Blood Glucose and Risk of Incident and Fatal Cancer in the Metabolic Syndrome and Cancer Project (Me-Can): Analysis of Six Prospective Cohorts

Tanja Stocks and colleagues carry out an analysis of six European cohorts and confirm that abnormal glucose metabolism is linked with increased risk of cancer overall and at specific sites

Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial

Abstract Background Pay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. This study examined the incremental cost-effectiveness of a P4P strategy found to be highly effective in improving the implementation and effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment (EBT) for adolescent substance use disorders (SUDs). Methods Building on a $30 million national initiative to implement A-CRA in SUD treatment settings, urn randomization was used to assign 29 organizations and their 105 therapists and 1173 patients to one of two conditions (implementation-as-usual (IAU) control condition or IAU+P4P experimental condition). It was not possible to blind organizations, therapists, or all research staff to condition assignment. All treatment organizations and their therapists received a multifaceted implementation strategy. In addition to those IAU strategies, therapists in the IAU+P4P condition received US$50 for each month that they demonstrated competence in treatment delivery (A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions found to be associated with significantly improved patient outcomes (target A-CRA). Incremental cost-effectiveness ratios (ICERs), which represent the difference between the two conditions in average cost per treatment organization divided by the corresponding average difference in effectiveness per organization, and quality-adjusted life years (QALYs) were the primary outcomes. Results At trial completion, 15 organizations were randomized to the IAU condition and 14 organizations were randomized to the IAU+P4P condition. Data from all 29 organizations were analyzed. Cluster-level analyses suggested the P4P strategy led to significantly higher average total costs compared to the IAU control condition, yet this average increase of 5$333), a 325% increase in the average number of patients who received the targeted dosage of treatment (ICER = $453), and a 325$8.134). Further supporting P4P as a cost-effective implementation strategy, the cost per QALY was only $8681 (95$1191–$16,171). Conclusion This study provides experimental evidence supporting P4P as a cost-effective implementation strategy. Trial registration NCT01016704

Multivariable Relationships between Patient Characteristics, Type of Lifestyle Modification Program, and Changes in Cardiac Risk Factors over Two Years^a.

a<p>Statistical significance (Sig.): *p<0.05, †p<0.01, ‡p<0.001.</p>b<p>Reference group is the (MBMI) program.</p>c<p>Quarter denotes quarter year (3-month period).</p>d<p>Reference group is stable angina.</p><p>MBMI is the Benson-Henry Mind/Body Medical Institute. Ornish is The Dean Ornish Program for Reversing Heart Disease. BMI denotes body mass index; HDL denotes high density lipoprotein; LDL denotes low density lipoprotein; METS denotes metabolic equivalents; PCI is percutaneous coronary intervention; CABG is coronary artery bypass graft surgery; AMI is acute myocardial infarction.</p><p>Multivariable Relationships between Patient Characteristics, Type of Lifestyle Modification Program, and Changes in Cardiac Risk Factors over Two Years^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0114772#nt107" target="_blank">a</a>}.</p

Average Changes in Cardiac Risk Factor Levels from Baseline Values by Program and Time Point.

<p>Statistical significance: N denotes not significant, *p<0.05, †p<0.01, ‡p<0.001.</p><p>MBMI is the Benson-Henry Mind/Body Medical Institute. Ornish is The Dean Ornish Program for Reversing Heart Disease. BMI is body mass index; SBP is systolic blood pressure; DBP is diastolic blood pressure; mmHg is millimeters mercury; HDL is high density lipoprotein; LDL is low density lipoprotein; METs are metabolic equivalents; mos. denotes months of follow-up; ANY denotes all participants at the follow-up time; FULL denotes participants with final (24 month) data; n denotes the number of participants in that column. Data are not shown for 24 mos. ANY, but the patients and results are very similar to those for 24 mos. FULL.</p><p>Average Changes in Cardiac Risk Factor Levels from Baseline Values by Program and Time Point.</p

Risk Factor Changes in the Two Lifestyle Modification Programs Based on Multivariable Regressions with Quadratic Terms for Time.

<p>Notes: MBMI denotes the Cardiac Wellness Program of the Benson-Henry Mind Body Institute; Ornish is The Dean Ornish Program for Reversing Heart Disease. BMI denotes body mass index; LDL denotes low density lipoprotein; HDL denotes high density lipoprotein; SBP denotes systolic blood pressure; DBP denotes diastolic blood pressure.</p

Baseline Levels of Cardiac Risk Factors.

<p>SD is standard deviation; BMI is body mass index; SBP is systolic blood pressure; DBP is diastolic blood pressure; mmHg is millimeters of mercury; mg/dl is milligrams per deciliter; HDL is high density lipoprotein; LDL is low density lipoprotein; cardiac functional capacity is rated on a 15-point scale; higher scores indicate better cardiac function. MBMI is the Benson-Henry Mind/Body Medical Institute. Ornish is The Dean Ornish Program for Reversing Heart Disease.</p><p>Baseline Levels of Cardiac Risk Factors.</p

Proportions of Participants in Each Lifestyle Modification Program at Targeted Risk Factor Levels at Each Time Point.

<p>Notes: Targets defined as body mass index (BMI) < = 25; systolic blood pressure (SBP) <140 mm Hg; low density lipoprotein (LDL) <100 mg/dl; high density lipoprotein (HDL)>40 mg/dl (male) or>50 mg/dl (female). Mon denotes months. Statistical significance: * p<0.05, ** p<0.01, *** p<0.001, N denotes not significant. McNemar’s chi-square test was used for hypothesis testing. MBMI denotes the Cardiac Wellness Program of the Benson-Henry Mind Body Institute, Ornish is The Dean Ornish Program for Reversing Heart Disease.</p