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Tag: chief scientific officer

  • A Simple Marketing Technique Could Make America Healthier

    A Simple Marketing Technique Could Make America Healthier

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    This article was originally published in Knowable Magazine.

    Death from colorectal cancer can be prevented by regular screenings. Controlling high blood pressure could prolong the lives of the nearly 500,000 Americans who die from this disease each year. Vaccinations help prevent tetanus, which could otherwise be lethal.

    Clearly, preventive medicine can make a big difference to health.

    And yet most people don’t get the preventive care that could save their lives. Indeed, as of 2015, only 8 percent of U.S. adults 35 and older had received all immunizations, cancer screenings, and other high-priority services recommended for them.

    Researchers seeking to change that are borrowing a page from Facebook, Google, and other tech companies. By rapidly comparing small differences in how they communicate with patients—a process known as A/B testing—health-care workers can quickly learn what works and what doesn’t. The approach has already delivered several actionable improvements, though not everyone is convinced of its value.

    Tech-oriented companies use A/B testing to make decisions about marketing slogans, web-page colors, and lots of other options. The key is randomization, meaning that people are randomly assigned to see different versions of whatever is being tested. Does a bigger “Subscribe” button on a website generate more clicks than a smaller one? Does one headline over a story capture more readers than another?

    Read: There’s no such thing as a casual interaction with your doctor anymore

    Leora Horwitz, an internist and a health-services researcher at NYU Langone Health, and her colleagues adopted this technique—which they call rapid randomized controlled trials—to learn how to improve the delivery of health-care services. Randomized controlled trials, or RCTs, are widely used in medicine, typically to test new drugs or other disease treatments. For example, patients may be randomly assigned to receive either a new drug or the current standard treatment, then followed for months or years to assess whether the new drug works better. But those trials are slow and expensive, in part because researchers have to recruit people willing to be in a medical experiment.

    Rapid RCTs, by contrast, are not used to study new treatments, so nobody has to be recruited to participate. Rather, Horwitz’s goal is to improve health-care delivery through quick trials in which one can repeatedly test and fine-tune changes to health-care delivery based on what researchers learn from each test.

    “We are randomizing what we’re doing so that we can quickly and accurately assess whether what we are doing is working,” says Horwitz, who wrote about the approach in the 2023 Annual Review of Public Health.

    For example, Horwitz and her colleagues wanted to figure out how to get patients to book appointments to address care gaps—preventive services that are overdue. Because of the huge number of patients, physicians’ offices can’t contact everyone by telephone or through the online portal that NYU Langone uses to communicate with patients. So the health system needed to understand what type of reminders were most effective.

    In the A/B test, patients with care gaps were divided into two sets: those who had signed up for an online-portal account and those who had not. Patients in each set were then sorted into different groups based on their health-care history. Patients who, based on past behavior, were unlikely to initiate appointments on their own were put in higher-risk groups; those who had eventually booked their own appointments in the past were assigned to lower-risk groups.

    In one part of the test, several thousand patients who had no portal account were randomized so that some received a telephone-call reminder and others did not. Patients who received a phone call booked appointments to address 6.2 percent of the care gaps, compared with just 0.5 percent among those who were not called.

    In another part of the test, some patients with portal accounts received a reminder message through that channel, while others did not. Of those who received the message, 13 percent scheduled the needed services, compared with 1.1 percent of those who were not contacted.

    Importantly, the experiments revealed that a phone-call reminder was the most effective way to reach the subgroups of patients who were high-risk and the least likely to get their preventive services without a nudge. Shortly after the test results were known, NYU Langone prioritized all of its highest-risk patients to receive telephone reminders and greatly expanded its capacity for sending messages through the patient portal.

    “When we learn something, we apply that to all of our messaging quickly,” Horwitz says. That immediately extends what they’ve learned to tens of thousands of people. “That’s gratifying.”

    Read: Do you really want to read what your doctor writes about you?

    NYU Langone’s A/B testing is why many of the medical center’s female patients are now receiving short messages to remind them to schedule their mammograms. The researchers used rapid RCTs to test the wording on reminders sent through the online portal: Would shorter messages get better results? Indeed, patients who received a 78-word reminder scheduled nearly twice as many mammograms as those who received the old 155-word message.

    In another investigation, to find out how to boost vaccination rates among very young children, Horwitz and her team turned to rapid randomized tests that compared one-text and two-text reminders to parents against no text reminder at all. Only the two-text reminder—one sent at 6 p.m., the other sent at noon two days later—made a difference, tripling the number of appointments scheduled. Most appointments were made after the second text, suggesting that this booster reminder was what triggered the parents to act.

