Improving the timeliness of birth registration in Fiji through a financial incentive.

Background: Fiji is a Pacific Island nation with the predominant ethnic groups indigenous Fijians (iTaukei) (62 %) and Fijians of Indian descent (31 %). This study reports on the effect of a Parental Assistance Payment Program (PAPP) tied to on-time birth registration, available in Fiji from August 2018 to July 2020. Methods: Unit record birth registration data (n = 117,829) for children born during 2016-22 were used to calculate mean birth-to-registration intervals and the likelihood of on-time birth registration (within 365 days) before the PAPP (January 2016-July 2018) compared to during the PAPP (August 2018-July 2020), by population disaggregations (sex, ethnicity, age, marital status). Results: During the PAPP, mean birth-to-registration intervals declined sharply by 81 %, from 665 days (95 %CI: 658-671) to 124 days (121-127). The largest declines were among i-Taukei children (803 to 139 days, 83 %) compared to non-iTaukei (283 to 76 days, 73 %); mothers aged 10-19 years (880 to 134 days, 85 %) compared to ≥20 years (653 to 123 days, 81 %); and single mothers (983 to 145 days, 85 %) compared to married mothers (570 to 115 days, 80 %). On-time birth registration increased from 57 % to 93 %, and the adjusted hazard ratio showed children born during the PAPP were 2.3 times more likely (95 %CI: 2.2-2.4) to have their birth registered on-time compared to children born before the PAPP. When the PAPP was discontinued in August 2020, the birth-to-registration interval increased sharply in all population groups. Conclusions: During the two-year period the PAPP was available, it was highly effective at improving the timeliness of birth registration, particularly among iTaukei children, young mothers, and single mothers. After the PAPP was discontinued, the timeliness of birth registration deteriorated sharply. Longer post-PAPP follow-up time (≠5 years) is required to determine whether the timeliness of birth registration has deteriorated to levels similar to those during the pre-PAPP period.

Pay-for-performance in Taiwan: A systematic review and meta-analysis of the empirical literature.

OBJECTIVES: This study aimed to assess the impact of pay-for-performance (P4P) programmes on healthcare in Taiwan. STUDY DESIGN: This was a systematic review and meta-analysis. METHODS: A systematic literature search was performed using the PubMed, Medline, Embase, Cochrane review, Scopus, Web of Science and PsycINFO databases up to July 2023. Meta-analysis of the available outcomes was conducted using a random-effects model. RESULTS: The search yielded 85 studies, of which 58 investigated the programme for diabetes mellitus (DM), eight looked at the programme for chronic kidney disease (CKD), and the remaining studies examined programmes for breast cancer, tuberculosis, schizophrenia and chronic obstructive pulmonary disease. The DM P4P programme was a cost-effective strategy associated with reduced hospitalisation and subsequent complications. The CKD P4P was associated with a lower risk of dialysis initiation. The P4P programme also improved outcomes in breast cancer, cure rates in tuberculosis, reduced admissions for schizophrenia and reduced acute exacerbation in chronic obstructive pulmonary disease. The meta-analysis revealed that the P4P programme for DM (odds ratio [OR] = 0.59; 95% confidence interval [CI] = 0.48-0.73) and CKD (OR = 0.73; 95% CI = 0.67-0.81) significantly reduced mortality risk. However, participation rate in the DM P4P programme was only 19% in 2014. CONCLUSIONS: P4P programmes in Taiwan improve quality of care. However, participation was voluntary and the participation rate was very low, raising the concern of selective enrolment of participants (i.e. 'cherry-picking' behaviour) by physicians. Future programme reforms should focus on well-designed features with the aim of reducing healthcare disparities.

Incentivizing green building technology: A financial perspective on sustainable development in India.

