A Randomized Trial of Choice Architecture and Mailed Colorectal Cancer Screening Outreach in a Community Health Setting.

BACKGROUND & AIMS: Mailed outreach for CRC screening increases uptake but it is unclear how to offer the choice of testing. We evaluated if the active choice between colonoscopy and fecal immunochemical test (FIT), or FIT alone, increased response compared to colonoscopy alone. METHODS: This pragmatic randomized controlled trial at a community health center included patients between ages 50-74 who were not up to date with CRC screening. Patients were randomized 1:1:1 to: (1) Colonoscopy Only, (2) Active Choice of Colonoscopy or FIT, or (3) FIT Only. Patients received an outreach letter with instructions for testing (colonoscopy referral and/ or enclosed FIT kit), a reminder letter at 2 months, and another reminder at 3-5 months via text message or automated voice recording. The primary outcome was CRC screening completion within 6 months. RESULTS: Among 738 patients in the final analysis, the mean age was 58.7 (SD 6.2); 48.6% were insured by Medicaid and 24.3% by Medicare; 71.7% were White, 16.9% were Black, and 7.3% were Hispanic/ Latino. At 6 months, 5.6% (95% CI, 2.8 to 8.5) completed screening in the Colonoscopy Only arm, 12.8% (95% CI, 8.6 to 17.0) in the Active Choice arm, and 11.3% (95% CI, 7.4 to 15.3) in the FIT Only arm. Compared to Colonoscopy Only, there was a significant increase in screening in Active Choice (absolute difference of 7.1%; 95% CI, 2.0 to 12.2; p=0.006) and FIT Only (absolute difference of 5.7%; 95% CI, 0.8 to 10.6; p=0.02). CONCLUSION: Both choice of testing and FIT alone increased response and may align with patient preferences.

Behavioral Interventions to Improve Breast Cancer Screening Outreach: Two Randomized Clinical Trials.

Importance: Despite public health efforts, breast cancer screening rates remain below national goals. Objective: To evaluate whether bulk ordering, text messaging, and clinician endorsement increase breast cancer screening rates. Design, Setting, and Participants: Two concurrent, pragmatic, randomized clinical trials, each with a 2-by-2 factorial design, were conducted between October 25, 2021, and April 25, 2022, in 2 primary care regions of an academic health system. The trials included women aged 40 to 74 years with at least 1 primary care visit in the past 2 years who were eligible for breast cancer screening. Interventions: Patients in trial A were randomized in a 1:1 ratio to receive a signed bulk order for mammogram or no order; in a factorial design, patients were concurrently randomized in a 1:1 ratio to receive or not receive text message reminders. Patients in trial B were randomized in a 1:1 ratio to receive a message signed by their primary care clinician (clinician endorsement) or from the organization (standard messaging); in a factorial design, patients were concurrently randomized in a 1:1 ratio to receive or not receive text message reminders. Main Outcomes and Measures: The primary outcome was the proportion of patients who completed a screening mammogram within 3 months. Results: Among 24 632 patients included, the mean (SD) age was 60.4 (7.5) years. In trial A, at 3 months, 15.4% (95% CI, 14.6%-16.1%) of patients in the bulk order arm and 12.7% (95% CI, 12.1%-13.4%) in the no order arm completed a mammogram, showing a significant increase (absolute difference, 2.7%; 95% CI, 1.6%-3.6%; P < .001). In the text messaging comparison arms, 15.1% (95% CI, 14.3%-15.8%) of patients receiving a text message completed a mammogram compared with 13.0% (95% CI, 12.4%-13.7%) of those in the no text messaging arm, a significant increase (absolute difference of 2.1%; 95% CI, 1.0%-3.0%; P < .001). In trial B, at 3 months, 12.5% (95% CI, 11.3%-13.7%) of patients in the clinician endorsement arm completed a mammogram compared with 11.4% (95% CI, 10.3%-12.5%) of those in the standard messaging arm, which was not significant (absolute difference, 1.1%; 95% CI, -0.5% to 2.7%; P = .18). In the text messaging comparison arms, 13.2% (95% CI, 12.0%-14.4%) of patients receiving a text message completed a mammogram compared with 10.7% (95% CI, 9.7%-11.8%) of those in the no text messaging arm, a significant increase (absolute difference, 2.5%; 95% CI, 0.8%-4.0%; P = .003). Conclusions and Relevance: These findings show that text messaging women after initial breast cancer screening outreach via either electronic portal or mailings, as well as bulk ordering with or without text messaging, can increase mammogram completion rates. Trial Registration: ClinicalTrials.gov Identifier: NCT05089903.

