A pragmatic parallel arm randomized-controlled trial of a multi-pronged electronic health record-based clinical decision support tool protocol to reduce low-value antipsychotic prescriptions among older adults with Alzheimer's and related dementias.

Among patients with Alzheimer's disease and its related dementias (ADRD) with behavioral disturbances, antipsychotic prescriptions have limited efficacy and increase the risk of death. Yet, physicians continue to routinely prescribe low-value antipsychotic medications for behavioral disturbances among patients with ADRD. We designed a pragmatic randomized-controlled trial to measure the impact of a behavioral economic electronic health record (EHR) clinical decision support (CDS) intervention to reduce physician prescriptions of new antipsychotic medications among patients with ADRD. Utilizing a pragmatic parallel arm randomized-controlled trial design, the study will randomize eligible physicians from a large academic health system to either receive a EHR CDS intervention or not (control) when they prescribe a new antipsychotic medication during visits with patients with ADRD. The intervention will include three components: 1) alerts prescribers that antipsychotic prescriptions increase mortality risk (motivating physicians' intrinsic desire for non-malfeasance); 2) offers non-pharmacological behavioral resources for caregivers; 3) auto-defaults the prescription to contain the lowest dose and number of pill-days (n = 30) without refills if the prescriber does not cancel the order (appealing to default bias). Over 1 year, we will compare the cumulative total of new antipsychotic pill-days prescribed (primary outcome) by physicians in the intervention group versus in the control group. The study protocol meets international SPIRIT guidelines. Behavioral economics, or the study of human behavior as a function of more than rational incentives, considering a whole host of cognitive and social psychological preferences, tendencies, and biases, is increasingly recognized as an important conceptual framework to improve physician behavior. This pragmatic trial is among the first to combine two distinct behavioral economic principles, a desire for non-malfeasance and default bias, to improve physician prescribing patterns for patients with ADRD. We anticipate this trial will substantially advance understanding of how behavioral-economic informed EHR CDS tools can potentially reduce harmful, low-value care among patients with ADRD.

Cohort design to assess the association between post-hospital primary care physician follow-up visits and hospital readmissions.

While multifaceted post-hospitalization interventions can succeed in preventing hospital readmissions, many of these interventions are labor-intensive and costly. We hypothesized that a timely post-discharge primary care physician (PCP) visit alone might prevent hospital readmission. We conducted a retrospective cohort study to assess whether post-hospitalization PCP visits within 14 days of discharge were associated with lower rates of 30-day hospital readmission. In a secondary analysis we also assessed: whether visits with a PCP at 7-days post-discharge changed rates of hospital readmissions and whether post-hospitalization PCP visits were associated with decreased 90-day hospital readmissions. We included all adults with a PCP who were discharged from an inpatient medical service in a large, urban integrated academic health system from January 1, 2019 to September 9, 2019 in our analysis. We performed unadjusted bivariate analyses to measure the associations between having a PCP visit within 14 and 7 days of discharge and hospital readmission within 30 and 90 days. Then we constructed multivariate logistic regression models including patient medical and utilization characteristics to estimate the adjusted odds of a patient with a post-hospitalization PCP visit experiencing a 30-day hospital readmission (primary outcome) and 90-day readmission (secondary outcome). A total of 9236 patients were discharged; mean age was 57.9 years and 59.7% were female. Of the study population, 35.6% (n = 3284) and 24.1% (n = 2224) of patients had a post-hospitalization PCP visit within 14 days and or 7 days, respectively. Overall, 1259 (13.6%) and 2153 (23.3%) of discharged patients were readmitted at 30 and 90 days, respectively. In unadjusted analyses, having a post discharge PCP visit was not associated with decreased hospital readmission rates, but after adjusting for sociodemographic, medical and utilization characteristics, having a post-hospitalization PCP visit at 14 and 7 days was associated with lower hospital readmission rates at 30 days: 0.68 (95% CI 0.59-0.79) and 0.76 (95% CI 0.66-0.89), respectively; and 90 days: 0.76 (95% CI 0.68-0.85) and 0.80 (95% CI 0.70-0.91), respectively. In this large integrated urban academic health system, having a post-hospitalization PCP visit within 14- and 7-days of hospital discharge was associated with lower rates of readmission at 30 and 90 days. Further studies should examine whether improving access to PCP visits post hospitalization reduces readmissions rates.

