Peer Comparison Research Articles

Keep It Brief and Targeted: Driving Performance Feedback Report Features to Use with Novice Drivers

Driving evaluations aim to ensure adequate skills; however, feedback beyond pass/fail is needed for improvement. Therefore, the goal of this study was to inform driving feedback report design to ensure ease of use and understandability while motivating improvements. Participants ages 18–25 years (n = 521) were recruited from CloudResearch Prime Panels to rate one of nine report design conditions with various combinations of five key features: performance summary presence, action plan (AP) length, AP order, AP grading system, and peer comparison presence; they then completed questionnaires. Participants were more motivated to improve when a summary was present (p = 0.02); they rated reports easier to use if they had a long AP (p = 0.01), a short AP paired with a summary (p = 0.007), or an AP with a number grade (p = 0.016); and they rated reports easier to understand if they had a short AP (p = 0.002) or an AP ordered by worst-to-best performance (p = 0.05). These results suggest that feedback reports designed with a performance summary and short, targeted action plan starting with the biggest area for improvement are likely to motivate action to improve driving skills while being easy to use and understand. Future research should evaluate the effect of such a redesigned report on driving outcomes among young drivers.

Developmental changes in students' use of dimensional comparisons to form ability self-concepts in math and verbal domains.

Dimensional comparisons (i.e., comparing own performances across domains) may drive an increasing differentiation in students' math and verbal self-concepts over time, but little longitudinal research has directly tested this assumption. Using cross-sequential data spanning Grades 1-12 (N=1069, ages 6-18, 92% White, 2% Black, 51% female, collected 1987-1996), this study charted age-related changes in the role of dimensional comparisons in students' ability self-concept formation. It used three types of self-concept measures: peer comparisons, cross-domain comparisons, and no comparisons. Results indicated that the increase in students' use of dimensional comparisons in self-evaluations substantially contributed to the increasing differentiation in students' math and verbal self-concepts over time. Findings highlight the importance of dimensional comparisons in the development of students' ability self-concepts.

Impact of cost-awareness education and surgeon-led positive deviance on intraoperative costs of thoracoscopic lobectomy

ObjectiveDisposable instrument use during video-assisted thoracoscopic lobectomy is a significant driver of cost. The purpose of the study was to measure the effect of increasing surgeon cost awareness via successive “value improvement initiatives” on instrument costs. MethodsWe prospectively collected disposable instrument use data for all video-assisted thoracoscopic lobectomies performed by 5 Board-certified thoracic surgeons over 4 successive time periods: Period 1: control group of consecutive video-assisted thoracoscopic lobectomies before interventions; Period 2: video-assisted thoracoscopic lobectomies after displaying disposables price list in operating room; Period 3: video-assisted thoracoscopic lobectomies after educational presentation outlining disposable instrument price differences; Period 4: video-assisted thoracoscopic lobectomies after surgeon self-assessment with peer comparison of cost data from Period 3 and positive deviance seminar identifying the lowest-cost surgeon to lead discussion of optimal cost-reduction strategies. Instrument use and costs were compared among the 4 groups using the Kruskal–Wallis test. ResultsA total of 373 lobectomy cases were analyzed. Compared with Period 1, median stapler-related and total disposable costs for video-assisted thoracoscopic lobectomy cases decreased after successive value improvement initiatives, with lowest costs in Period 4 (P < .0001). Multiple linear regression analysis demonstrated per lobectomy disposables cost reduction of $397.53 in Period 4, after controlling for surgeon and lobe (P < .0001). Operating room time was reduced after successive value improvement initiatives (P < .0001). ConclusionsCost awareness and surgeon engagement activities were associated with sustained cost reduction for video-assisted thoracoscopic lobectomies. Surgeon self-assessment, peer comparison, and positive deviance seminar were associated with the largest cost reduction. Significant hospital cost-savings may be realized with surgeon-led value improvement initiatives.

Lights, Camera, Action: How CEO Relative Pay Influences Firm Competitive Aggressiveness

By integrating ideas from upper echelons and relative deprivation theory, we extend the work on the microfoundations of the behavioral theory of the firm to articulate how deviations from a CEO’s personal aspirations can impact firm behavior. Specifically, we explore how CEO pay relative to peers impacts the firm’s competitive aggressiveness. We theorize that CEOs’ peer comparisons and need for visibility motivate them to chase the next higher level, suggesting that unlike firms that have relatively stable aspiration groups based on factors such as size and industry, CEOs adapt their peer groups to fit their increasing aspiration. We propose industry competitive intensity as a boundary condition to our theory, arguing that it both reduces CEO discretion over competitive repertoires and increases self-evaluation that reduces the impact of cognitive biases. Our empirical analysis of 1,536 firms and 92,018 competitive actions over a 15-year time span provided strong support for our hypotheses.

