Early anticoagulation in patients with stroke and atrial fibrillation is associated with fewer ischaemic lesions at 1 month: the ATTUNE study.

BACKGROUND: The optimal time to commence anticoagulation in patients with atrial fibrillation (AF) after ischaemic stroke or transient ischaemic attack (TIA) is unclear, with guidelines differing in recommendations. A limitation of previous studies is the focus on clinically overt stroke, rather than radiologically obvious diffusion-weighted imaging ischaemic lesions. We aimed to quantify silent ischaemic lesions and haemorrhages on MRI at 1 month in patients commenced on early (<4 days) vs late (≥4 days) anticoagulation. We hypothesised that there would be fewer ischaemic lesions and more haemorrhages in the early anticoagulant group at 1-month MRI. METHODS: A prospective multicentre, observational cohort study was performed at 11 Australian stroke centres. Clinical and MRI data were collected at baseline and follow-up, with blinded imaging assessment performed by two authors. Timing of commencement of anticoagulation was at the discretion of the treating stroke physician. RESULTS: We recruited 276 patients of whom 208 met the eligibility criteria. The average age was 74.2 years (SD±10.63), and 79 (38%) patients were female. Median National Institute of Health Stroke Scale score was 5 (IQR 1-12). Median baseline ischaemic lesion volume was 5 mL (IQR 2-17). There were a greater number of new ischaemic lesions on follow-up MRI in patients commenced on anticoagulation ≥4 days after index event (17% vs 8%, p=0.04), but no difference in haemorrhage rates (22% vs 32%, p=0.10). Baseline ischaemic lesion volume of ≤5 mL was less likely to have a new haemorrhage at 1 month (p=0.02). There was no difference in haemorrhage rates in patients with an initial ischaemic lesion volume of >5 mL, regardless of anticoagulation timing. CONCLUSION: Commencing anticoagulation <4 days after stroke or TIA is associated with fewer ischaemic lesions at 1 month in AF patients. There is no increased rate of haemorrhage with early anticoagulation. These results suggest that early anticoagulation after mild-to-moderate acute ischaemic stroke associated with AF might be safe, but randomised controlled studies are needed to inform clinical practice.

A cross-cultural comparison of a measure of parent perceptions among families of children with autism in Vietnam.

LAY ABSTRACT: Raising an autistic child can affect many aspects of families' lives. Parents are responsible for many decisions, from initiating evaluation to selecting and implementing treatments. How parents conceptualize the course and nature of their child's diagnosis influences these processes and parents' own well-being. Parents' perceptions about their children's autism are also affected by cultural contexts and understanding of autism. The Illness Perception Questionnaire-Revised (IPQ-R) is widely used to study cognitions in chronic health research and has been adapted and validated to measure parents' perceptions and beliefs about their children's ASD (IPQ-R-ASD). However, such studies are mostly conducted in high-income countries (HICs) with western, individualistic cultural values (e.g. United States, Canada). Therefore, it is unclear whether the IPQ-R-ASD is a useful instrument in understanding parents' perceptions of autism in Vietnam, a lower- and middle-income country (LMIC) with collectivistic Asian cultural values. These differences suggest that parents in Vietnam may have cognitive representations of their children's autism that differ from those of parents living in HIC, western countries. The purpose of this study was to examine the usability of the translated Vietnamese IPQ-R-ASD that may, ultimately, help explore Vietnamese parents' autism perceptions. While the study's result indicated the usability of the translated measure in Vietnam, when interpreted with Vietnamese norms, results also highlighted notable differences between Vietnamese and North American parents' perceptions of autism that warrant further research.

Evaluation of a Housing First programme for people from the public mental health sector with severe and persistent mental illnesses and precarious housing: Housing, health and service use outcomes.

