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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 eScholarship.org Powered by the California Digital Library 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. iii 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 vi 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 vii 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 viii

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physicians' adherence to the clinical care guidelines for prescribing HIV medications. 2017. The first chapter examines the role of physician networks in promoting quality (more adher- ent) HIV care. Physicians' non-adherence to clinical care .. 2015 – 2016 NIA Predoctoral Fellowship, UCLA.
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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 eScholarship.org Powered by the California Digital Library 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. iii 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 vi 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 vii 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 viii

Description:
physicians' adherence to the clinical care guidelines for prescribing HIV medications. 2017. The first chapter examines the role of physician networks in promoting quality (more adher- ent) HIV care. Physicians' non-adherence to clinical care .. 2015 – 2016 NIA Predoctoral Fellowship, UCLA.
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