Open Enrollment Research Articles

Abstract P034: Prevent Cancer-Greenville: identifying and influencing cancer risk

Abstract Purpose: Prevent Cancer - Greenville started in 2018 and provides study participants the opportunity to have their risk of developing cancer stratified into a personalized plan of screening and behavior modification as well as contribute to longitudinal cancer prevention research. Prevent Cancer - Greenville’s dual objectives include a participant educational focus based on individual risks as well as a long-term research objective of correlation of lifestyle and environmental influences on an individual’s molecular constitution and for those affected, the development of a cancer. Methods: Volunteer participants are accrued through open enrollment which is promoted through Prisma News, printed and online news articles, community events and a listing on the National Institute of Health clinicaltrials.gov website. Participants must be at least 18 years of age and must speak English to enroll. Enrollees participate in a yearly risk assessment, including diet, exercise, body composition using bioimpedance spectroscopy, and individual risk factors, with the data banked in a longitudinal manner. At each yearly visit, blood, urine, and buccal swab specimens are collected and stored along with participant’s lifestyle habits, body composition, and medical history as discrete data points. The potential to store thousands of participants’ specimens yearly for a decade or more creates an opportunity to retrospectively identify the likely multiple and sequential molecular events leading to the development of cancer. In short, patients eventually developing a malignancy will have a biological repository of DNA, RNA, and proteins that can potentially be deciphered as “steppingstones” leading to their illness. These molecular signatures will open the prospect of predicting cancer event pathways before clinical cancer develops, helping to correlate the epigenetic hallmarks of cancer development (nutrition, exercise, body fat content, microbiome). Results: Our team analyzed the current data collection for the 848 total participants accrued. The participants are 77.2% female and 22.8% male. Race is made up of 91.6% Caucasian, 6.3% African American, 1.3% Asian, and 0.7% Other. Ethnicity includes 2.6% Hispanic or Latino and 97.4% Non-Hispanic or Latino. A total of 11 participants have developed cancer since enrollment in the study. A total of 1600 buccal aliquots, 4,496 blood aliquots, and 888 urine aliquots are currently stored in the biorepository. Germline testing provided by a genetic counselor outside of the study identified 107 participants with pathogenic gene variants. Conclusion: The sequential annual visits will allow future molecular mapping and support strategies for early identification of malignancy and prevention of clinical disease through targeted interventions. To date, improving diversity has been challenging despite continued efforts. Citation Format: Larry Gluck, Armand DeSollar, Matthew Hudson, LeAnn Perkins, Julia Yates, Susan Webb, Gina Franco. Prevent Cancer-Greenville: identifying and influencing cancer risk. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P034.

Predicting resident satisfaction with public schools in small town Iowa

Estimates of resident satisfaction with public education have great utility in public administration, especially among decision makers in shrinking small communities. But such estimates are typically obtained via surveys, which are costly and often unreliable at high spatial resolutions given low response rates. Our study found that satisfaction with public schools among residents of small communities can be reasonably estimated at the community level using public data. Several models generalized adequately to unseen data—these models typically included the following covariates: state student assessment scores, school reorganizations, net open enrollment, and the cost of educational outcomes relative to neighboring districts. Our findings thus amount to a cost‐effective survey alternative for gauging satisfaction with public schools in small Iowa communities.

Health plan switching and satisfaction in a Medicaid MLTSS program.

