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Nuckols TK, Chen PG, Shetty KD, Brara HS, Anand N, Qureshi N, Skaggs DL, Doctor JN, Pevnick JM, Mannion AF. Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons. PLoS One 2024; 19:e0300475. [PMID: 38640131 PMCID: PMC11029649 DOI: 10.1371/journal.pone.0300475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/20/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design "surgical appropriateness nudges" to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis. METHODS The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1-5, 5 = strongly agree). RESULTS Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4). CONCLUSIONS Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.
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Affiliation(s)
- Teryl K. Nuckols
- RAND Corporation, Santa Monica, CA, United States of America
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Peggy G. Chen
- RAND Corporation, Santa Monica, CA, United States of America
| | | | - Harsimran S. Brara
- Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, United States of America
| | - Neel Anand
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Nabeel Qureshi
- RAND Corporation, Santa Monica, CA, United States of America
| | - David L. Skaggs
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, Los Angeles, CA, United States of America
| | - Joshua M. Pevnick
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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Doctor JN, Meeker D, Fox CR, Persell SD, Wagner Z, Bouskill KE, Zanocco KA, Romanelli RJ, Brummett CM, Kirkegaard A, Watkins KE. A call for community-shared decisions. BMJ Evid Based Med 2024:bmjebm-2023-112641. [PMID: 38604618 DOI: 10.1136/bmjebm-2023-112641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Affiliation(s)
- Jason N Doctor
- University of Southern California Sol Price School of Public Policy, Los Angeles, California, USA
| | | | - Craig R Fox
- University of California Los Angeles Anderson School of Management, Los Angeles, California, USA
| | - Stephen D Persell
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | | | - Kyle A Zanocco
- University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Chad M Brummett
- University of Michigan Medical School, Ann Arbor, Michigan, USA
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Anderson AT, Mack WJ, Horiuchi SS, Paulukonis S, Zhou M, Snyder AB, Doctor JN, Kipke M, Coates T, Freed G. National Quality Indicators in Pediatric Sickle Cell Anemia. Pediatrics 2024; 153:e2022060804. [PMID: 38444343 PMCID: PMC10982541 DOI: 10.1542/peds.2022-060804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2023] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVE To assess nationally endorsed claims-based quality measures in pediatric sickle cell anemia (SCA). METHODS Using data from the Sickle Cell Data Collection programs in California and Georgia from 2010 to 2019, we evaluated 2 quality measures in individuals with hemoglobin S/S or S/β-zero thalassemia: (1) the proportion of patients aged 3 months to 5 years who were dispensed antibiotic prophylaxis for at least 300 days within each measurement year and (2) the proportion of patients aged 2 to 15 years who received at least 1 transcranial Doppler ultrasound (TCD) within each measurement year. We then evaluated differences by year and tested whether performance on quality measures differed according to demographic and clinical factors. RESULTS Only 22.2% of those in California and 15.5% in Georgia met or exceeded the quality measure for antibiotic prophylaxis, with increased odds associated with rural residence in Georgia (odds ratio 1.61; 95% confidence interval 1.21-2.14) compared with urban residence and a trend toward increased odds associated with a pediatric hematologist prescriber (odds ratio 1.28; 95% confidence interval 0.97, 1.69) compared with a general pediatrician. Approximately one-half of the sample received an annual assessment of stroke risk using TCD (47.4% in California and 52.7% in Georgia), with increased odds each additional year in both states and among younger children. CONCLUSIONS The rates of receipt of recommended antibiotic prophylaxis and annual TCD were low in this sample of children with SCA. These evidence-based quality measures can be tracked over time to help identify policies and practices that maximize survival in SCA.
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Affiliation(s)
- Ashaunta T. Anderson
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California
- Children’s Hospital Los Angeles, Los Angeles, California
| | - Wendy J. Mack
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | | | | | - Mei Zhou
- Georgia Health Policy Center, Georgia State University, Atlanta, Georgia
| | - Angela B. Snyder
- Georgia Health Policy Center, Georgia State University, Atlanta, Georgia
| | - Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California, Los Angeles, California
| | - Michele Kipke
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California
- Children’s Hospital Los Angeles, Los Angeles, California
| | - Thomas Coates
- Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California
- Children’s Hospital Los Angeles, Los Angeles, California
| | - Gary Freed
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
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Persell SD, Petito LC, Lee JY, Meeker D, Doctor JN, Goldstein NJ, Fox CR, Rowe TA, Linder JA, Chmiel R, Peprah YA, Brown T. Reducing Care Overuse in Older Patients Using Professional Norms and Accountability : A Cluster Randomized Controlled Trial. Ann Intern Med 2024; 177:324-334. [PMID: 38315997 DOI: 10.7326/m23-2183] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Effective strategies are needed to curtail overuse that may lead to harm. OBJECTIVE To evaluate the effects of clinician decision support redirecting attention to harms and engaging social and reputational concerns on overuse in older primary care patients. DESIGN 18-month, single-blind, pragmatic, cluster randomized trial, constrained randomization. (ClinicalTrials.gov: NCT04289753). SETTING 60 primary care internal medicine, family medicine and geriatrics practices within a health system from 1 September 2020 to 28 February 2022. PARTICIPANTS 371 primary care clinicians and their older adult patients from participating practices. INTERVENTION Behavioral science-informed, point-of-care, clinical decision support tools plus brief case-based education addressing the 3 primary clinical outcomes (187 clinicians from 30 clinics) were compared with brief case-based education alone (187 clinicians from 30 clinics). Decision support was designed to increase salience of potential harms, convey social norms, and promote accountability. MEASUREMENTS Prostate-specific antigen (PSA) testing in men aged 76 years and older without previous prostate cancer, urine testing for nonspecific reasons in women aged 65 years and older, and overtreatment of diabetes with hypoglycemic agents in patients aged 75 years and older and hemoglobin A1c (HbA1c) less than 7%. RESULTS At randomization, mean clinic annual PSA testing, unspecified urine testing, and diabetes overtreatment rates were 24.9, 23.9, and 16.8 per 100 patients, respectively. After 18 months of intervention, the intervention group had lower adjusted difference-in-differences in annual rates of PSA testing (-8.7 [95% CI, -10.2 to -7.1]), unspecified urine testing (-5.5 [CI, -7.0 to -3.6]), and diabetes overtreatment (-1.4 [CI, -2.9 to -0.03]) compared with education only. Safety measures did not show increased emergency care related to urinary tract infections or hyperglycemia. An HbA1c greater than 9.0% was more common with the intervention among previously overtreated diabetes patients (adjusted difference-in-differences, 0.47 per 100 patients [95% CI, 0.04 to 1.20]). LIMITATION A single health system limits generalizability; electronic health data limit ability to differentiate between overtesting and underdocumentation. CONCLUSION Decision support designed to increase clinicians' attention to possible harms, social norms, and reputational concerns reduced unspecified testing compared with offering traditional case-based education alone. Small decreases in diabetes overtreatment may also result in higher rates of uncontrolled diabetes. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Stephen D Persell
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago; and Center for Primary Care Innovation, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.D.P., J.A.L.)
| | - Lucia C Petito
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (L.C.P.)
| | - Ji Young Lee
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
| | | | - Jason N Doctor
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California (J.N.D.)
| | - Noah J Goldstein
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, California (N.J.G., C.R.F.)
| | - Craig R Fox
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, California (N.J.G., C.R.F.)
| | - Theresa A Rowe
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
| | - Jeffrey A Linder
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago; and Center for Primary Care Innovation, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (S.D.P., J.A.L.)
| | - Ryan Chmiel
- Information Services, Northwestern Memorial HealthCare, Chicago, Illinois (R.C.)
| | - Yaw Amofa Peprah
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
| | - Tiffany Brown
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois (J.Y.L., T.A.R., Y.A.P., T.B.)
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Mulligan K, Baid D, Doctor JN, Phelps CE, Lakdawalla DN. Risk preferences over health: Empirical estimates and implications for medical decision-making. J Health Econ 2024; 94:102857. [PMID: 38232447 DOI: 10.1016/j.jhealeco.2024.102857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/19/2024]
Abstract
Mainstream health economic theory implies that an expected gain in health-related quality of life (HRQoL) produces the same value for consumers, regardless of baseline health. Several strands of recent research call this implication into question. Generalized Risk-Adjusted Cost-Effectiveness (GRACE) demonstrates theoretically that baseline health status influences value, so long as consumers are not risk-neutral over health. Prior empirical literature casts doubt on risk-neutral expected utility-maximization in the health domain. We estimate utility over HRQoL in a nationally representative U.S. population and use our estimates to measure risk preferences over health. We find that individuals are risk-seeking at low levels of health, become risk-averse at health equal to 0.485 (measured on a 0-1 scale), and are most risk-averse at perfect health (coefficient of relative risk aversion = 4.51). We develop the resulting implications for medical decision making, cost-effectiveness analyses, and the proper theory of health-related decision making under uncertainty.
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Affiliation(s)
- Karen Mulligan
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA; Schaffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Verna & Peter Dauterive Hall, Los Angeles, CA, 90089, USA
| | - Drishti Baid
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA
| | - Jason N Doctor
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA; Schaffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Verna & Peter Dauterive Hall, Los Angeles, CA, 90089, USA
| | - Charles E Phelps
- Department of Economics, University of Rochester, 238 Harkness Hall, 280 Hutchison Road, Box 270156, Rochester, NY, 14627, USA
| | - Darius N Lakdawalla
- Sol Price School of Public Policy, University of Southern California, Ralph and Goldy Lewis Hall 312, Los Angeles, CA, 90089, USA; Schaffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Verna & Peter Dauterive Hall, Los Angeles, CA, 90089, USA; School of Pharmacy, University of Southern California, 1985 Zonal Ave, Los Angeles, CA, 90089, USA.
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Wagner Z, Kirkegaard A, Mariano LT, Doctor JN, Yan X, Persell SD, Goldstein NJ, Fox CR, Brummett CM, Romanelli RJ, Bouskill K, Martinez M, Zanocco K, Meeker D, Mudiganti S, Waljee J, Watkins KE. Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions: A Randomized Clinical Trial. JAMA Health Forum 2024; 5:e240077. [PMID: 38488780 PMCID: PMC10943416 DOI: 10.1001/jamahealthforum.2024.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/29/2023] [Indexed: 03/18/2024] Open
Abstract
Importance Excess opioid prescribing after surgery can result in prolonged use and diversion. Email feedback based on social norms may reduce the number of pills prescribed. Objective To assess the effectiveness of 2 social norm-based interventions on reducing guideline-discordant opioid prescribing after surgery. Design, Setting, and Participants This cluster randomized clinical trial conducted at a large health care delivery system in northern California between October 2021 and October 2022 included general, obstetric/gynecologic, and orthopedic surgeons with patients aged 18 years or older discharged to home with an oral opioid prescription. Interventions In 19 hospitals, 3 surgical specialties (general, orthopedic, and obstetric/gynecologic) were randomly assigned to a control group or 1 of 2 interventions. The guidelines intervention provided email feedback to surgeons on opioid prescribing relative to institutionally endorsed guidelines; the peer comparison intervention provided email feedback on opioid prescribing relative to that of peer surgeons. Emails were sent to surgeons with at least 2 guideline-discordant prescriptions in the previous month. The control group had no intervention. Main Outcome and Measures The probability that a discharged patient was prescribed a quantity of opioids above the guideline for the respective procedure during the 12 intervention months. Results There were 38 235 patients discharged from 640 surgeons during the 12-month intervention period. Control-group surgeons prescribed above guidelines 36.8% of the time during the intervention period compared with 27.5% and 25.4% among surgeons in the peer comparison and guidelines arms, respectively. In adjusted models, the peer comparison intervention reduced guideline-discordant prescribing by 5.8 percentage points (95% CI, -10.5 to -1.1; P = .03) and the guidelines intervention reduced it by 4.7 percentage points (95% CI, -9.4 to -0.1; P = .05). Effects were driven by surgeons who performed more surgeries and had more guideline-discordant prescribing at baseline. There was no significant difference between interventions. Conclusions and Relevance In this cluster randomized clinical trial, email feedback based on either guidelines or peer comparison reduced opioid prescribing after surgery. Guideline-based feedback was as effective as peer comparison-based feedback. These interventions are simple, low-cost, and scalable, and may reduce downstream opioid misuse. Trial Registration ClinicalTrials.gov NCT05070338.
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Affiliation(s)
| | | | | | - Jason N. Doctor
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Xiaowei Yan
- Palo Alto Medical Foundation, Palo Alto, California
| | - Stephen D. Persell
- Division of General Internal Medicine, Department of Medicine, Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Noah J. Goldstein
- Anderson School of Management, Department of Psychology, and Geffen School of Medicine, University of California at Los Angeles, Los Angeles
| | - Craig R. Fox
- Anderson School of Management, Department of Psychology, and Geffen School of Medicine, University of California at Los Angeles, Los Angeles
| | | | - Robert J. Romanelli
- Palo Alto Medical Foundation, Palo Alto, California
- RAND Europe, Westbrook Centre, Cambridge, United Kingdom
| | | | | | - Kyle Zanocco
- Section of Endocrine Surgery, Division of General Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Daniella Meeker
- Keck School of Medicine, USC Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California
- Yale School of Medicine, New Haven, Connecticut
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Lakdawalla DN, Doctor JN. A principled approach to non-discrimination in cost-effectiveness. Eur J Health Econ 2024:10.1007/s10198-023-01659-7. [PMID: 38411845 DOI: 10.1007/s10198-023-01659-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/05/2023] [Indexed: 02/28/2024]
Abstract
The US Inflation Reduction Act (IRA) prohibits the Centers for Medicare and Medicaid Services (CMS) from using standard quality-adjusted life-years or other value assessment methods that discriminate against the aged, terminally ill, or disabled when setting maximum fair prices for prescription drugs. This policy has reignited interest in methods for assessing value without discrimination. Equal value of life-years gained (EVL), healthy years in total (HYT), and Generalized Risk-Adjusted Cost-Effectiveness (GRACE) have emerged as proposals. Neither EVL nor HYT rests on well-articulated microeconomic foundations. We show that they produce decisions that are inconsistent over time in a variety of ways, including: (1) failure to support additivity and indirect comparison in cases where the standard-of-care therapy changes over time; (2) strictly negative value of survival gains that accrue from a new, better standard-of-care, particularly for the disabled themselves; (3) unbounded average value of survival gains; and (4) non-convex survival preferences. We propose an alternative method that relies on GRACE and its microeconomic foundations.
