Improving HIV/AIDS Care: Promoting HIV/AIDS Treatment Adherence Through Physician Peer

88 Pages·2017·1.94 MB·English

UCLA
UCLA Electronic Theses and Dissertations
Title
Improving HIV/AIDS Care: Promoting HIV/AIDS Treatment Adherence Through Physician Peer
Effects and Behavioral Incentives for Patients
Permalink
https://escholarship.org/uc/item/32v388ns
Author
Stecher, Chad Daniel
Publication Date
2017

Peer reviewed|Thesis/dissertation
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University of California
UNIVERSITY OF CALIFORNIA
LosAngeles
ImprovingHIV/AIDSCare:
PromotingHIV/AIDSTreatmentAdherenceThrough
PhysicianPeerEffectsandBehavioralIncentivesforPatients
Adissertationsubmittedinpartialsatisfaction
oftherequirementsforthedegreeof
DoctorofPhilosophyinEconomics
by
ChadDanielStecher
2017
©Copyrightby
ChadDanielStecher
2017
ABSTRACT OF THE DISSERTATION
ImprovingHIV/AIDSCare:
PromotingHIV/AIDSTreatmentAdherenceThrough
PhysicianPeerEffectsandBehavioralIncentivesforPatients
by
ChadDanielStecher
DoctorofPhilosophyinEconomics
UniversityofCalifornia,LosAngeles,2017
ProfessorDoraLuisaCosta,Chair
This dissertation identifies new healthcare policy mechanisms for promoting greater adherence
among both physicians and patients to the HIV medication guidelines. The first chapter uses
insurance claims data for the sample, compiled by Dr. Arleen Leibowitz, of HIV-infected patients
who were insured by Medicare and Medicaid in California between 2007 and 2010 to analyze
physicians’adherencetotheclinicalcareguidelinesforprescribingHIVmedications. Thesecond
and third chapters were written in collaboration with Dr. Sebastian Linnemayr, and describe the
impact of the Rewarding Adherence Program (RAP) on promoting greater medication adherence
among HIV-infected patients in Kampala, Uganda. The second chapter was originally published
in AIDS and Behavior in May of 2015, and the third chapter was published in AIDS in March of
2017.
Thefirstchapterexaminestheroleofphysiciannetworksinpromotingquality(moreadher-
ent) HIV care. Physicians’ non-adherence to clinical care guidelines has been observed for many
health conditions, and has particularly damaging repercussions for both HIV-infected patients’
health and for policies to reduce the domestic HIV epidemic. I identify physician peers through
shared patients and develop repeated observations of medication regimen and disease monitoring
quality across physicians and patients. Using the structure of physician networks to create instru-
mental variables, I find heterogeneous effects across peer types. Generalist peers have no effect
ii
on medication decisions, but a one percent improvement in HIV specialist peers’ medication regi-
men quality increases generalists’ medication regimen quality by 0.15 percent. Simulations show
that improving generalists’ network connections to specialists could provide adherent medication
regimenstoanadditional2,779patientsinCaliforniain2010,reducingtheannualnumberofnew
infections by 5 percent. These findings illustrate the potential for network connections to diffuse
complex treatment protocols and suggest specific mechanisms for reducing the HIV epidemic,
whichisdisproportionatelyburdeningunderrepresenteddemographiccommunitiesintheU.S.
Thesecondchapterdescribestheinfluenceofbehavioraldecisionbiasesonpatients’medica-
tion adherence. Behavioral economic theory has been used to study a number of health behaviors
such as smoking and drug use, but there is little knowledge of how these insights relate to HIV
prevention and care. In this chapter, we present novel evidence on the prevalence of the com-
mon behavioral decision-making errors of present-bias, overoptimism, and information salience
among 155 Ugandan HIV patients, and quantify their association with lower medication adher-
ence. These findings indicate that behavioral economic tools may be used to screen for future
adherence problems and to better design and target interventions addressing these behavioral bi-
asesandtheassociatedsuboptimaladherence.
The third chapter measures the impact of behavioral economic incentives on combating de-
cisionbiasesandimprovingpatients’HIVmedicationadherenceinsub-SaharanAfrica. 155HIV-
positive men and women in Kampala, Uganda aged 19-78 were randomized to 1 of 2 intervention
groupsoracontrolgroupreceivingtheusualstandardofcare. Participantsinthefirstintervention
groupwereeligibleforprizedrawingsconditionalonattendingscheduledclinicappointments;eli-
gibilityinthesecondgroupwasbasedonantiretroviralmedicationadherencemeasuredbymedical
event monitoring system caps. Results from the first nine months of this intervention show statis-
tically significant improvements in the percent of participants who maintain mean adherence rates
of 90% or higher in both intervention groups relative to the control. Such behavioral incentives
representahighlycost-effectiveandscalablemechanismforimprovingadherenceinthisregion.
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ThedissertationofChadDanielStecherisapproved.
ArleenLeibowitz
SebastianLinnemayr
AdrianaLleras-Muney
KathleenMcGarry
DoraLuisaCosta,CommitteeChair
UniversityofCalifornia,LosAngeles
2017
iv
TothememoryofJimmyBromberg
v
Contents
1 TheRoleofPhysicianNetworksinPromotingQualityHIVCare 1
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2.1 HIVCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2.2 PhysicianNetworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.3 DataandSampleSelection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.3.1 PrimaryDataSources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.3.2 QualityofCareMeasures . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.3.3 AnalyticSamples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.3.4 PatientSharingNetworks . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.4 MethodsforEstimatingPhysicianNetworkEffects . . . . . . . . . . . . . . . . . 14
1.4.1 PeerEffectsintheFirstModelingApproach . . . . . . . . . . . . . . . . . 15
1.4.2 PeerEffectsintheSecondModelingApproach . . . . . . . . . . . . . . . 19
1.5 ObservedQualityandPhysicianNetworks . . . . . . . . . . . . . . . . . . . . . . 20
1.5.1 QualityofHIVCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.5.2 PhysicianNetworkCharacteristics . . . . . . . . . . . . . . . . . . . . . . 21
1.6 EstimationResultsandDiscussion . . . . . . . . . . . . . . . . . . . . . . . . . . 23
1.6.1 EstimatedPeerEffectsthroughtheFirstModelingApproach . . . . . . . . 23
1.6.2 EstimatedPeerEffectsthroughtheSecondModelingApproach . . . . . . 28
1.7 SimulatedPhysicianNetworkRedesign . . . . . . . . . . . . . . . . . . . . . . . 32
1.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
2 TheImpactofBehavioralBiasesonMedicationAdherence 57
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
2.2 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
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2.2.1 MeasurementofBehavioralEconomicBiases . . . . . . . . . . . . . . . . 60
2.2.2 AdherenceMeasures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
2.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
2.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
2.6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3 BehavioralEconomicIncentivestoImproveMedicationAdherence 65
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
3.2 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.2.1 StudySetting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.2.2 StudyDesignandParticipants . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.2.3 StatisticalAnalyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
3.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
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List of Figures
1.1 PhysicianNetworkinPalmSprings,CA . . . . . . . . . . . . . . . . . . . . . . . 47
1.2 PhysicianNetworkinSanDiego,CA . . . . . . . . . . . . . . . . . . . . . . . . . 48
1.3 SimulatedNetworkRedesigninLosAngeles,CA . . . . . . . . . . . . . . . . . . 49
1.4 ImprovedAdherencetoMedicationGuidelinesUnderSimulatations . . . . . . . . 50
3.1 FlowofStudyParticipants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.2 ObservedDistributionof9-MonthMeanAdherence . . . . . . . . . . . . . . . . . 71
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