When peer comparison information harms physician well-being.

Policymakers and business leaders often use peer comparison information-showing people how their behavior compares to that of their peers-to motivate a range of behaviors. Despite their widespread use, the potential impact of peer comparison interventions on recipients' well-being is largely unknown. We conducted a 5-mo field experiment involving 199 primary care physicians and 46,631 patients to examine the impact of a peer comparison intervention on physicians' job performance, job satisfaction, and burnout. We varied whether physicians received information about their preventive care performance compared to that of other physicians in the same health system. Our analyses reveal that our implementation of peer comparison did not significantly improve physicians' preventive care performance, but it did significantly decrease job satisfaction and increase burnout, with the effect on job satisfaction persisting for at least 4 mo after the intervention had been discontinued. Quantitative and qualitative evidence on the mechanisms underlying these unanticipated negative effects suggest that the intervention inadvertently signaled a lack of support from leadership. Consistent with this account, providing leaders with training on how to support physicians mitigated the negative effects on well-being. Our research uncovers a critical potential downside of peer comparison interventions, highlights the importance of evaluating the psychological costs of behavioral interventions, and points to how a complementary intervention-leadership support training-can mitigate these costs.

Effect of Patient Portal Messaging Before Mailing Fecal Immunochemical Test Kit on Colorectal Cancer Screening Rates: A Randomized Clinical Trial.

Importance: Colorectal cancer (CRC) screening reduces CRC mortality; however, screening rates remain well below the national benchmark of 80%. Objective: To determine whether an electronic primer message delivered through the patient portal increases the completion rate of CRC screening in a mailed fecal immunochemical test (FIT) outreach program. Design, Setting, and Participants: In this randomized clinical quality improvement trial at the University of California, Los Angeles Health of 2339 patients enrolled in a FIT mailing program from August 28, 2019, to September 20, 2020, patients were randomly assigned to either the control or intervention group, and the screening completion rate was measured at 6 months. Participants were average-risk managed care patients aged 50 to 75 years, with a valid mailing address, no mailed CRC outreach in the previous 6 months, and an active electronic health record (EHR) patient portal who were due for CRC screening. Data were analyzed on an intention-to-treat basis. Interventions: Eligible patients were randomly assigned to receive either (1) the standard FIT mailed outreach (control group) or (2) the standard FIT mailed outreach plus an automated primer to notify patients of the upcoming mailed FIT sent through the electronic patient portal (intervention group). Main Outcomes and Measures: The primary outcome was the screening completion rate (ie, returning the FIT). Secondary outcomes were (1) were the time to CRC screening from the FIT mailing date, (2) screening modality completed, and (3) the effect of opening the electronic primer on screening completion rate. Results: The study included 2339 patients (1346 women [57.5%]; mean [SD] age, 58.9 [7.5] years). The screening completion rate was higher in the intervention group than in the control group (37.6% [445 of 1182] vs 32.1% [371 of 1157]; P = .005). The time to screening was shorter in the intervention group than in the control group (adjusted hazard ratio, 1.24; 95% CI, 1.08-1.42; P = .003). The proportion of each screening test modality completed was similar in both groups. In a subanalysis of the 900 of 1182 patients (76.1%) in the intervention group who opened the patient portal primer message, there was a 7.3-percentage point (95% CI, 2.3-12.4 percentage points) increase in CRC screening (local mean treatment effect; P = .004). Conclusions and Relevance: Implementation of an electronic patient portal primer message in a mailed FIT outreach program led to a significant increase in CRC screening and improvement in the time to screening completion. The findings provide an evidence base for additional refinements to mailed FIT outreach quality improvement programs in large health systems. Trial Registration: ClinicalTrials.gov Identifier: NCT05115916.

Examining the role of COVID-19 testing availability on intention to isolate: A Randomized hypothetical scenario.

