Peer Comparison Research Articles

Compensation for poor character learning: intact visual and phonetic strategies among Chinese children with dyslexia.

The present study investigated whether and to what extent children with dyslexia utilize visual and phonetic strategies in character learning. A paired associate learning paradigm was used in two experiments to train children's pronunciation-orthography associations of novel words, with a recall task 1week later for retention. Experiment 1 included 32 Mandarin-speaking fifth graders with dyslexia (dyslexia group) and 28 age-matched peers (comparison group) and manipulated the availability of an arbitrary bolded stroke in Chinese character (visual cue, available vs. unavailable) of eight low-frequency real characters. The dyslexia group demonstrated poorer character learning effects than the comparison group, whereas the similar interference effect of visual cues was found across groups. Sixty-six fifth-grade children participated in Experiment 2 (dyslexia, N = 34). The regularity of phonetic cues of 12 pseudo-characters was manipulated into regular, semiregular, irregular, providing full, partial, or no pronunciation cues. The dyslexia group demonstrated comparable learning outcomes of regular pseudo-characters, but poorer learning on semiregular and irregular pseudo-characters than the comparison group. Importantly, they utilize semiregular phonetic cues. In both experiments, the two groups did not differ on the retention of learning. Taken together, children with dyslexia perform poorer in the learning stage, but not in visual or phonetic strategies or the retention of learning. Like their peers, they do not use arbitrary visual cues but utilize phonetic cues, and thus compensate for poor learning of regular characters and alleviate that of semiregular characters.

Vulnerability to interrogative suggestibility from negative life events. A comparison of separated asylum-seeking youth and age-matched peers.

The consistency of young asylum-seeker's verbal testimony is often critical in determining the outcome of their claims. It is well established that an interviewee may change their answers to appease an interviewer or in response to suggestions. Experiencing adversity during childhood may increase vulnerability in such interview situations. Here, the vulnerability to interview pressure of asylum-seeking youth separated from their caregivers as minors was compared with age-matched peers. Thirty participants (16–23 years) completed the Gudjonsson Suggestibility Scale (GSS2, measures of negative life events (NLEs) and non-verbal cognitive functioning measures. Vulnerability to interrogative suggestibility, non-verbal cognitive functioning and number of NLEs was compared between two groups. This preliminary data showed asylum-seeking youth as significantly more vulnerable to Shift; changes in response to interviewer feedback. NLEs and lower non-verbal cognitive functioning were significantly more common among the separated youth increasing vulnerability to Shift. The implications are discussed.

Improving antimicrobial prescribing for upper respiratory infections in the emergency department: Implementation of peer comparison with behavioral feedback.

To reduce inappropriate antibiotic prescribing for acute respiratory infections (ARIs) by employing peer comparison with behavioral feedback in the emergency department (ED). A controlled before-and-after study. The study was conducted in 5 adult EDs at teaching and community hospitals in a health system. Adults presenting to the ED with a respiratory condition diagnosis code. Hospitalized patients and those with a diagnosis code for a non-respiratory condition for which antibiotics are or may be warranted were excluded. After a baseline period from January 2016 to March 2018, 3 EDs implemented a feedback intervention with peer comparison between April 2018 and December 2019 for attending physicians. Also, 2 EDs in the health system served as controls. Using interrupted time series analysis, the inappropriate ARI prescribing rate was calculated as the proportion of antibiotic-inappropriate ARI encounters with a prescription. Prescribing rates were also evaluated for all ARIs. Attending physicians at intervention sites received biannual e-mails with their inappropriate prescribing rate and had access to a dashboard that was updated daily showing their performance relative to their peers. Among 28,544 ARI encounters, the inappropriate prescribing rate remained stable at the control EDs between the 2 periods (23.0% and 23.8%). At the intervention sites, the inappropriate prescribing rate decreased significantly from 22.0% to 15.2%. Between periods, the overall ARI prescribing rate was 38.1% and 40.6% in the control group and 35.9% and 30.6% in the intervention group. Behavioral feedback with peer comparison can be implemented effectively in the ED to reduce inappropriate prescribing for ARIs.

