Peer Comparison Research Articles

What drives project success in online labour markets? A bilateral perspective on freelancers and clients

ABSTRACT Despite some advantages over traditional (offline) labour markets – such as lower search costs, better matching and improved monitoring – online labour markets (OLMs) have not taken off as initially expected. In this paper, we study the challenges of managing projects in OLMs and discuss factors that limit perceived success both from the perspective of the employer and the freelancer. Using psychological contract theory, we theorise how common OLM features including contracts with virtual monitoring, multi-freelancer projects, and simultaneous projects by a client trigger the perception of psychological contract breach among OLM participants and reduce perceived project success for both participants. We test these hypotheses using an extensive dataset with more than 143,000 transactions on the world’s largest freelancing platform, Upwork, and find that – contrary to predictions from agency theory – projects equipped with strict freelancer monitoring (hourly-pay contracts) and projects enabling peer comparison (multi-freelancer projects or multiple simultaneous projects), lead to lower perceived project success both from the freelancer’s and the client’s perspective. Our work implies that transactions on online labour markets should not be viewed solely as agency relations, and that some features that supposedly reduce agency costs and improve efficiency on OLMs come at the cost of triggering the perception of psychological contract breach.

Financial well-being and capability of widening participation students and a text message intervention to improve it

University students are frequently cited as having some of the poorest financial well-being of the adult population, particularly those from widening participation backgrounds. Therefore, in a randomised controlled field experiment in 15 higher education institutions in England, we examine the impact of a light-touch text message intervention (over 10???12 weeks) aimed at improving the financial capability and well-being of widening participation students. The results suggest that such an intervention has little impact on improving financial well-being or capability from baseline levels although some effect was found on improved financial attitudes, peer comparison and information seeking. Overall, such an intervention is too light-touch to have a meaningful impact and future interventions are likely to need to be stronger nudges, perhaps changing the context and cognition simultaneously, if meaningful impacts on financial well-being are to be achieved.

IguideME

Personalized feedback is important for the learning process, but it is time consuming and particularly problematic in large-scale courses. While automatic feedback may help for self-regulated learning, not all forms of feedback are effective. Social comparison offers powerful feedback but is often loosely designed. We propose that intertwining meaningful feedback with well-designed peer comparison using a learning analytics dashboard provides a solution. Third-year bachelor students were randomly assigned to have access to the learning analytics dashboard IguideME (treatment, n=31) or no access (control, n=31). Dashboard users were asked to indicate their desired grade, which was used to construct peer-comparison groups. Personalized peer-comparison feedback was provided via the dashboard. The effects were studied using quantitative and qualitative data, including the Motivated Strategies for Learning Questionnaire (MSLQ) and the Achievement Goal Questionnaire (AGQ). Compared to the control group, the treatment group achieved higher scores for the MSLQ components “metacognitive self-regulation” and “peer learning,” and for the AGQ component “other-approach” (do better than others). The treatment group performed better on reading assignments and achieved higher grades for high-level Bloom exam questions. These data support the hypothesis that personalized peer-comparison feedback can be used to improve self-regulated learning and academic achievement.

Knowledge support for optimising antibiotic prescribing for common infections in general practices: evaluation of the effectiveness of periodic feedback, decision support during consultations and peer comparisons in a cluster randomised trial (BRIT2) – study protocol

IntroductionThis project applies a Learning Healthcare System (LHS) approach to antibiotic prescribing for common infections in primary care. The approach involves iterations of data analysis, feedback to clinicians and implementation...

Developing Evidence for Equitable Assessment Characteristics Based on Clinical Learner Preferences Using Discrete Choice Experiments.