BACKGROUND: Little information exists on how COVID-19 testing influences intentions to engage in risky behavior. Understanding the behavioral effects of diagnostic testing may highlight the role of adequate testing on controlling viral transmission. In order to evaluate these effects, simulated scenarios were conducted evaluating participant intentions to self-isolate based on COVID-19 diagnostic testing availability and results. METHODS: Participants from the United States were recruited through an online survey platform (Amazon Mechanical Turk) and randomized to one of three hypothetical scenarios. Each scenario asked participants to imagine having symptoms consistent with COVID-19 along with a clinical diagnosis from their physician. However, scenarios differed in either testing availability (testing available v. unavailable) or testing result (positive v. negative test). The primary outcome was intention to engage in high-risk COVID-19 behaviors, measured using an 11-item mean score (range 1-7) that was pre-registered prior to data collection. Multi-variable linear regression was used to compare the mean composite scores between conditions. The randomized survey was conducted between July 23rd to July 29th, 2020. RESULTS: A total of 1400 participants were recruited through a national, online, opt-in survey. Out of 1194 respondents (41.6% male, 58.4% female) with a median age of 38.5 years, participants who had no testing available in their clinical scenario showed significantly greater intentions to engage in behavior facilitating COVID-19 transmission compared to those who received a positive confirmatory test result scenario (mean absolute difference (SE): 0.14 (0.06), P = 0.016), equating to an 11.1% increase in mean score risky behavior intentions. Intention to engage in behaviors that can spread COVID-19 were also positively associated with male gender, poor health status, and Republican party affiliation. CONCLUSION: Testing availability appears to play an independent role in influencing behaviors facilitating COVID-19 transmission. Such findings shed light on the possible negative externalities of testing unavailability. TRIAL REGISTRATION: Effect of Availability of COVID-19 Testing on Choice to Isolate and Socially Distance, NCT04459520, https://clinicaltrials.gov/ct2/show/NCT04459520.

Relationship between exercise intensity and stress levels among U.S. medical students.

BACKGROUND: Physical activity may protect the mental health of medical students, yet it is unknown which types and intensities of physical activity have the greatest potential to improve medical student well-being. OBJECTIVE: We characterize the relationship between exercise intensity and stress levels of U.S. medical students, thereby informing the design of future well-being interventions. DESIGN: Two cross-sectional validated surveys assessing stress and physical activity were administered one year apart at the David Geffen School of Medicine at UCLA. A total of 1,046 out of 1,392 medical students responded (75%). An ordered logistic regression was used to determine the association between stress and each level of exercise intensity (inactivity, moderate-activity, and health-enhancing physical activity [HEPA]). These exercise intensity groupings were compared to the CDC guidelines for aerobic exercise. RESULTS: While achieving either moderate-activity or HEPA is compliant with the CDC guidelines for aerobic exercise, the additional intensity of exercise required to achieve HEPA was associated with a 26% increase in the probability of being in the lowest stress quartile and a 22% decrease in the probability of being in the highest stress quartile. Medical student physical activity levels were on-par with the national average per the CDC exercise guidelines (65% vs. 58%), but medical student HEPA levels were significantly lower than the national average (27% vs. 64%; OR 0.21; 95% CI 0.12-0.37). CONCLUSIONS: There is a large disparity in rates of the highest intensity physical activity (HEPA) between medical students and the age-adjusted national average, which has previously been overlooked by the binary CDC exercise guidelines. The fact that HEPA levels are not optimized and more strongly associated with lower stress levels relative to less intense forms of exercise makes it a promising new target for future well-being interventions among medical trainees.

Impact of COVID-19 on Primary Care Quality Measures in an Academic Integrated Health System.

BACKGROUND: Access to primary care was hindered by the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: Evaluate changes in health screening rates before and during the pandemic. DESIGN: Retrospective analysis of health maintenance and disease management screening rates among primary care patients before and during the pandemic. PARTICIPANTS: Over 150,000 patients of a large, academic health system. MAIN MEASURES: Six quality measures were analyzed: colon cancer, breast cancer, cervical cancer, diabetes Hgb A1C, diabetes eye, and diabetes nephropathy monitoring. Based on US Preventative Services Task Force screening guidelines, we determined which patients were due for at least one of the quality measures. We tracked completion rates during three time periods: pre-pandemic (January 1-March 3, 2020), stay-at-home (March 4-May 8, 2020), and phased reopening (May 9-July 8, 2020). Differences in quality measure completion rates were evaluated using mixed-effects logistic regression models. KEY RESULTS: Compared to pre-pandemic rates, completion of all health screenings declined during the stay-at-home period: mammograms (OR: 0.34; 95% CI: 0.31-0.37), cervical cancer (OR: 0.83; 95% CI: 0.76-0.91), colorectal cancer (OR: 0.25; 95% CI: 0.23-0.28), diabetes eye (OR: 0.34; 95% CI: 0.29-0.41), diabetes Hgb A1c (OR: 0.41; 95% CI: 0.37-0.46), and diabetes nephropathy (OR: 0.46, 95% CI: 0.41-0.53). During phased reopening, completion of all quality measures increased compared to the stay-at-home period, except for cervical cancer screening (OR: 0.83; 95% CI: 0.76-0.92). There was a persistent reduction in completion of all quality measures, except for diabetic nephropathy monitoring (OR: 0.99; 95% CI: 0.89-1.09), during phased reopening compared to pre-pandemic. CONCLUSIONS: Healthcare screening rates were reduced during the early part of the COVID-19 pandemic and did not fully recover to pre-pandemic rates by July 2020. Future research should aim to clarify the long-term impacts of delayed health screenings. New interventions should be considered for expanding remote preventative health services.

