Publications by authors named "Charlene A Wong"

55 Publications

COVID-19 Vaccine Administration, by Race and Ethnicity - North Carolina, December 14, 2020-April 6, 2021.

MMWR Morb Mortal Wkly Rep 2021 Jul 16;70(28):991-996. Epub 2021 Jul 16.

COVID-19 has disproportionately affected non-Hispanic Black or African American (Black) and Hispanic persons in the United States (1,2). In North Carolina during January-September 2020, deaths from COVID-19 were 1.6 times higher among Black persons than among non-Hispanic White persons (3), and the rate of COVID-19 cases among Hispanic persons was 2.3 times higher than that among non-Hispanic persons (4). During December 14, 2020-April 6, 2021, the North Carolina Department of Health and Human Services (NCDHHS) monitored the proportion of Black and Hispanic persons* aged ≥16 years who received COVID-19 vaccinations, relative to the population proportions of these groups. On January 14, 2021, NCDHHS implemented a multipronged strategy to prioritize COVID-19 vaccinations among Black and Hispanic persons. This included mapping communities with larger population proportions of persons aged ≥65 years among these groups, increasing vaccine allocations to providers serving these communities, setting expectations that the share of vaccines administered to Black and Hispanic persons matched or exceeded population proportions, and facilitating community partnerships. From December 14, 2020-January 3, 2021 to March 29-April 6, 2021, the proportion of vaccines administered to Black persons increased from 9.2% to 18.7%, and the proportion administered to Hispanic persons increased from 3.9% to 9.9%, approaching the population proportion aged ≥16 years of these groups (22.3% and 8.0%, respectively). Vaccinating communities most affected by COVID-19 is a national priority (5). Public health officials could use U.S. Census tract-level mapping to guide vaccine allocation, promote shared accountability for equitable distribution of COVID-19 vaccines with vaccine providers through data sharing, and facilitate community partnerships to support vaccine access and promote equity in vaccine uptake.
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http://dx.doi.org/10.15585/mmwr.mm7028a2DOI Listing
July 2021

Strategies for research participant engagement: A synthetic review and conceptual framework.

Clin Trials 2021 Aug 20;18(4):457-465. Epub 2021 May 20.

Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.

Background: Research participant engagement, which we define as recruitment and retention in clinical trials, is a costly and challenging issue in clinical research. Research teams have leveraged a variety of strategies to increase research participant engagement in clinical trials, although a framework and evidence for effective participant engagement strategies are lacking. We (1) developed a novel conceptual framework for strategies used to recruit and retain participants in clinical trials based on their underlying behavioral principles and (2) categorized empirically tested recruitment and retention strategies in this novel framework.

Methods: We conducted a synthetic analysis of interventions tested in studies from two Cochrane reviews on clinical trial recruitment and retention, which included studies from 1986 to 2015. We developed a conceptual framework of behavioral strategies for increasing research participant engagement using deductive and inductive approaches with the studies included in the Cochrane reviews. Reviewed interventions were then categorized using this framework. We examined the results of reviewed interventions and categorized the effects on clinical trial recruitment and retention as significantly positive, null, or significantly negative; summary statistics are presented for the frequency and effects of each behavioral strategy type.

Results: We analyzed 141 unique interventions across 96 studies: 91 interventions targeted clinical trial research participant recruitment and 50 targeted retention. Our framework included 14 behavioral strategies to improve research participant engagement grouped into four general approaches: , , , and . The majority of interventions (54%) aimed to reduce barriers or cognitive burdens, with improving comprehension (27%) as the most common specific strategy identified. For recruitment, the most common behavioral strategies tested were building legitimacy or trust (38%) and framing risks and benefits (32%), while financial or material incentives (32%) and reducing financial, time, and social barriers (32%) were most common for retention interventions. Among interventions tested in randomized controlled trials, 51% had a null effect on research participant engagement, and 30% had a statistically significant positive effect.

Discussion: Clinical researchers have tested a wide range of interventions that leverage distinct behavioral strategies to achieve improved research participant recruitment and retention. Common behavioral strategies include building legitimacy or trust between research teams and participants, as well as improving participant comprehension of trial objectives and procedures. The high frequency of null effects among tested interventions suggests challenges in selecting the optimal interventions for increasing research participant engagement, although the proposed behavioral strategy categories can serve as a conceptual framework for developing and testing future interventions.
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http://dx.doi.org/10.1177/17407745211011068DOI Listing
August 2021

COVID-19 Response Strategies at Large Institutes of Higher Education in the United States: A Landscape Analysis, Fall 2020.