The impact of opioid prescribing report cards in Medicaid.

BACKGROUND: Performance feedback has been used for decades to improve health care quality and safety, with varying degrees of success. One example is the use of customized report cards that target inappropriate prescribing of high-risk medications, including opioids. Randomized controlled trials suggest that report cards are an effective tool to change opioid prescribing behavior, but their effectiveness in community settings is unclear. OBJECTIVE: To evaluate the impact of opioid prescribing report cards, which were mailed to Medicaid providers in Philadelphia, Pennsylvania. METHODS: Using a quasi-experimental approach, we compared trends in opioid prescribing by Medicaid providers in Philadelphia, who received a report card in late 2017, with Medicaid providers in surrounding counties, who did not receive report cards. First, we used propensity score matching to balance observed differences in the treatment and comparison groups; matching variables included provider specialty, sex, and selected characteristics of providers' Medicaid patient panels. We then estimated a difference-in-differences model to isolate the impact of report cards on opioid prescribing. RESULTS: The analytical sample included 1,598 providers in Philadelphia and 2,117 providers in surrounding counties, who prescribed opioids to 99,548 Medicaid patients during the study period. Although the number of Medicaid patients receiving opioids and the days supplied of opioids declined in both Philadelphia and surrounding counties during the study period, there was a larger reduction in Philadelphia Medicaid than in surrounding counties after the report cards were mailed. In the 6 months after the report cards were mailed (January 2018 to June 2018) compared with the 6 months before they were mailed (July 2017 to December 2017), we estimate that the reduction in opioid prescribing in Philadelphia Medicaid amounted to nearly 3 fewer Medicaid patients with an opioid prescription per month. CONCLUSIONS: After customized opioid prescribing report cards were mailed to Medicaid providers in Philadelphia, Pennsylvania, there was a statistically significant reduction in opioid prescribing to Medicaid patients relative to surrounding counties. Our findings suggest that opioid prescribing report cards with peer comparison are an effective way to influence opioid prescribing behavior among Medicaid providers. Report cards can complement other initiatives that target inappropriate opioid prescribing, such as prescription drug monitoring programs and prior authorization. DISCLOSURES: Drs Candon and Rothbard and Ms Shen received funding from Community Behavioral Health in Philadelphia, Pennsylvania. Drs Xue, Cole, and Donohue received funding from Pennsylvania Department of Human Services. Neither Community Behavioral Health nor the Pennsylvania Department of Human Services was involved in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication.

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

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

The effect of non-punitive peer comparison and performance feedback on drivers' behavior using the telematics: The first randomized trial in Iran

Background: Aggressive driving is the leading behavior resulting in fatal or nonfatal disabling injuries. Therefore, programs with the main focus on driving behavior could reduce the risk of traffic injuries remarkably. We aimed to investigate the role of non-punitive performance feedback on drivers' behavior and evaluate the persistence of the altered behavior by using in-vehicle telematics. Methods: This study was done as a randomized controlled trial by repeated-measures design to evaluate the non-punitive behavioral intervention's efficacy on the behavioral transition to safer driving for 1,289 bus and 104 taxi drivers. All participants were studied during 17 weeks through three stages: stage 0 (five weeks for collecting the baseline characteristics of the participants), stage 1 (nine weeks for randomizing the participants into intervention group or control group and sending the intervention group feedback via short message service), and stage 2 (three weeks for following-up the participants without sending feedback). The intervention group drivers received weekly text messages about the driving score and drivers' rank within their peer group.The study's primary outcome was the driver score changing pattern throughout the study calculated by a neuro-fuzzy scoring system composed of four factors: speed violation, harsh acceleration, harsh braking, and harsh turning. Results: Among the bus drivers, a significant positive effect of the intervention was found in stage 1 (P<0.0001) and in stage 2 (P<0.0001) regarding the calculated scoring system. Among the taxi drivers, a significant positive effect of the intervention was found in stage 1 (P<0.0001), but the effect was not significant in stage 2 (P=0.15). Conclusion: The results of this study were in favor of using telematics and its positive effect on driving performance. The reformed behavior persisted even after the intervention ceased. Practical Application: Behavioral interventions could be considered a promising strategy to enhance and promote safe driving performance.