This paper examines (1) the rate of plan switching among beneficiaries enrolled in a Medicaid managed long-term services and supports (MLTSS) program in Virginia, (2) barriers that prevent beneficiaries from changing plans, and (3) the extent to which a change in plans is associated with greater satisfaction with the current health plan. Survey data from a representative sample of 1048 members enrolled in Commonwealth Coordinated Care Plus, a Virginia Medicaid MLTSS program. The survey ascertained whether beneficiaries changed plans at the previous open enrollment period, whether they wanted to change plans but did not, and reasons for not following through with a plan change. Logistic regression analysis examined the association between the intention to change plans and satisfaction with the current health plan. Seven percent of respondents changed plans during the previous open enrollment. However, twice as many respondents (15%) wanted to change plans but did not. The main reason for not changing plans was uncertainty about whether the new plan would meet their needs better than their current plan. Logistic regression analysis shows that an intention to change plans (realized or not) was associated with higher odds (3.5 times higher) of being dissatisfied with the current health plan compared with beneficiaries who had no intention to change plans. Greater dissatisfaction after a recent plan change may indicate that these members have specific needs beyond the scope of services offered by managed care organizations.

Assessment of Churn in Coverage Among California’s Health Insurance Marketplace Enrollees

Individual health insurance marketplaces established through the Affordable Care Act of 2010 (ACA) fill a critical gap for those who lack other coverage options. The high degree of coverage turnover, or churn, has raised concerns about affordability and strategic behavior on the part of individuals to sign up only when they need care. To assess the role of California's ACA marketplaces in the broader health care landscape by understanding enrollment tenure and churn. This cross-sectional study analyzed survey data from a representative, probability-based sample of enrollees in California's ACA marketplace, Covered California, collected immediately after the open enrollment periods in 2018, 2019, and 2021. Administrative data from Covered California from January 1, 2014, to December 31, 2021, were used to analyze marketplace tenure. Survey data included 9571 heads of households aged 18 to 64 years who were newly enrolled or had recently terminated their plan, directly drawn from Covered California's administrative records. Administrative data included individuals up to age 65 years who enrolled in the marketplace during 2014 to 2021. New enrollment in or termination from health care coverage through California's ACA marketplace. Enrollment tenure in California's ACA marketplace, sources of coverage prior to enrolling and after terminating coverage, and demographic or plan characteristics associated with the decision to go uninsured. Median (IQR) length of coverage among 5.4 million enrollees (mean [SD] age, 38 [16] years; 17% Asian American/Native Hawaiian or other Pacific Islander, 2.5% Black or African American, 23% Latino [response options were Hispanic, Spanish, or Latino origin], 29% White, 7.5% categorized as other [including American Indian/Alaskan Native, multiple races, and other], and 21% of unknown race or ethnicity) was 14 (6-35) months, and 41% to 46% of enrollees disenrolled within 1 year, with substantial variation by subgroups. Despite this churn, only 14% (95% CI, 12%-15%) of 6474 terminating members surveyed across 3 years (2018, 2019, and 2021) reported being uninsured after leaving the marketplace, with the rest moving to job-based coverage or Medicaid. Most of those surveyed (mean [SE] percentage, 56% [0.016] individuals) reported having had employer-sponsored insurance or Medicaid prior to enrolling in the marketplace. Among subsidized renewal candidates, Latino candidates were 1.5 percentage points (95% CI, 0.8-2.3 percentage points) more likely to go uninsured compared with White candidates, and those with no expected physician visits in the coming year were 4.8 percentage points (95% CI, 2.4-7.2 percentage points) more likely to go uninsured vs those who expected physician visits. The results of this cross-sectional study of coverage churn found that ACA marketplaces served 2 distinct types of individuals, long-term enrollees but, more often, individuals with short-term-coverage needs due to a change in eligibility for other insurance. These results suggest that marketplaces are smoothing coverage disruptions and that policies to reduce gaps in coverage should be designed with this in mind.

School Choice, Local Discretion, and Stratification: Evidence From Inter-district Open Enrollment in Metro Detroit

School choice policies can, by design or in implementation, give schools and districts discretion over enrollment. In this study, I examine the effect of local discretion over inter-district open enrollment on non-resident enrollment. I use longitudinal data on open enrollment patterns and policies in the metropolitan Detroit area. I find that when districts set more restrictive open enrollment policies, they enroll fewer new non-resident students overall, due to a decrease in new Black, Hispanic, and low-income non-resident students specifically. When districts allow inter-district open enrollment, racial and socioeconomic segregation within those districts do not change, and racial isolation slightly increases. My findings suggest that regulating enrollment policies to reduce discretionary exclusion can increase access to inter-district choice for some low-income and racially minoritized students, but that these kinds of policy changes are unlikely to reduce racial segregation and socioeconomic stratification more broadly.

