchical model adjusted for multiple hypothesis testing.Ethics and disseminationUsing behavioural nudges rather than rigid policy changes allows us to target excessive prescribing without preventing clinicians from using their clinical judgement to address patient pain. All study activities have been approved by the RAND Human Subjects Protection Committee (ID 2018-0988). Findings will be disseminated through conference presentations, peer-reviewed publications and social media accounts.Trial registration numberNCT05070338.

Many HIV positive individuals are still undiagnosed, which has led health systems to try many approaches to expand HIV testing. In a randomized controlled trial, we found that behavioral economics interventions (opt-out testing and financial incentives) each improved HIV testing rates and these approaches are being implemented by several hospital systems. However, it is unclear if these strategies are cost-effective. We quantified the cost-effectiveness of different behavioral approaches to HIV screening-opt-out testing, financial incentives, and their combination-in terms of cost per new HIV diagnosis and infections averted. We estimated the incremental number of new HIV diagnoses and program costs using a mathematical screening model, and infections averted using and HIV transmission model. We used a 1-year time horizon and a hospital perspective. Switching from opt-into opt-out results in 39 additional diagnoses (56% increase) after 1-year at a cost of $3807 per new diagnosis. Switching from no incentive to a $1, $5, or $10 incentive adds 14, 13, and 28 new diagnoses (20, 19, and 41% increases) at a cost of $11,050, $17,984, and $15,298 per new diagnosis, respectively. Layering on financial incentives to opt-out testing enhances program effectiveness, though at a greater marginal cost per diagnosis. We found a similar pattern for infections averted. This is one of the first cost-effectiveness analyses of behavioral economics interventions in public health. Changing the choice architecture from opt-into opt-out and giving financial incentives for testing are both cost-effective in terms of detecting HIV and reducing transmission. For hospitals interested in increasing HIV screening rates, changing the choice architecture is an efficient strategy and more efficient than incentives.

Background We developed a novel intervention that uses behavioral economics incentives and mobile-health text messages to increase HIV knowledge and testing frequency among Latinx sexual minority men and Latinx transgender women. Here we provide a theoretically-grounded assessment regarding the intervention’s acceptability and feasibility. Methods We conducted 30-min exit interviews with a stratified sample of participants (n = 26 Latinx sexual minority men, 15 Latinx transgender women), supplemented with insights from study staff (n = 6). All interviews were recorded, transcribed, and translated for a content analysis using Dedoose. Cohen’s Kappa was 89.4% across coded excerpts. We evaluated acceptability based on how participants cognitively and emotionally reacted to the intervention and whether they considered it to be appropriate. We measured feasibility based on resource, scientific and process assessments (e.g., functionality of text messaging service, feedback on study recruitment procedures and surveys). Results Regarding acceptability, most participants clearly understood the intervention as a program to receive information about HIV prevention methods through text messages. Participants who did not complete the intervention shared they did not fully understand what it entailed at their initial enrollment, and thought it was a one-time engagement and not an ongoing program. Though some participants with a higher level of education felt the information was simplistic, most appreciated moving beyond a narrow focus on HIV to include general information on sexually transmitted infections; drug use and impaired sexual decision-making; and differential risks associated with sexual positions and practices. Latinx transgender women in particular appreciated receiving information about Pre-Exposure Prophylaxis. While participants didn’t fully understand the exact chances of winning a prize in the quiz component, most enjoyed the quizzes and chance of winning a prize. Participants appreciated that the intervention required a minimal time investment. Participants shared that the intervention was generally culturally appropriate. Regarding feasibility, most participants reported the text message platform worked well though inactive participants consistently said technical difficulties led to their disengagement. Staff shared that clients had varying reactions to being approached while being tested for HIV, with some unwilling to enroll and others being very open and curious about the program. Both staff and participants relayed concerns regarding the length of the recruitment process and study surveys. Conclusions Our theoretically-grounded assessment shows the intervention is both acceptable and feasible. Trial registration The trial was registered on May 5, 2017 with the ClinicalTrials.gov registry [NCT03144336].