The Golden Mean: The Risk‐Mitigating Effect of Combining Tournament Rewards with High‐Powered Incentives

The rewards received by financial managers depend on both relative performance - e.g., fund infows based on league table rankings, executive promotions based on peer comparisons - and absolute performance - e.g., bonus payments for meeting accounting targets, hedge-fund incentive fees. It is well known that both relative and absolute performance rewards engender risk taking. In this paper, we show that these two sources of risk taking, relative and absolute performance rewards, mollify the risk-taking incentives produced by the other: absolute performance rewards mitigate rank-motivated risk taking. Rank rewards mitigate risk taking motivated by absolute performance rewards.

When peer comparison information harms physician well-being

Policymakers and business leaders often use peer comparison information-showing people how their behavior compares to that of their peers-to motivate a range of behaviors. Despite their widespread use, the potential impact of peer comparison interventions on recipients' well-being is largely unknown. We conducted a 5-mo field experiment involving 199 primary care physicians and 46,631 patients to examine the impact of a peer comparison intervention on physicians' job performance, job satisfaction, and burnout. We varied whether physicians received information about their preventive care performance compared to that of other physicians in the same health system. Our analyses reveal that our implementation of peer comparison did not significantly improve physicians' preventive care performance, but it did significantly decrease job satisfaction and increase burnout, with the effect on job satisfaction persisting for at least 4 mo after the intervention had been discontinued. Quantitative and qualitative evidence on the mechanisms underlying these unanticipated negative effects suggest that the intervention inadvertently signaled a lack of support from leadership. Consistent with this account, providing leaders with training on how to support physicians mitigated the negative effects on well-being. Our research uncovers a critical potential downside of peer comparison interventions, highlights the importance of evaluating the psychological costs of behavioral interventions, and points to how a complementary intervention-leadership support training-can mitigate these costs.

How do disparate urbanization and climate change imprint on urban thermal variations? A comparison between two dynamic cities in Southeast Asia

This study assessed the combined influences of climate change and urbanization on land surface temperature (LST) and surface urban heat island (SUHI) in the Bangkok metropolitan region (BKK) and Ho Chi Minh City metropolitan area (HCM) during 1990–2020. We found climate change evidence from trends and variations of temperature extremes in both cities throughout the past three decades, especially for the significant upward trends of nighttime temperature in HCM (0.23 – 0.3 °C/decade). These cities have been undergoing rapid urbanization, in which HCM has a higher urbanization rate with an annual growth rate of 8.03%/year against BKK (4.26%/year). Landscape metrics have rapidly shifted towards urban aggregation and green space fragmentation along with urbanization. A peer comparison shows that BKK holds a greater urban size and LST intensity, while HCM leads in urban growth and SUHI magnitude. These changes jointly contribute to climbing SUHI intensity, especially the dramatic influence of surface changes. Yet, temperature extremes also play an indispensable role in regulating SUHI magnitude, in which the impact in HCM is considerable compared to the effect in BKK. The research findings provide crucial information for both cities – where incorporation of climate change resilience strategies and SUHI mitigation into the master plans for livable cities are recommended.

The protocol of improving safe antibiotic prescribing in telehealth: A randomized trial

BackgroundThe CDC estimates that over 40% of Urgent Care visits are for acute respiratory infections (ARI), more than half involving inappropriate antibiotic prescriptions. Previous randomized trials in primary care clinics resulted in reductions in inappropriate antibiotic prescribing, but antibiotic stewardship interventions in telehealth have not been systematically assessed. To better understand how best to decrease inappropriate antibiotic prescribing for ARIs in telehealth, we are conducting a large randomized quality improvement trial testing both patient- and physician-facing feedback and behavioral nudges embedded in the electronic health record. MethodsTeladoc® clinicians are assigned to one of 9 arms in a 3 × 3 randomized trial. Each clinician is assigned to one of 3 Commitment groups (Public, Private, Control) and one of 3 Performance Feedback groups (Benchmark Peer Comparison, Trending, Control). After randomly selecting ⅓ of states and associated clinicians required for patient-facing components of the Public Commitment intervention, remaining clinicians are randomized to the Control and Private Commitment arms. Clinicians are randomized to the Performance Feedback conditions. The primary outcome is change from baseline in antibiotic prescribing rate for qualifying ARI visits. Secondary outcomes include changes in inappropriate prescribing and revisit rates. Secondary analyses include investigation of heterogeneity of treatment effects. With 1530 clinicians and an intra-clinician correlation in antibiotic prescribing rate of 0.5, we have >80% power to detect 1–7% absolute differences in antibiotic prescribing among groups. DiscussionFindings from this trial may help inform telehealth stewardship strategies, determine whether significant differences exist between Commitment and Feedback interventions, and provide guidance for clinicians and patients to encourage safe and effective antibiotic use.ClinicalTrials.gov: NCT05138874.