Association of Electronic Self-Scheduling and Screening Mammogram Completion.

INTRODUCTION: The purpose of this study was to evaluate if an electronic health record (EHR) self-scheduling function was associated with changes in mammogram completion for primary care patients who were eligible for a screening mammogram using U.S. Preventive Service Task Force recommendations. METHODS: This was a retrospective cohort study (September 1, 2014-August 31, 2019, analyses completed in 2022) using a difference-in-differences design to examine mammogram completion before versus after the implementation of self-scheduling. The difference-in-differences estimate was the interaction between time (pre-versus post-implementation) and group (active EHR patient portal versus inactive EHR patient portal). The primary outcome was mammogram completion among all eligible patients, with completion defined as receiving a mammogram within 6 months post-visit. The secondary outcome was mammogram completion among patients who received a clinician order during their visit. RESULTS: The primary analysis included 35,257 patient visits. The overall mammogram completion rate in the pre-period was 22.2% and 49.7% in the post-period. EHR self-scheduling was significantly associated with increased mammogram completion among those with an active EHR portal, relative to patients with an inactive portal (adjusted difference 13.2 percentage points [95% CI 10.6-15.8]). For patients who received a clinician mammogram order at their eligible visit, self-scheduling was significantly associated with increased mammogram completion among patients with an active EHR portal account (adjusted difference 14.7 percentage points, [95% CI 10.9-18.5]). CONCLUSIONS: EHR-based self-scheduling was associated with a significant increase in mammogram completion among primary care patients. Self-scheduling can be a low-cost, scalable function for increasing preventive cancer screenings.

A randomized trial of mailed outreach with behavioral economic interventions to improve liver cancer surveillance.

BACKGROUND: Surveillance rates for HCC remain limited in patients with cirrhosis. We evaluated whether opt-out mailed outreach increased uptake with or without a $20 unconditional incentive. METHODS: This was a pragmatic randomized controlled trial in an urban academic health system including adult patients with cirrhosis or advanced fibrosis, at least 1 visit to a specialty practice in the past 2 years and no surveillance in the last 7 months. Patients were randomized in a 1:2:2 ratio to (1) usual care, (2) a mailed letter with a signed order for an ultrasound, or (3) a mailed letter with an order and a $20 unconditional incentive. The main outcome was the proportion with completion of ultrasound within 6 months. RESULTS: Among the 562 patients included, the mean age was 62.1 (SD 11.1); 56.8% were male, 51.1% had Medicare, and 40.6% were Black. At 6 months, 27.6% (95% CI: 19.5-35.7) completed ultrasound in the Usual care arm, 54.5% (95% CI: 47.9-61.0) in the Letter + Order arm, and 54.1% (95% CI: 47.5-60.6) in the Letter + Order + Incentive arm. There was a significant increase in the Letter + Order arm compared to Usual care (absolute difference of 26.9%; 95% CI: 16.5-37.3; p<0.001), but no significant increase in the Letter + Order + Incentive arm compared to Letter + Order (absolute difference of -0.4; 95% CI: -9.7 to 8.8; p=0.93). CONCLUSIONS: There was an increase in HCC surveillance from mailed outreach with opt-out framing and a signed order slip, but no increase in response to the financial incentive.

Patient randomised controlled trial of technology enabled strategies to promote treatment adherence in liver transplantation: rationale and design of the TEST trial.

BACKGROUND AND AIMS: Liver transplantation is a life-saving procedure for end-stage liver disease. However, post-transplant medication regimens are complex and non-adherence is common. Post-transplant medication non-adherence is associated with graft rejection, which can have long-term adverse consequences. Transplant centres are equipped with clinical staff that monitor patients post-transplant; however, digital health tools and proactive immunosuppression adherence monitoring has potential to improve outcomes. METHODS AND ANALYSIS: This is a patient-randomised prospective clinical trial at three transplant centres in the Northeast, Midwest and South to investigate the effects of a remotely administered adherence programme compared with usual care. The programme monitors potential non-adherence largely levering text message prompts and phenotypes the nature of the non-adhere as cognitive, psychological, medical, social or economic. Additional reminders for medications, clinical appointments and routine self-management support are incorporated to promote adherence to the entire medical regimen. The primary study outcome is medication adherence via 24-hour recall; secondary outcomes include additional medication adherence (ASK-12 self-reported scale, regimen knowledge scales, tacrolimus values), quality of life, functional health status and clinical outcomes (eg, days hospitalised). Study implementation, acceptability, feasibility, costs and potential cost-effectiveness will also be evaluated. ETHICS AND DISSEMINATION: The University of Pennsylvania Review Board has approved the study as the single IRB of record (protocol # 849575, V.1.4). Results will be published in peer-reviewed journals and summaries will be provided to study funders. TRIAL REGISTRATION NUMBER: NCT05260268.