    Though it’s still new to the health-care sector, the idea of rapid RCTs is catching on. One research team—an economist, a physician, and a public-policy expert, none of whom was affiliated with Horwitz’s group—used the technique to learn how to increase the use of preventive-care services by Black men, the U.S. demographic group with the lowest life expectancy.

    They recruited more than 1,300 Black men from Oakland, California–area barbershops and flea markets, asked them to fill out a health questionnaire, and gave them a coupon for a free health screening. A pop-up clinic, staffed with 14 Black and non-Black male doctors, was set up to provide the screenings, and the participating men were randomly assigned to a Black or a non-Black doctor. The result: Black men assigned to Black physicians were more likely to get diabetes screenings, flu vaccinations, and other preventive services than those assigned to non-Black doctors.

    Some experts doubt that rapid A/B testing will ever become commonplace in health care. Darren DeWalt, a physician who directs the Institute for Healthcare Quality Improvement at the University of North Carolina, likes the concept, but he thinks most health-care organizations will avoid it for ethical reasons, possibly because people tend to disapprove of randomization, even in the context of something as innocuous as appointment reminders. “People in this country don’t like the idea that they are randomly allocated to something, even something as simple as that,” DeWalt says. “There’s a lot of suspicion around researchers in health care.”

    Others criticize A/B testing as tinkering at the margins. Pierre Barker, the chief scientific officer for the nonprofit Institute for Healthcare Improvement in Boston, believes that significant improvements in health-care delivery require an in-depth analysis of the problem to be solved, which may require many changes to the system. By contrast, rapid randomized controlled trials focus on a single, discrete change—say, the words used in a telephone script—rather than a broader effort to understand why patients don’t get preventive services and what can be done to change that.

    “The attractiveness is how fast it can move, more than the size of the impact,” he says. “I remain to be convinced that you can get more than a small incremental change” from rapid randomized controlled trials.

    It is true that the majority of NYU Langone’s care gaps were not resolved by the new reminders, says Horwitz, but the tests did provide information that led to hundreds of potentially lifesaving services being performed. That is what convinces her that the health-care industry should embrace rapid randomized trials.

    “If you were working for a web company or an airline or any other industry, you would randomize as a matter of course—this is the standard practice,” she says. “But it is still very foreign in health care, and it shouldn’t be.”

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    Lola Butcher

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  • 23 Pandemic Decisions That Actually Went Right

    23 Pandemic Decisions That Actually Went Right

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    More than three years ago, the coronavirus pandemic officially became an emergency, and much of the world froze in place while politicians and public-health advisers tried to figure out what on Earth to do. Now the emergency is officially over—the World Health Organization declared so on Friday, and the Biden administration will do the same later this week.

    Along the way, almost 7 million people died, according to the WHO, and looking back at the decisions made as COVID spread is, for the most part, a demoralizing exercise. It was already possible to see, in January 2020, that America didn’t have enough masks; in February, that misinformation would proliferate; in March, that nursing homes would become death traps, that inequality would widen, that children’s education, patients’ care, and women’s careers would suffer. What would go wrong has been all too clear from the beginning.

    Not every lesson has to be a cautionary tale, however, and the end of the COVID-19 emergency may be, if nothing else, a chance to consider which pandemic policies, decisions, and ideas actually worked out for the best. Put another way: In the face of so much suffering, what went right?

    To find out, we called up more than a dozen people who have spent the past several years in the thick of pandemic decision making, and asked: When the next pandemic comes, which concrete action would you repeat in exactly the same way?

    What they told us is by no means a comprehensive playbook for handling a future public-health crisis. But they did lay out 23 specific tactics—and five big themes—that have kept the past few years from being even worse.