Future viability depends on ensuring a sustainable society because green energy methods may efficiently reduce greenhouse gas emissions. Nevertheless, stakeholders, consumers, and developers continue to be notably ignorant of the financial incentives connected to green technology. Moreover, there is still a dearth of studies on the range of financial incentives offered by different authorities in India. Monetary incentives, such as tax breaks, indirect tax exemptions, and refunds, are crucial in encouraging the use of green technology in the modern world. This study explores the importance of financial incentives for green building technologies in India, which also looks at the wide range of incentives provided by federal, state, and local governments. Furthermore, the study highlights various state government programs such as goods subsidies, exemptions from local taxes, and fee waivers. Notably, several incentives aimed at consumers, developers, and other stakeholders have been implemented by the Indian Green Building Council (IGBC). This review study emphasizes the effectiveness of financial incentives in green construction projects and draws attention to a clear knowledge gap regarding the adoption of green technology. This study also provides insights into potential future directions. Studies and research results emphasize the importance of spreading the word about financial incentives as a key factor in determining the adoption of green technologies. Many parties, including governmental organizations, municipal governments, developers, and clients engaged in green building technology projects, stand to gain increased awareness.

Attracting medical school graduates to residency programs in remotely located hospitals: the challenge lies beyond financial incentives.

BACKGROUND: Recruitment to residency programs in hospitals located in other than major hubs ("remotely located") is a challenge in many countries. In 2011, the Israeli Ministry of Health launched a 10-year financial incentive to encourage physicians to enroll in residency programs in such hospitals. Nearly 1 billion New Israeli Shekels (260 million US$) were invested in that program which had only limited success. As a new physician association's collective agreement is impending, we aimed to measure the effectiveness of selected incentives in attracting medical school graduates to residencies in remotely located hospitals. METHODS: This study included Israeli medical students in their final year of medical school. We used an online questionnaire with multiple-choice demographic questions and a 5-point Likert scale to gauge the effect of various incentives on their preference for residency location. RESULTS: Between July and November 2022, 522 students responded (405 studied in Israeli medical schools [out of 705 students] and 117 in foreign medical schools [out of 1936 students]). Forty-two percent had at least one clerkship in a remotely located hospital, and 24% had included at least one remotely located hospital among their top five choices for internship. Only 13% reported that they prefer a residency program in those institutions. The incentive selected by students as most persuasive was government assistance in acceptance to and financial support for a fellowship abroad, followed by a financial grant and fewer on-call hours. Only 7% of the students indicated that no incentive would influence them to choose a remotely located hospital for their residency training. Medical education in a remotely located university and the choice of at least one remotely located hospital among the top five choices for internship were significantly associated with positive incentive receptivity, whereas male sex and older age were associated with negative receptivity. CONCLUSION: This study on the attitudes of Israeli medical school graduates toward incentives aimed at attracting them to residencies in remotely located institutions revealed that career development opportunities and assistance in obtaining fellowships might influence their choice.

Impact of financial compensation on enrollment and participation in a remote, mobile-app based research study.

Background: There is no consensus on how to determine appropriate financial compensation for research recruitment. Selecting incentive amounts that are reasonable and respectful, without undue inducement, remains challenging. Previously, we demonstrated that incentive amount significantly impacts participants' willingness to complete various hypothetical research activities. Here we further explore this relationship in a mock decentralized study. Methods: Adult ResearchMatch volunteers were invited to join a prospective study where interested individuals were given an opportunity to view details for a study along with participation requirements, then offered a randomly generated compensation amount between $0 and $50 to enroll and participate. Individuals agreeing to participate were then asked to complete tasks using a remote mobile application (MyCap), for two weeks. Tasks included a weekly survey, a daily gratitude journal and daily phone tapping task. Results: Willingness to participate was 85% across all incentive levels but not significantly impacted by amount. Task completion appeared to increase as a function of compensation until a plateau at $25. While participants described the study as low burden and reported that compensation was moderately important to their decision to join, only 31% completed all study tasks. Conclusion: While offering compensation in this study did not have a strong effect on enrollment rate, this work provides insight into participant motivation when joining and participating in studies employing mobile applications.

Effectiveness of financial incentives on influenza vaccination among older adults in China: a randomized clinical trial.