Economics of a health system's direct-to-consumer telemedicine for its employees.

OBJECTIVES: To compare the mean per-episode unit cost for a direct-to-consumer (DTC) telemedicine service for medical center employees (OnDemand) with that of in-person care and to estimate whether the offered service increased the use of care. STUDY DESIGN: Propensity score-matched retrospective cohort study of adult employees and dependents of a large academic health system between July 7, 2017, and December 31, 2019. METHODS: To estimate differences in per-episode unit costs within 7 days, we compared costs between OnDemand encounters and conventional in-person encounters (primary care, urgent care, and emergency department) for any similar condition using a generalized linear model. We used interrupted time series analyses limited to the top 10 clinical conditions managed by OnDemand to estimate the effect of OnDemand's availability on the trends for overall employee per-month encounters. RESULTS: A total of 10,826 encounters among 7793 beneficiaries were included (mean [SD] age, 38.5 [10.9] years; 81.6% were women). The mean (SE) 7-day per-episode cost among employees and beneficiaries was lower for OnDemand encounters at $379.76 ($19.83) relative to non-OnDemand encounters at $493.49 ($25.53), a mean per-episode savings of $113.73 (95% CI, $50.36-$177.10; P < .001). After the introduction of OnDemand, among employees with encounters for the top 10 clinical conditions managed by OnDemand, the trend for encounter rates per 100 employees per month increased marginally (0.03; 95% CI, 0.00-0.05; P = .03). CONCLUSIONS: These results suggest that DTC telemedicine staffed by an academic health system and offered directly to employees reduced the per-episode unit costs and only marginally increased utilization, suggesting lower cost overall.

Factors Associated With Primary Care Physician Decision-making When Making Medication Recommendations vs Surgical Referrals.

Importance: Although objective data are used routinely in prescription drug recommendations, it is unclear how referring physicians apply evidence when making surgeon or hospital recommendations for surgery. Objective: To compare the factors associated with the hospital or surgeon referral decision-making process with that used for prescription medication recommendations. Design, Setting, and Participants: This qualitative study comprised interviews conducted between April 26 and May 18, 2021, of a purposive sample of 21 primary care physicians from a large primary care network in the Northeast US. Main Outcomes and Measures: Main outcomes were the factors considered when making prescription medication recommendations vs referral recommendations to specific surgeons or hospitals for surgery. Results: All 21 participant primary care physicians (14 women [66.7%]) reported use of evidence-based decision support tools and patient attributes for prescription medication recommendations. In contrast, for surgeon and hospital referral recommendations, primary care physicians relied on professional experience and training, personal beliefs about surgical quality, and perceived convenience. Primary care physicians cited perceived limitations of existing data on surgical quality as a barrier to the use of such data in the process of making surgical referrals. Conclusions and Relevance: As opposed to the widespread use of objective decision support tools for guidance on medication recommendations, primary care physicians relied on subjective factors when making referrals to specific surgeons and hospitals. The findings of this study highlight the potential to improve surgical outcomes by introducing accessible, reliable data as an imperative step in the surgical referral process.

Comparison of Simulated Outcomes of Colorectal Cancer Surgery at the Highest-Performing vs Chosen Local Hospitals.

