Using Behavioral Economics to Reduce Low-Value Care Among Older Adults: A Cluster Randomized Clinical Trial.

Importance: Use of low-value care is common among older adults. It is unclear how to best engage clinicians and older patients to decrease use of low-value services. Objective: To test whether the Committing to Choose Wisely behavioral economic intervention could engage primary care clinicians and older patients to reduce low-value care. Design, Setting, and Participants: Stepped-wedge cluster randomized clinical trial conducted at 8 primary care clinics of an academic health system and a private group practice between December 12, 2017, and September 4, 2019. Participants were primary care clinicians and older adult patients who had diabetes, insomnia, or anxiety or were eligible for prostate cancer screening. Data analysis was performed from October 2019 to November 2023. Intervention: Clinicians were invited to commit in writing to Choosing Wisely recommendations for older patients to avoid use of hypoglycemic medications to achieve tight glycemic control, sedative-hypnotic medications for insomnia or anxiety, and prostate-specific antigen tests to screen for prostate cancer. Committed clinicians had their photographs displayed on clinic posters and received weekly emails with alternatives to these low-value services. Educational handouts were mailed to applicable patients before scheduled visits and available at the point of care. Main Outcomes and Measures: Patient-months with a low-value service across conditions (primary outcome) and separately for each condition (secondary outcomes). For patients with diabetes, or insomnia or anxiety, secondary outcomes were patient-months in which targeted medications were decreased or stopped (ie, deintensified). Results: The study included 81 primary care clinicians and 8030 older adult patients (mean [SD] age, 75.1 [7.2] years; 4076 men [50.8%] and 3954 women [49.2%]). Across conditions, a low-value service was used in 7627 of the 37 116 control patient-months (20.5%) and 7416 of the 46 381 intervention patient-months (16.0%) (adjusted odds ratio, 0.79; 95% CI, 0.65-0.97). For each individual condition, there were no significant differences between the control and intervention periods in the odds of patient-months with a low-value service. The intervention increased the odds of deintensification of hypoglycemic medications for diabetes (adjusted odds ratio, 1.85; 95% CI, 1.06-3.24) but not sedative-hypnotic medications for insomnia or anxiety. Conclusions and Relevance: In this stepped-wedge cluster randomized clinical trial, the Committing to Choose Wisely behavioral economic intervention reduced low-value care across 3 common clinical situations and increased deintensification of hypoglycemic medications for diabetes. Use of scalable interventions that nudge patients and clinicians to achieve greater value while preserving autonomy in decision-making should be explored more broadly. Trial Registration: ClinicalTrials.gov Identifier: NCT03411525.

Functional Diversification and the Plant Secondary Cell Wall.

Much evidence exists suggesting the presence of genetic functional diversification in plants, though literature associated with the role of functional diversification in the evolution of the plant secondary cell wall (SCW) has sparsely been compiled and reviewed in a recent context. This review aims to elucidate, through the examination of gene phylogenies associated with its biosynthesis and maintenance, the role of functional diversification in shaping the critical, dynamic, and characteristic organelle, the secondary cell wall. It will be asserted that gene families resulting from gene duplication and subsequent functional divergence are present and are heavily involved in SCW biosynthesis and maintenance. Furthermore, diversification will be presented as a significant driver behind the evolution of the many functional characteristics of the SCW. The structure and function of the plant cell wall and its constituents will first be explored, followed by a discussion on the phenomenon of gene duplication and the resulting genetic functional divergence that can emerge. Finally, the major constituents of the SCW and their individual relationships with duplication and divergence will be reviewed to the extent of current knowledge on the subject.

Golf course living leads to a diet shift for American alligators.

Human-driven land use change can fundamentally alter ecological communities, especially the diversity and abundance of large-bodied predators. Yet, despite the important roles large-bodied predators play in structuring communities through feeding, there have been only a few investigations of how the feeding patterns of large-bodied predators change in human-dominated landscapes. One group of large-bodied predators that has been largely overlooked in the context of land use change is the crocodilians. To help fill these gaps, we studied the feeding patterns of juvenile American alligators (Alligator mississippiensis) on neighboring barrier islands on the southeast coast of Georgia, USA. Jekyll Island has multiple golf courses and substantial amounts of human activity, while Sapelo Island does not have any golf courses and a much smaller amount of human activity. We found that juvenile alligator populations on both islands ate the same types of prey but in vastly different quantities. Sapelo Island alligators primarily consumed crustaceans while alligators that lived on Jekyll Island's golf courses ate mostly insects/arachnids. Furthermore, the Jekyll Island alligators exhibited a much more generalist feeding pattern (individuals mostly ate the same types of prey in the same quantities) than the more specialized Sapelo Island alligators (diets were more varied across individuals). The most likely explanation for our results is that alligators living on golf courses have different habitat use patterns and have access to different prey communities relative to alligators in more natural habitats. Thus, land use change can strongly alter the feeding patterns of large-bodied predators and, as a result, may affect their body condition, exposure to human-made chemicals, and role within ecological communities.

