The Healthy Democracy Kit: design, implementation, uptake, and impact of a novel voter registration toolkit for healthcare settings.

BACKGROUND: Access to voting is increasingly recognized as a social determinant of health. Health equity could be improved if healthcare workers (HCWs) routinely assessed the voter registration status of patients during clinical encounters and helped direct them towards appropriate resources. However, little consensus exists on how to achieve these tasks efficiently and effectively in healthcare settings. Intuitive and scalable tools that minimize workflow disruptions are needed. The Healthy Democracy Kit (HDK) is a novel voter registration toolkit for healthcare settings, featuring a wearable badge and posters that display quick response (QR) and text codes directing patients to an online hub for voter registration and mail-in ballot requests. The objective of this study was to assess national uptake and impact of the HDK prior to the 2020 United States (US) elections. METHODS: Between 19 May and 3 November 2020, HCWs and institutions could order and use HDKs to help direct patients to resources, free of cost. A descriptive analysis was conducted to summarize the characteristics of participating HCWs and institutions as well as the resultant total persons helped prepare to vote. RESULTS: During the study period, 13,192 HCWs (including 7,554 physicians, 2,209 medical students, and 983 nurses) from 2,407 affiliated institutions across the US ordered 24,031 individual HDKs. Representatives from 604 institutions (including 269 academic medical centers, 111 medical schools, and 141 Federally Qualified Health Centers) ordered 960 institutional HDKs. Collectively, HCWs and institutions from all 50 US states and the District of Columbia used HDKs to help initiate 27,317 voter registrations and 17,216 mail-in ballot requests. CONCLUSIONS: A novel voter registration toolkit had widespread organic uptake and enabled HCWs and institutions to successfully conduct point-of-care civic health advocacy during clinical encounters. This methodology holds promise for future implementation of other types of public health initiatives. Further study is needed to assess downstream voting behaviors from healthcare-based voter registration.

The Vot-ER Healthy Democracy Campaign: A National Medical Student Competition to Increase Voting Access.

PROBLEM: Voting affords citizens a direct say in the leaders and policies that affect their health. However, less than 20% of eligible U.S. citizens have been offered the chance to register to vote at a government-funded agency like a hospital or clinic that provides Medicaid or Medicare services. Medical students are well positioned to increase voting access due to their interactions with multiple actors in health care settings, including patients, visitors, colleagues, and others. APPROACH: Vot-ER, a nonpartisan, nonprofit organization that aims to promote civic engagement in health care settings, launched the inaugural Healthy Democracy Campaign from July 20 to October 9, 2020. As part of this national, gamification-based competition, medical student captains were recruited to lead teams of health care trainees and professionals that helped eligible adults start the voter registration and/or mail-in ballot request process before the November 2020 elections. Post competition, medical student captains were surveyed about their motivations for participating and skills and knowledge gained. OUTCOMES: In total, 128 medical student captains at 80 medical schools in 31 states and the District of Columbia formed teams that helped 15,692 adults start the voter registration and/or mail-in ballot request process. Eighty-two (64.1%) captains responded to the post competition survey, representing 56 (70.0%) of the participating schools. The top-ranked motivation for participating in the campaign was the desire to address social and racial inequities (37, 45.1%). Respondents reported gaining skills and knowledge in several aspects of civic engagement, including community organizing (67, 81.7%) and voting rights (63, 76.8%). The majority of respondents planned to incorporate voter registration into their future practice (76, 92.7%). NEXT STEPS: Future Healthy Democracy Campaigns will aim to continue closing the voting access gap and promote the long-term inclusion of hands-on civic engagement in medical education and practice.

Loss-Framed Financial Incentives and Personalized Goal-Setting to Increase Physical Activity Among Ischemic Heart Disease Patients Using Wearable Devices: The ACTIVE REWARD Randomized Trial.