OBJECTIVE: To determine how weekly text messages and small incentives impact HIV knowledge and frequency of HIV testing among Latinx sexual minority men (LSMM) and transgender women (LTGW). DESIGN: Prospectively randomized participants into 2 intervention arms compared with a nonrandomized comparison group. SETTING: Bienestar, a primarily Latinx focused HIV service provider located across Los Angeles County. SUBJECTS, PARTICIPANTS: Two hundred eighteen participants self-identifying as LSMM or LTGW, HIV negative, having regular mobile phone access, ≥18 years, and fluent in English or Spanish. INTERVENTION: The “information only” (IO) group received text messages with HIV prevention information. The “information plus” (IP) group additionally could win incentives by answering weekly quiz questions correctly and testing for HIV once every 3 months. We followed participants for 12 months. MAIN OUTCOME MEASURE(S): HIV knowledge and frequency of HIV testing. RESULTS: We found no effect on HIV knowledge in the IO group but a statistically significant improvement in the IP group (79.2%–88.1%; P = 0.007). The frequency of HIV testing was higher in both intervention groups relative to the comparison group: On average, 22.0% of IO participants and 24.9% of IP participants tested at a Bienestar site within a given 3-month period, compared with 13.0% in the comparison group. This represents unadjusted relative risk ratios of 1.69 for the IO group (95% CI: 1.25 to 2.1; P < 0.01) and 1.91 for the IP group (95% CI: 1.51 to 2.31; P < 0.01), respectively. CONCLUSIONS: This study demonstrates that a simple, low-cost intervention may help increase HIV testing frequency among LSMM and LTGW, 2 groups at high HIV risk.

Using data from an 18-month randomized trial, we estimate large and sustained impacts on water purification and child health of a program providing monthly coupons for free water treatment solution (diluted chlorine) to households with young children. The program is more effective and much more cost-effective than asking Community Health Workers (CHWs) to distribute free chlorine to households during routine monthly visits. That is because only 40% of households make use of free chlorine, targeting through CHWs is worse than self-targeting through coupon redemption, and water treatment promotion by CHWs does not increase chlorine use among free chlorine beneficiaries. Non- use of free chlorine is driven by households who have a protected water source and those who report that chlorine makes water taste bad.

Ninety-nine percent of global maternal deaths occur in low- and middle-income countries. The high mortality rates are often attributed to a large portion of births occurring outside of formal health care facilities. This has prompted the creation of programs to promote the use of formal delivery care. However, poor-quality care in health facilities in low- and middle-income countries is well documented. It is not clear that shifting births into health facilities in these settings necessarily leads to better-quality care. We present results from a randomized controlled trial in Nigeria that evaluated a conditional cash transfer intervention that paid pregnant women to deliver in a health facility. We found that the intervention led to a 41 percent increase in facility deliveries. We also found improvements in the quality of delivery care (as a result of more births taking place in formal health care settings) and in overall satisfaction with care. We found no evidence of a reduction in preventable complications that led to maternal deaths, though we found some improvements in self-reported health. Our results indicate that promoting facility deliveries can improve the quality of care received, even in settings where formal care quality is poor. However, modest quality improvements might not be sufficient to substantially improve health outcomes.

A contingent cash transfer program in Nigeria—in which expectant mothers were given $14 if they used prenatal, delivery, and postnatal services—led to a large increase in the use of such care and a substantial reduction in child deaths.

