A Content Analysis of Indoor Tanning Twitter Chatter During COVID-19 Shutdowns: Cross-Sectional Qualitative Study.

BACKGROUND: Indoor tanning is a preventable risk factor for skin cancer. Statewide shutdowns during the COVID-19 pandemic resulted in temporary closures of tanning businesses. Little is known about how tanners reacted to losing access to tanning businesses. OBJECTIVE: This study aimed to analyze Twitter (subsequently rebranded as X) chatter about indoor tanning during the statewide pandemic shutdowns. METHODS: We collected tweets from March 15 to April 30, 2020, and performed a directed content analysis of a random sample of 20% (1165/5811) of tweets from each week. The 2 coders independently rated themes (κ=0.67-1.0; 94%-100% agreement). RESULTS: About half (589/1165, 50.6%) of tweets were by people unlikely to indoor tan, and most of these mocked tanners or the act of tanning (562/589, 94.9%). A total of 34% (402/1165) of tweets were posted by users likely to indoor tan, and most of these (260/402, 64.7%) mentioned missing tanning beds, often citing appearance- or mood-related reasons or withdrawal. Some tweets by tanners expressed a desire to purchase or use home tanning beds (90/402, 22%), while only 3.9% (16/402) mentioned tanning alternatives (eg, self-tanner). Very few tweets (29/1165, 2.5%) were public health messages about the dangers of indoor tanning. CONCLUSIONS: Findings revealed that during statewide shutdowns, half of the tweets about indoor tanning were mocking tanning bed users and the tanned look, while about one-third were indoor tanners reacting to their inability to access tanning beds. Future work is needed to understand emerging trends in tanning post pandemic.

Characteristics associated with poor atrial fibrillation-related quality of life in adults with atrial fibrillation.

PURPOSE: Few studies have examined the relationship between poor atrial fibrillation-related quality of life (AFQoL) and a battery of geriatric factors. The objective of this study is to describe factors associated with poor AFQoL in older adults with atrial fibrillation (AF) with a focus on sociodemographic and clinical factors and a battery of geriatric factors. METHODS: Cross-sectional analysis of a prospective cohort study of participants aged 65+ with high stroke risk and AF. AFQoL was measured using the validated Atrial Fibrillation Effect on Quality of Life (score 0-100) and categorized as poor (<80) or good (80-100). Chi-square and t -tests evaluated differences in factors across poor AFQoL and significant characteristics ( P  < 0.05) were entered into a logistic regression model to identify variables related to poor AFQoL. RESULTS: Of 1244 participants (mean age 75.5), 42% reported poor AFQoL. Falls in the past 6 months, pre/frail and frailty, depression, anxiety, social isolation, vision impairment, oral anticoagulant therapy, rhythm control, chronic obstructive pulmonary disease and polypharmacy were associated with higher odds of poor AFQoL. Marriage and college education were associated with a lower odds of poor AFQoL. CONCLUSIONS: More than 4 out of 10 older adults with AF reported poor AFQoL. Geriatric factors associated with higher odds of reporting poor AFQoL include recent falls, frailty, depression, anxiety, social isolation and vision impairment. Findings from this study may help clinicians screen for patients with poor AFQoL who could benefit from tailored management to ensure the delivery of patient-centered care and improved well being among older adults with AF.

Proof-of-Concept Feasibility Trial of a Dissonance-Based Sun Safety Intervention for Young Adult Tanners.

BACKGROUND: Melanoma is the second most common cancer in young adults. Social media may be a means to conduct interventions to increase sun safety in young adults. PURPOSE: We conducted a randomized proof-of-concept pilot trial to evaluate the feasibility and acceptability of a dissonance-based social media intervention designed to promote sun safety in young adult tanners. METHODS: Young adult tanners (N = 66) were randomized into two 4-week interventions in which participants were incentivized to create content for a social media campaign on healthy skin or healthy lifestyle. Feasibility outcomes included retention, participation, acceptability, and contamination. We also examined the impact of participation on motivation to engage in the target health behaviors and outdoor tanning intentions. RESULTS: Retention was 100%. Most Healthy Skin (88%) and Healthy Lifestyle participants (91%) created ≥1 post. Acceptability was high with 94% and 97% of participants in Healthy Skin and Healthy Lifestyle conditions, respectively, agreeing they would recommend the campaign to a friend. At 4 weeks, Healthy Skin participants reported greater declines in motivation to tan indoors (p = .0017) and outdoors (p = .0003), and greater increases in motivation to wear sunscreen (p = .0009) and protective clothing (p = .0342). Healthy Skin participants reported greater declines in intentions to tan outdoors in the next year (p = .0286). CONCLUSIONS: A dissonance-based, social media sun safety intervention was feasible and acceptable. Future research should examine the efficacy and longer-term effects of this intervention in young adults at elevated risk for skin cancer. TRIAL REGISTRATION: Clinicaltrials.gov NCT03834974 https://clinicaltrials.gov/ct2/show/NCT03834974.