Importance: Variation in outcomes across hospitals adversely affects surgical patients. The use of high-quality hospitals varies by population, which may contribute to surgical disparities. Objective: To simulate the implications of data-driven hospital selection for social welfare among patients who underwent colorectal cancer surgery. Design, Setting, and Participants: This economic evaluation used the hospital inpatient file from the Florida Agency for Health Care Administration. Surgical outcomes of patients who were treated between January 1, 2016, and December 31, 2018 (training cohort), were used to estimate hospital performance. Costs and benefits of care at alternative hospitals were assessed in patients who were treated between January 1, 2019, and December 31, 2019 (testing cohort). The cohorts comprised patients 18 years or older who underwent elective colorectal resection for benign or malignant neoplasms. Data were analyzed from March to October 2022. Exposures: Using hierarchical logistic regression, we estimated the implications of hospital selection for in-hospital mortality risk in patients in the training cohort. These estimates were applied to patients in the testing cohort using bayesian simulations to compare outcomes at each patient's highest-performing and chosen local hospitals. Analyses were stratified by race and ethnicity to evaluate the potential implications for equity. Main Outcomes and Measures: The primary outcome was the mean patient-level change in social welfare, a composite measure balancing the value of reduced mortality with associated costs of care at higher-performing hospitals. Results: A total of 21 098 patients (mean [SD] age, 67.3 [12.0] years; 10 782 males [51.1%]; 2232 Black [10.6%] and 18 866 White [89.4%] individuals) who were treated at 178 hospitals were included. A higher-quality local hospital was identified for 3057 of 5000 patients (61.1%) in the testing cohort. Selecting the highest-performing hospital was associated with a 26.5% (95% CI, 24.5%-29.0%) relative reduction and 0.24% (95% CI, 0.23%-0.25%) absolute reduction in mortality risk. A mean amount of $1953 (95% CI, $1744-$2162) was gained in social welfare per patient treated. Simulated reassignment to a higher-quality local hospital was associated with a 23.5% (95% CI, 19.3%-32.9%) relative reduction and 0.26% (95% CI, 0.21%-0.30%) absolute reduction in mortality risk for Black patients, with $2427 (95% CI, $1697-$3158) gained in social welfare. Conclusions and Relevance: In this economic evaluation, using procedure-specific hospital performance as the primary factor in the selection of a local hospital for colorectal cancer surgery was associated with improved outcomes for both patients and society. Surgical outcomes data can be used to transform care and guide policy in colorectal cancer.

Hospital Discharge on Enteral Nutrition is Associated with Increased Hospital Readmissions.

Background: Enteral nutrition (EN) delivered via an enteric access device is employed to correct severe malnutrition and feed patients with pathology restricting oral intake, and is often initiated in the hospital. There are limited data on the clinical outcomes of patients discharged from the hospital on EN. We sought to assess whether discharge with enteral nutrition (DCEN) was independently associated with increased hospital readmissions and to assess the frequency of DCEN in our hospital.Methods: We conducted a retrospective cohort study of all hospital discharges from a tertiary care hospital between 7/2017 and 12/2019. The primary and secondary outcomes were 30- and 90-day readmissions respectively. We evaluated demographic and clinical characteristics of patients, nutrition status, and readmissions as reported in the electronic health record per hospital encounter. Logistic regressions were performed for 30- and 90-day readmissions based on DCEN.Results: Of 80,080 hospital encounters, 2527 (3.2%) encounters resulted in discharge with EN. 30-day readmissions occurred in 22.8% of encounters with DCEN and 12.5% of encounters without (p < 0.001). 90-day readmissions occurred in 35.1% and 20.4% of encounters with and without DCEN respectively (p < 0.001). The unadjusted odds ratio for 30-day readmissions for encounters with DCEN was 2.07 (CI 1.88-2.28). When adjusted for age, race, sex, Charlson Comorbidity Index, and malnutrition co-diagnosis, the odds ratio was 1.40 (CI 1.27-1.55).Conclusions: Patients with DCEN have a significantly higher likelihood of 30- and 90-day readmission. Targeted interventions and improved post-discharge care for this identified high-risk population may decrease hospital readmissions.[Box: see text].

Effect of Text Messaging and Behavioral Interventions on COVID-19 Vaccination Uptake: A Randomized Clinical Trial.

