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1.
JAMA Netw Open ; 4(10): e2127799, 2021 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-34665240

RESUMO

Importance: Mortality across US counties varies considerably, from 252 to 1847 deaths per 100 000 people in 2018. Although patient satisfaction with health care is associated with patient- and facility-level health outcomes, the association between health care satisfaction and community-level health outcomes is not known. Objective: To examine the association between online ratings of health care facilities and mortality across US counties and to identify language specific to 1-star (lowest rating) and 5-star (highest rating) reviews in counties with high vs low mortality. Design, Setting, and Participants: This retrospective population-based cross-sectional study examined reviews and ratings of 95 120 essential health care facilities across 1301 US counties. Counties that had at least 1 essential health care facility with reviews available on Yelp, an online review platform, were included. Essential health care was defined according to the 10 essential health benefits covered by Affordable Care Act insurance plans. Main Outcomes and Measures: The mean rating of essential health care facilities was calculated by county from January 1, 2015, to December 31, 2019. Ratings were on a scale of 1 to 5 stars, with 1 being the worst rating and 5 the best. County-level composite measures of health behaviors, clinical care, social and economic factors, and physical environment were obtained from the University of Wisconsin School of Medicine and Public Health County Health Rankings database. The 2018 age-adjusted mortality by county was obtained from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiological Research database. Multiple linear regression analysis was used to estimate the association between mean facility rating and mortality, adjusting for county health ranking variables. Words with frequencies of use that were significantly different across 1-star and 5-star reviews in counties with high vs low mortality were identified. Results: The 95 120 facilities meeting inclusion criteria were distributed across 1301 of 3142 US counties (41.4%). At the county level, a 1-point increase in mean rating was associated with a mean (SE) age-adjusted decrease of 18.05 (3.68) deaths per 100 000 people (P < .001). Words specific to 1-star reviews in high-mortality counties included told, rude, and wait, and words specific to 5-star reviews in low-mortality counties included Dr, pain, and professional. Conclusions and Relevance: This study found that, at the county level, higher online ratings of essential health care facilities were associated with lower mortality. Equivalent online ratings did not necessarily reflect equivalent experiences of care across counties with different mortality levels, as evidenced by variations in the frequency of use of key words in reviews. These findings suggest that online ratings and reviews may provide insight into unequal experiences of essential health care.

3.
J Am Heart Assoc ; 10(19): e020596, 2021 Oct 05.
Artigo em Inglês | MEDLINE | ID: mdl-34558301

RESUMO

Background Online platforms are used to manage aspects of our lives including health outside clinical settings. Little is known about the effectiveness of using online platforms to manage hypertension. We assessed effects of tweeting/retweeting cardiovascular health content by individuals with poorly controlled hypertension on systolic blood pressure (SBP) and patient activation. Methods and Results We conducted this 2-arm randomized controlled trial. Eligibility included diagnosis of hypertension; SBP >140 mm Hg; and an existing Twitter account or willingness to create one to follow study Twitter account. Intervention arm was asked to tweet/retweet health content 2×/week using a specific hashtag for study duration (6 months). The main measures include primary outcome change in SBP; secondary outcome point change in Patient Activation Measure (PAM). We remotely recruited and enrolled 611 participants, mean age 52 (SD, 11.7). Mean baseline SBP for the intervention group was 155.8 and for control was 155.6. At 6 months, mean SBP for intervention group was 137.6 and for control was 135.7. Mean change in SBP from baseline to 6 months for the intervention group was -18.5 and for control was -19.8 (P=0.48). Mean PAM at baseline for the intervention group was 70.3 for control was 72.7. At 6 months, mean PAM scores were 71.1 (intervention) and 75.6 (control). Mean change in PAM score for the intervention group was 0.0 and for control was 3.3 (P=0.12). Conclusions Recruiting and engaging patients and collecting outcome measures remotely are feasible using Twitter. Encouraging patients with poorly controlled hypertension to tweet or retweet health content on Twitter did not improve SBP or PAM score at 6 months. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02622256.

