Prescribing Behavior Research Articles

Effects of pharmaceutical promotions on antibiotics prescribing behavior of Nigerian private medical practitioners

Objectives: About 80% of pharmaceutical marketing efforts are directed toward physicians who are important decision-makers to patients’ medication needs. Pharmaceutical marketing can affect drug prescriptions, which, in turn, may adversely impact prescription practices. This study investigated the effect of pharmaceutical promotions on the antibiotic prescribing behavior of private practice physicians. Materials and Methods: A cross-sectional and descriptive design was employed. Self-administered questionnaires, scaled on a linear 5-point Likert Scale, were distributed among 268 physicians attending the 44th annual scientific conference of the Association of Nigerian Private Medical Practitioners at Ibadan, in Southwest Nigeria. Results: The study achieved a response rate of 94%, and 243 completely filled questionnaires were included for data analysis using R version 4. Cronbach’s alpha reliability of the research instrument was found to be 0.991, indicating an excellent internal consistency. Most of the physicians were male (71%), medical officers (83%), and 49% were between the ages of 51 and 60 years. About 65% had over 20 years of practice experience. A majority, 211 (87%), have prescribed antibiotics under the influence of pharmaceutical companies’ promotions. However, Fisher’s exact tests demonstrated a weak association between relevant independent variables and the dependent variable (P > 0.05). Conclusion: Product detailing by pharmaceutical sales representatives was the most popular form of promotion and company-sponsored presentations had the greatest influence on the physicians’ prescription practice. It is, therefore, recommended that pharmaceutical promotions should be well regulated to guard against unethical practices.

Targeting Technology in Underserved Adults With Type 1 Diabetes: Effect of Diabetes Practice Transformations on Improving Equity in CGM Prescribing Behaviors.

Continuous glucose monitoring (CGM) is associated with improved outcomes in type 1 diabetes, but racial-ethnic disparities exist in use. We were interested in examining whether addressing structural health care barriers would change provider prescribing behaviors to make CGM access more equitable. From January 2019 to December 2021, we used multilevel stakeholder input to develop and implement several non-grant-funded practice transformations targeted toward equity, which included 1) developing a type 1 diabetes clinic, 2) conducting social needs assessments and management, 3) training support staff to place trial CGMs at the point of care, 4) optimizing prescription workflows, and 5) educating providers on CGM. Transformations were prioritized based on feasibility, acceptability, and sustainability. To examine effect on prescribing behaviors, we collected monthly aggregate data from the electronic medical record and performed multiple linear regression to examine and compare change in CGM prescriptions over the 3 years of transformation. In total, we included 1,357 adults with type 1 diabetes in the analysis (mean ± SD age 38 ± 18 years; 30% Black [n = 406], 45% Hispanic [n = 612], 12% White [n = 164]; and 74% publicly insured [n = 1,004]). During the period of transformation, CGM prescription rates increased overall from 15% to 69% (P < 0.001). Improvements were seen equally among Black (12% to 72%), Hispanic (15% to 74%), and White adults (20% to 48%) (between-group P = 0.053). Diabetes practice transformations that target equity, offload provider burdens, and focus on feasible sustainable stakeholder-driven solutions can have powerful effects on provider prescribing behaviors to reduce root causes of inequity in CGM among underserved adults with type 1 diabetes. Continued focus is needed on upstream determinants of downstream CGM use.

The potential existence of ‘Small Individual Formulary’ in prescribing behaviour: a qualitative semi-structured interview study

Abstract Objectives There is a widely held but previously unsubstantiated belief that prescribers tend to consider and use a limited set of medications when making prescribing decisions. This study aimed to enhance understanding of the process of prescribing decision making in a real-world context. Methods Using constructivist grounded theory methodology, we conducted semi-structured interviews with 11 healthcare providers in Georgia state. The providers, most of whom are physicians of different specialties, shared their perspectives about prescribing decision making and their perceptions about using a limited set of medications in daily practice. Key findings Three themes emerged from the qualitative analysis: (1) prescribers recognized the existence of ‘small individual formularies’ and considered it helpful in simplifying prescribing decision making; (2) healthcare providers employed an algorithm to initiate and step up drug therapy for patients; (3) formulary and patient affordability played a vital role in prescribing. Conclusions Physicians and other prescribers consider and use a limited set of prescription drugs based on their internal prescribing behaviour algorithm. Strategies could be developed to help stakeholders use this information to improve medication use.

Adult Children’s Recollections of Their White Parents’ Moral Memorable Messages about Racial Difference

ABSTRACT A new lens for exploring family socialization about racism and racial differences, the crux of the study is college students“ (N = 181) recalled moral memorable messages (MMM) from their White parents about racial outgroups. Among those who recalled a message, the most common theme was ‘Equal Treatment,’ and included subthemes consistent with both colorblind and multicultural ideologies. ‘Racism is Real and Wrong’ prescribed uncovering and working against one’s own and others” racist acts. Adult children’s message agreement and identification with the message’s sender were both significantly greater for these two themes than for the “Racial outgroups are unequal and unwelcome” theme, which included displays and prescriptions of racist behavior. Implications are discussed in relation to existent theorizing, and for use in future research on family communication about racial difference.