J Adolesc Health 2021 04;68(4):683-685

Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina; Department of Pediatrics, Children's Health and Discovery Initiative, Duke University School of Medicine, Durham, North Carolina; Sanford School of Public Policy, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.

Purpose: To examine the pandemic response plans of institutes of higher education (i.e., colleges and universities), including COVID-19 prevention, enforcement, and testing strategies.

Method: Data from the largest public (n = 50) and private (n = 50) US institutes of higher education were collected from October 30 to November 20, 2020.

Results: Most institutes of higher education (n = 93) offered some in-person teaching in the Fall 2020 semester; most adopted masking (100%) and physical distancing (99%) mandates. Other preventive strategies included on-campus housing de-densification (58%), classroom de-densification (61%), mandated COVID-19-related training (39%), and behavioral compacts (43%). Testing strategies included entry testing (65%), testing at regular intervals (32%), population sample testing (46%), and exit testing (15%). More private than public institutes implemented intercollegiate athletics bans, behavioral compacts, and suspension clauses for noncompliance.

Conclusions: Variability in COVID-19 prevention and testing strategies highlights the need for national recommendations and the equitable distribution of sufficient pandemic response resources to institutes of higher education.
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http://dx.doi.org/10.1016/j.jadohealth.2021.01.016DOI Listing
April 2021

Sidebar: North Carolina's Process for Developing Our COVID-19 Vaccine Plan.

N C Med J 2021 Mar-Apr;82(2):127-128

Chief health policy officer for COVID-19, North Carolina Department of Health and Human Services, Raleigh, North Carolina.

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http://dx.doi.org/10.18043/ncm.82.2.127DOI Listing
March 2021

Winning the Hearts and Minds of Young Adults in the COVID-19 Pandemic.

J Adolesc Health 2021 03;68(3):441-442

Department of Pediatrics, Children's Health and Discovery Initiative, Duke School of Medicine, Durham North Carolina; Duke-Margolis Center for Public Policy, Duke University, Durham North Carolina.

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http://dx.doi.org/10.1016/j.jadohealth.2020.12.131DOI Listing
March 2021

The Need for New Cost Measures in Pediatric Value-Based Payment.

Pediatrics 2021 02 12;147(2). Epub 2021 Jan 12.

Children's Health & Discovery Initiative, Department of Pediatrics, School of Medicine, Duke University, Durham, North Carolina; and.

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http://dx.doi.org/10.1542/peds.2019-4037DOI Listing
February 2021

Impact of COVID-19-related School Closures on the Drivers of Child Health.

N C Med J 2021 Jan-Feb;82(1):50-56

associate professor of pediatrics, Division of Critical Care Medicine, Department of Pediatrics, Duke University Hospital; member, Duke Clinical Research Institute, Durham, North Carolina.

The COVID-19 pandemic resulted in large-scale school closures in an effort to reduce the spread of disease. This article reviews the potential impact of COVID-19-related school closures on the health of children in North Carolina, with particular attention to the impact of school closures on drivers of child health.
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http://dx.doi.org/10.18043/ncm.82.1.50DOI Listing
January 2021

The Dose-Response Relationship Between Physical Activity and Cardiometabolic Health in Adolescents.

Am J Prev Med 2021 01;60(1):95-103

Duke Clinical Research Institute, Durham, North Carolina; Duke Center for Childhood Obesity Research, Duke University School of Medicine, Durham, North Carolina; Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Duke Children's Health and Discovery Initiative, Duke University School of Medicine, Durham, North Carolina.

Introduction: This study examines the dose-response relationship between moderate-to-vigorous physical activity and cardiometabolic measures in adolescents.

Methods: Cross-sectional spline analyses were performed using 2003-2016 National Health and Nutrition Examination Survey data among adolescents (aged 12-19 years, N=9,195) on objectively measured (2003-2006) and self-reported (2007-2016) weekly mean minutes of moderate-to-vigorous physical activity and cardiometabolic measures (systolic and diastolic blood pressure, total cholesterol, high-density lipoprotein, BMI, and cardiorespiratory fitness). Inflection points were determined for nonlinear relationships.