Behavioural nudges increase COVID-19 vaccinations.

Enhancing vaccine uptake is a critical public health challenge1. Overcoming vaccine hesitancy2,3 and failure to follow through on vaccination intentions3 requires effective communication strategies3,4. Here we present two sequential randomized controlled trials to test the effect of behavioural interventions on the uptake of COVID-19 vaccines. We designed text-based reminders that make vaccination salient and easy, and delivered them to participants drawn from a healthcare system one day (first randomized controlled trial) (n = 93,354 participants; clinicaltrials number NCT04800965) and eight days (second randomized controlled trial) (n = 67,092 individuals; clinicaltrials number NCT04801524) after they received a notification of vaccine eligibility. The first reminder boosted appointment and vaccination rates within the healthcare system by 6.07 (84%) and 3.57 (26%) percentage points, respectively; the second reminder increased those outcomes by 1.65 and 1.06 percentage points, respectively. The first reminder had a greater effect when it was designed to make participants feel ownership of the vaccine dose. However, we found no evidence that combining the first reminder with a video-based information intervention designed to address vaccine hesitancy heightened its effect. We performed online studies (n = 3,181 participants) to examine vaccination intentions, which revealed patterns that diverged from those of the first randomized controlled trial; this underscores the importance of pilot-testing interventions in the field. Our findings inform the design of behavioural nudges for promoting health decisions5, and highlight the value of making vaccination easy and inducing feelings of ownership over vaccines.

A telehealth intervention to promote weight loss and physical activity in overweight primary care patients.

INTERVENTION: This pilot study was a 16-week Telehealth intervention using wearable devices, automated text messaging, and trained health coaching, in primary care clinics of an academic medical center. Thirty patients were enrolled in three cohorts, ages 18-64, BMI > 27, and MVPA < 150 minutes per week. The primary outcome was weight loss per week. RESULTS: Twenty-two participants had a significant median weight loss of -0.29 kg per week and mean change of -3.9 kg in total weight, -1.8 in BMI, and -3.8% of total bodyweight (all P<.001). MVPA increased 67 min per week (P=.003). CONCLUSION: This pilot telehealth intervention suggests that, when combined, these tools may be used effectively by primary care teams to promote weight loss and physical activity in their patients.

Strength fitness and body weight status on markers of cardiometabolic health.

