1
|
Lau-Min KS, Marini J, Shah NK, Pucci D, Blauch AN, Cambareri C, Mooney B, Agarwal P, Johnston C, Schumacher RP, White K, Gabriel PE, Rosin R, Jacobs LA, Shulman LN. Pilot Study of a Mobile Phone Chatbot for Medication Adherence and Toxicity Management Among Patients With GI Cancers on Capecitabine. JCO Oncol Pract 2024; 20:483-490. [PMID: 38237102 DOI: 10.1200/op.23.00365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/11/2023] [Accepted: 12/04/2023] [Indexed: 04/12/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Kelsey S Lau-Min
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Jessica Marini
- Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA
| | - Nishant K Shah
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Donna Pucci
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Abigail N Blauch
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Bethany Mooney
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Parul Agarwal
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Peter E Gabriel
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Roy Rosin
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA
| | - Linda A Jacobs
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
2
|
Meer E, Ramakrishnan M, Whitehead G, Leri D, Rosin R, VanderBeek B. Validation of an Automated Symptom-based Triage Tool in Ophthalmology. Appl Clin Inform 2023. [PMID: 36990454 DOI: 10.1055/a-2065-4613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
OBJECTIVE 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 1/1/21 and 1/1/22 was performed. Concordance between triage category and severity of diagnosis on the subsequent clinic visit was assessed. RESULTS The online triage tool was utilized 1370 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% non-urgent. 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.
Collapse
Affiliation(s)
- Elana Meer
- Ophthalmology, University of California San Francisco, San Francisco, United States
- Ophthalmology, University of Pennsylvania Health System, Philadelphia, United States
| | - Meera Ramakrishnan
- Ophthalmology, University of Pennsylvania Health System, Philadelphia, United States
| | - Gideon Whitehead
- Ophthalmology, University of Pennsylvania Health System, Philadelphia, United States
- Center for Healthcare Innovation, Penn Medicine, Philadelphia, United States
| | - Damien Leri
- Center for Healthcare Innovation, Penn Medicine, Philadelphia, United States
| | - Roy Rosin
- Center for Healthcare Innovation, Penn Medicine, Philadelphia, United States
| | - Brian VanderBeek
- Ophthalmology, University of Pennsylvania Health System, Philadelphia, United States
| |
Collapse
|
3
|
Lau-Min KS, Marini J, Shah N, Pucci D, Blauch A, Cambareri C, Mooney B, Johnston C, Schumacher RP, White K, Gabriel PE, Rosin R, Jacobs LA, Shulman LN. An augmented intelligence mobile phone chatbot for medication adherence and toxicity management among patients with gastrointestinal cancers on capecitabine. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
424 Background: Capecitabine (cape), an oral chemotherapy, is the treatment backbone for many GI cancers. Its complex dosing and narrow therapeutic index make medication adherence and toxicity management crucial for quality patient care. Methods: We conducted a feasibility study of “Penny,” an augmented intelligence mobile phone chatbot that leverages algorithmic surveys and natural language processing (NLP) to engage with patients in conversational, bi-directional text messages. Penny provides patients with medication reminders tailored to their prescribed doses and schedules, sends weekly check-in messages, manages low-grade symptoms in real time, and escalates high-grade symptoms for resolution by the clinical team. Patients ≥18 years old receiving cape for the treatment of a GI cancer were accrued in sequential cohorts of 20 for participation over a three-month period. Feasibility was assessed during planned interim analyses and was predefined as the completion of a 20-patient cohort without a safety event, defined as the communication of incorrect medication or symptom management recommendations as ascertained by two independent clinician reviewers (Κ = 0.89). Secondary outcomes included patient-reported adherence and engagement with the chatbot’s weekly check-in messages. At study completion, all patients were invited to participate in structured interviews to provide feedback on the platform. Results: The first cohort of 20 patients was enrolled from 8/2021 to 4/2022; the median age was 57 years, and patients were primarily female (55%), white (65%), commercially insured (55%), and had colorectal cancer (55%). Chemotherapy regimens included cape with oxaliplatin (50%), concurrent RT (30%), temozolomide (5%), and monotherapy (15%). A total of 2,149 text messaging exchanges were reviewed with 150 (7%) medication-related and 9 (0.4%) symptom-related safety events identified. Most medication-related safety events were due to misalignment with prescribed chemotherapy schedules (55%) and doses (32%). Symptom-related safety events were primarily due to the misinterpretation of patient messages by Penny’s NLP functionality (89%). Average patient-reported adherence was 67% (SD 27%), and patients engaged with 27% (SD 24%) of the chatbot’s weekly check-in messages. In post-study interviews with 12 patients, participants reported that the medication reminders were reliable and user-friendly, whereas the symptom management tool was too simplistic to be helpful. Conclusions: Although Penny has not yet met its feasibility endpoint, the lessons learned from this first cohort have informed further refinements to the platform. Ongoing efforts aim to integrate Penny with the electronic health record and further train the chatbot’s NLP functionality to minimize medication- and symptom-related safety events, respectively. Clinical trial information: NCT05113264.