4.
Implement Sci ; 16(1): 90, 2021 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-34563227

RESUMO

BACKGROUND: Serious illness conversations (SICs) are an evidence-based approach to eliciting patients' values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics ("nudges") that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion-either alone or in combination with clinician nudges that additionally compare performance relative to peers-may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer. METHODS: We will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity. DISCUSSION: This will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04867850 . Registered on April 30, 2021. FUNDING: National Cancer Institute P50CA244690.

5.
J Grad Med Educ ; 13(4): 515-525, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34434512

RESUMO

Background: The COVID-19 pandemic forced numerous unprecedented systemic changes within residency programs and hospital systems. Objective: We explored how the COVID-19 pandemic, and associated changes in clinical and educational experiences, were related to internal medicine residents' well-being in the early months of the pandemic. Methods: Across 4 internal medicine residency programs in the Northeast United States that have previously participated in the iCOMPARE study, all 394 residents were invited to participate in a study with open-ended survey prompts about well-being approximately every 2 weeks in academic year 2019-2020. In March and April 2020, survey prompts were refocused to COVID-19. Content analysis revealed themes in residents' open-ended responses to 4 prompts. Results: One hundred and eighty-six residents expressed interest, and 88 were randomly selected (47%). There were 4 main themes: (1) in early days of the pandemic, internal medicine residents reported fear and anxiety about uncertainty and lack of personal protective equipment; (2) residents adapted and soon were able to reflect, rest, and pursue personal wellness; (3) communication from programs and health systems was inconsistent early in the pandemic but improved in clarity and frequency; (4) residents appreciated the changes programs had made, including shorter shifts, removal of pre-rounding, and telemedicine. Conclusions: COVID-19 introduced many challenges to internal medicine residency programs and to resident well-being. Programs made structural changes to clinical schedules, educational/conference options, and communication that boosted resident well-being. Many residents hoped these changes would continue regardless of the pandemic's course.


Assuntos
COVID-19 , Internato e Residência , Ansiedade , Humanos , Pandemias , SARS-CoV-2
6.
Implement Sci ; 16(1): 72, 2021 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-34266468

RESUMO

BACKGROUND: Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. METHODS: A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or "nudges") promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. DISCUSSION: This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021.

7.
J Med Internet Res ; 23(6): e29395, 2021 06 09.
Artigo em Inglês | MEDLINE | ID: mdl-34106074

RESUMO

BACKGROUND: In 2020, the number of internet users surpassed 4.6 billion. Individuals who create and share digital data can leave a trail of information about their habits and preferences that collectively generate a digital footprint. Studies have shown that digital footprints can reveal important information regarding an individual's health status, ranging from diet and exercise to depression. Uses of digital applications have accelerated during the COVID-19 pandemic where public health organizations have utilized technology to reduce the burden of transmission, ultimately leading to policy discussions about digital health privacy. Though US consumers report feeling concerned about the way their personal data is used, they continue to use digital technologies. OBJECTIVE: This study aimed to understand the extent to which consumers recognize possible health applications of their digital data and identify their most salient concerns around digital health privacy. METHODS: We conducted semistructured interviews with a diverse national sample of US adults from November 2018 to January 2019. Participants were recruited from the Ipsos KnowledgePanel, a nationally representative panel. Participants were asked to reflect on their own use of digital technology, rate various sources of digital information, and consider several hypothetical scenarios with varying sources and health-related applications of personal digital information. RESULTS: The final cohort included a diverse national sample of 45 US consumers. Participants were generally unaware what consumer digital data might reveal about their health. They also revealed limited knowledge of current data collection and aggregation practices. When responding to specific scenarios with health-related applications of data, they had difficulty weighing the benefits and harms but expressed a desire for privacy protection. They saw benefits in using digital data to improve health, but wanted limits to health programs' use of consumer digital data. CONCLUSIONS: Current privacy restrictions on health-related data are premised on the notion that these data are derived only from medical encounters. Given that an increasing amount of health-related data is derived from digital footprints in consumer settings, our findings suggest the need for greater transparency of data collection and uses, and broader health privacy protections.


