Effectiveness and cost-effectiveness of incentives as a tool for prevention of non-communicable diseases: A systematic review

The rising epidemic of non-communicable diseases (NCDs) poses substantial health and economic challenges to both individuals and society. Application of incentive-based strategies based on traditional and behavioural economic theory has emerged as a potential strategy to address rising rates of NCDs. Yet, whether or not incentives truly represent a promising strategy for addressing NCDs has not been systematically addressed nor is it clear whether certain behavioural economic strategies outperform others or simply offering a cash-based incentive for meeting a goal. In this systematic review we aim to determine whether there is an evidence base for any of these strategies. Forty-eight published randomized controlled trials (70 contrasts) evaluating the effectiveness of incentive-based strategies for improvements in NCD risk-factors were reviewed. Our primary conclusion is that there is a lack of compelling evidence that incentives of any form represent a compelling NCD reduction strategy. More evidence for long-term effectiveness and cost-effectiveness is needed to justify third party funding of any incentive based strategy

DIMMI DOVE VIVI E TI DIRÒ COME STAI: UN’INDAGINE EMPIRICA SUGLI EFFETTI DELLA DEPRIVAZIONE DEL QUARTIERE DI RESIDENZA SUI RISULTATI DI SALUTE

La presenza di un’elevata concentrazione delle condizioni di malattia nelle aree disagiate è un tema molto dibattuto di salute pubblica. Da una parte si sostiene che tale concentrazione sia la manifestazione dell’effetto della povertà e del disagio individuale (effetto composizionale), mentre più di recente si è cominciato ad ipotizzare che anche il contesto possa esercitare un’influenza autonoma sui risultati di salute. Questo lavoro rappresenta il primo tentativo empirico per l’Italia di verificare l’effetto della deprivazione del quartiere di residenza in termini di inquinamento ambientale, criminalità, vandalismo e degrado urbano sulle condizioni di salute percepita, la presenza di malattie croniche e la presenza di condizioni di disabilità di lunga durata. Il lavoro mostra, come, accanto ad un forte effetto delle condizioni socio-economiche individuali, le cattive condizioni sociali ed ambientali del quartiere di residenza esercitino un’influenza non trascurabile sulla salute, soprattutto per le donne e gli individui disagiati dal punto di vista socio-economico. L’effetto della deprivazione, inoltre, sembra essere più marcato nelle regioni centrosettentrionali rispetto a quelle meridionali probabilmente a causa di una maggiore deprivazione relativa. Questi risultati suggeriscono di accompagnare ad i tradizionali interventi di politica sociale aventi come focus l’individuo, politiche tese a migliorare le condizioni sociali, economiche ed ambientali dei quartieri disagiati, con possibili benefici sulla salute fruibili dalle intere comunità che li abitano.Neighbourhood, Deprivazione Socio-Economica, Salute

Demand for Cancer Screening Services: Results From Randomized Controlled Discrete Choice Experiments

Objectives: Low uptake of cancer screening services is a global concern. Our aim was to understand factors that influence the screening decision, including screening and treatment subsidies and a gain-frame message designed to present screening as awin–win. Methods: We analyzed preferences for mammography and Pap smear among women in Singapore by means of discretechoice experiments while randomly exposing half of respondents to a gain-framed public health message promoting thebenefits of screening. Results: Results showed that the message did not influence stated uptake, and given the levels shown, respondents were influenced more by treatment attributes, including effectiveness and out-of-pocket cost should they test positive, than by screening attributes, including the offer of a monetary incentive for screening. Respondents also underestimated the survival chances of screen-detected breast and cervical cancers. Conclusions: Combined, these findings suggest that correcting misconceptions about screen-detected cancer prognosis orproviding greater financial protection for those who test positive could be more effective and more cost-effective thans ubsidizing screening directly in increasing screening uptakes

Using Adherence-Contingent Rebates on Chronic Disease Treatment Costs to Promote Medication Adherence: Results from a Randomized Controlled Trial