INTRODUCTION: Recent evidence suggests that resistance training (RT) may reduce metabolic and cardiovascular disease risk. We investigated whether overweight/class I obese individuals by BMI classification with high strength fitness exhibit cardiovascular/metabolic phenotypes similar to those overweight/obese and untrained or those normal-weight with high strength fitness. METHODS: A total of 90 young males were categorized into three groups: overweight untrained (OU, n = 30, BMI > 27 kg·m⁻²), overweight trained (OT, n = 30, BMI > 27 kg·m⁻², RT ≥ 4 d·wk⁻¹), and normal-weight trained (NT, n = 30, BMI < 25 kg·m⁻², RT ≥ 4 d·wk⁻¹). Participants were assessed for strength, body composition, central/peripheral blood pressures, arterial stiffness, and markers of cardiovascular and metabolic health. RESULTS: Body weight was similar in OT and OU and greater than NT (P < 0.00001), and fat mass was different in all groups (P < 0.001). Compared to OU, NT and OT groups exhibited higher relative strength (NT = 46.7%, OT = 44.4%, P < 0.00001), subendocardial viability ratio (NT = 21.0%, P < 0.001; OT = 17.0%, P < 0.01), and lower brachial/central blood pressures (NT P < 0.001; OT P ≤ 0.05); augmentation index and pulse-wave velocity were lower only in OT (P < 0.05). Total cholesterol, low-density lipoprotein (NT P < 0.01, OT P < 0.05), triglycerides (NT = -50.4%, OT = -41.8%, P < 0.001), oxidized LDL (NT = -39.8%, OT = -31.8%, P < 0.001), and CRP (NT = -63.7%, OT = -67.4%, P < 0.01) levels were lower and high-density lipoprotein (NT = 26.9%, OT = 21.4%, P < 0.001) levels were higher in NT and OT compared to OU. NT and OT also exhibited lower amylin (NT = -55.8%, OT = -40.8%) and leptin (NT = -84.6%, OT = -59.4%) and higher adiponectin (NT = 87.5%, P < 0.001; OT = 78.1%, P < 0.01) and sex hormone-binding globulin (NT = 124.4%, OT = 92.3%, P < 0.001). Despite greater total and trunk fat in OT compared with NT, other than glucose and insulin, which were lower in NT than in both OT and OU (OT P < 0.01, OU P < 0.001), OT did not exhibit any impaired biomarker/phenotype compared to NT. CONCLUSIONS: These findings provide evidence that overweight/class I obese individuals with high strength fitness exhibit metabolic/cardiovascular risk profiles similar to normal-weight, fit individuals rather than overweight/class I obese unfit individuals. Strength training may be important to metabolic and cardiovascular health.

Resistance training improves indices of muscle insulin sensitivity and ß-cell function in overweight/obese, sedentary young men.

We examined the effects of RT on oral glucose tolerance test (OGTT)-derived indices of muscle insulin sensitivity, hepatic insulin resistance, ß-cell function, and skeletal muscle proteins related to glucose transport in overweight/obese, sedentary young men. Twenty-eight participants [median body mass index (BMI) 30.9 kg/m(2); age 22 yr] completed 12 wk of RT (3 sessions/wk) and were assessed for changes in OGTT-derived indices, resting metabolic rate, body composition, serum adipokines, and skeletal muscle protein content [hexokinase 2 (HK2), glucose transporter type 4 (GLUT4), RAC-ß serine/threonine-protein kinase (AKT2), glycogen synthase kinase 3ß, and insulin receptor substrate 1]. Individualized responses to RT were also evaluated. RT significantly improved insulin and glucose area under the curve (both P < 0.03). With the use of OGTT indices of insulin action, we noted improved muscle insulin sensitivity index (mISI; P = 0.03) and oral disposition index (P = 0.03). BMI, lean body mass (LBM), and relative strength also increased (all P < 0.03), as did skeletal muscle protein content of HK2, GLUT4, and AKT2 (26-33%; all P < 0.02). Hepatic insulin resistance index, adiponectin, leptin, and total amylin did not change. Further analysis demonstrated the presence of highly individualized responsiveness to RT for glucose tolerance and other outcomes. RT improved oral indices of muscle insulin sensitivity and ß-cell function but not hepatic insulin resistance in overweight/obese young men. In addition to the increase in LBM, the improvements in insulin action may be due, in part, to increases in key insulin signaling proteins.

Untrained young men have dysfunctional HDL compared with strength-trained men irrespective of body weight status.