AIMS AND CONTEXT: This paper reports the evaluation of the Doorway program (2015-18) in Melbourne, Australia. Doorway extends the original Housing First (HF) model in providing housing support to people with precarious housing at-risk of homelessness with Serious and Persistent Mental Illnesses (SPMIs) receiving care within Victoria's public mental health system. Doorway participants source and choose properties through the open rental market, and receive rental subsidies, assistance, advocacy and brokerage support through their Housing and Recovery Worker (HRW). The aim of this study is to estimate Doorway's impact on participants' housing, quality of life and mental health service use. METHODOLOGY: The study employed a a quasi-experimental study design with a comparison group, adjusted for ten potential confounders. The primary outcome measure was days of secure housing per participant. Secure housing status, health service usage and quality of life (HoNOS) data were extracted from participants' electronic hospital and Doorway records in deidentified, non-reidentifiable form. Analysis for continuous outcome variables was based on multivariate GLM modelling. RESULTS: Doorway housed 89 (57%) of 157 accepted participants. The 157 Doorway participants overall were also housed for significantly more days (119.4 extra days per participant) than control participants, albeit after some delay in locating and moving into housing (mean 14 weeks). There was a significant, positive Doorway effect on health outcomes (all and one dimension of the HoNOS). Doorway participants had significantly reduced length of stay during acute and community hospital admissions (7.4 fewer days per participant) compared with the control group. CONCLUSION: The Doorway model represents a new and substantial opportunity to house, enhance health outcomes and reduce mental health service use for people with SPMIs from the public mental health sector and at-risk of homelessness.

Behavioral interventions to improve population health outreach for hepatitis C screening: randomized clinical trial.

OBJECTIVE: To evaluate whether opt out framing, messaging incorporating behavioral science concepts, or electronic communication increases the uptake of hepatitis C virus (HCV) screening in patients born between 1945 and 1965. DESIGN: Pragmatic randomized controlled trial. SETTING: 43 primary care practices from one academic health system (Philadelphia, PA, USA) between April 2019 and May 2020. PARTICIPANTS: Patients born between 1945 and 1965 with no history of screening and at least two primary care visits in the two years before the enrollment period. INTERVENTIONS: This multilevel trial was divided into two studies. Substudy A included 1656 eligible patients of 17 primary care clinicians who were randomized in a 1:1 ratio to a mailed letter about HCV screening (letter only), or a similar letter with a laboratory order for HCV screening (letter+order). Substudy B included the remaining 19 837 eligible patients followed by 417 clinicians. Active electronic patient portal users were randomized 1:5 to receive a mailed letter about HCV screening (letter), or an electronic patient portal message with similar content (patient portal); inactive patient portal users were mailed a letter. In a factorial design, patients in substudy B were also randomized 1:1 to receive standard content (usual care), or content based on principles of social norming, anticipated regret, reciprocity, and commitment (behavioral content). MAIN OUTCOME MEASURES: Proportion of patients who completed HCV testing within four months. RESULTS: 21 303 patients were included in the intention-to-treat analysis. Among the 1642 patients in substudy A, 19.2% (95% confidence interval 16.5% to 21.9%) completed screening in the letter only arm and 43.1% (39.7% to 46.4%) in the letter+order arm (P<0.001). Among the 19 661 patients in substudy B, 14.6% (13.9% to 15.3%) completed screening with usual care content and 13.6% (13.0% to 14.3%) with behavioral science content (P=0.06). Among active patient portal users, 17.8% (16.0% to 19.5%) completed screening after receiving a letter and 13.8% (13.1% to 14.5%) after receiving a patient portal message (P<0.001). CONCLUSIONS: Opt out framing and effort reduction by including a signed laboratory order with outreach increased screening for HCV. Behavioral science messaging content did not increase uptake, and mailed letters achieved a greater response rate than patient portal messages. TRIAL REGISTRATION: ClinicalTrials.gov NCT03712553.

Phenotyping physician practice patterns and associations with response to a nudge in the electronic health record for influenza vaccination: A quasi-experimental study.

