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This randomized clinical trial evaluates the effect of prescriber notifications of a patient’s fatal overdose on opioid prescribing, including decreases in morphine milligram equivalents, new patients taking opioids, and patients taking a high dose, at 4 to 12 months after notification.

ObjectivesThis 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.DesignCross-sectional.SettingAltaMed, a Federally Qualified Health Center in Los Angeles.ParticipantsA 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 measureSeropositive status.ResultsWe 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.ConclusionsSARS-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 numberNCT04901624.

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

Purpose Inflammatory bowel disease (IBD) patients experience diverse symptoms and the impact of these different symptoms varies substantially. Current disease activity measures do not account for the relative importance of the different symptoms and severity levels. In this study, we aimed to quantify the relative importance of different symptoms for IBD patients and to develop a patient preference-weighted symptom (PWS) score to assess symptom burden in IBD. Methods We performed a choice-based conjoint analysis (CBCA) survey with 129 IBD patients to estimate the relative importance of four common IBD symptoms: stool frequency, abdominal pain, blood in stools, and urgency. We then developed the PWS score using the preferences obtained from the CBCA, which we validated against existing measures. Results CBCA revealed that urgency was the most important symptom to patients, followed by abdominal pain and blood in stools. Urgency associated with incontinence received particularly high scores and was perceived to be more than 3 times as important as urgency without incontinence. Our results confirmed that different symptoms are not equally bothersome, and we showed that the relation between symptom-level and importance is not linear. The PWS score, which we developed using these estimates was highly correlated with existing disease activity measures. Conclusions We quantified the relative importance of four common IBD symptoms and developed the PWS score for IBD, which takes the relative importance of different symptoms and symptom-levels into account. The PWS score can be used to obtain a patient-centered assessment of symptom burden.

IMPORTANCE: The extent of clinician-level variation in the overuse of testing or treatment in older adults is not well understood. OBJECTIVE: To examine clinician-level variation for three new measures of potentially inappropriate use of medical services in older adults. DESIGN: Retrospective analysis of overall means and clinician-level variation in performance on three new measures. SUBJECTS: Adults aged 65 years and older who had office visits with outpatient primary or immediate care clinicians within a single academic medical center health system between July 1, 2016, and June 30, 2017. MEASURES: Two electronic clinical quality measures representing potentially inappropriate use of medical services in older adults: prostate-specific antigen testing against guidelines (PSA) in men aged 76 and older; urinalysis or urine culture for non-specific reasons in women aged 65 and older; and one intermediate outcome measure: hemoglobin A1c less than 7.0 in adults aged 75 and older with diabetes mellitus treated with insulin or oral hypoglycemic medication. RESULTS: Sixty-nine clinicians and 2009 patients contributed observations to the PSA measure, 144 clinicians and 5933 patients contributed to the urinalysis/urine culture measure, and 42 clinicians and 665 patients contributed to the diabetes measure. Meaningful clinician-level performance variation was greatest for the PSA measure (intraclass correlation coefficient [ICC] = 0.27), followed by the urinalysis/urine culture measure (ICC = 0.18), and the diabetes measure (ICC = 0.024). The range of possible overuse across clinician quartiles was 8–54% for the PSA measure, 3–35% for the urinalysis/urine culture measure, and 13–49% for the diabetes measure. The odds ratios of overuse in the highest quartile compared with the lowest for the PSA, urinalysis/urine culture, and diabetes measures were 99.3 (95% CI 43 to 228), 15.7 (10 to 24), and 6.0 (3.3 to 11), respectively. CONCLUSIONS: Within the same health system, rates of potential overuse in elderly patients varied greatly across clinicians, particularly for the process measures examined. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05748-8) contains supplementary material, which is available to authorized users.

