Effect of Peer Benchmarking on Specialist Electronic Consult Performance in a Los Angeles Safety-Net: a Cluster Randomized Trial.

BACKGROUND: Since the advent of COVID-19, accelerated adoption of systems that reduce face-to-face encounters has outpaced training and best practices. Electronic consultations (eConsults), structured communications between PCPs and specialists regarding a case, have been effective in reducing face-to-face specialist encounters. As the health system rapidly adapts to multiple new practices and communication tools, new mechanisms to measure and improve performance in this context are needed. OBJECTIVE: To test whether feedback comparing physicians to top performing peers using co-specialists' ratings improves performance. DESIGN: Cluster-randomized controlled trial PARTICIPANTS: Eighty facility-specialty clusters and 214 clinicians INTERVENTION: Providers in the feedback arms were sent messages that announced their membership in an elite group of "Top Performers" or provided actionable recommendations with feedback for providers that were "Not Top Performers." MAIN MEASURES: The primary outcomes were changes in peer ratings in the following performance dimensions after feedback was received: (1) elicitation of information from primary care practitioners; (2) adherence to institutional clinical guidelines; (3) agreement with peer's medical decision-making; (4) educational value; (5) relationship building. KEY RESULTS: Specialists showed significant improvements on 3 of the 5 consultation performance dimensions: medical decision-making (odds ratio 1.52, 95% confidence interval 1.08-2.14, p<.05), educational value (1.86, 1.17-2.96) and relationship building (1.63, 1.13-2.35) (both p<.01). CONCLUSIONS: The pandemic has shed light on clinicians' commitment to professionalism and service as we rapidly adapt to changing paradigms. Interventions that appeal to professional norms can help improve the efficacy of new systems of practice. We show that specialists' performance can be measured and improved with feedback using aspirational norms. TRIAL REGISTRATION: clinicaltrials.gov NCT03784950.

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial.

IMPORTANCE: Interventions based on behavioral science might reduce inappropriate antibiotic prescribing. OBJECTIVE: To assess effects of behavioral interventions and rates of inappropriate (not guideline-concordant) antibiotic prescribing during ambulatory visits for acute respiratory tract infections. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized clinical trial conducted among 47 primary care practices in Boston and Los Angeles. Participants were 248 enrolled clinicians randomized to receive 0, 1, 2, or 3 interventions for 18 months. All clinicians received education on antibiotic prescribing guidelines on enrollment. Interventions began between November 1, 2011, and October 1, 2012. Follow-up for the latest-starting sites ended on April 1, 2014. Adult patients with comorbidities and concomitant infections were excluded. INTERVENTIONS: Three behavioral interventions, implemented alone or in combination: suggested alternatives presented electronic order sets suggesting nonantibiotic treatments; accountable justification prompted clinicians to enter free-text justifications for prescribing antibiotics into patients' electronic health records; peer comparison sent emails to clinicians that compared their antibiotic prescribing rates with those of "top performers" (those with the lowest inappropriate prescribing rates). MAIN OUTCOMES AND MEASURES: Antibiotic prescribing rates for visits with antibiotic-inappropriate diagnoses (nonspecific upper respiratory tract infections, acute bronchitis, and influenza) from 18 months preintervention to 18 months afterward, adjusting each intervention's effects for co-occurring interventions and preintervention trends, with random effects for practices and clinicians. RESULTS: There were 14,753 visits (mean patient age, 47 years; 69% women) for antibiotic-inappropriate acute respiratory tract infections during the baseline period and 16,959 visits (mean patient age, 48 years; 67% women) during the intervention period. Mean antibiotic prescribing rates decreased from 24.1% at intervention start to 13.1% at intervention month 18 (absolute difference, -11.0%) for control practices; from 22.1% to 6.1% (absolute difference, -16.0%) for suggested alternatives (difference in differences, -5.0% [95% CI, -7.8% to 0.1%]; P = .66 for differences in trajectories); from 23.2% to 5.2% (absolute difference, -18.1%) for accountable justification (difference in differences, -7.0% [95% CI, -9.1% to -2.9%]; P < .001); and from 19.9% to 3.7% (absolute difference, -16.3%) for peer comparison (difference in differences, -5.2% [95% CI, -6.9% to -1.6%]; P < .001). There were no statistically significant interactions (neither synergy nor interference) between interventions. CONCLUSIONS AND RELEVANCE: Among primary care practices, the use of accountable justification and peer comparison as behavioral interventions resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01454947.

