The impact of financial incentives on utilization and outcomes of diabetes prevention programs among Medicaid managed care adults in New York state.

Diabetes prevalence has risen rapidly and has become a global health challenge. The Diabetes Prevention Program (DPP) has been shown to prevent or delay the development of diabetes among individuals with prediabetes. Yet, diabetes prevention studies within the Medicaid population are limited and results are mixed. This study aimed to evaluate the impact of different financial incentive strategies on the utilization of the DPP for Medicaid managed care adults in New York State. A four-arm randomized controlled trial was conducted among Medicaid managed care adult enrollees diagnosed with prediabetes and/or obesity. Study participants were offered a 16-week DPP with various incentive strategies based on class attendance and weight loss as follows: Attendance-Only, Weight-Loss Only, and both Attendance and Weight-Loss. A control group was offered DPP with no incentives for attendance or weight loss. We evaluated the impact of incentives on achievement of the program completion and weight-loss milestone. Participants who received incentives for the Attendance-Only class were least likely to be lost to follow-up, more likely to complete the program, and had two times higher percentage of meeting the weight-loss milestone compared to the control group. Results for the other incentive cohorts were mixed. A strong positive association was observed for participants who attended 9 or more classes and weight-loss regardless of incentive strategies. Providing monetary incentives for DPP class attendance had a positive impact on program completion and achieving the weight-loss milestone. However, the results from this study indicate that participant enrollment and retention remained challenges despite the incentives.

Effect of Process- and Outcome-Based Financial Incentives on Weight Loss Among Prediabetic New York Medicaid Patients: A Randomized Clinical Trial.

PURPOSE: To determine whether different financial incentives are effective in promoting weight loss among prediabetic Medicaid recipients. DESIGN: Four-group, multicenter, randomized clinical trial. SETTING AND PARTICIPANTS: Medicaid managed care enrollees residing in New York, aged 18 to 64 years, and diagnosed as prediabetic or high risk for diabetes (N = 703). INTERVENTION: In a 16-week program, participants were randomly assigned to one of 4 arms: (1) control (no incentives), (2) process incentives for attending weekly Diabetes Prevention Program sessions, (3) outcome incentives for achieving weekly weight loss goals, and (4) combined process and outcome incentives. MEASURES: Weight loss over a 16-week period; proportion who completed educational sessions; proportion who met weight loss goals. ANALYSIS AND RESULTS: No intervention arm achieved greater reduction in weight than control (outcome incentive -6.6 lb [-9.1 to -4.1 lb], process incentive -7.3 lb [-9.5 to -5.1 lb], combined incentive -5.8 lb [-8.8 to -2.8 lb], control -7.9 lb [-11.1 to -4.7 lb]; all P > .29). Session attendance in the process incentive arm (50%) was significantly higher than control (31%; P < .0001) and combined incentive arms (28%; P < .0001), but not significantly higher than the outcome incentive arm (38%). CONCLUSION: Process incentives increased session attendance, but when combined at half strength with outcome incentives did not achieve that effect. There were no significant effects of either process or outcomes incentives on weight loss.

Financial Incentives for Chronic Disease Management: Results and Limitations of 2 Randomized Clinical Trials With New York Medicaid Patients.

PURPOSE: To identify whether financial incentives promote improved disease management in Medicaid recipients diagnosed with hypertension or diabetes, respectively. DESIGN: Four-group, multicenter, randomized clinical trials. SETTING AND PARTICIPANTS: Between 2013 and 2016, New York State Medicaid managed care members diagnosed with hypertension (N = 920) or with diabetes (N = 959). INTERVENTION: Participants in each 6-month trial were randomly assigned to 1 of 4 arms: (1) process incentives-earned by attending primary care visits and/or receiving prescription medication refills, (2) outcome incentives-earned by reducing systolic blood pressure (hypertension) or hemoglobin A1c (HbA1c; diabetes) levels, (3) combined process and outcome incentives, and (4) control (no incentives). MEASURES: Systolic blood pressure (hypertension) and HbA1c (diabetes) levels, primary care visits, and medication prescription refills. Analysis and Results: At 6 months, there were no statistically significant differences between intervention arms and the control arm in the change in systolic blood pressure, P = .531. Similarly, there were no significant differences in blood glucose control (HbA1c) between the intervention arms and control after 6 months, P = .939. The majority of participants had acceptable systolic blood pressure (<140 mm Hg) or blood glucose (<8.0%) levels at baseline and throughout the study. CONCLUSION: Financial incentives-regardless of whether they were delivered based on disease-relevant outcomes, process activities, or a combination of the two-have a negligible impact on health outcomes for Medicaid recipients diagnosed with either hypertension or diabetes in 2 studies in which, among other design and operational limitations, the majority of recipients had relatively well-controlled diseases at the time of enrollment.