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Affiliation(s)
- Darius N Lakdawalla
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, USA.
| | - Jason N Doctor
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, USA
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Linder JA, Persell SD, Kelley MA, Friedberg M, Goldstein NJ, Knight TK, Kaiser KM, Doctor JN, Mack WJ, Tibbels J, McCabe B, Haenchen S, Meeker D. Antibiotic prescribing for acute respiratory infections during the coronavirus disease 2019 (COVID-19) pandemic: Patterns in a nationwide telehealth service provider. Infect Control Hosp Epidemiol 2024:1-4. [PMID: 38329093 DOI: 10.1017/ice.2023.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
We examined 3,046,538 acute respiratory infection (ARI) encounters with 6,103 national telehealth physicians from January 2019 to October 2021. The antibiotic prescribing rates were 44% for all ARIs; 46% were antibiotic appropriate; 65% were potentially appropriate; 19% resulted from inappropriate diagnoses; and 10% were related to coronavirus disease 2019 (COVID-19) diagnosis.
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Affiliation(s)
- Jeffrey A Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Center for Primary Care Innovation, Institute for Public Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephen D Persell
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Center for Primary Care Innovation, Institute for Public Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Marcella A Kelley
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California
- School of Pharmacy, University of Southern California, Los Angeles, California
| | - Mark Friedberg
- Blue Cross Blue Shield of Massachusetts, Boston, Massachusetts
| | - Noah J Goldstein
- Anderson School of Management, University of California at Los Angeles, Los Angeles, California
| | - Tara K Knight
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California
| | - Katrina M Kaiser
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California
| | - Jason N Doctor
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California
| | - Wendy J Mack
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | | | - Daniella Meeker
- Yale School of Medicine, Yale University, New Haven, Connecticut
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Haenchen S, McCabe B, Mack WJ, Doctor JN, Linder JA, Persell SD, Tibbels J, Meeker D. Use of Telehealth Information for Early Detection: Insights From the COVID-19 Pandemic. Am J Public Health 2024; 114:218-225. [PMID: 38335480 PMCID: PMC10862224 DOI: 10.2105/ajph.2023.307499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
Objectives. To examine whether the addition of telehealth data to existing surveillance infrastructure can improve forecasts of cases and mortality. Methods. In this observational study, we compared accuracy of 14-day forecasts using real-time data available to the National Syndromic Surveillance Program (standard forecasts) to forecasts that also included telehealth information (telehealth forecasts). The study was performed in a national telehealth service provider in 2020 serving 50 US states and the District of Columbia. Results. Among 10.5 million telemedicine encounters, 169 672 probable COVID-19 cases were diagnosed by 5050 clinicians, with a rate between 0.79 and 47.8 probable cases per 100 000 encounters per day (mean = 8.37; SD = 10.75). Publicly reported case counts ranged from 0.5 to 237 916 (mean: 53 913; SD = 47 466) and 0 to 2328 deaths (mean = 1035; SD = 550) per day. Telehealth-based forecasts improved 14-day case forecasting accuracy by 1.8 percentage points to 30.9% (P = .06) and mortality forecasting by 6.4 percentage points to 26.9% (P < .048). Conclusions. Modest improvements in forecasting can be gained from adding telehealth data to syndromic surveillance infrastructure. (Am J Public Health. 2024;114(2):218-225. https://doi.org/10.2105/AJPH.2023.307499).
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Affiliation(s)
- Steven Haenchen
- Steven Haenchen, Bridget McCabe, and Jason Tibbels are with Teladoc Health, Purchase, NY. Wendy J. Mack is with Keck School of Medicine, University of Southern California, Los Angeles. Jason N. Doctor is with Schaeffer Center for Health Policy and Economics, University of Southern California. Jeffrey A. Linder and Stephen D. Persell are with Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Daniella Meeker is with Yale School of Medicine, Yale University, New Haven, CT
| | - Bridget McCabe
- Steven Haenchen, Bridget McCabe, and Jason Tibbels are with Teladoc Health, Purchase, NY. Wendy J. Mack is with Keck School of Medicine, University of Southern California, Los Angeles. Jason N. Doctor is with Schaeffer Center for Health Policy and Economics, University of Southern California. Jeffrey A. Linder and Stephen D. Persell are with Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Daniella Meeker is with Yale School of Medicine, Yale University, New Haven, CT
| | - Wendy J Mack
- Steven Haenchen, Bridget McCabe, and Jason Tibbels are with Teladoc Health, Purchase, NY. Wendy J. Mack is with Keck School of Medicine, University of Southern California, Los Angeles. Jason N. Doctor is with Schaeffer Center for Health Policy and Economics, University of Southern California. Jeffrey A. Linder and Stephen D. Persell are with Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Daniella Meeker is with Yale School of Medicine, Yale University, New Haven, CT
| | - Jason N Doctor
- Steven Haenchen, Bridget McCabe, and Jason Tibbels are with Teladoc Health, Purchase, NY. Wendy J. Mack is with Keck School of Medicine, University of Southern California, Los Angeles. Jason N. Doctor is with Schaeffer Center for Health Policy and Economics, University of Southern California. Jeffrey A. Linder and Stephen D. Persell are with Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Daniella Meeker is with Yale School of Medicine, Yale University, New Haven, CT
| | - Jeffrey A Linder
- Steven Haenchen, Bridget McCabe, and Jason Tibbels are with Teladoc Health, Purchase, NY. Wendy J. Mack is with Keck School of Medicine, University of Southern California, Los Angeles. Jason N. Doctor is with Schaeffer Center for Health Policy and Economics, University of Southern California. Jeffrey A. Linder and Stephen D. Persell are with Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Daniella Meeker is with Yale School of Medicine, Yale University, New Haven, CT
| | - Stephen D Persell
- Steven Haenchen, Bridget McCabe, and Jason Tibbels are with Teladoc Health, Purchase, NY. Wendy J. Mack is with Keck School of Medicine, University of Southern California, Los Angeles. Jason N. Doctor is with Schaeffer Center for Health Policy and Economics, University of Southern California. Jeffrey A. Linder and Stephen D. Persell are with Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Daniella Meeker is with Yale School of Medicine, Yale University, New Haven, CT
| | - Jason Tibbels
- Steven Haenchen, Bridget McCabe, and Jason Tibbels are with Teladoc Health, Purchase, NY. Wendy J. Mack is with Keck School of Medicine, University of Southern California, Los Angeles. Jason N. Doctor is with Schaeffer Center for Health Policy and Economics, University of Southern California. Jeffrey A. Linder and Stephen D. Persell are with Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Daniella Meeker is with Yale School of Medicine, Yale University, New Haven, CT
| | - Daniella Meeker
- Steven Haenchen, Bridget McCabe, and Jason Tibbels are with Teladoc Health, Purchase, NY. Wendy J. Mack is with Keck School of Medicine, University of Southern California, Los Angeles. Jason N. Doctor is with Schaeffer Center for Health Policy and Economics, University of Southern California. Jeffrey A. Linder and Stephen D. Persell are with Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL. Daniella Meeker is with Yale School of Medicine, Yale University, New Haven, CT
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Doctor JN, Kelley MA, Goldstein NJ, Lucas J, Knight T, Stewart EP. A randomized trial looking at planning prompts to reduce opioid prescribing. Nat Commun 2024; 15:263. [PMID: 38216566 PMCID: PMC10786898 DOI: 10.1038/s41467-023-44573-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/20/2023] [Indexed: 01/14/2024] Open
Abstract
Prior work has demonstrated that personalized letters are effective at reducing opioid and benzodiazepine prescribing, but it is unclear whether If/when-then planning prompts would enhance this effect. We conducted a decedent-clustered trial which randomized 541 clinicians in Los Angeles County to receive a standard (n = 284), or comparator (n = 257) version of a letter with If/when-then prompts. We found a significant 12.85% (6.83%, 18.49%) and 8.32% (2.34%, 13.93%) decrease in the primary outcomes morphine (MME) and diazepam milligram equivalents (DME), respectively. This study confirms the benefit of planning prompts, and repeat letter exposure among clinicians with poor patient outcomes. Limitations include lack of generalizability and small sample size. Clinicaltrials.gov registration: NCT03856593.
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Affiliation(s)
- Jason N Doctor
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, 90089, USA.
| | | | - Noah J Goldstein
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, CA, 90095, USA
| | - Jonathan Lucas
- Department of Medical Examiner-Coroner, County of Los Angeles, Los Angeles, CA, USA
| | - Tara Knight
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, 90089, USA
| | - Emily P Stewart
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, 90089, USA
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11
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Langford AV, Schneider CR, Reeve E, Doctor JN, Gnjidic D. Comment on: "Patient Perceptions of Opioids and Benzodiazepines and Attitudes Toward Deprescribing". Drugs Aging 2024; 41:77-78. [PMID: 38165603 DOI: 10.1007/s40266-023-01086-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 01/04/2024]
Affiliation(s)
- Aili V Langford
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia.
| | - Carl R Schneider
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Emily Reeve
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Jason N Doctor
- Sol Price School of Public Policy, University of Southern California, California, USA
| | - Danijela Gnjidic
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
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12
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Langford AV, Bero L, Lin CWC, Blyth FM, Doctor JN, Holliday S, Jeon YH, Moullin JC, Murnion B, Nielsen S, Penm J, Reeve E, Reid S, Wale J, Osman R, Gnjidic D, Schneider CR. Context matters: using an Evidence to Decision (EtD) framework to develop and encourage uptake of opioid deprescribing guideline recommendations at the point-of-care. J Clin Epidemiol 2024; 165:111204. [PMID: 37931823 DOI: 10.1016/j.jclinepi.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVES To describe the development and use of an Evidence to Decision (EtD) framework when formulating recommendations for the Evidence-Based Clinical Practice Guideline for Deprescribing Opioid Analgesics. STUDY DESIGN AND SETTING Evidence was derived from an overview of systematic reviews and qualitative studies conducted with healthcare professionals and people who take opioids for pain. A multidisciplinary guideline development group conducted extensive EtD framework review and iterative refinement to ensure that guideline recommendations captured contextual factors relevant to the guideline target setting and audience. RESULTS The guideline development group considered and accounted for the complexities of opioid deprescribing at the individual and health system level, shaping recommendations and practice points to facilitate point-of-care use. Stakeholders exhibited diverse preferences, beliefs, and values. This variability, low certainty of evidence, and system-level policies and funding models impacted the strength of the generated recommendations, resulting in the formulation of four 'conditional' recommendations. CONCLUSION The context within which evidence-based recommendations are considered, as well as the political and health system environment, can contribute to the success of recommendation implementation. Use of an EtD framework allowed for the development of implementable recommendations relevant at the point-of-care through consideration of limitations of the evidence and relevant contextual factors.
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Affiliation(s)
- Aili V Langford
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia.
| | - Lisa Bero
- School of Medicine, Colorado School of Public Health and Center for Bioethics and Humanities, University of Colorado Anschutz Medical Center, Denver, CO, USA
| | - Chung-Wei Christine Lin
- Faculty of Medicine and Health, School of Public Health, Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia; Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Fiona M Blyth
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jason N Doctor
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Simon Holliday
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Yun-Hee Jeon
- Faculty of Medicine and Health, Sydney Nursing School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joanna C Moullin
- School of Population Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Bridin Murnion
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia; Department of Pharmacy, Prince of Wales Hospital, Randwick, Australia
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Sharon Reid
- Specialty of Addiction Medicine, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Drug Health Services, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Janet Wale
- Independent Consumer Representative, Melbourne, Victoria, Australia
| | - Rawa Osman
- NPS MedicineWise, Sydney, New South Wales, Australia
| | - Danijela Gnjidic
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | - Carl R Schneider
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
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Sullivan MD, Linder JA, Doctor JN. Centers for Disease Control and Prevention Guideline for Prescribing Opioids, 2022-Need for Integrating Dosing Benchmarks With Shared Decision-Making. JAMA Intern Med 2023; 183:899-900. [PMID: 37459113 DOI: 10.1001/jamainternmed.2023.2847] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
This viewpoint evaluates the CDC’s 2022 clinical practice guideline for prescribing opioids and suggests a model for supplemented shared decision-making between patients and clinicians about long-term opioid therapy.
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Affiliation(s)
- Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Jeffrey A Linder
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jason N Doctor
- Department of Health Policy and Management, Price School of Public Policy, University of Southern California, Los Angeles
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Doctor JN, Goldstein NJ, Fox CR, Linder JA, Persell SD, Stewart EP, Knight TK, Meeker D. Clinician Job Satisfaction After Peer Comparison Feedback: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2317379. [PMID: 37289454 PMCID: PMC10251208 DOI: 10.1001/jamanetworkopen.2023.17379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/24/2023] [Indexed: 06/09/2023] Open
Abstract
Importance Interventions that improve clinician performance through feedback should not contribute to job dissatisfaction or staff turnover. Measurement of job satisfaction may help identify interventions that lead to this undesirable consequence. Objective To evaluate whether mean job satisfaction was less than the margin of clinical significance among clinicians who received social norm feedback (peer comparison) compared with clinicians who did not. Design, Setting, and Participants This secondary, preregistered, noninferiority analysis of a cluster randomized trial compared 3 interventions to reduce inappropriate antibiotic prescribing in a 2 × 2 × 2 factorial design from November 1, 2011, to April 1, 2014. A total of 248 clinicians were enrolled from 47 clinics. The sample size for this analysis was determined by the number of nonmissing job satisfaction scores from the original enrolled sample, which was 201 clinicians from 43 clinics. Data analysis was performed from October 12 to April 13, 2022. Interventions Feedback comparing individual clinician performance to top-performing peers, delivered in monthly emails (peer comparison). Main Outcomes and Measures The primary outcome was a response to the following statement: "Overall, I am satisfied with my current job." Responses ranged from 1 (strongly disagree) to 5 (strongly agree). Results A total of 201 clinicians (response rate, 81%) from 43 of the 47 clinics (91%) provided a survey response about job satisfaction. Clinicians were primarily female (n = 129 [64%]) and board certified in internal medicine (n = 126 [63%]), with a mean (SD) age of 48 (10) years. The clinic-clustered difference in mean job satisfaction was greater than -0.32 (β = 0.11; 95% CI, -0.19 to 0.42; P = .46). Therefore, the preregistered null hypothesis that peer comparison is inferior by resulting in at least a 1-point decrease in job satisfaction by 1 in 3 clinicians was rejected. The secondary null hypothesis that job satisfaction was similar among clinicians randomized to social norm feedback was not able to be rejected. The effect size did not change when controlling for other trial interventions (t = 0.08; P = .94), and no interaction effects were observed. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, peer comparison did not lead to lower job satisfaction. Features that may have protected against dissatisfaction include clinicians' agency over the performance measure, privacy of individual performance, and allowing all clinicians to achieve top performance. Trial Registration ClinicalTrials.gov Identifiers: NCT05575115 and NCT01454947.