Disparities in the Uptake of Telemedicine and Implications for Clinical Trial Enrollment in Patients With Breast Cancer

Purpose/ObjectivesSince the COVID-19 pandemic, telemedicine has emerged as an alternative to office visits in routine radiation oncology practice. The purpose of this study was to identify factors associated with patient preference for an initial consult via telemedicine and correlation with clinical trial enrollment.Materials/MethodsWe evaluated breast cancer patients seen during the open enrollment of a prospective randomized trial from 06/01/2020 to 05/13/2021. Univariate and multivariate logistic regression models were used to identify factors associated with virtual vs in-person initial consultation. All statistical tests were two-sided and the null hypothesis was rejected for p<0.05.ResultsWe identified 476 patient consultations with 259 office visits and 217 telemedicine visits. On multivariate analysis, increased age, unemployment, chemotherapy receipt and radiation at our institution were associated with decreased usage of telemedicine for consultation visit. Out of 217 patients who underwent a telemedicine initial consultation, 10% were eligible to enroll on the trial and of those eligible, 76% enrolled. Out of 259 patients who underwent office visit initial consultation, 14% were eligible to enroll on the trial and of those eligible, 53% enrolled. Among eligible patients, there was no statistically significant difference in clinical trial enrollment between telemedicine and office visits.ConclusionOlder patients, unemployed patients, those receiving chemotherapy and those who subsequently received radiation at our institution were less likely to use telemedicine for their initial consult. Despite these disparities in telemedicine usage, there was no difference in clinical trial enrollment. Telemedicine may be an effective platform for clinical trial enrollment though further strategies to improve its access are essential.

The Effect of Private School Choice Regulations on School Participation: Experimental Evidence from the Christian School Sector

ABSTRACT Private school choice programs’ success depends partly on the supply of private schools. Many parents prioritize a religious education for their children. Therefore, it is important to consider how religious private schools may respond to various program regulations. We conducted an experimental study surveying a national sample of 354 leaders of Association of Christian Schools International (ACSI) member schools, the second largest private school organization of any kind in the United States. We find evidence that while over four-fifths of Christian school leaders are inclined to participate with no changes to school operations, open enrollment mandates reduce participation rates by 62 percentage points and employment regulations reduce participation rates by 79 percentage points.

Effects of Repealing the ACA Individual Mandate Penalty on Insurance Coverage and Marketplace Enrollment: Evidence From State Mandates in Massachusetts and New Jersey.

Congress eliminated the individual mandate penalty of the Affordable Care Act (ACA) effective January 1, 2019. To examine the effects of repealing the ACA mandate penalty on private health insurance coverage and marketplace enrollment by leveraging state-based mandates in Massachusetts and New Jersey. We employ synthetic control and difference-in-differences methods to compare insurance and enrollment changes separately in Massachusetts and New Jersey, which had insurance mandates effective in 2019, to other states without such mandates. Adults aged 18-64 years with income of 150-300% and above 300% of the Federal Poverty Level who participated in the 2016-2019 American Community Survey (ACS) and adults aged 18-64 enrolled in insurance marketplaces based on state-level data from the 2016-2021 Marketplace Open Enrollment Period Public Use Files (MOEP-PUF). Any insurance, individually purchased coverage, and employer-sponsored coverage from the ACS and marketplace enrollment from the MOEP-PUF. Changes in any coverage, individually purchased coverage, and employer-sponsored coverage rates are relatively small (generally in the range of 1-2 percentage points) and statistically nonsignificant in both Massachusetts and New Jersey compared with states without mandates. Furthermore, there is no discernable difference by eligibility for marketplace subsidies based on income level in the ACS data. Similarly, estimates for changes in marketplace enrollment are also small overall and statistically nonsignificant. Private insurance coverage rates and marketplace enrollment for adults 18-64 do not appear to have changed thus far owing to the 2019 repeal of the ACA individual mandate penalty.