Online Health Information-Seeking Among Older Women With Chronic Illness: Analysis of the Women's Health Initiative.

BACKGROUND: Understanding how older patients with chronic illnesses use the internet to obtain health information is relevant for the design of digital interventions aimed at improving the health and well-being of adults aged 65 years and older; this cohort represents the sickest, most expensive, and fastest-growing segment of the US population. OBJECTIVE: The objective of our study was to describe online health information-seeking behavior among older patients with chronic illnesses and to compare the characteristics of patients who report using the internet to obtain health information with those who do not. METHODS: The study population included 72,806 women aged 65 years and older enrolled in the Women's Health Initiative (WHI), a national cohort study, who completed a 2014 supplemental questionnaire assessing everyday technology use and internet use for researching health conditions. Comparisons were made between participants with and without a history of chronic illness and between users and nonusers of online sources for health information. Multivariate logistic regression was used to estimate odds ratios (ORs) and 95% CIs. RESULTS: Of the total, 59% (42,887/72,806) of older women used the internet for health information. Compared with women who did not use the internet to obtain health information, those who used the internet were younger (median age: 76 vs 81 years), more likely to be non-Hispanic white (90% [38,481/42,887] vs 87% [26,017/29,919]), earned a higher income (over $US 50,000: 55% [23,410/42,887] vs 33% [9991/29,919]), achieved a higher educational level (more than high school: 87% [37,493/42,887] vs 75% [22,377/29,919]), and were more likely to live with a partner (52% [22,457/42,887] vs 36% [10,759/29,919]) (all P<.001). Women with Alzheimer disease were least likely to report online health information-seeking compared to those without the disease (OR 0.41, 95% CI 0.38-0.43). In contrast, women with a recent diagnosis of cancer, within the previous 2 years (OR 1.23, 95% CI 1.11-1.36) or 2-5 years ago (OR 1.09, 95% CI 1.00-1.19), were most likely to use the internet for health information. CONCLUSIONS: Nearly 6 in 10 older women participating in the WHI reported using the internet to obtain health information. Patients recently diagnosed with cancer are more likely to be looking for health information online, even after adjustment for age, suggesting that these patients may have a greater need for digital health resources.

Content analysis of Twitter chatter about indoor tanning.

Twitter may be useful for learning about indoor tanning behavior and attitudes. The objective of this study was to analyze the content of tweets about indoor tanning to determine the extent to which tweets are posted by people who tan, and to characterize the topics of tweets. We extracted 4,691 unique tweets from Twitter using the terms "tanning bed" or "tanning salon" over 7 days in March 2016. We content analyzed a random selection of 1,000 tweets, double-coding 20% of tweets (κ = 0.74, 81% agreement). Most tweets (71%) were by tanners (n = 699 individuals) and included tweets expressing positive sentiment about tanning (57%), and reports of a negative tanning experience (17%), burning (15%), or sleeping in a tanning bed (9%). Four percent of tweets were by tanning salon employees. Tweets posted by people unlikely to be tanners (15%) included tweets mocking tanners (71%) and health warnings (29%). The term "tanning bed" had higher precision for identifying individuals who engage in indoor tanning than "tanning salon"; 77% versus 45% of tweets captured by these search terms were by individuals who engaged in indoor tanning, respectively. Extrapolating to the full data set of 4,691 tweets, findings suggest that an average of 468 individuals who engage in indoor tanning can be identified by their tweets per day. The majority of tweets were from tanners and included reports of especially risky habits (e.g., burning, falling asleep). Twitter provides opportunity to identify indoor tanners and examine conversations about indoor tanning.

Does provider advice to increase physical activity differ by activity level among US adults with cardiovascular disease risk factors?

