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Background: Prior studies on disparities in postoperative opioid prescribing have focused primarily on in-hospital opioid administration or long-term opioid use, with fewer studies examining discharge opioid prescribing for adults, and no studies looking across different surgical subspecialties or service lines. We sought to examine racial and ethnic disparities in postoperative opioid prescribing to test the hypothesis that racial and ethnic minority groups receive opioid prescriptions at postoperative discharge with lower morphine milligram equivalents (MME) than non-Hispanic whites (NHW). Methods: We utilized electronic health records (EHR) data across 24 hospitals from a healthcare delivery system in northern California from January 1, 2015 to February 2, 2020 (study period). The sample included adult patients undergoing a procedure during the study period, discharged to home with an opioid prescription. Cross-sectional, secondary data analyses were conducted to examine differences by race and ethnicity in opioid prescribing, measured as MME, among patients who underwent select, but commonly performed, surgical procedures. Linear regression models included adjustment for factors that would likely influence prescribing decisions and race and ethnicity-specific propensity weights. Opioid prescribing, overall and by race and ethnicity, was also compared to postoperative opioid guidelines. Results: Among 61,564 patients, on adjusted regression analysis, non-Hispanic Black (NHB) patients received prescriptions with higher mean MME than NHW patients (+6.4% [95% confidence interval: 4.4%, 8.3%]), whereas Hispanic and non-Hispanic Asian patients received lower mean MME (-4.2% [-5.1%, -3.2%] and -3.6% [-4.8%, -2.3%], respectively). Nevertheless, 72.8% of all patients received prescriptions above guidelines, ranging from 71.0% to 80.3% by race and ethnicity. Disparities in prescribing were eliminated among Hispanic and NHB patients versus NHW patients when prescriptions were written within guideline recommendations. Conclusions: Racial and ethnic disparities in opioid prescribing exist in the postoperative setting, yet all groups received prescriptions above guideline recommendations. Policies encouraging guideline-based postoperative prescribing can reduce disparities and overall excess prescribing.

IntroductionSurgical patients are commonly prescribed more opioids at discharge than needed to manage their postoperative pain. These excess opioids increase the risks of new persistent opioid use, opioid-induced ventilatory impairment and opioid diversion. This study tests the effectiveness of two behavioural nudges, one based on peer behaviour and one based on best practice guidelines, in reducing excessive postoperative opioid prescriptions.Methods and analysisThe study will be conducted at 19 hospitals within a large healthcare delivery system in northern California, USA. Three surgical specialties (general surgery, orthopaedic surgery and obstetric/gynaecological surgery) at each hospital will be randomised either to a control group or to one of two active intervention arms. One intervention is grounded in the theory of injunctive norms, and provides feedback to surgeons on their postoperative opioid prescribing relative to prescribing guidelines endorsed by their institution. The other intervention draws from the theory of descriptive norms, and provides feedback similar to the first intervention but using peers’ behaviour rather than guidelines as the benchmark for the surgeon’s prescribing behaviour. The interventions will be delivered by a monthly email. Both interventions will be active for twelve months. The effects of each intervention relative to the control group and to each other will be tested using a four-level hierarchical model adjusted for multiple hypothesis testing.Ethics and disseminationUsing behavioural nudges rather than rigid policy changes allows us to target excessive prescribing without preventing clinicians from using their clinical judgement to address patient pain. All study activities have been approved by the RAND Human Subjects Protection Committee (ID 2018-0988). Findings will be disseminated through conference presentations, peer-reviewed publications and social media accounts.Trial registration numberNCT05070338.

This study examines the impact of grade retention on behavioral outcomes under a comprehensive assessment-based student promotion policy in New York City. To isolate the causal effect of grade rete...