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Affiliation(s)
- Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Noah J. Goldstein
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, California
| | - Craig R. Fox
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, California
| | - Jeffrey A. Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephen D. Persell
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Emily P. Stewart
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Tara K. Knight
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Daniella Meeker
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Biomedical Informatics & Data Science, Yale University School of Medicine, New Haven, Connecticut
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Doctor JN, Berg AH, Knight TK, Kadono M, Stewart E, Sonik R, Hochman M, Sood N. Cross-sectional study examining household factors associated with SARS-CoV-2 seropositivity in low-income children in Los Angeles. BMJ Open 2023; 13:e070291. [PMID: 37258079 PMCID: PMC10254815 DOI: 10.1136/bmjopen-2022-070291] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 05/12/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVES This study aims to quantify the degree to which an underserved, Hispanic population in Los Angeles is impacted by SARS-CoV-2, and determine factors associated with paediatric seropositivity. DESIGN Cross-sectional. SETTING AltaMed, a Federally Qualified Health Center in Los Angeles. PARTICIPANTS A random sample of households who had received healthcare at AltaMed Medical Group was invited to participate. Households with at least one adult and one paediatric participant between 5 and 17 years of age were eligible to participate. Consented participants completed a survey on social determinants of health and were tested for antibodies using Abbott Architect SARS-CoV-2-IgG and SARS-CoV-2-IgM tests. PRIMARY OUTCOME MEASURE Seropositive status. RESULTS We analysed 390 adults (mean age in years, 38.98 (SD 12.11)) and 332 paediatric participants (11.26 (SD 3.51)) from 196 households. Estimated seropositivity was 52.11% (95% CI 49.61% to 55.19%) in paediatric participants and 63.58% (95% CI 60.39% to 65.24%) in adults. Seropositivity was 11.47% (95% CI 6.82% to 14.09%) lower in paediatric participants, but high relative to other populations. A household member with type 2 diabetes (OR 2.94 (95% CI 1.68 to 5.14)), receipt of food stamps (OR 1.66 (95% CI 1.08 to 2.56)) and lower head-of-household education (OR 1.73 (95% CI 1.06 to 2.84)) were associated with paediatric seropositivity. CONCLUSIONS SARS-CoV-2 seropositivity is high in Hispanic children and adolescents in Los Angeles. Food insecure households with low head-of-household education, and at least one household member with type 2 diabetes, had the highest risk. These factors may inform paediatrician COVID-19 mitigation recommendations. TRIAL REGISTRATION NUMBER NCT04901624.
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Affiliation(s)
- Jason N Doctor
- University of Southern California Sol Price School of Public Policy, Los Angeles, California, USA
| | - Anders H Berg
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Tara K Knight
- University of Southern California Sol Price School of Public Policy, Los Angeles, California, USA
| | - Mika Kadono
- Institute of Health Equity, AltaMed Health Services Corporation, Los Angeles, California, USA
| | - Emily Stewart
- University of Southern California Sol Price School of Public Policy, Los Angeles, California, USA
| | - Rajan Sonik
- Institute of Health Equity, AltaMed Health Services Corporation, Los Angeles, California, USA
| | - Michael Hochman
- Institute of Health Equity, USC Keck School of Medicine, Los Angeles, California, USA
| | - Neeraj Sood
- University of Southern California Sol Price School of Public Policy, Los Angeles, California, USA
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Doctor JN, Stewart E, Lev R, Lucas J, Knight T, Nguyen A, Menchine M. Effect of Prescriber Notifications of Patient's Fatal Overdose on Opioid Prescribing at 4 to 12 Months: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2249877. [PMID: 36607639 PMCID: PMC9856831 DOI: 10.1001/jamanetworkopen.2022.49877] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
This randomized clinical trial evaluates the effect of prescriber notifications of a patient’s fatal overdose on opioid prescribing, including decreases in morphine milligram equivalents, new patients taking opioids, and patients taking a high dose, at 4 to 12 months after notification.
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Affiliation(s)
- Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Emily Stewart
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles
| | - Roneet Lev
- Emergency Department, Scripps Mercy Hospital San Diego, San Diego, California
| | - Jonathan Lucas
- Department of Medical Examiner-Coroner, County of Los Angeles, Los Angeles, California
| | - Tara Knight
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Andy Nguyen
- Global Blood Therapeutics, South San Francisco, California
| | - Michael Menchine
- Department of Emergency Medicine, University of Southern California, Los Angeles
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17
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Rowe TA, Brown T, Lee JY, Linder JA, Meeker D, Doctor JN, Goldstein NJ, Fox CR, Persell SD. Development and pilot testing of EHR-nudges to reduce overuse in older primary care patients. Arch Gerontol Geriatr 2023; 104:104794. [PMID: 36115068 PMCID: PMC9682472 DOI: 10.1016/j.archger.2022.104794] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Unnecessary testing and treatment of common conditions in older adults can lead to significant morbidity and mortality. The primary objective of this study was to develop and pilot test a set of clinical decision support (CDS) alerts informed by social psychology to address overuse in three areas related to ambulatory care of older adults. METHODS We developed three electronic health record (EHR) CDS alerts to address overuse and pilot tested them from January 17, 2019 to July 17, 2019. We enrolled 14 primary care physicians from three practices within a large health system who cared for adults aged 65 years and older. Three measures of overuse applied to patients meeting the following criteria: ordering of prostate-specific antigen (PSA) for prostate cancer screening in adult men aged 76 years and older, ordering of urinalysis or urine cultures (UA or UC) for non-specific reasons to identify bacteriuria in women aged 65 years and older, and overtreatment of diabetes with insulin or oral hypoglycemic medications in adults aged at 75 years and older (DM). Clinicians received CDS alerts when criteria for any of the three overuse measures were met. We then surveyed clinicians to evaluate their experience with the CDS alerts. RESULTS The number of clinical encounters that triggered CDS alerts was 19 for PSA, 48 for UA/UC and 128 for DM. For PSA encounters, 4 (21%) orders were not performed after the alert. In the UA/UC encounters 29 (60%) orders were not performed after the alert. For the DM encounters, 21 (34%) had diabetes therapy reduced following the alert. Survey respondents indicated that the alerts were clinically accurate and sometimes led them to change their clinical action. CONCLUSIONS These CDS alerts were feasible to implement and may minimize unnecessary testing and treatment of common conditions in older adults.
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Affiliation(s)
- Theresa A Rowe
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.
| | - Tiffany Brown
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Ji Young Lee
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jeffrey A Linder
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Daniella Meeker
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA, United States
| | - Jason N Doctor
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA, United States
| | - Noah J Goldstein
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, United States
| | - Craig R Fox
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, United States
| | - Stephen D Persell
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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18
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Kelley MA, Lev R, Lucas J, Knight T, Stewart E, Menchine M, Doctor JN. Association of Fatal Overdose Notification Letters With Prescription of Benzodiazepines: Secondary Analysis of a Randomized Clinical Trial. JAMA Intern Med 2022; 182:1099-1100. [PMID: 35994260 PMCID: PMC9396468 DOI: 10.1001/jamainternmed.2022.3372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/18/2022] [Indexed: 11/14/2022]
Abstract
This secondary analysis of a randomized clinical trial examines the association of receipt of an injunction letter from a medical examiner following a patient’s drug overdose with patterns of benzodiazepine prescribing among physicians.
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Affiliation(s)
- Marcella A. Kelley
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles
| | - Roneet Lev
- Emergency Department, Scripps Mercy Hospital San Diego, San Diego, California
| | - Jonathan Lucas
- Department of Medical Examiner–Coroner, County of Los Angeles, California
| | - Tara Knight
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Emily Stewart
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles
| | - Michael Menchine
- Department of Emergency Medicine, University of Southern California, Los Angeles
| | - Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles
- Sol Price School of Public Policy, University of Southern California, Los Angeles
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19
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McCabe BK, Linder JA, Doctor JN, Friedberg M, Fox CR, Goldstein NJ, Knight TK, Kaiser K, Tibbels J, Haenchen S, Persell SD, Warberg R, Meeker D. Corrigendum to "The protocol of improving safe antibiotic prescribing in telehealth: A randomized trial [Contemporary Clin Trials, Volume 119 (2022), p.1/106834]. Contemp Clin Trials 2022; 121:106927. [PMID: 36156262 DOI: 10.1016/j.cct.2022.106927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Jason N Doctor
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, United States of America; Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, United States of America
| | - Mark Friedberg
- Blue Cross Blue Shield of Massachusetts, Boston, MA, United States of America
| | - Craig R Fox
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, United States of America
| | - Noah J Goldstein
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, United States of America
| | - Tara K Knight
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, United States of America; Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, United States of America
| | - Katrina Kaiser
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, United States of America; Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, United States of America
| | - Jason Tibbels
- Teladoc Health, Inc., Purchase, NY, United States of America
| | - Steve Haenchen
- Teladoc Health, Inc., Purchase, NY, United States of America
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Rebecca Warberg
- Teladoc Health, Inc., Purchase, NY, United States of America
| | - Daniella Meeker
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
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Brown T, Zelch B, Lee JY, Doctor JN, Linder JA, Sullivan MD, Goldstein NJ, Rowe TA, Meeker D, Knight T, Friedberg MW, Persell SD. A Qualitative Description of Clinician Free-Text Rationales Entered within Accountable Justification Interventions. Appl Clin Inform 2022; 13:820-827. [PMID: 36070799 PMCID: PMC9451951 DOI: 10.1055/s-0042-1756366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Requiring accountable justifications-visible, clinician-recorded explanations for not following a clinical decision support (CDS) alert-has been used to steer clinicians away from potentially guideline-discordant decisions. Understanding themes from justifications across clinical content areas may reveal how clinicians rationalize decisions and could help inform CDS alerts. METHODS We conducted a qualitative evaluation of the free-text justifications entered by primary care physicians from three pilot interventions designed to reduce opioid prescribing and, in older adults, high-risk polypharmacy and overtesting. Clinicians encountered alerts when triggering conditions were met within the chart. Clinicians were asked to change their course of action or enter a justification for the action that would be displayed in the chart. We extracted all justifications and grouped justifications with common themes. Two authors independently coded each justification and resolved differences via discussion. Three physicians used a modified Delphi technique to rate the clinical appropriateness of the justifications. RESULTS There were 560 justifications from 50 unique clinicians. We grouped these into three main themes used to justify an action: (1) report of a particular diagnosis or symptom (e.g., for "anxiety" or "acute pain"); (2) provision of further contextual details about the clinical case (e.g., tried and failed alternatives, short-term supply, or chronic medication); and (3) noting communication between clinician and patient (e.g., "risks and benefits discussed"). Most accountable justifications (65%) were of uncertain clinical appropriateness. CONCLUSION Most justifications clinicians entered across three separate clinical content areas fit within a small number of themes, and these common rationales may aid in the design of effective accountable justification interventions. Justifications varied in terms of level of clinical detail. On their own, most justifications did not clearly represent appropriate clinical decision making.
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Affiliation(s)
- Tiffany Brown
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Brittany Zelch
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, United States
| | - Ji Young Lee
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, United States
| | - Jeffrey A. Linder
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Mark D. Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, United States
| | - Noah J. Goldstein
- Anderson School of Management, University of California at Los Angeles, Los Angeles, California, United States
| | - Theresa A. Rowe
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States
| | - Daniella Meeker
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, United States
| | - Tara Knight
- Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, United States
| | - Mark W. Friedberg
- Blue Cross Blue Shield of Massachusetts, Boston, Massachusetts, United States,Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Stephen D. Persell
- Division of General Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States,Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States,Address for correspondence Stephen D. Persell, MD, MPH 750N Lake Shore Dr., 10th Floor, Chicago, IL 60611United States
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21
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Persell SD, Brown T, Doctor JN, Fox CR, Goldstein NJ, Handler SM, Hanlon JT, Lee JY, Linder JA, Meeker D, Rowe TA, Sullivan MD, Friedberg MW. Development of High-Risk Geriatric Polypharmacy Electronic Clinical Quality Measures and a Pilot Test of EHR Nudges Based on These Measures. J Gen Intern Med 2022; 37:2777-2785. [PMID: 34993860 PMCID: PMC9411452 DOI: 10.1007/s11606-021-07296-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 11/23/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Inappropriate polypharmacy, prevalent among older patients, is associated with substantial harms. OBJECTIVE To develop measures of high-risk polypharmacy and pilot test novel electronic health record (EHR)-based nudges grounded in behavioral science to promote deprescribing. DESIGN We developed and validated seven measures, then conducted a three-arm pilot from February to May 2019. PARTICIPANTS Validation used data from 78,880 patients from a single large health system. Six physicians were pre-pilot test environment users. Sixty-nine physicians participated in the pilot. MAIN MEASURES Rate of high-risk polypharmacy among patients aged 65 years or older. High-risk polypharmacy was defined as being prescribed ≥5 medications and satisfying ≥1 of the following high-risk criteria: drugs that increase fall risk among patients with fall history; drug-drug interactions that increase fall risk; thiazolidinedione, NSAID, or non-dihydropyridine calcium channel blocker in heart failure; and glyburide, glimepiride, or NSAID in chronic kidney disease. INTERVENTIONS Physicians received EHR alerts when renewing or prescribing certain high-risk medications when criteria were met. One practice received a "commitment nudge" that offered a chance to commit to addressing high-risk polypharmacy at the next visit. One practice received a "justification nudge" that asked for a reason when high-risk polypharmacy was present. One practice received both. KEY RESULTS Among 55,107 patients 65 and older prescribed 5 or more medications, 6256 (7.9%) had one or more high-risk criteria. During the pilot, the mean (SD) number of nudges per physician per week was 1.7 (0.4) for commitment, 0.8 (0.5) for justification, and 1.9 (0.5) for both interventions. Physicians requested to be reminded to address high-risk polypharmacy for 236/833 (28.3%) of the commitment nudges and acknowledged 441 of 460 (95.9%) of justification nudges, providing a text response for 187 (40.7%). CONCLUSIONS EHR-based measures and nudges addressing high-risk polypharmacy were feasible to develop and implement, and warrant further testing.
