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J Gen Intern Med ; 2022 Jan 17.
Artigo em Inglês | MEDLINE | ID: mdl-35037172


BACKGROUND: Despite success in increasing other health behaviors, financial incentives have shown limited to no effect on colorectal cancer (CRC screening. Little is known about the factors shaping why and for whom incentives improve screening. OBJECTIVE: To explore the perspective of participants enrolled in a larger, four-arm pragmatic trial at urban family medicine practices which assessed and failed to detect significant effects of financial incentives on at-home CRC screening completion. DESIGN: We performed a mixed methods study with a subset of randomly selected patients, stratified by study arm, following completion of the pragmatic trial. PARTICIPANTS: Sixty patients (46.9% enrollment rate) who were eligible and overdue for colorectal cancer screening at the time of trial enrollment and who continued to receive care at family medicine practices affiliated with an urban academic health system completed the interview and questionnaire. MAIN MEASURES: Using Andersen's behavioral model, a semi-structured interview guide assessed motivators, barriers, and facilitators to screening completion and the impact of incentives on decision-making. Participants also completed a brief questionnaire evaluating demographics, screening beliefs, and clinical characteristics. KEY RESULTS: The majority of patients (n = 49; 82%) reported that incentives would not change their decision to complete or not complete CRC screening, which was confirmed by qualitative data as largely due to high perceived health benefits. Those who stated financial incentives would impact their decision (n = 11) were significantly less likely to agree that CRC screening is beneficial (72.7% vs 95.9%; p < 0.05) or that CRC could be cured if detected early (63.6% vs 98.0%; p < 0.05). CONCLUSIONS: Financial incentives are likely not an effective behavioral intervention to increase CRC screening for all but may be powerful for increasing short-term benefit and therefore completion for some. Targeting financial incentive interventions according to patient screening beliefs may prove a cost-effective strategy in primary care outreach programs to increase CRC screening.

Implement Sci ; 16(1): 90, 2021 09 25.
Artigo em Inglês | MEDLINE | ID: mdl-34563227


BACKGROUND: Serious illness conversations (SICs) are an evidence-based approach to eliciting patients' values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics ("nudges") that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion-either alone or in combination with clinician nudges that additionally compare performance relative to peers-may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer. METHODS: We will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity. DISCUSSION: This will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies. TRIAL REGISTRATION: , NCT04867850 . Registered on April 30, 2021. FUNDING: National Cancer Institute P50CA244690.

Neoplasias , Assistência Terminal , Comunicação , Economia Comportamental , Feminino , Humanos , Neoplasias/terapia , Cuidados Paliativos
Implement Sci ; 16(1): 72, 2021 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-34266468


BACKGROUND: Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. METHODS: A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or "nudges") promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. DISCUSSION: This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. TRIAL REGISTRATION:, NCT04737031 . Registered 3 February 2021.

Neoplasias , Fumar , Tabaco , Economia Comportamental , Humanos , Neoplasias/terapia , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Uso de Tabaco
Psychol Assess ; 31(1): 82-99, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30299119


Beck's insight-that beliefs about one's self, future, and environment shape behavior-transformed depression treatment. Yet environment beliefs remain relatively understudied. We introduce a set of environment beliefs-primal world beliefs or primals-that concern the world's overall character (e.g., the world is interesting, the world is dangerous). To create a measure, we systematically identified candidate primals (e.g., analyzing tweets, historical texts, etc.); conducted exploratory factor analysis (N = 930) and two confirmatory factor analyses (N = 524; N = 529); examined sequence effects (N = 219) and concurrent validity (N = 122); and conducted test-retests over 2 weeks (n = 122), 9 months (n = 134), and 19 months (n = 398). The resulting 99-item Primals Inventory (PI-99) measures 26 primals with three overarching beliefs-Safe, Enticing, and Alive (mean α = .93)-that typically explain ∼55% of the common variance. These beliefs were normally distributed; stable (2 weeks, 9 months, and 19 month test-retest results averaged .88, .75, and .77, respectively); strongly correlated with many personality and wellbeing variables (e.g., Safe and optimism, r = .61; Enticing and depression, r = -.52; Alive and meaning, r = .54); and explained more variance in life satisfaction, transcendent experience, trust, and gratitude than the BIG 5 (3%, 3%, 6%, and 12% more variance, respectively). In sum, the PI-99 showed strong psychometric characteristics, primals plausibly shape many personality and wellbeing variables, and a broad research effort examining these relationships is warranted. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Atitude , Cultura , Mineração de Dados/métodos , Processamento de Linguagem Natural , Psicometria/instrumentação , Humanos , Psicometria/normas