1. Journal Club 埼玉医科大学 総合医療センター 内分泌・糖尿病内科 Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University 松田 昌文 Matsuda, Masafumi 2016 年 3 月 17 日 8:30-8:55 ８階 医局 Patel MS, Asch DA, Rosin R, Small DS, Bellamy SL, Heuer J, Sproat S, Hyson C, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D, Taylor DH, Hilbert V, Zhu J, Yang L, Wang X, Volpp KG. Framing Financial Incentives to Increase Physical Activity Among Overweight and Obese Adults: A Randomized, Controlled Trial. Ann Intern Med. 2016 Mar 15;164(6):385-94. doi: 10.7326/M15-1635. Chow N, Shearer D, Tildesley HG, Aydin Plaa J, Pottinger B, Pawlowska M, White A, Priestman A, Ross SA, Tildesley HD. Determining starting basal rates of insulin infusion for insulin pump users: a comparison between methods. BMJ Open Diabetes Res Care. 2016 Mar 1;4(1):e000145. doi: 10.1136/bmjdrc-2015- 000145.

2. From the Perelman School of Medicine at the University of Pennsylvania, Penn Medicine Center for Health Care Innovation, Wharton School of the University of Pennsylvania, Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute of the University of Pennsylvania, and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania; Massachusetts General Hospital, Boston, Massachusetts; and Columbia University Medical Center, New York, New York. Ann Intern Med. 2016 Mar 15;164(6):385-94. doi: 10.7326/M15-1635.

3. Background: Financial incentive designs to increase physical activity have not been well-examined. Objective: To test the effectiveness of 3 methods to frame financial incentives to increase physical activity among overweight and obese adults.

4. Design: Randomized, controlled trial. (ClinicalTrials.gov: NCT 02030119) Setting: University of Pennsylvania. Participants: 281 adult employees (body mass index ≥27 kg/m 2 ). Intervention: 13-week intervention. Participants had a goal of 7000 steps per day and were randomly assigned to a control group with daily feedback or 1 of 3 financial incentive programs with daily feedback: a gain incentive ($1.40 given each day the goal was achieved), lottery incentive (daily eligibility [expected value approximately $1.40] if goal was achieved), or loss incentive ($42 allocated monthly upfront and $1.40 removed each day the goal was not achieved). Participants were followed for another 13 weeks with daily performance feedback but no incentives. Measurements: Primary outcome was the mean proportion of participant-days that the 7000-step goal was achieved during intervention. Secondary outcomes included mean proportion of participant-days achieving the goal during follow-up and mean daily steps during intervention and follow-up.

7. Participants were electronically randomly assigned to the control group or to 1 of 3 intervention groups with an equivalent expected economic value of $1.40, which is a value used in prior work (34). For 26 weeks, participants in all 4 groups received daily feedback on whether they had achieved the 7000-step goal in the prior day.34 The control group received no other intervention aside from daily feedback. For the 13-week intervention, the intervention groups included a gain incentive in which participants received $1.40 for each day they met the goal, a loss incentive in which $1.40 was taken away from a monthly incentive ($42 allocated upfront) each time the daily goal was not met, or a daily lottery incentive. Persons in the lottery-incentive group selected a 2-digit number between 00 and 99. One winning number was randomly selected daily during the intervention period. If a participant's number had a single-digit match (an 18% chance), he or she won $5. If the participant's number had a 2-digit match (a 1% chance), he or she won $50. Participants were eligible to collect the reward only if the 7000-step goal was achieved on the prior day. Ineligible participants were informed what they would have won if they had achieved the goal, drawing on evidence that the desire to avoid regret can be motivating (23, 24, 35, 36).23243536 Incentives were offered only during the 13-week intervention, but daily performance feedback was delivered for the entire 26 weeks.

12. Results: The mean proportion of participant-days achieving the goal was 0.30 (95% CI, 0.22 to 0.37) in the control group, 0.35 (CI, 0.28 to 0.42) in the gain- incentive group, 0.36 (CI, 0.29 to 0.43) in the lottery- incentive group, and 0.45 (CI, 0.38 to 0.52) in the loss- incentive group. In adjusted analyses, only the loss incentive group had a significantly greater mean proportion of participant-days achieving the goal than control (adjusted difference, 0.16 [CI, 0.06 to 0.26]; P = 0.001), but the adjusted difference in mean daily steps was not significant (861 [CI, 24 to 1746]; P = 0.056). During follow-up, daily steps decreased for all incentive groups and were not different from control.

