Text vs Patient Portal Messaging to Improve Influenza Vaccination Coverage: A Health System-Wide Randomized Clinical Trial

Importance

Increasing influenza vaccination rates is a public health priority. One method recommended by the US Centers for Disease Control and Prevention and others is for health systems to send reminders nudging patients to be vaccinated.

Objective

To evaluate and compare the effect of electronic health record (EHR)-based patient portal reminders vs text message reminders on influenza vaccination rates across a health system.

Design, Setting, and Participants

This 3-arm randomized clinical trial was conducted from September 7, 2022, to April 30, 2023, among primary care patients within the University of California, Los Angeles (UCLA) health system.

Interventions

Arm 1 received standard of care. The health system sent monthly reminder messages to patients due for an influenza vaccine by portal (arm 2) or text (arm 3). Arm 2 had a 2 × 2 nested design, with fixed vs responsive monthly reminders and preappointment vs no preappointment reminders. Arm 3 had 1 × 2 design, with preappointment vs no preappointment reminders. Preappointment reminders for eligible patients were sent 24 and 48 hours before scheduled primary care visits. Fixed reminders (in October, November, and December) involved identical messages via portal or text. Responsive portal reminders involved a September message asking patients about their plans for vaccination, with a follow-up reminder if the response was affirmative but the patient was not yet vaccinated.

Main Outcomes and Measures

The primary outcome was influenza vaccination by April 30, 2023, obtained from the UCLA EHR, including vaccination from pharmacies and other sources.

Results

A total of 262 085 patients (mean [SD] age, 45.1 [20.7] years; 237 404 [90.6%] adults; 24 681 [9.4%] children; 149 349 [57.0%] women) in 79 primary care practices were included (87 257 in arm 1, 87 478 in arm 2, and 87 350 in arm 3). At the entire primary care population level, none of the interventions improved influenza vaccination rates. All groups had rates of approximately 47%. There was no statistical or clinically significant improvement following portal vs text, preappointment reminders vs no preappointment reminders (portal and text reminders combined), or responsive vs fixed monthly portal reminders.

Conclusions and Relevance

At the population level, neither portal nor text reminders for influenza vaccination were effective. Given that vaccine hesitancy may be a major reason for the lack of impact of portal or text reminders, more intensive interventions by health systems are needed to raise influenza vaccination coverage levels.

Trial Registration

ClinicalTrials.gov Identifier: NCT05525494.

Biochemical Recurrence Surrogacy for Clinical Outcomes After Radiotherapy for Adenocarcinoma of the Prostate

PURPOSE

The surrogacy of biochemical recurrence (BCR) for overall survival (OS) in localized prostate cancer remains controversial. Herein, we evaluate the surrogacy of BCR using different surrogacy analytic methods.

MATERIALS AND METHODS

Individual patient data from 11 trials evaluating radiotherapy dose escalation, androgen deprivation therapy (ADT) use, and ADT prolongation were obtained. Surrogate candidacy was assessed using the Prentice criteria (including landmark analyses) and the two-stage meta-analytic approach (estimating Kendall's tau and the R2). Biochemical recurrence-free survival (BCRFS, time from random assignment to BCR or any death) and time to BCR (TTBCR, time from random assignment to BCR or cancer-specific deaths censoring for noncancer-related deaths) were assessed.

RESULTS

Overall, 10,741 patients were included. Dose escalation, addition of short-term ADT, and prolongation of ADT duration significantly improved BCR (hazard ratio [HR], 0.71 [95% CI, 0.63 to 0.79]; HR, 0.53 [95% CI, 0.48 to 0.59]; and HR, 0.54 [95% CI, 0.48 to 0.61], respectively). Adding short-term ADT (HR, 0.91 [95% CI, 0.84 to 0.99]) and prolonging ADT (HR, 0.86 [95% CI, 0.78 to 0.94]) significantly improved OS, whereas dose escalation did not (HR, 0.98 [95% CI, 0.87 to 1.11]). BCR at 48 months was associated with inferior OS in all three groups (HR, 2.46 [95% CI, 2.08 to 2.92]; HR, 1.51 [95% CI, 1.35 to 1.70]; and HR, 2.31 [95% CI, 2.04 to 2.61], respectively). However, after adjusting for BCR at 48 months, there was no significant treatment effect on OS (HR, 1.10 [95% CI, 0.96 to 1.27]; HR, 0.96 [95% CI, 0.87 to 1.06] and 1.00 [95% CI, 0.90 to 1.12], respectively). The patient-level correlation (Kendall's tau) for BCRFS and OS ranged between 0.59 and 0.69, and that for TTBCR and OS ranged between 0.23 and 0.41. The R2 values for trial-level correlation of the treatment effect on BCRFS and TTBCR with that on OS were 0.563 and 0.160, respectively.

CONCLUSION

BCRFS and TTBCR are prognostic but failed to satisfy all surrogacy criteria. Strength of correlation was greater when noncancer-related deaths were considered events.

A Multisite Electronic Health Record Integrated Remote Monitoring Intervention for Hypertension Improvement: Protocol for a Randomized Pragmatic Comparative Effectiveness Trial

BACKGROUND

Hypertension is a major contributor to various adverse health outcomes. Although previous studies have shown the benefits of home blood pressure (BP) monitoring over office-based measurements, there is limited evidence comparing the effectiveness of whether a BP monitor integrated into the electronic health record is superior to a nonintegrated BP monitor.

OBJECTIVE

In this paper, we describe the protocol for a pragmatic multisite implementation of a quality improvement initiative directly comparing integrated to nonintegrated BP monitors for hypertension improvement.

METHODS

We will conduct a randomized, comparative effectiveness trial at 3 large academic health centers across California. The 3 sites will enroll a total of 660 participants (approximately n=220 per site), with 330 in the integrated BP monitor arm and 330 in the nonintegrated BP control arm. The primary outcome of this study will be the absolute difference in systolic BP in mm Hg from enrollment to 6 months. Secondary outcome measures include binary measures of hypertension (controlled vs uncontrolled), hypertension-related health complications, hospitalizations, and death. The list of possible participants will be generated from a central data warehouse. Randomization will occur after enrollment in the study. Participants will use their assigned BP monitor and join site-specific hypertension interventions. Cross-site learning will occur at regular all-site meetings facilitated by the University of California, Los Angeles Value-Based Care Research Consortium. A pre- and poststudy questionnaire will be conducted to further evaluate participants' perspectives regarding their BP monitor. Linear mixed effects models will be used to compare the primary outcome measure between study arms. Mixed effects logistic regression models will be used to compare secondary outcome measures between study arms.

RESULTS

The study will start enrolling participants in the second quarter of 2023 and will be completed by the first half of 2024. Results will be published by the end of 2024.

CONCLUSIONS

This pragmatic trial will contribute to the growing field of chronic care management using remote monitoring by answering whether a hypertension intervention coupled with an electronic health record integrated home BP monitor improves patients' hypertension better than a hypertension intervention with a nonintegrated BP monitor. The outcomes of this study may help health system decision makers determine whether to invest in integrated BP monitors for vulnerable patient populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05390502; clinicaltrials.gov/study/NCT05390502.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45915.

Choosing Wisely interventions to reduce antibiotic overuse in the safety net

OBJECTIVES

Physician pay-for-performance (P4P) programs frequently target inappropriate antibiotics. Yet little is known about P4P programs' effects on antibiotic prescribing among safety-net populations at risk for unintended harms from reducing care. We evaluated effects of P4P-motivated interventions to reduce antibiotic prescriptions for safety-net patients with acute respiratory tract infections (ARTIs).

STUDY DESIGN

Interrupted time series.

METHODS

A nonrandomized intervention (5/28/2015-2/1/2018) was conducted at 2 large academic safety-net hospitals: Los Angeles County+University of Southern California (LAC+USC) and Olive View-UCLA (OV-UCLA). In response to California's 2016 P4P program to reduce antibiotics for acute bronchitis, 5 staggered Choosing Wisely-based interventions were launched in combination: audit and feedback, clinician education, suggested alternatives, procalcitonin, and public commitment. We also assessed 5 unintended effects: reductions in Healthcare Effectiveness Data and Information Set (HEDIS)-appropriate prescribing, diagnosis shifting, substituting antibiotics with steroids, increasing antibiotics for ARTIs not penalized by the P4P program, and inappropriate withholding of antibiotics.

RESULTS

Among 3583 consecutive patients with ARTIs, mean antibiotic prescribing rates for ARTIs decreased from 35.9% to 22.9% (odds ratio [OR], 0.60; 95% CI, 0.39-0.93) at LAC+USC and from 48.7% to 27.3% (OR, 0.81; 95% CI, 0.70-0.93) at OV-UCLA after the intervention. HEDIS-inappropriate prescribing rates decreased from 28.9% to 19.7% (OR, 0.69; 95% CI, 0.39-1.21) at LAC+USC and from 40.9% to 12.5% (OR, 0.72; 95% CI, 0.59-0.88) at OV-UCLA. There was no evidence of unintended consequences.

CONCLUSIONS

These real-world multicomponent interventions responding to P4P incentives were associated with substantial reductions in antibiotic prescriptions for ARTIs in 2 safety-net health systems without unintended harms.

Evaluating the predictive ability of natural language processing in identifying tertiary/quaternary cases in prioritization workflows for interhospital transfer

Objectives

Tertiary and quaternary (TQ) care refers to complex cases requiring highly specialized health services. Our study aimed to compare the ability of a natural language processing (NLP) model to an existing human workflow in predictively identifying TQ cases for transfer requests to an academic health center.