Air change rates and interzonal flows in residences, and the need for multi-zone models for exposure and health analyses.

Air change rates (ACRs) and interzonal flows are key determinants of indoor air quality (IAQ) and building energy use. This paper characterizes ACRs and interzonal flows in 126 houses, and evaluates effects of these parameters on IAQ. ACRs measured using weeklong tracer measurements in several seasons averaged 0.73 ± 0.76 h(-1) (median = 0.57 h(-1), n = 263) in the general living area, and much higher, 1.66 ± 1.50 h(-1) (median = 1.23 h(-1), n = 253) in bedrooms. Living area ACRs were highest in winter and lowest in spring; bedroom ACRs were highest in summer and lowest in spring. Bedrooms received an average of 55 ± 18% of air from elsewhere in the house; the living area received only 26 ± 20% from the bedroom. Interzonal flows did not depend on season, indoor smoking or the presence of air conditioners. A two-zone IAQ model calibrated for the field study showed large differences in pollutant levels between the living area and bedroom, and the key parameters affecting IAQ were emission rates, emission source locations, air filter use, ACRs, interzonal flows, outdoor concentrations, and PM penetration factors. The single-zone models that are commonly used for residences have substantial limitations and may inadequately represent pollutant concentrations and exposures in bedrooms and potentially other environments other where people spend a substantial fraction of time.

VOC composition of current motor vehicle fuels and vapors, and collinearity analyses for receptor modeling.

The formulation of motor vehicle fuels can alter the magnitude and composition of evaporative and exhaust emissions occurring throughout the fuel cycle. Information regarding the volatile organic compound (VOC) composition of motor fuels other than gasoline is scarce, especially for bioethanol and biodiesel blends. This study examines the liquid and vapor (headspace) composition of four contemporary and commercially available fuels: gasoline (<10% ethanol), E85 (85% ethanol and 15% gasoline), ultra-low sulfur diesel (ULSD), and B20 (20% soy-biodiesel and 80% ULSD). The composition of gasoline and E85 in both neat fuel and headspace vapor was dominated by aromatics and n-heptane. Despite its low gasoline content, E85 vapor contained higher concentrations of several VOCs than those in gasoline vapor, likely due to adjustments in its formulation. Temperature changes produced greater changes in the partial pressures of 17 VOCs in E85 than in gasoline, and large shifts in the VOC composition. B20 and ULSD were dominated by C(9) to C(16)n-alkanes and low levels of the aromatics, and the two fuels had similar headspace vapor composition and concentrations. While the headspace composition predicted using vapor-liquid equilibrium theory was closely correlated to measurements, E85 vapor concentrations were underpredicted. Based on variance decomposition analyses, gasoline and diesel fuels and their vapors VOC were distinct, but B20 and ULSD fuels and vapors were highly collinear. These results can be used to estimate fuel related emissions and exposures, particularly in receptor models that apportion emission sources, and the collinearity analysis suggests that gasoline- and diesel-related emissions can be distinguished.

Gaseous and Particulate Emissions from Diesel Engines at Idle and under Load: Comparison of Biodiesel Blend and Ultralow Sulfur Diesel Fuels.