Medicaid Applications Spike during Marketplace Open Enrollment: Lessons from Covered California.

The expansion of Medicaid coverage as part of the Affordable Care Act has insured millions of Americans and reduced costly churn in the program. A large increase in Medicaid applications during Marketplace open enrollment would indicate two potential information gaps: 1) individuals do not know that they are eligible, and/or 2) individuals do not know that they can enroll in Medicaid year-round. We used statewide monthly Medicaid applications data for California over a three-year period (July 2016 to June 2019) to assess whether Marketplace open enrollment influences Medicaid applications. Over one-third of all Medicaid applications (35.0%) were received during months with Marketplace open enrollment, and daily average Medicaid application volume was 32.5% higher in those months than in months outside of open enrollment. These findings generate concerns about whether there is enough consumer education and outreach to potential enrollees to limit coverage gaps and associated barriers in access to care.

Association of Funding Cuts to the Patient Protection and Affordable Care Act Navigator Program With Privately Sponsored Television Advertising

Many individuals eligible for coverage in the Patient Protection and Affordable Care Act (ACA) marketplace remain unenrolled because of information barriers. Whether the private sector or the public sector should conduct outreach to address these barriers is a topic of active debate. To determine whether cuts to the funding of the ACA navigator program were associated with changes in the volume of private sector advertising. Using data from the 2015 to 2019 open enrollment periods, this economic evaluation analyzed the changes in advertising associated with 2017 to 2019 cuts to navigator program funding. A difference-in-difference analysis was used to compare outcomes before and after the cuts in counties with higher and lower exposure to the navigator program. Health insurance advertising was measured using data from Kantar/Campaign Media Analysis Group in collaboration with the Wesleyan Media Project, the most comprehensive data available on local broadcast and national cable advertising. The data set included all counties that met the eligibility criteria for the navigator program from 2015 through 2019. Data were analyzed from August 2021 to May 2022. Counties were classified as having higher or lower exposure to the navigator program according to the intensity of program activity in 2016, before the funding cuts. Counties served only by statewide navigator programs were categorized as lower exposure, while those also served by local navigator programs were categorized as higher exposure. Number of privately sponsored television advertisement airings for the ACA individual health insurance marketplace during the 2015 to 2019 open enrollment periods in each county, adjusted for population. All counties in 33 states that met the eligibility criteria for the navigator program from 2015 through 2019 were included in the analysis (2435 counties). Cuts to the navigator program were not associated with changes in the number of privately sponsored health insurance advertisements aired. Results were similar under several alternative approaches including an event study specification. In this study of the association between television advertising and navigator funding in the ACA marketplaces, private sector entities did not increase their advertising to compensate for declines in government-sponsored navigator activity. This finding can inform policy debates about the extent to which the private sector adjusts in response to changes in government outreach, and thus improve the design of state waivers and federal funding allocations.

Analysis of Affordable Health Care.