Collapse
Affiliation(s)
- Kelsey S. Lau-Min
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Nishant Shah
- University of Pennsylvania, Department of Radiation Oncology, Philadelphia, PA
| | - Donna Pucci
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Abigail Blauch
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Christine Cambareri
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Bethany Mooney
- University of Pennsylvania Health System, Philadelphia, PA
| | | | | | | | | | | | - Linda A. Jacobs
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | |
Collapse
|
4
|
Mehta SJ, Mallozzi C, Shaw PA, Reitz C, McDonald C, Vandertuyn M, Balachandran M, Kopinsky M, Sevinc C, Johnson A, Ward R, Park SH, Snider CK, Rosin R, Asch DA. Effect of Text Messaging and Behavioral Interventions on COVID-19 Vaccination Uptake: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2216649. [PMID: 35696165 PMCID: PMC9194662 DOI: 10.1001/jamanetworkopen.2022.16649] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | | | - Pamela A. Shaw
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Caitlin McDonald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Matthew Vandertuyn
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Mohan Balachandran
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Michael Kopinsky
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Christianne Sevinc
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Aaron Johnson
- Penn Medicine, University of Pennsylvania, Philadelphia
| | - Robin Ward
- Penn Medicine, University of Pennsylvania, Philadelphia
| | - Sae-Hwan Park
- Penn Medicine, University of Pennsylvania, Philadelphia
| | | | - Roy Rosin
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| |
Collapse
|
5
|
Bange EM, Coughlin KQ, Brown TJ, Li W, Moriarty E, Bange TE, Rosin R, Josephs M, Smith DR, Cohen RB, Getz KD, Ragusano D, Balar E, Schuchter LM, Balachandran M, Long Q, Shulman LN, Guerra C, Mamtani R. Saving TIME: Accuracy of a text intervention to minimize the time burden of cancer care. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.6527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6527 Background: Patients with cancer spend substantial time receiving cancer care. There is a need for innovative strategies to decrease the time burden of cancer therapy. The current care model consists largely of in-person visits to assess treatment toxicity. Most patients treated with immunotherapy, however, do not experience substantial toxicity. We designed and evaluated a text-based instrument to identify patients without symptoms of immunotherapy toxicity. This instrument has the potential to be combined with lab assessment to identify individuals who can safely proceed directly to treatment, lessening the need for in-person office visits. Methods: This cross-sectional study evaluated the performance characteristics of a text-based instrument to identify patient-reported immunotherapy toxicity, against the gold standard in-person provider assessment documented in the electronic medical record (EMR). Those eligible for inclusion spoke English, were receiving single agent immune checkpoint blockade for a solid tumor, and had access to a mobile device with text messaging capabilities. The instrument contained 16 questions adapted from the NCI Pro-CTCAE and was administered via text-message 96 hours prior to the patient’s scheduled infusion visit. Patient perspectives were quantified via a 13-item questionnaire. Results: Between October 1 and November 25, 2021, 50 patients enrolled in the study, and 45 patients completed the instrument (90% response). The median age was 68 (IQR 60-72), 31 (62%) were male, and 44 (88%) were white. Most patients received either pembrolizumab (n=27, 54%) or nivolumab (n=17, 34%) in the palliative setting (n=37, 74%) for genitourinary (n=15, 30%), lung (n=13, 26%), or skin (n=11, 22%) cancer. Patients who completed the instrument were younger (median age 67 vs 76) than those who did not complete the instrument. The prevalence of immune related toxicity documented in the EMR was 57.8%. The sensitivity and negative predictive value of the instrument was 100% (95% CI 0.87-1.00) and 100% (95% CI 0.664-1.00), respectively; other accuracy parameters are presented in the Table. The patient user questionnaire revealed that visual impairment, lack of access to a smart phone, and lack of recognition of the instrument were barriers to completion. Conclusions: A text-based platform is both feasible and effective at identifying patients who are not experiencing symptoms of immune toxicity, and when combined with lab assessment, can eliminate office visits for up to 47% of patients. A prospective clinical trial to assess this is underway (NCT05134636). [Table: see text]
Collapse
Affiliation(s)
| | | | - Timothy J Brown
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Wenrui Li
- University of Pennsylvania, Philadelphia, PA
| | | | - Tara E. Bange
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | - Kelly D. Getz
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Eesha Balar
- University of Pennsylvania, Philadelphia, PA
| | | | | | - Qi Long
- University of Pennsylvania, Philadelphia, PA
| | | | - Carmen Guerra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ronac Mamtani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
6
|
Lowenstein M, Perrone J, Xiong RA, Snider CK, O’Donnell N, Hermann D, Rosin R, Dees J, McFadden R, Khatri U, Meisel ZF, Mitra N, Delgado MK. Sustained Implementation of a Multicomponent Strategy to Increase Emergency Department-Initiated Interventions for Opioid Use Disorder. Ann Emerg Med 2022; 79:237-248. [PMID: 34922776 PMCID: PMC8860858 DOI: 10.1016/j.annemergmed.2021.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/15/2021] [Accepted: 10/18/2021] [Indexed: 12/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Margaret Lowenstein
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA.
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Ruiying Aria Xiong
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | | | - Nicole O’Donnell
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Davis Hermann
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA
| | - Roy Rosin
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA
| | - Julie Dees
- Family Service Association of Bucks County, Langhorne, PA
| | - Rachel McFadden
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Utsha Khatri
- Department of Emergency Medicine, Mount Sinai Icahn School of Medicine, New York, NY
| | - Zachary F. Meisel
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Nandita Mitra
- Department: Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - M. Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| |
Collapse
|
7
|
Agarwal AK, Southwick L, Schneider R, Pelullo A, Ortiz R, Klinger EV, Gonzales RE, Rosin R, Merchant RM. Crowdsourced Community Support Resources Among Patients Discharged From the Emergency Department During the COVID-19 Pandemic: Pilot Feasibility Study. JMIR Ment Health 2022; 9:e31909. [PMID: 35037886 PMCID: PMC8869378 DOI: 10.2196/31909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/09/2021] [Accepted: 12/23/2021] [Indexed: 01/27/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Anish K Agarwal
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Lauren Southwick
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Rachelle Schneider
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Arthur Pelullo
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Robin Ortiz
- Departments of Pediatrics and Population Health, NYU Grossman School of Medicine, Institute for Excellence in Health Equity, New York, NY, United States
| | - Elissa V Klinger
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Rachel E Gonzales
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Roy Rosin
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA, United States
| | - Raina M Merchant
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
8
|
Soegaard Ballester JM, Bass GD, Urbani R, Fala G, Patel R, Leri D, Steinkamp JM, Denson JL, Rosin R, Adusumalli S, Hanson CW, Koppel R, Airan-Javia S. A Mobile, Electronic Health Record-Connected Application for Managing Team Workflows in Inpatient Care. Appl Clin Inform 2021; 12:1120-1134. [PMID: 34937103 PMCID: PMC8695057 DOI: 10.1055/s-0041-1740256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jacqueline M Soegaard Ballester