Medical education is only beginning to explore the factors that contribute to equitable assessment in clinical settings. Increasing knowledge about equitable assessment ensures a quality medical education experience that produces an excellent, diverse physician workforce equipped to address the health care disparities facing patients and communities. Through the lens of the Anti-Deficit Achievement framework, the authors aimed to obtain evidence for a model for equitable assessment in clinical training. A discrete choice experiment approach was used which included an instrument with 6 attributes each at 2 levels to reveal learner preferences for the inclusion of each attribute in equitable assessment. Self-identified underrepresented in medicine (UIM) and not underrepresented in medicine (non-UIM) (N = 306) fourth-year medical students and senior residents in medicine, pediatrics, and surgery at 9 institutions across the United States completed the instrument. A mixed-effects logit model was used to determine attributes learners valued most. Participants valued the inclusion of all assessment attributes provided except for peer comparison. The most valued attribute of an equitable assessment was how learner identity, background, and trajectory were appreciated by clinical supervisors. The next most valued attributes were assessment of growth, supervisor bias training, narrative assessments, and assessment of learner's patient care, with participants willing to trade off any of the attributes to get several others. There were no significant differences in value placed on assessment attributes between UIM and non-UIM learners. Residents valued clinical supervisors valuing learner identity, background, and trajectory and clinical supervisor bias training more so than medical students. This study offers support for the components of an antideficit-focused model for equity in assessment and informs efforts to promote UIM learner success and guide equity, diversity, and inclusion initiatives in medical education.

Best practice guidance for antibiotic audit and feedback interventions in primary care: a modified Delphi study from the Joint Programming Initiative on Antimicrobial resistance: Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN)

BackgroundPrimary care is a critical partner for antimicrobial stewardship efforts given its high human antibiotic usage. Peer comparison audit and feedback (A&F) is often used to reduce inappropriate antibiotic prescribing. The design and implementation of A&F may impact its effectiveness. There are no best practice guidelines for peer comparison A&F in antibiotic prescribing in primary care.ObjectiveTo develop best practice guidelines for peer comparison A&F for antibiotic prescribing in primary care in high income countries by leveraging international expertise via the Joint Programming Initiative on Antimicrobial Resistance—Primary Care Antibiotic Audit and Feedback Network.MethodsWe used a modified Delphi process to achieve convergence of expert opinions on best practice statements for peer comparison A&F based on existing evidence and theory. Three rounds were performed, each with online surveys and virtual meetings to enable discussion and rating of each best practice statement. A five-point Likert scale was used to rate consensus with a median threshold score of 4 to indicate a consensus statement.ResultsThe final set of guidelines include 13 best practice statements in four categories: general considerations (n = 3), selecting feedback recipients (n = 1), data and indicator selection (n = 4), and feedback delivery (n = 5).ConclusionWe report an expert-derived best practice recommendations for designing and evaluating peer comparison A&F for antibiotic prescribing in primary care. These 13 statements can be used by A&F designers to optimize the impact of their quality improvement interventions, and improve antibiotic prescribing in primary care.

Assessing trends in breast care surveillance metrics after implementing surgeon-specific tracking and performance reporting in a large, integrated cancer network.

There are few quality metrics and benchmarks specific to surgical oncology. Development of a surgeon-level performance metrics system based on peer comparisons is hypothesized to positively influence surgical decision-making. This study established a tracking and reporting system comprised of evidence and consensus-based metrics to assess breast care delivered by individual surgeons. Surgeons' performance is assessed by a surveillance tracking system of metrics pertaining to referrals and surgical elements. This retrospective analysis of prospectively collected breast care data reports on recurring 6-month and cumulative data from nine care locations from 2015 to 2021. Breast care was provided to 6659 patients by 41 surgeons. A total of 27 breast care metrics were evaluated over 7 years. Metrics with consistent, proficient results were retired after 18 months, including the rate of core biopsy, specimen orientation, and referrals to medical oncology, genetics, and fertility, among others. In clinically node-negative, hormone receptor-positive patients 70 years of age or older, the cumulative rate of sentinel lymph node (SLN) biopsy significantly decreased by 40% over 5.5 years (p<.001). The overall breast conservation rate for T0-T2 cancer increased 10% over 7 years. At the surgeon level, improvements were made in the median number of SLNs removed and in operative note documentation. Implementation of a surgeon-specific, peer comparison-based metric and tracking system has yielded substantive changes in breast care management. This process and governance structure can serve as a model for quantification of breast care at other institutions and for other disease sites.

