Archive

Archive for the ‘Journal of the American Medical Association’ Category

Wearable Devices as Facilitators, Not Drivers, of Health Behavior Change

March 11, 2015 Comments off

Wearable Devices as Facilitators, Not Drivers, of Health Behavior Change
Source: Journal of the American Medical Association

Several large technology companies including Apple, Google, and Samsung are entering the expanding market of population health with the introduction of wearable devices. This technology, worn in clothing or accessories, is part of a larger movement often referred to as the “quantified self.” The notion is that by recording and reporting information about behaviors such as physical activity or sleep patterns, these devices can educate and motivate individuals toward better habits and better health. The gap between recording information and changing behavior is substantial, however, and while these devices are increasing in popularity, little evidence suggests that they are bridging that gap.

Only 1% to 2% of individuals in the United States have used a wearable device, but annual sales are projected to increase to more than $50 billion by 2018.1 Some of these devices aim at individuals already motivated to change their health behaviors. Others are being considered by health care organizations, employers, insurers, and clinicians who see promise in using these devices to better engage less motivated individuals. Some of these devices may justify that promise, but less because of their technology and more because of the behavioral change strategies that can be designed around them.

Most health-related behaviors such as eating well and exercising regularly could lead to meaningful improvements in population health only if they are sustained. If wearable devices are to be part of the solution, they either need to create enduring new habits, turning external motivations into internal ones (which is difficult), or they need to sustain their external motivation (which is also difficult). This requirement of sustained behavior change is a major challenge, but many mobile health applications have not yet leveraged principles from theories of health behavior.2

Feedback loops could be better designed around wearable devices to sustain engagement by using concepts from behavioral economics.3 Individuals are often motivated by the experience of past rewards and the prospect of future rewards. Lottery-based designs leverage the fact that individuals tend to assign undue weight to small probabilities and are more engaged by intermittent variable rewards than with constant reinforcement. Anticipated regret, an individual’s concern or anxiety over the reward he or she might not win, can have a significant effect on decision making. Feedback could be designed to use this concept by informing individuals what they would have won had they been adherent to the new behavior. Building new habits may be best facilitated by presenting frequent feedback with appropriate framing and by using a trigger that captures the individual’s attention at those moments when he or she is most likely to take action.

Improving Long-term Psychiatric Care: Bring Back the Asylum

January 29, 2015 Comments off

Improving Long-term Psychiatric Care: Bring Back the Asylum
Source: Journal of the American Medical Association

During the past half century, the supply of inpatient psychiatric beds in the United States has largely vanished. In 1955, 560 000 patients were cared for in state psychiatric facilities; today there are fewer than one-tenth that number: 45 000. Given the doubling of the US population, this represents a 95% decline, bringing the per capita public psychiatric bed count to about the same as it was in 1850—14 per 100 000 people.1 A much smaller number of private psychiatric beds has fluctuated since the 1970s in response to policy and regulatory shifts that create varying financial incentives.

As a result, few high-quality, accessible long-term care options are available for a significant segment of the approximately 10 million US residents with serious mental illness. This population includes adults who are assessed as lacking insight and chronically psychotic, unable to care for themselves, and potentially dangerous to themselves and the public. These persons frequently have refractory schizophrenia and bipolar disorder. The void is both ethically unacceptable and financially costly.

The Anatomy of Medical Research: US and International Comparisons

January 15, 2015 Comments off

The Anatomy of Medical Research: US and International Comparisons
Source: Journal of the American Medical Association

Importance
Medical research is a prerequisite of clinical advances, while health service research supports improved delivery, access, and cost. Few previous analyses have compared the United States with other developed countries.

Objectives
To quantify total public and private investment and personnel (economic inputs) and to evaluate resulting patents, publications, drug and device approvals, and value created (economic outputs).

Evidence Review
Publicly available data from 1994 to 2012 were compiled showing trends in US and international research funding, productivity, and disease burden by source and industry type. Patents and publications (1981-2011) were evaluated using citation rates and impact factors.

Findings
(1) Reduced science investment: Total US funding increased 6% per year (1994-2004), but rate of growth declined to 0.8% per year (2004-2012), reaching $117 billion (4.5%) of total health care expenditures. Private sources increased from 46% (1994) to 58% (2012). Industry reduced early-stage research, favoring medical devices, bioengineered drugs, and late-stage clinical trials, particularly for cancer and rare diseases. National Insitutes of Health allocations correlate imperfectly with disease burden, with cancer and HIV/AIDS receiving disproportionate support. (2) Underfunding of service innovation: Health services research receives $5.0 billion (0.3% of total health care expenditures) or only 1/20th of science funding. Private insurers ranked last (0.04% of revenue) and health systems 19th (0.1% of revenue) among 22 industries in their investment in innovation. An increment of $8 billion to $15 billion yearly would occur if service firms were to reach median research and development funding. (3) Globalization: US government research funding declined from 57% (2004) to 50% (2012) of the global total, as did that of US companies (50% to 41%), with the total US (public plus private) share of global research funding declining from 57% to 44%. Asia, particularly China, tripled investment from $2.6 billion (2004) to $9.7 billion (2012) preferentially for education and personnel. The US share of life science patents declined from 57% (1981) to 51% (2011), as did those considered most valuable, from 73% (1981) to 59% (2011).

Conclusions and Relevance
New investment is required if the clinical value of past scientific discoveries and opportunities to improve care are to be fully realized. Sources could include repatriation of foreign capital, new innovation bonds, administrative savings, patent pools, and public-private risk sharing collaborations. Given international trends, the United States will relinquish its historical international lead in the next decade unless such measures are undertaken.