- Division of General Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Geoffrey D Bass
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Richard Urbani
- Department of Information Services, Penn Medicine, Philadelphia, Pennsylvania, United States
| | - Glenn Fala
- Department of Information Services, Penn Medicine, Philadelphia, Pennsylvania, United States
| | - Rutvij Patel
- Department of Information Services, Penn Medicine, Philadelphia, Pennsylvania, United States
| | - Damien Leri
- Center for Healthcare Innovation, Penn Medicine, Philadelphia, Pennsylvania, United States
| | - Jackson M Steinkamp
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Joshua L Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, Louisiana, United States
| | - Roy Rosin
- Center for Healthcare Innovation, Penn Medicine, Philadelphia, Pennsylvania, United States.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Srinath Adusumalli
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Clarence William Hanson
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Office of the Chief Medical Information Officer, Penn Medicine, Philadelphia, Pennsylvania, United States
| | - Ross Koppel
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Institute of Biomedical Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Department of Sociology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Department of Biomedical informatics, University of Buffalo (SUNY), Buffalo, New York, United States
| | - Subha Airan-Javia
- Section of Hospital Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Founder/CEO, CareAlign, Philadelphia, Pennsylvania, United States
| |
Collapse
|
9
|
Meer EA, Herriman M, Lam D, Parambath A, Rosin R, Volpp KG, Chaiyachati KH, McGreevey JD. Design, Implementation, and Validation of an Automated, Algorithmic COVID-19 Triage Tool. Appl Clin Inform 2021; 12:1021-1028. [PMID: 34734403 DOI: 10.1055/s-0041-1736627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Elana A Meer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Maguire Herriman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Doreen Lam
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Andrew Parambath
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Roy Rosin
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States
| | - Kevin G Volpp
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Department of Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States
| | - Krisda H Chaiyachati
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States.,Department of Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States.,Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - John D McGreevey
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States.,Office of the Chief Medical Information Officer, University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States.,Center for Applied Health Informatics, University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States
| |
Collapse
|
10
|
Choi K, Gitelman Y, Leri D, Deleener ME, Hahn L, O'Malley C, Lang E, Patel N, Jones T, Emperado K, Erickson C, Rosin R, Asch D, Hanson CW, Adusumalli S. Insourcing and scaling a telemedicine solution in under 2 weeks: Lessons for the digital transformation of health care. Healthc (Amst) 2021; 9:100568. [PMID: 34293616 PMCID: PMC9616708 DOI: 10.1016/j.hjdsi.2021.100568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/24/2021] [Accepted: 07/10/2021] [Indexed: 11/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Katherine Choi
- University of Pennsylvania Health System, Penn Medicine Center for Health Care Innovation, 3400 Civic Center Blvd, 14(th) Floor South Pavilion, Philadelphia, PA, 19104, USA.
| | - Yevgeniy Gitelman
- University of Pennsylvania Health System, Penn Medicine Center for Health Care Innovation, 3400 Civic Center Blvd, 14(th) Floor South Pavilion, Philadelphia, PA, 19104, USA; University of Pennsylvania Health System, Hospital Medicine, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Damien Leri
- University of Pennsylvania Health System, Penn Medicine Center for Health Care Innovation, 3400 Civic Center Blvd, 14(th) Floor South Pavilion, Philadelphia, PA, 19104, USA.
| | - Mary Elisabeth Deleener
- University of Pennsylvania Health System, Office of the Chief Medical Information Officer, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Lauren Hahn
- University of Pennsylvania Health System, Penn Medicine Center for Health Care Innovation, 3400 Civic Center Blvd, 14(th) Floor South Pavilion, Philadelphia, PA, 19104, USA.
| | - Christina O'Malley
- University of Pennsylvania Health System, Penn Medicine Center for Health Care Innovation, 3400 Civic Center Blvd, 14(th) Floor South Pavilion, Philadelphia, PA, 19104, USA.
| | - Erik Lang
- University of Pennsylvania Health System, Information Services, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Neha Patel
- University of Pennsylvania Health System, Office of the Chief Medical Information Officer, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA; University of Pennsylvania Health System, Internal Medicine, Division of General Internal Medicine, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Timothy Jones
- University of Pennsylvania Health System, Information Services, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Kert Emperado
- University of Pennsylvania Health System, EHR Transformation, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Christopher Erickson
- University of Pennsylvania Health System, EHR Transformation, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Roy Rosin
- University of Pennsylvania Health System, Penn Medicine Center for Health Care Innovation, 3400 Civic Center Blvd, 14(th) Floor South Pavilion, Philadelphia, PA, 19104, USA.
| | - David Asch
- University of Pennsylvania Health System, Penn Medicine Center for Health Care Innovation, 3400 Civic Center Blvd, 14(th) Floor South Pavilion, Philadelphia, PA, 19104, USA.
| | - C William Hanson
- University of Pennsylvania Health System, Office of the Chief Medical Information Officer, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA; University of Pennsylvania Health System, Anesthesia, Surgery and Internal Medicine, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Srinath Adusumalli
- University of Pennsylvania Health System, Penn Medicine Center for Health Care Innovation, 3400 Civic Center Blvd, 14(th) Floor South Pavilion, Philadelphia, PA, 19104, USA; University of Pennsylvania Health System, Office of the Chief Medical Information Officer, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA; University of Pennsylvania Health System, Cardiology, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| |
Collapse
|
11
|
Mahraj K, Chaiyachati KH, Asch DA, Fala G, Do D, Lam D, Miller A, Mannion N, Stoloff V, Halbritter A, Huffenberger AM, Shuttleworth J, O’Donnell JA, Green-McKenzie J, Patel K, Rosin R, Kruse G, Brennan P, Volpp KG. Developing a Large-Scale Covid-19 Surveillance System to Reopen Campuses. NEJM Catalyst 2021. [PMCID: PMC8208605 DOI: 10.1056/cat.21.0049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
To open campuses safely, the University of Pennsylvania (Penn) and its health system (UPHS), with six hospitals and hundreds of outpatient practices, needed to develop an early warning system to identify the infected and exposed among Penn and UPHS campus members — 70,000 faculty, staff, and students who were at risk of transmitting severe acute respiratory syndrome coronavirus 2, or Covid-19. This warning system would help to minimize future spread by preventing individuals with concerning symptoms or recent exposures from coming into contact with others and, when necessary, streamline access to testing, self-isolation guidance, contact tracing, and medical care. The authors describe the challenges in designing, implementing, and continuously improving PennOpen Pass and the Red Pass Management System, a part-digital, part-human screening system. The lessons learned while developing and implementing PennOpen Pass provide key insights for the future of innovations in health care as we move toward improving the health of communities long after the pandemic.