Social comparisons and groundwater use: Evidence from Colorado and Kansas

AbstractIn the United States, agriculture is responsible for the majority of consumptive water use. To reduce consumptive use in water scarce regions, policymakers have implemented a number of costly interventions. These interventions range from land retirement to subsidies that encourage the adoption of efficient irrigation technologies. In nonagricultural contexts, costly policy interventions have been complemented by low‐cost interventions inspired by behavioral economics. Whether these behavioral interventions are effective in the context of commercial farming is not well understood. In a preregistered, randomized field intervention, we estimate the impact of social (peer) comparisons on agricultural groundwater users in Colorado and Kansas. More than three thousand irrigators were randomized to receive either an annual peer comparison or no comparison. The peer comparison contrasted each irrigator's groundwater use to the distribution of use by neighboring irrigators. The comparison intervention reduced average annual groundwater use by 4.05% [95% CI (−5.87%, − 2.21%)], resulting in an aggregate reduction of more than 21,000 acre‐feet per year at a cost less than $1.31 per acre‐foot conserved. The estimated treatment effect was larger among irrigators with lower pre‐intervention water use. In the 3‐year experiment, we observed no evidence that the treatment effect substantially attenuated over time. We did, however, detect within‐irrigator spillovers in the treatment group: groundwater use also declined among wells that were not included in the peer comparisons (peer comparisons included a maximum of three wells). The results imply that social comparisons can be a cost‐effective tool, alongside other policy interventions, aimed at reducing agricultural water use.

Conformity or contrast? Simultaneous effect of grademates and classmates on students’ educational aspirations

This study examines the relationship between peers' cognitive abilities and students' educational aspirations. The big-fish-little-pond effect (BFLPE) predicts that compared with equally able counterparts, students tend to have higher educational aspirations when the average ability of their surrounding peers is relatively low. Meanwhile, the local dominance effect claims that the association changes between educational aspirations and peers' ability from relatively local to relatively distant peers; closer distance leads to stronger associations. In addition, some empirical findings contradict the notion that students' aspirations are positively associated with their high-achieving classmates. This study combines the BFLPE and local dominance effect into one theoretical framework and explores whether the “higher aspiration-inferior peers” hypothesis stands at the class and grade levels. Using data from the 2014–2015 China Education Panel Survey and employing multilevel regression modeling, this study finds opposite associations in class and grade. The findings indicate that when classmates' cognitive ability is controlled, students feel negative pressure from their grademates. Better performance exhibited by their grademates results in their relatively low educational aspirations. However, at the class level, the negative correlation by peer comparison with excellent classmates is offset by positive associations brought about by these peers. The findings of this study support the hypotheses that students' educational aspirations are positively correlated with their peers’ cognitive abilities as long as their local peers are relatively high achievers, and their distant peers are relatively low achievers.

Audit, Feedback, and Education to Improve Quality and Outcomes in Transurethral Resection and Single-Instillation Intravesical Chemotherapy for Nonmuscle Invasive Bladder Cancer Treatment: Protocol for a Multicenter International Observational Study With an Embedded Cluster Randomized Trial.