Materials and methods

Data on interhospital transfers were queried from the electronic health record for the 6-month period from July 1, 2020 to December 31, 2020. The NLP model was allowed to generate predictions on the same cases as the human predictive workflow during the study period. These predictions were then retrospectively compared to the true TQ outcomes.

Results

There were 1895 transfer cases labeled by both the human predictive workflow and the NLP model, all of which had retrospective confirmation of the true TQ label. The NLP model receiver operating characteristic curve had an area under the curve of 0.91. Using a model probability threshold of ≥0.3 to be considered TQ positive, accuracy was 81.5% for the NLP model versus 80.3% for the human predictions (P = .198) while sensitivity was 83.6% versus 67.7% (P<.001).

Discussion

The NLP model was as accurate as the human workflow but significantly more sensitive. This translated to 15.9% more TQ cases identified by the NLP model.

Conclusion

Integrating an NLP model into existing workflows as automated decision support could translate to more TQ cases identified at the onset of the transfer process.

Behind closed doors: Protective social behavior during the COVID-19 pandemic

The success of personal non-pharmaceutical interventions as a public health strategy requires a high level of compliance from individuals in private social settings. Strategies to increase compliance in these hard-to-reach settings depend upon a comprehensive understanding of the patterns and predictors of protective social behavior. Social cognitive models of protective behavior emphasize the contribution of individual-level factors while social-ecological models emphasize the contribution of environmental factors. This study draws on 28 waves of survey data from the Understanding Coronavirus in America survey to measure patterns of adherence to two protective social behaviors-private social-distancing behavior and private masking behavior-during the COVID-19 pandemic and to assess the role individual and environmental factors play in predicting adherence. Results show that patterns of adherence fall into three categories marked by high, moderate, and low levels of adherence, with just under half of respondents exhibiting a high level of adherence. Health beliefs emerge as the single strongest predictor of adherence. All other environmental and individual-level predictors have relatively poor predictive power or primarily indirect effects.

Evaluation of behavioral economic strategies to raise influenza vaccination rates across a health system: Results from a randomized clinical trial

Influenza vaccination rates are low. Working with a large US health system, we evaluated three health system-wide interventions using the electronic health record's patient portal to improve influenza vaccination rates. We performed a two-arm RCT with a nested factorial design within the treatment arm, randomizing patients to usual-care control (no portal interventions) or to one or more portal interventions. We included all patients within this health system during the 2020-2021 influenza vaccination season, which overlapped with the COVID-19 pandemic. Through the patient portal, we simultaneously tested: pre-commitment messages (sent September 2020, asking patients to commit to a vaccination); monthly portal reminders (October - December 2020), direct appointment scheduling (patients could self-schedule influenza vaccination at multiple sites); and pre-appointment reminder messages (sent before scheduled primary care appointments, reminding patients about influenza vaccination). The main outcome measure was receipt of influenza vaccine (10/01/2020-03/31/2021). We randomized 213,773 patients (196,070 adults ≥18 years, 17,703 children). Influenza vaccination rates overall were low (39.0%). Vaccination rates for study arms did not differ: Control (38.9%), pre-commitment vs no pre-commitment (39.2%/38.9%), direct appointment scheduling yes/no (39.1%/39.1%), pre-appointment reminders yes/no (39.1%/39.1%); p > 0.017 for all comparisons (p value cut-off adjusted for multiple comparisons). After adjusting for age, gender, insurance, race, ethnicity, and prior influenza vaccination, none of the interventions increased vaccination rates. We conclude that patient portal interventions to remind patients to receive influenza vaccine during the COVID-19 pandemic did not raise influenza immunization rates. More intensive or tailored interventions are needed beyond portal innovations to increase influenza vaccination.

Racial Disparities in Quantitative MRI for African American and White Men with Prostate Cancer

The risk of prostate cancer (PCa) is strongly influenced by race and ethnicity. The purpose of this study is to investigate differences in the diagnostic performance of multiparametric MRI (mpMRI) in African American (AA) and white (W) men. 111 patients (37 AA and 74 W men) were selected from the study's initial cohort of 885 patients after matching age, prostate-specific antigen, and prostate volume. The diagnostic performance of mpMRI was assessed using detection rates (DRs) and positive predictive values (PPVs) with/without combining Ktrans (volume transfer constant) stratified by prostate zones for AA and W sub-cohorts. The DRs of mpMRI for clinically significant PCa (csPCa) lesions in AA and W sub-cohort with PI-RADS scores ≥ 3 were 67.3% vs. 80.3% in the transition zone (TZ; p=0.026) and 81.2% vs. 76.1% in the peripheral zone (PZ; p>0.9). The Ktrans of csPCa in AA men was significantly higher than in W men (0.23±0.08 min-1 vs. 0.19±0.07 min-1; p=0.022). This emphasizes that there are race-related differences in the performance of mpMRI and quantitative MRI measures that are not reflected in age, PSA, and prostate volume.

Improved outcomes in rheumatoid arthritis with obesity after a weight loss intervention: randomized trial

OBJECTIVE

To examine whether a weight loss intervention programme improves RA disease activity and/or musculoskeletal ultrasound synovitis measures in obese RA patients.

METHODS

We conducted a proof-of-concept, 12-week, single-blind, randomized controlled trial of obese RA patients (BMI ≥ 30) with 28-joint DAS (DAS28)  ≥ 3.2 and with evidence of power Doppler synovitis. Forty patients were randomized to the diet intervention (n = 20) or control group (n = 20). Diet intervention consisted of a hypocaloric diet of 1000-1500 kcal/day and high protein meal replacements. Co-primary outcomes included change in DAS28 and power Doppler ultrasound (PDUS)-34. Clinical disease activity, imaging, biomarkers, adipokines and patient-reported outcomes were monitored throughout the trial. Recruitment terminated early. All analyses were based on intent-to-treat for a significance level of 0.05.

RESULTS

The diet intervention group lost an average 9.5 kg/patient, while the control group lost 0.5 kg (P < 0.001). Routine Assessment of Patient Index Data 3 (RAPID3) improved, serum leptin decreased and serum adiponectin increased significantly within the diet group and between the groups (all P < 0.03). DAS28 decreased, 5.2 to 4.2, within the diet group (P < 0.001; -0.51 [95% CI -1.01, 0.00], P = 0.056, between groups). HAQ-Disability Index (HAQ-DI) improved significantly within the diet group (P < 0.04; P = 0.065 between group). Ultrasound measures and the multi-biomarker disease activity score did not differ between groups (PDUS-34 -2.0 [95% CI -7.00, 3.1], P = 0.46 between groups).

CONCLUSION

Obese RA patients on the diet intervention achieved weight loss. There were significant between group improvements for RAPID3, adiponectin and leptin levels, and positive trends for DAS28 and HAQ-DI. Longer-term, larger weight loss studies are needed to validate these findings, and will allow for further investigative work to improve the clinical management of obese RA patients.

TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov, NCT02881307.

Behavioral and Social Drivers of COVID-19 Vaccination in the United States, August-November 2021

INTRODUCTION

COVID-19 vaccines are safe, effective, and widely available, but many adults in the U.S. have not been vaccinated for COVID-19. This study examined the associations between behavioral and social drivers of vaccination with COVID-19 vaccine uptake in the U.S. adults and their prevalence by region.

METHODS

A nationally representative sample of U.S. adults participated in a cross-sectional telephone survey in August-November 2021; the analysis was conducted in January 2022. Survey questions assessed self-reported COVID-19 vaccine initiation, demographics, and behavioral and social drivers of vaccination.

RESULTS

Among the 255,763 respondents, 76% received their first dose of COVID-19 vaccine. Vaccine uptake was higher among respondents aged ≥75 years (94%), females (78%), and Asian non-Hispanic people (94%). The drivers of vaccination most strongly associated with uptake included higher anticipated regret from nonvaccination, risk perception, and confidence in vaccine safety and importance, followed by work- or school-related vaccination requirements, social norms, and provider recommendation (all p<0.05). The direction of association with uptake varied by reported level of difficulty in accessing vaccines. The prevalence of all of these behavioral and social drivers of vaccination was highest in the Northeast region and lowest in the Midwest and South.

CONCLUSIONS

This nationally representative survey found that COVID-19 vaccine uptake was most strongly associated with greater anticipated regret, risk perception, and confidence in vaccine safety and importance, followed by vaccination requirements and social norms. Interventions that leverage these social and behavioral drivers of vaccination have the potential to increase COVID-19 vaccine uptake and could be considered for other vaccine introductions.

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.

A Description of the Imaging Innovations for Placental Assessment in Response to Environmental Pollution Study

OBJECTIVE

 The aim of Placental Assessment in Response to Environmental Pollution Study (PARENTs) was to determine whether imaging of the placenta by novel multiparametric magnetic resonance imaging (MRI) techniques in early pregnancy could help predict adverse pregnancy outcomes (APOs) due to ischemic placental disease (IPD). Additionally, we sought to determine maternal characteristics and environmental risk factors that contribute to IPD and secondary APOs.