BACKGROUND: Health systems routinely implement changes to the design of electronic health records (EHRs). Physician behavior may vary in response and methods to identify this variation could help to inform future interventions. The objective of this study was to phenotype primary care physician practice patterns and evaluate associations with response to an EHR nudge for influenza vaccination. METHODS AND FINDINGS: During the 2016-2017 influenza season, 3 primary care practices at Penn Medicine implemented an active choice intervention in the EHR that prompted medical assistants to template influenza vaccination orders for physicians to review during the visit. We used latent class analysis to identify physician phenotypes based on 9 demographic, training, and practice pattern variables, which were obtained from the EHR and publicly available sources. A quasi-experimental approach was used to evaluate response to the intervention relative to control practices over time in each of the physician phenotype groups. For each physician latent class, a generalized linear model with logit link was fit to the binary outcome of influenza vaccination at the patient visit level. The sample comprised 45,410 patients with a mean (SD) age of 58.7 (16.3) years, 67.1% were white, and 22.1% were black. The sample comprised 56 physicians with mean (SD) of 24.6 (10.2) years of experience and 53.6% were male. The model segmented physicians into groups that had higher (n = 41) and lower (n = 15) clinical workloads. Physicians in the higher clinical workload group had a mean (SD) of 818.8 (429.1) patient encounters, 11.6 (4.7) patient appointments per day, and 4.0 (1.1) days per week in clinic. Physicians in the lower clinical workload group had a mean (SD) of 343.7 (129.0) patient encounters, 8.0 (2.8) patient appointments per day, and 3.1 (1.2) days per week in clinic. Among the higher clinical workload group, the EHR nudge was associated with a significant increase in influenza vaccination (adjusted difference-in-difference in percentage points, 7.9; 95% CI, 0.4-9.0; P = .01). Among the lower clinical workload group, the EHR nudge was not associated with a significant difference in influenza vaccination rates (adjusted difference-in-difference in percentage points, -1.0; 95% CI, -5.3-5.8; P = .90). CONCLUSIONS: A model-based approach categorized physician practice patterns into higher and lower clinical workload groups. The higher clinical workload group was associated with a significant response to an EHR nudge for influenza vaccination.

Seeking Consensus on the Terminology of Value-Based Transformation Through use of a Delphi Process.

Collaboration among diverse stakeholders involved in the value transformation of health care requires consistent use of terminology. The objective of this study was to reach consensus definitions for the terms value-based care, value-based payment, and population health. A modified Delphi process was conducted from February 2017 to July 2017. An in-person panel meeting was followed by 3 rounds of surveys. Panelists anonymously rated individual components of definitions and full definitions on a 9-point Likert scale. Definitions were modified in an iterative process based on results of each survey round. Participants were a panel of 18 national leaders representing population health, health care delivery, academic medicine, payers, patient advocacy, and health care foundations. Main measures were survey ratings of definition components and definitions. At the conclusion of round 3, consensus was reached on the following definition for value-based payment, with 13 of 18 panelists (72.2%) assigning a high rating (7- 9) and 1 of 18 (5.6%) assigning a low rating (1-3): "Value-based payment aligns reimbursement with achievement of value-based care (health outcomes/cost) in a defined population with providers held accountable for achieving financial goals and health outcomes. Value-based payment encourages optimal care delivery, including coordination across healthcare disciplines and between the health care system and community resources, to improve health outcomes, for both individuals and populations." The iterative process elucidated specific areas of agreement and disagreement for value-based care and population health but did not reach consensus. Policy makers cannot assume uniform interpretation of other concepts underlying health care reform efforts.

Association of an Active Choice Intervention in the Electronic Health Record Directed to Medical Assistants With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening Tests.