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Affiliation(s)
- Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Dr., 10th floor, Chicago, IL, 60611, USA. .,Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Tiffany Brown
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Dr., 10th floor, Chicago, IL, 60611, USA
| | - Jason N Doctor
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.,Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Craig R Fox
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Noah J Goldstein
- UCLA Anderson School of Management, UCLA Geffen School of Medicine, Los Angeles, CA, USA
| | - Steven M Handler
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Geriatric Research Education and Clinical Center/Center for Health Equity Research and Promotion, VA Pittsburgh Health System, Pittsburgh, PA, USA
| | - Joseph T Hanlon
- Division of Geriatric Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Geriatric Research Education and Clinical Center/Center for Health Equity Research and Promotion, VA Pittsburgh Health System, Pittsburgh, PA, USA
| | - Ji Young Lee
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Dr., 10th floor, Chicago, IL, 60611, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Dr., 10th floor, Chicago, IL, 60611, USA.,Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniella Meeker
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.,Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Theresa A Rowe
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Dr., 10th floor, Chicago, IL, 60611, USA
| | - Mark D Sullivan
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Mark W Friedberg
- Brigham and Women's Hospital, Harvard Medical School, RAND Corporation, Boston, MA, USA
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22
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McCabe B, Linder JA, Doctor JN, Friedberg M, Fox CR, Goldstein NJ, Knight TK, Kaiser K, Tibbels J, Haenchen S, Persell SD, Warberg R, Meeker D. The protocol of improving safe antibiotic prescribing in telehealth: A randomized trial. Contemp Clin Trials 2022; 119:106834. [PMID: 35724841 DOI: 10.1016/j.cct.2022.106834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The CDC estimates that over 40% of Urgent Care visits are for acute respiratory infections (ARI), more than half involving inappropriate antibiotic prescriptions. Previous randomized trials in primary care clinics resulted in reductions in inappropriate antibiotic prescribing, but antibiotic stewardship interventions in telehealth have not been systematically assessed. To better understand how best to decrease inappropriate antibiotic prescribing for ARIs in telehealth, we are conducting a large randomized quality improvement trial testing both patient- and physician-facing feedback and behavioral nudges embedded in the electronic health record. METHODS Teladoc® clinicians are assigned to one of 9 arms in a 3 × 3 randomized trial. Each clinician is assigned to one of 3 Commitment groups (Public, Private, Control) and one of 3 Performance Feedback groups (Benchmark Peer Comparison, Trending, Control). After randomly selecting ⅓ of states and associated clinicians required for patient-facing components of the Public Commitment intervention, remaining clinicians are randomized to the Control and Private commitment arms. Clinicians are randomized to the Performance Feedback conditions. The primary outcome is change from baseline in antibiotic prescribing rate for qualifying ARI visits. Secondary outcomes include changes in inappropriate prescribing and revisit rates. Secondary analyses include investigation of heterogeneity of treatment effects. With 1530 clinicians and an intra-clinician correlation in antibiotic prescribing rate of 0.5, we have >80% power to detect 1-7% absolute differences in antibiotic prescribing among groups. DISCUSSION Findings from this trial may help inform telehealth stewardship strategies, determine whether significant differences exist between Commitment and Feedback interventions, and provide guidance for clinicians and patients to encourage safe and effective antibiotic use. CLINICALTRIALS gov: NCT05138874.
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Affiliation(s)
- Bridget McCabe
- School of Medicine, University of Washington, Seattle, WA, United States of America; Teladoc Health
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Jason N Doctor
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, United States of America; Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, United States of America
| | - Mark Friedberg
- Blue Cross Blue Shield of Massachusetts, Boston, MA, United States of America
| | - Craig R Fox
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, United States of America
| | - Noah J Goldstein
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, United States of America
| | - Tara K Knight
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, United States of America
| | - Katrina Kaiser
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, United States of America; Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, United States of America
| | | | | | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | | | - Daniella Meeker
- Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
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Duan L, Lee MS, Adams JL, Sharp AL, Doctor JN. Opioid and Naloxone Prescribing Following Insertion of Prompts in the Electronic Health Record to Encourage Compliance With California State Opioid Law. JAMA Netw Open 2022; 5:e229723. [PMID: 35499826 PMCID: PMC9062689 DOI: 10.1001/jamanetworkopen.2022.9723] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Opioid addiction or dependency is a serious crisis in the US that affects public health as well as social and economic welfare. The State of California passed Assembly Bill (AB) 2760 in 2018 that mandates the coprescription of naloxone and opioids for patients with a high overdose risk. OBJECTIVE To assess whether the AB 2760-based electronic prompts were associated with increased naloxone orders for opioid users and reduced opioid prescribing when integrated into the practitioner workflow. DESIGN, SETTING, AND PARTICIPANTS This cohort study used interrupted time series mixed models to evaluate data obtained from the regional integrated health care system Kaiser Permanente Southern California (KPSC) from January 1, 2018, to December 31, 2019. Clinician participants were continuously employed at KPSC during the study period and ordered an opioid analgesic for eligible patients in 2018. Patient participants were KPSC members aged 18 years or older who received an opioid analgesic prescription during the study period. A series of AB 2760-based electronic prompts were integrated into the KPSC electronic health record system on December 27, 2018. The prompts are triggered or activated when 1 or more opioid prescribing conditions, defined in the AB 2760, are met at outpatient visits. Data were analyzed from January 8, 2021, to September 15, 2021. EXPOSURES Assembly Bill 2760-based electronic prompts for outpatient opioid prescriptions in the electronic health record system. MAIN OUTCOMES AND MEASURES Primary outcomes were changes in outpatient naloxone order rates among patients who were prescribed opioids and changes in outpatient opioid prescribing rates. Secondary outcomes were total morphine milligram equivalents (MMEs) ordered per prescriber-month, prompts-targeted objectives, and unintended consequences. Risk for opioid abuse among 3 types of patients was also assessed. RESULTS The 6515 eligible clinicians (mean [SD] age, 45.9 [9.43] years; 3604 men [55.3%]) included in the study served 500 711 unique patients in 1 903 289 outpatient encounters (mean [SD] age, 60.4 [15.67] years; 1 121 004 women [58.9%]) in which an opioid analgesic was prescribed. Naloxone order rate increased from 2.0% in December 2018 to 13.2% in January 2019 and then continued to increase to 27.1% in December 2019. Outpatient opioid prescribing rates decreased by 15.1% (rate ratio [RR], 0.85; 95% CI, 0.83-0.87) per prescriber-month when the electronic prompts were implemented. The postimplementation trend increased by 0.7% per prescriber-month (RR, 1.01; 95% CI, 1.01-1.01); the overall trend was still decreasing. The total MMEs per prescriber-month decreased by 7.8% (RR, 0.92; 95% CI, 0.89-0.96) after implementation of the prompts. The postimplementation trend tapered off. Other safe opioid prescribing measures also improved after implementation (decreases in concomitant muscle relaxants orders [RR, 0.94; 95% CI, 0.89-1.00], initial [RR, 0.86; 0.83-0.89] and renewal [RR, 0.65; 95% CI, 0.62-0.69] opioid orders, and long-term high-dose orders [RR, 0.96; 95% CI, 0.94-0.98]). CONCLUSIONS AND RELEVANCE This study found an association between implementation of AB 2760-based prompts and increased naloxone order rate; improved opioid prescribing measures (ie, decreased concomitant muscle relaxants orders, initial and renewal opioid orders, and long-term high-dose orders), except monthly median MMEs; and reduced opioid prescribing. The findings suggest that opioid overdose risks can be mitigated by encouraging safe prescribing habits.
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Affiliation(s)
- Lewei Duan
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - John L. Adams
- Kaiser Permanente Center for Effectiveness and Safety Research, Pasadena, California
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Adam L. Sharp
- Department of Emergency Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Jason N. Doctor
- Price School of Public Policy, University of Southern California, Los Angeles
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24
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Meeker D, Friedberg MW, Knight TK, Doctor JN, Zein D, Cayasso-McIntosh N, Goldstein NJ, Fox CR, Linder JA, Persell SD, Dea S, Giboney P, Yee HF. Effect of Peer Benchmarking on Specialist Electronic Consult Performance in a Los Angeles Safety-Net: a Cluster Randomized Trial. J Gen Intern Med 2022; 37:1400-1407. [PMID: 34505234 PMCID: PMC8428492 DOI: 10.1007/s11606-021-07002-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Since the advent of COVID-19, accelerated adoption of systems that reduce face-to-face encounters has outpaced training and best practices. Electronic consultations (eConsults), structured communications between PCPs and specialists regarding a case, have been effective in reducing face-to-face specialist encounters. As the health system rapidly adapts to multiple new practices and communication tools, new mechanisms to measure and improve performance in this context are needed. OBJECTIVE To test whether feedback comparing physicians to top performing peers using co-specialists' ratings improves performance. DESIGN Cluster-randomized controlled trial PARTICIPANTS: Eighty facility-specialty clusters and 214 clinicians INTERVENTION: Providers in the feedback arms were sent messages that announced their membership in an elite group of "Top Performers" or provided actionable recommendations with feedback for providers that were "Not Top Performers." MAIN MEASURES The primary outcomes were changes in peer ratings in the following performance dimensions after feedback was received: (1) elicitation of information from primary care practitioners; (2) adherence to institutional clinical guidelines; (3) agreement with peer's medical decision-making; (4) educational value; (5) relationship building. KEY RESULTS Specialists showed significant improvements on 3 of the 5 consultation performance dimensions: medical decision-making (odds ratio 1.52, 95% confidence interval 1.08-2.14, p<.05), educational value (1.86, 1.17-2.96) and relationship building (1.63, 1.13-2.35) (both p<.01). CONCLUSIONS The pandemic has shed light on clinicians' commitment to professionalism and service as we rapidly adapt to changing paradigms. Interventions that appeal to professional norms can help improve the efficacy of new systems of practice. We show that specialists' performance can be measured and improved with feedback using aspirational norms. TRIAL REGISTRATION clinicaltrials.gov NCT03784950.
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Affiliation(s)
- Daniella Meeker
- Department of Population and Public Health Sciences, University of Southern California, 2250 Alcazar St, Los Angeles, CA, 90033, USA.
| | - Mark W Friedberg
- Brigham and Women's Hospital, Boston, MA, USA
- Blue Cross Blue Shield of Massachusetts, Boston, MA, USA
| | - Tara K Knight
- Sol Price School of Public Policy & Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, USA
| | - Jason N Doctor
- Sol Price School of Public Policy & Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, USA
| | - Dina Zein
- Department of Population and Public Health Sciences, University of Southern California, 2250 Alcazar St, Los Angeles, CA, 90033, USA
| | | | - Noah J Goldstein
- Anderson School of Management, University of California, Los Angeles, Los Angeles, USA
| | - Craig R Fox
- Anderson School of Management, University of California, Los Angeles, Los Angeles, USA
| | - Jeffrey A Linder
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stephen D Persell
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stanley Dea
- Los Angeles County Department of Health Services, Los Angeles, CA, USA
| | - Paul Giboney
- Los Angeles County Department of Health Services, Los Angeles, CA, USA
| | - Hal F Yee
- Los Angeles County Department of Health Services, Los Angeles, CA, USA
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25
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Doctor JN, Sullivan MD. Knowledge Translation and the Opioid Crisis. Am J Public Health 2022; 112:S15-S17. [PMID: 35143265 PMCID: PMC8842211 DOI: 10.2105/ajph.2021.306670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Jason N Doctor
- Jason N. Doctor is with the Sol Price School of Public Policy, University of Southern California, Los Angeles. Mark D. Sullivan is with the School of Medicine, University of Washington, Seattle
| | - Mark D Sullivan
- Jason N. Doctor is with the Sol Price School of Public Policy, University of Southern California, Los Angeles. Mark D. Sullivan is with the School of Medicine, University of Washington, Seattle
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Kelley MA, Persell SD, Linder JA, Friedberg MW, Meeker D, Fox CR, Goldstein NJ, Knight TK, Zein D, Sullivan M, Doctor JN. The protocol of the Application of Economics & Social psychology to improve Opioid Prescribing Safety trial 2 (AESOPS-2): Availability of opioid harm. Contemp Clin Trials 2022; 112:106650. [PMID: 34896295 PMCID: PMC8869359 DOI: 10.1016/j.cct.2021.106650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 11/29/2021] [Accepted: 12/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND High levels of opioid prescribing in the United States has resulted in an alarming trend in opioid-related harms. The objective of Trial 2 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-2) is to dampen the intensity and frequency of opioid prescribing in accordance with the Centers for Disease Control and Prevention recommendation to "go low and slow". We aim to accomplish this by notifying clinicians of harmful patient outcomes, which we expect to increase the mental availability of risks associated with opioid use. METHODS The trial is multi-site. Random assignment determines if prescribers to persons who suffer an opioid overdose (fatal or nonfatal) learn of this event (intervention) or practice usual care (control). Clinicians in the intervention group receive a letter notifying them of their patient's overdose. The primary outcome is the change in clinician weekly milligram morphine equivalent (MME) prescribed in a 6-month period before and after receiving the letter. Additional outcomes are the change in the proportion of patients prescribed at least 50 daily MME and in the proportion of patients referred to medication assisted treatment. Group differences in these outcomes will be compared using an intent-to-treat difference-in-differences framework with a mixed-effects regression model to estimate clinician MME. DISCUSSION The AESOPS-2 trial will provide new knowledge about whether increasing prescribers' awareness of patients' opioid-related overdoses leads to a reduction in opioid prescribing. Additionally, this trial may better inform how to reduce opioid use disorder and opioid overdoses by lowering population exposure to these drugs. TRIAL REGISTRATION ClinicalTrials.gov: NCT04758637.