OBJECTIVES: To investigate the short-term and long-term effectiveness of different levels of financial incentives on increasing the willingness to vaccinate and vaccine uptake. METHODS: A randomized controlled trial was conducted to investigate the effectiveness of financial incentives of three groups with monetary incentives (CNY 20, CNY 40, and CNY 60; 1 CNY = 0.13 EUR) vs. a control group-CNY 0-on influenza vaccine uptake among 720 older adults (≥60 years) in Beijing, China. The primary outcome was vaccine uptake, and the secondary outcomes were intention to vaccinate and length of time to immunization. RESULTS: Financial incentive significantly promoted higher intention to influenza vaccination (120/178 [67.42%] vs. 442/542 [81.55%]; Relative Risk [RR], 1.21; 95% CI, 1.02-1.42) and higher vaccination participation (74/178 [41.57%] vs. 316/542 [58.30%]; RR, 1.39; 95% CI, 1.10-1.75). CNY 60 had the largest impact on the intention to vaccinate (15.00% vs. 13.48% and 13.90%) and vaccination uptake (19.42% vs. 14.05% and 16.67%) compared with CNY 20 and CNY 40. Time to vaccination was significantly lower among participants receiving incentives than those without ([37.21 days; 95% CI, 34.33-39.99] vs. [48.27 days; 95% CI, 43.47-53.07]; Hazard Ratio [HR] 1.57, 95% CI 1.22-2.03). We found no long-term influence of financial incentives on vaccination decisions in the following year (217/542, 40.04% vs. 65/178, 36.52%; RR 1.08, 95% CI 0.82-1.42). DISCUSSION: Our study suggests that modest financial incentives will boost short-term influenza vaccination rates and shorten the length of time to immunization in China. No one single-time financial incentive had a long-term effect on future vaccination behaviours or helped establish regular vaccination behaviours.

Nonprofit behavior altered by monetary donations: evidence from the U.S. hospice industry.

This study investigates whether reliance on monetary donations alters nonprofit firms' behaviors. Specifically, in the hospice industry, a shorter patients' length of stay (LOS) speeds up overall patient turnover, allowing a hospice to serve more patients and expand its donation network. We measure hospices' donation reliance using the donation-revenue ratio, which indicates the importance of donations for revenue structure. By exploiting the supply shifter of donation, we adopt the number of donors as an instrument to control for the potential endogeneity issue. Our result suggests that a one-percentage-point increase in the donation-revenue ratio decreases patient LOS by 8%. Hospices that are more reliant on donations serve patients diagnosed with diseases that have shorter life expectancies to achieve a lower average LOS of all patients' stay. Overall, we find that monetary donations alter the behavior of nonprofit organizations.

Do COVID-19 Vaccination Policies Backfire? The Effects of Mandates, Vaccination Passports, and Financial Incentives on COVID-19 Vaccination.

Faced with the challenges of motivating people to vaccinate, many countries have introduced policy-level interventions to encourage vaccination against COVID-19. For example, mandates were widely imposed requiring individuals to vaccinate to work and attend school, and vaccination passports required individuals to show proof of vaccination to travel and access public spaces and events. Furthermore, some countries also began offering financial incentives for getting vaccinated. One major criticism of these policies was the possibility that they would produce reactance and thus undermine voluntary vaccination. This article therefore reviews relevant empirical evidence to examine whether this is indeed the case. Specifically, we devote separate sections to reviewing and discussing the impacts of three major policies that were implemented during the COVID-19 pandemic: vaccination mandates, vaccination passports, and the provision of financial incentives. A careful analysis of the evidence provides little support that these policies backfire but instead can effectively promote vaccination at the population level. The policies are not without limitations, however, such as their inability to mobilize those that are strongly hesitant to vaccines. Finally, we discuss how policy-level interventions should be designed and implemented to address future epidemics and pandemics.

Protocol update and baseline characteristics for the TRIal to slow the Progression of Diabetes (TRIPOD) randomized controlled trial.