BACKGROUND: Regular physical activity reduces the risk of cardiovascular events, but most ischemic heart disease (IHD) patients do not obtain enough. METHODS AND RESULTS: ACTIVE REWARD (A Clinical Trial Investigating Effects of a Randomized Evaluation of Wearable Activity Trackers with Financial Rewards) was a 24-week home-based, remotely monitored, randomized trial with a 16-week intervention (8-week ramp-up incentive phase and 8-week maintenance incentive phase) and an 8-week follow-up. Patients used wearable devices to track step counts and establish a baseline. Patients in control received no other interventions. Patients in the incentive arm received personalized step goals and daily feedback for all 24 weeks. In the ramp-up incentive phase, daily step goals increased weekly by 15% from baseline with a maximum of 10 000 steps and then remained fixed. Each week, $14 was allocated to a virtual account; $2 could be lost per day for not achieving step goals. The primary outcome was change in mean daily steps from baseline to the maintenance incentive phase. Ischemic heart disease patients had a mean (SD) age of 60 (11) years and 70% were male. Compared with control, patients in the incentive arm had a significantly greater increase in mean daily steps from baseline during ramp-up (1388 versus 385; adjusted difference, 1061 [95% confidence interval, 386-1736]; P<0.01), maintenance (1501 versus 264; adjusted difference, 1368 [95% confidence interval, 571-2164]; P<0.001), and follow-up (1066 versus 92; adjusted difference, 1154 [95% confidence interval, 282-2027]; P<0.01). CONCLUSIONS: Loss-framed financial incentives with personalized goal setting significantly increased physical activity among ischemic heart disease patients using wearable devices during the 16-week intervention, and effects were sustained during the 8-week follow-up. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02531022.

Effect of Financial Incentives on Glucose Monitoring Adherence and Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes: A Randomized Clinical Trial.

Importance: Glycemic control often deteriorates during adolescence and the transition to young adulthood for patients with type 1 diabetes. The inability to manage type 1 diabetes effectively during these years is associated with poor glycemic control and complications from diabetes in adult life. Objective: To determine the effect of daily financial incentives on glucose monitoring adherence and glycemic control in adolescents and young adults with type 1 diabetes. Design, Setting, and Participants: The Behavioral Economic Incentives to Improve Glycemic Control Among Adolescents and Young Adults With Type 1 Diabetes (BE IN CONTROL) study was an investigator-blinded, 6-month, 2-arm randomized clinical trial conducted between January 22 and November 2, 2016, with 3-month intervention and follow-up periods. Ninety participants (aged 14-20) with suboptimally controlled type 1 diabetes (hemoglobin A1c [HbA1c] >8.0%) were recruited from the Diabetes Center for Children at the Children's Hospital of Philadelphia. Interventions: All participants were given daily blood glucose monitoring goals of 4 or more checks per day with 1 or more level within the goal range (70-180 mg/dL) collected with a wireless glucometer. The 3-month intervention consisted of a $60 monthly incentive in a virtual account, from which $2 was subtracted for every day of nonadherence to the monitoring goals. During a 3-month follow-up period, the intervention was discontinued. Main Outcomes and Measures: The primary outcome was change in HbA1c levels at 3 months. Secondary outcomes included adherence to glucose monitoring and change in HbA1c levels at 6 months. All analyses were by intention to treat. Results: Of the 181 participants screened, 90 (52 [57.8%] girls) were randomized to the intervention (n = 45) or control (n = 45) arms. The mean (SD) age was 16.3 (1.9) years. The intervention group had significantly greater adherence to glucose monitoring goals in the incentive period (50.0% vs 18.9%; adjusted difference, 27.2%; 95% CI, 9.5% to 45.0%; P = .003) but not in the follow-up period (15.3% vs 8.7%; adjusted difference, 3.9%; 95% CI, -2.0% to 9.9%; P = .20). The change in HbA1c levels from baseline did not differ significantly between groups at 3 months (adjusted difference, -0.08%; 95% CI, -0.69% to 0.54%; P = .80) or 6 months (adjusted difference, 0.03%; 95% CI, -0.55% to 0.60%; P = .93). Conclusions and Relevance: Among adolescents and young adults with type 1 diabetes, daily financial incentives improved glucose monitoring adherence during the incentive period but did not significantly improve glycemic control. Trial Registration: clinicaltrials.gov Identifier: NCT02568501.

Use of social media across US hospitals: descriptive analysis of adoption and utilization.