Results: For objective moderate-to-vigorous physical activity, female adolescents had significant nonlinear associations with inflection points at 90 minutes/week for BMI percentile and systolic blood pressure. Male adolescents had inflection points at 150 weekly minutes of objective activity for BMI percentile and cardiorespiratory fitness. BMI percentile was about 7% lower for female and male adolescents at 150 weekly minutes of objectively measured moderate-to-vigorous physical activity than at 0 minutes. For self-reported moderate-to-vigorous physical activity, inflection points were at 375 minutes/week (diastolic blood pressure for female adolescents) and 500 minutes/week (systolic blood pressure for male adolescents).

Conclusions: Among several significant dose-response relationships between physical activity and cardiometabolic health in adolescents, consistent and often nonlinear relationships were identified for BMI, with inflection points at 90-150 minutes of objective moderate-to-vigorous physical activity. Notable differences in associations and linearity were identified by sex and physical activity measure (objective or self-reported). These results support calls for any increase in physical activity among adolescents and suggest that recommendations closer to the adult guidelines of 150 weekly minutes of physical activity may be health promoting and more attainable for youth than the current recommendation of 420 weekly minutes.
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http://dx.doi.org/10.1016/j.amepre.2020.06.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769140PMC
January 2021

Applying Behavioral Economics to Improve Adolescent and Young Adult Health: A Developmentally-Sensitive Approach.

J Adolesc Health 2021 Jul 4;69(1):17-25. Epub 2020 Dec 4.

Duke Sanford School of Public Policy, Durham, North Carolina; Fuqua School of Business, Durham North Carolina.

Each day, adolescents and young adults (AYAs) choose to engage in behaviors that impact their current and future health. Behavioral economics represents an innovative lens through which to explore decision-making among AYAs. Behavioral economics outlines a diverse set of phenomena that influence decision-making and can be leveraged to develop interventions that may support behavior change. Up to this point, behavioral economic interventions have predominantly been studied in adults. This article provides an integrative review of how behavioral economic phenomena can be leveraged to motivate health-related behavior change among AYAs. We contextualize these phenomena in the physical and social environments unique to AYAs and the neurodevelopmental changes they undergo, highlighting opportunities to intervene in AYA-specific contexts. Our review of the literature suggests behavioral economic phenomena leveraging social choice are particularly promising for AYA health. Behavioral economic interventions that take advantage of AYA learning and development have the potential to positively impact youth health and well-being over the lifespan.
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http://dx.doi.org/10.1016/j.jadohealth.2020.10.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175460PMC
July 2021

Pediatric accountable health communities: Insights on needed capabilities and potential solutions.

Healthc (Amst) 2020 Dec 7;8(4):100481. Epub 2020 Oct 7.

Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.

Background: Pediatric accountable health communities (AHCs) are emerging collaborative models that integrate care across health and social service sectors. We aimed to identify needed capabilities and potential solutions for implementing pediatric AHCs.

Methods: We conducted a directed content analysis of responses to a Request for Information (RFI) from the Center for Medicare & Medicaid Innovation on the Integrated Care for Kids Model (n = 1550 pages from 202 respondents). We then interviewed pediatric health policy stakeholders (n = 18) to further investigate responses from the RFI. All responses were coded using a consensual qualitative research approach in 2019.

Results: To facilitate service integration, respondents emphasized the need for cross-sector organizational alignment and data sharing. Recommended solutions included designating "Bridge Organizations" to operationalize service integration across sectors and developing integrated data sharing systems. Respondents called for improved validation and collection methods for data relating to school performance, social drivers of health, family well-being, and patient experience. Recommended solutions included aligning health and education data privacy regulations and utilizing metrics with cross-sector relevance. Respondents identified that mechanisms are needed to blend health and social service funding in alternative payment models (APMs). Recommended solutions included guidance on cross-sector care coordination payments, shared savings arrangements, and capitation to maximize spending flexibility.

Conclusions: Pediatric AHCs could provide more integrated, high-value care for children. Respondents highlighted the need for shared infrastructure and cross-sector alignment of measures and financing.