Use of Actors or Peers as Simulated Clients in Veterinary Communication Training.

Using simulated clients is an effective teaching method for training and assessing communication skills in veterinary education. The aim of this study is to evaluate the use of actors and peers in communication skills training in veterinary medicine. For this purpose, the subjective perception of the use of actors was assessed in a first study using a paper-based self-evaluation survey. In a second study, different groups of veterinary students who trained their communication skills with actors or peers were compared in an electronic Objective Structured Clinical Examination (eOSCE) assessment with regard to their outcomes of communication proficiency. All participants reported the actors to be helpful and supportive in learning communication skills. Above all, participants highly rated the achieved authenticity when using actors as well as feedback sessions. Regarding the comparison of actors and peers as teaching methods, no significant difference in the performance of veterinary students in an eOSCE was identified. Despite the lack of objective evidence, both methods may be considered valuable and accepted teaching tools. Training with peers gives students an opportunity to learn how to conduct structured history interviews and to understand pet owners' motives at an early stage of undergraduate veterinary training. Change of perspective is considered a positive training element. However, when portraying authentic and standardized emotions and reactions and giving formative feedback based on the pet owners' internal perspectives, actors are beneficial for training advanced veterinary students and graduates in difficult conversation topics.

Sigma metrics in laboratory medicine: A call for harmonization

Background and aimSigma metrics are applied in clinical laboratories to assess the quality of analytical processes. A parameter associated to a Sigma > 6 is considered “world class” whereas a Sigma < 3 is “poor” or “unacceptable”. The aim of this retrospective study was to quantify the impact of different approaches for Sigma metrics calculation. Material and methodsTwo IQC levels of 20 different parameters were evaluated for a 12–month period. Sigma metrics were calculated using the formula: (allowable total error (TEa) (%) – bias (%))/(coefficient of variation (CV) (%)). Method precision was calculated monthly or annually. The bias was obtained from peer comparison program (PCP) or external quality assessment program (EQAP), and 9 different TEa sources were included. ResultsThere was a substantial monthly variation of Sigma metrics for all combinations, with a median variation of 32% (IQR, 25.6–41.3%). Variation across multiple analyzers and IQC levels were also observed. Furthermore, TEa source had the highest impact on Sigma calculation with proportions of Sigma > 6 ranging from 17.5% to 84.4%. The nature of bias was less decisive. ConclusionIn absence of a clear consensus, we recommend that laboratories calculate Sigma metrics on a sufficiently long period of time (>6 months) and carefully evaluate the choice of TEa source.

The Impact of Dynamic Real-Time Feedback on Patient Satisfaction Scores.

Providers' communication skills have a significant impact on patients' satisfaction. Improved patients' satisfaction has been positively correlated with various healthcare and financial outcomes. Patients' satisfaction in the inpatient setting is measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. In this study, we evaluated the impact of dynamic real-time feedback to the providers on the HCAHPS scores. This was a randomized study conducted at our 550-bed level-1 tertiary care center. Twenty-six out of 27 hospitalists staffing our 12 medicine teams (including teams containing advanced practice providers (APPs) and house-staff teams) were randomized into intervention and control groups. Our research assistant interviewed 1110 patients over a period of 7 months and asked them the three provider communication-specific questions from the HCAHPS survey. Our intervention was a daily computer-generated email which alerted providers to their performance on HCAHPS questions (proportions of "always" responses) along with the performance of their peers and Medicare benchmarks. The intervention and control groups were similar with regard to baseline HCAHPS scores and clinical experience. The proportion of "always" responses to the three questions related to provider communication was statistically significantly higher in the intervention group compared to the control group (86% vs 80.5%, p-value 0.00001). It was also noted that the HCAHPS scores were overall lower on the house-staff teams and higher on the teams with APPs. Real-time patients' feedback to inpatient providers with peer comparison via email has a positive impact on the provider-specific HCAHPS scores.

Oncologist Peer Comparisons as a Behavioral Science Strategy to Improve Hospice Utilization.

