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ThePREDICTTrial
PredictionusingaRandomizedEvaluationofDatacollectionIntegrated
throughConnectedTechnologiesOgochukwu Ufio
Advisors:Mitesh PatelMD,MBA,MSCarolineCarney,BA
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TableofContents
• AboutNudgeUnit• Background• PACUREstudy• ProjectSignificance• Methods• Challenges• MyRole/LessonsLearned
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AboutNudgeUnit
MissionTheNudgeUnitaimstoleverageinsightsfrombehaviouralsciences,principallybehaviouraleconomics,todesignandtestinterventionsthatsteerprovidersandpatientstowardbetterdecisionstoimprovehealthcaredeliveryandoutcomes
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ChangingdefaultprescriptionsettingsinEMRincreasedratesofgeneric
drugs• ChangeindefaultimplementedacrossUPHSfrombrandnametogenericprescription
• Optoutmechanismincreasedgenericprescribingratesfrom75%to98%
• Genericsdrugsassociatedwithhighermedicationadherence,improvedclinicaloutcomesandreducedcosts.
• Behavioraleconomictechniquechangingphysicianandpatientbehaviour
Mitesh etal,2016
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NudgeUnitProjects• PriceTransparency forinpatientlaboratorytesting(PRICETrial)
• Usingactivechoiceandpeercomparisonstoincreasestatinprescriptionrates(PRESCRIBETrial)
• Usingdefaultoptionstoincreasegenericmedicationprescribingrates(PrescriptionDefaults)
• Usingdefaultoptionstodecreaseopioidprescribingdurations(OpioidPrescriptionDefaults)
• Gamification andincentivespromoteweightloss(theLoseitTrial)
• Gamification andsocialincentivestoimproveglycemiccontrolamongobesediabeticadults(iDiabetes Trial)
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RiskPredictionModelsforHospitalReadmission:ASystematicReview
• Objective– summarizevalidatedreadmissionriskpredictionmodels
– describetheirperformance– assesssuitabilityforclinicaloradministrativeuse
• Conclusion– 26modelswereassessedandfoundtoperformpoorly– Focusesprimarilyonclaimsdata&EHR
Devan etal,2011
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Variablesconsideredbystudiesinevaluatingtheriskofreadmission
Variable Includedinfinalmodelin(n) outof26models
Medical comorbidities 24
Mental healthcomorbidities(mentalhealthillness,substanceabuse)
9-11
Illnessseverity 1-4
Priorutilization(hospitalizations,ERvisits,clinic visits,indexhospitallengthofstay)
4-14
Overall healthandfunction(mobility,visual,hearing,cognitivestatus)
1-7
Socialdemographic factors(age,race/ethnicity,gender)
7-19
Socialdeterminants ofhealth(SES,Education,insurancestatus,socialsupport)
0-5
Fewmodelsincludedvariablesassociatedwithoverallhealthandfunction,illnessseverityandsocialdeterminantsofhealth
Devan etal,2011
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PACURERetrospectiveStudy• AseparatestudyfromthePREDICTTrial• Examinesretrospectivedataonpatientsadmittedand
dischargedbetween1/1/2012and9/30/2014fromUPHS• Standardpredictionmodelapproachusingclaimsdataand
EHRdata• Additionalvariables:social/behaviouraldeterminantsof
health- continuityofcare&substanceabuse• 9080patientshavebeenidentified
HowthisstudydiffersfromPREDICT• PREDICTisanenhancedapproach• PREDICTbuildsonthisstudybyusingstep,sleepandsurvey
data
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PREDICTTrialSignificance
• Whatisalreadyknownonthistopic– Transitioncareinterventionscanreducereadmissions– Identifyinghighriskpatientscanreducereadmissions– Existingpredictionmodelsperformpoorly– Priorstudiesfocusedonclaimsdataandelectronichealthrecords
• Whatquestionthisstudyaddresses– Whatcanlearningaboutpatient’sstepsandsleepingtellusabouttheirlikelihoodforreadmissions?