Importance: COVID-19 vaccine uptake among urban populations remains low. Objective: To evaluate whether text messaging with outbound or inbound scheduling and behaviorally informed content might increase COVID-19 vaccine uptake. Design, Setting, and Participants: This randomized clinical trial with a factorial design was conducted from April 29 to July 6, 2021, in an urban academic health system. The trial comprised 16 045 patients at least 18 years of age in Philadelphia, Pennsylvania, with at least 1 primary care visit in the past 5 years, or a future scheduled primary care visit within the next 3 months, who were unresponsive to prior outreach. The study was prespecified in the trial protocol, and data were obtained from the intent-to-treat population. Interventions: Eligible patients were randomly assigned in a 1:20:20 ratio to (1) outbound telephone call only by call center, (2) text message and outbound telephone call by call center to those who respond, or (3) text message, with patients instructed to make an inbound telephone call to a hotline. Patients in groups 2 and 3 were concurrently randomly assigned in a 1:1:1:1 ratio to receive different content: standard messaging, clinician endorsement (eg, "Dr. XXX recommends"), scarcity ("limited supply available"), or endowment framing ("We have reserved a COVID-19 vaccine appointment for you"). Main Outcomes and Measures: The primary outcome was the proportion of patients who completed the first dose of the COVID-19 vaccine within 1 month, according to the electronic health record. Secondary outcomes were the completion of the first dose within 2 months and completion of the vaccination series within 2 months of initial outreach. Additional outcomes included the percentage of patients with invalid cell phone numbers (wrong number or nontextable), no response to text messaging, the percentage of patients scheduled for the vaccine, text message responses, and the number of telephone calls made by the access center. Analysis was on an intention-to-treat basis. Results: Among the 16 045 patients included, the mean (SD) age was 36.9 (11.1) years; 9418 (58.7%) were women; 12 869 (80.2%) had commercial insurance, and 2283 (14.2%) were insured by Medicaid; 8345 (52.0%) were White, 4706 (29.3%) were Black, and 967 (6.0%) were Hispanic or Latino. At 1 month, 14 of 390 patients (3.6% [95% CI, 1.7%-5.4%]) in the outbound telephone call-only group completed 1 vaccine dose, as did 243 of 7890 patients (3.1% [95% CI, 2.7%-3.5%]) in the text plus outbound call group (absolute difference, -0.5% [95% CI, -2.4% to 1.4%]; P = .57) and 253 of 7765 patients (3.3% [95% CI, 2.9%-3.7%]) in the text plus inbound call group (absolute difference, -0.3% [95% CI, -2.2% to 1.6%]; P = .72). Among the 15 655 patients receiving text messaging, 118 of 3889 patients (3.0% [95% CI, 2.5%-3.6%]) in the standard messaging group completed 1 vaccine dose, as did 135 of 3920 patients (3.4% [95% CI, 2.9%-4.0%]) in the clinician endorsement group (absolute difference, 0.4% [95% CI, -0.4% to 1.2%]; P = .31), 100 of 3911 patients (2.6% [95% CI, 2.1%-3.1%]) in the scarcity group (absolute difference, -0.5% [95% CI, -1.2% to 0.3%]; P = .20), and 143 of 3935 patients (3.6% [95% CI, 3.0%-4.2%]) in the endowment group (absolute difference, 0.6% [95% CI, -0.2% to 1.4%]; P = .14). Conclusions and Relevance: There was no detectable increase in vaccination uptake among patients receiving text messaging compared with telephone calls only or behaviorally informed message content. Trial Registration: ClinicalTrials.gov Identifier: NCT04834726.

Remote Monitoring and Behavioral Economics in Managing Heart Failure in Patients Discharged From the Hospital: A Randomized Clinical Trial.

