Use and Outcomes of Dexamethasone in the Management of Malignant Small Bowel Obstruction.

Objective: To describe rates of dexamethasone use in the nonoperative management of malignant small bowel obstruction (mSBO) and their outcomes. Background: mSBO is common in patients with advanced abdominal-pelvic cancers. Management includes prioritizing quality of life and avoiding surgical intervention when possible. The use of dexamethasone to restore bowel function is recommended in the National Comprehensive Cancer Network guidelines for mSBO. Yet, it is unknown how often dexamethasone is used for mSBO and whether results from nonresearch settings support its use. Methods: This is a multicenter retrospective cohort study including unique admissions for mSBO from January 1, 2019 to December 31, 2021. Dexamethasone use and management outcomes were summarized with descriptive statistics and multiple logistic regression. Results: Among 571 admissions (68% female, mean age 63 years, 85% history of abdominal surgery) that were eligible and initially nonoperative, 26% [95% confidence interval (CI) = 23%-30%] received dexamethasone treatment (69% female, mean age 62 years, 87% history of abdominal surgery). Dexamethasone use by site ranged from 13% to 52%. Among dexamethasone recipients, 13% (95% CI = 9%-20%) subsequently required nonelective surgery during the same admission and 4 dexamethasone-related safety-events were reported. Amongst 421 eligible admissions where dexamethasone was not used, 17% (95% CI = 14%-21%) required nonelective surgery. Overall, the unadjusted odds ratio (OR) for nonelective surgery with dexamethasone use compared to without its use was 0.7 (95% CI = 0.4-1.3). Using multiple logistic regression, OR after adjusting for site, age, sex, history of abdominal surgery, nasogastric tube, and Gastrografin use was 0.6 (95% CI = 0.3-1.1). Conclusion: Dexamethasone was used in about 1 in 4 eligible mSBO admissions with high variability of use between tertiary academic centers. This multicenter retrospective cohort study suggested an association between dexamethasone use and lower rates of nonelective surgery, representing a potential opportunity for quality improvement.

Similarities and Differences Between Pragmatic Trials and Hybrid Effectiveness-Implementation Trials.

Pragmatism in clinical trials is focused on increasing the generalizability of research findings for routine clinical care settings. Hybridism in clinical trials (i.e., assessing both clinical effectiveness and implementation success) is focused on speeding up the process by which evidence-based practices are developed and adopted into routine clinical care. Even though pragmatic trial methodologies and implementation science evolved from very different disciplines, Pragmatic Trials and Hybrid Effectiveness-Implementation Trials share many similar design features. In fact, these types of trials can easily be conflated, creating the potential for investigators to mislabel their trial type or mistakenly use the wrong trial type to answer their research question. Blurred boundaries between trial types can hamper the evaluation of grant applications, the scientific interpretation of findings, and policy-making. Acknowledging that most trials are not pure Pragmatic Trials nor pure Hybrid Effectiveness-Implementation Trials, there are key differences in these trial types and they answer very different research questions. The purpose of this paper is to clarify the similarities and differences of these trial types for funders, researchers, and policy-makers. In addition, recommendations are offered to help investigators choose, label, and operationalize the most appropriate trial type to answer their research question. These recommendations complement existing reporting guidelines for clinical effectiveness trials (TIDieR) and implementation trials (StaRI).

Operative vs Nonoperative Management of Acute Cholecystitis During the Different Trimesters of Pregnancy.