Collapse
Affiliation(s)
- Katy Mahraj
- Director of Operations for the Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Krisda H. Chaiyachati
- Medical Director for PennOpen Pass, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - David A. Asch
- Executive Director for the Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Glenn Fala
- Associate Chief Information Officer, Software Development, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - David Do
- Assistant Professor of Clinical Neurology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Doreen Lam
- Medical Student, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amy Miller
- Information Technology Director, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nancy Mannion
- Interim Nurse Manager for PennLINKS at the Center for Connected Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Vanessa Stoloff
- Medical Director at University of Pennsylvania Student Health Service, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashlee Halbritter
- Director of Campus Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ann Marie Huffenberger
- Director of Operations for the Center for Connected Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Julie Shuttleworth
- University Operations Lead for PennOpen Pass, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Judith A. O’Donnell
- Professor of Clinical Medicine and Director of Infection Prevention and Control at Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Judith Green-McKenzie
- Professor of Medicine and Division of Occupational & Environmental Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Kash Patel
- Vice President and Chief Technology Officer, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Roy Rosin
- Chief Innovation Officer, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Greg Kruse
- Associate Vice President of Strategic Operations, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - P.J. Brennan
- Chief Medical Officer, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Kevin G. Volpp
- Professor of Medicine and Director for the Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
12
|
Buckley R, Spadaro A, Rosin R, Shea JA, Myers JS. Comparing the Effects of Design Thinking and A3 Problem-Solving on Resident Attitudes Toward Systems Change. J Grad Med Educ 2021; 13:231-239. [PMID: 33897957 PMCID: PMC8054598 DOI: 10.4300/jgme-d-20-00793.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/08/2020] [Accepted: 01/22/2021] [Indexed: 11/06/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Ryan Buckley
- At the time of research, Ryan Buckley, MD, was a Faculty Member, Perelman School of Medicine at the University of Pennsylvania, and is now Assistant Professor of Clinical Medicine, Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Department of Medicine, Vanderbilt University Medical Center
| | - Anthony Spadaro
- Anthony Spadaro, MD, MPH, is a Resident Physician, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Roy Rosin
- Roy Rosin, MBA, is Chief Innovation Officer, Penn Medicine, University of Pennsylvania
| | - Judy A. Shea
- Judy A. Shea, PhD, is Professor of Medicine, Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Jennifer S. Myers
- Jennifer S. Myers, MD, is Professor of Clinical Medicine, Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| |
Collapse
|
13
|
Agarwal AK, Hahn L, Rosin R, Merchant RM. Exploring digital methods to capture self-reported on-shift sentiment amongst academic emergency department physicians. Am J Emerg Med 2020; 46:760-762. [PMID: 32981812 DOI: 10.1016/j.ajem.2020.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- Anish K Agarwal
- University of Pennsylvania Department of Emergency Medicine, Philadelphia, PA, United States of America; Penn Medicine Center for Digital Health, University of Pennsylvania, Philadelphia, PA, United States of America; Penn Medicine Center for Healthcare Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America.
| | - Lauren Hahn
- Penn Medicine Center for Digital Health, University of Pennsylvania, Philadelphia, PA, United States of America; Penn Medicine Center for Healthcare Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Roy Rosin
- Penn Medicine Center for Digital Health, University of Pennsylvania, Philadelphia, PA, United States of America; Penn Medicine Center for Healthcare Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Raina M Merchant
- University of Pennsylvania Department of Emergency Medicine, Philadelphia, PA, United States of America; Penn Medicine Center for Digital Health, University of Pennsylvania, Philadelphia, PA, United States of America; Penn Medicine Center for Healthcare Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| |
Collapse
|
14
|
Agarwal AK, Hahn L, Pelullo A, Rosin R, Merchant RM. Capturing Real-Time Emergency Department Sentiment: A Feasibility Study Using Touch-Button Terminals. Ann Emerg Med 2019; 75:727-732. [PMID: 31493921 DOI: 10.1016/j.annemergmed.2019.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/28/2019] [Accepted: 07/01/2019] [Indexed: 11/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- Anish K Agarwal
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA; Penn Medicine Center for Digital Health, University of Pennsylvania, Philadelphia, PA; Penn Medicine Center for Healthcare Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Lauren Hahn
- Penn Medicine Center for Digital Health, University of Pennsylvania, Philadelphia, PA; Penn Medicine Center for Healthcare Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Arthur Pelullo
- Penn Medicine Center for Digital Health, University of Pennsylvania, Philadelphia, PA; Penn Medicine Center for Healthcare Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Roy Rosin
- Penn Medicine Center for Healthcare Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Raina M Merchant
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA; Penn Medicine Center for Digital Health, University of Pennsylvania, Philadelphia, PA; Penn Medicine Center for Healthcare Innovation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| |
Collapse
|
15
|
Mooney Berges B, Cambareri C, Takvorian SU, Serpa M, Shulman LN, Bekelman JE, Rendle KA, Argon J, Rosin R. Leveraging a conversational agent to support adherence to oral anticancer agents: A usability study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6534 Background: Identifying effective, scalable strategies to ensure patient adherence to oral anticancer agents (OACAs) is a major challenge. Previous studies have shown widely variable rates of adherence, and suboptimal adherence is associated with decreased effectiveness and higher costs. A small but growing literature supports digital health behavioral interventions across a variety of chronic illnesses, including in cancer. In particular, conversational agents—or technologies that mimic human conversation using text or spoken language—have shown early promise in supporting behavior change, but have yet to be rigorously tested in the context of OACAs. Methods: A rapid cycle prototyping approach led to the development of ‘Penny’ – a bidirectional, conversational agent that engages patients via text messaging, and leverages natural language processing and machine learning to learn from clinical interactions. Core functionalities include: (1) real-time dosing instructions, (2) motivational reminders, and (3) symptom monitoring with self-management support. We conducted a four-month usability study between December 24, 2017 and May 1, 2018 in a large academic cancer center. At monthly intervals for the first 12 weeks of follow-up, research staff conducted qualitative interviews with participants to evaluate usability and acceptance. Results: 11 patients with gastrointestinal neuroendocrine cancer on capecitabine and temozolomide were approached regarding the study. Of these, 10 agreed to participate (ages 45 to 71). Overall, participant satisfaction was high with a Net Promoter Score of 100. Reliability of Penny’s algorithmic branching to provide accurate dosing information and symptom triage was also high: symptoms were accurately graded 100% of the time, and there was appropriate self-management advice or provider triage 100% of the time. Average daily adherence (based on self-report) was 98%. Participants reported that 3 emergency room visits were avoided during the study period. Conclusions: In preliminary testing, a mobile phone-based conversational agent was a usable and acceptable means of supporting OACA adherence. Expanded study testing patient safety and efficacy is underway.