BACKGROUND: Type 2 diabetes (T2D), a major risk factor for cardiovascular disease and other adverse health conditions, is on the rise in Singapore. TRIPOD is a randomized controlled trial aimed to determine whether complementing usual care with an evidence-based diabetes management package (DMP) -comprising access to an evidence-based app, health coaching, pedometer, glucometer and weighing scale, with or without a financial rewards scheme (M-POWER rewards), can improve mean HbA1c levels at months 6 and 12. METHODS: The protocol was published in Trials, accessible via https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-019-3749-x 1. This manuscript updates the protocol with changes to the study design due to challenges with recruitment and presents baseline characteristics. Key updates include changing the arm allocation ratio from 1:1:1 (Arm 1-Usual Care: Arm 2-DMP: Arm 3-DMP+M-POWER rewards) to 10:1:10, the sample size from 339 to 269, the intervention period from two to one year, and the primary hypothesis to focus solely on differences between Usual Care and DMP+M-POWER rewards. Recruitment for the study began on 19 October 2019 and ended on 4 June 2022. RESULTS: The average age of participants was 55.0 (SD9.7) years old and 64.2% were male. The majority of participants (76.8%) were Chinese, 4.9% Malay and 18.3% Indian and of other ethnicities. 67.0% had a monthly household income of SGD$4000 or more. The mean baseline HbA1c was 8.10% (SD 0.95) and the mean body mass index was 26.8 kg/m2 (SD 5.3). DISCUSSION: The final participant completed month 12 follow-up data collection on 8 June 2023. All pre-planned analyses will be conducted and final results reported. TRIAL REGISTRATION: ClinicalTrials.gov NCT03800680 . Registered on 11 January 2019.

Uptake of a Universal Sports Subsidy Program for School-Aged Children: A Population Data Analysis.

BACKGROUND: Around 40% of Australian children do not participate in sport. Cost is a major barrier to participation, particularly for children from low socioeconomic backgrounds. This study aimed to evaluate the uptake of a population-level children's sports subsidy scheme, including sociodemographic differences in uptake. METHODS: A state-wide cross-sectional analysis comparing sports voucher claimants (primary school-aged children with a valid Medicare or Australian visa number) from the 2019 financial year with population census data from South Australia. Chi-square was used to examine whether the percentage of eligible children who claimed a voucher differed based on age, sex, socioeconomic status (SES), and geographical remoteness. Subgroup analyses were conducted for the lowest 2 socioeconomic disadvantage deciles, split by gender. Scatterplots were used to compare sports between high and low SES children. RESULTS: A total of 74,668 children claimed sports vouchers (45.5% of eligible children). Children who were relatively younger, female, from low socioeconomic backgrounds, and from major cities were least likely to claim the voucher. The 5 most common sports were Australian rules football (30.2%), netball (13.6%), soccer (13.1%), gymnastics (10.4%), and basketball (5.7%), with the popular sports similar for high and low SES children. CONCLUSIONS: Future work is needed to understand how Sports Voucher, and sport participation rates have changed over time, and to improve voucher uptake among girls, city dwellers, and low SES children.

Identifying the Most Effective Recruitment Strategy Using Financial Reimbursements for a Web-Based Peer Network Study With Young People Aged 16-18 Years: Protocol for a Randomized Controlled Trial.

BACKGROUND: Peers are an important determinant of health and well-being during late adolescence; however, there is limited quantitative research examining peer influence. Previous peer network research with adolescents faced methodological limitations and difficulties recruiting young people. OBJECTIVE: This study aims to determine whether a web-based peer network survey is effective at recruiting adolescent peer networks by comparing 2 strategies for reimbursement. METHODS: This study will use a 2-group randomized trial design to test the effectiveness of reimbursements for peer referral in a web-based cross-sectional peer network survey. Young people aged 16-18 years recruited through Instagram, Snapchat, and a survey panel will be randomized to receive either scaled group reimbursement (the experimental group) or fixed individual reimbursement (the control group). All participants will receive a reimbursement of Aus $5 (US $3.70) for their own survey completion. In the experimental group (scaled group reimbursement), all participants within a peer network will receive an additional Aus $5 (US $3.70) voucher for each referred participant who completes the study, up to a maximum total value of Aus $30 (US $22.20) per participant. In the control group (fixed individual reimbursement), participants will only be reimbursed for their own survey completion. Participants' peer networks are assessed during the survey by asking about their close friends. A unique survey link will be generated to share with the participant's nominated friends for the recruitment of secondary participants. Outcomes are the proportion of a participant's peer network and the number of referred peers who complete the survey. The required sample size is 306 primary participants. Using a multilevel logistic regression model, we will assess the effect of the reimbursement intervention on the proportion of primary participants' close friends who complete the survey. The secondary aim is to determine participant characteristics that are associated with successfully recruiting close friends. Young people aged 16-18 years were involved in the development of the study design through focus groups and interviews (n=26). RESULTS: Participant recruitment commenced in 2022. CONCLUSIONS: A longitudinal web-based social network study could provide important data on how social networks and their influence change over time. This trial aims to determine whether scaled group reimbursement can increase the number of peers referred. The outcomes of this trial will improve the recruitment of young people to web-based network studies of sensitive health issues. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/44813.

