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Background: Providing individuals with immediate, consistent inducements for health behaviors that do not provide proximal tangible benefits may promote adherence to diabetes self-management behaviors. Objective: To evaluate whether financial incentives lead to improvement in glycemic control and self-management behaviors in adolescents with type 1 diabetes. Methods: We conducted a randomized controlled crossover study with 12-18 year olds with type 1 diabetes. Adolescents self-selected target self-management behaviors (e.g., increase continuous glucose monitor [CGM] sensor wear time) and outcome goals (e.g., improve time in range [TIR]) and could earn up to $180 in each 3-month intervention cycle. Adolescents cycled through 3 study arms every 3 months: gain-framed payment where adolescents earned money for meeting behavioral goals, loss-framed payment where adolescents lost a portion of a weekly payment for not meeting behavioral goals, and usual care. Adolescents earned or lost $1.75 per day in the financial incentives arms, and a $2.75 weekly bonus for meeting their outcome-based goal. Goals were modeled against study arms with generalized linear mixed models to account for the longitudinal nature of the crossover design. Results: Out of 39 participants (mean age 16.1 years, 54% male, mean baseline HbA1c 9.42%, 38% insulin pump use, 95% CGM use) , 34 completed the trial. Mean HbA1c aggregated over all interventions was lower compared to baseline at 9.07% (p=0.13) and there was no difference in HbA1c among the 3 arms. Compared to the mean TIR for those under usual care of 39%, mean TIR under gain- and loss-frames were 45% (p Conclusions: Financial incentives can improve adolescent self-management behaviors and time in range in the short term and merits further longitudinal study to evaluate the effects on glycemic control and health care utilization. Disclosure F. Malik: n/a. T. Chen: None. M. Manzueta: None. J. Yi-frazier: None. C. Pihoker: None. J. L. Leblanc: None. S. K. Shah: None. D. Wright: None. Funding American Diabetes Association (1-18-ICTS-100)

**Objective:** To evaluate whether “Don’t Know” (DK) responses conveyed meaningful information when provided by oncologists in a national survey on medicinal cannabis (MC). **Study Setting:** This study is a secondary analysis of national survey data (n=237) collected between November 2016 and January 2017. **Methods:** The national survey asked oncologists about views regarding MC’s risks/benefits, and whether they had sufficient knowledge to make MC recommendations clinically. Cognitive testing of the survey instrument (n=5) suggested that physicians did not always feel that they possessed adequate MC knowledge in all domains, so DKs were added to six of 27 survey items. (Three items were batteries of questions while three were single questions.) We constructed bar graphs for the sum of DK responses in each battery and for the sum of all DK responses in the survey. Mann-Whitney tests compared medians for all DK responses within Yes/No responses to the sufficient knowledge question. **Principal Findings:** Statistically significant associations between DK responses and the sufficient knowledge question indicate that DK answers improved data quality by providing all respondents with an answer category that they feel fits their “true” answer. Associations between DK answers and other background variables such as respondents’ age, sex, and race are also discussed. The logistic regressions found that possessing sufficient knowledge was the only variable significant across six of the nine regressions, and the direction was consistent with the bivariate findings. **Conclusion:** In this study, DKs appear to be valid responses, improving data quality by providing some respondents with an answer category that best fits their “true” answer. Future surveys aiming to learn about physicians’ views regarding emerging treatments might consider including the DK response option in some items.

Purpose: Adolescents with type 1 diabetes (T1D) often struggle with diabetes self-care tasks and achieving optimal glycemic control. Financial incentive (FI) programs may improve T1D self-care and health outcomes. We aimed to quantify adolescent preferences for the structure of FI. Methods: We performed a discrete choice experiment with 12-18 year-olds with T1D from two pediatric hospital endocrinology clinics in Seattle (n = 185) and Boston (n = 141). We used a literature review and focus groups to identify key attributes of FI: (1) monthly value of the reward, (2) payment structure (positive vs. negative reinforcement), and (3) difficulty of behaviors being incentivized. Using these three attributes, we generated a balanced set of profiles representing hypothetical FI using a fractional factorial design. In twelve choice questions, adolescents were shown a pair of profiles and chose the FI option more likely to motivate them to increase adherence to recommended self-care. The options presented were tailored to adolescents’ modes of insulin administration and glucose monitoring and to adolescents’ individual rating of the difficulty of completing each behavior. We used a multinomial logit choice model to analyze data. Results: The value of the reward was the primary driver of preferences, accounting for 50% of preferences. Adolescents significantly preferred FI with a positive vs. negative reinforcement payment structure ($5.17 (95% CI: $4.11, $6.25)) and preferred higher FI for performing hard vs. easier behaviors ($6.95 (95% CI: $4.57, $8.33)). Preferences were associated with respondent age and HbA1c (p Conclusions: Adolescent stated preferences should inform the design of a T1D FI intervention, which can then be tested in randomized controlled trials to determine the impact of FI on T1D self-care adherence and health outcomes. Latent class analyses can identify subgroups with differential preferences and will explore subgroup characteristics. Disclosure D. Wright: None. K. Chalmers: None. J. L. Leblanc: None. J. Yi-frazier: None. S. K. Shah: None. K. Garvey: None. K. Senturia: None. C. Pihoker: None. F. Malik: None. Funding American Diabetes Association (1-18-ICTS-100 to D.W.)