Collapse
Affiliation(s)
| | | | | | - Mike Serpa
- University of Pennsylvania Health System, Philadelphia, PA
| | | | | | | | | | | |
Collapse
|
16
|
Chaiyachati KH, Rosin R, Shea JA. Ridesharing and Text Messaging for Patients With Medicaid-Further Information-Reply. JAMA Intern Med 2018; 178:868-869. [PMID: 29868751 DOI: 10.1001/jamainternmed.2018.1929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Krisda H Chaiyachati
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Roy Rosin
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Penn Medicine Center for Health Care Innovation, Philadephia, Pennsylvania
| | - Judy A Shea
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| |
Collapse
|
17
|
Chaiyachati KH, Hubbard RA, Yeager A, Mugo B, Shea JA, Rosin R, Grande D. Rideshare-Based Medical Transportation for Medicaid Patients and Primary Care Show Rates: A Difference-in-Difference Analysis of a Pilot Program. J Gen Intern Med 2018; 33:863-868. [PMID: 29380214 PMCID: PMC5975142 DOI: 10.1007/s11606-018-4306-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 12/01/2017] [Accepted: 12/28/2017] [Indexed: 01/29/2023]
Abstract
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.
Collapse
Affiliation(s)
- Krisda H Chaiyachati
- VA Advanced Fellow at the Cpl. Michael Crescenz VA Medical Center, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Brian Mugo
- Massachusetts General Hospital, Boston, MA, USA
| | - Judy A Shea
- Division of General Internal Medicine at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Roy Rosin
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | - David Grande
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Division of General Internal Medicine at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
18
|
Patel MS, Volpp KG, Rosin R, Bellamy SL, Small DS, Heuer J, Sproat S, Hyson C, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Asch DA. A Randomized, Controlled Trial of Lottery-Based Financial Incentives to Increase Physical Activity Among Overweight and Obese Adults. Am J Health Promot 2018. [PMID: 29534597 DOI: 10.1177/0890117118758932] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Mitesh S Patel
- 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,2 Wharton School, University of Pennsylvania, Philadelphia, PA, USA.,3 LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA.,4 The Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA.,5 Center for Health Equity Research and Promotion, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Kevin G Volpp
- 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,2 Wharton School, University of Pennsylvania, Philadelphia, PA, USA.,3 LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA.,4 The Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA.,5 Center for Health Equity Research and Promotion, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Roy Rosin
- 4 The Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA
| | - Scarlett L Bellamy
- 6 The Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Dylan S Small
- 2 Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Jack Heuer
- 7 Division of Human Resources, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan Sproat
- 7 Division of Human Resources, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Hyson
- 7 Division of Human Resources, University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy Haff
- 8 Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Samantha M Lee
- 9 Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Lisa Wesby
- 3 LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen Hoffer
- 3 LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - David Shuttleworth
- 3 LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Devon H Taylor
- 3 LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria Hilbert
- 3 LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jingsan Zhu
- 3 LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Lin Yang
- 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Xingmei Wang
- 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,2 Wharton School, University of Pennsylvania, Philadelphia, PA, USA.,3 LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA.,5 Center for Health Equity Research and Promotion, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| |
Collapse
|
19
|
Chaiyachati KH, Hubbard RA, Yeager A, Mugo B, Lopez S, Asch E, Shi C, Shea JA, Rosin R, Grande D. Association of Rideshare-Based Transportation Services and Missed Primary Care Appointments: A Clinical Trial. JAMA Intern Med 2018; 178:383-389. [PMID: 29404572 DOI: 10.1001/jamainternmed.2017.8336] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
Collapse
Affiliation(s)
- Krisda H Chaiyachati
- Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Rebecca A Hubbard
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Alyssa Yeager
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Brian Mugo
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Elizabeth Asch
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania
| | - Catherine Shi
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania
| | - Judy A Shea
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Roy Rosin
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania
| | - David Grande
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
20
|
Abstract
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.