Unnecessary testing and treatment of common conditions in older adults can lead to significant morbidity and mortality. The primary objective of this study was to develop and pilot test a set of clinical decision support (CDS) alerts informed by social psychology to address overuse in three areas related to ambulatory care of older adults.We developed three electronic health record (EHR) CDS alerts to address overuse and pilot tested them from January 17, 2019 to July 17, 2019. We enrolled 14 primary care physicians from three practices within a large health system who cared for adults aged 65 years and older. Three measures of overuse applied to patients meeting the following criteria: ordering of prostate-specific antigen (PSA) for prostate cancer screening in adult men aged 76 years and older, ordering of urinalysis or urine cultures (UA or UC) for non-specific reasons to identify bacteriuria in women aged 65 years and older, and overtreatment of diabetes with insulin or oral hypoglycemic medications in adults aged at 75 years and older (DM). Clinicians received CDS alerts when criteria for any of the three overuse measures were met. We then surveyed clinicians to evaluate their experience with the CDS alerts.The number of clinical encounters that triggered CDS alerts was 19 for PSA, 48 for UA/UC and 128 for DM. For PSA encounters, 4 (21%) orders were not performed after the alert. In the UA/UC encounters 29 (60%) orders were not performed after the alert. For the DM encounters, 21 (34%) had diabetes therapy reduced following the alert. Survey respondents indicated that the alerts were clinically accurate and sometimes led them to change their clinical action.These CDS alerts were feasible to implement and may minimize unnecessary testing and treatment of common conditions in older adults.

Author(s): Yadav, Kabir; Meeker, Daniella; Mistry, Rakesh D; Doctor, Jason N; Fleming-Dutra, Katherine E; Fleischman, Ross J; Gaona, Samuel D; Stahmer, Aubyn; May, Larissa | Abstract: BackgroundAntibiotics are commonly prescribed during emergency department (ED) and urgent care center (UCC) visits for viral acute respiratory infection (ARI). We evaluate the comparative effectiveness of an antibiotic stewardship intervention adapted for acute care ambulatory settings (adapted intervention) to a stewardship intervention that additionally incorporates behavioral nudges (enhanced intervention) in reducing inappropriate prescriptions.MethodsThis study was a pragmatic, cluster-randomized clinical trial conducted in three academic health systems comprising five adult and pediatric EDs and four UCCs. Randomization of the nine sites was stratified by health system; all providers at each site received either the adapted or the enhanced intervention. The main outcome was the proportion of antibiotic-inappropriate ARI diagnosis visits that received an outpatient antibiotic prescription by individual providers. We estimated a hierarchical mixed-effects logistic regression model comparing visits during the influenza season for 2016 to 2017 (baseline) and 2017 to 2018 (intervention).ResultsThere were 44,820 ARI visits among 292 providers across all nine cluster sites. Antibiotic prescribing for ARI visits dropped from 6.2% (95% confidence interval [CI]n= 4.5% to 7.9%) to 2.4% (95% CIn= 1.3% to 3.4%) during the study period. We found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.2% (95% CIn= 1.0% to 3.4%) to 1.5% (95% CIn= 0.7% to 2.3%) with an odds ratio of 0.67 (95% CIn= 0.54 to 0.82). Difference-in-differences between the two interventions was not significantly different.ConclusionImplementation of antibiotic stewardship for ARI is feasible and effective in the ED and UCC settings. More intensive behavioral nudging methods were not more effective in high-performance settings.

This secondary analysis of a randomized clinical trial examines the association of receipt of an injunction letter from a medical examiner following a patient’s drug overdose with patterns of benzodiazepine prescribing among physicians.

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.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 have80% power to detect 1-7% absolute differences in antibiotic prescribing among groups.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.gov: NCT05138874.

Inappropriate polypharmacy, prevalent among older patients, is associated with substantial harms.To develop measures of high-risk polypharmacy and pilot test novel electronic health record (EHR)-based nudges grounded in behavioral science to promote deprescribing.We developed and validated seven measures, then conducted a three-arm pilot from February to May 2019.Validation used data from 78,880 patients from a single large health system. Six physicians were pre-pilot test environment users. Sixty-nine physicians participated in the pilot.Rate of high-risk polypharmacy among patients aged 65 years or older. High-risk polypharmacy was defined as being prescribed ≥5 medications and satisfying ≥1 of the following high-risk criteria: drugs that increase fall risk among patients with fall history; drug-drug interactions that increase fall risk; thiazolidinedione, NSAID, or non-dihydropyridine calcium channel blocker in heart failure; and glyburide, glimepiride, or NSAID in chronic kidney disease.Physicians received EHR alerts when renewing or prescribing certain high-risk medications when criteria were met. One practice received a "commitment nudge" that offered a chance to commit to addressing high-risk polypharmacy at the next visit. One practice received a "justification nudge" that asked for a reason when high-risk polypharmacy was present. One practice received both.Among 55,107 patients 65 and older prescribed 5 or more medications, 6256 (7.9%) had one or more high-risk criteria. During the pilot, the mean (SD) number of nudges per physician per week was 1.7 (0.4) for commitment, 0.8 (0.5) for justification, and 1.9 (0.5) for both interventions. Physicians requested to be reminded to address high-risk polypharmacy for 236/833 (28.3%) of the commitment nudges and acknowledged 441 of 460 (95.9%) of justification nudges, providing a text response for 187 (40.7%).EHR-based measures and nudges addressing high-risk polypharmacy were feasible to develop and implement, and warrant further testing.