Purpose Individuals who struggle to provide substitute judgment for the critically ill often find it challenging to engage in decision making for therapeutic interventions. Although essential to the conduct of research, how these individuals respond to requests for clinical trial participation is poorly understood. Methods Survey data collected to examine surrogate attitudes toward research provided the conceptual framework to explore influences on decision making. Path analysis was used to derive the final model (nonlatent, fully recursive, 1 indicator/variable). Results Surrogates with list-wise complete records (406) were analyzed. The following variables were not retained in the final model: education, income, religiosity, decision-making experience, discussion of patient's wishes, number of individuals assisting with decision making, trust in care providers, difficulty making decisions, and responsibility for decision making. Being white and having experience making treatment decisions for the patient during the current intensive care unit encounter affected the likelihood the surrogate would permit participation in research positively (parameter estimates, 0.281 and 0.06, respectively). No variable reflecting difficulty functioning in the surrogate role was associated with permitting research participation. Conclusions We were unable to demonstrate a relationship between perceived difficulty in decision making in the surrogate role and receptivity to clinical trial participation.

Background Although almost every state medical marijuana (MM) law identifies cancer as a qualifying condition, little research supports MM’s use in oncology. We hypothesized that the discrepancy between these laws and the scientific evidence base poses clinical challenges for oncologists. Oncologists’ beliefs, knowledge, and practices regarding MM were examined in this study. Methods In November 2016, we mailed a survey on MM to a nationally-representative, random sample of 400 medical oncologists. Main outcome measures included whether oncologists reported discussing MM with patients, recommended MM clinically in the past year, or felt sufficiently informed to make such recommendations. The survey also queried oncologists’ views on MM’s comparative effectiveness for several conditions (including its use as an adjunct to standard pain management strategies) and its risks compared with prescription opioids. Bivariate and multivariate analyses were performed using standard statistical techniques. Results The overall response rate was 63%. Whereas only 30% of oncologists felt sufficiently informed to make recommendations regarding MM, 80% conducted discussions about MM with patients, and 46% recommended MM clinically. Sixty-seven percent viewed it as a helpful adjunct to standard pain management strategies, and 65% thought MM is equally or more effective than standard treatments for anorexia and cachexia. Conclusion Our findings identify a concerning discrepancy between oncologists’ self-reported knowledge base and their beliefs and practices regarding MM. Although 70% of oncologists do not feel equipped to make clinical recommendations regarding MM, the vast majority conduct discussions with patients about MM and nearly one-half do, in fact, recommend it clinically. A majority believes MM is useful for certain indications. These findings are clinically important and suggest critical gaps in research, medical education, and policy regarding MM.

Purpose Significant gaps exist in health care transition (HCT) preparation that can impact care and outcomes in young adults with chronic illness. No quality measure exists to directly assess adolescent experiences of HCT preparation. Our objective was to develop an adolescent-reported measure of the quality of HCT preparation received from pediatric health care providers. Methods The Adolescent Assessment of Preparation for Transition (ADAPT) is a 26-item mailed survey designed for completion by 16- and 17-year-old adolescents with a chronic health condition. Adolescents from three samples (two large Medicaid insurance plans [n = 3,000 each] and one large tertiary care pediatric hospital [n = 623]) were mailed the survey. An iterative developmental process included focus groups and cognitive interviews, and validity was assessed using confirmatory factor analysis and ordinal reliability coefficients. Results Reliability and validity was evaluated for the following three prespecified composite measures: (1) counseling on transition self-management; (2) counseling on prescription medication; and (3) transfer planning. Across the three samples, all but one measure had good internal consistency (ordinal reliability coefficient ≥ .7). Confirmatory factor analysis using tetrachoric correlation coefficients was stable across samples and supported the construct validity of the first two composite measures. Conclusions ADAPT is a reliable, validated instrument measuring the quality of HCT preparation experiences reported by adolescents with chronic disease. ADAPT will enable clinical programs and health care delivery systems to assess the quality of HCT preparation and provide targets for improvement in adolescent counseling related to transition.