Impact of mental health comorbidities on health care utilization and expenditure in a large US managed care adult population with ADHD.

OBJECTIVE: To estimate the health resource use (HRU) and expenditure of adult patients with attention deficit/hyperactivity disorder (ADHD) subsequently diagnosed with one or more mental health (MH) comorbidities. METHODS: Using Kaiser Permanente Southern California electronic medical records (January 1, 2006, to December 31, 2009), we identified adults with at least one ADHD diagnosis and at least two subsequent prescriptions fills for ADHD medication. The date of first MH comorbidity diagnosis after the index ADHD diagnosis was defined as the index transition date. Continuous eligibility 12 months before and after the index transition date was required. For patients with multiple transitions (≥2), the post-transition period reflected the 12 months after the second transition. HRU for all-cause inpatient, outpatient, emergency department, behavioral therapy, overall prescription fill counts, and ADHD-specific prescription fill counts and mean patient expenditure (2010 US $) were estimated. Generalized estimating equations were used to evaluate differences in HRU and expenditure between the pre- and post-transition periods, respectively. RESULTS: Of the 3809 patients with ADHD identified, 989 (26%) had at least one transition (n = 357 single and n = 632 multiple). From the pre- to the post-transition period, for single transition cohort, all HRU increased significantly except for behavioral therapy. In the multiple transition cohort, all HRU increased significantly. Total expenditure increased by mean ± SE of $1822 ± $306 and $4432 ± $301 (both P < 0.0001) in the single and multiple transition cohorts, respectively. CONCLUSIONS: Twenty-six percent of patients with ADHD transitioned to MH comorbid diagnoses. Increased HRU and expenditure were associated with MH transitions. Identifying of patients with ADHD at risk for MH comorbidities may help to improve their outcomes.

Antibiotic prescribing for acute respiratory infections during the coronavirus disease 2019 (COVID-19) pandemic: Patterns in a nationwide telehealth service provider.

We examined 3,046,538 acute respiratory infection (ARI) encounters with 6,103 national telehealth physicians from January 2019 to October 2021. The antibiotic prescribing rates were 44% for all ARIs; 46% were antibiotic appropriate; 65% were potentially appropriate; 19% resulted from inappropriate diagnoses; and 10% were related to coronavirus disease 2019 (COVID-19) diagnosis.

Use of behavioral economics and social psychology to improve treatment of acute respiratory infections (BEARI): rationale and design of a cluster randomized controlled trial [1RC4AG039115-01]--study protocol and baseline practice and provider characteristics.

BACKGROUND: Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs (e.g., educational or informational interventions) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians. METHODS/DESIGN: The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider's rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease. DISCUSSION: The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics. TRIALS REGISTRATION: ClinicalTrials.gov: NCT01454947.

Clinician Job Satisfaction After Peer Comparison Feedback: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Interventions that improve clinician performance through feedback should not contribute to job dissatisfaction or staff turnover. Measurement of job satisfaction may help identify interventions that lead to this undesirable consequence. Objective: To evaluate whether mean job satisfaction was less than the margin of clinical significance among clinicians who received social norm feedback (peer comparison) compared with clinicians who did not. Design, Setting, and Participants: This secondary, preregistered, noninferiority analysis of a cluster randomized trial compared 3 interventions to reduce inappropriate antibiotic prescribing in a 2 × 2 × 2 factorial design from November 1, 2011, to April 1, 2014. A total of 248 clinicians were enrolled from 47 clinics. The sample size for this analysis was determined by the number of nonmissing job satisfaction scores from the original enrolled sample, which was 201 clinicians from 43 clinics. Data analysis was performed from October 12 to April 13, 2022. Interventions: Feedback comparing individual clinician performance to top-performing peers, delivered in monthly emails (peer comparison). Main Outcomes and Measures: The primary outcome was a response to the following statement: "Overall, I am satisfied with my current job." Responses ranged from 1 (strongly disagree) to 5 (strongly agree). Results: A total of 201 clinicians (response rate, 81%) from 43 of the 47 clinics (91%) provided a survey response about job satisfaction. Clinicians were primarily female (n = 129 [64%]) and board certified in internal medicine (n = 126 [63%]), with a mean (SD) age of 48 (10) years. The clinic-clustered difference in mean job satisfaction was greater than -0.32 (ß = 0.11; 95% CI, -0.19 to 0.42; P = .46). Therefore, the preregistered null hypothesis that peer comparison is inferior by resulting in at least a 1-point decrease in job satisfaction by 1 in 3 clinicians was rejected. The secondary null hypothesis that job satisfaction was similar among clinicians randomized to social norm feedback was not able to be rejected. The effect size did not change when controlling for other trial interventions (t = 0.08; P = .94), and no interaction effects were observed. Conclusions and Relevance: In this secondary analysis of a randomized clinical trial, peer comparison did not lead to lower job satisfaction. Features that may have protected against dissatisfaction include clinicians' agency over the performance measure, privacy of individual performance, and allowing all clinicians to achieve top performance. Trial Registration: ClinicalTrials.gov Identifiers: NCT05575115 and NCT01454947.