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Affiliation(s)
- Marcella A. Kelley
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA.,School of Pharmacy, University of Southern California, Los Angeles, CA
| | - Stephen D. Persell
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jeffrey A. Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Daniella Meeker
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA.,Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Craig R. Fox
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA
| | - Noah J. Goldstein
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA
| | - Tara K. Knight
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA
| | - Dina Zein
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA
| | - Mark Sullivan
- School of Medicine, University of Washington, School of Medicine, Seattle, WA
| | - Jason N. Doctor
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA.,School of Pharmacy, University of Southern California, Los Angeles, CA.,Sol Price School of Public Policy, University of Southern California, Los Angeles, CA
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Kelley MA, Lucas J, Stewart E, Goldman D, Doctor JN. Opioid-related deaths before and after COVID-19 stay-at-home orders in Los Angeles County. Drug Alcohol Depend 2021; 228:109028. [PMID: 34500239 PMCID: PMC8411574 DOI: 10.1016/j.drugalcdep.2021.109028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Opioid-related morbidity and mortality has increased during the COVID-19 pandemic, yet specific information about the communities most affected remains unknown. Our objective is to evaluate decedent-level associations with an opioid-related death following the implementation of stay-at-home orders in Los Angeles County. METHODS This retrospective cohort study used data from the L.A. County Medical Examiner-Coroner to identify opioid-related deaths in 2019 and 2020. We used logistic regression to analyze the change in opioid-related deaths following a 30-day washout period after the start of stay-at-home orders. Independent variables included decedent age, gender, race and ethnicity, heroin or fentanyl present at the time of death, census tract-level education, and a scheduled drug prescription in the year before death. RESULTS Opioid-related deaths in L.A. County are most common in census tracts where a small percentage of the population has a Bachelor's degree. Following stay-at-home orders, Non-Hispanic Caucasian individuals had significantly more opioid-related deaths than Hispanic individuals (risk ratio (RR): 1.82 [95 % CI, 1.10-3.02]; P < 0.05) after adjusting for age, gender, and heroin or fentanyl use. Racial and ethnic differences in mortality were not explained by census tract-level education or recent scheduled drug prescriptions. DISCUSSION There has been an alarming rise in opioid-related deaths in L.A. County during 2020. The increase in opioid-related overdose deaths following the onset of COVID-19 and related policies occurred most often among Non-Hispanic Caucasian individuals. Further research on this trend's underlying cause is needed to inform policy recommendations during these simultaneous public health crises.
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Affiliation(s)
- Marcella A. Kelley
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA,Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Jonathan Lucas
- Department of Medical Examiner-Coroner, County of Los Angeles, CA, USA
| | - Emily Stewart
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA,Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Dana Goldman
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA,Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA,Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Jason N. Doctor
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA,Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA,Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA,Corresponding author at: The Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
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Kim J, Neumann L, Paul P, Day ME, Aratow M, Bell DS, Doctor JN, Hinske LC, Jiang X, Kim KK, Matheny ME, Meeker D, Pletcher MJ, Schilling LM, SooHoo S, Xu H, Zheng K, Ohno-Machado L. Privacy-protecting, reliable response data discovery using COVID-19 patient observations. J Am Med Inform Assoc 2021; 28:1765-1776. [PMID: 34051088 PMCID: PMC8194878 DOI: 10.1093/jamia/ocab054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/28/2020] [Accepted: 03/17/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To utilize, in an individual and institutional privacy-preserving manner, electronic health record (EHR) data from 202 hospitals by analyzing answers to COVID-19-related questions and posting these answers online. MATERIALS AND METHODS We developed a distributed, federated network of 12 health systems that harmonized their EHRs and submitted aggregate answers to consortia questions posted at https://www.covid19questions.org. Our consortium developed processes and implemented distributed algorithms to produce answers to a variety of questions. We were able to generate counts, descriptive statistics, and build a multivariate, iterative regression model without centralizing individual-level data. RESULTS Our public website contains answers to various clinical questions, a web form for users to ask questions in natural language, and a list of items that are currently pending responses. The results show, for example, that patients who were taking angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, within the year before admission, had lower unadjusted in-hospital mortality rates. We also showed that, when adjusted for, age, sex, and ethnicity were not significantly associated with mortality. We demonstrated that it is possible to answer questions about COVID-19 using EHR data from systems that have different policies and must follow various regulations, without moving data out of their health systems. DISCUSSION AND CONCLUSIONS We present an alternative or a complement to centralized COVID-19 registries of EHR data. We can use multivariate distributed logistic regression on observations recorded in the process of care to generate results without transferring individual-level data outside the health systems.
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Affiliation(s)
- Jihoon Kim
- UC San Diego Health Department of Biomedical Informatics, University of
California San Diego, La Jolla, California, USA
| | - Larissa Neumann
- Institute for Medical Information Processing, Biometry, and Epidemiology,
Ludwig Maximilian University of Munich, Munich, Germany
- LMU Klinikum, Department of Anesthesiology, Ludwig Maximilian University of
Munich, Munich, Germany
| | - Paulina Paul
- UC San Diego Health Department of Biomedical Informatics, University of
California San Diego, La Jolla, California, USA
| | - Michele E Day
- UC San Diego Health Department of Biomedical Informatics, University of
California San Diego, La Jolla, California, USA
| | | | - Douglas S Bell
- Biomedical Informatics Program, UCLA Clinical and Translational Science
Institute (CTSI), Los Angeles, California, USA
| | - Jason N Doctor
- USC Schaeffer Center for Health Policy and Economics, Price School of
Policy, University of Southern California, Los Angeles, California,
USA
| | - Ludwig C Hinske
- Institute for Medical Information Processing, Biometry, and Epidemiology,
Ludwig Maximilian University of Munich, Munich, Germany
- LMU Klinikum, Department of Anesthesiology, Ludwig Maximilian University of
Munich, Munich, Germany
| | - Xiaoqian Jiang
- School of Biomedical Informatics, The University of Texas Health Science
Center at Houston, Houston, Texas, USA
| | - Katherine K Kim
- Betty Irene Moore School of Nursing, University of California Davis Medical
Center, Sacramento, California, USA
- Health Informatics Division, Department of Public Health Sciences, School
of Medicine, UC Davis Health, Sacramento, California, USA
| | - Michael E Matheny
- GRECC Tennessee Valley Healthcare System, Nashville,
Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
| | - Daniella Meeker
- Department of Preventive Medicine, Keck School of Medicine of
USC, Los Angeles, California, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California, San
Francisco, San Francisco, California, USA
| | - Lisa M Schilling
- Data Science and Patient Value Program, University of Colorado Anschutz
Medical Campus, Aurora, Colorado, USA
| | - Spencer SooHoo
- Division of Informatics, Department of Biomedical Sciences, Cedars Sinai
Medical Center, Los Angeles, California, USA
| | - Hua Xu
- School of Biomedical Informatics, The University of Texas Health Science
Center at Houston, Houston, Texas, USA
| | - Kai Zheng
- Department of Informatics, Donald Bren School of Information and Computer
Sciences, University of California, Irvine, Irvine, California, USA
| | - Lucila Ohno-Machado
- UC San Diego Health Department of Biomedical Informatics, University of
California San Diego, La Jolla, California, USA
- Veteran Affairs San Diego Healthcare System, San Diego,
California, USA
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Bradley-Ewing A, Lee BR, Doctor JN, Meredith G, Goggin K, Myers A. A pilot intervention combining assessment and feedback with communication training and behavioral nudges to increase HPV vaccine uptake. Hum Vaccin Immunother 2021; 18:1885968. [PMID: 34085873 PMCID: PMC8920206 DOI: 10.1080/21645515.2021.1885968] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Human papillomavirus (HPV) causes >40,000 cancer diagnoses each year, yet vaccination rates remain low because widespread implementation of strategies to increase vaccinations has not occurred. Behavioral nudges have demonstrated efficacy in improving uptake of desired behaviors in health care settings but have not been tested for increasing HPV vaccinations. We assessed the impact of an intervention combining behavioral nudges with other proven strategies (i.e., assessment and feedback, provider communication training) on HPV vaccination rates and parental satisfaction in four Midwestern pediatric, outpatient practices. Practices were randomly assigned to receive either assessment and feedback or assessment and feedback combined with vaccine communication training and behavioral nudges in the form of vaccine commitment posters. Providers (n = 16) completed surveys regarding vaccine policies and parents (n = 215) reported on their child's vaccine history and satisfaction with the consultation. Three practices increased HPV vaccination rates (1-10%); however, there was no statistically significant difference by study arm. Most parents (M age 41.3; SD 8.1; 85% female, 68% White) indicated their child had previously initiated the HPV vaccine series (61%) and 72% indicated receipt of an HPV vaccine during the study visit. Concerns among HPV vaccine-hesitant parents (28%) included vaccine safety and believing the vaccine is unnecessary (40%). Most parents were satisfied with their consultation. Practices in both intervention groups increased vaccination rates. While some parents continue to harbor concerns about vaccine safety and necessity, parents welcomed discussions about HPV and were satisfied with their provider's communication regardless of their vaccine decisions.
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Affiliation(s)
- Andrea Bradley-Ewing
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Brian R Lee
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Jason N Doctor
- Department of Health Policy and Management, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
| | - Georgann Meredith
- Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Kathy Goggin
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, University of Missouri - Kansas City Schools of Medicine and Pharmacy, Kansas City, MO USA
| | - Angela Myers
- Division of Infectious Diseases, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
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Rowe TA, Brown T, Doctor JN, Linder JA, Persell SD. Examining primary care physician rationale for not following geriatric choosing wisely recommendations. BMC Fam Pract 2021; 22:95. [PMID: 33992080 PMCID: PMC8126116 DOI: 10.1186/s12875-021-01440-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 04/22/2021] [Indexed: 01/22/2023]
Abstract
Background The objective is to understand why physicians order tests or treatments in older adults contrary to published recommendations. Methods Participants: Physicians above the median for ≥ 1 measures of overuse representing 3 Choosing Wisely topics. Measurements: Participants evaluated decisions in a semi-structured interview regarding: 1) Screening men aged ≥ 76 with prostate specific antigen 2) Ordering urine studies in women ≥ 65 without symptoms 3) Overtreating adults aged ≥ 75 with insulin or oral hypoglycemic medications. Two investigators independently coded transcripts using qualitative analysis. Results Nineteen interviews were conducted across the three topics resulting in four themes. First, physicians were aware and knowledgeable of guidelines. Second, perceived patient preference towards overuse influenced physician action even when physicians felt strongly that testing was not indicated. Third, physicians overestimated benefits of a test and underemphasized potential harms. Fourth, physicians were resistant to change when patients appeared to be doing well. Conclusions Though physicians expressed awareness to avoid overuse, deference to patient preferences and the tendency to distort the chance of benefit over harm influenced decisions to order testing. Approaches for decreasing unnecessary testing must account for perceived patient preferences, make the potential harms of overtesting salient, and address clinical inertia among patients who appear to be doing well. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01440-w.
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Affiliation(s)
- Theresa A Rowe
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, 750 N Lakeshore Dr. 10th Floor, Chicago, IL, 60611, USA.
| | - Tiffany Brown
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, 750 N Lakeshore Dr. 10th Floor, Chicago, IL, 60611, USA
| | - Jason N Doctor
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, 750 N Lakeshore Dr. 10th Floor, Chicago, IL, 60611, USA
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, 750 N Lakeshore Dr. 10th Floor, Chicago, IL, 60611, USA.,Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Duan L, Doctor JN, Adams JL, Romley JA, Nguyen LA, An J, Lee MS. Comparison of Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation and Bioprosthetic Heart Valves. Am J Cardiol 2021; 146:22-28. [PMID: 33529622 DOI: 10.1016/j.amjcard.2021.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 12/24/2022]
Abstract
There are limited data regarding direct oral anticoagulants (DOACs) for stroke prevention in patients with bioprosthetic heart valves (BHVs) and atrial fibrillation (AF). The objectives of this study were to evaluate the ambulatory utilization of DOACs and to compare the effectiveness and safety of DOACs versus warfarin in patients with AF and BHVs. We conducted a retrospective cohort study at a large integrated health care delivery system in California. Patients with BHVs and AF treated with warfarin, dabigatran, rivaroxaban, or apixaban between September 12, 2011 and June 18, 2020 were identified. Inverse probability of treatment-weighted comparative effectiveness and safety of DOACs compared with warfarin were determined. Use of DOACs gradually increased since 2011, with a significant upward in trend after a stay-at-home order related to COVID-19. Among 2,672 adults with BHVs and AF who met the inclusion criteria, 439 were exposed to a DOAC and 2233 were exposed to warfarin. For the primary effectiveness outcome of ischemic stroke, systemic embolism and transient ischemic attack, no significant association was observed between use of DOACs compared with warfarin (HR 1.19, 95% CI 0.96 to 1.48, p = 0.11). Use of DOACs was associated with lower risk of the primary safety outcome of intracranial hemorrhage, gastrointestinal bleeding, and other bleed (HR 0.69, 95% CI 0.56 to 0.85, p < 0.001). Results were consistent across multiple subgroups in the sensitivity analyses. These findings support the use of DOACs for AF in patients with BHVs.