Key Points Question Was the implementation of mandatory consultation with a prescription drug monitoring program (PDMP) that integrates electronic health record (EHR) alerts associated with changes in the postoperative quantity of opioid medications prescribed at discharge after general, obstetric and gynecologic, and orthopedic surgery? Findings In this cross-sectional study of 93 760 adult patients within a large health care system who received a postoperative prescription for an opioid medication, implementation of mandatory PDMP consultation with EHR-based alerts was associated with significant decreases in postoperative opioid prescription quantities during the quarter in which the mandate was implemented after accounting for preimplementation prescribing patterns. Meaning This study found that implementation of legislation mandating PDMP consultation and the use of EHR alerts may be associated with changes in postoperative opioid prescribing behavior and decreases in the excess number of opioid tablets in circulation., Importance Legislation mandating consultation with a prescription drug monitoring program (PDMP) was implemented in California on October 2, 2018. This mandate requires PDMP consultation before prescribing a controlled substance and integrates electronic health record (EHR)–based alerts; prescribers are exempt from the mandate if they prescribe no more than a 5-day postoperative opioid supply. Although previous studies have examined the consequences of mandated PDMP consultation, few have specifically analyzed changes in postoperative opioid prescribing after mandate implementation. Objective To examine whether the implementation of mandatory PDMP consultation with concurrent EHR-based alerts was associated with changes in postoperative opioid quantities prescribed at discharge. Design, Setting, and Participants This cross-sectional study performed an interrupted time series analysis of opioid prescribing patterns within a large health care system (Sutter Health) in northern California between January 1, 2015, and February 1, 2020. A total of 93 760 adult patients who received an opioid prescription at discharge after undergoing general, obstetric and gynecologic (obstetric/gynecologic), or orthopedic surgery were included. Exposures Mandatory PDMP consultation before opioid prescribing, with concurrent integration of an EHR alert. Prescribers are exempt from this mandate if prescribing no more than a 5-day opioid supply postoperatively. Main Outcomes and Measures The primary outcome was the total quantity of opioid medications (morphine milligram equivalents [MMEs] and number of opioid tablets) prescribed at discharge before and after implementation of the PDMP mandate, with separate analyses by surgical specialty (general, obstetric/gynecologic, and orthopedic) and most common surgical procedure within each specialty (laparoscopic cholecystectomy, cesarean delivery, and knee arthroscopy). The secondary outcome was the proportion of prescriptions with a duration of longer than 5 days. Results Of 93 760 patients (mean [SD] age, 46.7 [17.6] years; 67.9% female) who received an opioid prescription at discharge, 65 911 received prescriptions before PDMP mandate implementation, and 27 849 received prescriptions after implementation. Most patients received general or obstetric/gynecologic surgery (48.6% and 30.1%, respectively), did not have diabetes (90.3%), and had never smoked (66.0%). Before the PDMP mandate was implemented, a decreasing pattern in opioid prescribing quantities was already occurring. During the quarter of implementation, total MMEs prescribed at discharge further decreased for all 3 surgical specialties (eg, medians for general surgery: β = −10.00 [95% CI, −19.52 to −0.48]; obstetric/gynecologic surgery: β = −18.65 [95% CI, −22.00 to −15.30]; and orthopedic surgery: β = −30.59 [95% CI, −40.19 to −21.00]) after adjusting for the preimplementation prescribing pattern. The total number of tablets prescribed also decreased across specialties (eg, medians for general surgery: β = −3.02 [95% CI, −3.47 to −2.57]; obstetric/gynecologic surgery: β = −4.86 [95% CI, −5.38 to −4.34]; and orthopedic surgery: β = −4.06 [95% CI, −5.07 to −3.04]) compared with the quarters before implementation. These reductions were not consistent across the most common surgical procedures. For cesarean delivery, the median number of tablets prescribed decreased during the quarter of implementation (β = −10.00; 95% CI, −10.10 to −9.90), but median MMEs did not (β = 0; 95% CI, −9.97 to 9.97), whereas decreases were observed in both median MMEs and number of tablets prescribed (MMEs: β = −33.33 [95% CI, −38.48 to −28.19]; tablets: β = −10.00 [95% CI, −11.17 to −8.82]) for laparoscopic cholecystectomy. For knee arthroscopy, no decreases were found in either median MMEs or number of tablets prescribed (MMEs: β = 10.00 [95% CI, −22.33 to 42.33; tablets: β = 0.83; 95% CI, −3.39 to 5.05). The proportion of prescriptions written for longer than 5 days also decreased significantly during the quarter of implementation across all 3 surgical specialties. Conclusions and Relevance In this cross-sectional study, the implementation of mandatory PDMP consultation with a concurrent EHR-based alert was associated with an immediate decrease in opioid prescribing across the 3 surgical specialties. These findings might be explained by prescribers’ attempts to meet the mandate exemption and bypass PDMP consultation rather than the PDMP consultation itself. Although policies coupled with EHR alerts may be associated with changes in postoperative opioid prescribing behavior, they need to be well designed to optimize evidence-based opioid prescribing., This cross-sectional study examines whether the implementation of mandated consultation with a prescription drug monitoring program was associated with changes in the quantity of postoperative opioid medications prescribed at discharge among adult patients in a health care system in California.