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Thepassiveintervention:
WatchOR PhoneApp
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Project’sSignificance
• Whatthisstudyaddstoourknowledge– Collectsanintegrateddataset– Comparesmethodsofactivitydatacollection
• Howisthisrelevanttopolicyandpractice– Improvereadmissionpredictionmodels– Aplatformfordesigningfutureinterventions– Forstateandnation-wideimplementation
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Method
• ApproachPatient• UPHShospitals• Assessinterest
Consent
• CreateaWTHaccount
• Completeaseriesofsurveys
Enroll • Activityistrackedusingphoneorwatch
• Duration- 6months
Randomize
•18yearsorolder•Abilitytoprovideconsent•AdmittedpatientatHUPorPennPresby MedCenter•SmartphonecompatibletoNokiaHealthMate•Walk10-15minute/Nohiporfootsurgery•Dischargedhome•LiveinPA/NJ•Hasanemailaddress
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Aseriesofselfreportedsurveysonpatientexperiences
• MedicalOutcomeStudySurvey– Assessesphysical,mentalandgeneralhealth
• DOSPERTRiskpreferences– Assessesrisktakinganduncertainty
• MMAS-8– Assessesmedicationtakingbehaviour
• BigFivePersonalitytest– Assessmentofpersonalityacross5dimensions:Openness,Conscientiousness,Agreeableness,Extraversion,Neuroticism
• IPAQ-SF– Assessesphysicalactivitylevels
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Method
• ApproachPatient• UPHShospitals• Assessinterest
Consent
• CreateaWTHaccount
• Completeaseriesofsurveys
Enroll • Activityistrackedusingphoneorwatch
• Duration- 6months
Randomize
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ComparingMethodsofTrackingActivityData
PhoneAppn=250
• Tracksstepcountsonly
• Lowercostforintervention
Watchn=250
• Tracksbothstepsandsleepingpattern
• Challengesinadoption
500patientsenrolled
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NokiaHealthMate AppFeatures• Steps
– Trackswalk,runand10+activities– Competewithfriendsandfamily
• Sleep– Assesseshowmuchsleepscheduleisshiftedandsleepduration
– Trackspatternandgraphstrends• Weight
– Monitorweighthistoryintheformofagraph– Useconnectedscalestomeasureweight– Thisfunctionalityisusedinthe iDiabetes study
• Heart– Monitorsheartrate– MonitorsbloodpressuremanuallyorviawirelessBPmonitor
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BehaviourModification• Patientshaveaccesstoactivitydatacollectedthroughapp
• Setdailystepgoals• Trackprogressovertime• Congratulatorybadges
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Approached (n=672)
Excluded (n=585)
•Not meeting inclusion criteria (n=293)
No smartphone (n=154)Not being discharged to home (n=66)Unable to walk (n=45)Not PA/NJ resident (n=10)Not English speaking (n=6)
•Declined to participate (n=293)
Phone App Group (n= 45)
AllocationRandomized (n=84)
Enrollment
App and Activity tracking watch (n= 44)
6monthpassivestepcollection
Reminderafter4daystopleaseopenapp
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AddressingLowrecruitment
84patientsenrolled
Logisticsofrecruitingonhospitalfloors
Changingandhiringstaff
Goal=500patients
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•WatchrebrandedonJune20•ChangedAPI•CausedtechnologicaldisconnectionswithWaytoHealth
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Role&TakeAways
• Recruitingpatients– Patientengagement– Managingpatientquestions– Datacollectionprocess
• Literaturesearch/review– Identifyingrelevantandtimelyresearcharticles
• Dealingwithprojectchallenges• Contributingtoprojectmeetings
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Acknowledgement
Mitesh PatelJoanneLevyCarolineCarneySafa BrowneNudgeUnitTeamHoagLevins
SUMR2017Cohort
Thankyou!
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Questions?
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ReferencesColemanEA,ParryC,ChalmersS,MinSJ.Thecaretransitionsintervention:resultsofarandomizedcontrolledtrial.ArchInternMed2006;166:1822-8.Kansagara D,EnglanderH,Salanitro A,etal.RiskPredictionModelsforHospitalReadmission:ASystematicReview. JAMA :thejournaloftheAmericanMedicalAssociation.2011;306(15):1688-1698.doi:10.1001/jama.2011.1515.Mitesh S.Patel,SusanC.Day,ScottD.Halpern,C.WilliamHanson,JosephR.Martinez,StevenHoneywell,KevinG.Volpp.GenericMedicationPrescriptionRatesAfterHealthSystem–WideRedesignofDefaultOptionsWithintheElectronicHealthRecord.JAMAInternalMedicine,2016NaylorMD,Brooten D,CampbellR,etal.Comprehensivedischargeplanningandhomefollow-upofhospitalizedelders:arandomizedclinicaltrial.JAMA:thejournaloftheAmericanMedicalAssociation1999;281:613-20.