Cross-sectional study examining household factors associated with SARS-CoV-2 seropositivity in low-income children in Los Angeles.

OBJECTIVES: This study aims to quantify the degree to which an underserved, Hispanic population in Los Angeles is impacted by SARS-CoV-2, and determine factors associated with paediatric seropositivity. DESIGN: Cross-sectional. SETTING: AltaMed, a Federally Qualified Health Center in Los Angeles. PARTICIPANTS: A random sample of households who had received healthcare at AltaMed Medical Group was invited to participate. Households with at least one adult and one paediatric participant between 5 and 17 years of age were eligible to participate. Consented participants completed a survey on social determinants of health and were tested for antibodies using Abbott Architect SARS-CoV-2-IgG and SARS-CoV-2-IgM tests. PRIMARY OUTCOME MEASURE: Seropositive status. RESULTS: We analysed 390 adults (mean age in years, 38.98 (SD 12.11)) and 332 paediatric participants (11.26 (SD 3.51)) from 196 households. Estimated seropositivity was 52.11% (95% CI 49.61% to 55.19%) in paediatric participants and 63.58% (95% CI 60.39% to 65.24%) in adults. Seropositivity was 11.47% (95% CI 6.82% to 14.09%) lower in paediatric participants, but high relative to other populations. A household member with type 2 diabetes (OR 2.94 (95% CI 1.68 to 5.14)), receipt of food stamps (OR 1.66 (95% CI 1.08 to 2.56)) and lower head-of-household education (OR 1.73 (95% CI 1.06 to 2.84)) were associated with paediatric seropositivity. CONCLUSIONS: SARS-CoV-2 seropositivity is high in Hispanic children and adolescents in Los Angeles. Food insecure households with low head-of-household education, and at least one household member with type 2 diabetes, had the highest risk. These factors may inform paediatrician COVID-19 mitigation recommendations. TRIAL REGISTRATION NUMBER: NCT04901624.

The protocol of the Application of Economics & Social psychology to improve Opioid Prescribing Safety trial 2 (AESOPS-2): Availability of opioid harm.

BACKGROUND: High levels of opioid prescribing in the United States has resulted in an alarming trend in opioid-related harms. The objective of Trial 2 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-2) is to dampen the intensity and frequency of opioid prescribing in accordance with the Centers for Disease Control and Prevention recommendation to "go low and slow". We aim to accomplish this by notifying clinicians of harmful patient outcomes, which we expect to increase the mental availability of risks associated with opioid use. METHODS: The trial is multi-site. Random assignment determines if prescribers to persons who suffer an opioid overdose (fatal or nonfatal) learn of this event (intervention) or practice usual care (control). Clinicians in the intervention group receive a letter notifying them of their patient's overdose. The primary outcome is the change in clinician weekly milligram morphine equivalent (MME) prescribed in a 6-month period before and after receiving the letter. Additional outcomes are the change in the proportion of patients prescribed at least 50 daily MME and in the proportion of patients referred to medication assisted treatment. Group differences in these outcomes will be compared using an intent-to-treat difference-in-differences framework with a mixed-effects regression model to estimate clinician MME. DISCUSSION: The AESOPS-2 trial will provide new knowledge about whether increasing prescribers' awareness of patients' opioid-related overdoses leads to a reduction in opioid prescribing. Additionally, this trial may better inform how to reduce opioid use disorder and opioid overdoses by lowering population exposure to these drugs. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04758637.