Background: Poor adherence to medications is a global public health concern with substantial health and cost implications, especially for chronic conditions. In the USA, poor adherence is estimated to cause 125,000 deaths and cost $US100 Billion annually. The most successful adherence-promoting strategies that have been identified so far have moderate effect, are relatively costly, and raise availability, feasibility, and/or scalability issues. Objective: The main objective of SIGMA (Study on Incentives for Glaucoma Medication Adherence) was to measure the effectiveness on medication adherence of a novel incentive strategy based on behavioral economics that we refer to as adherence-contingent rebates. These rebates offered patients a near-term benefit while leveraging loss aversion and regret nd increasing the salience of adherence. Methods: IGMA is a 6-month randomized, controlled, open-label, single-center superiority trial with two parallel arms. total of 100 non-adherent glaucoma patients from the Singapore National Eye Centre were randomized into intervention (adherence-contingent rebates) and usual care (no rebates) arms in a 1:1 ratio. The primary outcome was the mean change from baseline in percentage of adherent days at Month 6. The trial registration number is NCT02271269 and a detailed study protocol has been published elsewhere. Findings: We found that participants who were offered adherence-contingent rebates were adherent to all their edications on 73.1$US5.94 as of 2 November 2017) per month during the intervention period. Conclusion: This study shows that simultaneously leveraging several insights from behavioral economics can significantly improve medication adherence rates. The relatively low cost of the rebates and significant health and cost implications of medication non-adherence suggest that this strategy has the potential to cost-effectively improve health outcomes for many conditions

Study on Incentives for Glaucoma Medication Adherence (SIGMA): study protocol for a randomized controlled trial to increase glaucoma medication adherence using value pricing

BACKGROUND: Many glaucoma patients do not adhere to their medication regimens because they fail to internalize the (health) costs of non-adherence, which may not occur until years or decades later. Behavioural economic theory suggests that adherence rates can be improved by offering patients a near-term benefit. Our proposed strategy is to offer adherence-contingent rebates on medication and check-up costs. This form of value pricing (VP) ensures that rebates are granted only to those most likely to benefit. Moreover, by leveraging loss aversion, rebates are expected to generate a stronger behavioural response than equivalent financial rewards. METHODS/DESIGN: The main objective of the Study on Incentives for Glaucoma Medication Adherence (SIGMA) is to test the VP approach relative to usual care (UC) in improving medication adherence. SIGMA is a randomized, controlled, open-label, single-centre superiority trial with two parallel arms. A total of 100 non-adherent (Morisky Medication Adherence Scale ≤6) glaucoma patients from the Singapore National Eye Centre are block-randomized (blocking factor: single versus multiple medications users) into the VP and UC arms in a 1:1 ratio. The treatment received by VP patients will be strictly identical to that received by UC patients, with the only exception being that VP patients can earn either a 50 % or 25 % rebate on their glaucoma-related healthcare costs conditional on being adherent on at least 90 % or 75 % of days as measured by a medication event monitoring system. Masking the arm allocation will be precluded by the behavioural nature of the intervention but blocking size will not be disclosed to protect concealment. The primary outcome is the mean change from baseline in percentage of adherent days at month 6. A day will be counted as adherent when the patients take all their medication(s) within the appropriate dosing windows. DISCUSSION: This trial will provide evidence on whether adherence-contingent rebates can improve medication adherence among non-adherent glaucoma patients, and more generally whether this approach represents a promising strategy to cost-effectively improve chronic disease management. TRIAL REGISTRATION: NCT02271269 . Registered on 19 October 2014

Process- and Outcome-Based Financial Incentives to Improve Self-Management and Glycemic Control in People with Type 2 Diabetes in Singapore: A Randomized Controlled Trial

Background: Sub-optimally controlled diabetes increases risks for adverse and costly complications. Self-management including glucose monitoring, medication adherence, and exercise are key for optimal glycemic control, yet, poor self-management remains common. Objective: The main objective of the Trial to Incentivize Adherence for Diabetes (TRIAD) study was to determine the effectiveness of financial incentives in improving glycemic control among type 2 diabetes patients in Singapore, and to test whether process-based incentives tied to glucose monitoring, medication adherence, and physical activity are more effective than outcome-based incentives tied to achieving normal glucose readings. Methods: TRIAD is a randomized, controlled, multi-center superiority trial. A total of 240 participants who had at least one recent glycated hemoglobin (HbA1c) being 8.0% or more and on oral diabetes medication were recruited from two polyclinics. They were block-randomized (blocking factor: current vs. new glucometer users) into the usual care plus (UC +) arm, process-based incentive arm, and outcome-based incentive arm in a 2:3:3 ratio. The primary outcome was the mean change in HbA1c at month 6 and was linearly regressed on binary variables indicating the intervention arms, baseline HbA1c levels, a binary variable indicating titration change, and other baseline characteristics. Results: Our findings show that the combined incentive arms trended toward better HbA1c than UC + , but the difference is estimated with great uncertainty (difference − 0.31; 95% confidence interval [CI] − 0.67 to 0.06). Lending credibility to this result, the proportion of participants who reduced their HbA1c is higher in the combined incentive arms relative to UC + (0.18; 95% CI 0.04, 0.31). We found a small improvement in process- relative to outcome-based incentives, but this was again estimated with great uncertainty (difference − 0.05; 95% CI − 0.42 to 0.31). Consistent with this improvement, process-based incentives were more effective at improving weekly medication adherent days (0.64; 95% CI − 0.04 to 1.32), weekly physically active days (1.37; 95% CI 0.60–2.13), and quality of life (0.04; 95% CI 0.0–0.07) than outcome-based incentives. Conclusion: This study suggests that both incentive types may be part of a successful self-management strategy. Process-based incentives can improve adherence to intermediary outcomes, while outcome-based incentives focus on glycemic control and are simpler to administer