Plumbing vs Nudging: The Lasting Effect of Efficiency Improvements on Water Conservation

Abstract Mega-cities worldwide are facing water security challenges. We investigate two solutions to urban water security: improving plumbing and nudging consumers. We show that improving plumbing alone generates long-lasting effects in water conservation. Using anonymised water consumption data based on water bills from 1.5 million accounts in Singapore over 10 years, our staggered difference-in-differences estimates show that a nation-wide Home Improvement Programme reduces residential water consumption by 3.5%. The effect persists for a decade and is observed across population subgroups. The efficiency improvements also help in mitigating the effect of extreme environmental conditions on water use. Nation-wide nudging through peer comparison may not achieve similar outcomes.

Improving Patient Outcomes by Addressing Provider Variation in Emergency Department Asthma Care.

We used a retrospective cohort design to analyze 2 years of baseline data for asthma patient encounters. Providers were classified based on guideline adherence. We compared patient outcomes by provider adherence using Mann-Whitney U and Fisher's exact test. Our intervention included education with data feedback and peer comparison. We then analyzed changes in guideline adherence, the proportion of patients admitted, length of stay (LOS), and costs for this population over time using statistical process control charts. In our baseline data analysis, patients seen by less adherent physicians had a higher likelihood of admission (65.1% versus 50.8%, P < 0.001), a longer ED LOS (4.7 versus 4.2 h, P = 0.007), and higher costs ($1,896.20 versus $1,728.50, P < 0.001). Using SPC analysis, there was an improvement in guideline adherence by providers (64%-77%) with a mirrored improvement in patient adherence (76%-84%) associated with our interventions. Admissions decreased 1 year after the intervention; ED LOS and returns remained unchanged. In this study, we evaluated patient outcomes according to provider adherence to a clinical guideline and used the results to change provider behavior and improve patient outcomes. Active provision of feedback with peer comparison for providers was associated with improved adherence over time.

Social Recognition: Experimental Evidence from Blood Donors

Does social recognition motivate repeat contributors? We conduct large-scale experiments among members of Italy's main blood donors association, testing social recognition both through social media and in peer groups. We experimentally disentangle visibility concerns, peer comparisons and simple ask effects, and we study how exposure to different norms of behavior affects giving. Overall, asking increases giving by 20.4 percent. However, a simple ask to donate is at least as effective as asks that emphasize social recognition. Using peer groups, we show that visibility concerns do not generate additional donations, and we find that donations respond weakly and non-monotonically to social norms of giving. In an original study and two subsequent replications, we find no evidence that donors give blood for the prospect of their donations being observed by others on social media. Overall, our findings caution against over-reliance on social recognition to promote good citizenship.

Improving antibiotic prescribing for pediatric acute respiratory tract infections: A cluster randomized trial to evaluate individual versus clinic feedback.

To assess the effect of individual compared to clinic-level feedback on guideline-concordant care for 3 acute respiratory tract infections (ARTIs) among family medicine clinicians caring for pediatric patients. Cluster randomized controlled trial with a 22-month baseline, 26-month intervention period, and 12-month postintervention period. In total, 26 family medicine practices (39 clinics) caring for pediatric patients in Virginia, North Carolina, and South Carolina were selected based upon performance on guideline-concordance for 3 ARTIs, stratified by practice size. These were randomly allocated to a control group (17 clinics in 13 practices) or to an intervention group (22 clinics in 13 practices). All clinicians received an education session and baseline then monthly clinic-level rates for guideline-concordant antibiotic prescribing for ARTIs: upper respiratory tract infection (URI), acute bacterial sinusitis (ABS), and acute otitis media (AOM). For the intervention group only, individual clinician performance was provided. Both intervention and control groups demonstrated improvement from baseline, but the intervention group had significantly greater improvement compared with the control group: URI (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.37-1.92; P < 0.01); ABS (OR, 1.45; 95% CI, 1.11-1.88; P < 0.01); and AOM (OR, 1.59; 95% CI, 1.24-2.03; P < 0.01). The intervention group also showed significantly greater reduction in broad-spectrum antibiotic prescribing percentage (BSAP%): odds ratio 0.80, 95% CI 0.74-0.87, P < 0.01. During the postintervention year, gains were maintained in the intervention group for each ARTI and for URI and AOM in the control group. Monthly individual peer feedback is superior to clinic-level only feedback in family medicine clinics for 3 pediatric ARTIs and for BSAP% reduction. ClinicalTrials.gov identifier: NCT04588376, Improving Antibiotic Prescribing for Pediatric Respiratory Infection by Family Physicians with Peer Comparison.