There are limited data regarding direct oral anticoagulants (DOACs) for stroke prevention in patients with bioprosthetic heart valves (BHVs) and atrial fibrillation (AF). The objectives of this study were to evaluate the ambulatory utilization of DOACs and to compare the effectiveness and safety of DOACs versus warfarin in patients with AF and BHVs. We conducted a retrospective cohort study at a large integrated health care delivery system in California. Patients with BHVs and AF treated with warfarin, dabigatran, rivaroxaban, or apixaban between September 12, 2011 and June 18, 2020 were identified. Inverse probability of treatment-weighted comparative effectiveness and safety of DOACs compared with warfarin were determined. Use of DOACs gradually increased since 2011, with a significant upward in trend after a stay-at-home order related to COVID-19. Among 2,672 adults with BHVs and AF who met the inclusion criteria, 439 were exposed to a DOAC and 2233 were exposed to warfarin. For the primary effectiveness outcome of ischemic stroke, systemic embolism and transient ischemic attack, no significant association was observed between use of DOACs compared with warfarin (HR 1.19, 95% CI 0.96 to 1.48, p = 0.11). Use of DOACs was associated with lower risk of the primary safety outcome of intracranial hemorrhage, gastrointestinal bleeding, and other bleed (HR 0.69, 95% CI 0.56 to 0.85, p0.001). Results were consistent across multiple subgroups in the sensitivity analyses. These findings support the use of DOACs for AF in patients with BHVs.

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.

Background Outpatient antibiotic stewardship is needed to reduce inappropriate prescribing and minimize the development of resistant bacteria. We assessed primary care physicians’ perceptions of antibiotic resistance, antibiotic use, and the need for stewardship activities. Methods We conducted a national online survey of 1550 internal, family, and pediatric medicine physicians in the United States recruited from an opt-in panel of healthcare professionals. Descriptive statistics were generated for respondent demographics and question responses. Responses were also stratified by geographic region and medical specialty, with a χ 2 test used to assess for differences. Results More respondents agreed that antibiotic resistance was a problem in the United States (94%) than in their practice (55%) and that inappropriate antibiotic prescribing was a problem in outpatient settings (91%) than in their practice (37%). In addition, 60% agreed that they prescribed antibiotics more appropriately than their peers. Most respondents (91%) believed that antibiotic stewardship was appropriate in office-based practices, but they ranked antibiotic resistance as less important than other public health issues such as obesity, diabetes, opioids, smoking, and vaccine hesitancy. Approximately half (47%) believed they would need a lot of help to implement stewardship. Respondents indicated that they were likely to implement antibiotic stewardship efforts in response to feedback or incentives provided by payers or health departments. Conclusions Primary care physicians generally did not recognize antibiotic resistance and inappropriate prescribing as issues in their practice. This poses a challenge for the success of outpatient stewardship. Healthcare stakeholders will need to explore opportunities for feedback and incentive activities to encourage stewardship uptake., US primary care physicians recognize the threat of antibiotic resistance and inappropriate antibiotic prescribing nationally but not in their own practices. Healthcare stakeholders need to explore effective strategies for incentivizing stewardship implementation in these critical healthcare settings.