A virtual pilot optimization trial for African American/Black and Latino persons with non-suppressed HIV viral load grounded in motivational interviewing and behavioral economics.

Introduction: Virtual and low-touch behavioral interventions are needed for African American/Black and Latino persons living with HIV (PLWH) with barriers to HIV viral suppression, particularly during COVID-19. Guided by the multiphase optimization strategy, we explored three components for PLWH without viral suppression, grounded in motivational interviewing and behavioral economics: (1) motivational interviewing counseling, (2) 21-weeks of automated text messages and quiz questions about HIV management, and (3) financial rewards for viral suppression (lottery prize vs. fixed compensation). Methods: This pilot optimization trial used sequential explanatory mixed methods to explore the components' feasibility, acceptability, and preliminary evidence of effects using an efficient factorial design. The primary outcome was viral suppression. Participants engaged in baseline and two structured follow-up assessments over an 8-month period, and provided laboratory reports to document HIV viral load. A subset engaged in qualitative interviews. We carried out descriptive quantitative analyses. Then, qualitative data were analyzed using directed content analysis. Data integration used the joint display method. Results: Participants (N = 80) were 49 years old, on average (SD = 9), and 75% were assigned male sex at birth. Most (79%) were African American/Black, and the remainder were Latino. Participants were diagnosed with HIV 20 years previously on average (SD = 9). Overall, components were feasible (>80% attended) and acceptability was satisfactory. A total of 39% (26/66) who provided laboratory reports at follow-up evidenced viral suppression. Findings suggested no components were entirely unsuccessful. The lottery prize compared to fixed compensation was the most promising component level. In qualitative analyses, all components were seen as beneficial to individual wellbeing. The lottery prize appeared more interesting and engaging than fixed compensation. However, structural barriers including financial hardship interfered with abilities to reach viral suppression. The integrated analyses yielded areas of convergence and discrepancy and qualitative findings added depth and context to the quantitative results. Conclusions: The virtual and/or low-touch behavioral intervention components tested are acceptable and feasible and show enough potential to warrant refinement and testing in future research, particularly the lottery prize. Results must be interpreted in the context of the COVID-19 pandemic. Trial registration: NCT04518241 (https://clinicaltrials.gov/ct2/show/NCT04518241).

The Development of a Hypertension Prevention and Financial-Incentive mHealth Program Using a "No-Code" Mobile App Builder: Development and Usability Study.