    Good information makes everything else possible.
    1. Start immediate briefings for the public. At the beginning of March 2020, within days of New York City detecting its first case of COVID-19, Governor Andrew Cuomo and Mayor Bill de Blasio began giving daily or near-daily coronavirus press briefings, many of which included health experts along with elected officials. These briefings gave the public a consistent, reliable narrative to follow during the earliest, most uncertain days of the pandemic, and put science at the forefront of the discourse, Jay Varma, a professor of population health at Cornell University and a former adviser to de Blasio, told us.
    2. Let everyone see the information you have. In Medway, Massachusetts, for instance, the public-school system set up a data dashboard and released daily testing results.  This allowed the entire affected community to see the impact of COVID in schools, Armand Pires, the superintendent of Medway Public Schools, told us.
    3. Be clear that some data streams are better than others. During the first year of the pandemic, COVID-hospitalization rates were more consistent and reliable than, say, case counts and testing data, which varied with testing shortages and holidays, Erin Kissane, the managing editor of the COVID Tracking Project, told us.The project, which grew out of The Atlantic’s reporting on testing data, tracked COVID cases, hospitalizations, and deaths. CTP made a point of explaining where the data came from, what their flaws and shortcomings were, and why they were messy, instead of worrying about how people might react to this kind of information.
    4. Act quickly on the data. At the University of Illinois Urbana-Champaign, testing made a difference, because the administration acted quickly after cases started rising faster than predicted when students returned in fall of 2020, Rebecca Lee Smith, a UIUC epidemiologist, told us. The university instituted a “stay at home” order, and cases went down—and remained down. Even after the order ended, students and staff continued to be tested every four days so that anyone with COVID could be identified and isolated quickly.  
    5. And use it to target the places that may need the most attention. In California, a social-vulnerability index helped pinpoint areas to focus vaccine campaigns on, Brad Pollock, UC Davis’s Rolkin Chair in Public-Health Sciences and the leader of Healthy Davis Together, told us. In this instance, that meant places with migrant farmworkers and unhoused people, but this kind of precision public health could also work for other populations.
    6. Engage with skeptics. Rather than ignore misinformation or pick a fight with the people promoting it, Nirav Shah, the former director of Maine’s CDC, decided to hear them out, going on a local call-in radio show with hosts known to be skeptical of vaccines.
    A pandemic requires thinking at scale.
    1. Do pooled testing as early as possible. Medway’s public-school district used this technique, which combines samples from multiple people into one tube and then tests them all at once, to help reopen elementary schools in early 2021, said Pires, the Medway superintendent. Pooled testing made it possible to test large groups of people relatively quickly and cheaply.
    2. Choose technology that scales up quickly. Pfizer chose to use mRNA-vaccine tech in part because traditional vaccines are scaled up in stainless-steel vats, Jim Cafone, Pfizer’s senior vice president for global supply chain, told us. If the goal is to vaccinate billions of patients, “there’s not enough stainless steel in the world to do what you need to do,” he said. By contrast, mRNA is manufactured using lipid nanoparticle pumps, many more of which can fit into much less physical space.
    3. Take advantage of existing resources. UC Davis repurposed genomic tools normally used for agriculture for COVID testing, and was able to perform 10,000 tests a day,  Pollock, the UC Davis professor, told us.
    4. Use the Defense Production Act. This Cold War–era law, which allows the U.S. to force companies to prioritize orders from the government, is widely used in the defense sector. During the pandemic, the federal government invoked the DPA to break logjams in vaccine manufacturing, Chad Bown, a fellow at the Peterson Institute for International Economics who tracked the vaccine supply chain, told us. For example, suppliers of equipment used in pharmaceutical manufacturing were compelled to prioritize COVID-vaccine makers, and fill-and-finish facilities were compelled to bottle COVID vaccines first—ensuring that the vaccines the U.S. government had purchased would be delivered quickly.  
    Vaccines need to work for everyone.
    1. Recruit diverse populations for clinical trials. Late-stage studies on new drugs and vaccines have a long history of underrepresenting people from marginalized backgrounds, including people of color. That trend, as researchers have repeatedly pointed out, runs two risks: overlooking differences in effectiveness that might not appear until after a product has been administered en masse, and worsening the distrust built up after decades of medical racism and outright abuse. The COVID-vaccine trials didn’t do a perfect job of enrolling participants that fully represent the diversity of America, but they did better than many prior Phase 3 clinical trials despite having to rapidly enroll 30,000 to 40,000 adults, Grace Lee, the chair of CDC’s Advisory Committee on Immunization Practices, told us. That meant the trials were able to provide promising evidence that the shots were safe and effective across populations—and, potentially, convince wider swaths of the public that the shots worked for people like them.