The Effect of Peer Comparison Information on Effort in Endogenous Choice Environments

The Effect of Peer Comparison Information on Effort in Endogenous Choice Environments

The Effects of Peer Comparison Information on Physician Behavior and Well-being

The Effects of Peer Comparison Information on Physician Behavior and Well-being

145. Monthly Antibiotic Prescribing Peer Comparison Combined with In-person Education Decreases Antibiotic Prescribing for Acute Respiratory Infections

BackgroundInappropriate antibiotic prescribing is an important modifiable risk factor for antibiotic resistance. Approximately half of all antibiotics prescribed for acute respiratory infections (ARIs) in the United States may be inappropriate or unnecessary. The purpose of this quality improvement (QI) project was to evaluate the effect of three consecutive interventions on improving antibiotic prescribing for ARIs (i.e., pharyngitis, rhinosinusitis, bronchitis, common cold).MethodsThis was a pre-post analysis of an antimicrobial stewardship QI initiative to improve antibiotic prescribing for ARIs in six Veterans Affairs (VA) primary care clinics. Three distinct intervention phases occurred. Educational interventions included training on appropriate antibiotic prescribing for ARIs. During the first intervention period (8/2017-1/2019), education was presented virtually to primary care providers on a single occasion. In the second intervention period (2/2019-10/2019), in-person education with peer comparison was presented on a single occasion. In the third intervention period (11/2019-4/2020), education and prescribing feedback with peer comparison was presented once in-person followed by monthly emails of prescribing feedback with peer comparison. January 2016-July 2017 was used as a pre-intervention baseline period.The primary outcome was the antibiotic prescribing rate for all classifications of ARIs. Secondary outcomes included adherence to antibiotic prescribing guidance for pharyngitis and rhinosinusitis. Descriptive statistics and interrupted time series segmented regression were used to analyze the outcomes.ResultsMonthly antibiotic prescribing peer comparison emails in combination with in-person education was associated with a statistically significant 12.5% reduction in the rate of antibiotic prescribing for ARIs (p=0.0019). When provider education alone was used, the reduction in antibiotic prescribing was nonsignificant. ConclusionEducation alone does not significantly reduce antibiotic prescribing for ARIs, regardless of the delivery mode. In contrast, education followed by monthly prescribing feedback with peer comparison was associated with a statistically significant reduction in ARI antibiotic prescribing rates.Disclosures All Authors: No reported disclosures

Method Matters: Comparing Cancer-Related Adjustment of Siblings to Norms and Well-matched Peers.

The purpose of this study was to better understand conflicting findings in the literature regarding the adjustment of siblings of children with cancer by examining, in a single sample, differences in patterns of results as a function of reporter and comparator used (i.e., population norms, demographically matched classmates). Self- and parent-report standardized measures of depression, anxiety, and behavioral problems were collected for 67 siblings and 67 demographically matched classmates. Comparisons were made to norms and controls. Siblings consistently demonstrated poorer psychosocial functioning than their demographically matched peers across all measures but their scores did not differ from norms. A significantly greater percentage of siblings fell outside the normal range than that expected in the general population for parent-reported total and internalizing problems, but not for externalizing problems or the self-report measures. Findings regarding the psychological adjustment of siblings of children with cancer differ according to the research methods used. It is important to use rigorous methods such as demographically matched peer comparisons when investigating the impact of childhood cancer on siblings.

Peer Comparisons to Increase Responsible Opioid Prescribing Among Oral and Maxillofacial Surgeons

The field of oral and maxillofacial surgery has made a concerted effort to promote responsible opioid prescribing for postoperative pain control. A 2020 white paper from the American Association of Oral and Maxillofacial Surgeons (AAOMS) highlights some of these efforts, which includes supporting the mandatory usage of prescription drug monitoring programs, promoting continuing education courses, and developing evidence-based prescription guidelines.1 However, the job is not finished, as the opioid epidemic remains a public health challenge in the United States.

Pediatric research priorities in healthcare-associated infections and antimicrobial stewardship.