Hospice utilization metrics are essential for any serious effort to improve end-of-life care in oncology. However, oncologists do not routinely receive these personalized reports. We evaluated whether a behavioral science intervention, using peer comparisons coupled with social norms, was associated with improvements in hospice use. Oncologists at two academic practices of Johns Hopkins Medicine were randomly assigned to receive a peer comparison report by e-mail displaying individual hospice utilization metrics compared with top-performing peers or to receive no report. The data accrued for the intervention represented hospice utilization for the previous calendar year. The intervention period was from June 1, 2020, to December 30, 2020, and included oncologists from both the solid and hematologic malignancies programs. The primary outcome was the proportion of patients between groups with short hospice length of stay (LOS; defined as ≤ 7 days) after 6 months. Secondary outcomes included hospice referral rate, enrollment rate, and median LOS. Forty-seven oncologists participated. The percent of patients with a short hospice stay in the intervention group was lower (17.4%) compared with patients treated by physicians in the usual care group (46.3%, difference = 21.8%; 95% CI, 16.0 to 41.6; P < .001). Receipt of peer comparisons was associated with a greater likelihood of enrolling in hospice (73.7% v 42.8%; difference = 31.1%; 95% CI, 20.4 to 41.7; P < .001) and a longer hospice LOS (37.2 v 18.3 days; difference = 17.2; 95% CI, 8.8 to 25.7 days; P < .001). Peer comparisons improved hospice utilization metrics among a group of academic oncologists. Behavioral science offers one pragmatic strategy to overcome suboptimal oncologist decision-making biases related to hospice use.

Addressing the Drivers of Medical Test Overuse and Cascades: User-Centered Design to Improve Patient-Doctor Communication.

Low-value medical testing is a major component of health care overuse, both directly and through the potential for borderline and/or incidental results to trigger cascades (downstream services of uncertain value). The costs and harms from marginal test results and their cascades can add up. It is thus important to both prevent low-value tests at the outset and mitigate cascades when they arise. Informed by a framework for understanding and reducing overuse of care, this study employed user-centered design methods (focus groups and 1:1 design meetings) with patients and primary care physicians (PCPs) to understand the problem and iteratively develop an intervention. Design meetings with 15 PCPs, 12 patients, and 3 patient focus groups revealed myriad drivers for medical test overuse and cascades. Patients commonly believed that all medical tests yield definitive results and lack downsides. PCPs cited expert recommendations, limited time during visits, fear of lawsuits, and desire to be responsive to patients as reasons for ordering potentially low-value medical tests. To address these issues, an intervention was designed using patient pre-visit educational materials, clinician reference materials on test interpretation and incidental findings, and clinician peer comparison on test overuse. Overuse of medical testing is driven by a range of factors related to PCPs, patients, and their interactions. Multipronged interventions may have the potential to address these drivers after they are rigorously tested.

Implementation of a pilot novel objective peer comparison evaluation system in an emergency medicine residency program.

Emergency medicine (EM) residents are currently evaluated via The Milestones, which have been shown to be imperfect and subjective. There is also a need for residents to achieve competency in patient safety and quality improvement processes, which can be accomplished through provision of peer comparison metrics. This pilot study aimed to evaluate the implementation of an objective peer comparison system for metrics that quantified aspects of quality and safety, efficiency and throughput, and utilization. This pilot study took place at an academic, tertiary care center with a 3-year residency and 14 residents per postgraduate year (PGY) class. Metrics were compared within each PGY class using Wilcoxon signed-rank and rank-order analyses. Significant changes were seen in the majority of the metrics for all PGY classes. PGY3s accounted for the significant change in EKG and X-ray reads, while PGY1s and PGY2s accounted for the significant change in disposition to final note share. Physician evaluation to disposition decision was the only metric that did not reach significance in any class. These preliminary data suggest that providing objective metrics is possible. Peer comparison metrics could provide an effective objective addition to the milestone evaluation system currently in use.