STUDY DESIGN

 Potential patients in their first trimester of pregnancy, who agreed to MRI of the placenta and measures of assessment of environmental pollution, were recruited into PARENTs, a prospective population-based cohort study. Participants were seen at three study visits during pregnancy and again at their delivery from 2015 to 2019. We collected data from interviews, chart abstractions, and imaging. Maternal biospecimens (serum, plasma, and urine) at antepartum study visits and delivery specimens (placenta, cord, and maternal blood) were collected, processed, and stored. The primary outcome was a composite of IPD, which included any of the following: placental abruption, hypertensive disease of pregnancy, fetal growth restriction, or a newborn of small for gestational age.

RESULTS

 In this pilot cohort, of the 190 patients who completed pregnancy to viable delivery, 50 (26%) developed IPD. Among demographic characteristics, having a history of prior IPD in multiparous women was associated with the development of IPD. In the multiple novel perfusion measurements taken of the in vivo placenta using MRI, decreased high placental blood flow (mL/100 g/min) in early pregnancy (between 14 and 16 weeks) was found to be significantly associated with the later development of IPD.

CONCLUSION

 Successful recruitment of the PARENTs prospective cohort demonstrated the feasibility and acceptability of the use of MRI in human pregnancy to study the placenta in vivo and at the same time collect environmental exposure data. Analysis is ongoing and we hope these methods will assist researchers in the design of prospective imaging studies of pregnancy.

KEY POINTS

· MRI was acceptable and feasible for the study of the human placenta in vivo.. · Functional imaging of the placenta by MRI showed a significant decrease in high placental blood flow.. · Measures of environmental exposures are further being analyzed to predict IPD..

School-Age Children's Wellbeing and School-Related Needs During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

The COVID-19 pandemic and related school closures may have disrupted school-related supports and services important to children's wellbeing. However, we lack national data about US children's wellbeing and family priorities for school-related services. We sought to determine 1) children's social-emotional wellbeing and 2) needs and priorities for school-based services in the 2021-2022 school year among a US sample of parents of school-aged children.

METHODS

In June 2021, we surveyed 1504 parents of children enrolling in grades K-12 in the 2021-2022 school year participating in the Understanding America Study, a nationally representative probability-based Internet panel of families completing regular internet-based surveys (Response rate to this survey was 79.2%). Parents completed the Strengths and Difficulties Questionnaire and reported their needs for school-related services regarding "support getting healthcare", "mental wellness support", "food, housing, legal or transportation support", and "learning supports and enrichment." Weighted regressions examined associations among wellbeing, needs, and sociodemographic characteristics.

RESULTS

Approximately one-quarter of children had deficits in hyperactivity (26.1%), one-third in peer problems (32.6%), and 40% in prosocial areas. Most parents (83.5%) reported a school-related need, with 77% reporting learning supports and enrichment needs and 57% reporting mental wellness needs. The highest priority needs were for tutoring, socialization, increased instructional time, coping with stress, and physical activity.

CONCLUSIONS

US school children have high social-emotional and school-related needs. Investments in schools are urgently needed, particularly for learning supports and mental wellness, to meet the high demand for services and parents' priorities to support child health and wellbeing.

Association Between In-Person vs Telehealth Follow-up and Rates of Repeated Hospital Visits Among Patients Seen in the Emergency Department

Importance

For patients discharged from the emergency department (ED), timely outpatient in-person follow-up is associated with improved mortality, but the effectiveness of telehealth as follow-up modality is unknown.

Objective

To evaluate whether the rates of ED return visits and hospitalization differ between patients who obtain in-person vs telehealth encounters for post-ED follow-up care.

Design, Setting, and Participants

This retrospective cohort study included adult patients who presented to either of 2 in-system EDs of a single integrated urban academic health system from April 1, 2020, to September 30, 2021; were discharged home; and obtained a follow-up appointment with a primary care physician within 14 days of their index ED visit (15 total days).

Exposures

In-person vs telehealth post-ED discharge follow-up within 14 days.

Main Outcomes and Measures

Multivariable logistic regression was used to estimate the odds of ED return visits (primary outcome) or hospitalization (secondary outcome) within 30 days of an ED visit based on the modality of post-ED discharge follow-up. Models were adjusted for age, sex, primary language, race, ethnicity, Social Vulnerability Index, insurance type, distance to the ED, ambulatory billing codes for the index visit, and the time from ED discharge to follow-up.

Results

Overall, 12 848 patients with 16 987 ED encounters (mean [SD] age, 53 [20] years; 9714 [57%] women; 2009 [12%] Black or African American; 3806 [22%] Hispanic or Latinx; and 9858 [58%] White) were included; 11 818 (70%) obtained in-person follow-up, and 5169 (30%) obtained telehealth follow-up. Overall, 2802 initial ED encounters (17%) led to returns to the ED, and 676 (4%) led to subsequent hospitalization. In adjusted analyses, telehealth vs in-person follow-up visits were associated with increased rates of ED returns (28.3 [95% CI, 11.3-45.3] more ED returns per 1000 encounters) and hospitalizations (10.6 [95% CI, 2.9-18.3] more hospitalizations per 1000 encounters).

Conclusions and Relevance

In this cohort study of patients in an urban integrated health care system, those with telehealth follow-up visits after an ED encounter were more likely to return to the ED and be hospitalized than patients with in-person follow-up. The use of telehealth warrants further evaluation to examine its effectiveness as a modality for continuing care after an initial ED presentation for acute illness.

The prognostic value of early measures of the ventilatory ratio in the ARDS ROSE trial

Background

The ventilatory ratio (VR, [minute ventilation × PaCO₂]/[predicted body weight × 100 × 37.5]) is associated with mortality in ARDS. The aims of this study were to test whether baseline disease severity or neuromuscular blockade (NMB) modified the relationship between VR and mortality.

Methods

This was a post hoc analysis of the PETAL-ROSE trial, which randomized moderate-to-severe ARDS patients to NMB or control. Survival among patients with different VR trajectories or VR cutoff above and below the median was assessed by Kaplan–Meier analysis. The relationships between single-day or 48-h VR trajectories with 28- or 90-day mortality were tested by logistic regression. Randomization allocation to NMB and markers of disease severity were tested as confounders by multivariable regression and interaction term analyses.

Results

Patients with worsening VR trajectories had significantly lower survival compared to those with improving VR (n = 602, p < 0.05). Patients with VR > 2 (median) at day 1 had a significantly lower 90-day survival compared to patients with VR ≤ 2 (HR 1.36, 95% CI 1.10–1.69). VR at day 1 was significantly associated with 28-day mortality (OR = 1.40, 95% CI 1.15–1.72). There was no interaction between NMB and VR for 28-day mortality. APACHE-III had a significant interaction with VR at baseline for the outcome of 28-day mortality, such that the relationship between VR and mortality was stronger among patients with lower APACHE-III. There was a significant association between rising VR trajectory and mortality that was independent of NMB, baseline PaO₂/FiO₂ ratio and generalized markers of disease severity (Adjusted OR 1.81, 95% CI 1.28–2.84 for 28-day and OR 2.07 95% CI 1.41–3.10 for 90-day mortality). APACHE-III and NMB were not effect modifiers in the relationship between VR trajectory and mortality.

Conclusions

Elevated baseline and day 1 VR were associated with higher 28-day mortality. The relationship between baseline VR and mortality was stronger among patients with lower APACHE-III. APACHE-III was not an effect modifier for the relationship between VR trajectory and mortality, so that the VR trajectory may be optimally suited for prognostication and predictive enrichment. VR was not different between patients randomized to NMB or control, indicating that VR can be utilized without correcting for NMB.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04179-7.

The Structured Oral Examination: A Method to Improve Formative Assessment of Fellows in Pediatric Endocrinology

OBJECTIVE

A structured oral exam (SOE) can be utilized as a formative assessment to provide high-quality formative feedback to trainees, but has not been adequately studied in graduate medical education. We obtained fellow and faculty perspectives on: 1) educational effectiveness, 2) feasibility/acceptability, and 3) time/cost of a SOE for formative feedback.

METHODS

Four pediatric endocrinology cases were developed and peer-reviewed to generate a SOE. The exam was administered by faculty to pediatric endocrinology fellows individually, with feedback after each case. Fellow/faculty perspectives of the SOE were obtained through a questionnaire. Qualitative thematic analysis was utilized to analyze written comments generated by faculty and fellows.

RESULTS

Seven of 10 pediatric endocrinology fellowship programs and all 18 fellows within those programs agreed to participate. Thematic analysis of fellow and faculty comments resulted in 5 perceived advantages of the SOE: 1) improved identification of clinically relevant knowledge deficits, 2) improved assessment of clinical reasoning, 3) immediate feedback/teaching, 4) assurance of adequate teaching/assessment of uncommon cases, and 5) more clinically relevant assessment. Mean time to administer one case was 15.8 minutes (2.0) and was mentioned as a potential barrier to implementation. Almost all fellows (17/18, 94%) and faculty (6/7, 86%) would recommend or would most likely recommend implementation of the SOE into their curriculum.

CONCLUSIONS

The SOE utilized for formative feedback was perceived by fellows and faculty to have several educational advantages over current assessments and high acceptability. Objective educational advantages should be assessed on future studies of the SOE.