We examined the impact of strength fitness and body weight on the redox properties of high-density lipoprotein (HDL) and associations with indices of vascular and metabolic health. Ninety young men were categorized into three groups: 1) overweight untrained (OU; n = 30; BMI 30.7 ± 2.1 kg/m(2)); 2) overweight trained [OT; n = 30; BMI 29.0 ± 1.9; ≥4 d/wk resistance training (RT)]; and 3) lean trained (LT; n = 30; BMI 23.7 ± 1.4; ≥4 d/wk RT). Using a novel assay on the basis of the HDL-mediated rate of oxidation of dihydrorhodamine (DOR), we determined the functional (redox) properties of HDL and examined correlations between DOR and indices of vascular and metabolic health in the cohort. DOR was significantly lower in both trained groups compared with the untrained group (LT, 1.04 ± 0.49; OT, 1.39 ± 0.57; OU, 1.80 ± 0.74; LT vs. OU P < 0.00001; OT vs. OU P = 0.02), however, DOR in the OT group was not significantly different from that of the LT group. DOR was negatively associated with HDL-cholesterol (R = -0.64), relative strength (R = -0.42), sex hormone-binding globulin (R = -0.42), and testosterone (R = -0.35) (all P ≤ 0.001); whereas DOR was positively associated with triglycerides (R = 0.39, P = 0.002), oxidized low-density lipoprotein (R = 0.32), body mass index (R = 0.43), total mass (R = 0.35), total fat mass (R = 0.42), waist circumference (R = 0.45), and trunk fat mass (R = 0.42) (all P ≤ 0.001). Chronic RT is associated with improved HDL redox activity. This may contribute to the beneficial effects of RT on reducing cardiovascular disease risk, irrespective of body weight status.

Resistance training increases SHBG in overweight/obese, young men.

OBJECTIVE: Evidence suggests that SHBG affects glycemic control, predicts both T2D and metabolic syndrome, and is low in obese subjects. We sought to determine if resistance exercise training (RT) can increase sex hormone-binding globulin (SHBG) and ameliorate levels of related steroid hormones in overweight/obese, sedentary young men. MATERIALS/METHODS: 36 participants (BMI 31.4 kg/m(2), age 22 years) were randomized into an RT (12 weeks of training, 3/week) or control group (C, 12 weeks no training), and assessed for changes in SHBG, cortisol, testosterone, free testosterone (FT) and free androgen index (FAI). In addition, body composition and oral glucose tolerance testing was performed. RESULTS: 12 weeks of RT increased SHBG (P=0.01) and decreased FAI (P<0.05) and cortisol (P<0.05) compared to C. FT decreased in RT (P=0.01). Total testosterone did not change in either group. These changes were noted without weight loss, and in concert with increases in lean body mass (P=0.0002 vs C) and decreases in glucose area under the curve (AUC) (P=0.004), insulin AUC (P=0.03), and total (P=0.002) and trunk (P=0.003) fat mass in RT. CONCLUSION: In overweight/obese young men, RT increases SHBG and lowers FAI in obese young adult men.

Carotid intima-media thickness, dietary intake, and cardiovascular phenotypes in adolescents: relation to metabolic syndrome.

Little is known about the interrelationships between metabolic syndrome (MS), uric acid, and early carotid atherosclerosis with diet in adolescents. We investigated associations among diet, carotid intima-media thickness (cIMT), MS, uric acid, and other cardiovascular risk factors in adolescents. Two hundred forty-nine adolescents from 3 high schools in Central California-a predominately Hispanic (n = 119, 16.1 +/- 0.9 years old, 94% Hispanic), a mixed-ethnicity (n = 94, 15.7 +/- 1.2 years old), and a Seventh-day Adventist (SDA) (n = 33, 17.0 +/- 1.3 years old) high school-were assessed for cIMT, blood lipids, uric acid, blood glucose, systolic and diastolic blood pressure, body mass index (BMI), and dietary intake. Compared with SDA adolescents, the predominately Hispanic and mixed-ethnicity high school adolescents exhibited higher low-density lipoprotein and BMI percentile, whereas adolescents from the SDA and mixed-ethnicity high schools exhibited lower uric acid and fasting glucose levels than those from the Hispanic high school. After adjusting for age and sex, cIMT was only correlated with systolic blood pressure percentile (r = 0.16, P < .01). Controlling for age, levels of uric acid were correlated with BMI percentile (males: r = 0.59, P < .001; females: r = 0.24, P < .01), low-density lipoprotein (males: r = 0.40, P < .001; females: r = 0.20, P < .01), and total cholesterol in males (r = 0.38, P < .001). Despite no significant differences in the high school frequency of MS risk factors, 59% of adolescents had one or more MS risk factors. A relationship was noted between the number of MS risk factors and uric acid (P < .002). Most of the adolescents presented MS risk factors independent of ethnicity or a purportedly healthier lifestyle (SDA). Uric acid association with MS and its risk factors suggests its potentially heightened importance for the assessment of adolescent cardiovascular health.