Assuntos
Comportamento do Consumidor/estatística & dados numéricos , Informação de Saúde ao Consumidor/estatística & dados numéricos , Coleta de Dados/ética , Conjuntos de Dados como Assunto/provisão & distribuição , Entrevistas como Assunto , Privacidade/psicologia , Pesquisa Qualitativa , Adolescente , Adulto , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
8.
JAMA Netw Open ; 4(6): e2112842, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-34137829

RESUMO

Importance: Black patients hospitalized with COVID-19 may have worse outcomes than White patients because of excess individual risk or because Black patients are disproportionately cared for in hospitals with worse outcomes for all. Objectives: To examine differences in COVID-19 hospital mortality rates between Black and White patients and to assess whether the mortality rates reflect differences in patient characteristics by race or by the hospitals to which Black and White patients are admitted. Design, Setting, and Participants: This cohort study assessed Medicare beneficiaries admitted with a diagnosis of COVID-19 to 1188 US hospitals from January 1, 2020, through September 21, 2020. Exposure: Hospital admission for a diagnosis of COVID-19. Main Outcomes and Measures: The primary composite outcome was inpatient death or discharge to hospice within 30 days of admission. We estimated the association of patient-level characteristics (including age, sex, zip code-level income, comorbidities, admission from a nursing facility, and days since January 1, 2020) with differences in mortality or discharge to hospice among Black and White patients. To examine the association with the hospital itself, we adjusted for the specific hospitals to which patients were admitted. We used simulation modeling to estimate the mortality among Black patients had they instead been admitted to the hospitals where White patients were admitted. Results: Of the 44 217 Medicare beneficiaries included in the study, 24 281 (55%) were women; mean (SD) age was 76.3 (10.5) years; 33 459 participants (76%) were White, and 10 758 (24%) were Black. Overall, 2634 (8%) White patients and 1100 (10%) Black patients died as inpatients, and 1670 (5%) White patients and 350 (3%) Black patients were discharged to hospice within 30 days of hospitalization, for a total mortality-equivalent rate of 12.86% for White patients and 13.48% for Black patients. Black patients had similar odds of dying or being discharged to hospice (odds ratio [OR], 1.06; 95% CI, 0.99-1.12) in an unadjusted comparison with White patients. After adjustment for clinical and sociodemographic patient characteristics, Black patients were more likely to die or be discharged to hospice (OR, 1.11; 95% CI, 1.03-1.19). This difference became indistinguishable when adjustment was made for the hospitals where care was delivered (odds ratio, 1.02; 95% CI, 0.94-1.10). In simulations, if Black patients in this sample were instead admitted to the same hospitals as White patients in the same distribution, their rate of mortality or discharge to hospice would decline from the observed rate of 13.48% to the simulated rate of 12.23% (95% CI for difference, 1.20%-1.30%). Conclusions and Relevance: This cohort study found that Black patients hospitalized with COVID-19 had higher rates of hospital mortality or discharge to hospice than White patients after adjustment for the personal characteristics of those patients. However, those differences were explained by differences in the hospitals to which Black and White patients were admitted.


Assuntos
Afro-Americanos/estatística & dados numéricos , COVID-19/etnologia , COVID-19/mortalidade , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Mortalidade Hospitalar/etnologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Comorbidade , Feminino , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais , Humanos , Masculino , Medicare , SARS-CoV-2 , Estados Unidos/epidemiologia
9.
BMJ ; 373: n1022, 2021 05 18.
Artigo em Inglês | MEDLINE | ID: mdl-34006604

RESUMO

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


Assuntos
Controle Comportamental/métodos , Relações Comunidade-Instituição , Hepatite C/diagnóstico , Programas de Rastreamento/psicologia , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Idoso , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Masculino , Programas de Rastreamento/estatística & dados numéricos , Pessoa de Meia-Idade , Motivação , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Portais do Paciente , Pennsylvania , Serviços Postais , Atenção Primária à Saúde/estatística & dados numéricos , Resultado do Tratamento
11.
Healthc (Amst) ; 9(3): 100545, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33901987