Importance: Early cancer detection can lead to improved outcomes, but cancer screening tests are often underused. Objective: To evaluate the association of an active choice intervention in the electronic health record directed to medical assistants with changes in clinician ordering and patient completion of breast and colorectal cancer screening tests. Design, Setting, and Participants: A retrospective quality improvement study was conducted among 69 916 patients eligible for breast or colorectal cancer screening at 25 primary care practices at the University of Pennsylvania Health System between September 1, 2014, and August 31, 2017. Data analysis was conducted from January 21 to July 8, 2019. Interventions: From 2016 to 2017, 3 primary care practices at the University of Pennsylvania Health System implemented an active choice intervention in the electronic health record that prompted medical assistants to inform patients about cancer screening during check-in and template orders for clinicians to review during the visit. Main Outcomes and Measures: The primary outcome was clinician ordering of cancer screening tests. The secondary outcome was patient completion of cancer screening tests within 1 year of the primary care visit. Results: The sample eligible for breast cancer screening comprised 26 269 women with a mean (SD) age of 60.4 (6.9) years; 15 873 (60.4%) were white and 7715 (29.4%) were black. The sample eligible for colorectal cancer screening comprised 43 647 patients with a mean (SD) age of 59.4 (7.5) years; 24 416 (55.9%) were women, 19 231 (44.1%) were men, 29 029 (66.5%) were white, and 9589 (22.0%) were black. For breast cancer screening, the intervention was associated with a significant increase in clinician ordering of tests (22.2 percentage points; 95% CI, 17.2-27.6 percentage points; P < .001) but no change in patient completion (0.1 percentage points; 95% CI, -4.0 to 4.3 percentage points; P = .45). For colorectal cancer screening, the intervention was associated with a significant increase in clinician ordering of tests (13.7 percentage points; 95% CI, 8.0-18.9 percentage points; P < .001) but no change in patient completion (1.0 percentage points; 95% CI, -3.2 to 4.6 percentage points; P = .36). Conclusions and Relevance: An active choice intervention in the electronic health record directed to medical assistants was associated with a significant increase in clinician ordering of breast and colorectal cancer screening tests. However, it was not associated with a significant change in patient completion of either cancer screening test during a 1-year follow-up.

Electronic Pill Bottles or Bidirectional Text Messaging to Improve Hypertension Medication Adherence (Way 2 Text): a Randomized Clinical Trial.

BACKGROUND: Poor medication adherence contributes to inadequate control of hypertension. However, the value of adherence monitoring is unknown. OBJECTIVE: To evaluate the impact of monitoring adherence with electronic pill bottles or bidirectional text messaging on improving hypertension control. DESIGN: Three-arm pragmatic randomized controlled trial. PATIENTS: One hundred forty-nine primary care patients aged 18-75 with hypertension and text messaging capabilities who were seen at least twice in the prior 12 months with at least two out-of-range blood pressure (BP) measurements, including the most recent visit. INTERVENTIONS: Patients were randomized in a 1:2:2 ratio to receive (1) usual care, (2) electronic pill bottles for medication adherence monitoring (pill bottle), and (3) bidirectional text messaging for medication adherence monitoring (bidirectional text). MAIN MEASURES: Change in systolic BP during the final 4-month visit compared with baseline. KEY RESULTS: At the 4-month follow-up visit, mean (SD) change values in systolic blood pressure were - 4.7 (23.4) mmHg in usual care, - 4.3 (21.5) mmHg in the pill bottle arm, and - 4.6 (19.8) mmHg in the text arm. There was no significant change in systolic blood pressure between control and the pill bottle arm (p = 0.94) or the text messaging arm (p = 1.00), and the two intervention arms did not differ from each other (p = 0.93). CONCLUSIONS: Despite good measured adherence, neither feedback with electronic pill bottles nor bidirectional text messaging about medication adherence improved blood pressure control. Adherence to prescribed medications was not improved enough to affect BP control or it was not the primary driver of poor control. TRIAL REGISTRATION: clinicaltrials.gov (NCT02778542).

The Positive Effects of Accreditation on Graduate Medical Education Programs in Singapore.

BACKGROUND: There is worldwide interest in assessing the impact of accreditation systems to quantify their benefits to medical education and, through this, health care at the local and global levels. OBJECTIVE: We analyzed ACGME-I Resident Survey data from Singapore for 2011-2018 to assess the impact of accreditation on residents' evaluations of their programs. METHODS: We focused on 7 questions from the annual Resident Survey, which would be affected by accreditation compliance, along with a single global rating of respondents' overall perception of their program. We assessed for differences among specialty groupings (medical, surgical, and hospital-based) and Singapore's 3 health care systems. Repeated measures analysis of variance procedures was used to assess trends across time for the combined 8 items and each individual item. RESULTS: Analysis of the combined items showed significant improvement over the 7 years Singaporean programs had accreditation. There were no effects for specialty type or sponsoring institution. Analyses of individual questions showed 6 of 8 were significant for improvement. For the individual question related to duty hour compliance, there was a significant interaction between time and specialty, suggesting medical specialties showed greater improvement across time compared to surgical and hospital-based specialties. CONCLUSIONS: Implementation of accreditation in Singapore provided educational and clinical learning environment infrastructure not present prior to 2010, with the benefits of this reflected in residents' perceptions of their learning environment. Future assessments of the effects of accreditation might add stakeholder interviews to more fully describe its value and impact.

Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening.

Importance: As the clinic day progresses, clinicians may fall behind schedule and experience decision fatigue. However, the association of time of day with cancer screening rates is unknown. Objective: To evaluate the association of primary care clinic appointment time with clinician ordering and patient completion of breast and colorectal cancer screening. Design, Setting, and Participants: Retrospective, quality improvement study of 33 primary care practices in Pennsylvania and New Jersey from September 1, 2014, to August 31, 2016. Participants included adults eligible for breast or colorectal cancer screening. Data analysis was conducted from April 24, 2018, to November 8, 2018. Exposures: Clinic appointment time during each patient's first primary care physician visit in the study period. Main Outcomes and Measures: Primary outcome was clinician ordering of the screening test during the visit. Secondary outcome was patient completion of the tests within 1 year of the visit. Results: Among the 19 254 patients eligible for breast cancer screening, the mean (SD) age was 60.2 (6.9) years; 19 254 (100%) were female, 11 682 (60.7%) were white, and 5495 (28.5%) were black. Screening test order rates were highest at 8 am at 63.7%, decreased throughout the morning to 48.7% at 11 am, increased to 56.2% at noon, and then decreased to 47.8% at 5 pm (adjusted odds ratio [OR] for overall trend, 0.94; 95% CI, 0.93-0.96; P < .001). Trends in screening test completion rates were similar beginning at 33.2% at 8 am and decreasing to 17.8% at 5 pm (adjusted OR, 0.95; 95% CI, 0.94-0.97; P < .001). Among the 33 468 patients eligible for colorectal cancer screening, the mean (SD) age was 59.6 (7.4) years; 18 672 (55.8%) were female, 22 157 (66.2%) were white, and 7296 (21.8%) were black. Screening test order rates were 36.5% at 8 am, decreased to 31.3% by 11 am, increased at noon to 34.4%, and then decreased to 23.4% at 5 pm (adjusted OR, 0.94; 95% CI, 0.93-0.95; P < .001). Trends in screening test completion rates were similar beginning at 28.0% at 8 am and decreasing to 17.8% at 5 pm (adjusted OR, 0.97; 95% CI, 0.96-0.98; P < .001). Conclusions and Relevance: Clinician ordering of cancer screening tests significantly decreased as the clinic day progressed. Patient completion of cancer screening tests within 1 year of the visit was also lower as the primary care appointment time was later in the day. Future interventions targeting improvements in cancer screening should consider how time of day may influence these behaviors.

Counseling dropout, retention, and ethnic/language match for Asian Americans.

As a heterogeneous population, Asian Americans are typically studied as homogenous, as opposed to making distinctions among nationalities and first languages. The current study examined whether ethnic/language match and mismatch among 150 Asian client/counselor pairs predicted successful completion of counseling and number of treatment sessions while controlling for counseling dropout and retention predictors such as socioeconomic status and acculturation. The participant data were obtained from a deidentified database of clients and counselors at a community mental health center for Asian Americans in the Southwest region of the United States. The main finding was that ethnic/language matching of Asian client and counselor pairs predicted successful completion of counseling and number of treatment sessions. The results of the study suggest that, when feasible, ethnic/language matching of Asian American clients and counselors may minimize patient dropout from counseling. Given that this matching is usually unfeasible, the authors suggest several strategies for improving the retention of Asian-American clients (as well as other clients from international backgrounds) in counseling. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Impact of an interprofessional transition of care service on 30-day hospital reutilizations.