Obstetric Provider Attitudes and Office Practices for Maternal Influenza and Tdap Vaccination

Background: Although maternal vaccination with influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines improve health outcomes for pregnant individuals and infants, maternal vaccination rates are low. This study assessed obstetric providers' attitudes and practices related to influenza and Tdap vaccination in four large health systems in New York (NY) and California (CA). Methods: We conducted a cross-sectional survey of all obstetric providers within four health systems (two in NY, two in CA) to evaluate provider attitudes and office systems used for Tdap and influenza vaccination. The survey assessed perceptions of influenza and Tdap vaccination based on the Health Belief Model, and assessed office systems (reminders, prompts, standing orders, and patient education) and communication with pregnant patients related to influenza and Tdap vaccines. Results: We had 112 responses (52% response rate) for analyses. Respondents strongly supported vaccination during pregnancy but viewed influenza disease as less of a concern for newborns than for pregnant individuals (40% vs. 67% considered influenza disease to be very significant, p < 0.001). Only 84% agreed that giving influenza vaccine in the first trimester is very safe. Patient vaccine refusal was the most commonly named barrier for both influenza and Tdap vaccination. Providers frequently used office system prompts, but did not frequently use standing orders, patient educational materials, vaccine champions, and feedback on vaccination rates. Conclusions: While most providers consider influenza and Tdap vaccination important during pregnancy, there is room for improvement in focusing on the importance of maternal vaccination to the health of the infant, and increasing the use of office systems to improve vaccination during pregnancy.

Postoperative Trapped Lung After Orthotopic Liver Transplantation is a Predictor of Increased Mortality

Pleural effusions are a common complication of orthotopic liver transplantation (OLT), and chronic post-OLT pleural effusions have been associated with worse outcomes. Furthermore, “trapped lung” (TL), defined as a restrictive fibrous visceral pleural peel preventing lung re-expansion, may have prognostic significance. We performed a retrospective analysis of adult OLT recipients over a 9-year period at UCLA Medical Center. Post-OLT patients with persistent pleural effusions, defined by the presence of pleural fluid requiring drainage one to 12 months after OLT, were included for analysis. Outcomes for patients with and without TL were compared using univariate and multivariate analysis. Of the 1722 patients who underwent OLT, 117 (7%) patients met our criteria for persistent postoperative pleural effusion, and the incidence of TL was 21.4% (25/117). Compared to patients without TL, those with TL required more surgical pleural procedures (OR 59.8, 95%CI 19.7–181.4, p < 0.001), spent more days in the hospital (IRR 1.56, 95%CI 1.09–2.23, p = 0.015), and had a higher risk of mortality (HR 2.47, 95%CI 1.59–3.82, p < 0.001) following transplant. In sum, we found that post-OLT TL was associated with higher morbidity, mortality, and healthcare utilization. Future prospective investigation is warranted to further clarify the risk factors for developing postoperative pleural effusions and TL.

Impact of COVID-19 on Primary Care Quality Measures in an Academic Integrated Health System

BACKGROUND

Access to primary care was hindered by the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVE

Evaluate changes in health screening rates before and during the pandemic.

DESIGN

Retrospective analysis of health maintenance and disease management screening rates among primary care patients before and during the pandemic.

PARTICIPANTS

Over 150,000 patients of a large, academic health system.

MAIN MEASURES

Six quality measures were analyzed: colon cancer, breast cancer, cervical cancer, diabetes Hgb A1C, diabetes eye, and diabetes nephropathy monitoring. Based on US Preventative Services Task Force screening guidelines, we determined which patients were due for at least one of the quality measures. We tracked completion rates during three time periods: pre-pandemic (January 1-March 3, 2020), stay-at-home (March 4-May 8, 2020), and phased reopening (May 9-July 8, 2020). Differences in quality measure completion rates were evaluated using mixed-effects logistic regression models.

KEY RESULTS

Compared to pre-pandemic rates, completion of all health screenings declined during the stay-at-home period: mammograms (OR: 0.34; 95% CI: 0.31-0.37), cervical cancer (OR: 0.83; 95% CI: 0.76-0.91), colorectal cancer (OR: 0.25; 95% CI: 0.23-0.28), diabetes eye (OR: 0.34; 95% CI: 0.29-0.41), diabetes Hgb A1c (OR: 0.41; 95% CI: 0.37-0.46), and diabetes nephropathy (OR: 0.46, 95% CI: 0.41-0.53). During phased reopening, completion of all quality measures increased compared to the stay-at-home period, except for cervical cancer screening (OR: 0.83; 95% CI: 0.76-0.92). There was a persistent reduction in completion of all quality measures, except for diabetic nephropathy monitoring (OR: 0.99; 95% CI: 0.89-1.09), during phased reopening compared to pre-pandemic.

CONCLUSIONS

Healthcare screening rates were reduced during the early part of the COVID-19 pandemic and did not fully recover to pre-pandemic rates by July 2020. Future research should aim to clarify the long-term impacts of delayed health screenings. New interventions should be considered for expanding remote preventative health services.

Influence of Perceived Adolescent Vaccination Desire on Parent Decision for Adolescent COVID-19 Vaccination

PURPOSE

The purpose of this study was to assess the influence of adolescents' desire for COVID-19 vaccination on their parents' vaccination decision for their adolescent.

METHODS

We surveyed an internet-based panel of 1,051 parents of 1,519 adolescents aged 11-18 years from February to March 2021 about their adolescent's desire for COVID-19 vaccination and whether they consider this desire in their vaccination decision for the adolescent. We used multivariable Poisson regression to assess associations with parent-stated likelihood of adolescent vaccination.

RESULTS

A total of 58.3% of parents reported that they and their adolescents had the same vaccination desire; similarly, 58.3% considered their adolescent's desire in their vaccination decision. These latter parents were more likely to vaccinate their adolescent than parents who did not consider their adolescent's desire (adjusted risk ratio = 1.25 [95% confidence interval = 1.05-1.50]).

DISCUSSION

Most parents considered their adolescent's desire for COVID-19 vaccination. These parents were more likely to state that they will have their adolescent receive a COVID-19 vaccine.

Examining the role of COVID-19 testing availability on intention to isolate: A Randomized hypothetical scenario

Background

Little information exists on how COVID-19 testing influences intentions to engage in risky behavior. Understanding the behavioral effects of diagnostic testing may highlight the role of adequate testing on controlling viral transmission. In order to evaluate these effects, simulated scenarios were conducted evaluating participant intentions to self-isolate based on COVID-19 diagnostic testing availability and results.

Methods

Participants from the United States were recruited through an online survey platform (Amazon Mechanical Turk) and randomized to one of three hypothetical scenarios. Each scenario asked participants to imagine having symptoms consistent with COVID-19 along with a clinical diagnosis from their physician. However, scenarios differed in either testing availability (testing available v. unavailable) or testing result (positive v. negative test). The primary outcome was intention to engage in high-risk COVID-19 behaviors, measured using an 11-item mean score (range 1–7) that was pre-registered prior to data collection. Multi-variable linear regression was used to compare the mean composite scores between conditions. The randomized survey was conducted between July 23^rd to July 29^th, 2020.

Results

A total of 1400 participants were recruited through a national, online, opt-in survey. Out of 1194 respondents (41.6% male, 58.4% female) with a median age of 38.5 years, participants who had no testing available in their clinical scenario showed significantly greater intentions to engage in behavior facilitating COVID-19 transmission compared to those who received a positive confirmatory test result scenario (mean absolute difference (SE): 0.14 (0.06), P = 0.016), equating to an 11.1% increase in mean score risky behavior intentions. Intention to engage in behaviors that can spread COVID-19 were also positively associated with male gender, poor health status, and Republican party affiliation.

Conclusion

Testing availability appears to play an independent role in influencing behaviors facilitating COVID-19 transmission. Such findings shed light on the possible negative externalities of testing unavailability.

Trial registration

Effect of Availability of COVID-19 Testing on Choice to Isolate and Socially Distance, NCT04459520, https://clinicaltrials.gov/ct2/show/NCT04459520.

Effect of Personalized Messages Sent by a Health System's Patient Portal on Influenza Vaccination Rates: a Randomized Clinical Trial

BACKGROUND

Adult influenza vaccination rates are low. Tailored patient reminders might raise rates.

OBJECTIVE

Evaluate impact of a health system's patient portal reminders: (1) tailored to patient characteristics and (2) incorporating behavioral science strategies, on influenza vaccination rates among adults.

DESIGN

Pragmatic 6-arm randomized trial across a health system during the 2019-2020 influenza vaccination season. The setting was one large health system-53 adult primary care practices.

PARTICIPANTS

All adult patients who used the patient portal within 12 months, stratified by the following: young adults (18-64 years, without diabetes), older adults (≥65 years, without diabetes), and those with diabetes (≥18 years).

INTERVENTIONS

Patients were randomized within strata to either (1) pre-commitment reminder alone (1 message, mid-October), (2) pre-commitment + loss frame messages, (3) pre-commitment + gain frame messages, (4) loss frame messages alone, (5) gain frame messages alone, or (6) standard of care control. Patients in the pre-commitment group were sent a message in mid-October, asking if they planned on getting an influenza vaccination. Patients in loss or gain frame groups were sent up to 3 portal reminders (late October, November, and December, if no documented influenza vaccination in the EHR) about importance and safety of influenza vaccine.

MAIN MEASURES

Receipt of 1 influenza vaccine from 10/01/2019 to 03/31/2020.

KEY RESULTS

196,486 patients (145,166 young adults, 29,795 older adults, 21,525 adults with diabetes) were randomized. Influenza vaccination rates were as follows: for young adults 36.8%, for older adults 55.6%, and for diabetics 60.6%. On unadjusted and adjusted (for age, gender, insurance, race, ethnicity, and prior influenza vaccine history) analyses, influenza vaccination rates were not statistically different for any study group versus control.