The Centers for Medicare and Medicaid Services (CMS) uses Adult Hospital Consumer Assessment of Healthcare Providers and Systems (Adult HCAHPS®) scores for public reporting and pay-for-performance for most US hospitals, but no publicly available standardized survey of inpatient experience of care exists for pediatrics. To fill the gap, CMS and the Agency for Healthcare Research and Quality commissioned the development of a pediatric version (Child HCAHPS), a survey of parents/guardians of pediatric patients (

BACKGROUND:Collection of genetic biospecimens as part of critical illness investigations is increasingly commonplace. Oversight bodies vary in restrictions imposed on genetic research, introducing inconsistencies in study design, potential for sampling bias, and the possibility of being overly prohibitive of this type of research altogether. We undertook this study to better understand whether restrictions on genetic data collection beyond those governing research on cognitively intact subjects reflect the concerns of surrogates for critically ill patients. METHODS:We analyzed survey data collected from 1,176 patients in nonurgent settings and 437 surrogates representing critically ill adults. Attitudes pertaining to genetic data (familiarity, perceptions, interest in participation, concerns) and demographic information were examined using univariate and multivariate techniques. RESULTS:We explored differences among respondents who were receptive (1,333) and nonreceptive (280) to genetic sample collection. Whereas factors positively associated with receptivity to research participation were "complete trust" in health-care providers (OR, 2.091; 95% CI, 1.544-2.833), upper income strata (OR, 2.319; 95% CI, 1.308-4.114), viewing genetic research "very positively" (OR, 3.524; 95% CI, 2.122-5.852), and expressing "no worry at all" regarding disclosure of results (OR, 2.505; 95% CI, 1.436-4.369), black race was negatively associated with research participation (OR, 0.410; 95% CI, 0.288-0.585). We could detect no difference in receptivity to genetic sample collection comparing ambulatory patients and surrogates (OR, 0.738; 95% CI, 0.511-1.066). CONCLUSIONS:Expressing trust in health-care providers and viewing genetic research favorably were associated with increased willingness for study enrollment, while concern regarding breach of confidentiality and black race had the opposite effect. Study setting had no bearing on willingness to participate.

This article investigates the effect of the Boston Marathon Bombing on city residents— how the tragic incident changed, or did not change, how Bostonians live in and feel about their community and neighborhoods. Unlike prior research that began weeks or months after a terrorist attack and used retrospective reports, this study spans the focal event. An address-based sample of residents from three neighborhoods, distinct in racial and economic makeup was surveyed by mail using a three-contact protocol. About two-thirds of respondents answered a survey of neighborhood sentiments, and health and well-being in the days before the bombing (N = 581) and slightly over a third answered the survey after the bombing (N = 313). Assessments of safety, city and neighborhood satisfaction and solidarity, mental health, and other key measures vary greatly between the three neighborhoods, which are diverse in racial and economic composition, but also vary in proximity to the bomb site. Net of neighborhood differences, the bombing had a strong negative effect on neighborhood cohesion and reduced use of public transit. Strong interactions are also found between timing of survey completion (pre and post bombing) and neighborhood for assessments of neighborhood solidarity.

This article is an exploratory data analysis of the determinants of confidence in a surrogate decision maker who has been asked to permit an intensive care unit (ICU) patient's participation in genetic research. We pursue the difference between surrogates' and patients' confidence that the surrogate can accurately represent the patient's wishes. The article also explores whether greater confidence leads to greater agreement between patients and surrogates. Our data come from a survey conducted in three hospital ICUs. We interviewed 445 surrogates and 214 patients. The only thing that influences patients' confidence in their surrogate's decision is whether they had prior discussions with him or her; however, there are more influences operating on the surrogate's self-confidence. More confident surrogates are more likely to match their patients' wishes. Patients are more likely to agree to research participation than their surrogates would allow. The surrogates whose response did not match as closely were less trusting of the hospital staff, were less likely to allow patient participation if there were no direct benefits to the patient, had given less thought about the way genetic research is conducted, and were much less likely to have a person in their life who they would trust to make decisions for them if they were incapacitated.