Protocol for pragmatic randomised trial: integrating electronic health record-based behavioural economic 'nudges' into the electronic health record to reduce preoperative testing for patients undergoing cataract surgery.

INTRODUCTION: Robust randomised trial data have shown that routine preoperative (pre-op) testing for cataract surgery patients is inappropriate. While guidelines have discouraged testing since 2002, cataract pre-op testing rates have remained unchanged since the 1990s. Given the challenges of reducing low-value care despite strong consensus around the evidence, innovative approaches are needed to promote high-value care. This trial evaluates the impact of an interdisciplinary electronic health record (EHR) intervention that is informed by behavioural economic theory. METHODS AND ANALYSIS: This pragmatic randomised trial is being conducted at UCLA Health between June 2021 and June 2022 with a 12-month follow-up period. We are randomising all UCLA Health physicians who perform pre-op visits during the study period to one of the three nudge arms or usual care. These three nudge alerts address (1) patient harm, (2) increased out-of-pocket costs for patients and (3) psychological harm to the patients related to pre-op testing. The nudges are triggered when a physician starts to order a pre-op test. We hypothesise that receipt of a nudge will be associated with reduced pre-op testing. The primary outcome will be the change in the percentage of patients undergoing pre-op testing at 12 months. Secondary outcomes will include the percentage of patients undergoing specific categories of pre-op tests (labs, EKGs, chest X-rays (CXRs)), the efficacy of each nudge, same-day surgery cancellations and cost savings. ETHICS AND DISSEMINATION: The study protocol was approved by the institutional review board of the University of California, Los Angeles as well as a nominated Data Safety Monitoring Board. If successful, we will have created a tool that can be disseminated rapidly to EHR vendors across the nation to reduce inappropriate testing for the most common low-risk surgical procedures in the country. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier: NCT04104256.

Racial Disparities in Potentially Avoidable Hospitalizations During the COVID-19 Pandemic.

INTRODUCTION: Potentially avoidable hospitalizations are disproportionately experienced by racial and ethnic minorities and expose these groups to unnecessary iatrogenic harm (including the risk of nosocomial COVID-19) and undue financial burden. In working toward an overarching goal of eliminating racial and ethnic health disparities, it is important to understand whether and to what extent potentially avoidable hospitalizations have changed by race and ethnicity during the COVID-19 pandemic. METHODS: This single-center pre-post study included patients admitted to any UCLA Health hospital for an ambulatory care-sensitive condition between March-August 2019 (prepandemic period) and March-August 2020 (postpandemic period). Investigators measured the change in the number of potentially avoidable hospitalizations (defined per the Agency for Healthcare Research and Quality guidelines) stratified by race and ethnicity and calculated the 95% CIs for these hospitalizations using a cluster bootstrap procedure. RESULTS: Between March 1, 2020 and August 31, 2020, 347 of 4,838 hospitalizations (7.2%) were potentially avoidable, compared with 557 of 6,248 (8.9%) during the same 6-month period in 2019. Potentially avoidable hospitalizations decreased by 50.3% (95% CI=41.2, 60.9) among non-Hispanic Whites but only by 8.0% (95% CI= -16.2, 39.9) among African Americans (50.3% vs 8.0%, p=0.015). CONCLUSIONS: Racial disparities in potentially avoidable hospitalizations increased during the COVID-19 pandemic at a large urban health system. Given that the prepandemic rates of potentially avoidable hospitalizations were already higher among racial and ethnic minorities, especially among African Americans, this finding should cause alarm and lead to further exploration of the complex factors contributing to these disparities.

Quality improvement time-saving intervention to increase use of a clinical decision support tool to reduce low-value diagnostic imaging in a safety net health system.