There are two salient facts about health care in low and middle-income countries; 1) the private sector plays an important role and 2) the care provided is often of poor quality. Despite these facts we know little about what drives quality of care in the private sector and why patients continue to seek care from poor quality providers. We use two field studies in India that provide unique insight into this issue. First, we use a discrete choice experiment to show that patients are willing to pay higher prices for better technical quality (defined by correct treatment and correct diagnosis). Second, we use standardized patients to show that private providers who provide better technical quality are not able to charge higher prices. Instead providers are able to charge higher prices for elements of quality that the patient can observe (good patient interactions and more effort), which are less important for health outcomes. Taken together, this research highlights a market inefficiency and suggests that engaging patients with accessible information on technical quality of the providers in their community could shift demand to providers that provide better care and thus improve health outcomes.

Background Studies report serious adherence problems among youth (individuals age 15 to 24 years of age) in Uganda. Recent growth in mobile phone ownership among Ugandan youth has highlighted the potential of using text-based interventions to improve ART adherence. We therefore developed and conducted a randomized controlled trial and examined the acceptability, feasibility, and preliminary impact of a pilot intervention providing weekly real-time antiretroviral adherence feedback, based on information from a smart pill box, to HIV-positive Ugandan youth. Methods We randomized participants to a control group, or to receive messages with information on either their own adherence levels (Treatment 1 - T1), or their own adherence and peer adherence levels (Treatment 2 – T2). We conducted six focus groups with providers and youth ages 15-24, double coded interviews, and achieved a Cohen’s Kappa of 0.79. Result The quantitative and qualitative data show that the intervention was deemed acceptable and feasible. The direction and magnitude of the treatment effects for T2 are promising. Adherence in the control group decreased from 80% to 70% by the end of the study. In the T2 group, adherence increased initially and remained between 80% and 85% for the duration of the study. Regression models estimate a 3 percentage point increase in adherence in the initial 9 weeks of the study in the T2 group relative to the control, which grows to a 9 percentage point increase by the last 9 weeks of the study. The T1 intervention shows no signs of impact; adherence in the T1 group decreased from 84% to 74%. This pilot study was not powered to detect statistical differences. Conclusions Improving youth’s adherence by supplementing information about their adherence with information about adherence of peers is a promising new strategy that should be further evaluated in a fully-powered study. Providing one’s own adherence information alone appears to have less potential.

In this short communication, we discuss some key behavioral economic (BE) biases that likely minimize HIV prevention efforts, explore why certain key populations such as men who have sex with men or transgender women-may be more likely to succumb to these biases, and suggest how incentives informed by BE can support these populations in their effort to remain HIV-negative. Based on our formative work in an ongoing study, we discuss two important insights regarding the use of incentives to inform future HIV prevention efforts. First, participants often expressed more excitement for prizes that were viewed as fun (e.g., movie gift cards) or luxurious (e.g., cosmetics gift cards) rather than necessities (e.g., grocery store gift cards) of the same financial value and suggests that including an element of fun can be a powerful tool for incentivizing safe HIV-related behavior. Second, participants preferred not to be "paid" to display health behaviors, indicating the way incentives are given out (and perceived) is central to their success. Going forward, a BE perspective can help improve the impact of incentives - and increase their cost-effectiveness by carefully adapting them to the preferences of their recipients.

In this paper, we exploit a lottery in Tanzania, which randomly assigned eligible participants to receive $100 cash grants. The randomized nature of the lottery allows us to estimate the causal impact of positive income shocks on risky sexual behavior. We found that winning the lottery led men to have 0.28 (95 % CI 0.14, 0.55) more sexual partners and to a 0.21 (95 % CI 0.01-0.4) increase in the probability of unprotected sex with a non-primary partner relative to a control group of eligible non-winners. We found no significant effect of winning the lottery on the sexual behavior of women.