Lack of affordable health care affects the uninsured, commercially insured, and Medicare beneficiaries. Yet, the wide variation in providers' prices and practice styles suggests that more affordable care already may be available and data on low value and wasteful care suggest that lower cost care need not come at the expense of better quality. Although price variation has received the most attention in the literature and legislation, total cost of care is a function of both unit prices (fees) and the quantity of services. To partition provider-specific variation in total annual risk-adjusted per capita expenditures on health care services into variation in unit prices (fees) versus quantities of services, and to explore the relationship between low value, avoidable, discretionary, and recommended care to total health expenditures. The analysis is important because both prices and quantities of services can affect affordability and reductions in prices versus quantities have very different effects on providers' profits. 2018 data from the Minnesota State Employees Group Insurance Program (SEGIP) that offers a tiered cost-sharing health insurance benefit design to 130,000 State employees and their dependents (SEGIP "members"). Each year during open enrollment, SEGIP members choose a primary care clinic (PCC). The PCC can make decisions regarding both unit prices and prescribed services. PCCs are placed in one of four cost-sharing tiers based on the total annual risk-adjusted per capita health expenditures for the SEGIP members who choose their clinic. Members choosing higher cost PCCs face higher deductibles, copayments, and maximum out-of-pocket spending limits. Overall prices and use of inpatient, outpatient hospital, professional, and pharmaceutical services, total and avoidable use of emergency department visits and inpatient admissions, low value care, testing for patients with pneumonia, and recommended preventive care. Differences in total risk-adjusted annual per capita health expenditures across the care systems were substantial. Higher cost providers had both higher unit prices and higher use of services. Variation in the quantity of health care services explained more of the variance in total spending than variation in prices. Prices for professional services and use of inpatient, outpatient hospital, and pharmaceutical services, and ambulatory care sensitive admissions, contributed significantly to high total expenditures. Lower cost PCCs in the lowest cost-sharing tier had higher rates of low value care and lower emergency department visits per capita. Neither the number of investigations for patients with pneumonia nor the receipt of recommended mammography screening varied systematically by tier. Efforts to identify and expand sources of affordable care, including improved information and incentives for consumers, need to account for variation in both prices and quantities of services. Efforts to encourage more efficient use of health care services by providers need to consider the effect of those efforts on the provider's internal costs and thus their profits.

Review of Scandinavian leadership development programs: Open and closed customization

Leadership development programs (LDPs) have proliferated and diversified but still usually share the ambition of involving the participants’ on-the-job experiences. Yet, the dominant view hereof is crude, not acknowledging the variety of ways used to accomplish it. The Scandinavian context is illustrative for reviewing what we term ‘customization devices’ because of its tradition for LDPs with collective reflection, practice orientation, and broad participation. This review curates and synthesizes 31 studies evaluating empirical experiences with customization devices in Scandinavian university-based LDPs from no earlier than 2010. Such devices fall within three key categories, namely theories, cases, and relationships, and have three key effects: distancing from practice, dedicating to the program, and devising future action. Based on our findings, we challenge the dominant view that open enrollment programs cannot adequately mobilize participants’ experiences by theorizing the distinction between open and closed customization. The review further serves as a resource for LDP designers and instructors to carefully choose and mix customization devices that are complementary in their effects.

And Then There Were Three: The Decimation of the Affordable Care Act (ACA) CO-OPs.

The Consumer Operated and Oriented Plans (CO-OPs), the subject of Section 1322 of the Affordable Care Act (ACA), were to constitute "qualified nonprofit health insurance issuers." Designed with an eye toward increasing competition with the extant commercial and nonprofit insurance sector, the CO-OPs were to enhance consumer choice as well as hold down prices on the state and federal exchanges. To achieve these ends, the consumer-governed state-licensed CO-OPs were to target the individual and small-group markets. At least one qualified CO-OP was to be established in each and every state. By the fall of 2013, however, coincident with the first open enrollment period of the ACA, only 23 CO-OPs were on tap. At the time of this writing, only three of these CO-OPs remain operational in the states of Maine, Montana, and Wisconsin. Viewed in hindsight, the thorough dissolution of the CO-OPs was the product of incremental financial privation effectuated by congressional opponents of the ACA. In this Commentary, we revisit the ontogeny of the CO-OP construct, review its partisan dismantling, and explore the potential resurrection thereof.

ARTISTRY-3: Effect of nemvaleukin alfa with a less frequent IV dosing schedule as monotherapy and in combination with pembrolizumab and impact on the tumor microenvironment (TME) in patients (pts) with advanced solid tumors.