BACKGROUND: Regular physical activity (PA) is a key lifestyle component for hypertension prevention. Previous studies have shown that mobile health (mHealth) apps can be an effective tool for improving PA behaviors. However, adherence to and poor engagement with these apps is a challenge. A potential solution to overcome this challenge may be to combine financial incentives with innovative behavior theory, such as the Multiprocess Action Control (M-PAC) framework. Currently, there is a lack of PA financial incentive-driven M-PAC mHealth programs aimed at hypertension prevention. OBJECTIVE: We aimed to describe the process of developing an 8-week mHealth PA and financial-incentive hypertension education program (Healthy Hearts) and to evaluate usability of the Healthy Hearts program. METHODS: The first 2 stages of the Integrate, Design, Assess, and Share framework were used to guide the development of the Healthy Hearts program. The development process consisted of 2 phases. In phase 1, the research team met to discuss implementing the M-PAC framework to adopt an existing web-based hypertension prevention program to a mobile app. The app was developed using a no-code app development platform, Pathverse (Pathverse Inc), to help decrease overall development time. In phase 2, we created a prototype and conducted usability testing to evaluate lesson 1 of the Healthy Hearts program to further enhance the user experience. We used semistructured interviews and the mHealth App Usability Questionnaire to evaluate program acceptability and usability. RESULTS: Intervention development among the research team successfully created an 8-week financial-incentive hypertension education program for adults aged 40-65 years who did not currently meet the Canadian Physical Activity Guidelines (<150 minutes of moderate to vigorous PA per week). This program lasted 8 weeks and comprised 25 lessons guided by the M-PAC framework. The program used various behavior change techniques to further support PA adherence. Usability testing of the first lesson was successful, with 6 participants recruited for 2 rounds of testing. Feedback was gathered to enhance the content, layout, and design of the Healthy Hearts program to prepare the mHealth program for feasibility testing. Results of round 1 of usability testing suggested that the content delivered in the lessons was long. Therefore, the content was divided into multiple lessons before round 2 of usability testing, where feedback was only on design preferences. A minimum viable product was created with these results. CONCLUSIONS: The iterative development process and the usability assessments suggested by the Integrate, Design, Assess, and Share framework enabled participants to provide valuable feedback on the content, design, and layout of the program before advancing to feasibility testing. Furthermore, the use of the "no-code" app development tool enabled our team to rapidly make changes to the app based on user feedback during the iterative design process.

"It Goes Hand in Hand with Us Trying to Get More Kids to Play" Stakeholder Experiences in a Sport and Active Recreation Voucher Program.

Vouchers that reduce the cost of sport and active recreation participation have been shown to increase children's and adolescent's physical activity levels. Yet, the influence of government-led voucher programs on the capacity of sport and active recreation organisations is unclear. This qualitative study explored the experiences of stakeholders in the sport and recreation sector that were engaged in implementing the New South Wales (NSW) Government's Active Kids voucher program in Australia. Semi-structured interviews were conducted with 29 sport and active recreation providers. Interview transcriptions were analysed by a multidisciplinary team using the Framework method. Overall, participants reported that the Active Kids voucher program was an acceptable intervention to address the cost barrier to participation for children and adolescents. Three main steps influenced the capacity of organisations to deliver their sport and recreation programs and the voucher program: (1) Implementation priming-alignment of the intervention aims with stakeholder priorities and early information sharing, (2) Administrative ease-enhanced technology use and establishment of simple procedures, and (3) Innovation impacts-enablement of staff and volunteers to address barriers to participation for their participants. Future voucher programs should include strategies to enhance the capacity of sport and active recreation organisations to meet program guidelines and increase innovation.

Effects of Mobile-Based Financial Incentive Interventions for Adults at Risk of Developing Hypertension: Feasibility Randomized Controlled Trial.