There is growing support for an entrepreneurial community health worker (CHW) model, but the benefits of such a design are unclear. We randomly assigned CHWs in Uganda to sell treatment for child diarrhea door-to-door and retain the profits or to deliver treatment to homes for free. We find that, despite stronger financial incentives, the entrepreneurial model led to substantially less effort (fewer household visits) than the free delivery model. Qualitative evidence suggests that selling had a social penalty whereas free distribution was socially rewarding. Our results call into question the notion that an entrepreneurial model necessarily increases CHW effort relative to free distribution.

Life-saving technology used to treat catastrophic illnesses such as heart disease and cancer is often out of reach for the poor. As life expectancy increases in poor countries and the burden from chronic illnesses continues to rise, so will the unmet need for expensive tertiary care. Understanding how best to increase access to and reduce the financial burden of expensive tertiary care is a crucial task for the global health community in the coming decades. In 2010, Karnataka, a state in India, rolled out the Vajpayee Arogyashree scheme (VAS), a social health insurance scheme focused on increasing access to tertiary care for households below the poverty line. VAS was rolled out in a way that allowed for robust evaluation of its causal effects and several studies have examined various impacts of the scheme on poor households. In this analysis article, we summarise the key findings and assess how these findings can be used to inform other social health insurance schemes. First, the evidence suggests that VAS led to a substantial reduction in mortality driven by increased tertiary care utilisation as well as use of better quality facilities and earlier diagnosis. Second, VAS significantly reduced the financial burden of receiving tertiary care. Third, these benefits of social health insurance were achieved at a reasonable cost to society and taxpayers. Several unique features of VAS led to its success at improving health and financial well-being including effective outreach via health camps, targeting expensive conditions with high disease burden, easy enrolment process, cashless treatment, bundled payment for hospital services, participation of both public and private hospitals and prior authorisation to improve appropriateness of care.

This paper investigates the effects of health insurance on HIV testing rates among the US general population using nationally representative data from the Behavioral Risk Factor Surveillance Survey (BRFSS) for the years 1993 to 2003. We estimate recursive bivariate probit models with insurance coverage and HIV testing as the dependent variables. We use changes in Medicaid eligibility and distribution of firm size over time within a state as instruments for insurance coverage. The results suggest that (1) insurance coverage increases HIV testing rates, (2) insurance coverage increases HIV testing rates more among the high-risk population, and (3) the effects of insurance coverage on HIV testing for high-risk populations increased over time.

Objective To investigate whether enrollment in high-deductible health plans (HDHPs) led enrollees to choose lower-priced providers for office visits and laboratory tests. Study Setting Claims data from more than 40 large employers. Study Design We compared the change in price for office visits and laboratory tests for enrollees who switched to HDHPs versus enrollees who remained in traditional plans. We estimated separate models for enrollees who changed providers versus those who remained with the same provider to disentangle the effects of HDHPs on provider choice and negotiated prices. Data Collection Claims data from 2004 to 2010 on 1.8 million enrollees. Principle Findings After enrollment in HDHPs, 28 percent of enrollees changed physicians for office visits (compared to 19 percent in the Traditional Plan group, p

Diarrhea is the second leading cause of child mortality in India. Most deaths are cheaply preventable with the use of oral rehydration salts (ORS), yet many health providers still fail to provide ORS to children seeking diarrheal care. In this study, we use survey data to assess whether children visiting private providers for diarrheal care were less likely to use ORS than those visiting public providers. Results suggest that children who visited private providers were 9.5 percentage points less likely to have used ORS than those who visited public providers (95% CI 5-14). We complimented these results with in-depth interviews of 21 public and 17 private doctors in Gujarat, India, assessing potential drivers of public-private disparities in ORS use. Interview results suggested that lack of direct medication dispensing in the private sector might be a key barrier to ORS use in the private sector.