Objectives Little is known about the severity and long-term health and economic consequences of sarcopenia. We developed a sarcopenia index to measure severity in older Americans and estimated the long-term societal benefits generated by effective interventions to mitigate severity. Design Using a micro-simulation model, we quantified the potential societal value generated in the US in 2010–2040 by reductions in sarcopenia severity in older adults. All analyses were performed in Stata and SAS. Setting & Participants: Secondary data from the National Health and Nutrition Examination Survey (NHANES) (N = 1634) and Health and Retirement Study (HRS) (N = 952) were used to develop a sarcopenia severity index in older adults. Measurements Multitrait multi-method and factor analyses were used to validate and calibrate the sarcopenia severity index, which was modeled as a function of gait speed, walking without an assistive device, and moderate physical activity. Results In representative elderly populations, reducing sarcopenia severity by improving gait speed by 0.1 m/s in those with gait speed under 0.8 m/s generated a cumulative benefit of $65B by 2040 (2015 dollars). Improving walking ability in those with walking difficulty generated cumulative social benefit of $787B by 2040. Conclusions Reducing sarcopenia severity would generate significant health and economic benefits to society— almost $800B in the most optimistic scenarios. Electronic Supplementary Material Supplementary material is available for this article at 10.1007/s12603-018-1104-7 and is accessible for authorized users.

Health outcomes may depend on which treatment is received, whether choice of treatment is given, and whether a received treatment is the preferred therapy. We examined the effects of these key factors on the EuroQol-5D (EQ-5D-3L) in patients with PTSD. Two hundred patients aged 18–65 years with PTSD diagnosis enrolled in a doubly randomized preference trial (DRPT) examining treatment, choice of treatment, and treatment-preference effects of prolonged exposure therapy (PE) and pharmacotherapy with sertraline (SER) (clinicaltrials.gov Identifier: NCT00127673). We performed difference-in-difference analysis to estimate the treatment effects of prolonged exposure therapy (PE) as compared to pharmacotherapy with sertraline (SER), receipt of choice versus no-choice of treatment, and receipt of preferred versus non-preferred treatment on health-related quality-of-life (HRQOL) outcome using the EQ-5D-3L completed at baseline and 10-week post-treatment. The treatment effects of PE on the EQ-5D scores in overall patients and subgroup of patients who preferred PE were 0.150 (p = 0.025) and 0.223 (p

BACKGROUND: Overtesting and treatment of older patients is common and may lead to harms. The Choosing Wisely campaign has provided recommendations to reduce overtesting and overtreatment of older adults. Behavioral economics-informed interventions embedded within the electronic health record (EHR) have been shown to reduce overuse in several areas. Our objective is to conduct a parallel arm, pragmatic cluster-randomized trial to evaluate the effectiveness of behavioral-economics-informed clinical decision support (CDS) interventions previously piloted in primary care clinics and designed to reduce overtesting and overtreatment in older adults. METHODS/DESIGN: This trial has two parallel arms: clinician education alone vs. clinician education plus behavioral-economics-informed CDS. There are three co-primary outcomes for this trial: (1) prostate-specific antigen (PSA) screening in older men, (2) urine testing for non-specific reasons in older women, and (3) overtreatment of diabetes in older adults. All eligible primary care clinics from a large regional health system were randomized using a modified constrained randomization process and their attributed clinicians were included. Clinicians were recruited to complete a survey and educational module. We randomized 60 primary care clinics with 374 primary care clinicians and achieved adequate balance between the study arms for prespecified constrained variables. Baseline annual overuse rates for the three co-primary outcomes were 25%, 23%, and 17% for the PSA, urine, and diabetes measures, respectively. DISCUSSION: This trial is evaluating behavioral-economics-informed EHR-embedded interventions to reduce overuse of specific tests and treatments for older adults. The study will evaluate the effectiveness and safety of these interventions.