TPS2684 Background: Nemvaleukin alfa (nemvaleukin, ALKS 4230) is a novel engineered cytokine that selectively binds the intermediate-affinity interleukin-2 (IL-2) receptor, preferentially activating and expanding antitumor CD8+ T cells and NK effector cells, with minimal effect on regulatory T cells. Nemvaleukin was designed to leverage antitumor effects of the IL-2 pathway while limiting typical IL-2‒associated toxicity. In ARTISTRY-1, the recommended phase 2 dose (RP2D) for nemvaleukin monotherapy of 6 µg/kg IV on days 1 to 5 of a 21-day cycle elicited durable and deep responses in pts with advanced melanoma and renal cell carcinoma (Boni et al. ASCO 2021:abstr 2513). Responses with nemvaleukin plus pembrolizumab were also observed in platinum-resistant ovarian, breast, cervical, gastrointestinal, and genitourinary cancers. ARTISTRY-3 will investigate the effects of nemvaleukin as monotherapy and in combination with pembrolizumab on the TME in pts with advanced solid tumors, and in an additional cohort (Cohort 2), to further assess a less frequent IV dosing schedule for nemvaleukin. Methods: The phase 1/2, open-label ARTISTRY-3 (NCT04592653) study will enroll adults (≥18 years) with select advanced solid tumors, ≥1 accessible lesion for biopsy, ≥1 target lesion (per RECIST v1.1), ECOG PS of 0 or 1, estimated life expectancy of ≥3 months, adequate hematologic reserve, and adequate hepatic and renal function. Primary objectives: to evaluate effects of nemvaleukin monotherapy on the TME (Cohort 1) and to determine RP2D for less frequent dosing schedule (Cohort 2). Additional objectives are to evaluate: efficacy, safety, immunogenicity, and pharmacokinetics of nemvaleukin monotherapy; effects of nemvaleukin plus pembrolizumab on the TME; and correlative biomarkers of nemvaleukin as monotherapy and combination. Following the protocol amendment, additional pts enrolled in Cohort 1 will receive lead-in monotherapy at a dose selected based on results from Cohort 2, and pre- and on-treatment biopsies will be collected for TME assessments. Subsequent cycles will be administered in combination with pembrolizumab, and a biopsy may be collected at cycle 4 or 5. Tumor types eligible for Cohort 2 are selected based on activity observed in the ARTISTRY-1 study. A quantitative system pharmacology model was applied to identify a less frequent schedule for nemvaleukin monotherapy and combination. Cohort 2 will initially assess safety and tolerability of nemvaleukin at 1 dose per 21-day cycle. Two doses per 21-day cycle may be implemented to achieve optimal PK/PD parameters. Bayesian optimal interval design methodology with open enrollment will be applied to facilitate dose escalation decisions. Clinical trial information: NCT04592653.

ATTAC-MCC: Phase I/II study of autologous CD8+ and CD4+ transgenic T cells expressing a high affinity MCPyV-specific TCR combined with checkpoint inhibitors and class I MHC-upregulation in patients with metastatic MCC refractory to PD-1 axis blockade.