Importance: Close remote monitoring of patients following discharge for heart failure (HF) may reduce readmissions or death. Objective: To determine whether remote monitoring of diuretic adherence and weight changes with financial incentives reduces hospital readmissions or death following discharge with HF. Design, Setting, and Participants: The Electronic Monitoring of Patients Offers Ways to Enhance Recovery (EMPOWER) study, a 3-hospital pragmatic trial, randomized 552 adults recently discharged with HF to usual care (n = 280) or a compound intervention (n = 272) designed to inform clinicians of diuretic adherence and changes in patient weight. Patients were recruited from May 25, 2016, to April 8, 2019, and followed up for 12 months. Investigators were blinded to assignment but patients were not. Analysis was by intent to treat. Interventions: Participants randomized to the intervention arm received digital scales, electronic pill bottles for diuretic medication, and regret lottery incentives conditional on the previous day's adherence to both medication and weight measurement, with $1.40 expected daily value. Participants' physicians were alerted if participants' weights increased 1.4 kg in 24 hours or 2.3 kg in 72 hours or if diuretic medications were missed for 5 days. Alerts and weights were integrated into the electronic health record. Participants randomized to the control arm received usual care and no further study contact. Main Outcomes and Measures: Time to death or readmission for any cause within 12 months. Results: Of the 552 participants, 290 were men (52.5%); 291 patients (52.7%) were Black, 231 were White (41.8%), and 16 were Hispanic (2.9%); mean (SD) age was 64.5 (11.8) years. The mean (SD) ejection fraction was 43% (18.1%). Each month, approximately 75% of participants were 80% adherent to both medication and weight measurement. There were 423 readmissions and 26 deaths in the control group and 377 readmissions and 23 deaths in the intervention group. There was no significant difference between the 2 groups for the combined outcome of all-cause inpatient readmission or death (unadjusted hazard ratio, 0.91; 95% CI, 0.74-1.13; P = .40) and no significant differences in all-cause inpatient readmission or observation stay or death, all-cause cardiovascular readmission or death, time to first event, and total all-cause deaths. Participants in the intervention group were slightly more likely to spend fewer days in the hospital. Conclusions and Relevance: In this randomized clinical trial, there was no reduction in the combined outcome of readmission or mortality in a year-long intensive remote monitoring program with incentives for patients previously hospitalized for HF. Trial Registration: ClinicalTrials.gov Identifier: NCT02708654.

How Referring Providers Choose Specialists for Their Patients: a Systematic Review.

BACKGROUND: Physician referrals are a critical step in directing patients to high-quality specialists. Despite efforts to encourage referrals to high-volume hospitals, many patients receive treatment at low-volume centers with worse outcomes. We aimed to determine the most important factors considered by referring providers when selecting specialists for their patients through a systematic review of medical and surgical literature. METHODS: PubMed and Embase were searched from January 2000 to July 2021 using terms related to referrals, specialty, surgery, primary care, and decision-making. We included survey and interview studies reporting the factors considered by healthcare providers as they refer patients to specialists in the USA. Studies were screened by two independent reviewers. Quality was assessed using the CASP Checklist. A qualitative thematic analysis was performed to synthesize common decision factors across studies. RESULTS: We screened 1,972 abstracts and identified 7 studies for inclusion, reporting on 1,575 providers. Thematic analysis showed that referring providers consider factors related to the specialist's clinical expertise (skill, training, outcomes, and assessments), interactions between the patient and specialist (prior experience, rapport, location, scheduling, preference, and insurance), and interactions between the referring physician and specialist (personal relationships, communication, reputation, reciprocity, and practice or system affiliation). Notably, studies did not describe how providers assess clinical or technical skills. CONCLUSIONS: Referring providers rely on subjective factors and assessments to evaluate quality when selecting a specialist. There may be a role for guidelines and objective measures of quality to inform the choice of specialist by referring providers.

Effect of a Default Order vs an Alert in the Electronic Health Record on Hepatitis C Virus Screening Among Hospitalized Patients: A Stepped-Wedge Randomized Clinical Trial.

Importance: Hepatitis C virus (HCV) screening has been recommended for patients born between 1945 and 1965, but rates remain low. Objective: To evaluate whether a default order within the admission order set increases HCV screening compared with a preexisting alert within the electronic health record. Design, Setting, and Participants: This stepped-wedge randomized clinical trial was conducted from June 23, 2020, to April 10, 2021, at 2 hospitals within an academic medical center. Hospitalized patients born between 1945 and 1965 with no history of screening were included in the analysis. Interventions: During wedge 1 (a preintervention period), both hospital sites had an electronic alert prompting clinicians to consider HCV screening. During wedge 2, the first intervention wedge, the hospital site randomized to intervention (hospital B) had a default order for HCV screening implemented within the admission order set. During wedge 3, the second intervention wedge, the hospital site randomized to control (hospital A) had the default order set implemented. Main Outcomes and Measures: Percentage of eligible patients who received HCV screening during the hospital stay. Results: The study included 7634 patients (4405 in the control group and 3229 in the intervention group). The mean (SD) age was 65.4 (5.8) years; 4246 patients (55.6%) were men; 2142 (28.1%) were Black and 4625 (60.6%) were White; and 2885 (37.8%) had commercial insurance and 3950 (51.7%) had Medicare. The baseline rate of HCV screening in wedge 1 was 585 of 1560 patients (37.5% [95% CI, 35.1%-40.0%]) in hospital A and 309 of 1003 patients (30.8% [95% CI, 27.9%-33.7%]) in hospital B. The main adjusted model showed an increase of 31.8 (95% CI, 29.7-33.8) percentage points in test completion in the intervention group compared with the control group (P <. 001). Conclusions and Relevance: This stepped-wedge randomized clinical trial found that embedding HCV screening as a default order in the electronic health record substantially increased ordering and completion of testing in the hospital compared with a conventional interruptive alert. Trial Registration: Clinicaltrials.gov: NCT04525690.