Importance: Acute cholecystitis (AC) management during pregnancy requires balancing the risk of pregnancy loss or preterm delivery (adverse pregnancy outcomes [APOs]) with or without surgery. Guidelines recommend cholecystectomy across trimesters; however, trimester-specific evidence on the risks of AC and its management is lacking. Objective: To assess cholecystectomy frequency in pregnant people with AC, compare the rates of APOs in pregnant people with or without AC, and compare the rates of APOs in people with AC who did or did not undergo cholecystectomy. Design, Setting, and Participants: This retrospective, population-based cohort study used data for pregnant people with AC from the IBM MarketScan Commercial Claims and Encounters Database from January 1, 2007, to December 31, 2019, and a propensity score-matched cohort of pregnant people without AC. Trimester status (first [T1], second [T2], and third [T3]), APOs, and cholecystectomy were defined by administrative claims. Data were analyzed from October 2021 to July 2022. Exposures: Pregnant patients with or without AC. Pregnant patients with AC who did or did not receive cholecystectomy. Main Outcomes and Measures: The main outcomes were cholecystectomy during pregnancy and APOs (ie, preterm delivery and pregnancy loss). Pregnant patients with and without AC were compared to assess the association of AC with risk of APOs. Propensity score inverse-probability weighting was used to calculate treatment-associated APO risk among patients with 1-year follow-up. Results: The study included 5759 pregnant patients with AC (mean [SD] age, 30.1 [6.6] years) and 23 036 controls (mean [SD] age, 29.9 [6.7] years) after propensity score matching. Among 3426 pregnant patients with AC and 1-year follow-up, 1182 (34.5%) underwent cholecystectomy during the pregnancy (684 [41.7%] presenting with AC in T1, 404 [40.4%] in T2, and 94 [12.0%] in T3). Acute cholecystitis during pregnancy, irrespective of treatment, was associated with higher odds of APO compared with no AC during pregnancy across all trimesters (odds ratio [OR], 1.69 [95% CI, 1.54-1.85]). Compared with nonoperative management, receipt of surgery was associated with lower odds of APOs across all trimesters (OR, 0.75 [95% CI, 0.63-0.87]), in T1 (OR, 0.81 [95% CI, 0.66-1.00]), in T2 (OR, 0.71 [95% CI, 0.50-1.00]), and in T3 (OR, 0.45 [95% CI, 0.28-0.70]). Conclusions and Relevance: In this study, cholecystectomy was associated with lower risk of APO in patients with AC across all trimesters, with the greatest benefit in T3. However, only 34.5% overall and 12.0% of patients in T3 had a cholecystectomy. These findings support guidelines recommending cholecystectomy during pregnancy and should inform decision-making discussions. Greater guideline adherence and surgery use, especially in T3, may represent an opportunity to improve outcomes for pregnant people with AC.

Factors associated with lung cancer risk factor documentation.

Objectives: To identify factors associated with the minimum necessary information to determine an individual's eligibility for lung cancer screening (ie, sufficient risk factor documentation) and to characterize clinic-level variability in documentation. Study Design: Cross-sectional observational study using electronic health record data from an academic health system in 2019. Methods: We calculated the relative risk of sufficient lung cancer risk factor documentation by patient-, provider-, and system-level variables using Poisson regression models, clustering by clinic. We compared unadjusted, risk-adjusted, and reliability-adjusted proportions of patients with sufficient smoking documentation across 31 clinics using logistic regression models and 2-level hierarchical logit models to estimate reliability-adjusted proportions across clinics. Results: Among 20,632 individuals, 60% had sufficient risk factor documentation to determine screening eligibility. Patient-level factors inversely associated with risk factor documentation included Black race (relative risk [RR], 0.70; 95% CI, 0.60-0.81), non-English preferred language (RR, 0.60; 95% CI, 0.49-0.74), Medicaid insurance (RR, 0.64; 95% CI, 0.57-0.71), and nonactivated patient portal (RR, 0.85; 95% CI, 0.80-0.90). Documentation varied across clinics. The reliability-adjusted intraclass correlation coefficient decreased from 11.0% (95% CI, 6.9%-17.1%) to 5.3% (95% CI, 3.2%-8.6%), adjusting for covariates. Conclusions: We found a low rate of sufficient lung cancer risk factor documentation and associations of risk factor documentation based on patient-level factors such as race, insurance status, language, and patient portal activation. Risk factor documentation rates varied across clinics, and only approximately half the variation was explained by factors in our analysis.

Factors associated with recurrent appendicitis after successful treatment with antibiotics.