Collapse
Affiliation(s)
- Jeffrey K Hom
- Jeffrey K. Hom is with the Department of Medicine, Crescenz VA Medical Center, Philadelphia, PA. Christian Stillson and David Grande are with the Division of General Internal Medicine, University of Pennsylvania, Philadelphia. Roy Rosin is with the Penn Medicine Center for Health Care Innovation, University of Pennsylvania. Rachel Cahill and Evelyne Kruger are with Benefits Data Trust, Philadelphia
| | - Christian Stillson
- Jeffrey K. Hom is with the Department of Medicine, Crescenz VA Medical Center, Philadelphia, PA. Christian Stillson and David Grande are with the Division of General Internal Medicine, University of Pennsylvania, Philadelphia. Roy Rosin is with the Penn Medicine Center for Health Care Innovation, University of Pennsylvania. Rachel Cahill and Evelyne Kruger are with Benefits Data Trust, Philadelphia
| | - Roy Rosin
- Jeffrey K. Hom is with the Department of Medicine, Crescenz VA Medical Center, Philadelphia, PA. Christian Stillson and David Grande are with the Division of General Internal Medicine, University of Pennsylvania, Philadelphia. Roy Rosin is with the Penn Medicine Center for Health Care Innovation, University of Pennsylvania. Rachel Cahill and Evelyne Kruger are with Benefits Data Trust, Philadelphia
| | - Rachel Cahill
- Jeffrey K. Hom is with the Department of Medicine, Crescenz VA Medical Center, Philadelphia, PA. Christian Stillson and David Grande are with the Division of General Internal Medicine, University of Pennsylvania, Philadelphia. Roy Rosin is with the Penn Medicine Center for Health Care Innovation, University of Pennsylvania. Rachel Cahill and Evelyne Kruger are with Benefits Data Trust, Philadelphia
| | - Evelyne Kruger
- Jeffrey K. Hom is with the Department of Medicine, Crescenz VA Medical Center, Philadelphia, PA. Christian Stillson and David Grande are with the Division of General Internal Medicine, University of Pennsylvania, Philadelphia. Roy Rosin is with the Penn Medicine Center for Health Care Innovation, University of Pennsylvania. Rachel Cahill and Evelyne Kruger are with Benefits Data Trust, Philadelphia
| | - David Grande
- Jeffrey K. Hom is with the Department of Medicine, Crescenz VA Medical Center, Philadelphia, PA. Christian Stillson and David Grande are with the Division of General Internal Medicine, University of Pennsylvania, Philadelphia. Roy Rosin is with the Penn Medicine Center for Health Care Innovation, University of Pennsylvania. Rachel Cahill and Evelyne Kruger are with Benefits Data Trust, Philadelphia
| |
Collapse
|
21
|
Affiliation(s)
- David A Asch
- From the Center for Health Care Innovation, University of Pennsylvania (D.A.A., R.R.), and the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center (D.A.A.) - both in Philadelphia
| | - Roy Rosin
- From the Center for Health Care Innovation, University of Pennsylvania (D.A.A., R.R.), and the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center (D.A.A.) - both in Philadelphia
| |
Collapse
|
22
|
Patel MS, Patel N, Small DS, Rosin R, Rohrbach JI, Stromberg N, Hanson CW, Asch DA. Change In Length of Stay and Readmissions among Hospitalized Medical Patients after Inpatient Medicine Service Adoption of Mobile Secure Text Messaging. J Gen Intern Med 2016; 31:863-70. [PMID: 27016064 PMCID: PMC4945559 DOI: 10.1007/s11606-016-3673-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 02/22/2016] [Accepted: 03/10/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Changes in the medium of communication from paging to mobile secure text messaging may change clinical care, but the effects of these changes on patient outcomes have not been well examined. OBJECTIVE To evaluate the association between inpatient medicine service adoption of mobile secure text messaging and patient length of stay and readmissions. DESIGN Observational study. PARTICIPANTS Patients admitted to medicine services at the Hospital of the University of Pennsylvania (intervention site; n = 8995 admissions of 6484 patients) and Penn Presbyterian Medical Center (control site; n = 6799 admissions of 4977 patients) between May 1, 2012, and April 30, 2014. INTERVENTION Mobile secure text messaging. MAIN MEASURES Change in length of stay and 30-day readmissions, comparing patients at the intervention site to the control site before (May 1, 2012 to April 30, 2013) and after (May 1, 2013 to April 30, 2014) the intervention, adjusting for time trends and patient demographics, comorbidities, insurance, and disposition. KEY RESULTS During the pre-intervention period, the mean length of stay ranged from 4.0 to 5.0 days at the control site and from 5.2 to 6.7 days at the intervention site, but trends were similar. In the first month after the intervention, the mean length of stay was unchanged at the control site (4.7 to 4.7 days) but declined at the intervention site (6.0 to 5.4 days). Trends were mostly similar during the rest of the post-intervention period, ranging from 4.4 to 5.6 days at the control site and from 5.4 to 6.5 days at the intervention site. Readmission rates varied significantly within sites before and after the intervention, but overall trends were similar. In adjusted analyses, there was a significant decrease in length of stay for the intervention site relative to the control site during the post-intervention period compared to the pre-intervention period (-0.77 days ; 95 % CI, -1.14, -0.40; P < 0.001). There was no significant difference in the odds of readmission (OR, 0.97; 95 % CI: 0.81, 1.17; P = 0.77). These findings were supported by multiple sensitivity analyses. CONCLUSIONS Compared to a control group over time, hospitalized medical patients on inpatient services whose care providers and staff were offered mobile secure text messaging showed a relative decrease in length of stay and no change in readmissions.
Collapse
Affiliation(s)
- Mitesh S Patel
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,The Wharton School, University of Pennsylvania, Philadelphia, PA, USA. .,Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA. .,University of Pennsylvania Health System, Philadelphia, PA, USA.
| | - Neha Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Dylan S Small
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Roy Rosin
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | | | | | - C William Hanson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,University of Pennsylvania Health System, Philadelphia, PA, USA
| | - David A Asch
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.,Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,University of Pennsylvania Health System, Philadelphia, PA, USA
| |
Collapse
|
23
|
Patel MS, Volpp KG, Rosin R, Bellamy SL, Small DS, Fletcher MA, Osman-Koss R, Brady JL, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Asch DA. A Randomized Trial of Social Comparison Feedback and Financial Incentives to Increase Physical Activity. Am J Health Promot 2016; 30:416-24. [PMID: 27422252 PMCID: PMC6029434 DOI: 10.1177/0890117116658195] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To compare the effectiveness of different combinations of social comparison feedback and financial incentives to increase physical activity. DESIGN Randomized trial (Clinicaltrials.gov number, NCT02030080). SETTING Philadelphia, Pennsylvania. PARTICIPANTS Two hundred eighty-six adults. INTERVENTIONS Twenty-six weeks of weekly feedback on team performance compared to the 50th percentile (n = 100) or the 75th percentile (n = 64) and 13 weeks of weekly lottery-based financial incentive plus feedback on team performance compared to the 50th percentile (n = 80) or the 75th percentile (n = 44) followed by 13 weeks of only performance feedback. MEASURES Mean proportion of participant-days achieving the 7000-step goal during the 13-week intervention. ANALYSIS Generalized linear mixed models adjusting for repeated measures and clustering by team. RESULTS Compared to the 75th percentile without incentives during the intervention period, the mean proportion achieving the 7000-step goal was significantly greater for the 50th percentile with incentives group (0.45 vs 0.27, difference: 0.18, 95% confidence interval [CI]: 0.04 to 0.32; P = .012) but not for the 75th percentile with incentives group (0.38 vs 0.27, difference: 0.11, 95% CI: -0.05 to 0.27; P = .19) or the 50th percentile without incentives group (0.30 vs 0.27, difference: 0.03, 95% CI: -0.10 to 0.16; P = .67). CONCLUSION Social comparison to the 50th percentile with financial incentives was most effective for increasing physical activity.