Analyzing trends in treatment of acne vulgaris and adherence to the American Academy of Dermatology guidelines: A retrospective study

To the Editor: Acne vulgaris is a chronic inflammatory skin disease with varying treatments.1 Limited literature exists on the prescription behavior of physicians for acne. Evidence-based clinical guidelines from the American Academy of Dermatology (AAD) for acne vulgaris were published in 2016.2 Our objective was to analyze adherence to a subset of the AAD guidelines regarding antibiotic and combination therapy (Table I).

Impact of uncertainty intolerance on clinical reasoning: A scoping review of the 21st-century literature.

A scoping review was conducted using relevant keywords to scientific databases (i.e., Google Scholar, Medline, PsycINFOandPBSC) from September to November 2021. Complementary research included relevant articles and articles retrieved through Google Scholar's alert system. We included articles about healthcare professionals as defined by the French Public Health Code (As defined here: https://www.vie-publique.fr/fiches/37855-categories-de-professionnels-de-sante-code-se-la-sante-publique), and articles reporting on the impact of IU or uncertainty management on clinical reasoning. We retrieved 1853 articles, of which 8 were kept for final analysis considering our inclusion criteria. Two behaviour categories were affected by uncertainty intolerance: investigative and prescriptive behaviours. Regarding the investigation process, mismanagement of uncertainty appeared to lead to reasoning bias, potentially resulting in diagnostic errors. IU was associated with withholding information, more referrals to peers and less use of new medical interventions. Regarding prescription behaviours, IU among health professionals could lead to overprescribing unnecessary or dangerous tests. IU was also associated with more antibiotic prescriptions for conditions where antibiotics are to be used carefully. Few studies have yet addressed the impact of IU on clinical reasoning. IU's influence is primarily observed on investigative and prescribing behaviours. More studies are needed to fully understand the impact of IU on clinical reasoning itself, and not only on practical consequences.

Knowledge and Attitudes about Antibiotics and Antibiotic Resistance of 2404 UK Healthcare Workers.

Background: Using the COM-B model as a framework, an EU-wide survey aimed to ascertain multidisciplinary healthcare workers’ (HCWs’) knowledge, attitudes and behaviours towards antibiotics, antibiotic use and antibiotic resistance. The UK findings are presented here. Methods: A 43-item questionnaire was developed through a two-round modified Delphi consensus process. The UK target quota was 1315 respondents. Results: In total, 2404 participants responded. The highest proportion were nursing and midwifery professionals (42%), pharmacists (23%) and medical doctors (18%). HCWs correctly answered that antibiotics are not effective against viruses (97%), they have associated side effects (97%), unnecessary use makes antibiotics ineffective (97%) and healthy people can carry antibiotic-resistant bacteria (90%). However, fewer than 80% correctly answered that using antibiotics increases a patient’s risk of antimicrobial resistant infection or that resistant bacteria can spread from person to person. Whilst the majority of HCWs (81%) agreed there is a connection between their antibiotic prescribing behaviour and the spread of antibiotic-resistant bacteria, only 64% felt that they have a key role in controlling antibiotic resistance. The top three barriers to providing advice or resources were lack of resources (19%), insufficient time (11%) and the patient being uninterested in the information (7%). Approximately 35% of UK respondents who were prescribers prescribed an antibiotic at least once in the previous week to responding to the survey due to a fear of patient deterioration or complications. Conclusion: These findings highlight that a multifaceted approach to tackling the barriers to prudent antibiotic use in the UK is required and provides evidence for guiding targeted policy, intervention development and future research. Education and training should focus on patient communication, information on spreading resistant bacteria and increased risk for individuals.