IMPORTANCE: Electronic health record (EHR) clinical decision support (CDS) tools can provide evidence-based feedback at the point of care to reduce low-value imaging. Success of these tools has been limited partly due to lack of engagement by busy clinicians. OBJECTIVE: Measure the impact of a time-saving quality improvement intervention to increase engagement with a CDS tool for low back pain imaging ordering. DESIGN, SETTING AND PARTICIPANTS: We conducted a quasi-experimental difference-in-differences analysis at (BLINDED), examining back pain imaging orders from 29 May 2015 to 07 January 2016. The intervention site was (BLINDED) Emergency Medicine/Urgent Care Center (n=5736) and control sites included all other (BLINDED) hospitals and clinics (n=1621). In May 2015, the Department of Health Services installed a CDS tool that triggered a survey when clinicians ordered an imaging test, generating an 'appropriateness score' based on the American College of Radiology guidelines. Clinicians often bypassed the tool, resulting in 'unscored' tests. INTERVENTION: To increase clinician engagement with the tool and decrease the rate of unscored imaging tests, a new policy was implemented at the intervention site on 15 August 2015. If clinicians completed the CDS survey and scored an appropriateness score >3, they could forego a previously mandatory telephone call for pre-imaging utilisation review with the radiology department. MAIN OUTCOMES AND MEASURES: We used EHR data to measure pre-post-intervention differences in: (1) percentage of unscored tests and (2) percentage of tests with high appropriateness scores (>7). RESULTS: Percentage of unscored tests decreased from 69.4% to 10.4% at the intervention site and from 50.6% to 34.8% at the control sites (between-group difference: -23.3%, p<0.001). Percentage of high scoring tests increased from 26.5% to 75.0% at the intervention site and from 17.2% to 22.7% at the control sites (between-group difference: 19%, p<0.001). CONCLUSION: Workflow time-saving interventions may increase physician engagement with CDS tools and have potential to improve practice patterns.

A Collaboration Among Primary Care-Based Clinical Pharmacists and Community-Based Health Coaches.

BACKGROUND/OBJECTIVES: Medication discrepancies and adverse drug events are common following hospital discharge. This study evaluates whether a collaboration between community-based health coaches and primary care-based pharmacists was associated with a reduction in inpatient utilization following hospitalization. DESIGN: Retrospective cohort study using propensity score matching. SETTING: Urban academic medical center and surrounding community. PARTICIPANTS: Intervention patients (n = 494) were adults aged 65 and older admitted to the University of California, Los Angeles (UCLA) Ronald Reagan Medical Center during the study period and who met study inclusion criteria. A matched-control group was composed of patients with similar demographic and clinical characteristics who were admitted to the study site during the study period but who received usual care (n = 2,470). A greedy algorithm approach was used to conduct the propensity score match. INTERVENTION: Following acute hospitalization, a health coach conducted a home visit and transmitted all medication-related information to a pharmacist based in a primary care practice. The pharmacist compared this information with the patient's electronic medical record medication list and consulted with the patient's primary care provider to optimize medication management. MEASUREMENTS: Thirty-day readmissions (primary outcome), 60- and 90-day readmissions, and 30-day emergency department (ED) visits (secondary outcomes) to UCLA Health. RESULTS: Among 494 patients who received the intervention, 307 (62.1%) were female with a mean age of 83.0 years (interquartile range [IQR] = 76-90 years). Among 2,470 matched-control patients, 1,541 (62.4%) were female with a mean age of 82.7 years (IQR = 74.9-89.5 years). For the propensity score match, standardized mean differences were below .1 for 23 of 25 variables, indicating good balance. Patients who received this intervention had a significantly lower predicted probability of being readmitted within 30 days compared with matched-control patients (10.6%; 95% confidence interval [CI] = 7.9-13.2) vs 21.4%; 95% CI = 19.8-23.0; P value < .001). CONCLUSION: A home visit conducted by a health coach combined with a medication review by a primary care-based pharmacist may prevent subsequent inpatient utilization.

The Affordable Care Act's Impacts on Access to Insurance and Health Care for Low-Income Populations.