Exposure of tomato (Lycopersicon esculentum) to silver nanoparticles and silver nitrate: physiological and molecular response.

Silver nanoparticles (AgNPs) are among the most widely used nanomaterials, with applications in sectors as diverse as communications, energy, medicine, and agriculture. This diverse application of AgNPs increases the risk of the release of these materials into the environment and raises the potential for transfer into plants and, subsequently, the human body. To better understand the effects of NPs in agricultural systems, this study investigates plant physiological and molecular responses upon exposure to AgNPs in comparison to silver nitrate (AgNO3). Tomato seedlings (Lycopersison esculentum) were exposed to 10, 20, or 30 mg/L silver (Ag), AgNO3, or AgNPs in hydroponic media for 7 days. A number of endpoints were measured, including plant growth, photosynthetic pigments, oxidative and antioxidant responses. The results showed 2-7 times lower growth rate in plants exposed to silver compared to the control. H2O2 and malondialdehyde as oxidative stress indicators were, respectively, 1.7 and 4 times higher in plants exposed to all forms of silver compared to the control. The antioxidative responses increased significantly in plants exposed to Ag and AgNPs compared to the control. However, plants exposed to AgNO3 showed up to 50% lower enzymatic antioxidant activity. At the molecular level, the expression of genes involved in defense responses, including ethylene-inducing xylanase (EIX), peroxidase 51 (POX), and phenylalanine ammonia lyase, were significantly upregulated upon exposure to silver. The molecular and physiological data showed exposure to all forms of silver resulted in oxidative stress and exposure to AgNPs induced antioxidative and defense responses. However, exposure to AgNO3 resulted in phytotoxicity and failure in antioxidative responses. It indicates the higher reactivity and phytotoxicity of the ionic form of silver compared to NPs. The findings of this study add important information to efforts in attempting to characterize the exposure and risk associated with the release of nanomaterials in the environment.

The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment.

BACKGROUND: Pain management racial disparities exist, yet it is unclear whether disparities exist in pain management in advanced cancer. OBJECTIVE: To examine the effect of race on physicians' pain assessment and treatment in advanced lung cancer and the moderating effect of patient activation. DESIGN: Randomized field experiment. Physicians consented to see two unannounced standardized patients (SPs) over 18 months. SPs portrayed 4 identical roles-a 62-year-old man with advanced lung cancer and uncontrolled pain-differing by race (black or white) and role (activated or typical). Activated SPs asked questions, interrupted when necessary, made requests, and expressed opinions. PARTICIPANTS: Ninety-six primary care physicians (PCPs) and oncologists from small cities, and suburban and rural areas of New York, Indiana, and Michigan. Physicians' mean age was 52 years (SD = 27.17), 59% male, and 64% white. MAIN MEASURES: Opioids prescribed (or not), total daily opioid doses (in oral morphine equivalents), guideline-concordant pain management, and pain assessment. KEY RESULTS: SPs completed 181 covertly audio-recorded visits that had complete data for the model covariates. Physicians detected SPs in 15% of visits. Physicians prescribed opioids in 71% of visits; 38% received guideline-concordant doses. Neither race nor activation was associated with total opioid dose or guideline-concordant pain management, and there were no interaction effects (p > 0.05). Activation, but not race, was associated with improved pain assessment (ẞ, 0.46, 95% CI 0.18, 0.74). In post hoc analyses, oncologists (but not PCPs) were less likely to prescribe opioids to black SPs (OR 0.24, 95% CI 0.07, 0.81). CONCLUSIONS: Neither race nor activation was associated with opioid prescribing; activation was associated with better pain assessment. In post hoc analyses, oncologists were less likely to prescribe opioids to black male SPs than white male SPs; PCPs had no racial disparities. In general, physicians may be under-prescribing opioids for cancer pain. TRIAL REGISTRATION: NCT01501006.

The social and behavioral influences (SBI) study: study design and rationale for studying the effects of race and activation on cancer pain management.

BACKGROUND: Racial disparities exist in the care provided to advanced cancer patients. This article describes an investigation designed to advance the science of healthcare disparities by isolating the effects of patient race and patient activation on physician behavior using novel standardized patient (SP) methodology. METHODS/DESIGN: The Social and Behavioral Influences (SBI) Study is a National Cancer Institute sponsored trial conducted in Western New York State, Northern/Central Indiana, and lower Michigan. The trial uses an incomplete randomized block design, randomizing physicians to see patients who are either black or white and who are "typical" or "activated" (e.g., ask questions, express opinions, ask for clarification, etc.). The study will enroll 91 physicians. DISCUSSION: The SBI study addresses important gaps in our knowledge about racial disparities and methods to reduce them in patients with advanced cancer by using standardized patient methodology. This study is innovative in aims, design, and methodology and will point the way to interventions that can reduce racial disparities and discrimination and draw links between implicit attitudes and physician behaviors. TRIAL REGISTRATION: https://clinicaltrials.gov/ , #NCT01501006, November 30, 2011.