BACKGROUND: Hypertension is the leading modifiable risk factor for cardiovascular disease and mortality. Adopting lifestyle modifications, like increasing physical activity (PA), can be an effective strategy in blood pressure (BP) control, but many adults do not meet the PA guidelines. Financial incentive interventions have the power to increase PA levels but are often limited due to cost. Further, mobile health technologies can make these programs more scalable. There is a gap in the literature about the most feasible and effective financial incentive PA framework; thus, pay-per-minute (PPM) and self-funded investment incentive (SFII) frameworks were explored. OBJECTIVE: The aims were to (1) determine the feasibility (recruitment, engagement, and acceptability) of an 8-week mobile-based PPM and SFII hypertension prevention PA program and (2) explore the effects of PPM and SFII interventions relative to a control on the PA levels, BP, and PA motivation. METHODS: In total, 55 adults aged 40-65 years not meeting the Canadian PA guidelines were recruited from Facebook and randomized into the following groups: financial incentive groups, PPM or SFII, receiving up to CAD $20 each (at the time of writing: CAD $1=US $0.74), or a control group without financial incentive. PPM participants received CAD $0.02 for each minute of moderate-to-vigorous PA (MVPA) per week up to the PA guidelines and the SFII received CAD $2.50 for each week they met the PA guidelines. Feasibility outcome measures (recruitment, engagement, and acceptability) were assessed. Secondary outcomes included changes in PA outcomes (MVPA and daily steps) relative to baseline were compared among PPM, SFII, and control groups at 4 and 8 weeks using linear regressions. Changes in BP and relative autonomy index relative to baseline were compared among the groups at follow-up. RESULTS: Participants were randomized to the PPM (n=19), SFII (n=18), or control (n=18) groups. The recruitment, retention rate, and engagement were 77%, 75%, and 65%, respectively. The intervention received overall positive feedback, with 90% of comments praising the intervention structure, financial incentive, and educational materials. Relative to the control at 4 weeks, the PPM and SFII arms increased their MVPA with medium effect (PPM vs control: η2p=0.06, mean 117.8, SD 514 minutes; SFII vs control: η2p=0.08, mean 145.3, SD 616 minutes). At 8 weeks, PPM maintained a small effect in MVPA relative to the control (η2p=0.01, mean 22.8, SD 249 minutes) and SFII displayed a medium effect size (η2p=0.07, mean 113.8, SD 256 minutes). Small effects were observed for PPM and SFII relative to the control for systolic blood pressure (SBP) and diastolic blood pressure (DBP) (PPM: η2p=0.12, Δmean SBP 7.1, SD 23.61 mm Hg; η2p=0.04, Δmean DBP 3.5, SD 6.2 mm Hg; SFII: η2p=0.01, Δmean SBP -0.4, SD 1.4 mm Hg; η2p=0.02, Δmean DBP -2.3, SD 7.7 mm Hg) and relative autonomy index (PPM: η2p=0.01; SFII: η2p=0.03). CONCLUSIONS: The feasibility metrics and preliminary findings suggest that a future full-scale randomized controlled trial examining the efficacy of PPM and SFII relative to a control is feasible, and studies with longer duration are warranted.

A Pragmatic Randomized Controlled Trial of Financial Incentives in Case Management for Homeless Adults With Mental Illness.

OBJECTIVE: Financial incentives can facilitate behavior change and service engagement in health care settings, but research on their use with adults experiencing homelessness is limited. This study examined the effectiveness of financial incentives in improving service engagement and health outcomes among homeless adults with mental illness in Toronto. METHODS: The authors of this randomized controlled trial recruited 176 participants receiving brief multidisciplinary case management services for homeless adults with mental illness after hospital discharge. In a 1:1 randomization design, 87 participants received a financial incentive of CAN$20 for every week they remained engaged with the service for up to 6 months. The remaining 89 participants received treatment as usual. The primary outcome was service contact rates for up to 6 months of follow-up. Secondary outcomes included self-reported health status, mental health symptoms, substance use, quality of life, housing stability, acute health service use, and working alliance. Negative binomial regression models, analyses of covariance, generalized estimating equations models, and Wilcoxon rank sum tests were used to examine differences between the financial incentive and treatment-as-usual groups across outcomes of interest. RESULTS: No significant differences were found between the financial incentive and treatment-as-usual groups in service contact rates or any of the secondary outcomes examined over the 6-month period. CONCLUSIONS: In low-barrier, brief case management programs tailored to the needs of adults experiencing homelessness, financial incentives may not affect service engagement or health outcomes. Further research is needed to identify the effect of financial incentives on engagement in other services, including housing-based interventions.

Financial incentives for infection prevention and antimicrobial stewardship to reduce antibiotic use: Japan's nationwide observational study.

BACKGROUND: The Japanese government introduced financial incentives to reduce nationwide antibiotic use in hospital settings. AIM: This study aimed to determine whether the nationwide financial incentives for creating infection prevention and control (IPC) teams introduced in 2012 and antimicrobial stewardship (ASP) teams introduced in 2018 were associated with changes in antibiotic use and health resource utilization at a national level. METHODS: We conducted time-series analyses and a difference-in-differences study consisting of 3,057,517 inpatients with infectious diseases from 472 medical facilities during fiscal years 2011-2018 using a nationally representative inpatient database in Japan. The primary outcome was the days of therapy (DOT) of antibiotic use per 100 patient-days (PDs). The secondary outcomes consisted of types of antibiotic used, health resource utilization, and mortality. RESULTS: A total of 5,201,304 financial incentives were observed during 2012-2018, which resulted in a total of 12.1 billion JPY (≈110 million USD). Time-series analyses found decreasing trends in total antibiotic use (79.3-72.5 DOTs/100 PDs (8.6% reduction)) and carbapenem use (9.0-7.0 DOTs/100 PDs (7.8% reduction)) from 2011 to 2018 without adversely affecting other healthcare outcomes (e.g., mortality). In the difference-in-differences analyses, we did not observe meaningful changes in total antibiotic use between the incentivized and unincentivized hospitals for ASP teams, except for the northern part of Japan. No dose-response relationships were observed between the amount of financial incentives and reductions in antibiotic use during 2011-2019. CONCLUSIONS: Further research and efforts are needed to accelerate antimicrobial stewardship in hospital settings in Japan.

