The influence of social norms varies with "others" groups: Evidence from COVID-19 vaccination intentions.

The theory that health behaviors spread through social groups implies that efforts to control COVID-19 through vaccination will succeed if people believe that others in their groups are getting vaccinated. But "others" can refer to many groups, including one's family, neighbors, fellow city or state dwellers, or copartisans. One challenge to examining these understudied distinctions is that many factors may confound observed relationships between perceived social norms (what people believe others do) and intended behaviors (what people themselves will do), as there are plausible common causes for both. We address these issues using survey data collected in the United States during late fall 2020 (n = 824) and spring 2021 (n = 996) and a matched design that approximates pair-randomized experiments. We find a strong relationship between perceived vaccination social norms and vaccination intentions when controlling for real risk factors (e.g., age), as well as dimensions known to predict COVID-19 preventive behaviors (e.g., trust in scientists). The strength of the relationship declines as the queried social group grows larger and more heterogeneous. The relationship for copartisans is second in magnitude to that of family and friends among Republicans but undetectable for Democrats. Sensitivity analysis shows that these relationships could be explained away only by an unmeasured variable with large effects (odds ratios between 2 and 15) on social norms perceptions and vaccination intentions. In addition, a prediction from the "false consensus" view that intentions cause perceived social norms is not supported. We discuss the implications for public health policy and understanding social norms.

A randomized control trial evaluating the effects of police body-worn cameras.

Police body-worn cameras (BWCs) have been widely promoted as a technological mechanism to improve policing and the perceived legitimacy of police and legal institutions, yet evidence of their effectiveness is limited. To estimate the effects of BWCs, we conducted a randomized controlled trial involving 2,224 Metropolitan Police Department officers in Washington, DC. Here we show that BWCs have very small and statistically insignificant effects on police use of force and civilian complaints, as well as other policing activities and judicial outcomes. These results suggest we should recalibrate our expectations of BWCs' ability to induce large-scale behavioral changes in policing, particularly in contexts similar to Washington, DC.

Seroprevalence of SARS-CoV-2 Antibodies in Rhode Island From a Statewide Random Sample.

Objectives. To characterize statewide seroprevalence and point prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Rhode Island.Methods. We conducted a cross-sectional survey of randomly selected households across Rhode Island in May 2020. Antibody-based and polymerase chain reaction (PCR)-based tests for SARS-CoV-2 were offered. Hispanics/Latinos and African Americans/Blacks were oversampled to ensure adequate representation. Seroprevalence estimations accounted for test sensitivity and specificity and were compared according to age, race/ethnicity, gender, housing environment, and transportation mode.Results. Overall, 1043 individuals from 554 households were tested (1032 antibody tests, 988 PCR tests). The estimated seroprevalence of SARS-CoV-2 antibodies was 2.1% (95% credible interval [CI] = 0.6, 4.1). Seroprevalence was 7.5% (95% CI = 1.3, 17.5) among Hispanics/Latinos, 3.8% (95% CI = 0.0, 15.0) among African Americans/Blacks, and 0.8% (95% CI = 0.0, 2.4) among non-Hispanic Whites. Overall PCR-based prevalence was 1.5% (95% CI = 0.5, 3.1).Conclusions. Rhode Island had low seroprevalence relative to other settings, but seroprevalence was substantially higher among African Americans/Blacks and Hispanics/Latinos. Rhode Island sits along the highly populated northeast corridor, making our findings broadly relevant to this region of the country. Continued monitoring via population-based sampling is needed to quantify these impacts going forward.

AN EMPIRICAL METHOD FOR MATERIALITY: WOULD CONFLICT OF INTEREST DISCLOSURES CHANGE PATIENT DECISIONS?