Key Points Question Was the implementation of mandatory consultation with a prescription drug monitoring program (PDMP) that integrates electronic health record (EHR) alerts associated with changes in the postoperative quantity of opioid medications prescribed at discharge after general, obstetric and gynecologic, and orthopedic surgery? Findings In this cross-sectional study of 93 760 adult patients within a large health care system who received a postoperative prescription for an opioid medication, implementation of mandatory PDMP consultation with EHR-based alerts was associated with significant decreases in postoperative opioid prescription quantities during the quarter in which the mandate was implemented after accounting for preimplementation prescribing patterns. Meaning This study found that implementation of legislation mandating PDMP consultation and the use of EHR alerts may be associated with changes in postoperative opioid prescribing behavior and decreases in the excess number of opioid tablets in circulation., Importance Legislation mandating consultation with a prescription drug monitoring program (PDMP) was implemented in California on October 2, 2018. This mandate requires PDMP consultation before prescribing a controlled substance and integrates electronic health record (EHR)–based alerts; prescribers are exempt from the mandate if they prescribe no more than a 5-day postoperative opioid supply. Although previous studies have examined the consequences of mandated PDMP consultation, few have specifically analyzed changes in postoperative opioid prescribing after mandate implementation. Objective To examine whether the implementation of mandatory PDMP consultation with concurrent EHR-based alerts was associated with changes in postoperative opioid quantities prescribed at discharge. Design, Setting, and Participants This cross-sectional study performed an interrupted time series analysis of opioid prescribing patterns within a large health care system (Sutter Health) in northern California between January 1, 2015, and February 1, 2020. A total of 93 760 adult patients who received an opioid prescription at discharge after undergoing general, obstetric and gynecologic (obstetric/gynecologic), or orthopedic surgery were included. Exposures Mandatory PDMP consultation before opioid prescribing, with concurrent integration of an EHR alert. Prescribers are exempt from this mandate if prescribing no more than a 5-day opioid supply postoperatively. Main Outcomes and Measures The primary outcome was the total quantity of opioid medications (morphine milligram equivalents [MMEs] and number of opioid tablets) prescribed at discharge before and after implementation of the PDMP mandate, with separate analyses by surgical specialty (general, obstetric/gynecologic, and orthopedic) and most common surgical procedure within each specialty (laparoscopic cholecystectomy, cesarean delivery, and knee arthroscopy). The secondary outcome was the proportion of prescriptions with a duration of longer than 5 days. Results Of 93 760 patients (mean [SD] age, 46.7 [17.6] years; 67.9% female) who received an opioid prescription at discharge, 65 911 received prescriptions before PDMP mandate implementation, and 27 849 received prescriptions after implementation. Most patients received general or obstetric/gynecologic surgery (48.6% and 30.1%, respectively), did not have diabetes (90.3%), and had never smoked (66.0%). Before the PDMP mandate was implemented, a decreasing pattern in opioid prescribing quantities was already occurring. During the quarter of implementation, total MMEs prescribed at discharge further decreased for all 3 surgical specialties (eg, medians for general surgery: β = −10.00 [95% CI, −19.52 to −0.48]; obstetric/gynecologic surgery: β = −18.65 [95% CI, −22.00 to −15.30]; and orthopedic surgery: β = −30.59 [95% CI, −40.19 to −21.00]) after adjusting for the preimplementation prescribing pattern. The total number of tablets prescribed also decreased across specialties (eg, medians for general surgery: β = −3.02 [95% CI, −3.47 to −2.57]; obstetric/gynecologic surgery: β = −4.86 [95% CI, −5.38 to −4.34]; and orthopedic surgery: β = −4.06 [95% CI, −5.07 to −3.04]) compared with the quarters before implementation. These reductions were not consistent across the most common surgical procedures. For cesarean delivery, the median number of tablets prescribed decreased during the quarter of implementation (β = −10.00; 95% CI, −10.10 to −9.90), but median MMEs did not (β = 0; 95% CI, −9.97 to 9.97), whereas decreases were observed in both median MMEs and number of tablets prescribed (MMEs: β = −33.33 [95% CI, −38.48 to −28.19]; tablets: β = −10.00 [95% CI, −11.17 to −8.82]) for laparoscopic cholecystectomy. For knee arthroscopy, no decreases were found in either median MMEs or number of tablets prescribed (MMEs: β = 10.00 [95% CI, −22.33 to 42.33; tablets: β = 0.83; 95% CI, −3.39 to 5.05). The proportion of prescriptions written for longer than 5 days also decreased significantly during the quarter of implementation across all 3 surgical specialties. Conclusions and Relevance In this cross-sectional study, the implementation of mandatory PDMP consultation with a concurrent EHR-based alert was associated with an immediate decrease in opioid prescribing across the 3 surgical specialties. These findings might be explained by prescribers’ attempts to meet the mandate exemption and bypass PDMP consultation rather than the PDMP consultation itself. Although policies coupled with EHR alerts may be associated with changes in postoperative opioid prescribing behavior, they need to be well designed to optimize evidence-based opioid prescribing., This cross-sectional study examines whether the implementation of mandated consultation with a prescription drug monitoring program was associated with changes in the quantity of postoperative opioid medications prescribed at discharge among adult patients in a health care system in California.