BACKGROUND: As more patients with appendicitis are treated with antibiotics, factors associated with recurrence may help inform individualized prognostication and decision-making. METHODS: This cohort study, using data from the Comparison of Outcomes of Antibiotic Drugs and Appendectomy trial, examined patients treated with antibiotics who did not undergo appendicectomy in the first 30 days. Patients who had appendicectomy between 30 days and 1 year were compared with those who did not. Marginalized logistic regression models were used to calculate adjusted risk differences (RDs) to estimate the association between baseline patient factors and the risk of undergoing an appendicectomy between 30 days and 1 year. RESULTS: Of 601 patients treated with antibiotics who did not undergo appendicectomy within 30 days (mean age 38.0 years; 217 women (36.1 per cent)), 144 had an appendicectomy and 56 were lost to follow-up between 30 days and 1 year. The estimated rate of appendicectomy between 30 days and 1 year was 28.6 (95 per cent c.i. 25.0 to 32.8) per cent. After adjustment for other factors, nausea, vomiting, or anorexia at baseline presentation was associated with an increased rate of appendicectomy between 30 days and 1 year (adjusted RD 17.52, 95 per cent c.i. 8.64 to 26.40). The presence of an appendicolith (adjusted RD 3.64, -6.08 to 13.36), or an abscess, perforation, or fat stranding on initial imaging (adjusted RD -7.23, -17.41 to 2.95) was not strongly associated with appendicectomy between 30 days and 1 year. CONCLUSION: Most factors commonly associated with appendicitis severity were not strongly associated with an increased risk of undergoing appendicectomy in the longer term after treatment with antibiotics.

Diverticulitis is a population health problem: Lessons and gaps in strategies to implement and improve contemporary care.

The disease burden of diverticulitis is high across inpatient and outpatient settings, and the prevalence of diverticulitis has increased. Historically, patients with acute diverticulitis were admitted routinely for intravenous antibiotics and many had urgent surgery with colostomy or elective surgery after only a few episodes. Several recent studies have challenged the standards of how acute and recurrent diverticulitis are managed, and many clinical practice guidelines (CPGs) have pivoted to recommend outpatient management and individualized decisions about surgery. Yet the rates of diverticulitis hospitalizations and operations are increasing in the United States, suggesting there is a disconnect from or delay in adoption of CPGs across the spectrum of diverticular disease. In this review, we propose approaching diverticulitis care from a population level to understand the gaps between contemporary studies and real-world practice and suggest strategies to implement and improve future care.

Two decades of surgical randomized controlled trials: worldwide trends in volume and methodological quality.

BACKGROUND: RCTs are essential in guiding clinical decision-making but are difficult to perform, especially in surgery. This review assessed the trend in volume and methodological quality of published surgical RCTs over two decades. METHODS: PubMed was searched systematically for surgical RCTs published in 1999, 2009, and 2019. The primary outcomes were volume of trials and RCTs with a low risk of bias. Secondary outcomes were clinical, geographical, and funding characteristics. RESULTS: Some 1188 surgical RCTs were identified, of which 300 were published in 1999, 450 in 2009, and 438 in 2019. The most common subspecialty in 2019 was gastrointestinal surgery (50.7 per cent). The volume of surgical RCTs increased mostly in Asia (61, 159, and 199 trials), especially in China (7, 40, and 81). In 2019, countries with the highest relative volume of published surgical RCTs were Finland and the Netherlands. Between 2009 and 2019, the proportion of RCTs with a low risk of bias increased from 14.7 to 22.1 per cent (P = 0.004). In 2019, the proportion of trials with a low risk of bias was highest in Europe (30.5 per cent), with the UK and the Netherlands as leaders in this respect. CONCLUSION: The volume of published surgical RCTs worldwide remained stable in the past decade but their methodological quality improved. Considerable geographical shifts were observed, with Asia and especially China leading in terms of volume. Individual European countries are leading in their relative volume and methodological quality of surgical RCTs.

