Daniel Wiesen

Background: Although exclusive human milk feeding is beneficial for very low birth weight infants, rates remain suboptimal globally. This hybrid type 1 effectiveness-implementation trial evaluated structured lactation support combined with human donor milk banking in neonatal intensive care units (NICUs), primarily assessing effectiveness, with secondary assessment of implementation and economic outcomes. Methods: We conducted a stepped-wedge cluster-randomized trial in 15 German Level I NICUs (April 2022–March 2024). The Neo-MILK intervention comprised structured lactation counselling, multilingual materials, mobile app support for mothers/parents, and human donor milk banking. Implementation strategies included video-based staff training, guidelines, commitment nudges for medical staff, and support for human donor milk bank establishment. The primary outcome was exclusive mother’s own milk feeding at NICU discharge. Secondary outcomes included feeding status categories, clinical complications, length of stay, and maternal outcomes. Implementation outcomes were acceptability, feasibility, appropriateness, fidelity, and sustainability. Prespecified subgroup analyses examined birth weight (< 1,000 g vs. ≥1,000 g) and illness severity (CRIB ≥ 11 vs. p = 0.007) from a 43% baseline. Exclusive formula feeding decreased correspondingly. Subgroup analyses showed no significant effects in extremely low birth weight infants (< 1,000 g) or high-risk infants (CRIB ≥ 11). Clinical complications and length of stay showed no differences. Acceptability, appropriateness, and feasibility were high. Fidelity was sufficient, with prepartal counselling delivered as intended in 71% of cases. Human donor milk banks were established in 40% of sites. Sustainability indicators were promising, with 61% of staff reporting routine integration. Economic evaluation suggested potential net savings nationally in the base-case scenario. Conclusions: Structured lactation support with human donor milk banking increased exclusive mother’s own milk feeding across Level I NICUs, with no observed increase in complications or costs. Implementation appeared feasible, with indications of sustainability. Variable uptake and differential effects in highest-risk subgroups highlight the need for ongoing organizational support and tailored strategies to further optimize effectiveness. Clinical trial registration: German Clinical Trials Register DRKS00025058.

Background: Identifying and understanding implementation determinants is a critical step in the process of tailoring implementation strategies to local contexts. System Support Mapping (SSM) is a method rooted in systems thinking that offers a structured approach to exploring the responsibilities, needs, resources, and wishes of individuals within an implementation context. However, SSM has not yet been systematically described and applied as a methodology for identifying implementation determinants within multi-site implementation studies. This article introduces and illustrates the combined application of SSM and the Matrixed Multiple Case Study (MMCS) approach as a structured six-step methodology for identifying and analysing implementation determinants within and across sites, using data from the Neo-MILK project as an illustrative example. The project aimed to implement a structured lactation support programme for mothers of very low birth weight infants and establish human donor milk banks in German neonatal intensive care units (NICUs). Methods: To illustrate the six-step methodology, semi-structured interviews with key persons from five German NICUs, which were conducted during the early intervention phase, served as the empirical basis for demonstrating each methodological step. Transcripts were analysed using directed content analysis, with SSM elements serving as deductive categories and context-specific codes developed inductively. The MMCS approach was used to organise, compare, and synthesise findings within and across sites. Results: Applying the six-step methodology, we demonstrate the type of output each step produces, ranging from individual System Support Maps per key person and NICU (steps 1–3) to a sortable cross-site matrix (steps 4–6). The within-site analysis (step 5) illustrates how the methodology surfaces context-dependent perceptions of the same determinant, showing that a given resource category could be perceived as facilitating, inhibiting, or both, depending on individual responsibilities, needs, and local context. The cross-site analysis (step 6) demonstrates how the matrix structure makes homogeneous and heterogeneous determinant patterns visible across sites, indicating different contextual manifestations of the same determinant. Conclusion: The combined application of SSM and the MMCS approach provides a structured methodology for identifying and analysing implementation determinants that accounts for the perspectives of individual interest-holders and enables systematic within-site and cross-site comparison. The distinction between homogeneous and heterogeneous determinant patterns offers a basis for differentiating between cross-site and site-specific implementation strategies. Further research is needed to evaluate the use of SSM across multiple evaluation timepoints and its integration into initial and ongoing tailoring of implementation strategies. Trial registration: DRKS00025058; registered 6 May 2021.

We study the interplay of extrinsic and intrinsic motivations regarding the quality of care physicians provide. In particular, we analyze the role of personality traits in explaining the heterogeneity in responses to common physician payment systems. We utilize data from several behavioral experiments (659 subjects) on physician payment systems and from post-experimental surveys on personality traits. The experiments use equivalent health framings and decision situations with either fee-for-service (FFS) or capitation (CAP) as baseline payments. Blended payment systems—performance pay and mixed systems—are introduced at a within-subject level to complement the baseline payments. We find that personality traits contribute to explaining some heterogeneity in behavioral responses to payment incentives. Under baseline systems, more agreeable individuals provide higher quality of care. Blended payment systems enhance the aggregate treatment quality. Nevertheless, we observe a moderation effect in CAP-based blended systems: by Conscientiousness in mixed schemes, and by Conscientiousness and Agreeableness under performance pay. Quality increases are smaller for individuals higher in these traits. The moderation can be mainly explained by a ceiling effect, though we also observe a quality reduction/crowding-out effect. Our findings emphasize the importance of the interplay between financial incentives, physician provision behavior, and personality traits and inform the discussion on the design of tailored physician payment systems.