BACKGROUND: Use of social media has become widespread across the United States. Although businesses have invested in social media to engage consumers and promote products, less is known about the extent to which hospitals are using social media to interact with patients and promote health. OBJECTIVE: The aim was to investigate the relationship between hospital social media extent of adoption and utilization relative to hospital characteristics. METHODS: We conducted a cross-sectional review of hospital-related activity on 4 social media platforms: Facebook, Twitter, Yelp, and Foursquare. All US hospitals were included that reported complete data for the Centers for Medicare and Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Systems survey and the American Hospital Association Annual Survey. We reviewed hospital social media webpages to determine the extent of adoption relative to hospital characteristics, including geographic region, urban designation, bed size, ownership type, and teaching status. Social media utilization was estimated from user activity specific to each social media platform, including number of Facebook likes, Twitter followers, Foursquare check-ins, and Yelp reviews. RESULTS: Adoption of social media varied across hospitals with 94.41% (3351/3371) having a Facebook page and 50.82% (1713/3371) having a Twitter account. A majority of hospitals had a Yelp page (99.14%, 3342/3371) and almost all hospitals had check-ins on Foursquare (99.41%, 3351/3371). Large, urban, private nonprofit, and teaching hospitals were more likely to have higher utilization of these accounts. CONCLUSIONS: Although most hospitals adopted at least one social media platform, utilization of social media varied according to several hospital characteristics. This preliminary investigation of social media adoption and utilization among US hospitals provides the framework for future studies investigating the effect of social media on patient outcomes, including links between social media use and the quality of hospital care and services.

What is the current status of global health activities and opportunities in US orthopaedic residency programs?

BACKGROUND: Interest in developing national health care has been increasing in many fields of medicine, including orthopaedics. One manifestation of this interest has been the development of global health opportunities during residency training. QUESTIONS/PURPOSES: We assessed global health activities and opportunities in orthopaedic residency in terms of resident involvement, program characteristics, sources of funding and support, partner site relationships and geography, and program director opinions on global health participation and the associated barriers. METHODS: An anonymous 24-question survey was circulated to all US orthopaedic surgery residency program directors (n = 153) by email. Five reminder emails were distributed over the next 7 weeks. A total of 59% (n = 90) program directors responded. RESULTS: Sixty-one percent of responding orthopaedic residencies facilitated clinical experiences in developing countries. Program characteristics varied, but most used clinical rotation or elective time for travel (76%), which most frequently occurred during Postgraduate Year 4 (57%) and was used to provide pediatric (66%) or trauma (60%) care. The majority of programs (59%) provided at least some funding to traveling residents and sent accompanying attendings on all ventures (56%). Travel was most commonly within North America (85%), and 51% of participating programs have established international partner sites although only 11% have hosted surgeons from those partnerships. Sixty-nine percent of residency directors believed global health experiences during residency shape future volunteer efforts, 39% believed such opportunities help attract residents to a training program, and the major perceived challenges were funding (73%), faculty time (53%), and logistical planning (43%). CONCLUSIONS: Global health interest and activity are common among orthopaedic residency programs. There is diversity in the characteristics and geographical locations of such activity, although some consensus does exist among program directors around funding and faculty time as the largest challenges.

Management of acute appendicitis: the impact of CT scanning on the bottom line.

BACKGROUND: Acute appendicitis continues to be a common general surgical problem. Little is known about whether the contribution to margin has been affected by changes in technology. STUDY DESIGN: Patients undergoing appendectomy for acute appendicitis from June 2005 to May 2007 were evaluated for demographics, diagnostic and treatment alternatives, and outcomes. Financial outcomes were assessed. Efficiency, including admission to emergency department bed to incision (bed to knife time [BTK]), operative length, and hospital length of stay (LOS) were assessed. RESULTS: During the 2 years of the study, there were no differences in demographics, insurance status, case length, diagnostic accuracy, pathology, LOS, or outcomes. Both laparoscopy and CT use increased between the 2 study years (odds ratio [OR]: 1.68, p = 0.06; 95% CI, 0.98-2.89 and OR: 1.83, p = 0.06, CI, 0.98-3.45, respectively). Mean BTK time increased by about 1 hour: 465 minutes versus 521 minutes (p = 0.032; 95% CI, 0.08-1.78) in univariate analysis. However, multivariate analysis demonstrated no difference in BTK time between years (p = 0.136). After controlling for gender, year of operation, and insurance status, obtaining a CT study added 3.5 hours to BTK time (p < 0.001; 95% CI, 2.41-4.45). Women had BTK times 55 minutes longer than men when controlling for similar covariates (p = 0.027; 95% CI, 0.11-1.74). Laparoscopy contributed to shorter mean LOS (-0.78 days, p = 0.04), and gangrenous appendicitis (1.80 days, p < 0.001) and complications (4.23 days, p < 0.001) increased LOS. Mean contribution to margin decreased from $6,347 to $4,295 (p = 0.068). CONCLUSIONS: Increasing use of CT scanning in acute appendicitis increases cost of care, decreases contribution to margin, prolongs patient's stay in the emergency department, and delays time to operation.