Nonmuscle invasive bladder cancer (NMIBC) accounts for 75% of bladder cancers. It is common and costly. Cost and detriment to patient outcomes and quality of life are driven by high recurrence rates and the need for regular invasive surveillance and repeat treatments. There is evidence that the quality of the initial surgical procedure (transurethral resection of bladder tumor [TURBT]) and administration of postoperative bladder chemotherapy significantly reduce cancer recurrence rates and improve outcomes (cancer progression and mortality). There is surgeon-reported evidence that TURBT practice varies significantly across surgeons and sites. There is limited evidence from clinical trials of intravesical chemotherapy that NMIBC recurrence rate varies significantly between sites and that this cannot be accounted for by differences in patient, tumor, or adjuvant treatment factors, suggesting that how the surgery is performed may be a reason for the variation. This study primarily aims to determine if feedback on and education about surgical quality indicators can improve performance and secondarily if this can reduce cancer recurrence rates. Planned secondary analyses aim to determine what surgeon, operative, perioperative, institutional, and patient factors are associated with better achievement of TURBT quality indicators and NMIBC recurrence rates. This is an observational, international, multicenter study with an embedded cluster randomized trial of audit, feedback, and education. Sites will be included if they perform TURBT for NMIBC. The study has four phases: (1) site registration and usual practice survey; (2) retrospective audit; (3) randomization to audit, feedback, and education intervention or to no intervention; and (4) prospective audit. Local and national ethical and institutional approvals or exemptions will be obtained at each participating site. The study has 4 coprimary outcomes, which are 4 evidence-based TURBT quality indicators: a surgical performance factor (detrusor muscle resection); an adjuvant treatment factor (intravesical chemotherapy administration); and 2 documentation factors (resection completeness and tumor features). A key secondary outcome is the early cancer recurrence rate. The intervention is a web-based surgical performance feedback dashboard with educational and practical resources for TURBT quality improvement. It will include anonymous site and surgeon-level peer comparison, a performance summary, and targets. The coprimary outcomes will be analyzed at the site level while recurrence rate will be analyzed at the patient level. The study was funded in October 2020 and began data collection in April 2021. As of January 2023, there were 220 hospitals participating and over 15,000 patient records. Projected data collection end date is June 30, 2023. This study aims to use a distributed collaborative model to deliver a site-level web-based performance feedback intervention to improve the quality of endoscopic bladder cancer surgery. The study is funded and projects to complete data collection in June 2023. ClinicalTrials.org NCT05154084; https://clinicaltrials.gov/ct2/show/NCT05154084. DERR1-10.2196/42254.

Trade-Offs of Attending Better Schools: Achievement, Self-Perceptions and Educational Trajectories

Abstract This paper estimates the impacts of attending better middle schools on the test scores, on-time graduation, self-reported socio-emotional skills, aspirations and high school track choices of marginally admitted students. A regression discontinuity design comparing students just above and below the admission threshold to higher-achieving middle schools in Mexico shows some modest gains on externally graded tests, but adverse effects on grade point average and on-time graduation. By the end of middle school, marginally admitted students feel academically inferior to their peers, obtain worse scores on measures of conscientiousness, and are more likely to shift their aspirations and subsequent schooling choices from academic to vocational programmes. The results are consistent with the hypothesis that unfavourable peer comparisons, stemming from direct observation or subjective teacher assessments, can be sufficiently important to affect students’ educational trajectories.