Background: Regular physical activity (PA) lowers the risk of cardiovascular disease (CVD), but few US adults meet PA guidelines. The United States Preventive Services Task Force (USPSTF) recommends primary care providers offer PA counselling for CVD prevention. We examined the association between adherence to PA guidelines and reported provider advice to increase PA among US adults with overweight/obesity and ≥1 additional CVD risk factor. Methods: Cross-sectional data from the National Health and Nutrition Examination Survey (2011-2014) on PA and provider advice to increase PA were analysed for 4158 adults (≥20 years old) with overweight/obesity who reported ≥1 of hypertension, high cholesterol or impaired fasting glucose. Adherence to federal PA guidelines was determined using self-reported PA data from the Global Physical Activity Questionnaire. Meeting PA guidelines was defined as ≥150 minutes/week moderate intensity PA, ≥75 minutes/week vigorous intensity, or an equivalent combination. Participants self-reported provider advice to increase PA. Results: In total, 57.7% of US adults with overweight/obesity and ≥1 additional CVD risk factor who did not meet PA guidelines reported provider advice to increase PA compared to 49.7% of adults who met PA guidelines. Adults who did not meet PA guidelines were more likely to report provider PA advice (aOR = 1.21; 95% CI = 1.00-1.47). Conclusions: US adults with CVD risk factors who do not meet PA guidelines are more likely to receive provider advice to increase PA, but only half receive such advice. Strategies to increase provider advice are needed to improve adherence to USPSTF guidelines among US adults with overweight/obesity and additional CVD risk factors.

The association of dietary quality with colorectal cancer among normal weight, overweight and obese men and women: a prospective longitudinal study in the USA.

OBJECTIVE: Lower body mass index (BMI) and higher dietary quality reduce the risk of colorectal cancer (CRC). A full understanding of how these associations vary by sex and weight is lacking. METHODS: We used data from the National Institutes of Health - American Association of Retired Persons (NIH)-AARP) Diet and Health Study for 398 458 persons who were 50-71 years old in 1995-1996 and followed through 2006. Exposures were dietary quality as reflected by the Mediterranean Diet, the Healthy Eating Index-2010 and the Dietary Approaches to Stop Hypertension score, stratified by BMI category. The outcome was CRC diagnosis from cancer registry data. Cox regression models were adjusted for disease risk factors. RESULTS: Over a mean duration of 123 months of follow-up, there were 6515 new diagnoses of CRC (1953 among the normal weight, 2924 among the overweight and 1638 among the obese; 4483 among men and 2032 among women). For normal weight and overweight men, we found a strong dose-response pattern for the association of increasing quintile of dietary quality with decreasing risk of CRC; this pattern was observed for obese men as well, but less consistently across the three measures of dietary quality. The findings were of smaller magnitude and less consistent for women but still suggesting associations of similar direction. CONCLUSION: We observed that increased dietary quality was associated with lower risk of incident CRC up to 10 years later for men regardless of baseline weight category.

Association of Objectively Measured Physical Activity and Metabolic Syndrome Among US Adults With Osteoarthritis.

OBJECTIVE: To investigate the association between objectively measured physical activity and metabolic syndrome among adults with osteoarthritis (OA). METHODS: Using cross-sectional data from the 2003-2006 National Health and Nutrition Examination Survey, we identified 566 adults with OA with available accelerometer data assessed using Actigraph AM-7164 and measurements necessary to determine metabolic syndrome by the Adult Treatment Panel III. Analysis of variance was conducted to examine the association between continuous variables in each activity level and metabolic syndrome components. Logistic models estimated the relationship of quartile of daily minutes of different physical activity levels to odds of metabolic syndrome adjusted for socioeconomic and health factors. RESULTS: Among persons with OA, most were women average age of 62.1 years and average disease duration of 12.9 years. Half of adults with OA had metabolic syndrome (51.0%; 95% confidence interval [95% CI] 44.2%-57.8%), and only 9.6% engaged in the recommended 150 minutes per week of moderate/vigorous physical activity. Total sedentary time was associated with higher rates of metabolic syndrome and its components, while light and objectively measured moderate/vigorous physical activity was inversely associated with metabolic syndrome and its components. Higher levels of light activity were associated with lower prevalence of metabolic syndrome (quartile 4 versus quartile 1: adjusted odds ratio 0.45, 95% CI 0.24-0.84, P for linear trend < 0.005). CONCLUSION: Most US adults with OA are sedentary. Increased daily minutes in physical activity, especially in light intensity, is more likely to be associated with decreasing prevalence of metabolic syndrome among persons with OA.