Implications: Insights and solutions from this study can inform policymakers planning or implementing innovative, child-centered AHC models.

Level Of Evidence: Level V.
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http://dx.doi.org/10.1016/j.hjdsi.2020.100481DOI Listing
December 2020

Children And The Opioid Epidemic: Age-Stratified Exposures And Harms.

Health Aff (Millwood) 2020 10;39(10):1737-1742

Charlene A. Wong is an associate professor of pediatrics and public policy at Duke University, the Children's Health and Discovery Initiative, and the Duke-Margolis Center for Health Policy.

Using North Carolina Medicaid 2016-18 claims data, we found that approximately one in ten adolescents (10.8 percent) filled at least one opioid prescription per year. Dentists, advanced practice providers, and surgeons were common prescribers of opioids to children. In addition, half of children who experienced opioid-related adverse events had filled opioid prescriptions in the prior six months.
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http://dx.doi.org/10.1377/hlthaff.2020.00724DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157201PMC
October 2020

Digital Health Technology to Enhance Adolescent and Young Adult Clinical Preventive Services: Affordances and Challenges.

J Adolesc Health 2020 08;67(2S):S24-S33

Division of Adolescent and Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.

The lives of adolescents and young adults (AYAs) have become increasingly intertwined with technology. In this scoping review, studies about digital health tools are summarized in relation to five key affordances-social, cognitive, identity, emotional, and functional. Consideration of how a platform or tool exemplifies these affordances may help clinicians and researchers achieve the goal of using digital health technology to enhance clinical preventive services for AYAs. Across these five affordances, considerable research and development activity exists accompanied by signs of high promise, although the literature primarily reflects demonstration studies of acceptability or small sample experiments to discern impact. Digital health technology may afford an array of functions, yet its potential to enhance AYA clinical preventive services is met with three key challenges. The challenges discussed in this review are the disconnectedness between digital health tools and clinical care, threats to AYA privacy and security, and difficulty identifying high-value digital health products for AYA. The data presented are synthesized in calls to action for the use of digital health technology to enhance clinical preventive services and to ensure that the digital health ecosystem is relevant, effective, safe, and purposed for meeting the health needs of AYA.
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http://dx.doi.org/10.1016/j.jadohealth.2019.10.018DOI Listing
August 2020

The Dose-Response Relationship Between Physical Activity and Cardiometabolic Health in Young Adults.

J Adolesc Health 2020 08 19;67(2):201-208. Epub 2020 Jun 19.

Duke Clinical Research Institute, Durham, North Carolina; Duke Center for Childhood Obesity Research, Duke University School of Medicine, Durham, North Carolina; Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Children's Health and Discovery Institute, Duke University School of Medicine, Durham, North Carolina. Electronic address:

Purpose: Guidelines recommend 150 minutes of weekly moderate-to-vigorous physical activity (MVPA) for all adults, although physical activity level correlation with cardiometabolic health is not well characterized for young adults. We determined the dose-response relationship of MVPA on measures of cardiometabolic health in young adults.

Methods: We examined young adults (aged 20-29 years; N = 5,395, 47.9% female) in the 2003-2016 National Health and Nutrition Examination Survey. Exposures were objective (accelerometer based) and self-reported weekly mean minutes of MVPA. Cardiometabolic outcome measures were body mass index (BMI), high-density lipoprotein (HDL), total cholesterol, systolic blood pressure, and diastolic blood pressure. The dose-response relationships were assessed with unadjusted spline analyses. Sex-stratified outcomes were modeled using multivariable linear regression with mean estimated change presented for 150-minute dose increases of MVPA.

Results: Among females, associations between objective activity and cardiometabolic measures were all linear. Compared with no activity, 150 minutes of objective activity was associated with a lower BMI (-1.37 kg/m) and total cholesterol (-4.89 mg/dL), whereas 150 minutes of self-reported activity was associated with a higher HDL (1 mg/dL) and lower diastolic blood pressure (-.42 mm Hg). Among males, an inflection point was identified in the dose-response curves for objective activity with BMI around 100 minutes. Compared with no activity, 150 self-reported minutes was associated with lower BMI (-.26 kg/m), higher HDL (.52 mg/dL), and lower total cholesterol (-1.35 mg/dL).