An RCT is a form of research in which patients are divided randomly into two or more treatment groups to allow a fair and unbiased comparison of both treatments. RCTs are essential in guiding clinical decision-making, but are difficult to perform, especially in surgery. This review assessed the trend in volume and quality of published surgical RCTs over two decades. Surgical RCTs published in 1999, 2009, and 2019 were identified. The main outcome measures were volume of RCTs and trials with a low risk of bias. Different forms of bias can occur when research results are influenced by external factors. Some 1188 surgical RCTs were identified, of which 300 were published in 1999, 450 in 2009, and 438 in 2019. The volume of surgical RCTs published in these years increased mostly in Asia (61, 159, and 199 RCTs), especially in China (7, 40, and 81). In 2019, the countries with highest relative volume of published surgical RCTs were Finland and the Netherlands. Between 2009 and 2019, the proportion of RCTs with a low risk of bias increased from 14.7 to 22.1 per cent (P = 0.004). In 2019, the proportion of trials with a low risk of bias was highest in Europe (30.5 per cent), with the UK and the Netherlands as leaders in this respect. The volume of published surgical RCTs worldwide remained stable in the past decade but their methodological quality improved. Considerable geographical shifts were observed, with Asia and especially China leading in terms of volume. Individual European countries are leading in their relative volume and methodological quality of surgical RCTs.

Trial Participation and Outcomes Among English-Speaking and Spanish-Speaking Patients With Appendicitis Randomized to Antibiotics: A Secondary Analysis of the CODA Randomized Clinical Trial.

Importance: Spanish-speaking participants are underrepresented in clinical trials, limiting study generalizability and contributing to ongoing health inequity. The Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial intentionally included Spanish-speaking participants. Objective: To describe trial participation and compare clinical and patient-reported outcomes among Spanish-speaking and English-speaking participants with acute appendicitis randomized to antibiotics. Design, Setting, and Participants: This study is a secondary analysis of the CODA trial, a pragmatic randomized trial comparing antibiotic therapy with appendectomy in adult patients with imaging-confirmed appendicitis enrolled at 25 centers across the US from May 1, 2016, to February 28, 2020. The trial was conducted in English and Spanish. All 776 participants randomized to antibiotics are included in this analysis. The data were analyzed from November 15, 2021, through August 24, 2022. Intervention: Randomization to a 10-day course of antibiotics or appendectomy. Main Outcomes and Measures: Trial participation, European Quality of Life-5 Dimensions (EQ-5D) questionnaire scores (higher scores indicating a better health status), rate of appendectomy, treatment satisfaction, decisional regret, and days of work missed. Outcomes are also reported for a subset of participants that were recruited from the 5 sites with a large proportion of Spanish-speaking participants. Results: Among eligible patients 476 of 1050 Spanish speakers (45%) and 1076 of 3982 of English speakers (27%) consented, comprising the 1552 participants who underwent 1:1 randomization (mean age, 38.0 years; 976 male [63%]). Of the 776 participants randomized to antibiotics, 238 were Spanish speaking (31%). Among Spanish speakers randomized to antibiotics, the rate of appendectomy was 22% (95% CI, 17%-28%) at 30 days and 45% (95% CI, 38%-52%) at 1 year, while in English speakers, these rates were 20% (95% CI, 16%-23%) at 30 days and 42% (95% CI 38%-47%) at 1 year. Mean EQ-5D scores were 0.93 (95% CI, 0.92-0.95) among Spanish speakers and 0.92 (95% CI, 0.91-0.93) among English speakers. Symptom resolution at 30 days was reported by 68% (95% CI, 61%-74%) of Spanish speakers and 69% (95% CI, 64%-73%) of English speakers. Spanish speakers missed 6.69 (95% CI, 5.51-7.87) days of work on average, while English speakers missed 3.76 (95% CI, 3.20-4.32) days. Presentation to the emergency department or urgent care, hospitalization, treatment dissatisfaction, and decisional regret were low for both groups. Conclusions and Relevance: A high proportion of Spanish speakers participated in the CODA trial. Clinical and most patient-reported outcomes were similar for English- and Spanish-speaking participants treated with antibiotics. Spanish speakers reported more days of missed work. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Development and Feasibility Testing of a Decision Aid for Acute Appendicitis.