Exploring Why Financial Incentives Fail to Affect At-home Colorectal Cancer Screening: a Mixed Methods Study.

BACKGROUND: Despite success in increasing other health behaviors, financial incentives have shown limited to no effect on colorectal cancer (CRC screening. Little is known about the factors shaping why and for whom incentives improve screening. OBJECTIVE: To explore the perspective of participants enrolled in a larger, four-arm pragmatic trial at urban family medicine practices which assessed and failed to detect significant effects of financial incentives on at-home CRC screening completion. DESIGN: We performed a mixed methods study with a subset of randomly selected patients, stratified by study arm, following completion of the pragmatic trial. PARTICIPANTS: Sixty patients (46.9% enrollment rate) who were eligible and overdue for colorectal cancer screening at the time of trial enrollment and who continued to receive care at family medicine practices affiliated with an urban academic health system completed the interview and questionnaire. MAIN MEASURES: Using Andersen's behavioral model, a semi-structured interview guide assessed motivators, barriers, and facilitators to screening completion and the impact of incentives on decision-making. Participants also completed a brief questionnaire evaluating demographics, screening beliefs, and clinical characteristics. KEY RESULTS: The majority of patients (n = 49; 82%) reported that incentives would not change their decision to complete or not complete CRC screening, which was confirmed by qualitative data as largely due to high perceived health benefits. Those who stated financial incentives would impact their decision (n = 11) were significantly less likely to agree that CRC screening is beneficial (72.7% vs 95.9%; p < 0.05) or that CRC could be cured if detected early (63.6% vs 98.0%; p < 0.05). CONCLUSIONS: Financial incentives are likely not an effective behavioral intervention to increase CRC screening for all but may be powerful for increasing short-term benefit and therefore completion for some. Targeting financial incentive interventions according to patient screening beliefs may prove a cost-effective strategy in primary care outreach programs to increase CRC screening.

Causes of readmissions for patients discharged on enteral nutrition.

BACKGROUND AND AIMS: Patients discharged with enteral nutrition (EN) through an enteral access device (DCENs) are noted to have increased hospital readmissions, but data on the readmission causes are limited. We assessed the proportion of these readmissions attributed to EN and determined the contributing factors to readmissions. METHODS: Using electronic health record data, we conducted a retrospective cohort study of all hospital encounters in an academic, urban hospital from July 2017 to December 2019 with discharge with EN to find all unplanned readmissions at the same hospital within 90 days. For each readmission, we evaluated through chart review whether discharge documentation identified the primary cause of readmission to be EN-related and evaluated for EN-related plan adjustments upon discharge. RESULTS: Over the 30-month period, there were 224 and 442 readmissions within 30 and 90 days for DCENs, respectively. EN-related readmissions accounted for 20.5% of 30-day readmissions and 16.7% of 90-day readmissions. Among these, 44.6% (33 of 74) documented enteral access device issues, 40.5% (30 of 74) cited gastrointestinal symptoms that the team attributed to EN, and 14.9% (11 of 74) cited sodium imbalance. The EN plan was changed in 97.3% (72 of 74) of EN-related readmissions and 32.3% (119 of 368) of EN-unrelated admissions. 52.0% of 90-day readmissions were within 90 days of initiating EN. CONCLUSION: 20.5% of readmissions for DCENs are related to EN, with 52.0% occurring within 90 days of initiating EN. Quality improvement interventions targeting postdischarge care may decrease hospital readmissions in this high-risk and medically complex patient population.

Hospital Performance for Gastrointestinal Bleeding Mortality, Length of Stay, and Complication Rates in the USA.