Conclusions: The dose-response relationships between physical activity and cardiometabolic markers in young adults were predominantly linear, supporting public health calls for any increase in physical activity in this population.
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http://dx.doi.org/10.1016/j.jadohealth.2020.04.021DOI Listing
August 2020

The Project Baseline Health Study: a step towards a broader mission to map human health.

NPJ Digit Med 2020 5;3:84. Epub 2020 Jun 5.

Duke University, School of Medicine, Durham, NC USA.

The Project Baseline Health Study (PBHS) was launched to map human health through a comprehensive understanding of both the health of an individual and how it relates to the broader population. The study will contribute to the creation of a biomedical information system that accounts for the highly complex interplay of biological, behavioral, environmental, and social systems. The PBHS is a prospective, multicenter, longitudinal cohort study that aims to enroll thousands of participants with diverse backgrounds who are representative of the entire health spectrum. Enrolled participants will be evaluated serially using clinical, molecular, imaging, sensor, self-reported, behavioral, psychological, environmental, and other health-related measurements. An initial deeply phenotyped cohort will inform the development of a large, expanded virtual cohort. The PBHS will contribute to precision health and medicine by integrating state of the art testing, longitudinal monitoring and participant engagement, and by contributing to the development of an improved platform for data sharing and analysis.
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http://dx.doi.org/10.1038/s41746-020-0290-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275087PMC
June 2020

Mitigating the Impacts of the COVID-19 Pandemic Response on At-Risk Children.

Pediatrics 2020 07 21;146(1). Epub 2020 Apr 21.

Duke Children's Health and Discovery Initiative, Durham, North Carolina.

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http://dx.doi.org/10.1542/peds.2020-0973DOI Listing
July 2020

Medicaid and CHIP Child Health Beneficiary Incentives: Program Landscape and Stakeholder Insights.

Pediatrics 2019 08 9;144(2). Epub 2019 Jul 9.

Department of Pediatrics, School of Medicine.

Objectives: To describe the landscape of Medicaid and the Children's Health Insurance Program beneficiary incentive programs for child health and garner key stakeholder insights on incentive program rationale, child and family engagement, and program evaluation.

Methods: We identified beneficiary health incentive programs from 2005 to 2018 through a search of peer-reviewed and publicly available documents and through semistructured interviews with 80 key stakeholders (Medicaid and managed-care leadership, program evaluators, patient advocates, etc). This study highlights insights from 23 of these stakeholders with expertise on programs targeting child health (<18 years old) to understand program rationale, beneficiary engagement, and program evaluation.

Results: We identified 82 child health-targeted beneficiary incentive programs in Medicaid and the Children's Health Insurance Program. Programs most commonly incentivized well-child checks ( = 77), preventive screenings ( = 30), and chronic disease management ( = 30). All programs included financial incentives (eg, gift cards, premium incentives); some also offered incentive material prizes ( = 12; eg, car seats). Loss-framed incentives were uncommon ( = 1; eg, lost benefits) and strongly discouraged by stakeholders. Stakeholders suggested family engagement strategies including multigenerational incentives or incentives addressing social determinants of health. Regarding evaluation, stakeholders suggested incentivizing evidence-based preventive services (eg, vaccinations) rather than well-child check attendance, and considering proximal measures of child well-being (eg, school functioning).

Conclusions: As the landscape of beneficiary incentive programs for child health evolves, policy makers have unique opportunities to leverage intergenerational and social approaches for family engagement and to more effectively increase and evaluate programs' impact.
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http://dx.doi.org/10.1542/peds.2018-3161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6855824PMC
August 2019

Adolescent and Young Adult Recreational, Occupational, and Transportation Activity: Activity Recommendation and Weight Status Relationships.

J Adolesc Health 2019 07 1;65(1):147-154. Epub 2019 Apr 1.

Duke Center for Childhood Obesity Research, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; Division of Primary Care, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Duke Children's Health and Discovery Initiative, Duke University School of Medicine, Durham, North Carolina. Electronic address:

Purpose: Physical activity can occur in many settings, or domains, including recreation, occupation, and transportation. We described patterns of adolescent and young adult (YA) activity in each domain, and the extent that accounting for different domains impacts activity recommendation adherence. We also examined activity domain associations with weight status.