Clinician Job Satisfaction After Peer Comparison Feedback

Interventions that improve clinician performance through feedback should not contribute to job dissatisfaction or staff turnover. Measurement of job satisfaction may help identify interventions that lead to this undesirable consequence. To evaluate whether mean job satisfaction was less than the margin of clinical significance among clinicians who received social norm feedback (peer comparison) compared with clinicians who did not. This secondary, preregistered, noninferiority analysis of a cluster randomized trial compared 3 interventions to reduce inappropriate antibiotic prescribing in a 2 × 2 × 2 factorial design from November 1, 2011, to April 1, 2014. A total of 248 clinicians were enrolled from 47 clinics. The sample size for this analysis was determined by the number of nonmissing job satisfaction scores from the original enrolled sample, which was 201 clinicians from 43 clinics. Data analysis was performed from October 12 to April 13, 2022. Feedback comparing individual clinician performance to top-performing peers, delivered in monthly emails (peer comparison). The primary outcome was a response to the following statement: "Overall, I am satisfied with my current job." Responses ranged from 1 (strongly disagree) to 5 (strongly agree). A total of 201 clinicians (response rate, 81%) from 43 of the 47 clinics (91%) provided a survey response about job satisfaction. Clinicians were primarily female (n = 129 [64%]) and board certified in internal medicine (n = 126 [63%]), with a mean (SD) age of 48 (10) years. The clinic-clustered difference in mean job satisfaction was greater than -0.32 (β = 0.11; 95% CI, -0.19 to 0.42; P = .46). Therefore, the preregistered null hypothesis that peer comparison is inferior by resulting in at least a 1-point decrease in job satisfaction by 1 in 3 clinicians was rejected. The secondary null hypothesis that job satisfaction was similar among clinicians randomized to social norm feedback was not able to be rejected. The effect size did not change when controlling for other trial interventions (t = 0.08; P = .94), and no interaction effects were observed. In this secondary analysis of a randomized clinical trial, peer comparison did not lead to lower job satisfaction. Features that may have protected against dissatisfaction include clinicians' agency over the performance measure, privacy of individual performance, and allowing all clinicians to achieve top performance. ClinicalTrials.gov Identifiers: NCT05575115 and NCT01454947.

“My Cross-Border PhD Journey”: A Qualitative Study on the Educational and Life Challenges of Mainland Chinese PhD Students in Hong Kong

PhD students’ poor mental health has been increasingly concerning. However, challenges among PhD students studying aboard are understudied. The Educational and Life Transitions (ELT) model postulates that international PhD students are subject to both academic and acculturative stressors; however, relevant research is limited in the Chinese context. We examined mainland Chinese PhD students’ study and living experiences in Hong Kong using a qualitative approach. Through purposive sampling, 37 mainland Chinese PhD students in different disciplines from public-funded universities in Hong Kong were recruited to participate in online focus group interviews (December 2020–February 2021). The interviews were analyzed using the framework analysis method. Ten themes of academic/acculturative stressors were identified. The academic stressors included: (1) high expectations from the supervisors; (2) emphasis on self-discipline as PhD students; (3) peer comparison in academia; (4) difficulties shifting research directions/academic disciplines; (5) uncertainties about future career. The acculturative stressors included: (1) differences in the political environment; (2) language barriers; (3) difficulties living in Hong Kong; (4) limited social interaction with others; (5) local people’s discriminatory behaviors. This study sheds light on the stressors experienced by mainland Chinese PhD students in Hong Kong. To better address those students’ academic and acculturative stressors, cross-cultural training and additional support from supervisors/the university could be provided.

End-of-life spending analysis of randomized trial of machine learning nudges to prompt serious illness communication among patients with cancer.

6515 Background: Early serious illness conversations (SICs) between oncology clinicians and patients in the outpatient setting may improve mood and quality-of-life among patients with cancer. However, the impact of early SIC “nudges” on end-of-life spending is unknown. Methods: This was a secondary analysis of a stepped-wedge randomized trial (NCT03984773) that randomized 9 medical oncology practices and their high-risk patients at a large academic institution to a behavioral intervention to increase SICs (performance reports and peer comparisons; precommitments for high-risk patients; weekly opt-out text prompts before high-risk encounters) vs. standard of care, between June 2019 and April 2020. We identified high-risk patients using a machine learning (ML) algorithm predicting 180-day mortality. This secondary analysis included 1187 (957 intervention, 230 control) patients with complete data who died by December 2020. We abstracted spending (defined as inflation-adjusted reimbursements for acute care [inpatient + ED], office/outpatient care, intravenous chemotherapy, other therapy [e.g. radiation], long-term care, and hospice) from the institution’s accounting system; we captured spending at University of Pennsylvania inpatient, outpatient, and pharmacy settings. To evaluate intervention impacts on spending, we used a two-part model: first, logistic regression to model zero versus nonzero spending, and second, generalized linear models with gamma distribution and log-link function to model daily mean spending in the last 180 days of life. Models were adjusted for clinic and wedge fixed effects and clustered at the oncologist level. Results: Median age at death was 68 years (IQR 15.5), 317 (27%) patients were non-White, and 448 (38%) patients had a SIC prior to death. The intervention was associated with lower mean spending in the last 180 days of life (mean daily spending $377.96 [intervention] vs. $449.92 [control]; adjusted mean difference -$75.33, 95% CI -$136.42, -$14.23 , p = 0.016) (Table), translating to $13,559 total adjusted savings. Intervention patients incurred lower mean daily spending for chemotherapy (adjusted difference -$51.35, p &lt; 0.001), office/outpatient care (-$14.59, p &lt; 0.001), and other therapy (-$10.35, p = 0.043). The intervention was not associated with differences in end-of-life spending for acute care utilization, long-term care, and hospice. Results were consistent for spending in the last 30 and 90 days of life and after adjusting for age, race, and ethnicity. Conclusions: A ML intervention to prompt SICs led to end-of-life savings, driven by decreased chemotherapy and outpatient spending. Clinical trial information: NCT03984773 . [Table: see text]