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Kelley MA, Persell SD, Linder JA, Friedberg MW, Meeker D, Fox CR, Goldstein NJ, Knight TK, Zein D, Rowe TA, Sullivan MD, Doctor JN. The protocol of the Application of Economics & Social psychology to improve Opioid Prescribing Safety Trial 1 (AESOPS-1): Electronic health record nudges. Contemp Clin Trials 2021; 103:106329. [PMID: 33636344 PMCID: PMC8089040 DOI: 10.1016/j.cct.2021.106329] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/08/2021] [Accepted: 02/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is a lack of evidence that long-term opioid use offers benefit for noncancer pain and an abundance of evidence of harm. Despite clinical guidelines and education, prescribing continues at a higher rate than before the opioids crisis. The objective of trial 1 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-1) is to discourage unnecessary opioid prescribing in primary care by applying "behavioral insights"-empirically-tested social and psychological interventions that affect choice. METHODS AESOPS-1 randomizes primary care clinics in Illinois and California to behavioral intervention or control. Both arms receive opioid guideline education. Clinics randomized to the behavioral intervention arm receive nudges within the electronic health record (EHR) including: 1) an "accountable justification" entered in the chart, 2) a precommitment to address high-risk prescriptions, and 3) a "PainTracker" that broadens discussions about pain. The control arm receives no EHR-based intervention. The primary outcome is the change in weekly milligram morphine equivalents (MME) prescribed. The secondary outcome is the change in the proportion of patients prescribed at least 50 daily MME. To evaluate these outcomes, we will use a difference-in-differences mixed-effects regression model on clinician MME weekly or daily dose. The analysis will be "intent-to-treat." The intervention period is 18-months, with a 6-month follow-up period to measure persistence of effects. DISCUSSION The AESOPS-1 trial will evaluate the effect of EHR-based interventions in reducing noncancer opioid prescribing in primary care. AESOPS-1 may demonstrate practical and scalable strategies to lower unnecessary population exposure to opioids.
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Affiliation(s)
- Marcella A Kelley
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA, United States of America; School of Pharmacy, University of Southern California, Los Angeles, CA, United States of America
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Mark W Friedberg
- Blue Cross Blue Shield of Massachusetts, Boston, MA, United States of America
| | - Daniella Meeker
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America
| | - Craig R Fox
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, United States of America
| | - Noah J Goldstein
- Anderson School of Management, University of California at Los Angeles, Los Angeles, CA, United States of America
| | - Tara K Knight
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA, United States of America; Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, United States of America
| | - Dina Zein
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA, United States of America
| | - Theresa A Rowe
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Mark D Sullivan
- School of Medicine, University of Washington, School of Medicine, Seattle, WA, United States of America
| | - Jason N Doctor
- Schaeffer Center for Health Economics and Policy, University of Southern California, Los Angeles, CA, United States of America; School of Pharmacy, University of Southern California, Los Angeles, CA, United States of America; Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, United States of America.
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Doctor JN, Vaidya J, Jiang X, Wang S, Schilling LM, Ong T, Matheny ME, Ohno-Machado L, Meeker D. Efficient determination of equivalence for encrypted data. Comput Secur 2020; 97. [PMID: 33223585 DOI: 10.1016/j.cose.2020.101939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Secure computation of equivalence has fundamental application in many different areas, including health-care. We study this problem in the context of matching an individual's identity to link medical records across systems under the socialist millionaires' problem: Two millionaires wish to determine if their fortunes are equal without disclosing their net worth (Boudot, et al. 2001). In Theorem 2, we show that when a "greater than" algorithm is carried out on a totally ordered set it is easy to achieve secure matching without additional rounds of communication. We present this efficient solution to assess equivalence using a set intersection algorithm designed for "greater than" computation and demonstrate its effectiveness on equivalence of arbitrary data values, as well as demonstrate how it meets regulatory criteria for risk of disclosure.
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Affiliation(s)
- Jason N Doctor
- Schaeffer Center for Health Policy and Economics, University of Southern California, 635 Downey Way, Los Angeles, CA 90089-3333, United States
| | - Jaideep Vaidya
- Management Science & Information Systems Department, Rutgers University, Newark, NJ, United States
| | - Xiaoqian Jiang
- UCSD Health Department of Biomedical Informatics, UC San Diego, La Jolla, CA, United States
| | - Shuang Wang
- UCSD Health Department of Biomedical Informatics, UC San Diego, La Jolla, CA, United States
| | - Lisa M Schilling
- Department of Medicine, University of Colorado, Anschutz Medical Campus, CO, United States
| | - Toan Ong
- Department of Medicine, University of Colorado, Anschutz Medical Campus, CO, United States
| | - Michael E Matheny
- Geriatric Research Education and Clinical Care Service, Tennessee Valley Healthcare System VA, Nashville, TN, United States
- Department of Biomedical Informatics, Medicine, and Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lucila Ohno-Machado
- UCSD Health Department of Biomedical Informatics, UC San Diego, La Jolla, CA, United States
| | - Daniella Meeker
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Kim J, Neumann L, Paul P, Aratow M, Bell DS, Doctor JN, Hinske LC, Jiang X, Kim KK, Matheny ME, Meeker D, Pletcher MJ, Schilling LM, Soohoo S, Xu H, Zheng K, Ohno-machado L, for the R2D2 Consortium. Privacy-Protecting, Reliable Response Data Discovery Using COVID-19 Patient Observations.. [PMID: 32995818 PMCID: PMC7523159 DOI: 10.1101/2020.09.21.20196220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There is an urgent need to answer questions related to COVID-19’s clinical course and associations with underlying conditions and health outcomes. Multi-center data are necessary to generate reliable answers, but centralizing data in a single repository is not always possible. Using a privacy-protecting strategy, we launched a public Questions & Answers web portal (https://covid19questions.org) with analyses of comorbidities, medications and laboratory tests using data from 202 hospitals (59,074 COVID-19 patients) in the USA and Germany. We find, for example, that 8.6% of hospitalizations in which the patient was not admitted to the ICU resulted in the patient returning to the hospital within seven days from discharge and that, when adjusted for age, mortality for hospitalized patients was not significantly different by gender or ethnicity. Publicly Sharing Knowledge on COVID19 Without Sharing Patient-Level Data: A Privacy-Protecting Multivariate Analysis Approach
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Affiliation(s)
- Craig R Fox
- Anderson School of Management, University of California, Los Angeles, CA, USA
| | | | - Noah J Goldstein
- Anderson School of Management, University of California, Los Angeles, CA, USA
| | | | - Stephen D Persell
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey A Linder
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Zetts RM, Stoesz A, Garcia AM, Doctor JN, Gerber JS, Linder JA, Hyun DY. Primary care physicians' attitudes and perceptions towards antibiotic resistance and outpatient antibiotic stewardship in the USA: a qualitative study. BMJ Open 2020; 10:e034983. [PMID: 32665343 PMCID: PMC7365421 DOI: 10.1136/bmjopen-2019-034983] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 05/01/2020] [Accepted: 06/08/2020] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES At least 30% of outpatient antibiotic prescriptions are unnecessary. Outpatient antibiotic stewardship is needed to improve prescribing and address the threat of antibiotic resistance. A better understanding of primary care physicians (PCPs) attitudes towards antibiotic prescribing and outpatient antibiotic stewardship is needed to identify barriers to stewardship implementation and help tailor stewardship strategies. The aim of this study was to assess PCPs current attitudes towards antibiotic resistance, inappropriate antibiotic prescribing and the feasibility of outpatient stewardship efforts. DESIGN Eight focus groups with PCPs were conducted by an independent moderator using a moderator guide. Focus groups were audio recorded, transcribed and coded for major themes using deductive and inductive content analysis methods. SETTING Focus groups were conducted in four US cities: Philadelphia, Birmingham, Chicago and Los Angeles. PARTICIPANTS Two focus groups were conducted in each city-one with family medicine and internal medicine physicians and one with paediatricians. A total of 26 family medicine/internal medicine physicians and 26 paediatricians participated. RESULTS Participants acknowledged that resistance is an important public health issue, but not as important as other pressing problems (eg, obesity, opioids). Many considered resistance to be more of a hospital issue. While participants recognised inappropriate prescribing as a problem in outpatient settings, many felt that the key drivers were non-primary care settings (eg, urgent care clinics, retail clinics) and patient demand. Participants reacted positively to stewardship efforts aimed at educating patients and clinicians. They questioned the validity of antibiotic prescribing metrics. This scepticism was due to a number of factors, including the feasibility of capturing prescribing quality, a belief that physicians will 'game the system' to improve their measures, and dissatisfaction and distrust of quality measurement in general. CONCLUSIONS Stakeholders will need to consider physician attitudes and beliefs about antibiotic stewardship when implementing interventions aimed at improving prescribing.
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Affiliation(s)
- Rachel M Zetts
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
| | - Andrea Stoesz
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
| | - Andrea M Garcia
- Health & Science, American Medical Association, Chicago, Illinois, USA
| | - Jason N Doctor
- Department of Health Policy and Management, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Y Hyun
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
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Zetts RM, Garcia AM, Doctor JN, Gerber JS, Linder JA, Hyun DY. Primary Care Physicians' Attitudes and Perceptions Towards Antibiotic Resistance and Antibiotic Stewardship: A National Survey. Open Forum Infect Dis 2020; 7:ofaa244. [PMID: 32782909 PMCID: PMC7406830 DOI: 10.1093/ofid/ofaa244] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/11/2020] [Indexed: 01/08/2023] Open
Abstract
Background Outpatient antibiotic stewardship is needed to reduce inappropriate prescribing and minimize the development of resistant bacteria. We assessed primary care physicians’ perceptions of antibiotic resistance, antibiotic use, and the need for stewardship activities. Methods We conducted a national online survey of 1550 internal, family, and pediatric medicine physicians in the United States recruited from an opt-in panel of healthcare professionals. Descriptive statistics were generated for respondent demographics and question responses. Responses were also stratified by geographic region and medical specialty, with a χ 2 test used to assess for differences. Results More respondents agreed that antibiotic resistance was a problem in the United States (94%) than in their practice (55%) and that inappropriate antibiotic prescribing was a problem in outpatient settings (91%) than in their practice (37%). In addition, 60% agreed that they prescribed antibiotics more appropriately than their peers. Most respondents (91%) believed that antibiotic stewardship was appropriate in office-based practices, but they ranked antibiotic resistance as less important than other public health issues such as obesity, diabetes, opioids, smoking, and vaccine hesitancy. Approximately half (47%) believed they would need a lot of help to implement stewardship. Respondents indicated that they were likely to implement antibiotic stewardship efforts in response to feedback or incentives provided by payers or health departments. Conclusions Primary care physicians generally did not recognize antibiotic resistance and inappropriate prescribing as issues in their practice. This poses a challenge for the success of outpatient stewardship. Healthcare stakeholders will need to explore opportunities for feedback and incentive activities to encourage stewardship uptake.
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Affiliation(s)
- Rachel M Zetts
- The Pew Charitable Trusts, Washington, District of Columbia, USA
| | | | - Jason N Doctor
- Department of Health Policy and Management, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Y Hyun
- The Pew Charitable Trusts, Washington, District of Columbia, USA
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Rowe TA, Brown T, Lee JY, Linder JA, Friedberg MW, Doctor JN, Meeker D, Ciolino JD, Persell SD. Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement. J Gen Intern Med 2020; 35:1797-1802. [PMID: 32128687 PMCID: PMC7280408 DOI: 10.1007/s11606-020-05748-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/14/2020] [Indexed: 11/29/2022]
Abstract
IMPORTANCE The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood. OBJECTIVE To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults. DESIGN Retrospective analysis of overall means and clinician-level variation in performance on three new measures. SUBJECTS Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017. MEASURES Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication. RESULTS Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively. CONCLUSIONS Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.
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Affiliation(s)
- Theresa A Rowe
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Tiffany Brown
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ji Young Lee
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark W Friedberg
- RAND Corporation, Boston, MA, USA.,Blue Cross Blue Shield of Massachusetts, Boston, MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason N Doctor
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Daniella Meeker
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jody D Ciolino
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Rowe TA, Brown T, Lee JY, Linder JA, Friedberg MW, Doctor JN, Meeker D, Ciolino JD, Persell SD. Clinician-Level Variation in Three Measures Representing Overuse Based on the American Geriatrics Society Choosing Wisely Statement. J Gen Intern Med 2020. [PMID: 32128687 DOI: 10.1007/s11606-020-05748-8/figures/3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
IMPORTANCE The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood. OBJECTIVE To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults. DESIGN Retrospective analysis of overall means and clinician-level variation in performance on three new measures. SUBJECTS Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017. MEASURES Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication. RESULTS Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8-54% for the PSA measure, 3-35% for the urinalysis/urine culture measure, and 13-49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively. CONCLUSIONS Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined.