The Patient Protection and Affordable Care Act (ACA) expands access to health insurance in the United States, and, to date, an estimated 20 million previously uninsured individuals have gained coverage. Understanding the law's impact on coverage, access, utilization, and health outcomes, especially among low-income populations, is critical to informing ongoing debates about its effectiveness and implementation. Early findings indicate that there have been significant reductions in the rate of uninsurance among the poor and among those who live in Medicaid expansion states. In addition, the law has been associated with increased health care access, affordability, and use of preventive and outpatient services among low-income populations, though impacts on inpatient utilization and health outcomes have been less conclusive. Although these early findings are generally consistent with past coverage expansions, continued monitoring of these domains is essential to understand the long-term impact of the law for underserved populations.

Public Funds Account for Over 70 Percent of Health Care Spending in California.

In California, personal health care expenditures are estimated to total more than $367 billion in 2016. Approximately 71 percent of these expenditures will be paid for with public funds (i.e., taxpayer dollars). This estimated contribution of public funds to health care expenditures is much higher than estimates that include only major health insurance programs such as Medicare and Medicaid. Several additional public funding sources also contribute to health care expenditures in the state, including government spending for public employee health benefits, tax subsidies for employer-sponsored insurance and the Affordable Care Act (ACA) insurance exchange, and county health care expenditures. As health care reform continues to take effect, it will be important to monitor the public versus private contributions to state health care expenditures to ensure that funds are being distributed both efficiently and equitably.

Cost analysis of immediate postabortal IUD insertion compared to planned IUD insertion at the time of abortion follow up.

BACKGROUND: Immediate postabortal intrauterine device (IUD) insertion decreases rates of repeat abortions. However, only one third of high-volume, non-hospital abortion providers in the United States offer immediate postabortal IUD placement. STUDY DESIGN: We conducted a cost analysis from a public payer perspective to evaluate the potential cost savings associated with a policy of immediate postabortal IUD insertion, compared to planned IUD insertion at the time of abortion follow up. Sensitivity analyses and Monte Carlo simulation were performed. RESULTS: Considering only direct costs of contraception and pregnancy-related care over 1 year, immediate postabortal IUD provision decreases public program expenditures by US$111 per woman compared to planned IUD placement at follow up. Over 5 years, the savings increases to $4296 per woman, when public health and social program costs are also considered. CONCLUSION: Immediate postabortal IUD insertion is cost saving from a public payer perspective, compared to planned insertion at the time of follow up. These savings are seen over a wide range of model inputs.

Mexico's northern border conflict: collateral damage to health and human rights of vulnerable groups.

OBJECTIVE: To compare distributions of human rights violations and disease risk; to juxtapose these patterns against demographic and structural environmental variables, and to formulate implications for structural interventions. METHODS: Female sex workers who inject drugs were surveyed in Tijuana and Ciudad Juarez, Mexico. Structured interviews and testing for sexually transmitted infections (STIs) were conducted (October 2008 to October 2009). Frequencies of individual and environmental factors, including police abuse, risk of HIV infection, and protective behaviors, were compared between sites using univariate logistic regression. RESULTS: Of 624 women, almost half reported police syringe confiscation despite syringes being legal; 55.6% reported extortion (past 6 months), with significantly higher proportions in Ciudad Juarez (P < 0.001). Reports of recent solicitation of sexual favors (28.5% in Tijuana, 36.5% in Ciudad Juarez, P = 0.04) and sexual abuse (15.7% in Tijuana, 18.3% in Ciudad Juarez) by police were commonplace. Prevalence of STIs was significantly lower in Tijuana than in Ciudad Juarez (64.2% and 83.4%, P < 0.001), paralleling the lower prevalence of sexual risk behaviors there. Ciudad Juarez respondents reported significantly higher median number of monthly clients (6.8 versus 1.5, P < 0.001) and lower median pay per sex act (US$ 10 versus US$ 20, P < 0.001) (in the past month). Relative to Tijuana, security deployment, especially the army's presence, was perceived to have increased more in Ciudad Juarez in the past year (72.1% versus 59.2%, P = 0.001). CONCLUSIONS: Collateral damage from police practices in the context of Mexico's drug conflict may affect public health in the Northern Border Region. Itinerant officers may facilitate disease spread beyond the region. The urgency for mounting structural interventions is discussed.