To develop a pediatric research agenda focused on pediatric healthcare-associated infections and antimicrobial stewardship topics that will yield the highest impact on child health. The study included 26 geographically diverse adult and pediatric infectious diseases clinicians with expertise in healthcare-associated infection prevention and/or antimicrobial stewardship (topic identification and ranking of priorities), as well as members of the Division of Healthcare Quality and Promotion at the Centers for Disease Control and Prevention (topic identification). Using a modified Delphi approach, expert recommendations were generated through an iterative process for identifying pediatric research priorities in healthcare associated infection prevention and antimicrobial stewardship. The multistep, 7-month process included a literature review, interactive teleconferences, web-based surveys, and 2 in-person meetings. A final list of 12 high-priority research topics were generated in the 2 domains. High-priority healthcare-associated infection topics included judicious testing for Clostridioides difficile infection, chlorhexidine (CHG) bathing, measuring and preventing hospital-onset bloodstream infection rates, surgical site infection prevention, surveillance and prevention of multidrug resistant gram-negative rod infections. Antimicrobial stewardship topics included β-lactam allergy de-labeling, judicious use of perioperative antibiotics, intravenous to oral conversion of antimicrobial therapy, developing a patient-level "harm index" for antibiotic exposure, and benchmarking and or peer comparison of antibiotic use for common inpatient conditions. We identified 6 healthcare-associated infection topics and 6 antimicrobial stewardship topics as potentially high-impact targets for pediatric research.

The Effect of Peer Comparisons on Polluters: A Randomized Field Experiment among Wastewater Dischargers

Peer comparisons combine descriptive and injunctive messages about social norms. In experiments, these comparisons have encouraged pro-environmental behaviors among consumers. Consumers, however, are not the only sources of environmental externalities. Firms and other organizations also damage the environment. Yet organizations may not respond to peer comparisons in the same way that consumers respond because organizations have different objectives, constraints, and decision-making processes. In a pre-registered field experiment with 328 municipal wastewater treatment facilities in Kansas, we randomly sent some facilities a certified letter that contrasted, using text and a graphic, each facility’s discharge behavior to the behaviors of other facilities in the state. We estimate the effect of these peer comparisons on the degree to which the recipient facilities complied with discharge limits under the U.S. Clean Water Act. On average, letter recipients reported discharge ratios 8% lower than non-recipients in the eighteen-month period after letters were sent (95% CI [-15%, -1%]), although we cannot detect an effect in all post-treatment quarters. We believe that the results warrant further experimental replications and extensions to examine the cost-effectiveness of reducing pollution through peer comparisons.

Information, peer comparison and social interdependence: theorising the impacts of COVID-19 on Gulf domestic politics

This article theorizes three layers of impacts of the Coronavirus crisis on internal GCC politics, and then identifies potential causal mechanisms operating at each level. A first and primary layer concerns governance, and revolves around the state’s performance in managing the virus outbreak. A secondary level relates to scarcity and inequality, and is linked to the state’s handling of economic and social knock-on effects of the pandemic. A tertiary level is connected to peer comparison, and involves GCC states’ (lack of) coordination of political responses at the regional or sub-regional level. Several key factors emerge from the investigation as potent catalysts for new political dynamics in the Arab Gulf states. One is the unusual availability and clarity of information about state performance surrounding Covid-19, which stands in stark contrast to the general lack of reliable governance indicators for GCC and other MENA countries. Another is the universal nature of the Coronavirus shock, which allows Gulf citizens and residents to make direct comparisons of state performance and policy responses that may reveal a disproportionately negative (or positive) personal or collective outcome. Third, the person-to-person transmission of Covid-19 shatters the traditional social and geographical segregation of Gulf societies, with once-isolated communities now directly and profoundly impacted by each other’s behavior, preferences, and incentives. Finally, variation in resource endowments and political institutions across the GCC precludes easy regional harmonization of post-Covid social and economic policy, once more inviting individual comparison with relatively advantaged or disadvantaged peers in neighboring states.

Depressive Symptoms and Suicidality of Those Raised in Kincare: A Peer Comparison Study.

The rate at which children are raised in kincare has steadily been on the rise. Prior research indicates that this group of individuals are at an increased risk of mental health problems. The current study examined the suicidality and depressive symptoms of adults who were raised in kincare compared to those raised by their parents. There were a total of 1,486 participants, 171 of whom were adults raised in kincare, and 1,315 who were raised by one or both of their parents. Participants completed a measure of suicide risk and reported symptoms of depression and anhedonia.Those raised in kincare scored significantly higher on the measures of anhedonia and suicide risk. However, there were no differences in general depressive symptoms. Further analyses found that more frequent attendance of religious activities and higher levels of household income acted as protective factors. These findings suggest kincare is associated with adverse mental health outcomes.