Revisiting the Socratic method of teaching to improve third-year pharmacy students critical thinking and advanced pharmacy practice experience readiness in a critical care elective

BackgroundOne of the most important abilities we look to nurture and develop in pharmacy students is critical thinking. A critical care elective course was re-designed to optimize high-pressure situations to engage and target critical thinking, clinical reasoning, and advanced pharmacy practice experience (APPE) readiness using the Socratic method of teaching. Educational activityPharmacy students at Loma Linda University School of Pharmacy were selected and exposed to a high-pressure classroom environment with each day structured around the Socratic method of teaching. Pass/fail grades were earned daily based solely on verbal responses and discussions. The assessment tools used were: Health Sciences and Reasoning Test (HSRT) to measure critical thinking, an APPE-readiness survey of the entire third-year class for peer comparison, and a survey of the style and pedagogies used. Critical analysis of the educational activityThe elective students showed noteworthy gains on their HSRT results in an eight-week critical care elective course. They also had significantly more positive responses on the APPE-readiness survey relative to their classmates and rated this teaching style higher than a typical course. Revisiting and applying the Socratic method of teaching in a high-pressure course is an effective way to engage pharmacy students, producing substantial improvements in critical thinking, clinical reasoning, and APPE readiness in a short time. Lastly, it offers one way to incorporate a validated tool to measure critical thinking in pharmacy students for institutional assessment and accreditation that is widely available, easy to use, and cost friendly.

Rapid On-Site Evaluation Technical Exercise Using Digital Pathology: Peer Comparison in an External Quality Assurance Setting

Background: The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP) is a world leader in the provision of external quality assurance (EQA) for pathology laboratories. The development and delivery of new programmes are designed to meet the evolving needs of our participants and pathology practice. A cytopathology technical programme was established in 2018 to provide proficiency testing in routine cytopreparatory techniques. The cytopathology technical pilot focused on standard operating procedures and laboratory performance during rapid on-site evaluation (ROSE). The exercise aimed to assess the diagnostic adequacy and provide technical recommendations on each of the whole slide images from four fine-needle aspiration biopsy (FNAB) samples of the thyroid in a setting of ROSE. Methods: Four whole slide imaging cases, each comprising one Diff-Quik^TM stained preparation of an FNAB of the thyroid, were provided to all laboratories currently enrolled in the RCPAQAP Cytopathology diagnostic programmes. Each scanned image represented one slide from the first pass collected by a radiologist under ultrasound guidance. Participating laboratories were encouraged to distribute the exercise to individual staff members who attend ROSE procedures. A laboratory practice questionnaire was also conducted. Results: There were a total of 186 submissions received for the assessment across the four virtual cases provided. Although the assessment of on-site adequacy by participants showed high concordance across some of the cases, there was variation in the initial diagnostic evaluation and technical recommendation. Conclusions: ROSE has been adopted as a standard procedure in many laboratories worldwide. A peer comparison of participating laboratories in an EQA exercise has highlighted ROSE as susceptible to variation across standard operating procedures, the provision of diagnostic adequacy, diagnostic feedback to the attending clinician, and technical recommendation.

Behavioral Nudges to Improve Audit and Feedback Report Opening Among Antibiotic Prescribers: A Randomized Controlled Trial.

BackgroundPeer comparison audit and feedback has demonstrated effectiveness in improving antibiotic prescribing practices, but only a minority of prescribers view their reports. We rigorously tested 3 behavioral nudging techniques delivered by email to improve report opening.MethodsWe conducted a pragmatic randomized controlled trial among Ontario long-term care prescribers enrolled in an ongoing peer comparison audit and feedback program which includes data on their antibiotic prescribing patterns. Physicians were randomized to 1 of 8 possible sequences of intervention/control allocation to 3 different behavioral email nudges: a social peer comparison nudge (January 2020), a maintenance of professional certification incentive nudge (October 2020), and a prior participation nudge (January 2021). The primary outcome was feedback report opening; the primary analysis pooled the effects of all 3 nudging interventions.ResultsThe trial included 421 physicians caring for >28 000 residents at 450 facilities. In the pooled analysis, physicians opened only 29.6% of intervention and 23.9% of control reports (odds ratio [OR], 1.51 [95% confidence interval {CI}, 1.10–2.07], P = .011); this difference remained significant after accounting for physician characteristics and clustering (adjusted OR [aOR], 1.74 [95% CI, 1.24–2.45], P = .0014). Of individual nudging techniques, the prior participation nudge was associated with a significant increase in report opening (OR, 1.62 [95% CI, 1.06–2.47], P = .026; aOR, 2.16 [95% CI, 1.33–3.50], P = .0018). In the pooled analysis, nudges were also associated with accessing more report pages (aOR, 1.28 [95% CI, 1.14–1.43], P < .001).ConclusionsEnhanced nudging strategies modestly improved report opening, but more work is needed to optimize physician engagement with audit and feedback.Clinical Trials RegistrationNCT04187742.