The law has long been concerned with the agency problems that arise when advisors, such as attorneys or physicians, put themselves in financial relationships that create conflicts of interest. If the financial relationship is "material" to the transactions proposed by the advisor, then non-disclosure of the relationship may be pertinent to claims of malpractice, informed consent, and even fraud, as well as to professional discipline. In these sorts of cases, materiality is closely related to the question of causation, roughly turning on whether the withheld information might have changed the decision of a reasonable advisee (i.e., a patient). The injured plaintiff will predictably testify that the information would have impacted his or her choice, but that self-serving testimony may be unreliable. The fact finder is left to speculate about the counterfactual world in which the information was disclosed. This Article shows how randomized vignette-based experimentation may create a valuable form of evidence to address these questions, for both litigation and policymaking. To demonstrate this method and investigate conflicts of interest in healthcare in particular, we recruited 691 human subjects and asked them to imagine themselves as patients facing a choice about whether to undergo a cardiac stenting procedure recommended by a cardiologist. We manipulated the vignettes in a 2 x 3 between-subjects design, where we systematically varied the appropriateness of the proposed treatment, which was described in terms of patient risk without the procedure (low or high), and manipulated the type of disclosure provided by the physician (none, standard, or enhanced). We used physician ownership of the specialty hospital where the surgery would be performed as the conflict of interest, disclosed or not, and the "enhanced" disclosure included notice that such relationships have been associated with biases in prescribing behavior. We found that the mock patients were significantly less likely to follow the cardiologist's recommendation of surgical implantation of a drug-eluting stent when he disclosed a financial conflict of interest, regardless of whether the disclosure was standard or enhanced. We also found that the mock patients were more likely to choose the treatment when they faced greater risk without it. We did not, however, find that the disclosure made patients more discerning about the appropriateness of the procedure. We discuss the implications for law and policy. Mock patients seem likely to act upon such information, declining the low-value healthcare when conflicts are disclosed. This finding suggests that the information is material to such transactions, and that disclosures may be salutary for medical decisions. Arguably, therefore, physicians already have a duty under the common law to disclose the financial relationships they choose to accept. Other regulators and policymakers should recognize and clarify this duty, and courts should embrace this form of evidence. Methodologically, although this empirical approach has limits, it reduces speculation by fact finders and policymakers, by at least focusing their attention on the right questions.

A randomized controlled trial evaluating the effects of nurse-led triage of 911 calls.

To better connect non-emergent 911 callers to appropriate care, Washington, DC, routed low-acuity callers to nurses. Nurses could provide non-emergent transportation to a health centre, recommend self-care or return callers to the traditional 911 system. Over about one year, 6,053 callers were randomized (1:1) to receive a business-as-usual response (ncontrol = 3,023) or further triage (ntreatment = 3,030). We report on seven of nine outcomes, which were pre-registered ( https://osf.io/xderw ). The proportion of calls resulting in an ambulance dispatch dropped from 97% to 56% (ß = -1.216 (-1.324, -1.108), P < 0.001), and those resulting in an ambulance transport dropped from 73% to 45% (ß = -3.376 (-3.615, -3.137), P < 0.001). Among those callers who were Medicaid beneficiaries, within 24 hours, the proportion of calls resulting in an emergency department visit for issues classified as non-emergent or primary care physician (PCP) treatable dropped from 29.5% to 25.1% (ß = -0.230 (-0.391, -0.069), P < 0.001), and the proportion resulting in the caller visiting a PCP rose from 2.5% to 8.2% (ß = 1.252 (0.889, 1.615), P < 0.001). Over the longer time span of six months, we failed to detect evidence of impacts on emergency department visits, PCP visits or Medicaid expenditures. From a safety perspective, 13 callers randomized to treatment were eventually diagnosed with a time-sensitive illness, all of whom were quickly triaged to an ambulance response. These short-term effects suggest that nurse-led triage of non-emergent calls can safely connect callers to more appropriate, timely care.

Effectiveness of Behaviorally Informed Letters on Health Insurance Marketplace Enrollment: A Randomized Clinical Trial.

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

Letters designed with behavioural science increase influenza vaccination in Medicare beneficiaries.

The influenza ('flu') vaccination is low cost1 and effective, typically reducing the likelihood of infection by 50-60%2. It is recommended for nearly everyone older than 6 months of age3; yet, only 40% of Americans are immunized each year. Vaccination rates are higher among at-risk groups, such as those ≥65 years of age, but still only 6 in 10 receive it4. There have been numerous attempts to improve vaccination rates using strategies such as school-based programmes, financial incentives and reminders, but these have generally had limited success5-7. Of the attempts that are successful, most are expensive-limiting scalability-and have not been evaluated in the elderly8. Conversely, lower-cost interventions, such as mailed information, hold promise for a scalable solution, but their limited effectiveness may result from how they have been designed. We randomly assigned 228,000 individuals ≥66 years of age to one of five versions of letters intended to motivate vaccination, including versions with an implementation intention prompt and an enhanced active choice implementation prompt. We found that a single mailed letter significantly increased influenza vaccination rates compared with no letter. However, there was no difference in vaccination rates across the four different letters tailored with behavioural science techniques.

Effect of Peer Comparison Letters for High-Volume Primary Care Prescribers of Quetiapine in Older and Disabled Adults: A Randomized Clinical Trial.