INTRODUCTION: Patients with acute uncomplicated appendicitis will be increasingly asked to choose between surgery and antibiotic management. We developed a novel decision aid for patients in the emergency department (ED) with acute appendicitis who are facing this choice. We describe the development of the decision aid and an initial feasibility study of its implementation in a busy tertiary care ED. MATERIALS AND METHODS: We conducted a prepost survey analysis comparing patients before and after standardized implementation of the decision aid. Patients were surveyed about their experience making treatment decisions after discharge from the hospital. The primary outcome measure was the total score on the decisional conflict scale (; 0-100; lower scores better). RESULTS: The study included 24 participants (12 in the predecision aid period; 12 in the post period). Only 33% of participants in each group knew antibiotics were a treatment option prior to arriving at the ED. Prior to implementing the use of decision aid, only 75% of patients reported being told antibiotics were a treatment option, while this increased to 100% after implementation of the decision aid. The mean total decisional conflict scalescores were similar in the pre and post periods (mean difference = 0.13, 95% CI: -13 - 13, P > 0.9). CONCLUSIONS: This novel appendicitis decision aid was effectively integrated into clinical practice and helped toinform patients about multiple treatment options. These data support further large-scale testing of the decision aid as part of standardized pathways for the management of patients with acute appendicitis.

Verbal Descriptions of the Probability of Treatment Complications Lead to High Variability in Risk Perceptions: A Survey Study.

OBJECTIVE: To assess whether different methods for communicating the probability of treatment complications for operative and nonoperative appendicitis treatments result in differences in risk perception. BACKGROUND: Surgeons must communicate the probability of treatment complications to patients, and how risks are communicated may impact the accuracy and variability in patient risk perceptions and ultimately their decision making. METHODS: A series of online surveys of American adults communicated the probability of complications associated with surgical or antibiotic treatment of acute appendicitis. Probability was communicated with verbal descriptors (eg, "uncommon"), point estimates (eg, "3% risk"), or risk ranges (eg, "1% to 5%"). Respondents then estimated the probability of a complication for a "typical patient with appendicitis." The Fligner-Killeen test of homogeneity of variance was used to compare the variability in respondent risk estimates based on the method of probability communication. RESULTS: Among 296 respondents, variance in probability estimates was significantly higher when verbal descriptions were used compared to point estimates ( P < 0.001) or risk ranges ( P < 0.001). Identical verbal descriptors produced meaningfully different risk estimates depending on the complication being described. For example, "common" was perceived as a 45.6% for surgical site infection but 61.7% for antibiotic-associated diarrhea. CONCLUSION: Verbal probability descriptors are associated with widely varying and inaccurate perceptions about treatment risks. Surgeons should consider alternative ways to communicate probability during informed consent and shared decision-making discussions.

Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis: A Randomized Clinical Trial with an Observational Cohort.

OBJECTIVE: To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days. SUMMARY BACKGROUND DATA: The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes. METHODS: We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations. RESULTS: The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret. CONCLUSIONS: Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02800785.

Association of Patient Belief About Success of Antibiotics for Appendicitis and Outcomes: A Secondary Analysis of the CODA Randomized Clinical Trial.