Association Between 7 Years of Intensive Treatment of Type 1 Diabetes and Long-term Mortality

January 10, 2015 Comments off

Association Between 7 Years of Intensive Treatment of Type 1 Diabetes and Long-term Mortality
Source: Journal of the American Medical Association

Importance
Whether mortality in type 1 diabetes mellitus is affected following intensive glycemic therapy has not been established.

Objective
To determine whether mortality differed between the original intensive and conventional treatment groups in the long-term follow-up of the Diabetes Control and Complications Trial (DCCT) cohort.

Design, Setting, and Participants
After the DCCT (1983-1993) ended, participants were followed up in a multisite (27 US and Canadian academic clinical centers) observational study (Epidemiology of Diabetes Control and Complications [EDIC]) until December 31, 2012. Participants were 1441 healthy volunteers with diabetes mellitus who, at baseline, were 13 to 39 years of age with 1 to 15 years of diabetes duration and no or early microvascular complications, and without hypertension, preexisting cardiovascular disease, or other potentially life-threatening disease.

Interventions and Exposures
During the clinical trial, participants were randomly assigned to receive intensive therapy (n = 711) aimed at achieving glycemia as close to the nondiabetic range as safely possible, or conventional therapy (n = 730) with the goal of avoiding symptomatic hypoglycemia and hyperglycemia. At the end of the DCCT, after a mean of 6.5 years, intensive therapy was taught and recommended to all participants and diabetes care was returned to personal physicians.

Main Outcomes and Measures
Total and cause-specific mortality was assessed through annual contact with family and friends and through records over 27 years’ mean follow-up.

Results
Vital status was ascertained for 1429 (99.2%) participants. There were 107 deaths, 64 in the conventional and 43 in the intensive group. The absolute risk difference was −109 per 100 000 patient-years (95% CI, −218 to −1), with lower all-cause mortality risk in the intensive therapy group (hazard ratio [HR] = 0.67 [95% CI, 0.46-0.99]; P = .045). Primary causes of death were cardiovascular disease (24 deaths; 22.4%), cancer (21 deaths; 19.6%), acute diabetes complications (19 deaths; 17.8%), and accidents or suicide (18 deaths; 16.8%). Higher levels of glycated hemoglobin (HbA1c) were associated with all-cause mortality (HR = 1.56 [95% CI, 1.35-1.81 per 10% relative increase in HbA1c]; P < .001), as well as the development of albuminuria (HR = 2.20 [95% CI, 1.46-3.31]; P < .001).

Conclusions and Relevance
After a mean of 27 years’ follow-up of patients with type 1 diabetes, 6.5 years of initial intensive diabetes therapy was associated with a modestly lower all-cause mortality rate when compared with conventional therapy.

The Rise of the Medical Scribe: Industry Implications for the Advancement of Electronic Health Records

December 19, 2014 Comments off

The Rise of the Medical Scribe: Industry Implications for the Advancement of Electronic Health Records
Source: Journal of the American Medical Association

With federal meaningful-use incentives driving adoption of electronic health records (EHRs), physicians are increasingly concerned about the time spent documenting patient information and managing orders via computerized patient order entry (CPOE). Many perceive that the inefficiencies of EHRs are adversely affecting the quality of care, and because physicians see fewer patients per day, income may decline. Although physicians approve of EHRs in concept and appreciate their future promise, the current state of EHR technology has increased physician dissatisfaction. Poor EHR usability, time-consuming data entry, reduced patient care time, inability to exchange health information, and templated notes are central concerns. Physicians emphasize that EHR technology—especially user interfaces—must improve,1 and a new industry has emerged nationally to provide physicians with medical scribes.

Use of medical scribes—unlicensed individuals hired to enter information into the EHR under clinician supervision—has increased substantially. Scribes reportedly enable physicians to see more patients; generate more revenue; and improve productivity, efficiency, accuracy of clinical documentation and billing, and patient satisfaction.

Sharing and Reporting the Results of Clinical Trials

December 3, 2014 Comments off

Sharing and Reporting the Results of Clinical Trials
Source: Journal of the American Medical Association

The principle of data sharing dates to the dawn of scientific discovery—it is how researchers from different disciplines and countries form collaborations, learn from others, identify new scientific opportunities, and work to turn newly discovered information into shared knowledge and practical advances. When research involves human volunteers who agree to participate in clinical trials to test new drugs, devices, or other interventions, this principle of data sharing properly assumes the role of an ethical mandate. These participants are often informed that such research might not benefit them directly, but may affect the lives of others. If the clinical research community fails to share what is learned, allowing data to remain unpublished or unreported, researchers are reneging on the promise to clinical trial participants, are wasting time and resources, and are jeopardizing public trust.

Designing Smarter Pay-for-Performance Programs

November 14, 2014 Comments off

Designing Smarter Pay-for-Performance Programs
Source: Journal of the American Medical Association

Over the past decade, public and private payers have experimented with the use of financial incentives to motivate physicians to achieve quality and efficiency. The idea behind pay for performance is simple. Because individuals and organizations respond to incentives, physicians whose patients achieve desirable outcomes should be paid more as an incentive to improve their performance. Yet the results of pay-for-performance programs have been largely disappointing. One argument is that neither the right set of incentives nor the right set of metrics has been identified. Another explanation, which has received far less attention, is that the right set of patients has not been identified for targeted efforts.

Follow

Get every new post delivered to your Inbox.

Join 1,031 other followers