TPS9596 Background: Merkel cell carcinoma (MCC) is a highly aggressive skin cancer, with an incidence that has doubled in the last 20 years to approximately 3000 cases/year in the US. Over one-third of patients will develop widespread disease, and survival in these patients has been historically poor with a 5-year survival rate of &lt; 10%. MCC is highly immune-sensitive due to the antigenicity of the cancer-causing Merkel cell polyomavirus (MCPyV) expressed in most MCC tumors. Although immune checkpoint inhibitors (ICIs) targeting the PD-(L)1 axis show promising efficacy, most MCC patients will eventually relapse. There is no standard of care for patients that become refractory to ICIs. We hypothesize that cellular immune therapies targeting MCPyV may provide additional clinical benefit to these patients. To test this, we have engineered high-affinity TCR T cells against MCPyV and initiated a clinical trial. Methods: NCT03747484 is an ongoing phase I/II, open label, investigator-initiated trial (IIT) of FH-MCVA2TCR in combination with an anti-PD-(L)1 checkpoint inhibitor and an agent to upregulate MHC-I expression on tumor cells. The trial is conducted in patients aged 18 years or older with metastatic or unresectable, histologically confirmed virus-positive MCC whose disease has progressed on or after treatment with a PD-(L)1 axis checkpoint inhibitor. Patients undergo leukapheresis to collect white blood cells (WBCs) for TCR T cell product manufacturing. The cell product is administered on day 0. Patients receive an agent to upregulate MHC-I on tumor cells and continue on an anti-PD-(L)1 checkpoint inhibitor for up to one year. In phase I, three patients receive up to two infusions of dose level 1 of the T cell product. The primary objectives of phase I are to determine safety and tolerability based on dose-limiting toxicities (DLT) during an observation period of 28 days after the first infusion. Phase II enrolls patients at dose level 2. The total sample size of phase II is 12 patients. The first three patients are enrolled in a staggered manner and observed for DLTs. If no DLTs occur, the remaining sample size is accrued in open enrollment. The main objectives of phase II are safety based on number of adverse events and preliminary efficacy based on tumor response according to RECISTv1.1 and iRECIST. Secondary/exploratory objectives include cellular kinetics of TCR T cells, T cell phenotype, tumor infiltration kinetics, and MHC-I expression dynamics over time. After the first 12 months, patients transition to a long-term follow-up (LTFU) study for up to 15 years as per FDA guidelines. Clinical trial information: NCT03747484.

A Facebook-Delivered Weight Loss Intervention Using Open Enrollment: Randomized Pilot Feasibility Trial.

BackgroundBehavioral weight loss programs typically enroll 12-40 people into groups that then suffer from declining engagement over time. Web-based patient communities, on the other hand, typically offer no limits on capacity and membership is fluid. This model may be useful for boosting engagement in behavioral weight loss interventions, which could lead to better outcomes.ObjectiveIn this study, we aimed to examine the feasibility and acceptability of continuously enrolling participants into a Facebook-delivered weight loss intervention for the first 8 of 16 weeks relative to the same intervention where no new participants were enrolled after randomization.MethodsWe conducted a randomized pilot trial to compare a Facebook weight loss group that used open enrollment with a group that used closed enrollment on feasibility and acceptability in adults with BMI 27-45 kg/m2. The feasibility outcomes included retention, engagement, and diet tracking adherence. We described the percentage loss of ≥5% weight in both groups as an exploratory outcome. We also explored the relationship between total volume of activity in the group and weight loss. The participants provided feedback via web-based surveys and focus groups.ResultsRandomized participants (68/80, 85% women) were on average, aged 40.2 (SD 11.2) years with a mean BMI of 34.4 (SD 4.98) kg/m2. We enrolled an additional 54 participants (50/54, 93% female) in the open enrollment condition between weeks 1 and 8, resulting in a total group size of 94. Retention was 88% and 98% under the open and closed conditions, respectively. Randomized participants across conditions did not differ in engagement (P=.72), or diet tracking adherence (P=.42). Participant feedback in both conditions revealed that sense of community was what they liked most about the program and not enough individualized feedback was what they liked the least. Weight loss of ≥5% was achieved by 30% (12/40) of the participants randomized to the open enrollment condition and 18% (7/40) of the participants in the closed enrollment condition. Exploratory analyses revealed that the open condition (median 385, IQR 228-536.5) had a greater volume of engagement than the closed condition (median 215, IQR 145.5-292; P=.007). Furthermore, an increase of 100 in the total volume of engagement in the Facebook group each week was associated with an additional 0.1% weekly weight loss among the randomized participants (P=.02), which was independent of time, individual participant engagement, and sociodemographic characteristics.ConclusionsOpen enrollment was as feasible and acceptable as closed enrollment. A greater volume of engagement in the Facebook group was associated with weight loss, suggesting that larger groups that produce more engagement overall may be beneficial. Future research should examine the efficacy of the open enrollment approach for weight loss in a fully powered randomized trial.Trial RegistrationClinicalTrials.gov NCT02656680; https://clinicaltrials.gov/ct2/show/NCT02656680