Importance: A patient's belief in the likely success of a treatment may influence outcomes, but this has been understudied in surgical trials. Objective: To examine the association between patients' baseline beliefs about the likelihood of treatment success with outcomes of antibiotics for appendicitis in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial. Design, Setting, and Participants: This was a secondary analysis of the CODA randomized clinical trial. Participants from 25 US medical centers were enrolled between May 3, 2016, and February 5, 2020. Included in the analysis were participants with appendicitis who were randomly assigned to receive antibiotics in the CODA trial. After informed consent but before randomization, participants who were assigned to receive antibiotics responded to a baseline survey including a question about how successful they believed antibiotics could be in treating their appendicitis. Interventions: Participants were categorized based on baseline survey responses into 1 of 3 belief groups: unsuccessful/unsure, intermediate, and completely successful. Main Outcomes and Measures: Three outcomes were assigned at 30 days: (1) appendectomy, (2) high decisional regret or dissatisfaction with treatment, and (3) persistent signs and symptoms (abdominal pain, tenderness, fever, or chills). Outcomes were compared across groups using adjusted risk differences (aRDs), with propensity score adjustment for sociodemographic and clinical factors. Results: Of the 776 study participants who were assigned antibiotic treatment in CODA, a total of 425 (mean [SD] age, 38.5 [13.6] years; 277 male [65%]) completed the baseline belief survey before knowing their treatment assignment. Baseline beliefs were as follows: 22% of participants (92 of 415) had an unsuccessful/unsure response, 51% (212 of 415) had an intermediate response, and 27% (111 of 415) had a completely successful response. Compared with the unsuccessful/unsure group, those who believed antibiotics could be completely successful had a 13-percentage point lower risk of appendectomy (aRD, -13.49; 95% CI, -24.57 to -2.40). The aRD between those with intermediate vs unsuccessful/unsure beliefs was -5.68 (95% CI, -16.57 to 5.20). Compared with the unsuccessful/unsure group, those with intermediate beliefs had a lower risk of persistent signs and symptoms (aRD, -15.72; 95% CI, -29.71 to -1.72), with directionally similar results for the completely successful group (aRD, -15.14; 95% CI, -30.56 to 0.28). Conclusions and Relevance: Positive patient beliefs about the likely success of antibiotics for appendicitis were associated with a lower risk of appendectomy and with resolution of signs and symptoms by 30 days. Pathways relating beliefs to outcomes and the potential modifiability of beliefs to improve outcomes merit further investigation. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Caveat emptor: The accuracy of claims data in appendicitis research.

BACKGROUND: International Classification of Disease, ninth/tenth revision codes are used to identify patients with appendicitis and classify severity of disease for research and hospital reimbursement. We sought to determine accuracy of International Classification of Disease, ninth/tenth revision codes in classifying appendicitis as uncomplicated versus complicated (defined as perforated, necrotic, or abscess) compared with the clinical gold standard: surgeon characterization of the appendix in the operative report. METHODS: Retrospective review of operative reports and discharge International Classification of Disease, ninth/tenth revision codes for patients ≥18 years old who underwent noninterval, nonincidental appendectomy between January 2012 and December 2019 at a tertiary referral center. Sensitivity, specificity, and positive predictive value were calculated for International Classification of Disease, ninth/tenth revision codes to classify appendicitis accurately as complicated compared with surgeon description. ICD-9/10 codes and surgeon description were categorized into complicated/uncomplicated based on the American Association for the Surgery of Trauma grading system. RESULTS: In the study, 1,495 patients with acute appendicitis underwent appendectomy. Per surgeon description, 200 (13%) were complicated and 1,295 (87%) uncomplicated. Compared with surgeon description, discharge International Classification of Disease, ninth/tenth revision codes did not accurately identify complicated appendicitis: sensitivity = 0.68, positive predictive value = 0.77. As a sensitivity analysis, the cohort was stratified by public versus private payers, and the results did not change. CONCLUSION: International Classification of Disease, ninth/tenth revision codes do not accurately identify surgeon-described complicated appendicitis. Nearly one-third of the cases of complicated appendicitis were coded as uncomplicated. Such misclassification negatively impacts reimbursement for complicated appendicitis care and could lead to misleading results in research and quality improvement activities that rely on these codes.

Applying Behavioral Nudges in a Dietary Comparator for Surgical Trials: Developing the MediDiet.

INTRODUCTION: Dietary interventions are increasingly being proposed as alternatives to surgery for common gastrointestinal conditions. Integrating aspects of cognitive psychology (e.g., behavioral nudges) into dietary interventions is becoming popular, but evidence is lacking on their effectiveness and unintended effects. We assessed the effects of including nudges in the development of a dietary intervention based on the Mediterranean diet. METHODS: We conducted two-arm randomized surveys of United States adults. After a validated dietary questionnaire, participants received feedback about dietary consistency with a Mediterranean diet with (A) no nudge versus (B) one of several nudges: peer comparison, positive affect induction + peer comparison, or defaults. Participants rated their negative and positive emotions, motivation for dietary change, and interest in recipes. Responses were analyzed using baseline covariate-adjusted regression. RESULTS: Among 1709 participants, 56% were men and the median age was 36 y. Nudges as a class did not significantly affect the extent of negative or positive emotions, motivation, or interest. However, specific nudges had different effects: compared to no nudge, peer comparison blunted negative emotions and increased motivation, although decreased interest in recipes, while defaults increased interest in recipes but reduced motivation. CONCLUSIONS: In this pilot, behavioral nudges as a class of strategies did not improve participants' reactions to dietary feedback nor did they promote negative reactions. However, specific nudges may be better considered separately in their effects. Future testing should explore whether specific nudges including peer comparison and defaults improve dietary intervention effectiveness, especially in people with the specific gastrointestinal conditions of interest.