Tobacco counseling experience prior to starting medical school, tobacco treatment self-efficacy and knowledge among first-year medical students in the United States.

OBJECTIVE: To explore students' tobacco dependence counseling experiences prior to medical school and their associations with tobacco counseling self-efficacy, and familiarity with and perceived effectiveness of tobacco dependence treatment among first-year medical students in the United States. METHOD: In 2010, 1266 first-year medical students from 10 US medical schools completed a survey reporting their clinical experiences with specific tobacco counseling skills (e.g., 5As) prior to medical school. The survey also included questions on tobacco counseling self-efficacy, perceived physician impact on smokers, and familiarity and effectiveness of tobacco-related treatments. RESULTS: Half (50.4%) reported some tobacco counseling experiences prior to medical school (i.e. at least one 5A). Students with prior counseling experiences were more likely to have higher tobacco counseling self-efficacy, and greater familiarity with medication treatment, nicotine replacement treatment, and behavioral counseling for smoking cessation, compared to those with no prior experiences. Perceived physician impact on patient smoking outcomes did not differ by prior tobacco counseling experiences. CONCLUSIONS: Many first-year medical students may already be primed to learn tobacco dependence counseling skills. Enhancing early exposure to learning these skills in medical school is likely to be beneficial to the skillset of our future physicians.

Diet quality and history of gestational diabetes mellitus among childbearing women, United States, 2007-2010.

INTRODUCTION: Women with a history of gestational diabetes mellitus (GDM) have elevated risk of developing type 2 diabetes. Diet quality plays an important role in the prevention of type 2 diabetes. We compared diet quality among childbearing women with a history of GDM with the diet quality of childbearing women without a history of GDM. METHODS: We used data from the National Health and Nutrition Examination Survey for 2007 through 2010. We included women without diabetes aged 20 to 44 years whose most recent live infant was born within the previous 10 years and who completed two 24-hour dietary recalls. The Healthy Eating Index (HEI)-2010 estimated overall and component diet quality. Multivariable linear regression models estimated the association between a history of GDM and current diet quality, adjusting for age, education, smoking status, and health risk for diabetes. RESULTS: A history of GDM was reported by 7.7% of women. Compared with women without a history of GDM, women with a history of GDM had, on average, 3.4 points lower overall diet quality (95% confidence interval [CI], -6.6 to -0.2) and 0.9 points lower score for consumption of green vegetables and beans (95% CI, -1.4 to -0.4). Other dietary component scores did not differ by history of GDM. CONCLUSION: In the United States, women with a history of GDM have lower diet quality compared with women who bore a child and do not have a history of GDM. Improving diet quality may be a strategy for preventing type 2 diabetes among childbearing women.

Healthy lifestyle and decreasing risk of heart failure in women: the Women's Health Initiative observational study.

BACKGROUND: The impact of a healthy lifestyle on risk of heart failure (HF) is not well known. OBJECTIVES: The objectives of this study were to evaluate the effect of a combination of lifestyle factors on incident HF and to further investigate whether weighting each lifestyle factor has additional impact. METHODS: Participants were 84,537 post-menopausal women from the WHI (Women's Health Initiative) observational study, free of self-reported HF at baseline. A healthy lifestyle score (HL score) was created wherein women received 1 point for each healthy criterion met: high-scoring Alternative Healthy Eating Index, physically active, healthy body mass index, and currently not smoking. A weighted score (wHL score) was also created in which each lifestyle factor was weighted according to its independent magnitude of effect on HF. The incidence of hospitalized HF was determined by trained adjudicators using standardized methodology. RESULTS: There were 1,826 HF cases over a mean follow-up of 11 years. HL score was strongly associated with risk of HF (multivariable-adjusted hazard ratio [HR] [95% confidence interval (CI)] 0.49 [95% CI: 0.38 to 0.62], 0.36 [95% CI: 0.28 to 0.46], 0.24 [95% CI: 0.19 to 0.31], and 0.23 [95% CI: 0.17 to 0.30] for HL score of 1, 2, 3, and 4 vs. 0, respectively). The HL score and wHL score were similarly associated with HF risk (HR: 0.46 [95% CI: 0.41 to 0.52] for HL score; HR: 0.48 [95% CI: 0.42 to 0.55] for wHL score, comparing the highest tertile to the lowest). The HL score was also strongly associated with HF risk among women without antecedent coronary heart disease, diabetes, or hypertension. CONCLUSIONS: An increasingly healthy lifestyle was associated with decreasing HF risk among post-menopausal women, even in the absence of antecedent coronary heart disease, hypertension, and diabetes. Weighting the lifestyle factors had minimal impact.