Mexico’s northern border conflict: collateral damage to health and human rights of vulnerable groups / El conflicto en la frontera norte de México: daños colaterales a la salud y los derechos humanos en grupos vulnerables

Objective. To compare distributions of human rights violations and disease risk; to juxtaposethese patterns against demographic and structural environmental variables, and to formulateimplications for structural interventions.Methods. Female sex workers who inject drugs were surveyed in Tijuana and CiudadJuarez, Mexico. Structured interviews and testing for sexually transmitted infections (STIs)were conducted (October 2008 to October 2009). Frequencies of individual and environmentalfactors, including police abuse, risk of HIV infection, and protective behaviors, were comparedbetween sites using univariate logistic regression.Results. Of 624 women, almost half reported police syringe confiscation despite syringesbeing legal; 55.6% reported extortion (past 6 months), with significantly higher proportions inCiudad Juarez (P < 0.001). Reports of recent solicitation of sexual favors (28.5% in Tijuana,36.5% in Ciudad Juarez, P = 0.04) and sexual abuse (15.7% in Tijuana, 18.3% in CiudadJuarez) by police were commonplace. Prevalence of STIs was significantly lower in Tijuanathan in Ciudad Juarez (64.2% and 83.4%, P < 0.001), paralleling the lower prevalence ofsexual risk behaviors there. Ciudad Juarez respondents reported significantly higher mediannumber of monthly clients (6.8 versus 1.5, P < 0.001) and lower median pay per sex act(US$ 10 versus US$ 20, P < 0.001) (in the past month). Relative to Tijuana, security deployment,especially the army’s presence, was perceived to have increased more in Ciudad Juarezin the past year (72.1% versus 59.2%, P = 0.001).Conclusions. Collateral damage from police practices in the context of Mexico’s drug conflictmay affect public health in the Northern Border Region. Itinerant officers may facilitate diseasespread beyond the region. The urgency for mounting structural interventions is discussed.

Objetivo. Comparar las distribuciones de las violaciones a los derechos humanos yel riesgo de enfermedades; yuxtaponer los patrones obtenidos con las variables demográficasy estructurales del entorno, y formular las implicaciones de llevar a cabointervenciones estructurales.Métodos. Se entrevistaron trabajadoras del sexo que consumían drogas inyectablesen Tijuana y Ciudad Juárez, México. Entre octubre del 2008 y octubre del 2009 sellevaron a cabo entrevistas estructuradas y pruebas para detectar infecciones de transmisiónsexual (ITS). Se compararon entre las dos ciudades las frecuencias de factoresindividuales y ambientales, como el abuso policial, el riesgo de infección por el VIH ylas conductas protectoras, usando regresión logística de una sola variable.Resultados. De 624 mujeres, casi la mitad comunicaron la confiscación de jeringaspor la policía a pesar de que es legal poseerlas; 55,6% informaron extorsión (en losúltimos 6 meses), con proporciones significativamente mayores en Ciudad Juárez(P < 0,001). Los informes de solicitación reciente de favores sexuales (28,5% en Tijuana,36,5% en Ciudad Juárez, P = 0,04) y de abuso sexual (15,7% en Tijuana, 18,3%en Ciudad Juárez) por la policía fueron comunes. La prevalencia de ITS fue significativamentemenor en Tijuana que en Ciudad Juárez (64,2% y 83,4%, P < 0,001), en formaanáloga a la menor prevalencia de conductas sexuales de riesgo en la primera ciudad.Las mujeres entrevistadas en Ciudad Juárez informaron una mediana del número declientes mensual significativamente mayor (6,8 frente a 1,5, P < 0,001) y una medianadel pago por acto sexual menor (US$ 10 frente a US$ 20, P < 0,001) en el último mes.En el último año, las mujeres entrevistadas percibieron un mayor aumento del desplieguede seguridad, especialmente la presencia del ejército, en Ciudad Juárez queen Tijuana (72,1% frente a 59,2%, P = 0,001).Conclusiones. Los daños colaterales derivados de las prácticas policiales en el contextodel conflicto de narcotráfico de México pueden afectar a la salud pública enla región de la frontera norte de México. Los oficiales itinerantes pueden facilitar lapropagación de enfermedades más allá de la región. Se analiza la urgencia para establecerintervenciones estructurales.