BACKGROUND: Hospitals are held accountable for quality metrics, through public reporting programs and by payers. However, little is known about hospital performance in GIB nationally. METHODS: A retrospective longitudinal analysis utilizing Vizient's database was performed to identify GIB hospitalizations across 349 hospitals from 2016 to 2018. The primary outcome was risk-adjusted mortality; secondary outcomes included risk-adjusted length of stay and complication rate. Trends in performance were characterized using quintiles, with analysis of concordance within hospitals and across hospitals over time. Pearson's correlation coefficients were performed to assess the relationship among metrics. RESULTS: 28.1% of hospitals had a steadily improving risk-adjusted mortality index from 2016 to 2018, while 15.5% were steadily worsening in mortality. For LOS, 25.2% of hospitals were improving, while 22.4% deteriorated. For complication rate, 22.9% of hospitals steadily improved, while 19.2% of hospitals deteriorated. Although many hospitals improved substantially in one outcome, they did not necessarily improve in all outcomes. Of the 98 hospitals that steadily improved in mortality from 2016 to 2018, only 8 out of 98 steadily improved in all three outcomes (8.3%). Across all 3 years, mortality was weakly correlated with LOS (r = 0.22, p < 0.001), but not with the rate of complications (r = 0.08, p = 0.12). CONCLUSION: Hospital performance metrics for GIB, such as mortality, length of stay, and complication rate, are weakly correlated and thus likely measure different aspects of care. While many hospitals improved over time, few hospitals improved in all three metrics. Additionally, many hospitals are deteriorating over time, and further research is needed to determine which care processes are associated with better outcomes.

Clinician Decisions After Notification of Elevated Blood Pressure Measurements From Patients in a Remote Monitoring Program.

Importance: Guidelines recommend using telehealth for hypertension management, but insufficient evidence is available to guide strategies for incorporating telehealth data into clinical practice. Objective: To describe how primary care teams responded to elevated remote blood pressure (BP) alerts in the electronic health record (EHR) in a randomized clinical trial of BP telemonitoring conducted in routine practice settings. Design, Setting, and Participants: This retrospective cohort study reviewed EHR documentation from May 8, 2018, to August 9, 2019, in a single urban academic family practice site. Primary care teams comprising 28 attending physicians and nurse practitioners, residents, and nurses cared for 162 patients in a text-based clinical trial of remote BP monitoring remote BP monitoring. Data were analyzed from October 21, 2019, to April 30, 2021. Exposures: Clinicians received a direct message in their EHR inbox when patients submitted at least 3 elevated BP readings. Main Outcomes and Measures: Categories and frequencies of clinician action, created via review of EHR-documented clinician responses to EHR alerts by 2 physicians. Results: Patients in this study (n = 162) were predominantly female (111 [68.5%]) and Black or African American (146 [90.1%]), whereas attending physicians (n = 21) were predominantly female (13 [61.9%]) and non-Hispanic White (19 [90.5%]) with a mean (SD) age of 51.6 (11.1) years. Five hundred fifty-two alerts fell into 12 categories of clinical actions. Clinicians acted on 343 alerts (62.1%). Common remote activities were to reconcile medications and assess adherence (120 of 552 alerts [21.7%]) and verify BP measurement technique (65 of 552 alerts [11.8%]). Clinicians also commonly requested appointments (120 of 552 alerts [21.7%]) and/or saw the patient in a subsequent office visit (114 of 552 alerts [20.7%]). Ninety-six alerts (17.4%) resulted in medication changes; half of these changes were remote (48 of 96 [50.0%]), and the other half were visit-based. For 209 of 552 alerts (37.9%), no changes were made to the care plan, typically without documenting clinical rationale (196 of 209 instances [93.8%]). Exploratory EHR review was used to infer potential clinical rationale for 106 (54.1%) of such cases, but there was insufficient information for the remaining 90 (45.9%). Conclusions and Relevance: These findings suggest that EHR alerts for elevated BP during remote monitoring were effective in prompting a mix of remote and office-based management. It was also common for the plan of care to remain unchanged, possibly suggesting need for more refined alerts and improved clinician support.

The Electronic Health Record as the Primary Data Source in a Pragmatic Trial: A Case Study.

HIGHLIGHTS: Electronic health records are not a single system but a series of overlapping and legacy systems that require time and expertise to use efficiently.Commonly measured patient characteristics such as weight and body mass index are relatively easy to locate for most trial enrollees but less common characteristics, like ejection fraction, are not.Acquiring essential supplementary data-in this trial, state data on hospital admission-can be a lengthy and difficult process.