Although relative performance feedback in the form of rankings appears to be effective in improving health outcomes, it may have either motivating or demotivating effects for individual physicians. Potential factors influencing such effects include a physician’s ability and the design of the ranking system itself; however, there is limited understanding of these factors. Using a controlled lab-in-the-field experiment with practicing and future physicians as subjects ([ ]), we systematically analyze effort within small teams under different ranking systems. Exogenously varying the number and position of the thresholds defining the ranking system, we observe that the addition of a threshold to create a new rank is motivating—that is, increases effort—only among individuals capable of exceeding that threshold; the effort of other individuals may remain unchanged or even decrease. In particular, a highly granular ranking system with ranks spanning the entire range of possible outcomes maximizes overall physician effort; high thresholds serve to motivate high-ability individuals, whereas moderate and low thresholds provide opportunities for improvement to lower-ability individuals who cannot reach the high thresholds. Our results suggest that, to motivate their teams effectively, clinical leaders should provide rank feedback using a system under which physicians of all ability types can improve their rank through increased effort. This paper was accepted by Stefan Scholtes, healthcare management. Funding: This work was supported by C-SEB Center for Social and Economic Behavior at the University of Cologne (Junior Startup Grant No: Rd04-2016-JSUG-Huesmann) and the School of Business and Economics at the University of Münster (Junior Researcher Promotion Fund). This research was initiated while Daniel Wiesen was employed at the Institute of Health and Society at the Department of Health Management and Health Economics, University of Oslo (Norway), supported by the Research Council of Norway [IRECOHEX, Grant No. 231776]. Y. S. Ndiaye gratefully acknowledges support by the German Science Foundation through Germany’s Excellence Strategy [EXC 2126/1 390838866]. Supplemental Material: The online appendix and data files are available at https://doi.org/10.1287/mnsc.2022.00990 .

Over the past three decades, advancements in collection methods for hematopoietic stem cell transplantation substantially reduced invasiveness and safety concerns. To what extent, however, registered donors are informed about extraction methods and how their beliefs drive their willingness to follow through with a donation is not well understood. Inaccurate beliefs about extraction methods may cause donors to overestimate their perceived cost, potentially reducing donations. In a survey with about 24,000 potential donors in Germany’s largest stem-cell registry, we investigate how beliefs about extraction methods affect potential donors’ willingness to follow through with a stem cell donation. We find widespread misconceptions about extraction methods, with many donors attributing a significant fraction of stem cell extractions to be coming from never-used methods. Importantly, a lack of knowledge and misconceptions about extraction methods persist among registered donors, often anchored to methods that prevailed at the time of registration. Exploring the link between donors’ beliefs and their (stated) willingness to donate, we find that accurate beliefs about lower extraction costs correlate with a 2.2–2.9 percentage points higher willingness to donate, representing a 40% reduction in donor unavailability. Our results highlight the need for informational campaigns to correct donors’ misconceptions and potentially save more lives among blood cancer patients.

How performance pay affects physicians’ medical service provision and the quality of care is relevant for researchers and policy-makers alike. This paper systematically studies how performance pay, complementing either fee-for-service or capitation, affects physicians’ medical service provision and the quality of care for heterogeneous patients. Using a series of controlled behavioral experiments with physicians and students, we test the incentive effect of performance pay at a within-subject level. We consider a performance pay scheme which grants a discrete bonus if a quality threshold is reached, which varies with the patients’ severity of illness. We find that performance pay significantly reduces non-optimal service provision and enhances the quality of care. Effect sizes depend on the patients’ severity of illness and whether performance pay is blended with fee-for-service or capitation. Health policy implications, including a cost benefit analysis of introducing performance pay, are discussed.

The health sector requires skilled, altruistic, and motivated individuals to perform complex tasks for which ex-post incentives may prove ineffective. Understanding the determinants of self-selection into health professions is therefore critical. We investigate this issue relying on data from surveys and incentivized dictator games. We compare applicants to medical and healthcare schools in Italy and Austria with non-applicants from the same regions and age cohorts. Drawing on a wide range of individual characteristics, we employ machine learning techniques for variable selection. Our findings show that higher cognitive ability, greater altruism, and the personality trait of conscientiousness are positively associated with the likelihood of applying to medical or nursing school, while neuroticism is negatively associated. Additionally, individuals with a strong identification with societal goals and those with parents working as doctors are more likely to pursue medical education. These results provide evidence of capable, altruistic, and motivated individuals self-selecting into the health sector, a necessary condition for building a high-quality healthcare workforce.