RESUMO

OBJECTIVE: We sought to determine the feasibility of the Practical Alternative to Hospitalization (PATH) program, an intervention that offers ED clinicians an outpatient care pathway for patients initially designated for inpatient admission or observation. METHODS: We evaluated a novel care delivery model that was piloted at a tertiary academic medical center in December 2019. An advanced practice provider screened patients designated for inpatient admission or observation and identified eligible participants. Outpatient services were customized for each patient but primarily included care coordination and monitoring through telemedicine and home health services. The primary feasibility outcome was the proportion of eligible patients who were enrolled in the program, as well as patient outcomes after discharge including return ED visits and averted ED boarding time. RESULTS: A total of 199 patients were designated for inpatient admission or observation during PATH program hours. Of 52 eligible patients, 30 (58%) were enrolled. The mean participant age was 62.5 years (SD 17.5), and 25 (83%) had non-Hispanic Black race/ethnicity. The most common disease conditions were chest pain, heart failure, and hyperglycemia. 4 (13%) enrolled patients returned to an ED within 30 days. We estimate that ED boarding time was reduced by 8.2 h (SD 8.1) per patient. CONCLUSION: Emergency physicians and patients were willing to use a novel service that provided an alternative disposition to hospitalization. IMPLICATIONS: alternative payment models that seek to reduce hospital utilization and cost may consider strengthening systems to monitor and coordinate care for patients after ED discharge.

12.
JMIR Cardio ; 5(1): e24473, 2021 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-33605888

RESUMO

BACKGROUND: Current atherosclerotic cardiovascular disease (ASCVD) predictive models have limitations; thus, efforts are underway to improve the discriminatory power of ASCVD models. OBJECTIVE: We sought to evaluate the discriminatory power of social media posts to predict the 10-year risk for ASCVD as compared to that of pooled cohort risk equations (PCEs). METHODS: We consented patients receiving care in an urban academic emergency department to share access to their Facebook posts and electronic medical records (EMRs). We retrieved Facebook status updates up to 5 years prior to study enrollment for all consenting patients. We identified patients (N=181) without a prior history of coronary heart disease, an ASCVD score in their EMR, and more than 200 words in their Facebook posts. Using Facebook posts from these patients, we applied a machine-learning model to predict 10-year ASCVD risk scores. Using a machine-learning model and a psycholinguistic dictionary, Linguistic Inquiry and Word Count, we evaluated if language from posts alone could predict differences in risk scores and the association of certain words with risk categories, respectively. RESULTS: The machine-learning model predicted the 10-year ASCVD risk scores for the categories <5%, 5%-7.4%, 7.5%-9.9%, and ≥10% with area under the curve (AUC) values of 0.78, 0.57, 0.72, and 0.61, respectively. The machine-learning model distinguished between low risk (<10%) and high risk (>10%) with an AUC of 0.69. Additionally, the machine-learning model predicted the ASCVD risk score with Pearson r=0.26. Using Linguistic Inquiry and Word Count, patients with higher ASCVD scores were more likely to use words associated with sadness (r=0.32). CONCLUSIONS: Language used on social media can provide insights about an individual's ASCVD risk and inform approaches to risk modification.

13.
JAMA Netw Open ; 4(1): e2034553, 2021 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-33492374

RESUMO

Importance: Outpatient colonoscopy is important for colorectal cancer screening. However, nonadherence and poor bowel preparation are common. Objective: To determine if an automated text messaging intervention with a focus on informational and reminder functions could improve attendance rates and bowel preparation quality for outpatient colonoscopy. Design, Setting, and Participants: This randomized clinical trial was conducted in an endoscopy center at an urban academic medical center. Adult patients scheduled for outpatient colonoscopy between January and September 2019 were enrolled by telephone call (early phase) or by automated text message (late phase). Data were analyzed from October 2019 to January 2020. Interventions: After enrollment, patients were randomized in a 1:1 ratio to usual care (ie, written instructions and nurse telephone call) or to the intervention (ie, usual care plus an automated series of 9 educational or reminder text messages in the week prior to scheduled colonoscopy). Main Outcomes and Measures: The primary outcome was appointment attendance rate with good or excellent bowel preparation. Secondary outcomes included appointment attendance rate, bowel preparation quality (poor or inadequate, fair or adequate, and good or excellent), and cancellation lead time (in days). Results: Among 753 patients included and randomized in the trial (median [interquartile range] age, 56 [49-64] years; 364 [48.3%] men; 429 [57.2%] Black), 367 patients were randomized to the intervention group and 386 patients were randomized to the control group. There was no significant difference in the primary outcome between groups (patients attending appointments with good or excellent bowel preparation: intervention, 195 patients [53.1%]; control, 210 patients [54.4%]; P = .73), including when stratified by early or late phase enrollment groups. Similarly, there were no significant differences in secondary outcomes. Conclusions and Relevance: This randomized clinical trial found no significant difference in appointment attendance or bowel preparation quality with an automated text messaging intervention compared with the usual care control. Future work could optimize the content and delivery of text message interventions or identify patient subgroups that may benefit from this approach. Trial Registration: ClinicalTrials.gov Identifier: NCT03710213.