The protocol of improving safe antibiotic prescribing in telehealth: A randomized trial.

BACKGROUND: The CDC estimates that over 40% of Urgent Care visits are for acute respiratory infections (ARI), more than half involving inappropriate antibiotic prescriptions. Previous randomized trials in primary care clinics resulted in reductions in inappropriate antibiotic prescribing, but antibiotic stewardship interventions in telehealth have not been systematically assessed. To better understand how best to decrease inappropriate antibiotic prescribing for ARIs in telehealth, we are conducting a large randomized quality improvement trial testing both patient- and physician-facing feedback and behavioral nudges embedded in the electronic health record. METHODS: Teladoc® clinicians are assigned to one of 9 arms in a 3 × 3 randomized trial. Each clinician is assigned to one of 3 Commitment groups (Public, Private, Control) and one of 3 Performance Feedback groups (Benchmark Peer Comparison, Trending, Control). After randomly selecting ⅓ of states and associated clinicians required for patient-facing components of the Public Commitment intervention, remaining clinicians are randomized to the Control and Private Commitment arms. Clinicians are randomized to the Performance Feedback conditions. The primary outcome is change from baseline in antibiotic prescribing rate for qualifying ARI visits. Secondary outcomes include changes in inappropriate prescribing and revisit rates. Secondary analyses include investigation of heterogeneity of treatment effects. With 1530 clinicians and an intra-clinician correlation in antibiotic prescribing rate of 0.5, we have >80% power to detect 1-7% absolute differences in antibiotic prescribing among groups. DISCUSSION: Findings from this trial may help inform telehealth stewardship strategies, determine whether significant differences exist between Commitment and Feedback interventions, and provide guidance for clinicians and patients to encourage safe and effective antibiotic use. CLINICALTRIALS: gov: NCT05138874.

The protocol of the Application of Economics & Social psychology to improve Opioid Prescribing Safety Trial 1 (AESOPS-1): Electronic health record nudges.

BACKGROUND: There is a lack of evidence that long-term opioid use offers benefit for noncancer pain and an abundance of evidence of harm. Despite clinical guidelines and education, prescribing continues at a higher rate than before the opioids crisis. The objective of trial 1 of the Application of Economics & Social psychology to improve Opioid Prescribing Safety (AESOPS-1) is to discourage unnecessary opioid prescribing in primary care by applying "behavioral insights"-empirically-tested social and psychological interventions that affect choice. METHODS: AESOPS-1 randomizes primary care clinics in Illinois and California to behavioral intervention or control. Both arms receive opioid guideline education. Clinics randomized to the behavioral intervention arm receive nudges within the electronic health record (EHR) including: 1) an "accountable justification" entered in the chart, 2) a precommitment to address high-risk prescriptions, and 3) a "PainTracker" that broadens discussions about pain. The control arm receives no EHR-based intervention. The primary outcome is the change in weekly milligram morphine equivalents (MME) prescribed. The secondary outcome is the change in the proportion of patients prescribed at least 50 daily MME. To evaluate these outcomes, we will use a difference-in-differences mixed-effects regression model on clinician MME weekly or daily dose. The analysis will be "intent-to-treat." The intervention period is 18-months, with a 6-month follow-up period to measure persistence of effects. DISCUSSION: The AESOPS-1 trial will evaluate the effect of EHR-based interventions in reducing noncancer opioid prescribing in primary care. AESOPS-1 may demonstrate practical and scalable strategies to lower unnecessary population exposure to opioids.

Nonadherence to clinical practice guidelines and medications for multiple chronic conditions in a California Medicaid population.