CONCLUSIONS

Patient reminders sent by a health system's patient portal that were tailored to patient demographics (young adults, older adults, diabetes) and that incorporated two behavioral economic messaging strategies (pre-commitment and loss/gain framing) were not effective in raising influenza vaccination rates.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov (NCT04110314).

Effect of Patient Portal Messaging Before Mailing Fecal Immunochemical Test Kit on Colorectal Cancer Screening Rates: A Randomized Clinical Trial

IMPORTANCE

Colorectal cancer (CRC) screening reduces CRC mortality; however, screening rates remain well below the national benchmark of 80%.

OBJECTIVE

To determine whether an electronic primer message delivered through the patient portal increases the completion rate of CRC screening in a mailed fecal immunochemical test (FIT) outreach program.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical quality improvement trial at the University of California, Los Angeles Health of 2339 patients enrolled in a FIT mailing program from August 28, 2019, to September 20, 2020, patients were randomly assigned to either the control or intervention group, and the screening completion rate was measured at 6 months. Participants were average-risk managed care patients aged 50 to 75 years, with a valid mailing address, no mailed CRC outreach in the previous 6 months, and an active electronic health record (EHR) patient portal who were due for CRC screening. Data were analyzed on an intention-to-treat basis.

INTERVENTIONS

Eligible patients were randomly assigned to receive either (1) the standard FIT mailed outreach (control group) or (2) the standard FIT mailed outreach plus an automated primer to notify patients of the upcoming mailed FIT sent through the electronic patient portal (intervention group).

MAIN OUTCOMES AND MEASURES

The primary outcome was the screening completion rate (ie, returning the FIT). Secondary outcomes were (1) were the time to CRC screening from the FIT mailing date, (2) screening modality completed, and (3) the effect of opening the electronic primer on screening completion rate.

RESULTS

The study included 2339 patients (1346 women [57.5%]; mean [SD] age, 58.9 [7.5] years). The screening completion rate was higher in the intervention group than in the control group (37.6% [445 of 1182] vs 32.1% [371 of 1157]; P = .005). The time to screening was shorter in the intervention group than in the control group (adjusted hazard ratio, 1.24; 95% CI, 1.08-1.42; P = .003). The proportion of each screening test modality completed was similar in both groups. In a subanalysis of the 900 of 1182 patients (76.1%) in the intervention group who opened the patient portal primer message, there was a 7.3-percentage point (95% CI, 2.3-12.4 percentage points) increase in CRC screening (local mean treatment effect; P = .004).

CONCLUSIONS AND RELEVANCE

Implementation of an electronic patient portal primer message in a mailed FIT outreach program led to a significant increase in CRC screening and improvement in the time to screening completion. The findings provide an evidence base for additional refinements to mailed FIT outreach quality improvement programs in large health systems.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05115916.

Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021

Importance

Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services.

Objective

To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance.

Design, Setting, and Participants

In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type.

Exposures

Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively.

Main Outcomes and Measures

Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening.

Results

More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types).

Conclusions and Relevance

Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increase in use of these ambulatory care services was significantly lower for participants with Medicaid or Medicare-Medicaid dual eligibility than for those insured by commercial, Medicare Advantage, or Medicare fee-for-service.

An Integrated, Scalable, Electronic Video Consent Process to Power Precision Health Research: Large, Population-Based, Cohort Implementation and Scalability Study

BACKGROUND

Obtaining explicit consent from patients to use their remnant biological samples and deidentified clinical data for research is essential for advancing precision medicine.

OBJECTIVE

We aimed to describe the operational implementation and scalability of an electronic universal consent process that was used to power an institutional precision health biobank across a large academic health system.

METHODS

The University of California, Los Angeles, implemented the use of innovative electronic consent videos as the primary recruitment tool for precision health research. The consent videos targeted patients aged ≥18 years across ambulatory clinical laboratories, perioperative settings, and hospital settings. Each of these major areas had slightly different workflows and patient populations. Sociodemographic information, comorbidity data, health utilization data (ambulatory visits, emergency room visits, and hospital admissions), and consent decision data were collected.

RESULTS

The consenting approach proved scalable across 22 clinical sites (hospital and ambulatory settings). Over 40,000 participants completed the consent process at a rate of 800 to 1000 patients per week over a 2-year time period. Participants were representative of the adult University of California, Los Angeles, Health population. The opt-in rates in the perioperative (16,500/22,519, 73.3%) and ambulatory clinics (2308/3390, 68.1%) were higher than those in clinical laboratories (7506/14,235, 52.7%; P<.001). Patients with higher medical acuity were more likely to opt in. The multivariate analyses showed that African American (odds ratio [OR] 0.53, 95% CI 0.49-0.58; P<.001), Asian (OR 0.72, 95% CI 0.68-0.77; P<.001), and multiple-race populations (OR 0.73, 95% CI 0.69-0.77; P<.001) were less likely to participate than White individuals.

CONCLUSIONS

This is one of the few large-scale, electronic video-based consent implementation programs that reports a 65.5% (26,314/40,144) average overall opt-in rate across a large academic health system. This rate is higher than those previously reported for email (3.6%) and electronic biobank (50%) informed consent rates. This study demonstrates a scalable recruitment approach for population health research.

The role of trust in the likelihood of receiving a COVID-19 vaccine: Results from a national survey

High acceptance of coronavirus disease 2019 (COVID-19) vaccines is instrumental to ending the pandemic. Vaccine acceptance by subgroups of the population depends on their trust in COVID-19 vaccines. We surveyed a probability-based internet panel of 7832 adults from December 23, 2020-January 19, 2021 about their likelihood of getting a COVID-19 vaccine and the following domains of trust: an individual's generalized trust, trust in COVID-19 vaccine's efficacy and safety, trust in the governmental approval process and general vaccine development process for COVID-19 vaccines, trust in their physician about COVID-19, and trust in other sources about COVID-19. We included identified at-risk subgroups: healthcare workers, older adults (65-74-year-olds and ≥ 75-year-olds), frontline essential workers, other essential workers, and individuals with high-risk chronic conditions. Of 5979 respondents, only 57.4% said they were very likely or somewhat likely to get a COVID-19 vaccine. More hesitant respondents (p < 0.05) included: women, young adults (18-49 years), Blacks, individuals with lower education, those with lower income, and individuals without high-risk chronic conditions. Lack of trust in the vaccine approval and development processes explained most of the demographic variation in stated vaccination likelihood, while other domains of trust explained less variation. We conclude that hesitancy for COVID-19 vaccines is high overall and among at-risk subgroups, and hesitancy is strongly tied to trust in the vaccine approval and development processes. Building trust is critical to ending the pandemic.

The Impact of Resident Holdover Admissions on Length of Hospital Stay and Risk of Transfer to an Intensive Care Unit

OBJECTIVE

Implementation of residency duty hour standards has led to adoption of different staffing models, such as the "holdover" model, whereby nighttime teams admit patients and transfer their care to daytime teams who provide ongoing care. In contrast, nonholdover teams at our institution are responsible for both admitting patients and providing ongoing care. We sought to determine whether patients admitted by holdover teams experience worse outcomes than those admitted by nonholdover teams.

METHODS

This is a retrospective cohort study of patients admitted to the internal medicine hospital service at a quaternary care hospital from July 2013 to June 2015. Primary outcomes included hospital length of stay (LOS) and transfer to an intensive care unit within 72 hours of admission. Secondary outcomes were any transfer to an intensive care unit, in-hospital mortality, discharge to home (versus discharge to postacute care facility), and readmission to the health system within 30 days of discharge.

RESULTS

We analyzed 5518 encounters, 64% of which were admitted by a holdover team. Outcomes were similar between study groups, except the LOS, which was 5.5 hours longer for holdover encounters in unadjusted analyses (5.18 versus 4.95 days, P = 0.04) but not significantly different in adjusted analyses. The mean discharge time was 4:00 p.m. for both groups, whereas the mean admission times were 12:00 a.m. and 4:00 p.m. for holdover and nonholdover encounters, respectively.

CONCLUSIONS

Holdover encounters at our institution were not associated with worse patient safety outcomes. A small increase in LOS may have been attributable to holdover patients having earlier admission and identical discharge times.

Changes in COVID-19 Vaccine Intent From April/May to June/July 2021

This study uses data from a nationally representative longitudinal study of adults in the US to examine individual-level change in vaccine intent and uptake between April and July 2021.

Likelihood of COVID-19 vaccination by subgroups across the US: post-election trends and disparities

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately impacted older individuals, those with lower educational attainment, and Black and Hispanic populations, yet vaccine hesitancy remains prevalent. Because widespread uptake of COVID-19 vaccines is critical to end the pandemic, addressing vaccine hesitancy is an important public health priority. Between April 1, 2020 and March 16, 2021, we have repeatedly surveyed a nationally representative online panel of adults and have tracked their stated likelihood of getting COVID-19 vaccinations. We present new evidence that in recent months disparities in self-reported likelihood of COVID-19 vaccination have narrowed by race/ethnicity, with an increasing proportion of Black individuals and Hispanic individuals indicating that they are likely to get a vaccine. At the same time, younger adults have progressively become less likely than older adults to state they will get a COVID-19 vaccine. Most vaccine-hesitant individuals are concerned about both vaccine efficacy and safety and do not trust the vaccine development or vaccine approval process. We conclude that outreach efforts to minority populations may be achieving their objectives in raising confidence in COVID-19 vaccines, but special outreach efforts are needed to address both vaccine hesitancy among younger adults and mistrust in the vaccine development and approval process.