The objective of this study was to evaluate the impact of an interprofessional Transitions of Care (TOC) service on 30-day hospital reutilization inclusive of hospital readmissions and ED visits. This was a retrospective cohort study including patients discharged from an academic medical center between September 2013 and October 2014. Patients scheduled for a hospital follow-up visit in the post-acute care clinic (PACC) were included in the intervention group and patients without a post-discharge interprofessional TOC service were included in the comparison group. The intervention included a hospital follow-up visit with an interprofessional healthcare team. The primary composite outcome was hospital reutilization, defined as a hospital readmission or ED visit within 30 days of the discharge date. Overall, 330 patients were included in each group. In the intention-to-treat analysis, the primary composite outcome was not significantly different between groups (16.97% vs. 19.39%, P = 0.4195) whereas in the per-protocol analysis (all patients who showed to their PACC appointment), the primary outcome was significantly different in favor of the intervention group (9.28% vs. 19.39%, P = 0.0009). When components were analyzed separately, there was a statistically significant difference in favor of intervention group for hospital readmissions, but there was no difference for ED visits. This study demonstrates that an outpatient interprofessional TOC service with patient engagement from a team of nurses, pharmacists, physicians, and social workers may reduce 30-day hospital readmissions but may not impact 30-day ED visits.

What am I thinking? Perspective-taking from the perspective of adolescents with autism.

Autistic people are often described as being impaired with regard to theory of mind, though more recent literature finds flaws in the theory of mind deficit paradigm. In addition, the predominant methods for examining theory of mind often rely on "observational" modes of assessment and do not adequately reflect the dynamic process of real-life perspective taking. Thus, it is imperative that researchers continue to test the autistic theory of mind deficit paradigm and explore theory of mind experiences through more naturalistic approaches. This study qualitatively examined theory of mind in 12 autistic adolescents through a series of semi-structured interviews. Interpretive phenomenological analysis of the data revealed four core themes in participants' theory of mind experiences and strategies, all of which highlighted how a more accurate representation of autistic theory of mind is one of difference rather than deficit. For instance, data showed that autistic heightened perceptual abilities may contribute to mentalizing strengths and that honesty in autism may be less dependent on systemizing rather than personal experience and choice. Such findings suggest that future research should reexamine autistic characteristics in light of their ability to enhance theory of mind processing. Understanding how an autistic theory of mind is uniquely functional is an imperative step toward both destigmatizing the condition and advocating for neurodiversity.

"In Safe Hands" - A costly integrated care program with limited benefits in stroke unit care.

Given reported favourable outcomes of accountable care unit models of health care delivery (Taylor et al., 2017; Stein et al., 2015; Kara et al., 2015), the Clinical Excellence Commission of NSW has embraced "In Safe Hands" (ISH) to enhance coordination of care. ISH embraces the structured interdisciplinary bedside round (SIBR) component, for which reported outcomes include reduced length of stay (Taylor et al., 2017; Stein et al., 2015; Kara et al., 2015), possible reduction in overall costs of care (Kara et al., 2015), and enhanced patient and staff satisfaction (O'Leary et al., 2011). It is not yet clear whether the benefits of such a model are translatable to the Australian Health Care System (Hunyh et al., 2016) and/or established units with an already strong multi-disciplinary approach to patient care. The purpose of this prospective cohort study of 200 participants was to assess the effect(s) of implementation of ISH in a stroke unit of a tertiary hospital in Sydney, Australia. Data on length of stay, re-admission rates, adverse events, as well as patient and nursing satisfaction, were collected pre and post implementation. There was no significant difference in length of stay in median days (5 (IQR 2-7) versus 4 (IQR 2-6), P = 0.55) or incidence of adverse events (10% versus 12%, P = 0.82). Stroke outcome disability scores were not affected by the intervention. There were no significant differences overall in reported patient and nursing satisfaction. Implementation of the ISH program cost approximately AUD$ 1805/week (USD$ 1365) in wages. The ISH program was a costly intervention of limited benefit in a well-established acute stroke unit. We here discuss potential reasons for the failure of this intervention to achieve its primary aim in this setting.

Patient and physician predictors of hyperlipidemia screening and statin prescription.