The challenges of measuring social cohesion in public health research: A systematic review and ecometric meta-analysis

The relationship between social cohesion and health has been studied for decades. Yet, due to the contextual nature of this concept, measuring social cohesion remains challenging. Using a meta-analytical framework, this review's goal was to study the ecometric measurement properties of social cohesion in order to describe dissimilarities in its measurement as well as bring a new perspective on the empirical usefulness of the concept itself. To this end, we analysed if, and to what extent, contextual-level reliability and intersubjective agreement of 78 social cohesion measurements varied under different measurement conditions like measurement instrument, spatial unit, ecometric model specification, or region. We found consistent evidence for the contextual nature of social cohesion, however, most variation existed between individuals, not contexts. While contextual dependence in response behaviour was fairly insensitive to item choices, population size within chosen spatial units of social cohesion measurements mattered. Somewhat counterintuitively, using spatial units with, on average, fewer residents did not yield systematically superior ecometric properties. Instead, our results underline that precise theory about the relevant contextual units of causal relationships between social cohesion and health is vital and cannot be replaced by empirical analysis. Although adjustment for respondent's characteristics had only small effects on ecometric properties, potential pitfalls of this analytic strategy are discussed in this paper. Finally, acknowledging the sensitivity of measuring social cohesion, we derived recommendations for future studies investigating the effects of contextual-level social characteristics on health

The importance and direction of current and future plant-UV research : break-out session discussions at the UV4Plants Network Meeting in Bled (April 15th -18th , 2018)

During the 2nd Network Meeting of UV4Plants at Bled (14th–18th April, 2018) the delegates engaged in a group discussion of prescient questions concerning the future of in plant-UV research. The discussion group was tasked to identify the most valuable directions for plant UV research to take, and to create a coherent framework for how to move the field forward. Here, the outcome of these discussions is summarised in sections that follow the composition of discussion groups as ideas taken from a molecular, biochemical and physiological perspective followed by those from an ecological and plant production perspective. In each case, first basic research questions are considered and then applications and methodological considerations are put forward. Finally, some common ground bringing the two perspectives together is discussed, with the aim of solving scaling problems and ways in which the UV4Plants network might be put to good use.Peer reviewe

Stimulation of synaptic vesicle exocytosis by the mental disease gene DISC1 is mediated by N-Type voltage-gated calcium channels

Lesions and mutations of the DISC1 (Disrupted-in-schizophrenia-1) gene have been linked to major depression, schizophrenia, bipolar disorder and autism, but the influence of DISC1 on synaptic transmission remains poorly understood. Using two independent genetic approaches-RNAi and a DISC1 KO mouse-we examined the impact of DISC1 on the synaptic vesicle (SV) cycle by population imaging of the synaptic tracer vGpH in hippocampal neurons. DISC1 loss-of-function resulted in a marked decrease in SV exocytic rates during neuronal stimulation and was associated with reduced Ca(2+) transients at nerve terminals. Impaired SV release was efficiently rescued by elevation of extracellular Ca(2+), hinting at a link between DISC1 and voltage-gated Ca(2+) channels. Accordingly, blockade of N-type Cav2.2 channels mimics and occludes the effect of DISC1 inactivation on SV exocytosis, and overexpression of DISC1 in a heterologous system increases Cav2.2 currents. Collectively, these results show that DISC1-dependent enhancement of SV exocytosis is mediated by Cav2.2 and point to aberrant glutamate release as a probable endophenotype of major psychiatric disorders