Effect of Integrating Machine Learning Mortality Estimates With Behavioral Nudges to Clinicians on Serious Illness Conversations Among Patients With Cancer

Serious illness conversations (SICs) are structured conversations between clinicians and patients about prognosis, treatment goals, and end-of-life preferences. Interventions that increase the rate of SICs between oncology clinicians and patients may improve goal-concordant care and patient outcomes. To determine the effect of a clinician-directed intervention integrating machine learning mortality predictions with behavioral nudges on motivating clinician-patient SICs. This stepped-wedge cluster randomized clinical trial was conducted across 20 weeks (from June 17 to November 1, 2019) at 9 medical oncology clinics (8 subspecialty oncology and 1 general oncology clinics) within a large academic health system in Pennsylvania. Clinicians at the 2 smallest subspecialty clinics were grouped together, resulting in 8 clinic groups randomly assigned to the 4 intervention wedge periods. Included participants in the intention-to-treat analyses were 78 oncology clinicians who received SIC training and their patients (N = 14 607) who had an outpatient oncology encounter during the study period. (1) Weekly emails to oncology clinicians with SIC performance feedback and peer comparisons; (2) a list of up to 6 high-risk patients (≥10% predicted risk of 180-day mortality) scheduled for the next week, estimated using a validated machine learning algorithm; and (3) opt-out text message prompts to clinicians on the patient's appointment day to consider an SIC. Clinicians in the control group received usual care consisting of weekly emails with cumulative SIC performance. Percentage of patient encounters with an SIC in the intervention group vs the usual care (control) group. The sample consisted of 78 clinicians and 14 607 patients. The mean (SD) age of patients was 61.9 (14.2) years, 53.7% were female, and 70.4% were White. For all encounters, SICs were conducted among 1.3% in the control group and 4.6% in the intervention group, a significant difference (adjusted difference in percentage points, 3.3; 95% CI, 2.3-4.5; P < .001). Among 4124 high-risk patient encounters, SICs were conducted among 3.6% in the control group and 15.2% in the intervention group, a significant difference (adjusted difference in percentage points, 11.6; 95% CI, 8.2-12.5; P < .001). In this stepped-wedge cluster randomized clinical trial, an intervention that delivered machine learning mortality predictions with behavioral nudges to oncology clinicians significantly increased the rate of SICs among all patients and among patients with high mortality risk who were targeted by the intervention. Behavioral nudges combined with machine learning mortality predictions can positively influence clinician behavior and may be applied more broadly to improve care near the end of life. ClinicalTrials.gov Identifier: NCT03984773.

Association of Peer Comparison Emails With Electronic Health Record Documentation of Cancer Stage by Oncologists

Systematically capturing cancer stage is essential for any serious effort by health systems to monitor outcomes and quality of care in oncology. However, oncologists do not routinely record cancer stage in machine-readable structured fields in electronic health records (EHRs). To evaluate whether a peer comparison email intervention that communicates an oncologist's performance on documenting cancer stage relative to that of peer physicians was associated with increased likelihood that stage was documented in the EHR. This 12-month, randomized quality improvement pilot study aimed to increase oncologist staging documentation in the EHR. The pilot study was performed at Massachusetts General Hospital Cancer Center from October 1, 2018, to September 30, 2019. Participants included 56 oncologists across 3 practice sites who treated patients in the ambulatory setting and focused on diseases that use standardized staging systems. Data were analyzed from July 2, 2019, to March 5, 2020. Peer comparison intervention with as many as 3 emails to oncologists during 6 months that displayed the oncologist's staging documentation rate relative to all oncologists in the study sample. The primary outcome was patient-level documentation of cancer stage, defined as the likelihood that a patient's stage of disease was documented in the EHR after the patient's first (eg, index) ambulatory visit during the pilot period. Among the 56 oncologists participating (32 men [57%]), receipt of emails with peer comparison data was associated with increased likelihood of documentation of cancer stage using the structured field in the EHR (23.2% vs 13.0% of patient index visits). In adjusted analyses, this difference represented an increase of 9.0 (95% CI, 4.4-13.5) percentage points (P = .002) in the probability that a patient's cancer stage was documented, a relative increase of 69% compared with oncologists who did not receive peer comparison emails. The association increased with each email that was sent, ranging from a nonsignificant 4.0 (95% CI, -0.8 to 8.8) percentage points (P = .09) after the first email to a statistically significant 11.2 (95% CI, 4.9-17.4) percentage points (P = .003) after the third email . The association was concentrated among an oncologist's new patients (increase of 11.8 [95% CI, 6.2-17.4] percentage points; P = .001) compared with established patients (increase of 1.6 [95% CI, -2.9 to 6.1] percentage points; P = .44) and persisted for 7 months after the email communications stopped. In a quality improvement pilot trial, peer comparison emails were associated with a substantial increase in oncologist use of the structured field in the EHR to document stage of disease.