Collapse
Affiliation(s)
- Mitesh S Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA Wharton School, University of Pennsylvania, Philadelphia, PA, USA LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA Center for Health Equity Research and Promotion, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Kevin G Volpp
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA Wharton School, University of Pennsylvania, Philadelphia, PA, USA LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA Center for Health Equity Research and Promotion, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Roy Rosin
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Scarlett L Bellamy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dylan S Small
- Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Michele A Fletcher
- University of Pennsylvania Health System, University of Pennsylvania, Philadelphia, PA, USA
| | - Rosemary Osman-Koss
- University of Pennsylvania Health System, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer L Brady
- University of Pennsylvania Health System, University of Pennsylvania, Philadelphia, PA, USA
| | - Nancy Haff
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Samantha M Lee
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Lisa Wesby
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen Hoffer
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - David Shuttleworth
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Devon H Taylor
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria Hilbert
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jingsan Zhu
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Lin Yang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Xingmei Wang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA Wharton School, University of Pennsylvania, Philadelphia, PA, USA LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA Center for Health Equity Research and Promotion, Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| |
Collapse
|
24
|
Patel MS, Asch DA, Rosin R, Small DS, Bellamy SL, Eberbach K, Walters KJ, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Volpp KG. Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial. J Gen Intern Med 2016; 31:746-54. [PMID: 26976287 PMCID: PMC4907949 DOI: 10.1007/s11606-016-3627-0] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 11/16/2015] [Accepted: 02/01/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND More than half of adults in the United States do not attain the minimum recommended level of physical activity to achieve health benefits. The optimal design of financial incentives to promote physical activity is unknown. OBJECTIVE To compare the effectiveness of individual versus team-based financial incentives to increase physical activity. DESIGN Randomized, controlled trial comparing three interventions to control. PARTICIPANTS Three hundred and four adult employees from an organization in Philadelphia formed 76 four-member teams. INTERVENTIONS All participants received daily feedback on performance towards achieving a daily 7000 step goal during the intervention (weeks 1- 13) and follow-up (weeks 14- 26) periods. The control arm received no other intervention. In the three financial incentive arms, drawings were held in which one team was selected as the winner every other day during the 13-week intervention. A participant on a winning team was eligible as follows: $50 if he or she met the goal (individual incentive), $50 only if all four team members met the goal (team incentive), or $20 if he or she met the goal individually and $10 more for each of three teammates that also met the goal (combined incentive). MAIN MEASURES Mean proportion of participant-days achieving the 7000 step goal during the intervention. KEY RESULTS Compared to the control group during the intervention period, the mean proportion achieving the 7000 step goal was significantly greater for the combined incentive (0.35 vs. 0.18, difference: 0.17, 95 % confidence interval [CI]: 0.07-0.28, p <0.001) but not for the individual incentive (0.25 vs 0.18, difference: 0.08, 95 % CI: -0.02-0.18, p = 0.13) or the team incentive (0.17 vs 0.18, difference: -0.003, 95 % CI: -0.11-0.10, p = 0.96). The combined incentive arm participants also achieved the goal at significantly greater rates than the team incentive (0.35 vs. 0.17, difference: 0.18, 95 % CI: 0.08-0.28, p < 0.001), but not the individual incentive (0.35 vs. 0.25, difference: 0.10, 95 % CI: -0.001-0.19, p = 0.05). Only the combined incentive had greater mean daily steps than control (difference: 1446, 95 % CI: 448-2444, p ≤ 0.005). There were no significant differences between arms during the follow-up period (weeks 14- 26). CONCLUSIONS Financial incentives rewarded for a combination of individual and team performance were most effective for increasing physical activity. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02001194.
Collapse
Affiliation(s)
- Mitesh S Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA.
- Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
| | - David A Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
- Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Roy Rosin
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | - Dylan S Small
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Scarlett L Bellamy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Nancy Haff
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Lisa Wesby
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen Hoffer
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - David Shuttleworth
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Devon H Taylor
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria Hilbert
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Jingsan Zhu
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Lin Yang
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Xingmei Wang
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin G Volpp
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
- LDI Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
- Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| |
Collapse
|
25
|
Patel MS, Asch DA, Rosin R, Small DS, Bellamy SL, Heuer J, Sproat S, Hyson C, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Volpp KG. Framing Financial Incentives to Increase Physical Activity Among Overweight and Obese Adults: A Randomized, Controlled Trial. Ann Intern Med 2016; 164:385-94. [PMID: 26881417 PMCID: PMC6029433 DOI: 10.7326/m15-1635] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Financial incentive designs to increase physical activity have not been well-examined. OBJECTIVE To test the effectiveness of 3 methods to frame financial incentives to increase physical activity among overweight and obese adults. DESIGN Randomized, controlled trial. (ClinicalTrials.gov: NCT 02030119). SETTING University of Pennsylvania. PARTICIPANTS 281 adult employees (body mass index ≥27 kg/m2). INTERVENTION 13-week intervention. Participants had a goal of 7000 steps per day and were randomly assigned to a control group with daily feedback or 1 of 3 financial incentive programs with daily feedback: a gain incentive ($1.40 given each day the goal was achieved), lottery incentive (daily eligibility [expected value approximately $1.40] if goal was achieved), or loss incentive ($42 allocated monthly upfront and $1.40 removed each day the goal was not achieved). Participants were followed for another 13 weeks with daily performance feedback but no incentives. MEASUREMENTS Primary outcome was the mean proportion of participant-days that the 7000-step goal was achieved during the intervention. Secondary outcomes included the mean proportion of participant-days achieving the goal during follow-up and the mean daily steps during intervention and follow-up. RESULTS The mean proportion of participant-days achieving the goal was 0.30 (95% CI, 0.22 to 0.37) in the control group, 0.35 (CI, 0.28 to 0.42) in the gain-incentive group, 0.36 (CI, 0.29 to 0.43) in the lottery-incentive group, and 0.45 (CI, 0.38 to 0.52) in the loss-incentive group. In adjusted analyses, only the loss-incentive group had a significantly greater mean proportion of participant-days achieving the goal than control (adjusted difference, 0.16 [CI, 0.06 to 0.26]; P = 0.001), but the adjusted difference in mean daily steps was not significant (861 [CI, 24 to 1746]; P = 0.056). During follow-up, daily steps decreased for all incentive groups and were not different from control. LIMITATION Single employer. CONCLUSION Financial incentives framed as a loss were most effective for achieving physical activity goals. PRIMARY FUNDING SOURCE National Institute on Aging.