Centralized Reminder/Recall for Human Papillomavirus Vaccination: Findings From Two States-A Randomized Clinical Trial

PURPOSE

Centralized reminder/recall (C-R/R) using Immunization Information Systems has been effective in increasing childhood immunization rates. Previously, C-R/R using autodialer for human papillomavirus (HPV) vaccine did not raise rates. We assessed C-R/R for HPV vaccine using other modalities and focused on younger adolescents.

METHODS

We conducted a three-arm pragmatic RCT in randomly sampled primary care practices in Colorado (n = 88) and New York (n = 136), proportionate to where adolescents received care. We randomized, within practices, adolescents aged 11-14 years who had not completed the HPV vaccination series to receive C-R/R using different modalities (Colorado: autodialer, mail, or control; New York: autodialer, text, or control). Up to two reminders were sent in intervention arms for each dose needed between 2/2017 and 12/2018.

RESULTS

In Colorado, no significant differences were found for series initiation (31.3% control, 31.1% autodial, 31.8% mail), with slight improvement for series completion in the autodialer arm (29.7% control, 31.1% autodialer, p = .04) but not the mail arm (30.9%, p = .06). No significant differences were found in New York for series initiation (24.1% for all arms) or completion (17.1% control, 16.9% autodial, 17.9% text). Adjusted analyses showed higher completion rates for the autodialer arm in Colorado but not for other arms. In Colorado, C-R/R reduced time to series completion by around 2 months. Cost per adolescent was $1.81 for mail; under $.40 for all other modalities.

CONCLUSIONS

C-R/R has less benefit for raising HPV vaccination rates than other studies have noted for childhood immunizations, although it may quicken series completion at little cost.

Parents' Intentions and Perceptions About COVID-19 Vaccination for Their Children: Results From a National Survey

OBJECTIVES

Assess the degree to which US parents are likely to have their children get coronavirus disease 2019 (COVID-19) vaccines and identify parental concerns about the vaccines.

METHODS

In February 2021 to March 2021, we surveyed parent members of a nationally representative probability-based Internet panel of ∼9000 adults regarding their intent to have their children receive a COVID-19 vaccination, perceptions of COVID-19 vaccines for children, and trust in sources of information about COVID-19 vaccines for children. We used descriptive and multivariate analyses to evaluate parent-stated likelihood of having their children get a COVID-19 vaccine and to assess the association between likelihood of child COVID-19 vaccination and child age, parent demographics, and parental perceptions about COVID-19 vaccines.

RESULTS

Altogether, 1745 parents responded (87% of eligible parents, 3759 children). Likelihood of child COVID-19 vaccination was as follows: very likely (28%), somewhat likely (18%), somewhat unlikely (9%), very unlikely (33%), and unsure (12%). The stated likelihood of child vaccination was greater among parents of older children (P < .001) as well as among parents who had a bachelor's degree or higher education (P < .001), had already received or were likely to receive a COVID-19 vaccine (P < .001), or had Democratic affiliation (P < .001); variations existed by race and ethnicity (P = .04). Parental concerns centered around vaccine safety and side effects. A key trusted source of information about COVID-19 vaccines for children was the child's doctor.

CONCLUSIONS

Less than one-half of US participants report that they are likely to have their child receive a COVID-19 vaccine. Pediatric health care providers have a major role in promoting and giving COVID-19 vaccination for children.

Behavioural nudges increase COVID-19 vaccinations

Enhancing vaccine uptake is a critical public health challenge1. Overcoming vaccine hesitancy2,3 and failure to follow through on vaccination intentions3 requires effective communication strategies3,4. Here we present two sequential randomized controlled trials to test the effect of behavioural interventions on the uptake of COVID-19 vaccines. We designed text-based reminders that make vaccination salient and easy, and delivered them to participants drawn from a healthcare system one day (first randomized controlled trial) (n = 93,354 participants; clinicaltrials number NCT04800965) and eight days (second randomized controlled trial) (n = 67,092 individuals; clinicaltrials number NCT04801524) after they received a notification of vaccine eligibility. The first reminder boosted appointment and vaccination rates within the healthcare system by 6.07 (84%) and 3.57 (26%) percentage points, respectively; the second reminder increased those outcomes by 1.65 and 1.06 percentage points, respectively. The first reminder had a greater effect when it was designed to make participants feel ownership of the vaccine dose. However, we found no evidence that combining the first reminder with a video-based information intervention designed to address vaccine hesitancy heightened its effect. We performed online studies (n = 3,181 participants) to examine vaccination intentions, which revealed patterns that diverged from those of the first randomized controlled trial; this underscores the importance of pilot-testing interventions in the field. Our findings inform the design of behavioural nudges for promoting health decisions5, and highlight the value of making vaccination easy and inducing feelings of ownership over vaccines.

The Association of Broadband Internet Access and Telemedicine Utilization in rural Western Tennessee: an observational study

Background

Broadband access has been highlighted as a national policy priority to improve access to care in rural communities.

Objective

To determine whether broadband internet availability was associated with telemedicine adoption among a rural patient population in western Tennessee.

Methods

Observational study using electronic medical record data from March 13th, 2019 to March 13th, 2021. Multivariable logistic regression incorporating individual-level characteristics with broadband availability, income, educational attainment, and primary care physician supply at the zip code level, and rural status as determined at the county level.

Setting

Single health system in western Tennessee.

Participants

Adult patients with one or more in-person or remote encounter in a health system in western Tennessee and residing in western Tennessee between March 13th, 2019 and March 13th, 2021 (N = 54,688).

Outcome measures

Completion of one or more video encounters in the year following March 13th, 2020 (N = 3199; 7%). Our primary characteristic of interest was the proportion of residents in each zip code with access to the internet meeting the Federal Communications Commission definition of broadband access, adjusting for age, gender, race, income, educational attainment, insurance type, rural status, and primary care provider supply.

Results

Patients in a rural western Tennessee health system were predominantly white (79%), residing in rural zip codes (73%) with median household incomes ($52,085) less than state and national averages. Patients residing in a zip code where there is 80 to 100% broadband access compared to 0 to 20% were more likely in the year following March 13th, 2020 to have completed both telemedicine and in-person visits ([OR; 95% CI] 1.57; 1.29, 1.94), completed only telemedicine visits (2.26; 1.71, 2.97), less likely to have only completed in-person visits (0.81; 0.74, 0.89), but no more or less likely to have accessed no care (1.07; 0.97, 1.18).

Discussion

The availability of broadband internet was shown to be one of many factors associated with the utilization of telemedicine for a rural, working-class community after March 13th, 2020.

Conclusions

Access to broadband internet is a determinant of access to telemedicine for patients in rural communities and should be a priority for policymakers interested in improving health and access to care for rural patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06746-0.

Performance of Deep Learning and Genitourinary Radiologists in Detection of Prostate Cancer Using 3-T Multiparametric Magnetic Resonance Imaging

BACKGROUND

Several deep learning-based techniques have been developed for prostate cancer (PCa) detection using multiparametric magnetic resonance imaging (mpMRI), but few of them have been rigorously evaluated relative to radiologists' performance or whole-mount histopathology (WMHP).

PURPOSE

To compare the performance of a previously proposed deep learning algorithm, FocalNet, and expert radiologists in the detection of PCa on mpMRI with WMHP as the reference.

STUDY TYPE

Retrospective, single-center study.

SUBJECTS

A total of 553 patients (development cohort: 427 patients; evaluation cohort: 126 patients) who underwent 3-T mpMRI prior to radical prostatectomy from October 2010 to February 2018.

FIELD STRENGTH/SEQUENCE

3-T, T2-weighted imaging and diffusion-weighted imaging.

ASSESSMENT

FocalNet was trained on the development cohort to predict PCa locations by detection points, with a confidence value for each point, on the evaluation cohort. Four fellowship-trained genitourinary (GU) radiologists independently evaluated the evaluation cohort to detect suspicious PCa foci, annotate detection point locations, and assign a five-point suspicion score (1: least suspicious, 5: most suspicious) for each annotated detection point. The PCa detection performance of FocalNet and radiologists were evaluated by the lesion detection sensitivity vs. the number of false-positive detections at different thresholds on suspicion scores. Clinically significant lesions: Gleason Group (GG) ≥ 2 or pathological size ≥ 10 mm. Index lesions: the highest GG and the largest pathological size (secondary).

STATISTICAL TESTS

Bootstrap hypothesis test for the detection sensitivity between radiologists and FocalNet.

RESULTS

For the overall differential detection sensitivity, FocalNet was 5.1% and 4.7% below the radiologists for clinically significant and index lesions, respectively; however, the differences were not statistically significant (P = 0.413 and P = 0.282, respectively).

DATA CONCLUSION

FocalNet achieved slightly lower but not statistically significant PCa detection performance compared with GU radiologists. Compared with radiologists, FocalNet demonstrated similar detection performance for a highly sensitive setting (suspicion score ≥ 1) or a highly specific setting (suspicion score = 5), while lower performance in between.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2.

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.

Patient Portal Reminders for Pediatric Influenza Vaccinations: A Randomized Clinical Trial

OBJECTIVES

In a large health system, we evaluated the effectiveness of electronic health record patient portal reminders in increasing pediatric influenza vaccination rates.