Effect of financial incentives on hospital-cardiologist integration and cardiac test location.

Starting around 2006, the Centers for Medicare and Medicaid Services (CMS) progressively reduced Medicare Fee-for-Service (M-FFS) payments for the principal noninvasive cardiac tests, when performed in a cardiologist office (Office), yet kept payments flat to increasing for the same tests, performed in the hospital-based outpatient (HBO) setting. This produced a growing gap between HBO and Office payments for the same tests, and thus an incentive for hospitals to acquire cardiology practices in order to move cardiac tests to the HBO location and capture the HBO/Office payment differential. We use difference-in-differences analysis, in which we compare national M-FFS trends in cardiac test location to those for a control group of several large, integrated Medicare Advantage (M-Adv) health systems over 2005-2015, which were not affected by these reimbursement changes, and provide evidence that these reimbursement changes led to a large shift in testing from Office to HBO. This shift was concurrent with a sharp rise in hospital-cardiologist integration. The rise in integration and the proportion of testing in HBO varied greatly across states. Independent practice remains viable in very large states, but is endangered in many states, and is all but extinct in a growing number of states.

The Association Between Financial Incentives and Job Performance Among Primary Care Providers in Six Provinces of China.

Objective: This study aims to explore the association between financial incentives and job performance of primary care providers (PCPs) from a nationally representative survey in China. Methods: This is a cross-sectional study conducted in six provinces of China in 2019. A sample of 1388 PCPs participated in the survey was selected using a stratified cluster sampling method. A self-administered questionnaire composed of socio-demographic, work-related characteristics, financial incentives received by PCPs and their job performance was used. The association between financial incentives and job performance are analyzed using logistic regression model. The significance level for statistics is set at P < 0.05. Results: The PCPs with higher real income level have lower contextual performance (OR = 0.67, p < 0.01) and learning performance (OR = 0.63, p < 0.01) than those with lower real income level. The PCPs with the expectation of income rising above 50% have lower contextual performance (OR = 0.66, p < 0.05) than those with the expectation of income rising above 20%. The PCPs with preference for monetary income have lower task performance (OR = 0.62, p < 0.01), contextual performance (OR = 0.55, p < 0.01) and learning performance (OR = 0.57, p < 0.01) than those without lower preference for monetary income. The percent of performance-based income has no significant effect on all the three dimensions of job performance. Conclusion: Financial incentive was regarded as the most important motivating factor of PCPs in China, but existing financial incentives received by PCPs could not improve their job performance. The findings can be attributed to the unsatisfying total income level, "intrinsic motivation crowding out" effect, and the poorly designed performance-based salary system for PCPs. Policy attention is called for to continuing efforts and system reform to increase the total income level for PCPs in China, and improve the performance-based salary system to better motivate PCPs and improve their job performance.

25 Years: Looking Back, Looking Forward.

Palliative medicine and the practice of palliative care has disseminated around the world for the past 25 years. In many countries, palliative medicine is a formally recognized specialty of medicine. Yet, there is a high variability, due in part to the variable resources devoted to its development. New research is needed to improve our ability to control symptoms and to know how best to implement the existing science so that the patients who need palliative care can get it easily and equitably. Achieving this level of access requires expertise in organizational structure and system change strategies. Building the evidence base for best practices requires us to forge research collaborations with collegues from all medical subspecialities, including experts from allied health disciplines, and partner closely with patients and families. It also compels us to look critically at ourselves to overcome the barriers we put in our own way to becoming a routine part of standard health care in all countries.