Methods: We examined physical activity among 11,157 adolescents and YAs in recreational, occupational, and transportation domains in the 2007-2016 National Health and Nutrition Examination Survey. We calculated proportions meeting weekly activity recommendations (adolescents: 420 minutes; YAs: 150 minutes) by domain. We compared adjusted odds of performing any activity in each domain by weight status. All estimates are weighted and stratified by age (adolescents: 12-19 years; YAs: 20-29 years) and sex.

Results: Most adolescents (90.9%) and YAs (86.7%) reported activity in at least one domain. Recreational activity accounted for an average of 60.2% (adolescents) and 42.5% (YAs) of an individual's total activity. Approximately half of YAs (50.2%) reported any occupational activity, which accounted for 44.6% (males) and 37.4% (females) of total activity minutes. Transportation accounted for 18.1% (adolescents) and 16.2% (YAs) of total activity. Activity recommendation adherence estimates increased when adding domains: recreation alone (34.9% adolescents, 45.6% YAs); recreation and occupation (47.2% adolescents, 68.7% YAs); and recreation, occupation, and transportation (53.5% adolescents, 74.7% YAs). Weight status was generally not associated with activity domains.

Conclusions: Adolescents and YAs accumulate substantial occupational and some transportation-related physical activity, resulting in more youth meeting activity recommendations when accounting for these activity domains than recreation alone.
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http://dx.doi.org/10.1016/j.jadohealth.2019.01.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6589358PMC
July 2019

Engaging Beneficiaries In Medicaid Programs That Incentivize Health-Promoting Behaviors.

Health Aff (Millwood) 2019 03;38(3):431-439

Charlene A. Wong ( ) is an assistant professor of pediatrics and public policy, and faculty in the Duke-Margolis Center for Health Policy and the Duke Clinical Research Institute, all at Duke University in Durham.

Medicaid programs are increasingly adopting incentive programs to improve health behaviors among beneficiaries. There is limited evidence on what incentives are being offered to Medicaid beneficiaries, how programs are engaging beneficiaries, and how programs are evaluated. In 2017-18 we synthesized available information on these programs and interviewed eighty policy stakeholders to identify the rationale behind key program design decisions and stakeholders' recommendations for beneficiary engagement and program evaluation. Key underlying program rationales included improving the use of preventive services and promoting personal responsibility. Beneficiary engagement strategies emphasized meeting members where they are and offering prizes or services customized for certain groups. Stakeholders recommended collaborating with external evaluators to design and conduct robust evaluations of incentive programs. Finally, stakeholders recommended aligning beneficiary incentives with provider incentives and other payment reforms through the use of common meaningful measures to streamline program evaluation.
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http://dx.doi.org/10.1377/hlthaff.2018.05427DOI Listing
March 2019

The Roles Of Assisters And Automated Decision Support Tools In Consumers' Marketplace Choices: Room For Improvement.

Health Aff (Millwood) 2019 03;38(3):473-481

Peter A. Ubel is the Madge and Dennis T. McLawhorn Professor of Business, Public Policy, and Medicine at Duke University.

Assisters provide in-person and phone-based support to help consumers narrow their plan options on the Affordable Care Act's health insurance Marketplaces. We elicited the perspectives of a national sample of thirty-two assisters from ten states on consumer plan selection and available Marketplace decision support tools (for example, total cost estimators and provider network look-up tools). Assisters identified several shortcomings that limited their use of decision support tools, such as nonspecific cost estimates and inaccurate provider network data. Assisters instead provided individualized cost estimates, called provider offices to verify network coverage, and found innovative strategies to help consumers access care affordably under their chosen plan. Two priorities emerged for optimizing consumers' Marketplace insurance selection process: improve the quality of data used in decision support tools and invest in assister programs. Assister strategies should be a benchmark for improving decision support tools, with lessons to be learned for future tool development.
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http://dx.doi.org/10.1377/hlthaff.2018.05021DOI Listing
March 2019

Providing Individual Research Results to Participants-Reply.

JAMA 2018 12;320(24):2601

Duke Forge, Duke University School of Medicine, Durham, North Carolina.

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http://dx.doi.org/10.1001/jama.2018.18111DOI Listing
December 2018

Return of Research Results to Study Participants: Uncharted and Untested.

JAMA 2018 Aug;320(5):435-436

Duke Forge, Duke University School of Medicine, Durham, North Carolina.