Importance: Antipsychotic agents, such as quetiapine fumarate, are frequently overprescribed for indications not supported by clinical evidence, potentially causing harm. Objective: To investigate if peer comparison letters targeting high-volume primary care prescribers of quetiapine meaningfully reduce their prescribing. Design, Setting, and Participants: Randomized clinical trial (intent to treat) conducted from 2015 to 2017 of prescribers and their patients nationwide in the Medicare program. The trial targeted the 5055 highest-volume primary care prescribers of quetiapine in 2013 and 2014 (approximately 5% of all primary care prescribers of quetiapine). Interventions: Prescribers were randomized (1:1 ratio) to receive a placebo letter or 3 peer comparison letters stating that their quetiapine prescribing was high relative to their peers and was under review by Medicare. Main Outcomes and Measures: The primary outcome was the total quetiapine days supplied by prescribers from the intervention start to 9 months. Secondary outcomes included quetiapine receipt from all prescribers by baseline patients, quetiapine receipt by patients with low-value or guideline-concordant indications for therapy, mortality, and hospital use. In exploratory analyses, the study followed outcomes to 2 years. Results: Of the 5055 prescribers, 231 (4.6%) were general practitioners, 2428 (48.0%) were in family medicine, and 2396 (47.4%) were in internal medicine; 4155 (82.2%) were male. All were included in the analyses. Over 9 months, the treatment arm supplied 11.1% fewer quetiapine days per prescriber vs the control arm (2456 vs 2864 days; percentage difference, 11.1% fewer days; 95% CI, -13.1% to -9.2% days; P < .001; adjusted difference, -319 days; 95% CI, -374 to -263 days; P < .001), which persisted through 2 years (15.6% fewer days; 95% CI, -18.1% to -13.0%; P < .001). At the patient level, individuals in the treatment arm received 3.9% (95% CI, -5.0% to -2.9%; P < .001) fewer days of quetiapine from all prescribers over 9 months, with a larger decrease among patients with low-value vs guideline-concordant indications (-5.9% [95% CI, -8.0% to -3.9%] vs -2.4% [95% CI, -4.0% to -0.9%], P = .01 for test that effects were equal for both patient groups). There was no evidence of substitution to other antipsychotics, and 9-month mortality and hospital use were similar between the treatment vs control arms. Conclusions and Relevance: Peer comparison letters caused substantial and durable reductions in quetiapine prescribing, with no evidence of negative effects on patients. Trial Registration: ClinicalTrials.gov identifier: NCT02467933.

Medicare Letters To Curb Overprescribing Of Controlled Substances Had No Detectable Effect On Providers.

Inappropriate prescribing is a rising threat to the health of Medicare beneficiaries and a drain on Medicare's finances. In this study we used a randomized controlled trial approach to evaluate a low-cost, light-touch intervention aimed at reducing the inappropriate provision of Schedule II controlled substances in the Medicare Part D program. Potential overprescribers were sent a letter explaining that their practice patterns were highly unlike those of their peers. Using rich administrative data, we were unable to detect an effect of these letters on prescribing. We describe ongoing efforts to build on this null result with alternative interventions. Learning about the potential of light-touch interventions, both effective and ineffective, will help produce a better toolkit for policy makers to improve the value and safety of health care.

Applying Behavioral Economics to Public Health Policy: Illustrative Examples and Promising Directions.

Behavioral economics provides an empirically informed perspective on how individuals make decisions, including the important realization that even subtle features of the environment can have meaningful impacts on behavior. This commentary provides examples from the literature and recent government initiatives that incorporate concepts from behavioral economics in order to improve health, decision making, and government efficiency. The examples highlight the potential for behavioral economics to improve the effectiveness of public health policy at low cost. Although incorporating insights from behavioral economics into public health policy has the potential to improve population health, its integration into government public health programs and policies requires careful design and continual evaluation of such interventions. Limitations and drawbacks of the approach are discussed.

The Novel New Jersey Eyewitness Instruction Induces Skepticism but Not Sensitivity.

In recent decades, social scientists have shown that the reliability of eyewitness identifications is much worse than laypersons tend to believe. Although courts have only recently begun to react to this evidence, the New Jersey judiciary has reformed its jury instructions to notify jurors about the frailties of human memory, the potential for lineup administrators to nudge witnesses towards suspects that they police have already identified, and the advantages of alternative lineup procedures, including blinding of the administrator. This experiment tested the efficacy of New Jersey's jury instruction. In a 2×2 between-subjects design, mock jurors (N = 335) watched a 35-minute murder trial, wherein identification quality was either "weak" or "strong" and either the New Jersey or a "standard" instruction was delivered. Jurors were more than twice as likely to convict when the standard instruction was used (OR = 2.55; 95% CI = 1.37-4.89, p < 0.001). The New Jersey instruction, however, did not improve juror's ability to discern quality; rather, jurors receiving those instructions indiscriminatingly discounted "weak" and "strong" testimony in equal measure.