Patient- and clinician-directed implementation strategies to improve serious illness communication for high-risk patients with cancer: A cluster-randomized pragmatic trial.

1514 Background: Early serious illness conversations (SICs) elicit patients’ values, goals, and care preferences and have been shown to improve outcomes and reduce end-of-life healthcare utilization for patients with cancer. However, most patients with cancer die without a documented SIC. Given prior evidence that strategies informed by behavioral economics (“nudges”) increase SIC rates, our objective was to test the independent and additive effects of clinician- and patient-directed nudges to increase SIC completion. Methods: We conducted a 2 × 2 factorial, cluster-randomized pragmatic trial (NCT04867850) to test the effects of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Usual care was an active control consisting of clinician-directed text messages sent before routine clinic sessions, identifying patients at high risk of 6-month mortality as predicted by a validated machine-learning prognostic algorithm. The clinician nudge additionally included weekly peer comparisons on clinician-level SIC completion rates. The patient nudge consisted of a patient-facing message sent electronically before an index clinic visit, asking a 3-question survey designed to prime patients for an SIC with their oncology team. Participants included medical/gynecologic oncologists and advanced practice providers (APPs) within a large academic health system and their high-risk patients. We independently randomized oncologist/APP clusters and patients to receive nudges vs. usual care. The primary outcome was a documented SIC in the electronic health record within 6 months of enrollment. Using a Cox proportional hazards model with cluster robust standard errors, we performed a time-to-event analysis and tested for heterogeneity of effect across prespecified subgroups. Results: From September 2021 to March 2022, the study accrued 4,450 patients (median age 67, 52.9% female, 17.3% Black, 2.7% Hispanic) seen by 166 clinicians across 4 hospitals and 6 community sites, randomized to clinician nudge (n=1,179), patient nudge (n=997), both (n=1,270), or active control (n=1,004). Overall patient-level rates of 6-month SIC completion were: 11.5% (clinician nudge), 11.5% (patient nudge), 14.1% (both), and 11.2% (active control). Compared to the active control, participants in the combination nudge arm were more likely to engage in SICs (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.00-2.40), whereas those in the clinician (HR 0.95, 95% CI 0.64-1.41) and patient (HR 0.99, 95% CI 0.73-1.33) nudge arms were not. There was no effect heterogeneity across age and race subgroups. Conclusions: Clinician- and patient-directed nudges may be synergistic in promoting serious illness communication at scale and equitably in routine cancer care. Effects on end-of-life care among decedents are forthcoming. Clinical trial information: NCT04867850 .