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Affiliation(s)
- Theresa A Rowe
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Tiffany Brown
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ji Young Lee
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark W Friedberg
- RAND Corporation, Boston, MA, USA
- Blue Cross Blue Shield of Massachusetts, Boston, MA, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason N Doctor
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Daniella Meeker
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jody D Ciolino
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Primary Care Innovation, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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40
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Darnall BD, Juurlink D, Kerns RD, Mackey S, Van Dorsten B, Humphreys K, Gonzalez-Sotomayor JA, Furlan A, Gordon AJ, Gordon DB, Hoffman DE, Katz J, Kertesz SG, Satel S, Lawhern RA, Nicholson KM, Polomano RC, Williamson OD, McAnally H, Kao MC, Schug S, Twillman R, Lewis TA, Stieg RL, Lorig K, Mallick-Searle T, West RW, Gray S, Ariens SR, Sharpe Potter J, Cowan P, Kollas CD, Laird D, Ingle B, Julian Grove J, Wilson M, Lockman K, Hodson F, Palackdharry CS, Fillingim RB, Fudin J, Barnhouse J, Manhapra A, Henson SR, Singer B, Ljosenvoor M, Griffith M, Doctor JN, Hardin K, London C, Mankowski J, Anderson A, Ellsworth L, Davis Budzinski L, Brandt B, Hartley G, Nickels Heck D, Zobrosky MJ, Cheek C, Wilson M, Laux CE, Datz G, Dunaway J, Schonfeld E, Cady M, LeDantec-Boswell T, Craigie M, Sturgeon J, Flood P, Giummarra M, Whelan J, Thorn BE, Martin RL, Schatman ME, Gregory MD, Kirz J, Robinson P, Marx JG, Stewart JR, Keck PS, Hadland SE, Murphy JL, Lumley MA, Brown KS, Leong MS, Fillman M, Broatch JW, Perez A, Watford K, Kruska K, Sophia You D, Ogbeide S, Kukucka A, Lawson S, Ray JB, Wade Martin T, Lakehomer JB, Burke A, Cohen RI, Grinspoon P, Rubenstein MS, Sutherland S, Walters K, Lovejoy T. International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering. Pain Med 2019; 20:429-433. [PMID: 30496540 DOI: 10.1093/pm/pny228] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Beth D Darnall
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Psychiatry and Behavioral Sciences (by courtesy), Palo Alto, California
| | - David Juurlink
- Division of Clinical Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | | | - Sean Mackey
- Division of Pain Medicine, Stanford Systems Neuroscience and Pain Lab, Stanford University School of Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Neurosciences and Neurology (by courtesy), Palo Alto, California
| | - Brent Van Dorsten
- Colorado Center for Behavioral Medicine, Colorado Pain Society, Denver, Colorado
| | | | - Julio A Gonzalez-Sotomayor
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon
| | - Andrea Furlan
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Adam J Gordon
- University of Utah School of Medicine, Salt Lake City, Utah.,Addiction Medicine, Salt Lake City VA Health Care System, Salt Lake City, Utah
| | - Debra B Gordon
- Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Diane E Hoffman
- Law & Health Care Program, University of Maryland Carey School of Law
| | - Joel Katz
- Psychology Department, York University, Toronto, Ontario, Canada
| | - Stefan G Kertesz
- Birmingham VA Medical Center, University of Alabama at Birmingham School of Medicine, Opioid Safety Initiative, Opiate Advice Team, Opioid Risk Mitigation Team, Birmingham, Alabama
| | - Sally Satel
- Yale University School of Medicine, New Haven, Connecticut.,American Enterprise Institute, Washington, DC
| | | | | | - Rosemary C Polomano
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania.,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | - Heath McAnally
- Northern Anesthesia & Pain Medicine, LLC, Eagle River, Alaska.,Alaska Society of Interventional Pain Physicians
| | | | - Stephan Schug
- University of Western Australia, Perth, Australia.,Royal Perth Hospital, Perth, Australia
| | - Robert Twillman
- Academy of Integrative Pain Management, Sonora, California.,Department of Psychiatry and Behavioral Sciences, University of Kansas School of Medicine, Kansas City, Kansas
| | - Terri A Lewis
- Southern Illinois University, Carbondale, Illinois.,National Changhua University of Education, Changhua, Taiwan, Republic of China
| | | | - Kate Lorig
- Stanford School of Medicine, Stanford, California
| | | | | | - Sarah Gray
- Spaulding Rehabilitation Hospital, Boston, Massachusetts.,Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Integrative Psychology and Behavioral Medicine, Boston, Massachusetts
| | - Steven R Ariens
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | | | - Penney Cowan
- American Chronic Pain Association, Rocklin, California
| | - Chad D Kollas
- Palliative & Supportive Care, Orlando Health UF Health Cancer Center, Orlando, Florida
| | - Danial Laird
- Flamingo Pain Specialists, PLLC, Las Vegas, Nevada
| | | | | | - Marian Wilson
- Program of Excellence in Addictions Research (Pain Self-Management/Opioid Use Disorder), Washington State University, Spokane, Washington.,College of Nursing, Washington State University, Spokane, Washington
| | - Kashelle Lockman
- Palliative Care, University of Iowa College of Pharmacy, Iowa City, Iowa
| | - Fiona Hodson
- Hunter Integrated Pain Service, John Hunter Hospital Campus, Newcastle, Australia
| | | | - Roger B Fillingim
- College of Dentistry.,Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, Florida
| | - Jeffrey Fudin
- Albany College of Pharmacy and Health Sciences, Albany, New York.,Western New England University College of Pharmacy, Springfield, Massachusetts
| | | | - Ajay Manhapra
- Advanced PACT Pain Clinic, Hampton VA Medical Center, Hampton, Virginia.,VA New England Mental Illness, West Haven, Connecticut.,Eastern Virginia Medical School, Norfolk, Virginia.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Steven R Henson
- Veteran of the United States Navy, Air Medical Physician's Association, Medical Missions Outreach
| | - Bruce Singer
- Urban Recovery Center, Silver Hill Hospital, New Canaan, Connecticut.,Chronic Pain and Recovery Center, Silver Hill Hospital, New Canaan, Connecticut
| | - Marie Ljosenvoor
- Critical Access Hospital Specialist in Hospice & Palliative Care, Cook Hospital & Care Center, Cook, Minnesota
| | | | - Jason N Doctor
- Health Policy & Management, University of Southern California, Los Angeles, California
| | | | | | | | | | | | | | | | - Greg Hartley
- Department of Physical Therapy, Academy of Geriatric Physical Therapy, University of Miami Miller School of Medicine
| | - Debbie Nickels Heck
- White River Heath Care, PC, Muncie, Indiana.,School of Medicine, Indiana University, Indianapolis, Indiana.,AIPM.,NEIGlobal.,AAPS
| | | | | | | | | | - Geralyn Datz
- Southern Behavioral Medicine Associates PLLC, Hattiesburg, Mississippi
| | - Justin Dunaway
- Institute of Clinical Excellence, STAND The Haiti Project, Portland, Oregon
| | - Eileen Schonfeld
- End of Life, Psychiatric and Mental Health Nurse, Long Term Care, Education, Alliance for the Treatment of Intractable Pain, Akron, Ohio
| | | | | | - Meredith Craigie
- CALHN Pain Management Unit, Woodville, Adelaide, South Australia, Australia.,Faculty of Pain Medicine, ANZCA
| | - John Sturgeon
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Pamela Flood
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | - Melita Giummarra
- Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | | | - Michael E Schatman
- Department of Public Health & Community Medicine, Boston Pain Care, Tufts University School of Medicine, Boston, Massachusetts
| | | | - Joshua Kirz
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | | | | | | | | | - Scott E Hadland
- Division of General Pediatrics, Grayken Center for Addiction, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | | | - Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, Michigan
| | | | | | | | | | | | - Kristine Watford
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Palo Alto, California
| | | | - Dokyoung Sophia You
- Department of Anesthesiology, Perioperative, and Pain Medicine, Palo Alto, California
| | - Stacy Ogbeide
- Clinical Department of Family & Community Medicine, UT Health, San Antonio, San Antonio, Texas.,Division of Behavioral Medicine, Department of Psychiatry, UT Health, San Antonio, San Antonio, Texas
| | | | - Susan Lawson
- Mental Health- Private Practice, Alliance for the Treatment of Intractable Pain, Huntington, West Virginia
| | - James B Ray
- Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, Iowa
| | - T Wade Martin
- Anesthesiology & Pain Management, Interventional Pain Medicine, Cahaba Pain & Spine Care, Hoover, Alabama
| | | | - Anne Burke
- Central Adelaide Local Health Network, Australian Pain Society
| | - Robert I Cohen
- Massachusetts Pain Initiative Legislative Council Leadership Advisory Group, ABMS ABA Diplomat in Anesthesiology and Pain Medicine, Newton Center, Massachusetts
| | - Peter Grinspoon
- Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc S Rubenstein
- Academy of Prevention & Health Promotion Therapies, Jersey LiveWell and Jersey Physical Therapy, Princeton, New Jersey
| | | | | | - Travis Lovejoy
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon
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41
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Meeker D, Goldberg J, Kim KK, Peneva D, Campos HDO, Maclean R, Selby V, Doctor JN. Patient Commitment to Health (PACT-Health) in the Heart Failure Population: A Focus Group Study of an Active Communication Framework for Patient-Centered Health Behavior Change. J Med Internet Res 2019; 21:e12483. [PMID: 31389339 PMCID: PMC6701162 DOI: 10.2196/12483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 04/30/2019] [Accepted: 05/14/2019] [Indexed: 12/25/2022] Open
Abstract
Background Over 6 million Americans have heart failure, and 1 in 8 deaths included heart failure as a contributing cause in 2016. Lifestyle changes and adherence to diet and exercise regimens are important in limiting disease progression. Health coaching and public commitment are two interactive communication strategies that may improve self-management of heart failure. Objective This study aimed to conduct patient focus groups to gain insight into how best to implement health coaching and public commitment strategies within the heart failure population. Methods Focus groups were conducted in two locations. We studied 2 patients in Oakland, California, and 5 patients in Los Angeles, California. Patients were referred by local cardiologists and had to have a diagnosis of chronic heart failure. We used a semistructured interview tool to explore several patient-centered themes including medication adherence, exercise habits, dietary habits, goals, accountability, and rewards. We coded focus group data using the a priori coding criteria for these domains. Results Medication adherence barriers included regimen complexity, forgetfulness, and difficulty coping with side effects. Participants reported that they receive little instruction from care providers on appropriate exercise and dietary habits. They also reported personal and social obstacles to achieving these objectives. Participants were in favor of structured goal setting, use of online social networks, and financial rewards as a means of promoting health lifestyles. Peers were viewed as better motivating agents than family members. Conclusions An active communication framework involving dissemination of diet- and exercise-related health information, structured goal setting, peer accountability, and financial rewards appears promising in the management of heart failure.
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Affiliation(s)
- Daniella Meeker
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, United States
| | | | - Katherine K Kim
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, CA, United States
| | - Desi Peneva
- Precision Health Economics, Los Angeles, CA, United States
| | | | - Ross Maclean
- Precision Health Economics, Los Angeles, CA, United States
| | - Van Selby
- Cardiology Division, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Jason N Doctor
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, United States
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42
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Yadav K, Meeker D, Mistry RD, Doctor JN, Fleming‐Dutra KE, Fleischman RJ, Gaona SD, Stahmer A, May L. A Multifaceted Intervention Improves Prescribing for Acute Respiratory Infection for Adults and Children in Emergency Department and Urgent Care Settings. Acad Emerg Med 2019; 26:719-731. [PMID: 31215721 DOI: 10.1111/acem.13690] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 10/29/2018] [Accepted: 12/22/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antibiotics are commonly prescribed during emergency department (ED) and urgent care center (UCC) visits for viral acute respiratory infection (ARI). We evaluate the comparative effectiveness of an antibiotic stewardship intervention adapted for acute care ambulatory settings (adapted intervention) to a stewardship intervention that additionally incorporates behavioral nudges (enhanced intervention) in reducing inappropriate prescriptions. METHODS This study was a pragmatic, cluster-randomized clinical trial conducted in three academic health systems comprising five adult and pediatric EDs and four UCCs. Randomization of the nine sites was stratified by health system; all providers at each site received either the adapted or the enhanced intervention. The main outcome was the proportion of antibiotic-inappropriate ARI diagnosis visits that received an outpatient antibiotic prescription by individual providers. We estimated a hierarchical mixed-effects logistic regression model comparing visits during the influenza season for 2016 to 2017 (baseline) and 2017 to 2018 (intervention). RESULTS There were 44,820 ARI visits among 292 providers across all nine cluster sites. Antibiotic prescribing for ARI visits dropped from 6.2% (95% confidence interval [CI] = 4.5% to 7.9%) to 2.4% (95% CI = 1.3% to 3.4%) during the study period. We found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.2% (95% CI = 1.0% to 3.4%) to 1.5% (95% CI = 0.7% to 2.3%) with an odds ratio of 0.67 (95% CI = 0.54 to 0.82). Difference-in-differences between the two interventions was not significantly different. CONCLUSION Implementation of antibiotic stewardship for ARI is feasible and effective in the ED and UCC settings. More intensive behavioral nudging methods were not more effective in high-performance settings.
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Affiliation(s)
- Kabir Yadav
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
- Los Angeles Biomedical Research Institute Torrance CA
| | - Daniella Meeker
- Schaeffer Center for Health Policy and Economics University of Southern California Los Angeles CA
| | - Rakesh D. Mistry
- Department of Pediatrics Section of Emergency Medicine Children's Hospital of Colorado Aurora CO
| | - Jason N. Doctor
- Schaeffer Center for Health Policy and Economics University of Southern California Los Angeles CA
| | | | | | - Samuel D. Gaona
- Department of Emergency Medicine University of California–Davis SacramentoCA
| | - Aubyn Stahmer
- Department of Psychiatry and Behavioral Sciences University of California–Davis SacramentoCA
| | - Larissa May
- Department of Emergency Medicine University of California–Davis SacramentoCA
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43
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Gong CL, Zangwill KM, Hay JW, Meeker D, Doctor JN. Behavioral Economics Interventions to Improve Outpatient Antibiotic Prescribing for Acute Respiratory Infections: a Cost-Effectiveness Analysis. J Gen Intern Med 2019; 34:846-854. [PMID: 29740788 PMCID: PMC6544688 DOI: 10.1007/s11606-018-4467-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 03/06/2018] [Accepted: 04/13/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Behavioral economics interventions have been shown to effectively reduce the rates of inappropriate antibiotic prescriptions for acute respiratory infections (ARIs). OBJECTIVE To determine the cost-effectiveness of three behavioral economic interventions designed to reduce inappropriate antibiotic prescriptions for ARIs. DESIGN Thirty-year Markov model from the US societal perspective with inputs derived from the literature and CDC surveillance data. SUBJECTS Forty-five-year-old adults with signs and symptoms of ARI presenting to a healthcare provider. INTERVENTIONS (1) Provider education on guidelines for the appropriate treatment of ARIs; (2) Suggested Alternatives, which utilizes computerized clinical decision support to suggest non-antibiotic treatment choices in lieu of antibiotics; (3) Accountable Justification, which mandates free-text justification into the patient's electronic health record when antibiotics are prescribed; and (4) Peer Comparison, which sends a periodic email to prescribers about his/her rate of inappropriate antibiotic prescribing relative to clinician colleagues. MAIN MEASURES Discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. KEY RESULTS Each intervention has lower costs but higher QALYs compared to provider education. Total costs for each intervention were $178.21, $173.22, $172.82, and $172.52, and total QALYs were 14.68, 14.73, 14.74, and 14.74 for the control, Suggested Alternatives, Accountable Justification, and Peer Comparison groups, respectively. Results were most sensitive to the quality-of-life of the uninfected state, and the likelihood and costs for antibiotic-associated adverse events. CONCLUSIONS Behavioral economics interventions can be cost-effective strategies for reducing inappropriate antibiotic prescriptions by reducing healthcare resource utilization.