METHODS

We conducted an intention-to-treat randomized clinical trial of 22 046 children from 6 months to <18 years of age in 53 primary care practices. Patients (or parent and/or proxies) who were active portal users were randomly assigned to receive reminder messages framed as gains or losses or no messages. They were separately randomly assigned to receive a precommitment message before the influenza season. The primary outcome was receipt of ≥1 seasonal influenza vaccinations. Additionally, children 6 months to <3 years of age due for a second influenza vaccine were randomly assigned to receive a reminder or no reminder for the second vaccination.

RESULTS

First-dose influenza vaccination rates were 56.9% in the control group, 58.0% in the loss-frame reminders group (P = .07), and 58.0% in the gain-frame group (P = .47). Rates were 58.3% in the precommitment group versus 57.0% in the control group (P = .11). Adjusted risk ratios for first vaccination were 1.02 (95% confidence interval [CI]: 1.00-1.04) for loss-frame reminders, 1.01 (95% CI: 0.98-1.05) for gain-frame reminders, and 1.02 (95% CI: 1.00-1.04) for precommitment messages versus controls. Second-dose vaccination rates were 44.1% in the control group and 55.0% in the reminder group, with an adjusted risk ratio of 1.25 (95% CI: 1.07-1.45).

CONCLUSIONS

Patient portal reminders for influenza vaccines in children, whether framed as gains or losses, did not increase first-dose influenza vaccination rates but were highly effective for the second dose of the vaccine.

A System-Wide Population Health Value Approach to Reduce Hospitalization Among Chronic Kidney Disease Patients: an Observational Study

BACKGROUND

Chronic kidney disease (CKD) is a leading cause of healthcare morbidity, utilization, and expenditures nationally, and caring for late-stage CKD populations is complex. Improving health system efficiency could mitigate these outcomes and, in the COVID-19 era, reduce risks of viral exposure.

OBJECTIVE

As part of a system-wide transformation to improve healthcare value among populations with high healthcare utilization and morbidity, UCLA Health evaluated a new patient-centered approach that we hypothesized would reduce inpatient utilization for CKD patients.

DESIGN

For 18 months in 2015-2016 and 12 months in 2017, we conducted an interrupted time series regression analysis to evaluate the intervention's impact on inpatient utilization. We used internal electronic health records and claims data across six payers.

PARTICIPANTS

A total of 1442 stage 4-5 CKD patients at a large academic medical center.

INTERVENTION

Between October and December 2016, the organization implemented a Population Health Value CKD intervention for the CKD stages 4-5 population. A multispecialty leadership team risk stratified the population and identified improvement opportunities, redesigned multispecialty care coordination pathways across settings, and developed greater ambulatory infrastructure to support care needs.

MAIN MEASURES

Outcomes included utilization of hospitalizations, emergency department (ED) visits, inpatient bed days, and 30-day all-cause readmissions.

KEY RESULTS

During the 12 months following intervention implementation, the monthly estimated rate of decline for hospitalizations was 5.4% (95% CI: 3.4-7.4%), which was 3.4 percentage points faster than the 18-month pre-intervention decline of 2.0% (95% CI: 1.0-2.2%) per month (p = 0.004). Medicare CKD patients' monthly ED visit rate of decline was 3.0% (95% CI: 1.2-4.8%) after intervention, which was 2.6 percentage points faster than the pre-intervention decline of 0.4% (95% CI: - 0.8 to 1.6%) per month (p = 0.02).

CONCLUSIONS

By creating care pathways that link primary and specialty care teams across settings with increased ambulatory infrastructure, healthcare systems have potential to reduce inpatient healthcare utilization.

Botulinum Toxin Type A for the Treatment of Post-traumatic Headache: A Randomized, Placebo-Controlled, Cross-over Study

INTRODUCTION

Botulinum toxin type A (BoNT/A) is an approved treatment for chronic migraine and has been shown to be effective in reducing number, days, and severity of headache in other headache disorders. Whether botulinum toxin is a safe and effective treatment specifically for post-traumatic headache (PTH), however, is unknown. This study sought to determine whether treatment with BoNT/A improved symptoms of PTH in military veterans.

MATERIALS AND METHODS

Forty subjects with PTH were randomized to receive treatment of either BoNT/A or a saline placebo. Sixteen weeks post-treatment or at return to baseline headache severity, subjects were crossed over to receive treatment with the other medication than previously treated with in the first session. Subjects recorded number of headaches, number of headache days, and headache pain severity in daily diaries. Outcome measures included change in the weekly number of headaches, number of headache days per week, and headache pain severity compared to baseline, and the change in number of headaches and number of headaches days at baseline compared to the rating scores averaged across weeks 6-11.

RESULTS

The number of headaches per week significantly decreased by 2.24 (43.3%) with BoNT/A treatment (P < .001) and significantly increased by 1.28 (35.1%) with placebo (P = .02) at the end of the 16 weeks and the difference between groups was also significant (P < .001). The number of headache days per week also significantly decreased by 2.24 (44.4%) at the end of 16 weeks with BoNT/A treatment (P < .001), was not significantly changed with placebo, and the difference between the two groups was significant (P < .001). Both the change in number of headaches and number of headache days averaged across weeks 6-11 compared to baseline were significantly decreased in the BoNT/A group (1.6 and 1.4, respectively) compared to a significant increase of 0.3 in number of weekly headaches and a nonsignificant decrease of 0.1 in number of headache days for the placebo group (P = .048 and P = .005, respectively). Headache pain severity was significantly reduced by 0.06 with botulinum toxin treatment (P = .02) and was not significantly increased by 0.04 in the placebo group with a significant difference between groups (P = .006).

CONCLUSIONS

Treatment with BoNT/A clinically and significantly improved the frequency and pain severity of PTH compared to placebo in military veterans. Limitations of the study include subject dropout, adherence to documenting variables daily in the dairy, and only one treatment of BoNT/A. Strengths include the cross-over study design, which demonstrated that BoNT/A was effective regardless of treatment order. This dataset is the first prospective study to evaluate BoNT/A as an intervention for symptoms of PTH and provides evidence that larger-scale and multiple treatment studies evaluating BoNT/A for this headache type are warranted.

Comparison of Childbirth Delivery Outcomes and Costs of Care Between Women Experiencing vs Not Experiencing Homelessness

IMPORTANCE

Women and families constitute the fastest-growing segments of the homeless population. However, there is limited evidence on whether women experiencing homelessness have poorer childbirth delivery outcomes and higher costs of care compared with women not experiencing homelessness.

OBJECTIVE

To compare childbirth delivery outcomes and costs of care between pregnant women experiencing homelessness vs those not experiencing homelessness.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 15 029 pregnant women experiencing homelessness and 308 242 pregnant women not experiencing homelessness who had a delivery hospitalization in 2014. The study used statewide databases that included all hospital admissions in 3 states (ie, Florida, Massachusetts, and New York). Delivery outcomes and delivery-associated costs were compared between pregnant women experiencing homelessness and those not experiencing homelessness cared for at the same hospital (analyzed using the overlap propensity-score weighting method and multivariable regression models with hospital fixed effects). The Benjamini-Hochberg false discovery rate procedure was used to account for multiple comparisons. Data were analyzed from January 2020 through May 2020.

EXPOSURE

Housing status at delivery hospitalization.

MAIN OUTCOMES AND MEASURES

Outcome variables included obstetric complications (ie, antepartum hemorrhage, placental abnormalities, premature rupture of the membranes, preterm labor, and postpartum hemorrhage), neonatal complications (ie, fetal distress, fetal growth restriction, and stillbirth), delivery method (ie, cesarean delivery), and delivery-associated costs.

RESULTS

Among 15 029 pregnant women experiencing homelessness (mean [SD] age, 28.5 [5.9] years) compared with 308 242 pregnant women not experiencing homelessness (mean [SD] age, 29.4 [5.8] years) within the same hospital, those experiencing homelessness were more likely to experience preterm labor (adjusted probability, 10.5% vs 6.7%; adjusted risk difference [aRD], 3.8%; 95% CI, 1.2%-6.5%; adjusted P = .03) and had higher delivery-associated costs (adjusted costs, $6306 vs $5888; aRD, $417; 95% CI, $156-$680; adjusted P = .02) compared with women not experiencing homelessness. Those experiencing homelessness also had a higher probability of placental abnormalities (adjusted probability, 4.0% vs 2.0%; aRD, 1.9%; 95% CI, 0.4%-3.5%; adjusted P = .053), although this difference was not statistically significant.

CONCLUSIONS AND RELEVANCE

This study found that women experiencing homelessness, compared with those not experiencing homelessness, who had a delivery and were admitted to the same hospital were more likely to experience preterm labor and incurred higher delivery-associated costs. These findings suggest wide disparities in delivery-associated outcomes between women experiencing homelessness and those not experiencing homelessness in the US. The findings highlight the importance for health care professionals to actively screen pregnant women for homelessness during prenatal care visits and coordinate their care with community health programs and social housing programs to make sure their health care needs are met.

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.

Pediatric patient portal use in one health system

OBJECTIVE

The study sought to assess, for children in one large health system, (1) characteristics of active users of the patient portal (≥1 use in prior 12 months), (2) portal use by adolescents, and (3) variations in pediatric patient portal use.

MATERIALS AND METHODS

We analyzed data from the electronic health record regarding pediatric portal use during 2017-2018 across a health system (39 871 pediatric patients).