Assuntos
Assistência Ambulatorial , Agendamento de Consultas , Catárticos/administração & dosagem , Colonoscopia , Cooperação do Paciente , Envio de Mensagens de Texto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistemas de Alerta
14.
J Gen Intern Med ; 36(7): 1958-1964, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33511567

RESUMO

BACKGROUND: Routine screening reduces colorectal cancer mortality, but screening rates fall below national targets and are particularly low in underserved populations. OBJECTIVE: To compare the effectiveness of a single text message outreach to serial text messaging and mailed fecal home test kits on colorectal cancer screening rates. DESIGN: A two-armed randomized clinical trial. PARTICIPANTS: An urban community health center in Philadelphia. Adults aged 50-74 who were due for colorectal cancer screening had at least one visit to the practice in the previously year, and had a cell phone number recorded. INTERVENTIONS: Participants were randomized (1:1 ratio). Individuals in the control arm were sent a simple text message reminder as per usual practice. Those in the intervention arm were sent a pre-alert text message offering the options to opt-out of receiving a mailed fecal immunochemical test (FIT) kit, followed by up to three behaviorally informed text message reminders. MAIN MEASURES: The primary outcome was participation in colorectal cancer screening at 12 weeks. The secondary outcome was the FIT kit return rate at 12 weeks. KEY RESULTS: Four hundred forty participants were included. The mean age was 57.4 years (SD ± 6.1). 63.4% were women, 87.7% were Black, 19.1% were uninsured, and 49.6% were Medicaid beneficiaries. At 12 weeks, there was an absolute 17.3 percentage point increase in colorectal cancer screening in the intervention arm (19.6%), compared to the control arm (2.3%, p < 0.001). There was an absolute 17.7 percentage point increase in FIT kit return in the intervention arm (19.1%) compared to the control arm (1.4%, p < 0.001). CONCLUSIONS: Serial text messaging with opt-out mailed FIT kit outreach can substantially improve colorectal cancer screening rates in an underserved population. TRIAL REGISTRATION: clinicaltrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03479645 ).


Assuntos
Neoplasias Colorretais , Envio de Mensagens de Texto , Adulto , Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer , Feminino , Humanos , Programas de Rastreamento , Pessoa de Meia-Idade , Sangue Oculto , Philadelphia/epidemiologia
15.
Healthc (Amst) ; 9(1): 100514, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33517180

RESUMO

1: Most large employers self-insure their employee health benefits, creating a motivation for employers to improve health care's value. 2: Employers who are also health care providers can aim for value through the direct provision of clinical services, not just through wellness programs or the design of insurance products. 3: Innovation and design methods can be systematically applied to health care problems to guide decisions about solutions which should or should not be scaled. 4: A virtual, on-demand urgent care service provided by a health care provider organization to its employees has the potential to reduce unnecessary emergency department visits and decrease the total cost of care.

16.
Am J Hosp Palliat Care ; 38(3): 230-237, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32648476

RESUMO

BACKGROUND: Digital tools to document care preferences in serious illnesses are increasingly common, but their impact is unknown. We developed a web-based advance directive (AD) featuring (1) modular content eliciting detailed care preferences, (2) the ability to electronically transmit ADs to the electronic health record (EHR), and (3) use of nudges to promote document transmission and sharing. OBJECTIVE: To compare a web-based, EHR-transmissible AD to a paper AD. METHODS: Patients with gastrointestinal and lung malignancies were randomized to the web or paper AD. The primary outcome was the proportion of patients with newly documented advance care plans in the EHR at 8 weeks. Secondary outcomes assessed through an e-mail survey included the change in satisfaction with end-of-life plans, AD acceptability, and self-reported sharing with a surrogate. RESULTS: Ninety-one participants were enrolled: 46 randomly allocated to the web AD and 45 to paper. Thirteen patients assigned to web AD (28%) had new documentation versus 7 (16%) assigned to paper (P = .14). Adjusted for demographic factors and primary diagnosis, the odds ratio of new documentation with web AD was 3.7 (95% CI: 0.8-17.0, P = .10). Satisfaction with advance care planning and AD acceptability were high in both groups and not significantly different. Among patients completing web ADs, 79% reported sharing plans with their caregivers, compared with 65% of those completing paper ADs (P = .40). CONCLUSION: Web-based ADs hold promise for promoting documentation and sharing of preferences, but larger studies are needed to quantify effects on these intermediate end points and on patient-centered outcomes.