    2. Try out multiple vaccines. No one can say for sure which vaccines might work or what problems each might run into. So drug companies tested several candidates at once in Phase I trials, Annaliesa Anderson, the chief scientific officer for vaccine research and development at Pfizer, told us; similarly, Operation Warp Speed placed big bets on six different options, Bown, the Peterson Institute fellow, pointed out.
    3. Be ready to vet vaccine safety—fast. The rarest COVID-vaccine side effects weren’t picked up in clinical trials. But the United States’ multipronged vaccine-safety surveillance program was sensitive and speedy enough that within months of the shots’ debut, researchers found a clotting issue linked to Johnson & Johnson, and a myocarditis risk associated with Pfizer’s and Moderna’s mRNA shots. They were also able to confidently weigh those risks against the immunizations’ many benefits. With these data in hand, the CDC and its advisory groups were able to throw their weight behind the new vaccines without reservations, said Lee, the ACIP chair.
    4. Make the rollout simple. When Maine was determining eligibility for the first round of COVID-19 vaccines, the state prioritized health-care workers and then green-lighted residents based solely on age—one of the most straightforward eligibility criteria in the country. Shah, the former head of Maine’s CDC, told us that he and other local officials credit the easy-to-follow system with Maine’s sky-high immunization rates, which have consistently ranked the state among the nation’s most vaccinated regions.
    5. Create vaccine pop-ups. For many older adults and people with limited mobility, getting vaccinated was largely a logistical challenge. Setting up temporary clinics where they lived—at senior centers or low-income housing, as in East Boston, for instance—helped ensure that transportation would not be an obstacle for them, said Josh Barocas, an infectious-diseases doctor at the University of Colorado School of Medicine.
    6. Give out boosters while people still want them. When boosters were first broadly authorized and recommended in the fall of 2021, there was a mad rush to immunization lines. In Maine, Shah said, local officials discovered that pharmacies were so low on staff and supplies that they were canceling appointments or turning people away. In response, the state’s CDC set up a massive vaccination center in Augusta. Within days, they’d given out thousands of shots, including both boosters and the newly authorized pediatric shots.
    Also, spend money.
    1. Basic research spending matters. The COVID vaccines wouldn’t have been ready for the public nearly as quickly without a number of existing advances in immunology,  Anthony Fauci, the former head of the National Institute of Allergy and Infectious Diseases, told us. Scientists had known for years that mRNA had immense potential as a delivery platform for vaccines, but before SARS-CoV-2 appeared, they hadn’t had quite the means or urgency to move the shots to market. And research into vaccines against other viruses, such as RSV and MERS, had already offered hints about the sorts of genetic modifications that might be needed to stabilize the coronavirus’s spike protein into a form that would marshal a strong, lasting immune response.
    2. Pour money into making vaccines before knowing they work. Manufacturing millions of doses of a vaccine candidate that might ultimately prove useless wouldn’t usually be a wise business decision. But Operation Warp Speed’s massive subsidies helped persuade manufacturers to begin making and stockpiling doses early on, Bown said. OWS also made additional investments to ensure that the U.S. had enough syringes and factories to bottle vaccines. So when the vaccines were given the green light, tens of millions of doses were almost immediately available.
    3. Invest in worker safety. The entertainment industry poured a massive amount of funds into getting COVID mitigations—testing, masking, ventilation, sick leave—off the ground so that it could resume work earlier than many other sectors. That showed what mitigation tools can accomplish if companies are willing to put funds toward them, Saskia Popescu, an infection-prevention expert in Arizona affiliated with George Mason University, told us.
    Lastly, consider the context.
    1. Rely on local relationships. To distribute vaccines to nursing homes, West Virginia initially eschewed the federal pharmacy program with CVS and Walgreens, Clay Marsh, West Virginia’s COVID czar, told us. Instead, the state partnered with local, family-run pharmacies that already provided these nursing homes with medication and flu vaccines. This approach might not have worked everywhere, but it worked for West Virginia.
    2. Don’t shy away from public-private partnerships. In Davis, California, a hotelier provided empty units for quarantine housing, Pollock said. In New York City, the robotics firm Opentrons helped NYU scale up testing capacity; the resulting partnership, called the Pandemic Response Lab, quickly slashed wait times for results, Varma, the former de Blasio adviser, said.
    3. Create spaces for vulnerable people to get help. People experiencing homelessness, individuals with substance-abuse disorders, and survivors of domestic violence require care tailored to their needs. In Boston, for example, a hospital recuperation unit built specifically for homeless people with COVID who were unable to self-isolate helped bring down hospitalizations in the community overall, Barocas said.
    4. Frame the pandemic response as a social movement. Involve not just public-health officials but also schools, religious groups, political leaders, and other sectors. For example, Matt Willis, the public-health officer for Marin County, California, told us, his county formed larger “community response teams” that agreed on and disseminated unified messages.

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    Rachel Gutman-Wei

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