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

Background Opioid-related morbidity and mortality has increased during the COVID-19 pandemic, yet specific information about the communities most affected remains unknown. Our objective is to evaluate decedent-level associations with an opioid-related death following the implementation of stay-at-home orders in Los Angeles County. Methods This retrospective cohort study used data from the L.A. County Medical Examiner-Coroner to identify opioid-related deaths in 2019 and 2020. We used logistic regression to analyze the change in opioid-related deaths following a 30-day washout period after the start of stay-at-home orders. Independent variables included decedent age, gender, race and ethnicity, heroin or fentanyl present at the time of death, census tract-level education, and a scheduled drug prescription in the year before death. Results Opioid-related deaths in L.A. County are most common in census tracts where a small percentage of the population has a Bachelor’s degree. Following stay-at-home orders, Non-Hispanic Caucasian individuals had significantly more opioid-related deaths than Hispanic individuals (risk ratio (RR): 1.82 [95 % CI, 1.10–3.02]; P < 0.05) after adjusting for age, gender, and heroin or fentanyl use. Racial and ethnic differences in mortality were not explained by census tract-level education or recent scheduled drug prescriptions. Discussion There has been an alarming rise in opioid-related deaths in L.A. County during 2020. The increase in opioid-related overdose deaths following the onset of COVID-19 and related policies occurred most often among Non-Hispanic Caucasian individuals. Further research on this trend's underlying cause is needed to inform policy recommendations during these simultaneous public health crises.

We present a theoretical model of Rabin’s famous calibration paradox that resolves confusions in the literature and that makes it possible to identify the causes of the paradox. Using suitable experimental stimuli, we show that the paradox truly violates expected utility and that it is caused by reference dependence. Rabin already showed that utility curvature alone cannot explain his paradox. We, more strongly, do not find any contribution of utility curvature to the explanation of the paradox. We find no contribution of probability weighting either. We conclude that Rabin’s paradox underscores the importance of reference dependence.

Feedback reduces opioid prescriptions Most people addicted to opioids began taking them because they were legally prescribed. Little attention has been paid to changing physicians' prescribing behavior. Using a randomized controlled trial format, Doctor et al. monitored the effect of notifying physicians who had a patient die of opioid overdose within 12 months of a prescription. The physicians received an injunction to prescribe safely from their county's medical examiner. This intervention led to reductions in high-intensity prescribing, reductions in the likelihood that an opioid-naïve patient received a prescription, and a reduction in overall cumulative opioid intake. Science , this issue p. 588

Background Effective prevention of HPV is possible, but < 50% of adolescents in the Midwest complete the recommended vaccine series. Strategies to increase HPV vaccination rates have demonstrated efficacy, however widespread implementation of these interventions has not been realized. Behavioral nudges have demonstrated efficacy in increasing uptake of desired heath behaviors among providers (e.g. hand hygiene, judicious antibiotic prescribing). This trial assessed the impact of an assessment and feedback, communication training, and behavioral nudge (i.e. poster-sized vaccine commitment statements) intervention (T3) on adolescent vaccination rates and parental satisfaction at four Midwestern pediatric practices. Methods Practices were randomly assigned to receive either 1) assessment and feedback or 2) T3 intervention. Providers (n=16) completed surveys regarding vaccine polices and parents of vaccine eligible adolescents (n=230) reported their child’s vaccine history and satisfaction with the consultation. Practice- level vaccination rates for Tdap, Meningococcal, and HPV were calculated through billing data queries from an integrated pediatric health network. Vaccination rates and provider/ parental responses were compared by intervention arm. Results All practices evidenced increased adolescent vaccine rates, ranging from 0.8% to 3.4% for Meningococcal and 1.3% to 12.1% for Tdap. Three of the four practices had increased HPV vaccination rates (1% to 10%), however there was no statistically significant difference by study arm. Most parents (M age 41.34; SD 8.05; 85% female, 68% White) indicated their child had previously initiated the HPV vaccine series (61%) and 72% indicated receipt of an HPV vaccine during the study visit. Concerns among HPV vaccine hesitant parents (n=60) included concerns about vaccine safety and necessity. Most (97%) of parents were satisfied with their consultation. Conclusion Practices in both intervention groups evidenced an increase in adolescent vaccination rates. While some parents had concerns about HPV vaccine safety and necessity, parents welcomed discussions about HPV vaccine and were satisfied with their provider’s communication regardless of their vaccine decisions. Disclosures Brian R. Lee, MPH, PhD, Merck (Grant/Research Support)

Subtle implementation details can greatly influence the effectiveness of behavioural nudges because of their inherent subjective and social nature, argue Craig Fox and colleagues