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Affiliation(s)
- Cynthia L Gong
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA.
| | - Kenneth M Zangwill
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Joel W Hay
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA
| | - Daniella Meeker
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA.,University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jason N Doctor
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA
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44
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Doctor JN, Nguyen A, Lev R, Lucas J, Knight T, Zhao H, Menchine M. Opioid prescribing decreases after learning of a patient's fatal overdose. Science 2018; 361:588-590. [PMID: 30093595 DOI: 10.1126/science.aat4595] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/05/2018] [Indexed: 01/08/2023]
Abstract
Most opioid prescription deaths occur among people with common conditions for which prescribing risks outweigh benefits. General psychological insights offer an explanation: People may judge risk to be low without available personal experiences, may be less careful than expected when not observed, and may falter without an injunction from authority. To test these hypotheses, we conducted a randomized trial of 861 clinicians prescribing to 170 persons who subsequently suffered fatal overdoses. Clinicians in the intervention group received notification of their patients' deaths and a safe prescribing injunction from their county's medical examiner, whereas physicians in the control group did not. Milligram morphine equivalents in prescriptions filled by patients of letter recipients versus controls decreased by 9.7% (95% confidence interval: 6.2 to 13.2%; P < 0.001) over 3 months after intervention. We also observed both fewer opioid initiates and fewer high-dose opioid prescriptions by letter recipients.
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Affiliation(s)
- Jason N Doctor
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA.
| | - Andy Nguyen
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Roneet Lev
- Emergency Department, Scripps Mercy Hospital San Diego, San Diego, CA, USA
| | - Jonathan Lucas
- Department of Medical Examiner-Coroner, Los Angeles County, Los Angeles, CA, USA
| | - Tara Knight
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Henu Zhao
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Michael Menchine
- Department of Emergency Medicine, University of Southern California, Los Angeles, CA, USA
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45
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Chen F, Jiang X, Wang S, Schilling LM, Meeker D, Ong T, Matheny ME, Doctor JN, Ohno-Machado L, Vaidya J. Perfectly Secure and Efficient Two-Party Electronic-Health-Record Linkage. IEEE Internet Comput 2018; 22:32-41. [PMID: 29867290 PMCID: PMC5983039 DOI: 10.1109/mic.2018.112102542] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Patient health data are often found spread across various sources. However, precision medicine and personalized care requires access to the complete medical records. The first step towards this is to enable the linkage of health records spread across different sites. Existing record linkage solutions assume that data is centralized with no privacy/security concerns restricting sharing. However, that is often untrue. Therefore, we design and implement a portable method for privacy-preserving record linkage based on garbled circuits to accurately and securely match records. We also develop a novel approximate matching mechanism that significantly improves efficiency.
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Affiliation(s)
- Feng Chen
- Health System Department of Biomedical Informatics, UC San Diego, La
Jolla, CA, 92093
| | - Xiaoqian Jiang
- Health System Department of Biomedical Informatics, UC San Diego, La
Jolla, CA, 92093
| | - Shuang Wang
- Health System Department of Biomedical Informatics, UC San Diego, La
Jolla, CA, 92093
| | - Lisa M. Schilling
- Department of Medicine, University of Colorado, Anschutz Medical
Campus, CO, 80045
| | - Daniella Meeker
- Keck School of Medicine, University of Southern California, Los
Angeles, CA 90089
| | - Toan Ong
- Department of Medicine, University of Colorado, Anschutz Medical
Campus, CO, 80045
| | - Michael E. Matheny
- Geriatric Research Education and Clinical Care Service, Tennessee
Valley Healthcare System VA, Nashville, TN 37212
- Departments of Biomedical Informatics, Medicine, and Biostatistics,
Vanderbilt University Medical Center, Nashville, TN 37235
| | - Jason N. Doctor
- Schaeffer Center for Health Policy & Economics, University of
Southern California, Los Angeles, CA 90033
| | - Lucila Ohno-Machado
- Health System Department of Biomedical Informatics, UC San Diego, La
Jolla, CA, 92093
| | - Jaideep Vaidya
- Management Science & Information Systems Department, Rutgers
University, Newark, NJ 07102
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46
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Linder JA, Meeker D, Fox CR, Friedberg MW, Persell SD, Goldstein NJ, Doctor JN. Effects of Behavioral Interventions on Inappropriate Antibiotic Prescribing in Primary Care 12 Months After Stopping Interventions. JAMA 2017; 318:1391-1392. [PMID: 29049577 PMCID: PMC5818848 DOI: 10.1001/jama.2017.11152] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study examines assesses inappropriate antibiotic prescribing 12 months after stopping a randomized clinical trial of a behavioral intervention intended to reduce the rate of inappropriate antibiotic prescribing for acute respiratory infections.
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Affiliation(s)
- Jeffrey A. Linder
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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47
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Kalet AM, Doctor JN, Gennari JH, Phillips MH. Developing Bayesian networks from a dependency‐layered ontology: A proof‐of‐concept in radiation oncology. Med Phys 2017; 44:4350-4359. [DOI: 10.1002/mp.12340] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 04/10/2017] [Accepted: 05/05/2017] [Indexed: 01/06/2023] Open
Affiliation(s)
- Alan M. Kalet
- Department of Radiation Oncology University of Washington Medical Center Seattle WAUSA
| | - Jason N. Doctor
- Department of Pharmaceutical and Health Economics University of Southern California Los Angeles CAUSA
| | - John H. Gennari
- Department of Biomedical Informatics and Medical Education University of Washington Seattle WAUSA
| | - Mark H. Phillips
- Department of Biomedical Informatics and Medical Education University of Washington Seattle WAUSA
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Gong CL, Hay JW, Meeker D, Doctor JN. Prescriber preferences for behavioural economics interventions to improve treatment of acute respiratory infections: a discrete choice experiment. BMJ Open 2016; 6:e012739. [PMID: 27660322 PMCID: PMC5051402 DOI: 10.1136/bmjopen-2016-012739] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To elicit prescribers' preferences for behavioural economics interventions designed to reduce inappropriate antibiotic prescribing, and compare these to actual behaviour. DESIGN Discrete choice experiment (DCE). SETTING 47 primary care centres in Boston and Los Angeles. PARTICIPANTS 234 primary care providers, with an average 20 years of practice. MAIN OUTCOMES AND MEASURES Results of a behavioural economic intervention trial were compared to prescribers' stated preferences for the same interventions relative to monetary and time rewards for improved prescribing outcomes. In the randomised controlled trial (RCT) component, the 3 computerised prescription order entry-triggered interventions studied included: Suggested Alternatives (SA), an alert that populated non-antibiotic treatment options if an inappropriate antibiotic was prescribed; Accountable Justifications (JA), which prompted the prescriber to enter a justification for an inappropriately prescribed antibiotic that would then be documented in the patient's chart; and Peer Comparison (PC), an email periodically sent to each prescriber comparing his/her antibiotic prescribing rate with those who had the lowest rates of inappropriate antibiotic prescribing. A DCE study component was administered to determine whether prescribers felt SA, JA, PC, pay-for-performance or additional clinic time would most effectively reduce their inappropriate antibiotic prescribing. Willingness-to-pay (WTP) was calculated for each intervention. RESULTS In the RCT, PC and JA were found to be the most effective interventions to reduce inappropriate antibiotic prescribing, whereas SA was not significantly different from controls. In the DCE however, regardless of treatment intervention received during the RCT, prescribers overwhelmingly preferred SA, followed by PC, then JA. WTP estimates indicated that each intervention would be significantly cheaper to implement than pay-for-performance incentives of $200/month. CONCLUSIONS Prescribing behaviour and stated preferences are not concordant, suggesting that relying on stated preferences alone to inform intervention design may eliminate effective interventions. TRIAL REGISTRATION NUMBER NCT01454947; Results.
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Affiliation(s)
- Cynthia L Gong
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California, USA
| | - Joel W Hay
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California, USA
| | - Daniella Meeker
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California, USA
- University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jason N Doctor
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California, USA
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Persell SD, Doctor JN, Friedberg MW, Meeker D, Friesema E, Cooper A, Haryani A, Gregory DL, Fox CR, Goldstein NJ, Linder JA. Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial. BMC Infect Dis 2016; 16:373. [PMID: 27495917 PMCID: PMC4975897 DOI: 10.1186/s12879-016-1715-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 07/13/2016] [Indexed: 11/29/2022] Open
Abstract
Background Clinicians frequently prescribe antibiotics inappropriately for acute respiratory infections (ARIs). Our objective was to test information technology-enabled behavioral interventions to reduce inappropriate antibiotic prescribing for ARIs in a randomized controlled pilot test trial. Methods Primary care clinicians were randomized in a 2 × 2 × 2 factorial experiment with 3 interventions: 1) Accountable Justifications; 2) Suggested Alternatives; and 3) Peer Comparison. Beforehand, participants completed an educational module. Measures included: rates of antibiotic prescribing for: non-antibiotic-appropriate ARI diagnoses, acute sinusitis/pharyngitis, all other diagnoses/symptoms of respiratory infection, and all three ARI categories combined. Results We examined 3,276 visits in the pre-intervention year and 3,099 in the intervention year. The antibiotic prescribing rate fell for non-antibiotic-appropriate ARIs (24.7 % in the pre-intervention year to 5.2 % in the intervention year); sinusitis/pharyngitis (50.3 to 44.7 %); all other diagnoses/symptoms of respiratory infection (40.2 to 25.3 %); and all categories combined (38.7 to 24.2 %; all p < 0.001). There were no significant relationships between any intervention and antibiotic prescribing for non-antibiotic-appropriate ARI diagnoses or sinusitis/pharyngitis. Suggested Alternatives was associated with reduced antibiotic prescribing for other diagnoses or symptoms of respiratory infection (odds ratio [OR], 0.62; 95 % confidence interval [CI], 0.44–0.89) and for all ARI categories combined (OR, 0.72; 95 % CI, 0.54–0.96). Peer Comparison was associated with reduced prescribing for all ARI categories combined (OR, 0.73; 95 % CI, 0.53–0.995). Conclusions We observed large reductions in antibiotic prescribing regardless of whether or not study participants received an intervention, suggesting an overriding Hawthorne effect or possibly clinician-to-clinician contamination. Low baseline inappropriate prescribing may have led to floor effects. Trial Registration ClinicalTrials.gov: NCT01454960. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1715-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stephen D Persell
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA. .,Center for Primary Care Innovation, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.
| | - Jason N Doctor
- USC Schaeffer Center for Health Policy and Economics, University of Southern California, 3335 S. Figueroa Street, Unit A, Los Angeles, CA, 90089-7273, USA
| | - Mark W Friedberg
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital; Harvard Medical School, 1620 Tremont Street, BC-3-2X, Boston, MA, 02120, USA.,RAND, 20 Park Plaza, Suite 920, Boston, MA, 02116, USA
| | - Daniella Meeker
- USC Schaeffer Center for Health Policy and Economics, University of Southern California, 3335 S. Figueroa Street, Unit A, Los Angeles, CA, 90089-7273, USA.,RAND, 1776 Main St., Santa Monica, CA, 90401, USA
| | - Elisha Friesema
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.,Center for Primary Care Innovation, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA
| | - Andrew Cooper
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA
| | - Ajay Haryani
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA
| | - Dyanna L Gregory
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA
| | - Craig R Fox
- Department of Psychology, UCLA Anderson School of Management; David Geffen School of Medicine at UCLA, UCLA, 110 Westwood Plaza D-511, Los Angeles, CA, 90095, USA
| | - Noah J Goldstein
- Department of Psychology, UCLA Anderson School of Management; David Geffen School of Medicine at UCLA, UCLA, 110 Westwood Plaza D-511, Los Angeles, CA, 90095, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital; Harvard Medical School, 1620 Tremont Street, BC-3-2X, Boston, MA, 02120, USA
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Huesch MD, Galstyan A, Ong MK, Doctor JN. Using Social Media, Online Social Networks, and Internet Search as Platforms for Public Health Interventions: A Pilot Study. Health Serv Res 2016; 51 Suppl 2:1273-90. [PMID: 27161093 PMCID: PMC4874940 DOI: 10.1111/1475-6773.12496] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To pilot public health interventions at women potentially interested in maternity care via campaigns on social media (Twitter), social networks (Facebook), and online search engines (Google Search). DATA SOURCES/STUDY SETTING Primary data from Twitter, Facebook, and Google Search on users of these platforms in Los Angeles between March and July 2014. STUDY DESIGN Observational study measuring the responses of targeted users of Twitter, Facebook, and Google Search exposed to our sponsored messages soliciting them to start an engagement process by clicking through to a study website containing information on maternity care quality information for the Los Angeles market. PRINCIPAL FINDINGS Campaigns reached a little more than 140,000 consumers each day across the three platforms, with a little more than 400 engagements each day. Facebook and Google search had broader reach, better engagement rates, and lower costs than Twitter. Costs to reach 1,000 targeted users were approximately in the same range as less well-targeted radio and TV advertisements, while initial engagements-a user clicking through an advertisement-cost less than $1 each. CONCLUSIONS Our results suggest that commercially available online advertising platforms in wide use by other industries could play a role in targeted public health interventions.
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Affiliation(s)
- Marco D. Huesch
- USC Leonard D. Schaeffer Center for Health Policy and EconomicsUniversity of Southern CaliforniaLos AngelesCA
| | - Aram Galstyan
- Information Sciences InstituteUniversity of Southern CaliforniaMarina del ReyCA
- Department of Computer ScienceViterbi School of EngineeringUniversity of Southern CaliforniaMarina del ReyCA
| | - Michael K. Ong
- Division of General Internal Medicine and Health Services ResearchDavid Geffen School of Medicine at the University of CaliforniaLos AngelesCA
- Veterans Administration Los AngelesLos AngelesCA
| | - Jason N. Doctor
- USC Leonard D. Schaeffer Center for Health Policy and EconomicsUniversity of Southern CaliforniaLos AngelesCA
- School of PharmacyUniversity of Southern CaliforniaLos AngelesCA
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