OBJECTIVES: Appropriate lipid management has been demonstrated to reduce cardiovascular events, but rates of hyperlipidemia screening and statin therapy are suboptimal. We aimed to evaluate patient and physician predictors of guideline-concordant hyperlipidemia screening and statin prescription. STUDY DESIGN: Retrospective study of patients with primary care provider (PCP) visits from 2014 to 2016 at the University of Pennsylvania Health System. METHODS: Data on patients, screening orders, and prescriptions were obtained from the electronic health record. Multivariate logistic regression models were fit to binary outcomes of lipid screening and statin prescription. RESULTS: Among 97,189 eligible patients, 79.9% had an order for hyperlipidemia screening. In adjusted models, significant patient predictors of greater odds of having screening ordered included a history of diabetes (odds ratio [OR], 1.19; 95% CI, 1.10-1.29; P <.001) or hypertension (OR, 1.16; 95% CI, 1.10-1.23; P <.001). Significant provider predictors of lower odds of having screening ordered were being a resident PCP (OR, 0.63; 95% CI, 0.43-0.93; P = .021) or being trained in family medicine (OR, 0.37; 95% CI, 0.30-0.47; P <.001). Among 40,845 eligible patients, 56.1% were prescribed a statin. In adjusted models, significant patient predictors of greater odds of being prescribed a statin were if they had a history of diabetes (OR, 2.70; 95% CI, 2.32-3.13; P <.001) or clinical cardiovascular disease (OR, 2.26; 95% CI, 1.85-2.76; P <.001). Significant provider predictors of lower odds of being prescribed a statin were being a physician assistant (OR, 0.65; 95% CI, 0.52-0.81; P <.001) or female (OR, 0.82; 95% CI, 0.70-0.96; P = .01). CONCLUSIONS: Both patient and provider factors significantly predicted guideline-concordant care for hyperlipidemia screening and statin therapy.

Social Incentives and Gamification to Promote Weight Loss: The LOSE IT Randomized, Controlled Trial.

BACKGROUND: Social networks influence obesity patterns, but interventions to leverage social incentives to promote weight loss have not been well evaluated. OBJECTIVE: To test the effectiveness of gamification interventions designed using insights from behavioral economics to enhance social incentives to promote weight loss. DESIGN: The Leveraging Our Social Experiences and Incentives Trial (LOSE IT) was a 36-week randomized, controlled trial with a 24-week intervention and 12-week follow-up. PARTICIPANTS: One hundred and ninety-six obese adults (body mass index ≥ 30) comprising 98 two-person teams. INTERVENTIONS: All participants received a wireless weight scale, used smartphones to track daily step counts, formed two-person teams with a family member or friend, and selected a weight loss goal. Teams were randomly assigned to control or one of two gamification interventions for 36 weeks that used points and levels to enhance collaborative social incentives. One of the gamification arms also had weight and step data shared regularly with each participant's primary care physician (PCP). MAIN OUTCOME MEASURES: The primary outcome was weight loss at 24 weeks. Secondary outcomes included weight loss at 36 weeks. KEY RESULTS: At 24 weeks, participants lost significant weight from baseline in the control arm (mean: - 3.9 lbs; 95% CI: - 6.1 to - 1.7; P < 0.001), the gamification arm (mean: - 6.6 lbs; 95% CI: - 9.4 to - 3.9; P < 0.001), and the gamification arm with PCP data sharing (mean: - 4.8 lbs; 95% CI: - 7.4 to - 2.3; P < 0.001). At 36 weeks, weight loss from baseline remained significant in the control arm (mean: - 3.5 lbs; 95% CI: - 6.1 to - 0.8; P = 0.01), the gamification arm (mean: - 6.3 lbs; 95% CI: - 9.2 to - 3.3; P < 0.001), and the gamification arm with PCP data sharing (mean: - 5.2 lbs; 95% CI: - 8.5 to - 2.0; P < 0.01). However, in the main adjusted model, there were no significant differences in weight loss between each of the intervention arms and control at either 12, 24, or 36 weeks. CONCLUSIONS: Using digital health devices to track behavior with a partner led to significant weight loss through 36 weeks, but the gamification interventions were not effective at promoting weight loss when compared to control. TRIAL REGISTRATION: clinicaltrials.gov Identifier: 02564445.

Constraining estimates of global soil respiration by quantifying sources of variability.