OBJECTIVES: To assess and profile quality of care in California Medicaid beneficiaries with chronic conditions. DESIGN: Retrospective cohort study. SETTING: California from 2002 to 2004. PATIENTS: 1,123,577 beneficiaries. INTERVENTION: Eligibility and claims data (2002-2004) were used to identify beneficiaries with dyslipidemia, hypertension, coronary artery disease (CAD), heart failure, or diabetes. MAIN OUTCOME MEASURES: Quality of care was based on nonadherence with clinical practice guidelines including recommended medications. Chi-square was used to evaluate nonadherence and patient characteristics. RESULTS: The proportion of patients without a prescription fill for recommended medications varied by disease (43% hypertension, 40% dyslipidemia and CAD, and 25% diabetes and heart failure). For Medicaid-only beneficiaries with diabetes, 78% lacked glycosylated hemoglobin tests, 62% lacked low-density lipoprotein cholesterol tests, and 50% lacked eye exams. Medication nonadherence was high (69% hypertension, 64% CAD, 57% heart failure, 48% dyslipidemia, 41% diabetes). Overall, younger age, Medicaid-only status, and black/other race were associated with poorer rates. CONCLUSION: Quality of care was suboptimal, with nonadherence varying by condition. Programs targeting both patients and providers and addressing patient-related characteristics (e.g., age, race) and policy reform addressing alterable factors (e.g., insurance eligibility) should be developed to improve guideline adherence.

Evaluating use patterns of and adherence to medications for benign prostatic hyperplasia.

PURPOSE: We investigated adherence to benign prostatic hyperplasia medications in a California Medicaid population. MATERIALS AND METHODS: Using California Medicaid data on 1995 to 2004 we identified adult males 40 years old or older with 1 or more diagnosis and 2 or more prescription fills for benign prostatic hyperplasia. Patients with 2 fills on the same day were assigned to the multiple medication cohort. Adherence was measured using the medication possession ratio for the index medication and the proportion of days covered for any benign prostatic hyperplasia medication. Patients with a medication possession ratio or proportion of days covered of 0.8 or greater were considered adherent. A Cox proportional hazards model was used to assess the relative hazards associated with discontinuation. Multiple logistic regression was used to investigate factors associated with nonadherence or a benign prostatic hyperplasia related procedure. RESULTS: Of the total population of 2,640 men 40% were adherent with any benign prostatic hyperplasia medication. A significantly greater proportion of patients using multiple medications and finasteride were adherent with any benign prostatic hyperplasia medication (62% and 55%, respectively, p <0.0001). Doxazosin, terazosin and tamsulosin use was associated with nonadherence (p = 0.008, 0.04 and 0.03, respectively). Younger patients and those changing medications were more likely to discontinue (p = 0.01 and <0.0001), while patients using multiple medications and those experiencing a gap were at lower risk for discontinuation (p = 0.01 and <0.0001, respectively). Predictors of a procedure included an index prescription in 1999 or later, a urologist visit and nonadherence to any benign prostatic hyperplasia medication (p = 0.01, <0.0001 and <0.0001, respectively). CONCLUSIONS: Adherence to alpha-blockers was less than adherence to finasteride or multiple medications and nonadherence was significantly associated with a procedure. Interventions focused on improving adherence to benign prostatic hyperplasia medications are clearly needed.

Transition probabilities and predictors of adherence in a California Medicaid population using antihypertensive and lipid-lowering medications.

OBJECTIVES: To determine adherence rates, transition probabilities, and factors associated with transition from higher to lower adherence in antihypertensive (AH) and lipid-lowering (LL) medications. METHODS: California Medicaid data (1995-2003) were used to identify hypertensive patients with prescriptions for both AH and LL medications. Proportion of days covered (PDC) was used to define three adherence classifications: fully adherent (FA, PDC >or= 0.8), partially adherent (PA, 0.2

Quality of anticoagulation monitoring in nonvalvular atrial fibrillation patients: comparison of anticoagulation clinic versus usual care.