A study examining the long-term causal effects of student retention in grades 3 through 8 found no evidence of systematic effects on attendance and suspensions. Retention in earlier grades was less likely to produce disadvantageous outcomes.

In the past decade, there has been a proliferation of community- and school-based college readiness programs designed to increase the participation of students who have traditionally been underrepresented in higher education. However, few of these college readiness programs have been empirically evaluated. This study examines the impact of one such intervention, the College Bound, St. Louis (CB) program. Using propensity weighting and doubly robust modeling, we found CB participants were more likely to reach proficiency on the End of Course exams, to obtain at least a B grade in a number of foundational college courses, to take more AP or honors courses, and to attend a 4-year postsecondary institution than similarly situated non-participants. Future directions for evaluating similar college readiness programs are discussed.

This article examines the impacts of summer instruction and test-based grade retention in New York City. We use a research design that exploits test score cutoffs used in assignment to these treatments. We find modest positive effects of summer instruction on English language arts (ELA) achievement for students assigned to summer instruction because of poor ELA performance but find little evidence of positive effects of summer instruction on math outcomes. After netting out estimates of differential test score growth within grades across years, the estimated effects of grade retention are substantial and positive through seventh grade on both math and ELA outcomes, suggesting that the additional year of instruction in fifth grade leads to improvements in subsequent grade achievement.

There is an increasing interest in using longitudinal measures of student achievement to estimate individual teacher effects. Current multivariate models assume each teacher has a single effect on student outcomes that persists undiminished to all future test administrations (complete persistence [CP]) or can diminish with time but remains perfectly correlated (variable persistence [VP]). However, when state assessments do not use a vertical scale or the evolution of the mix of topics present across a sequence of vertically aligned assessments changes as students advance in school, these assumptions of persistence may not be consistent with the achievement data. We develop the “generalized persistence” (GP) model, a Bayesian multivariate model for estimating teacher effects that accommodates longitudinal data that are not vertically scaled by allowing less than perfect correlation of a teacher’s effects across test administrations. We illustrate the model using mathematics assessment data.

When constructed response test items are scored by more than one rater, the repeated ratings allow for the consideration of individual rater bias and variability in estimating student proficiency. Several hierarchical models based on item response theory have been introduced to model such effects. In this article, the authors demonstrate how these models may be extended to include covariates of the rating process. For example, how do features of an essay grader’s training affect his or her performance? The authors show how to include covariates by embedding a linear model at appropriate levels of the model hierarchy. Depending on the level, such covariates may be thought of as determining fixed effects or random effects on the rating process. The authors also discuss the appropriate design matrix for such covariates, discuss how to incorporate needed identifiability constraints, and illustrate the methods using data from a rating study of a student assessment.

There is increased interest in value-added models relying on longitudinal student-level test score data to isolate teachers’ contributions to student achievement. The complex linkage of students to...

RAND researchers conducted a three-year study of New York City's promotion policy, using interviews, case studies, student surveys, and demographic and test score data to determine its effects on the outcomes of 5th-grade students held to the policy.

This research brief summarizes the results of a 2006 pilot survey of military retirees, providing information on retirees' enrollment in civilian health care plans and reliance on TRICARE, the Department of Defense-sponsored health insurance.