Mediterranean and Dietary Approaches to Stop Hypertension dietary patterns and risk of sudden cardiac death in postmenopausal women.

BACKGROUND: The Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets are characterized by higher intake of fruit, vegetables, whole grains, and unsaturated fatty acids. All of these foods and nutrients may affect cholesterol, inflammation, the development of atherosclerosis, and, therefore, risk of cardiac death. OBJECTIVE: Our objective was to examine the association between the Mediterranean and DASH dietary patterns and risk of sudden cardiac death (SCD) in women. DESIGN: We used a prospective cohort of 93,122 postmenopausal women enrolled in the Women's Health Initiative study between 1993 and 1998 and followed for an average of 10.5 y. Women completed a food-frequency questionnaire (FFQ) twice during follow-up. We scored their diets according to how closely the reported diet resembled each dietary pattern. SCD was defined as death that occurred within 1 h of symptom onset. RESULTS: A higher Mediterranean diet score was associated with lower risk of SCD (HR: 0.64; 95% CI: 0.43, 0.94) when women in the highest quintile were compared with women in the lowest quintile after adjustment for age, total energy, race, income, smoking, and physical activity. After adjustment for potential mediators, the association was similar (HR: 0.67; 95% CI: 0.46, 0.99). A higher DASH diet score was not associated with risk of SCD. However, sodium intake, which is a crucial component of the DASH dietary pattern, was not well characterized by the FFQ. CONCLUSION: The Mediterranean dietary pattern may be associated with lower risk of SCD in women. This trial was registered at clinicaltrials.gov as NCT00000611.

Obesity and late-age survival without major disease or disability in older women.

IMPORTANCE: The effect of obesity on late-age survival in women without disease or disability is unknown. OBJECTIVE: To investigate whether higher baseline body mass index and waist circumference affect women's survival to 85 years of age without major chronic disease (coronary disease, stroke, cancer, diabetes mellitus, or hip fracture) and mobility disability. DESIGN, SETTING, AND PARTICIPANTS: Examination of 36,611 women from the Women's Health Initiative observational study and clinical trial programs who could have reached 85 years or older if they survived to the last outcomes evaluation on September 17, 2012. Recruitment was from 40 US clinical centers from October 1993 through December 1998. Multinomial logistic regression models were used to estimate odds ratios and 95% CIs for the association of baseline body mass index and waist circumference with the outcomes, adjusting for demographic, behavioral, and health characteristics. MAIN OUTCOMES AND MEASURES: Mutually exclusive classifications: (1) survived without major chronic disease and without mobility disability (healthy); (2) survived with 1 or more major chronic disease at baseline but without new disease or disability (prevalent diseased); (3) survived and developed 1 or more major chronic disease but not disability during study follow-up (incident diseased); (4) survived and developed mobility disability with or without disease (disabled); and (5) did not survive (died). RESULTS: Mean (SD) baseline age was 72.4 (3.0) years (range, 66-81 years). The distribution of women classified as healthy, prevalent diseased, incident diseased, disabled, and died was 19.0%, 14.7%, 23.2%, 18.3%, and 24.8%, respectively. Compared with healthy-weight women, underweight and obese women were more likely to die before 85 years of age. Overweight and obese women had higher risks of incident disease and mobility disability. Disability risks were striking. Relative to healthy-weight women, adjusted odds ratios (95% CIs) of mobility disability were 1.6 (1.5-1.8) for overweight women and 3.2 (2.9-3.6), 6.6 (5.4-8.1), and 6.7 (4.8-9.2) for class I, II, and III obesity, respectively. Waist circumference greater than 88 cm was also associated with higher risk of earlier death, incident disease, and mobility disability. CONCLUSIONS AND RELEVANCE: Overall and abdominal obesity were important and potentially modifiable factors associated with dying or developing mobility disability and major chronic disease before 85 years of age in older women.