(Digitally) Connecting Students, Schools, and Districts: Measuring the Size and Popularity of K-12 Public and Charter School District Websites

As open enrollment charter districts have continued to grow in Texas, researchers and policymakers have continued to investigate how charter districts market themselves to the public in an effort to recruit students, teachers, and finances. Although a wealth of research has examined how charter districts recruit students, teachers, and finances through traditional methods, recent developments in computer science now allows researchers to measure the size and visibility of district websites on the Internet. As a result, this study uses the Texas Education Agency and SEMrush data from the 2018–2019 school year to compare the website size and popularity of charter school district and traditional public school district websites to understand how these districts invest in their robustness of their web presence. Results suggest that when compared to traditional public school districts in Texas, charter school districts publish smaller websites ( p &lt; 0.001) and are less popular on the Internet ( p &lt; 0.001) than traditional public peers. Implications for research, policy, and competition between open enrollment charter districts and traditional public school districts are addressed.

Effectiveness of Behaviorally Informed Letters on Health Insurance Marketplace Enrollment

Every year during the open enrollment period, hundreds of thousands of individuals across the Affordable Care Act marketplaces begin the enrollment process but fail to complete it, thereby resulting in coverage gaps or going uninsured. To investigate if low-cost ($0.55 per person) letters can increase health insurance enrollment. This intent-to-treat randomized clinical trial was conducted during the final 2 weeks of the 2015 open enrollment period among the 37 states on the HealthCare.gov platform. The trial targeted 744 510 individuals who started the enrollment process but had yet to complete it. Data were analyzed from January through August 2021. Study participants were randomized to either a no-letter control group or to 1 of 8 letter variants that drew on evidence from the behavioral sciences about what motivates individuals to take action. The primary outcome was the health insurance enrollment rate at the end of the open enrollment period. Of the 744 510 individuals (mean [SD] age, 41.9 [19.6] years; 53.9% women), 136 122 (18.3%) were in the control group and 608 388 (81.7%) were in the treatment group. Most lived in Medicaid nonexpansion states (72.7%), and a plurality were between 30 and 50 years old (41.0%). For race and ethnicity, 3.0% self-identified as Asian, 14.0% as Black, 5.1% as Hispanic, 39.8% as non-Hispanic White, and 38.2% as other or unknown. By the end of the open enrollment period, 4.0% of the control group enrolled in health insurance coverage. Comparatively, the enrollment rate in the pooled treatment group was 4.3%, which demonstrated an increase of 0.3 percentage points (95% CI, 0.2-0.4 percentage points; P<.001), yielding 1753 marginal enrollments. Letters that used action language caused larger enrollment effects, particularly among Black individuals (increase of 1.6 percentage points; 95% CI, 0.6-2.7 percentage points; P = .003) and Hispanic individuals (increase of 1.5 percentage points; 95% CI, 0.0-3.0 percentage points; P = .046) in Medicaid expansion states. This randomized clinical trial shows that letters designed with best practices from the behavioral sciences literature were a low-cost way to increase health insurance enrollment in the Affordable Care Act marketplaces. More research is needed to understand what messages are most effective amid the recently passed American Rescue Plan. ClinicalTrials.gov Identifier: NCT05010395.

Alleviating Barriers during the Pandemic at an Open Enrollment HBCU

Alleviating Barriers during the Pandemic at an Open Enrollment HBCU

Evaluation of a stand-alone mobile mindfulness app in people experiencing infertility: the protocol for an exploratory randomised controlled trial (MoMiFer-RCT)

IntroductionInfertility and its treatment bring a considerable emotional burden. Increasing evidence demonstrates the effectiveness of smartphone-delivered mindfulness apps for reducing symptoms of emotional distress in both clinical and non-clinical populations....