Diesel exhaust emissions have been reported for a number of engine operating strategies, after-treatment technologies, and fuels. However, information is limited regarding emissions of many pollutants during idling and when biodiesel fuels are used. This study investigates regulated and unregulated emissions from both light-duty passenger car (1.7 L) and medium-duty (6.4 L) diesel engines at idle and load and compares a biodiesel blend (B20) to conventional ultralow sulfur diesel (ULSD) fuel. Exhaust aftertreatment devices included a diesel oxidation catalyst (DOC) and a diesel particle filter (DPF). For the 1.7 L engine under load without a DOC, B20 reduced brake-specific emissions of particulate matter (PM), elemental carbon (EC), nonmethane hydrocarbons (NMHCs), and most volatile organic compounds (VOCs) compared to ULSD; however, formaldehyde brake-specific emissions increased. With a DOC and high load, B20 increased brake-specific emissions of NMHC, nitrogen oxides (NOx), formaldehyde, naphthalene, and several other VOCs. For the 6.4 L engine under load, B20 reduced brake-specific emissions of PM2.5, EC, formaldehyde, and most VOCs; however, NOx brake-specific emissions increased. When idling, the effects of fuel type were different: B20 increased NMHC, PM2.5, EC, formaldehyde, benzene, and other VOC emission rates from both engines, and changes were sometimes large, e.g., PM2.5 increased by 60% for the 6.4 L/2004 calibration engine, and benzene by 40% for the 1.7 L engine with the DOC, possibly reflecting incomplete combustion and unburned fuel. Diesel exhaust emissions depended on the fuel type and engine load (idle versus loaded). The higher emissions found when using B20 are especially important given the recent attention to exposures from idling vehicles and the health significance of PM2.5. The emission profiles demonstrate the effects of fuel type, engine calibration, and emission control system, and they can be used as source profiles for apportionment, inventory, and exposure purposes.

Particle Concentrations and Effectiveness of Free-Standing Air Filters in Bedrooms of Children with Asthma in Detroit, Michigan.

Asthma can be exacerbated by environmental factors including airborne particulate matter (PM) and environmental tobacco smoke (ETS). We report on a study designed to characterize PM levels and the effectiveness of filters on pollutant exposures of children with asthma. 126 households with an asthmatic child in Detroit, Michigan, were recruited and randomized into control or treatment groups. Both groups received asthma education; the latter also received a free-standing high efficiency air filter placed in the child's bedroom. Information regarding the home, emission sources, and occupant activities was obtained using surveys administered to the child's caregiver and a household inspection. Over a one-week period, we measured PM, carbon dioxide (CO(2)), environmental tobacco smoke (ETS) tracers, and air exchange rates (AERs). Filters were installed at midweek. Before filter installation, PM concentrations averaged 28 µg m(-3), number concentrations averaged 70,777 and 1,471 L(-1) in 0.3-1.0 and 1-5 µm size ranges, respectively, and the median CO(2) concentration was 1,018 ppm. ETS tracers were detected in 23 of 38 homes where smoking was unrestricted and occupants included smokers and, when detected, PM concentrations were elevated by an average of 15 µg m(-3). Filter use reduced PM concentrations by an average of 69 to 80%. Simulation models representing location conditions show that filter air flow, room volume and AERs are the key parameters affecting PM removal, however, filters can achieve substantial removal in even "worst" case applications. While PM levels in homes with asthmatic children can be high, levels can be dramatically reduced using filters.

Permeation of gasoline, diesel, bioethanol (E85), and biodiesel (B20) fuels through six glove materials.

Biofuels and conventional fuels differ in terms of their evaporation rates, permeation rates, and exhaust emissions, which can alter exposures of workers, especially those in the fuel refining and distribution industries. This study investigated the permeation of biofuels (bioethanol 85%, biodiesel 20%) and conventional petroleum fuels (gasoline and diesel) through gloves used in occupational settings (neoprene, nitrile, and Viton) and laboratories (latex, nitrile, and vinyl), as well as a standard reference material (neoprene sheet). Permeation rates and breakthrough times were measured using the American Society for Testing and Materials F739-99 protocol, and fuel and permeant compositions were measured by gas chromatography/mass spectrometry. In addition, we estimated exposures for three occupational scenarios and recommend chemical protective clothing suitable for use with motor fuels. Permeation rates and breakthrough times depended on the fuel-glove combination. Gasoline had the highest permeation rate among the four fuels. Bioethanol (85%) had breakthrough times that were two to three times longer than gasoline through neoprene, nitrile Sol-Vex, and the standard reference materials. Breakthrough times for biodiesel (20%) were slightly shorter than for diesel for the latex, vinyl, nitrile examination, and the standard neoprene materials. The composition of permeants differed from neat fuels, e.g., permeants were significantly enriched in the lighter aromatics including benzene. Viton was the best choice among the tested materials for the four fuels tested. Among the scenarios, fuel truck drivers had the highest uptake via inhalation based on the personal measurements available in the literature, and gasoline station attendants had highest uptake via dermal exposure if gloves were not worn. Appropriate selection and use of gloves can protect workers from dermal exposures; however, current recommendations from the National Institute for Occupational Safety and Health should be revised to account for contemporary fuel formulations that routinely contain ethanol.