17.
Acad Pediatr ; 21(1): 129-138, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32730914

RESUMO

OBJECTIVE: Message framing can be leveraged to motivate adult smokers to quit, but its value for parents in pediatric settings is unknown. Understanding parents' preferences for smoking cessation messages may help clinicians tailor interventions to increase quitting. METHODS: We conducted a discrete choice experiment in which parent smokers of pediatric patients rated the relative importance of 26 messages designed to increase smoking cessation treatment. Messages varied on who the message featured (child, parent, and family), whether the message was gain- or loss-framed (emphasizing benefits of engaging or costs of failing to engage in treatment), and the specific outcome included (eg, general health, cancer, respiratory illnesses, and financial impact). Participants included 180 parent smokers at 4 pediatric primary care sites. We used latent class analysis of message ratings to identify groups of parents with similar preferences. Multinomial logistic regression described child and parent characteristics associated with group membership. RESULTS: We identified 3 groups of parents with similar preferences for messages: Group 1 prioritized the impact of smoking on the child (n = 92, 51%), Group 2 favored gain-framed messages (n = 63, 35%), and Group 3 preferred messages emphasizing the financial impact of smoking (n = 25, 14%). Parents in Group 2 were more likely to have limited health literacy and have a child over age 6 and with asthma, compared to Group 1. CONCLUSIONS: We identified 3 groups of parent smokers with different message preferences. This work may inform testing of tailored smoking cessation messages to different parent groups, a form of behavioral phenotyping supporting motivational precision medicine.

18.
Med Decis Making ; 41(1): 9-20, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33218296

RESUMO

Behavioral interventions involving electronic devices, financial incentives, gamification, and specially trained staff to encourage healthy behaviors are becoming increasingly prevalent and important in health innovation and improvement efforts. Although considerations of cost are key to their wider adoption, cost information is lacking because the resources required cannot be costed using standard administrative billing data. Pragmatic clinical trials that test behavioral interventions are potentially the best and often only source of cost information but rarely incorporate costing studies. This article provides a guide for researchers to help them collect and analyze, during the trial and with little additional effort, the information needed to inform potential adopters of the costs of adopting a behavioral intervention. A key challenge in using trial data is the separation of implementation costs, the costs an adopter would incur, from research costs. Based on experience with 3 randomized clinical trials of behavioral interventions, this article explains how to frame the costing problem, including how to think about costs associated with the control group, and describes methods for collecting data on individual costs: specifications for costing a technology platform that supports the specialized functions required, how to set up a time log to collect data on the time staff spend on implementation, and issues in getting data on device, overhead, and financial incentive costs.