BACKGROUND: Prior research suggests that receiving specialized anticoagulation services enables patients to achieve better clinical outcomes. OBJECTIVE: To assess the quality of anticoagulation therapy in patients with atrial fibrillation who were enrolled in an anticoagulation clinic (ACC) versus usual care (UC). METHODS: Using Sharp Rees-Stealy physician group claims data, we estimated time spent in therapeutic range and time to first major bleeding episode or stroke for ACC and UC patients. t-Tests were used to compare time in therapeutic range proportions, and Kaplan-Meier survival analysis was performed to compare rates of bleeding and stroke between groups. RESULTS: We identified 1107 patients (351 ACC, 756 UC) treated with anticoagulation therapy for atrial fibrillation with more than one international normalized ratio (INR) reported between March 2001 and March 2004. ACC patients spent a greater proportion (68.14%) of time in therapeutic range compared with UC patients (42.07%; p < 0.001). There was a significant difference between groups in average time between INR tests (ACC = 14.31 days, UC = 18.39 days; p < 0.001). ACC patients were 59% less likely to experience a bleed following the index date than were UC patients (HR = 0.41; 95% CI 0.2444 to 0.6999; p = 0.001), but type of care was not a significant predictor for stroke (HR = 0.95; 95% CI 0.5125 to 1.7777; p value NS). CONCLUSIONS: Results from this observational study reinforce the positive impact that anticoagulation services have on anticoagulation therapy outcomes, emphasizing the importance of providing such services for patients undergoing treatment with warfarin.

Opinions regarding the Academy of Managed Care Pharmacy dossier submission guidelines: results of a small survey of managed care organizations and pharmaceutical manufacturers.

BACKGROUND: In recent years, there has been more emphasis on determining the total value of a drug product, which includes safety and efficacy information and clinical and economic value relative to other therapies. The Academy of Managed Care Pharmacy (AMCP) Format for Formulary Submissions was intended as a tool to assist health care providers in evaluating and selecting drug products. OBJECTIVE: The purpose of this research was to gain the perspectives of a sample of managed care organizations (MCOs) and pharmaceutical manufacturers regarding the AMCP Format submission and evaluation process, as well as their comments on possible future direction for these guidelines as an important part of the formulary decision-making process. METHODS: A random sample of large (>1 million lives) and small (<1 million lives) MCOs was generated using telephone numbers from the National Directory of Managed Care Organizations' database. Pharmaceutical manufacturer respondents were identified from the Pharmaceutical Research and Manufacturers of America (PhRMA) Foundation's Health Outcomes Committee. Telephone interviews were conducted by 2 researchers between September 2004 and October 2005. Respondents from both pharmaceutical manufacturers and MCOs nationwide were familiar with the AMCP dossier preparation and review process, allowing us to compare perspectives from each group. The interview was designed to assess the following key areas: economic models, organizational burden, confidentiality, overall value, and future expectations. RESULTS: Representatives from 20 MCOs and 7 pharmaceutical manufacturers completed the interview; 21 MCO representatives refused to participate, citing company policy. Nearly all (87.5%) of the MCO personnel contacted reviewed dossiers within their organization. However, MCO respondents indicated that only 40% of all drugs they reviewed included dossiers from the manufacturers. For drug evaluation at the level of the pharmacy and therapeutics committee, we found that drugs were compared with a variety of products, with 11 respondents reporting comparisons with a placebo, and all respondents reporting a comparison with at least 1 other branded product. On average, 53.5% of the dossiers MCOs received included budget-impact models, and 39.3% included cost-effectiveness analyses (CEAs) or cost-benefit analyses. Of the dossiers with economic models, less than half (46.2%) were deemed adequate. Nearly two thirds of MCO respondents reported that they modified the provided model with their own population statistics, as many reported that manufacturers do not make models directly applicable to their health plan population. The perspectives of the pharmaceutical manufacturers varied dramatically from the MCO respondents with regard to the inclusion of economic models. Five of the 7 respondents indicated that their companies always included an economic model in the submitted dossiers. One respondent indicated that 85% of company dossiers included models, and another reported that 50% of dossiers included CEA models. Both MCOs and pharmaceutical manufacturers commented that organizational burden was high, with 70% of both groups reporting the use of outside consultants to assist in the dossier process. CONCLUSIONS: Overall, findings for this study suggest that awareness of the AMCP Format is high among MCOs and pharmaceutical manufacturers, but aligning objectives between the 2 organization types is necessary. Conceptually, proving a drug value beyond what the U.S. Food and Drug Administration requires is a reasonable request, something most respondents agreed on. However, less than half of all drugs reviewed had a dossier. In contrast to MCO respondents, pharmaceutical manufacturers appear to have a more positive outlook on the role of the AMCP Format in effectively communicating the value of a new drug product. Further steps need to be taken to improve acceptance and integration of the AMCP Format.