Quantifying global soil respiration (RSG ) and its response to temperature change are critical for predicting the turnover of terrestrial carbon stocks and their feedbacks to climate change. Currently, estimates of RSG range from 68 to 98 Pg C year-1 , causing considerable uncertainty in the global carbon budget. We argue the source of this variability lies in the upscaling assumptions regarding the model format, data timescales, and precipitation component. To quantify the variability and constrain RSG , we developed RSG models using Random Forest and exponential models, and used different timescales (daily, monthly, and annual) of soil respiration (RS ) and climate data to predict RSG . From the resulting RSG estimates (range = 66.62-100.72 Pg), we calculated variability associated with each assumption. Among model formats, using monthly RS data rather than annual data decreased RSG by 7.43-9.46 Pg; however, RSG calculated from daily RS data was only 1.83 Pg lower than the RSG from monthly data. Using mean annual precipitation and temperature data instead of monthly data caused +4.84 and -4.36 Pg C differences, respectively. If the timescale of RS data is constant, RSG estimated by the first-order exponential (93.2 Pg) was greater than the Random Forest (78.76 Pg) or second-order exponential (76.18 Pg) estimates. These results highlight the importance of variation at subannual timescales for upscaling to RSG. The results indicated RSG is lower than in recent papers and the current benchmark for land models (98 Pg C year-1 ), and thus may change the predicted rates of terrestrial carbon turnover and the carbon to climate feedback as global temperatures rise.

Effect of an Automated Patient Dashboard Using Active Choice and Peer Comparison Performance Feedback to Physicians on Statin Prescribing: The PRESCRIBE Cluster Randomized Clinical Trial.

Importance: Statins are not prescribed to approximately 50% of patients who could benefit from them. Objective: To evaluate the effectiveness of an automated patient dashboard using active choice framing with and without peer comparison feedback on performance to nudge primary care physicians (PCPs) to increase guideline-concordant statin prescribing. Design, Setting, and Participants: This 3-arm cluster randomized clinical trial was conducted from February 21, 2017, to April 21, 2017, at 32 practice sites in Pennsylvania and New Jersey. Participants included 96 PCPs and 4774 patients not previously receiving statin therapy. Data were analyzed from April 25, 2017, to June 16, 2017. Interventions: Primary care physicians in the 2 intervention arms were emailed a link to an automated online dashboard listing their patients who met national guidelines for statin therapy but had not been prescribed this medication. The dashboard included relevant patient information, and for each patient, PCPs were asked to make an active choice to prescribe atorvastatin, 20 mg, once daily, atorvastatin at another dose, or another statin or not prescribe a statin and select a reason. The dashboard was available for 2 months. In 1 intervention arm, the email to PCPs also included feedback on their statin prescribing rate compared with their peers. Primary care physicians in the usual care group received no interventions. Main Outcomes and Measures: Statin prescription rates. Results: Patients had a mean (SD) age of 62.4 (8.3) years and a mean (SD) 10-year atherosclerotic cardiovascular disease risk score of 13.6 (8.2); 2625 (55.0%) were male, 3040 (63.7%) were white, and 1318 (27.6%) were black. In the active choice arm, 16 of 32 PCPs (50.0%) accessed the patient dashboard, but only 2 of 32 (6.3%) signed statin prescription orders. In the active choice with peer comparison arm, 12 of 32 PCPs (37.5%) accessed the patient dashboard and 8 of 32 (25.0%) signed statin prescription orders. Statins were prescribed in 40 of 1566 patients (2.6%) in the usual care arm, 116 of 1743 (6.7%) in the active choice arm, and 117 of 1465 (8.0%) in the active choice with peer comparison arm. In the main adjusted model, compared with usual care, there was a significant increase in statin prescribing in the active choice with peer comparison arm (adjusted difference in percentage points, 5.8; 95% CI, 0.9-13.5; P = .008), but not in the active choice arm (adjusted difference in percentage points, 4.1; 95% CI, -0.8 to 13.1; P = .11). Conclusions and Relevance: An automated patient dashboard using both active choice framing and peer comparison feedback led to a modest but significant increase in guideline-concordant statin prescribing rates. Trial Registration: ClinicalTrials.gov Identifier: NCT03021759.