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http://dx.doi.org/10.1001/jama.2018.7898DOI Listing
August 2018

Association of Physical Activity With Income, Race/Ethnicity, and Sex Among Adolescents and Young Adults in the United States: Findings From the National Health and Nutrition Examination Survey, 2007-2016.

JAMA Pediatr 2018 08;172(8):732-740

Duke Center for Childhood Obesity Research, Duke University, Durham, North Carolina.

Importance: Physical activity in youth is associated with adult health. Understanding the prevalence and factors of moderate to vigorous physical activity among adolescents and young adults will guide public health and policy efforts.

Objectives: To describe the current patterns of physical activity and duration among adolescents and young adults and to identify the direction and magnitude of associations between physical activity and income, race/ethnicity, and sex.

Design, Setting, And Participants: This cross-sectional secondary data analysis used the self-reported physical activity data of adolescents and young adults from the National Health and Nutrition Examination Survey from 2007 through 2016. This data set is a multistage probability sample of the noninstitutionalized US population and allows estimates that represent the US population. The years 2007 through 2016 were selected because of the consistent physical activity questions during this period. Adolescents and young adults aged 12 to 29 years who responded to the survey were included. Individuals who were underweight were excluded. Data analysis was performed from October 17, 2017, to April 27, 2018.

Main Outcomes And Measures: Self-reported physical activity duration and intensity.

Results: Of the 9472 participants, 4771 (50.4%) were males, and the weighted mean age (range) was 20.6 (12-19) years. Across all demographic categories, females reported less physical activity than did their male counterparts. White adolescent males were most likely (89.3%; 95% CI, 86.5%-92.1%) and black females aged 18 to 24 years were least likely (45%; 95% CI, 39.0%-51.0%) to report any physical activity. Among those who were active, black males aged 18 to 24 years reported the longest duration of activity (77.9 minutes per day; 95% CI, 66.4-89.3 minutes per day), and black females aged 25 to 29 years reported the shortest duration of activity (33.2 minutes per day; 95% CI, 28.1-38.2 minutes per day). In adjusted models, younger age, white race, and higher income were associated with greater physical activity.

Conclusions And Relevance: Female adolescents and young adults were not meeting the recommended guidelines for physical activity, and substantial disparities by race and income levels were noted. These data highlight opportunities for targeted physical activity programming and policy efforts.
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http://dx.doi.org/10.1001/jamapediatrics.2018.1273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6142913PMC
August 2018

Shopping on the Public and Private Health Insurance Marketplaces: Consumer Decision Aids and Plan Presentation.

J Gen Intern Med 2018 08 29;33(8):1400-1410. Epub 2018 May 29.

Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.

Background: The design of the Affordable Care Act's (ACA) health insurance marketplaces influences complex health plan choices.

Objective: To compare the choice environments of the public health insurance exchanges in the fourth (OEP4) versus third (OEP3) open enrollment period and to examine online marketplace run by private companies, including a total cost estimate comparison.

Design: In November-December 2016, we examined the public and private online health insurance exchanges. We navigated each site for "real-shopping" (personal information required) and "window-shopping" (no required personal information).

Participants: Public (n = 13; 12 state-based marketplaces and HealthCare.gov ) and private (n = 23) online health insurance exchanges.

Main Measures: Features included consumer decision aids (e.g., total cost estimators, provider lookups) and plan display (e.g., order of plans). We examined private health insurance exchanges for notable features (i.e., those not found on public exchanges) and compared the total cost estimates on public versus private exchanges for a standardized consumer.

Results: Nearly all studied consumer decision aids saw increased deployment in the public marketplaces in OEP4 compared to OEP3. Over half of the public exchanges (n = 7 of 13) had total cost estimators (versus 5 of 14 in OEP3) in window-shopping and integrated provider lookups (window-shopping: 7; real-shopping: 8). The most common default plan orders were by premium or total cost estimate. Notable features on private health insurance exchanges were unique data presentation (e.g., infographics) and further personalized shopping (e.g., recommended plan flags). Health plan total cost estimates varied substantially between the public and private exchanges (average difference $1526).