Physical activity and screen time in metabolically healthy obese phenotypes in adolescents and adults.

INTRODUCTION: The purpose of this study was to examine levels of physical activity (PA) and screen time (ST) in metabolically healthy obese (MHO) and metabolically unhealthy obese (MUO) adolescents and adults. METHODS: NHANES data from obese adolescents (12-18 years, BMI z-score ≥ 95th percentile) and adults (19-85 years, BMI ≥ 30 kg/m(2)) were pooled from 2003-2005 cycles. Metabolic phenotypes were categorized as MHO (0 or 1 cardiometabolic risk factor; triglycerides, HDL-C, blood pressure, or glucose) or MUO (≥2 cardiometabolic risk factors). Logistic regression models estimated associations between phenotype and PA/ST adjusted for age, gender, BMI, race/ethnicity, menopausal status, and NHANES cycle. RESULTS: Among adolescents, PA was not associated with MHO. In contrast, MHO adults 19-44 years were 85% more likely to engage in active transportation and 2.7 times more likely to be involved in light intensity usual daily activity versus sitting. For each minute per day, adults 45-85 years were 36% more likely to have the MHO phenotype with higher levels of moderate PA. ST was not associated with metabolic phenotypes in adolescents or adults. CONCLUSION: The current study provides evidence that PA, but not ST, differs between MHO and MUO in adults, but not in adolescents. Future studies are needed to confirm results.

Depression severity, diet quality, and physical activity in women with obesity and depression.

Major depressive disorder (MDD) is prevalent in clinical weight-loss settings and predicts poor weight-loss outcomes. It is unknown whether the severity of depressive symptoms among those with MDD is associated with diet quality or physical activity levels. This knowledge is important for improving weight-loss treatment for these patients. It was hypothesized that more severe depression is associated with poorer diet quality and lower physical activity levels among individuals with obesity and MDD. Participants were 161 women with current MDD and obesity enrolled in the baseline phase of a weight-loss trial between 2007 and 2010. Depression severity was measured with the Beck Depression Inventory II. The Alternate Healthy Eating Index was applied to data from three 24-hour diet recalls to capture overall diet quality. Daily metabolic equivalents expended per day were calculated from three 24-hour physical activity recalls. Greater depression severity was associated with poorer overall diet quality (estimate=-0.26, standard error 0.11; P=0.02), but not with physical activity (estimate=0.07, standard error 0.05; P=0.18), in linear regression models controlling for income, education, depression-related appetite change, binge eating disorder, and other potential confounds. Associations with diet quality were primarily driven by greater intake of sugar (r=0.20; P<0.01), saturated fat (r=0.21; P<0.01), and sodium (r=0.22; P<0.01). More severe depression was associated with poorer overall diet quality, but not physical activity, among treatment-seeking women with MDD and obesity. Future studies should identify mechanisms linking depression to diet quality and determine whether diet quality improves with depression treatment.

A mixed method study of the merits of e-prescribing drug alerts in primary care.

OBJECTIVES: The objective of this paper was to describe primary care prescribers' perspectives on electronic prescribing drug alerts at the point of prescribing. DESIGN: We used a mixed-method study which included clinician surveys (web-based and paper) and focus groups with prescribers and staff. PARTICIPANTS: Prescribers (n = 157) working in one of 64 practices using 1 of 6 e-prescribing technologies in 6 US states completed the quantitative survey and 276 prescribers and staff participated in focus groups. MEASUREMENTS: The study measures self-reported frequency of overriding of drug alerts; open-ended responses to: "What do you think of the drug alerts your software generates for you?" RESULTS: More than 40% of prescribers indicated they override drug-drug interactions most of the time or always (range by e-prescribing system, 25% to 50%). Participants indicated that the software and the interaction alerts were beneficial to patient safety and valued seeing drug-drug interactions for medications prescribed by others. However, they noted that alerts are too sensitive and often unnecessary. Participant suggestions included: (1) run drug alerts on an active medication list and (2) allow prescribers to set the threshold for severity of alerts. CONCLUSIONS: Primary care prescribers recognize the patient safety value of drug prescribing alerts embedded within electronic prescribing software. Improvements to increase specificity and reduce alert overload are needed.