Multi-faceted approach to decreasing inappropriate antibiotic prescribing for viral upper respiratory tract infections

Background: Prescribing of antibiotics for viral upper respiratory infection (URI) remains a pressing public health problem. We sought to reduce inappropriate prescribing of antibiotics for viral URIs at primary-care practices at Mayo Clinic Arizona (MCA). Methods: Diagnostic codes for URIs commonly caused by viruses were categorized as tier 3 (ie, never prescribe). The inappropriate prescribing rate was defined as the number of tier 3 encounters resulting in a prescription for a URI antibiotic divided by the total number of tier 3 encounters. MCA primary-care departments, including family medicine, community internal medicine, emergency medicine, and women’s health internal medicine, were included in the intervention. Each department was briefed on the project, including baseline department prescribing data, and was provided education. Education topics included appropriate indications for antibiotics, patient-centered strategies for reducing antibiotic use, and a review of electronic resources developed specifically for the project. Resources included a syndromic ambulatory order panel (EZ ID Respiratory Order Panel) and a viral prescription pad, which contains simplified over-the-counter recommendations for symptomatic management of viral URIs and patient education. Quarterly peer comparison reports were provided to the department chairs and/or site leads. Our goal was to reduce inappropriate prescribing by 22% in 2022. An Epic dashboard (SlicerDicer model) was developed to track data on an ongoing basis. We used χ2 tests to compare categorical variables. Results: Department education was completed by June 2022 (Fig. 1). The annual antibiotic prescribing rate for tier 3 encounters decreased by 29% from a baseline rate 23.6% in 2021 to 16.4% in 2022 (P &lt; .001). The posteducation prescribing rate (June 2022–December 2022) was 13.1%. Utilization of the EZ ID ambulatory order panel increased from an average of 1.5 uses per month in 2021 to 13.3 uses per month in 2022 (Fig. 2). Repeated healthcare contact for URIs within 14 days of tier 3 encounters did not differ among patients prescribed and not prescribed an antibiotic in all of 2022 (3.8% vs 3.9%; P = .91) or during the posteducation period (1.8% vs 4.2%; P = .14). There was no appreciable diagnostic shift over the course of 2022 (Fig. 3). Conclusions: A multifaceted intervention, which included baseline education, promotion of syndrome-specific order panels, dissemination of resources for symptomatic management, and distribution of peer comparison reports, resulted in significant reduction of inappropriate antibiotic prescribing for URIs.Disclosure: None

Spillover Effects of Preventive Regulation and Corporate R&D Investment Catering: Evidence from China

ABSTRACT This paper explores the spillover effect of proactive preventive regulation represented by R&D expense inquiry letters (hereafter, RDILs) and its impact mechanism. Using deterrence theory and Chinese A-share listed firms from 2015–2020, we find that the industry receiving RDILs has a regulation effect on the R&D investment intensity catering motive of the non-receiving firms in the industry. That is, there is an industry spillover effect of RDILs regulation. The results of the regulatory mechanism analysis show that the industry spillover effect of RDILs regulation is more pronounced for non-receiving firms with more severe R&D manipulation intensity or weaker product market competitive positions. Further analysis shows that the inclusion of peer comparison questions in the RDILs increases the industry spillover effect of the inquiry letter regulation. We also find that the industry spillover effects of RDILs regulation result in higher future innovation quality for non-receiving firms. Overall, our study enriches our understanding of the effectiveness of inquiry letter regulation and provides some guidance for regulators’ regulatory practice.

Feasibility of a low-intensity intervention to improve antimicrobial use in outpatient settings