Collapse
|
26
|
Affiliation(s)
- David A Asch
- From the Center for Health Care Innovation, University of Pennsylvania (D.A.A., R.R.), and the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center (D.A.A.) - both in Philadelphia
| | | |
Collapse
|
27
|
Affiliation(s)
- David A Asch
- From the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center (D.A.A.); and the Center for Health Care Innovation, Perelman School of Medicine (D.A.A., C.T., K.B.M., R.R.), and the Mack Institute for Innovation Management, the Wharton School (C.T.), University of Pennsylvania - all in Philadelphia
| | | | | | | |
Collapse
|
28
|
Abstract
Young homocystinuria patients suffering from lens dislocation frequently have to undergo eye surgery. We describe a 16-year-old girl with mild mental retardation who became psychotic-delirant immediately after the last of three lentectomia operations performed under general thiopental anaesthesia. Because methionine, homocysteine, its oxidation product homocysteate and cysteine are potent glutamate agonists, the disturbance of the sulphur containing amino acid (SCAA) metabolism in homocystinuria patients may alter the function of cerebral glutamatergic transmission. The chronic and acute neurological and psychiatric symptoms of homocystinuria patients offer a clue to studies of the neurotoxic but also antipsychotic potency of glutamate agonists like the SCAAs in humans.
Collapse
Affiliation(s)
- G Eschweiler
- Universitätsklinik für Psychiatrie und Psychotherapie, Germany
| | | | | | | |
Collapse
|
29
|
Abstract
We studied the kinematic patterns of gait initiation in 31 patients with Parkinson's disease and in 20 age- and sex-matched normals by using an optoelectronic tracking system (ELITE). Position markers were attached to the skin overlying the ankle, knee, hip, elbow, shoulder, and zygomatic bone. Subjects were instructed to start walking immediately after an acoustic go signal. Gait initiation was defined as the phase between standing motionless and steady-state locomotion. This phase was subdivided into a movement preparation period (the time between go signal and movement onset) and a movement execution period (the time between movement onset and the end of the first stride). Onset and duration of ankle, knee, hip, trunk, and arm motion within the first stride were analyzed. Movement preparation time was significantly increased in Parkinson's disease (p = 0.01), whereas movement execution times were similar in both groups (p = 0.23). Initiation of ankle, knee, hip, arm, and trunk movements was delayed in patients as compared with healthy subjects, but the relative timing and the sequence of submovements was comparable in both groups, indicating that the overall pattern of submovements was preserved in the patients. Our data suggest that gait initiation deficits in Parkinson's disease cannot be explained by a disordered sequence of limb and trunk submovements. More likely, gait initiation problems originate from the basal ganglia's internal cueing deficit for movement sequences, delaying onset and slowing the execution of all subcomponents.
Collapse
Affiliation(s)
- R Rosin
- Department of Neurology, University of Tübingen, Germany
| | | | | |
Collapse
|
30
|
Müller V, Mohr B, Rosin R, Pulvermüller F, Müller F, Birbaumer N. Short-term effects of behavioral treatment on movement initiation and postural control in Parkinson's disease: a controlled clinical study. Mov Disord 1997; 12:306-14. [PMID: 9159724 DOI: 10.1002/mds.870120308] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
In a controlled clinical study, we investigated the effects of behavioral treatment on postural and gait initiation problems idiopathic Parkinson's disease (PD). Comparable groups of patients received therapy (experimental group, n = 15) and nonspecific psychological treatment (control group, n = 14) for 10 weeks. We monitored various variables reflecting properties of posture and gait initiation by using an optoelectronic motion analyzer (electronic movement analysis system, ELITE). A clinician blind to group membership of the patients assessed PD severity with the United Parkinson's Disease Rating Scale (UPDRS) before and after the treatment period. ELITE measures of postural stability and movement initiation revealed treatment-specific effects. In addition, UPDRS motor scores showed significant improvement only after behavioral treatment. We conclude that behavioral treatment in Parkinson's disease may improve motor disabilities in moderately advanced PD patients.
Collapse
Affiliation(s)
- V Müller
- Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Germany
| | | | | | | | | | | |
Collapse
|
31
|
Goebel HH, Meyermann R, Rosin R, Schlote W. Characteristic morphologic manifestation of CADASIL, cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy, in skeletal muscle and skin. Muscle Nerve 1997; 20:625-7. [PMID: 9140375 DOI: 10.1002/(sici)1097-4598(199705)20:5<625::aid-mus17>3.0.co;2-v] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- H H Goebel
- Department of Neuropathology, Mainz University Medical Center, Germany
| | | | | | | |
Collapse
|
32
|
Rosin R. Do Honeybees Dance? Bioscience 1992. [DOI: 10.2307/1311646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
33
|
|
34
|
Rosin R. Rejection and Revolution. Science 1987; 235:16a. [PMID: 17769293 DOI: 10.1126/science.235.4784.16a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
35
|
|
36
|
|
37
|
|
38
|
Affiliation(s)
- R. Rosin
- Department of Zoology, Hebrew University of Jerusalem, Israel
| |
Collapse
|
39
|
Affiliation(s)
- R. Rosin
- Department of Zoology, Hebrew University of Jerusalem, Israel
| |
Collapse
|
40
|
|
41
|
|
42
|
|
43
|
|
44
|
|
45
|
|
46
|
|
47
|
Rosin R. A new type of poison gland found in the scorpion Nebo hierichonticus (E. Sim.) (Diplocentridae, Scorpiones). Riv Parassitol 1965; 26:111-22. [PMID: 5866788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
|
48
|
|
49
|
Affiliation(s)
- R. Rosin
- Laboratory of Entomology and Venomous Animals, Hebrew University of Jerusalem, Jerusalem, Israel
| | - A. Shulov
- Laboratory of Entomology and Venomous Animals, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|