RESULTS

Altogether, 63.5% of pediatric patients were active portal users. Children (proxies) who were boys, privately insured, white, and spoke English were more likely to be active users. Common uses involved messaging with physicians, medications, allergies, letters, and laboratory results. By 15 years of age, >50% of adolescents used the portal by themselves (without a proxy). Pediatric portal use varied widely across practices.

DISCUSSION

Pediatric or adolescent portal use is quite high, but large variations exist.

CONCLUSION

Use of the portal for pediatric care may reflect varying pediatric patient engagement.

Does carrier fluid reduce low flow drug infusion error from syringe size?

BACKGROUND

Critically ill neonates and pediatric patients commonly require multiple low flow infusions. Volume limitations are imposed by small body habitus and co-morbidities like cardiopulmonary disease, renal failure, or fluid overload. Vascular access is limited by diminutive veins. Maintenance fluids or parenteral nutrition in conjunction with actively titrated infusions such as insulin, fentanyl, prostaglandins, inotropes and vasopressors may necessitate simultaneous infusions using a single lumen to maintain vascular catheter patency. This requirement for multiple titratable infusions requires concentrated medications at low flows, rather than more dilute drugs at higher flows that in combination may volume overload small infants.

AIM

To determine whether carrier fluid reduces variability that variability of low flow drug infusions is proportional to syringe size in pediatric critical care.

METHODS

We assessed concentrations of orange “drug” in a 0.2 mL/h low flow clinical model with blue dyed carrier fluid at 5 mL/h, using 3-, 10-, or 60-mL syringes. A graduated volumetric pipette was used to measure total flow. Mean time to target concentration was 30, 21, and 46 min in 3-, 10-, and 60-mL syringes, respectively (P = 0.42). After achieving target concentration, more dilute drug was delivered by 60-mL (P < 0.001) and 10-mL syringes (P = 0.04) compared to 3-mL syringes. Drug overdoses were observed during the initial 45 min of infusion in 10-and 60-mL syringes. Total volumes infused after target concentration were less in the 60-mL condition compared to 3-mL (P < 0.01) and 10-mL (P < 0.001) syringes.

RESULTS

Linear mixed effects models demonstrated lesser delivered drug concentrations in the initial 30 min by 3-mL compared to 10-and 60-mL syringes (P = 0.005 and P < 0.001, respectively) but greater drug concentrations and total infused drug in the subsequent 30-60 and 60-90 min intervals with the 3- and 10-mL compared to 60-mL syringes.

CONCLUSION

With carrier fluid, larger syringes were associated with significantly less drug delivery, less total volume delivered, and other flow problems in our low flow drug model. Carrier fluid should not be used to compensate for inappropriately large syringes in critical low flow drug infusions.

Prevalence and characteristics of HPV vaccine hesitancy among parents of adolescents across the US

BACKGROUND

While many clinicians encounter parents or adolescents who refuse HPV vaccine, little is known about the prevalence of hesitancy for HPV vaccine nationally or its association with vaccination.

METHODS

In April 2019, we surveyed families with adolescents 11-17 years using a national online panel (Knowledge Panel®) as the sampling frame. We assessed the prevalence of HPV vaccine hesitancy with the validated 9-item Vaccine Hesitancy Scale (VHS). We used multivariate analyses to assess demographic factors associated with HPV vaccine hesitancy. We also assessed practical barriers to receipt of HPV vaccine and the relationship between barriers and hesitancy. Finally, we evaluated the association between both HPV vaccine hesitancy and practical barriers on HPV vaccine receipt or refusal.

RESULTS

2,177 parents out of 4,185 sampled (52%) completed the survey, 2,020 qualified (lived with adolescent). Using a VHS cut-off score > 3 out of 5 points, 23% of US parents were hesitant about HPV vaccine. Hesitancy was lower among those with Hispanic ethnicity. At least one out of five parents disagreed that the HPV vaccine is beneficial for their adolescent, that the vaccine is effective, protects against HPV-related cancers, or that they followed their adolescent's health-care provider's recommendation about the vaccine. Many were concerned about vaccine side effects and the novelty of the vaccine. Adolescents living with vaccine-hesitant parents were less than one-third as likely to have received the vaccine (RR = 0.29, 95% CI 0.24, 0.35) or completed the vaccine series (RR = 0.29, 95% CI 0.23, 0.36), and were 6-fold more likely to have refused the vaccine because of parental vaccine-related concerns (RR = 6.09, 95% CI = 5.26, 7.04). Most practical barriers were independently associated with vaccine receipt but not with vaccine refusal.

CONCLUSIONS

HPV vaccine hesitancy is common nationally and strongly related to both under-vaccination and vaccine refusal.

Parental Hesitancy About Routine Childhood and Influenza Vaccinations: A National Survey

BACKGROUND AND OBJECTIVES

The World Health Organization has designated vaccine hesitancy as 1 of the 10 leading threats to global health, yet there is limited current national data on prevalence of hesitancy among US parents. Among a nationally representative sample of US parents, we aimed to (1) assess and compare prevalence of hesitancy and factors driving hesitancy for routine childhood and influenza vaccination and (2) examine associations between sociodemographic characteristics and hesitancy for routine childhood or influenza vaccination.

METHODS

In February 2019, we surveyed families with children using the largest online panel generating representative US samples. After weighting, we assessed hesitancy using a modified 5-point Vaccine Hesitancy Scale and labeled parents as hesitant if they scored >3.

RESULTS

A total of 2176 of 4445 parents sampled completed the survey (response rate 49%). Hesitancy prevalence was 6.1% for routine childhood and 25.8% for influenza vaccines; 12% strongly and 27% somewhat agreed they had concerns about serious side effects of both routine childhood and influenza vaccines. A total of 70% strongly agreed that routine childhood vaccines are effective versus 26% for influenza vaccine (P < .001). In multivariable models, an educational level lower than a bachelor's degree and household income <400% of the federal poverty level predicted hesitancy about both routine childhood and influenza vaccines.

CONCLUSIONS

Almost 1 in 15 US parents are hesitant about routine childhood vaccines, whereas >1 in 4 are hesitant about influenza vaccine. Furthermore, 1 in 8 parents are concerned about vaccine safety for both routine childhood and influenza vaccines, and only 1 in 4 believe influenza vaccine is effective. Vaccine hesitancy, particularly for influenza vaccine, is prevalent in the United States.

Effect of Patient Portal Reminders Sent by a Health Care System on Influenza Vaccination Rates: A Randomized Clinical Trial

Importance

Influenza vaccination rates across the US are low. Because few practices send patient reminders for influenza vaccination, a scalable patient reminder system is needed.

Objective

To evaluate the effect of patient reminders sent via a health care system's electronic health record patient portal on influenza vaccination rates.

Design, Setting, and Participants

This pragmatic, 4-arm randomized clinical trial was performed from October 1, 2018, to March 31, 2019, across the UCLA (University of California, Los Angeles) health care system. A total of 164 205 patients in 52 primary care practices who had used the patient portal within 12 months were included.

Interventions

Patients due for an influenza vaccine were sent a letter via the patient portal of the health care system reminding them about the importance of influenza vaccination, safety of the vaccine, and morbidity associated with influenza. Patients were randomized within primary care practices to 1 of 4 study groups (no reminder [n = 41 070] vs 1 reminder [n = 41 055], 2 reminders [n = 41 046], or 3 reminders [n = 41 034]).

Main Outcomes and Measures

The primary outcome was receipt of 1 or more influenza vaccines as documented in the electronic health record, which was supplemented with influenza vaccination data from external sources (eg, pharmacies). Secondary outcomes were influenza vaccination rates among subgroups and influenza vaccinations self-reported by patients in reply to the portal-based query as having been received elsewhere.

Results

A total of 164 205 patients (mean [SD] age, 46.2 [19.6] years; 95 779 [58.3%] female) were randomly allocated to 1 of the 4 study arms. In the primary analysis across all ages and not including patient self-reported vaccinations in reply to portal reminders, influenza vaccination rates were 37.5% for those receiving no reminders, 38.0% for those receiving 1 reminder (P = .008 vs no reminder), 38.2% for those receiving 2 reminders (P = .03 vs no reminder), and 38.2% for those receiving 3 reminders (P = .02 vs no reminder). In the secondary analysis not including patient self-reported vaccinations, among adults aged 18 to 64 years (vaccination rates: 32.0% in the control group, 32.8% in the 1-reminder group, 32.8% in the 2-reminder group, and 32.8% in the 3-reminder group; P = .001), male patients (vaccination rates: 37.3% vs 38.3%, 38.6%, and 38.8%; P = .001), non-Hispanic patients (vaccination rates: 37.6% vs 38.2%, 38.3%, and 38.2%; P = .004), and those who were not vaccinated in the prior 2 years (vaccination rates: 15.3% vs 15.9%, 16.3%, and 16.1%; P < .001), vaccination rates were higher in the portal reminder groups than in the control group; the findings in these 3 subgroups mirrored the findings in the entire population. When self-reported vaccinations received elsewhere were included, influenza vaccination rates were 1.4 to 2.9 percentage points higher in the portal reminder groups, with a dose-response effect (0 reminders: 15 537 [37.8%]; 1 reminder: 16 097 [39.2%]; 2 reminders: 16 426 [40.0%]; and 3 reminders: 16 714 [40.7%]; P < .001).

Conclusions and Relevance

Generic patient portal reminders were effective in minimally increasing influenza vaccination rates, but more intensive or more targeted patient motivational strategies appear to be needed.

Trial Registration

ClinicalTrials.gov Identifier: NCT03666026.