Decreased Overall and Inappropriate Antibiotic Prescribing in a Veterans Affairs Hospital Emergency Department following a Peer Comparison-Based Stewardship Intervention.

Antibiotic prescribing is very common in emergency departments (EDs). Optimal stewardship intervention strategies in EDs are not well defined. We conducted a prospective, observational cohort study in a Veterans Affairs ED in which clinician education and monthly e-mail-based peer comparisons were directed against all oral antibiotic prescribing for discharged patients. Oral antibiotic prescriptions were compared in baseline (June 2016 to December 2017) and intervention (January to June 2018) periods using an interrupted time series regression model. Prescribing appropriateness was compared during January to June 2017 and the intervention period. During the intervention period, antibiotic prescriptions decreased monthly by 10.4 prescriptions per 1,000 ED visits (P = 0.07 [95% confidence interval {CI}, -21.7 to 1.0]). The relative decrease in the trend of antibiotic prescriptions during the intervention period compared to baseline was 9.9 prescriptions per 1,000 ED visits per month (P = 0.07 [95% CI, -20.9 to 1.0]). The intervention was associated with a significant decrease and increase in amoxicillin-clavulanate and cephalexin prescriptions, respectively (P < 0.001, P = 0.004). Decreasing trends in ciprofloxacin prescriptions during the baseline period were maintained during the intervention. Unnecessary antibiotic prescribing (i.e., antibiotic not indicated) decreased from 55.6% to 38.7% during the intervention (30.4% decrease, P = 0.003). Optimal antibiotic prescribing (i.e., antibiotics were indicated, and a guideline-concordant agent was prescribed for guideline-concordant duration) increased by 36% (21.6% to 29.3%, P = 0.12). A peer comparison-based stewardship intervention directed at ED clinicians was associated with reductions in overall and unnecessary oral antibiotic prescribing. There is potential to further improve antibiotic use as suboptimal prescribing remained common.

Peer Comparison Intervention to Improve Antibiotic Prescribing in Dentistry

Background: Dentists prescribe an estimated 13% of outpatient antibiotic courses, many of which may be unnecessary. Health departments are in a unique position to support implementation of antibiotic stewardship across healthcare facilities, including in dental offices. A customized peer comparison message with feedback regarding prescribing frequencies was effective in reducing inappropriate prescribing among primary care physicians in Massachusetts and California. We tested the effect of a peer comparison message for antibiotic prescribing on dentists in the Massachusetts Medicaid program. Methods: We analyzed data from September 2018 to July 2019 for prescriptions of antibiotic courses by dentists to identify the highest prescribing dentists. We used their national provider identifier (NPI) to deduplicate providers and we searched for addresses using the CMS online database. On March 25, 2019, the high prescribers were sent a hard copy letter from the Massachusetts Department of Public Health stating that they were “among the 1% of frequent prescribers.” In addition, the letter provided citations to professional guidelines and prescribing best practices and invited participation in health department–sponsored training for continuing education credits. We tracked the monthly number of antibiotics prescribed by provider before and after the mailing and compared those who received the letter (intervention) to those whose address was either out of state or undeliverable (comparison). Results: Prescribing records for 3,008 dentists were available from September 2018 through July 2019. Most (67%) prescribed &lt;10 antibiotic courses in the 11-month period; the mean monthly antibiotic courses prescribed ranged from 1.2 to 1.6, and the median monthly prescriptions was 0. However, 33% prescribed 10–199 antibiotics, and 1% prescribed &gt;200. Of these 28 comprising the highest 1% , 15 received the intervention letter. The others were either out of state (N = 3) or the letter was returned undelivered (N = 10). The average monthly number of antibiotic courses prescribed before the intervention was similar in the intervention and comparison groups (25.0 and 24.2, respectively). In the 4 months after the intervention, the average did not change in the intervention group but increased slightly in the comparison group (25.2 and 26.2, respectively). The intervention had no significant effect (P = .80). Conclusions: We observed no effect of this peer comparison message among a small sample of dentists in the Massachusetts Medicaid program. This finding may be due to multiple factors, including the small number of the targeted prescribers, the use of a relatively friendly message for communicating with the high prescribers, and the possibility that other forms of communication would be more effective.Funding: NoneDisclosures: None