Conclusions: The ACA's public health insurance exchanges offered more tools in OEP4 to help consumers select a plan. While private health insurance exchanges presented notable features, the total cost estimates for a standardized consumer varied widely on public versus private exchanges.
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http://dx.doi.org/10.1007/s11606-018-4483-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082189PMC
August 2018

Making the Case for Value-Based Payment Reform in Children's Health Care.

JAMA Pediatr 2018 06;172(6):513-514

Margolis Center for Health Policy, Duke University, Durham, North Carolina.

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http://dx.doi.org/10.1001/jamapediatrics.2018.0129DOI Listing
June 2018

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

JAMA Pediatr 2017 12;171(12):1176-1183

Leonard Davis Institute of Health Economics, Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, Philadelphia.

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.
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http://dx.doi.org/10.1001/jamapediatrics.2017.3233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583649PMC
December 2017

Pediatric Price Transparency: Still Opaque With Opportunities for Improvement.

Hosp Pediatr 2017 10 5;7(10):565-571. Epub 2017 Sep 5.

Leonard Davis Institute of Health Economics.

Objectives: Price transparency is gaining importance as families' portion of health care costs rise. We describe (1) online price transparency data for pediatric care on children's hospital Web sites and state-based price transparency Web sites, and (2) the consumer experience of obtaining an out-of-pocket estimate from children's hospitals for a common procedure.

Methods: From 2015 to 2016, we audited 45 children's hospital Web sites and 38 state-based price transparency Web sites, describing availability and characteristics of health care prices and personalized cost estimate tools. Using secret shopper methodology, we called children's hospitals and submitted online estimate requests posing as a self-paying family requesting an out-of-pocket estimate for a tonsillectomy-adenoidectomy.

Results: Eight children's hospital Web sites (18%) listed prices. Twelve (27%) provided personalized cost estimate tool (online form = 5 and/or phone number = 9). All 9 hospitals with a phone number for estimates provided the estimated patient liability for a tonsillectomy-adenoidectomy (mean $6008, range $2622-$9840). Of the remaining 36 hospitals without a dedicated price estimate phone number, 21 (58%) provided estimates (mean $7144, range $1200-$15 360). Two of 4 hospitals with online forms provided estimates. Fifteen (39%) state-based Web sites distinguished between prices for pediatric and adult care. One had a personalized cost estimate tool.

Conclusions: Meaningful prices for pediatric care were not widely available online through children's hospital or state-based price transparency Web sites. A phone line or online form for price estimates were effective strategies for hospitals to provide out-of-pocket price information. Opportunities exist to improve pediatric price transparency.
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http://dx.doi.org/10.1542/hpeds.2017-0020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6345274PMC
October 2017

Pediatric and Adult Physician Networks in Affordable Care Act Marketplace Plans.

Pediatrics 2017 Apr 1;139(4). Epub 2017 Mar 1.

Leonard Davis Institute of Health Economics, and.

Objectives: To describe and compare pediatric and adult specialty physician networks in marketplace plans.

Methods: Data on physician networks, including physician specialty and address, in all 2014 individual marketplace silver plans were aggregated. Networks were quantified as the fraction of providers in the underlying rating area within a state that participated in the network. Narrow networks included none available networks (ie, no providers available in the underlying area) and limited networks (ie, included <10% of the available providers in the underlying area). Proportions of narrow networks between pediatric and adult specialty providers were compared.

Results: Among the 1836 unique silver plan networks, the proportions of narrow networks were greater for pediatric (65.9%) than adult specialty (34.9%) networks ( < .001 for all specialties). Specialties with the highest proportion of narrow networks for children were infectious disease (77.4%) and nephrology (74.0%), and they were highest for adults in psychiatry (49.8%) and endocrinology (40.8%). A larger proportion of pediatric networks (43.8%) had no available specialists in the underlying area when compared with adult networks (10.4%) ( < .001 for all specialties). Among networks with available specialists in the underlying area, a higher proportion of pediatric (39.3%) than adult (27.3%) specialist networks were limited ( < .001 except psychiatry).

Conclusions: Narrow networks were more prevalent among pediatric than adult specialists, because of both the sparseness of pediatric specialists and their exclusion from networks. Understanding narrow networks and marketplace network adequacy standards is a necessary beginning to monitor access to care for children and families.
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http://dx.doi.org/10.1542/peds.2016-3117DOI Listing
April 2017