Use of Insurance Against a Small Loss as an Incentive Strategy.

The success of extended warranties and buyer protection plans suggests that insurance against a small loss has high decision utility. We explore whether the behavioral insight that people are highly averse to small chances of loss can be used to create a powerful incentive that has very low expected value. We compare decisions of individuals offered fixed payments for healthy choices to those offered insurance in exchange for healthy choices. We test the prediction that aversion to small losses will result in very high rates of health behavior uptake in exchange for insurance. Three hundred participants endowed with a $2 bonus randomly received one of two incentives for completing a scheduled health risk assessment: (1) an insurance guarantee against the 1% risk of losing the $2 bonus or (2) a fixed payment at the expected value of the insurance. Relative to the fixed payment condition, participants in the insurance intervention were 70% more likely to meet their health risk assessment appointment (p < 0.01). Fixed payments of $2.59 were needed for every $1 spent on insurance to achieve the same behavioral effect. Loss aversion, probability weighting, and the certainty effect may account for this result. Incentive design may benefit from utilizing an insurance paradigm.

Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial.

IMPORTANCE: "Nudges" that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice. OBJECTIVE: To investigate the use of a behavioral "nudge" based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs). DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period); 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention). INTERVENTIONS: The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs. MAIN OUTCOMES AND MEASURES: Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status. RESULTS: Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (P = .02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time. CONCLUSIONS AND RELEVANCE: Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01767064.

Prevalence and incidence of adult attention deficit/hyperactivity disorder in a large managed care population.

OBJECTIVES: To estimate longitudinal trends in prevalence and incidence rates of adult ADHD 2006-2009. RESEARCH DESIGN AND METHODS: Kaiser Permanente Southern California (KPSC) electronic medical records were analyzed to assess prevalence and incidence rates for adult ADHD. Trends over time were estimated and compared using three case definitions (ADHD diagnosis only [DX], ADHD DX and ≥2 FDA-approved ADHD prescriptions [DX + RX], and ADHD DX and ≥1 behavioral therapy visit [DX + BT]). MAIN OUTCOME MEASURES: Prevalence and incidence rates of adult ADHD. RESULTS: Prevalence ranged from 151 (DX + RX) to 312 (DX) cases per 100,000 members in 2006, increasing to 239 (DX + RX) and 415 (DX) cases in 2009. Prevalence based on DX + BT declined from 185 in 2006 to 94 cases per 100,000 in 2009. In 2006, incidence ranged from 15 (DX + BT) to 68 (DX) cases per 100,000 person-years. Incidence rates remained stable throughout the study period. Stratified analyses based on DX + RX revealed only slight variations by gender, but sharp differences by age, with younger adults demonstrating a higher prevalence overall as well as dramatic increases over the study period. Prevalence was highest among Caucasians, increasing substantially across all race groups over time. LIMITATIONS: A limitation of this study is that incidence rates may not be representative of new cases if diagnoses existed prior to enrollment in KPSC. Similarly, prevalence rates may be affected if patients sought care outside of the health plan. CONCLUSIONS: Adult ADHD prevalence in this managed care organization appears low, but showed increasing prevalence and incidence rates over time.

Cost of care for early- and late-stage oral and pharyngeal cancer in the California Medicaid population.

BACKGROUND: This study documents the direct medical costs associated with treating oral and pharyngeal squamous cell carcinoma (OSCC) as early- or late-stage disease according to the current standard of care. METHODS: This retrospective analysis of California Medicaid claims data calculated direct payments for patients diagnosed with OSCC. Patients were defined as being treated for early- or late-stage disease based on treatment modality. Regression determined significant predictors of year-1 cost of care following diagnosis. RESULTS: Median year-1 cost of care following initial diagnosis was $25,319 for the 229 patients identified. Regression results determined that treatment modality and medical comorbidities were significant in predicting costs (p < .05). Costs for patients treated as having early-stage OSCC were approximately 36% less than for those treated as having late-stage disease (p = .002). CONCLUSION: Treatment for OSCC is a significant cost from Medicaid's perspective, and these data suggest early detection may ease its economic burden.