19.
JAMA Cardiol ; 6(1): 40-48, 2021 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-33031534

RESUMO

Importance: Statin therapy is underused for many patients who could benefit. Objective: To evaluate the effect of passive choice and active choice interventions in the electronic health record (EHR) to promote guideline-directed statin therapy. Design, Setting, and Participants: Three-arm randomized clinical trial with a 6-month preintervention period and 6-month intervention. Randomization conducted at the cardiologist level at 16 cardiology practices in Pennsylvania and New Jersey. The study included 82 cardiologists and 11 693 patients. Data were analyzed between May 8, 2019, and January 9, 2020. Interventions: In passive choice, cardiologists had to manually access an alert embedded in the EHR to select options to initiate or increase statin therapy. In active choice, an interruptive EHR alert prompted the cardiologist to accept or decline guideline-directed statin therapy. Cardiologists in the control group were informed of the trial but received no other interventions. Main Outcomes and Measures: Primary outcome was statin therapy at optimal dose based on clinical guidelines. Secondary outcome was statin therapy at any dose. Results: The sample comprised 11 693 patients with a mean (SD) age of 63.8 (9.1) years; 58% were male (n = 6749 of 11 693), 66% were White (n = 7683 of 11 693), and 24% were Black (n = 2824 of 11 693). The mean (SD) 10-year atherosclerotic cardiovascular disease (ASCVD) risk score was 15.4 (10.0); 68% had an ASVCD clinical diagnosis. Baseline statin prescribing rates at the optimal dose were 40.3% in the control arm, 39.1% in the passive choice arm, and 41.2% in the active choice arm. In adjusted analyses, the change in statin prescribing rates at optimal dose over time was not significantly different from control for passive choice (adjusted difference in percentage points, 0.2; 95% CI, -2.9 to 2.8; P = .86) or active choice (adjusted difference in percentage points, 2.4; 95% CI, -0.6 to 5.0; P = .08). In adjusted analyses of the subset of patients with clinical ASCVD, the active choice intervention resulted in a significant increase in statin prescribing at optimal dose relative to control (adjusted difference in percentage points, 3.8; 95% CI, 1.0-6.4; P = .008). No other subset analyses were significant. There were no significant changes in statin prescribing at any dose for either intervention. Conclusions and Relevance: The passive choice and active choice interventions did not change statin prescribing. In the subgroup of patients with clinical ASCVD, the active choice intervention led to a small increase in statin prescribing at the optimal dose, which could inform the design or targeting of future interventions. Trial Registration: ClinicalTrials.gov Identifier: NCT03271931.

20.
JAMA Intern Med ; 181(4): 471-478, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33351068

RESUMO

Importance: It is unknown how much the mortality of patients with coronavirus disease 2019 (COVID-19) depends on the hospital that cares for them, and whether COVID-19 hospital mortality rates are improving. Objective: To identify variation in COVID-19 mortality rates and how those rates have changed over the first months of the pandemic. Design, Setting, and Participants: This cohort study assessed 38 517 adults who were admitted with COVID-19 to 955 US hospitals from January 1, 2020, to June 30, 2020, and a subset of 27 801 adults (72.2%) who were admitted to 398 of these hospitals that treated at least 10 patients with COVID-19 during 2 periods (January 1 to April 30, 2020, and May 1 to June 30, 2020). Exposures: Hospital characteristics, including size, the number of intensive care unit beds, academic and profit status, hospital setting, and regional characteristics, including COVID-19 case burden. Main Outcomes and Measures: The primary outcome was the hospital's risk-standardized event rate (RSER) of 30-day in-hospital mortality or referral to hospice adjusted for patient-level characteristics, including demographic data, comorbidities, community or nursing facility admission source, and time since January 1, 2020. We examined whether hospital characteristics were associated with RSERs or their change over time. Results: The mean (SD) age among participants (18 888 men [49.0%]) was 70.2 (15.5) years. The mean (SD) hospital-level RSER for the 955 hospitals was 11.8% (2.5%). The mean RSER in the worst-performing quintile of hospitals was 15.65% compared with 9.06% in the best-performing quintile (absolute difference, 6.59 percentage points; 95% CI, 6.38%-6.80%; P < .001). Mean RSERs in all but 1 of the 398 hospitals improved; 376 (94%) improved by at least 25%. The overall mean (SD) RSER declined from 16.6% (4.0%) to 9.3% (2.1%). The absolute difference in rates of mortality or referral to hospice between the worst- and best-performing quintiles of hospitals decreased from 10.54 percentage points (95% CI, 10.03%-11.05%; P < .001) to 5.59 percentage points (95% CI, 5.33%-5.86%; P < .001). Higher county-level COVID-19 case rates were associated with worse RSERs, and case rate declines were associated with improvement in RSERs. Conclusions and Relevance: Over the first months of the pandemic, COVID-19 mortality rates in this cohort of US hospitals declined. Hospitals did better when the prevalence of COVID-19 in their surrounding communities was lower.


Assuntos
COVID-19/mortalidade , Hospitalização/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/diagnóstico , COVID-19/terapia , Estudos de Coortes , Cuidados Críticos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
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