13. Limitation: Single employer. Conclusion: Financial incentives framed as a loss were most effective for achieving physical activity goals. Primary Funding Source: National Institute on Aging.

14. Message BMI27 以上の大学職員 281 人を対象に、運動量 増加を促す 3 つの金銭的インセンティブの有効性 を検証。目標運動量は 1 日 7000 歩とした。 13 週 間の介入の結果、介入期間に占める目標達成日数 の平均比率は、対照群 0.30 、目標達成日ごとに 1.40 ドルの報奨金を獲得する群 0.35 、目標達成 日ごとに報奨金は獲得するが金額は変動する （ lottery incentive ）群 0.36 、目標を達成しな いと預託金から減額される群 0.45 で、預託金減 額型がもっとも有効だった。 https://www.m3.com/clinical/journal/16258

16. 1 Department of Biochemistry, University of British Columbia, Vancouver, British Columbia, Canada. 2 Department of Zoology, University of British Columbia, Vancouver, British Columbia, Canada. 3 Dartmouth College, Hanover, New Hampshire, USA. 4 Endocrine Research Society, Vancouver, British Columbia, Canada. 5 Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. 6 Department of Endocrinology and Metabolism, St. Paul's Hospital, Vancouver, British Columbia, Canada. 7 Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada. BMJ Open Diabetes Research and Care 2016;4:e000145. doi:10.1136/bmjdrc-2015-000145

17. Objective We aimed to assess the accuracy and safety of presently available methods of estimating starting basal insulin rates for patients with type 1 and 2 diabetes, and to compare them against an empirically derived standard basal rate and a newly developed regression formula.

18. Research design and methods Data on 61 patients with type 1 diabetes on continuous subcutaneous insulin infusion (CSII) therapy and 34 patients with type 2 diabetes on CSII were reviewed. Patient data were first analyzed for correlations between initial patient parameters and final basal rates. Starting basal rates were then retrospectively calculated for these patients according to the weight-based method (WB-M), the total daily dose (TDD) of insulin method (TDD-M), a flat empiric value, and a new formula developed by regression analysis of clinical data. These 4 methods were subsequently compared in their accuracy and potential risk of hypoglycemia.

20. The current formulas for estimating basal rates in adult patients with type 1 diabetes, in units per hour, using weight (in kg) or TDD of insulin are as follows:

21. The type 1 final basal rates were used to derive a linear regression using weight (kg) and TDD of longacting insulin (R2=0.507; p<0.005 and <0.001, respectively), which approximates to: It was found that only TDD of long-acting insulin was correlated with final basal rate (R2=0.558; p<0.001). A simple linear regression gives the formula:

22. Figure 1 Distribution of the absolute percentage differences of each basal rate estimate to final basal rates. Estimate methods include a regression, weight formula, total daily dose (TDD) of insulin formula and an empirical value. Different letters denote a significant difference between estimates. (A) Patients with type 1 diabetes (n=61). (B) Patients with type 2 diabetes (n=34).

23. Figure 2 Distribution of the percentage differences of each basal rate estimate to final basal insulin rates. Estimate methods include a regression, weight formula, total daily dose (TDD) of insulin formula and an empirical value. Different letters denote a significant difference between estimates. (A) Patients with type 1 diabetes (n=61). (B) Patients with type 2 diabetes (n=34).

24. Figure 3 Frequency of potential risk of hypoglycemia for each estimate method, defined as a percentage difference between the estimate and final basal rate. Estimates include a regression, weight formula, total daily dose (TDD) of insulin formula and an empirical value. (A) Patients with type 1 diabetes (n=61). (B) Patients with type 2 diabetes (n=34).

25. Results For type 1 diabetes, patient weight and TDD of long-acting insulin correlated with final basal rates. Both the regression formula and the TDD-M appeared safer than the WB-M and empirical estimates. For type 2 diabetes, only patient TDD of long-acting insulin correlated with final basal rates. The regression formula was significantly more accurate for patients with type 2 diabetes overall, but the TDD-M estimate was marginally safer.

26. Conclusions The pre-existing TDD-M was found to be the safest presently recommended estimate of initial basal rates for pump initiation in both type 1 and 2 diabetes. The best-fit regression was found to have potential use for type 2 CSII initiation.

27. Message ベーサルは 合計インスリン量 ÷ ２ の 3/4 で！