Background: Overall, ~12% of outpatient visits result in an antibiotic prescription, and 30% of those prescriptions are inappropriate. Behavioral nudges help influence practitioner behavior. We hypothesized that peer comparison combined with a behavioral nudge (a patient alert letter) would influence prescribers to reduce antibiotic prescriptions and improve antimicrobial stewardship in the outpatient setting. We pilot-tested this intervention in outpatient primary care clinics associated with a large Veterans Affairs (VA) medical center. Methods: We conducted a clustered randomized controlled trial of 12 community-based outpatient clinics. All practitioners in the intervention arm received quarterly comparative feedback reports and, when indicated, quarterly patient alert letters. Comparative feedback reports gave personalized feedback about antibiotic prescriptions for upper respiratory tract infections, comparing the recipient’s antibiotic prescriptions to the average for all practitioners at the primary care clinics included in our study. Patient alert letters notified practitioners to patients in their panel with recently detected Clostridioides difficile or resistant organism and their antibiotic exposures. We assessed outpatient visits during the preintervention period (April–September 2020), the intervention period (October 2020–September 2021), and the postintervention period (October 2021–September 2022). A mixed-effects logistic regression model predicting antibiotic prescriptions compared the arms across these periods. Results: The outpatient populations observed in the intervention and control arms were similar during each phase of the study. Prior to the intervention, the average proportion of visits with an antibiotic prescription was lower among clinics in the intervention arm (1.4% vs 1.8% in control arm; P = .45). This difference broadened slightly during the intervention period (1.4% vs 2.1%, respectively; P = .03) and the postintervention period (1.3% vs 2.1%, respectively; P = .01) (Fig. 1). Throughout the study, clinics in the intervention arm typically used more doxycycline and azithromycin and less amoxicillin-clavulanate and sulfamethoxazole-trimethoprim compared to clinics in the control arm. (Fig. 2). In the 6-month preintervention period, which coincided with the early phase of the COVID-19 pandemic, antibiotic prescriptions in the intervention compared to control clinics were similar. During the intervention and postintervention periods, the proportion of visits with an antibiotic prescription remained steady for clinics in the intervention arm and increased for those in the control arm. These results suggest that this pilot study using a low-intensity intervention consisting of comparative feedback reports and patient alert letters was successful in influencing the antibiotic prescribing behavior of primary care clinicians practicing in community-based outpatient clinics affiliated with a VA medical center.Financial support: This study was funded by Merck.Disclosures: None

Effects of acute psychosocial stress on source level EEG power and functional connectivity measures

The usage of EEG to uncover the influence of psychosocial stressors (PSSs) on neural activity has gained significant attention throughout recent years, but the results are often troubled by confounding stressor types. To investigate the effect of PSSs alone on neural activity, we employed a paradigm where participants are exposed to negative peer comparison as PSS, while other possible stressors are kept constant, and compared this with a condition where participants received neutral feedback. We analyzed commonly used sensor level EEG indices (frontal theta, alpha, and beta power) and further investigated whether source level power and functional connectivity (i.e., the temporal dependence between spatially seperated brain regions) measures, which have to our knowledge not yet been used, are more sensitive to PSSs than sensor level-derived EEG measures. Our results show that on sensor level, no significant frontal power changes are present (all p’s > 0.16), indicating that sensor level frontal power measures are not sensitive enough to be affected by only PSSs. On source level, we find increased alpha power (indicative of decreased cortical activity) in the left- and right precuneus and right posterior cingulate cortex (all p’s < 0.03) and increased functional connectivity between the left- and right precuneus (p < 0.001), indicating that acute, trial based PSSs lead to decreased precuneus/PCC activity, and possibly indicates a temporary disruption in the self-referential neural processes of an individual.

Avoiding Peer Information and Its Effects on Charity Crowdfunding: A Field Experiment

We study the behavior of an individual avoiding peer information from a natural field experiment of charity crowdfunding. The unique experimental design enables us to employ an instrumental variable strategy to identify how the behavior influences individual giving to and promotion of charity campaigns. We find that, even with free access, 89% of individuals chose not to seek peer information. These individuals were less likely, whereas their peers were more likely to give and help promote in the past. The behavior would reduce the total distribution of campaigns by 8.5% and the total donation amount by 7.7%. A stylized model is used to illustrate how the pressure from peer comparison drives the individuals not to seek the information and how this behavior could influence giving and promoting behaviors of a group of marginal individuals. This paper was accepted by Yan Chen, behavioral economics and decision analysis. Funding: The project was supported by the National Natural Science Foundation of China [Grants 72103110]. Supplemental Material: The data files are available at https://doi.org/10.1287/mnsc.2023.4807 .