Association Between Statewide Medicaid Opioid Policy and Postoperative Opioid Prescribing among Surgeons at a Large Safety-Net Hospital.

BACKGROUND: Restrictive state and payer policies may be effective in reducing opioid prescribing by surgeons, but their impact has not been well studied. In 2017, Washington Medicaid implemented an opiod prescribing limit of 42 pills, prompting a large regional safety-net hospital to implement a decision support intervention in response. We aimed to evaluate the effects on surgeons' prescribing. STUDY DESIGN: We retrospectively studied postoperative opioid prescribing (quantity of pills prescribed at discharge) to opioid-naïve surgical patients at a regional safety-net hospital from 2016 to 2020. We investigated associations between the policy and opioid prescribing by using interrupted time series analysis, adjusting for clinical and sociodemographic factors. RESULTS: A total of 12,799 surgical encounters involving opioid-naïve patients (59% male, mean age 52) were analyzed. Opioids were prescribed for 75%. From 2016 to 2020, the mean prescribed opioid quantity decreased from 36 pills to 17 pills. In interrupted time series analysis, the Medicaid policy implementation was associated with an immediate change of -8.4 pills (95% CI -12 to -4.7; p < 0.001) per prescription and a subsequent rate of decrease similar to that prepolicy. In a comparison of changes between patients insured through Medicaid vs Medicare, Medicaid patients had an immediate change of -9.8 pills (95% CI -19 to -0.76; p = 0.03) after policy implementation and continued decreases similar to those prepolicy. No immediate or subsequent policy-related changes were observed among Medicare patients. CONCLUSION: In a large regional safety-net institution, postoperative opioid prescriptions decreased in size over time, with immediate changes associated with a state Medicaid policy and corresponding decision support intervention. These findings pose implications for surgeons, hospital leaders, and payers seeking to address opioid use via judicious prescribing.

Effects of opioid addiction risk information on Americans' agreement with postoperative opioid minimization and perceptions of quality.

BACKGROUND: Judicious opioid prescribing and patient counseling, including in the postoperative context, are important efforts to address the U.S. opioid crisis. In discussions with patients and loved ones, there is commonly an emphasis on addiction risk. From a behavioral science standpoint, presenting addiction risk information represents a fear appeal. Clinicians may also seek to build trust and confidence by presenting balanced views of benefits and risks. However, little is known about if and how addiction risk information evokes negative emotions, affects perceptions of quality, and influences perspectives on judicious opioid prescribing. METHODS: We conducted a four-arm, randomized survey of U.S. adults involving a vignette about post-appendectomy pain management for a friend, including the quantity of opioids commonly prescribed. Participants were given either no additional information (control), addiction risk information, addiction plus health risk information, or addiction plus death risk information. We compared evoked affect, agreement with a reduced opioid prescription compared to common practice, and perceptions of quality. RESULTS: Among 1,546 participants (56% men, mean age 39), 78% agreed with reducing the quantity of opioids prescribed, relative to common practices. Compared to the control, providing addiction risk information did not impact the degree of evoked negative emotions or the likelihood of agreement with reduced opioid prescriptions. Providing opioid risk information increased the likelihood of high surgeon quality ratings. CONCLUSIONS: Among a sample of U.S. adults, presenting addiction risk did not effectively appeal to fear, nor increase agreement with judicious opioid prescribing. Alternative communication strategies may be needed for those purposes.