1038 Improving Adherence to Antibiotic Guidelines for the Treatment of Acute Cholecystitis: A Completed Audit Cycle

Abstract Aim Acute cholecystitis (AC) accounts for up to one third of emergency surgical admissions. The initial management of AC includes fluid resuscitation and appropriate antibiotic therapy. The aim of this study is to audit compliance with local microbiology guidelines for the treatment of AC and to develop interventions that improve compliance rates. Method All patients admitted from September to December 2020 with radiologically confirmed AC were included in an initial prospective audit (n=39 patients). Antibiotic prescriptions, patient demographics, presence of fever (&amp;gt;38°C), inflammatory markers and liver function tests were recorded. The results were disseminated, educational material produced, and antibiotic “champions” appointed to improve adherence to antibiotic guidelines. A prospective re-audit was conducted from May to June 2021 to establish the effectiveness of the interventions (n=49 patients). Compliance rates before and after the interventions were compared using a Chi-squared test. Binomial logistic regression was carried out to establish whether any patient demographic or clinical parameters were independent predictors of prescribing behaviour. Results Compliance to antibiotic guidelines for AC significantly improved following the interventions (12.8% vs 57.1%; p&amp;lt;0.001). Age, gender, temperature, inflammatory markers, and liver function tests were comparable in both groups and were not found to be independent predictors of non-compliant antibiotic prescription. Conclusions Adherence to antibiotic guidelines for AC can be improved with educational interventions and the appointment of individuals responsible for ensuring correct prescribing behaviour. Interestingly, patient demographics, signs of sepsis or liver function did not influence prescribing behaviour, suggesting that divergence from antibiotic guidelines may be due to ingrained prescribing dogma.

A Qualitative Content Analysis of Rural and Urban School Students' Menstruation-Related Questions in Bangladesh.

Nearly half of Bangladeshi girls reach menarche without knowledge of menstruation and many fear seeking support due to pervasive menstrual stigma. We aimed to explore the types of menstruation-related information and support adolescent female and male students want but may be uncomfortable verbalising. We installed a locked box in four school classrooms in rural and urban Bangladesh as part of a menstrual hygiene management pilot intervention between August 2017 and April 2018. Trained teachers provided puberty education to female and male students in classes 5–10 (ages 10–17 years) and encouraged students to submit questions anonymously to the boxes if they did not want to ask aloud. We conducted a content analysis of the 374 menstruation-related questions from a total of 834 submissions. Questions regarded experiences of menstrual bleeding (35%); menstrual symptoms and management (32%); menstrual physiology (19%); behavioural prescriptions and proscriptions (6%); concerns over vaginal discharge (4%); and menstrual stigma, fear, and social support (4%). Students wanted to understand the underlying causes of various menstrual experiences, and concern over whether particular experiences are indicative of health problems was pervasive. Ensuring comprehensive school-based menstruation education and strengthening engagement among schools, parents, and healthcare providers is important for improving access to reliable menstrual health information and may relieve adolescents’ concerns over whether their menstrual experiences are ’normal’.

Diagnostic Stewardship-The Impact of Rapid Diagnostic Testing for Paediatric Respiratory Presentations in the Emergency Setting: A Systematic Review.

Antimicrobial resistance is a growing public health crisis, propelled by inappropriate antibiotic prescription, in particular the over-prescription of antibiotics, prolonged duration of antibiotic therapy and the overuse of broad-spectrum antibiotics. The paediatric population, in particular, those presenting to emergency settings with respiratory symptoms, have been associated with a high rate of antibiotic prescription rates. Further research has now shown that many of these antibiotic prescriptions may have been avoided, with more targeted diagnostic methods to identify underlying aetiologies. The purpose of this systematic review was to assess the impact of rapid diagnostic testing, for paediatric respiratory presentations in the emergency setting, on antibiotic prescription rates. To review the relevant history, a comprehensive search of Medline, EMBASE and Cochrane Database of Systematic Reviews was performed. Eighteen studies were included in the review, and these studies assessed a variety of rapid diagnostic testing tools and outcome measures. Overall, rapid diagnostic testing was found to be an effective method of diagnostic antibiotic stewardship with great promise in improving antibiotic prescribing behaviours. Further studies are required to evaluate the use of rapid diagnostic testing with other methods of antibiotics stewardship, including clinical decisions aids and to increase the specificity of interventions following diagnosis to further reduce rates of antibiotic prescription.

Barriers and Facilitators to DATA Waivered Providers Prescribing Buprenorphine: A Qualitative Analysis Applying the Theory of Planned Behavior

Background: Provider beliefs about the treatment of people with addiction may influence their prescribing behavior. Objective: This study applied the Theory of Planned Behavior (TPB), to identify the salient beliefs of Drug Addiction Treatment Act of 2000 (DATA 2000) waivered providers, concerning prescribing buprenorphine to patients with Opioid Use Disorder (OUD). Methods: Texas buprenorphine providers participated in one of four online focus group discussions conducted in fall 2019. The focus group discussion were audio recorded and the total length was between 60-90 minutes. Thematic analysis was conducted to identify emerging themes and to categorize the behavioral, normative, and control beliefs related to buprenorphine prescribing. Results: Of the 14 total participants, 57% of the participants were male and annually treated between zero to sixty patients with buprenorphine. The codes generated were represented in thematic maps, specifying the positive or negative aspects of buprenorphine prescribing. Results indicate that providers’ primary motivation to prescribe buprenorphine was, implementation of a whole-patient approach through collaboration with behavioral health providers, in the provision of medications for opioid use disorder (MOUD). Providers primary normative belief was the recognition of key members of the medical community and patients’ families and friends as influential groups. Providers’ control beliefs focused on their ability to use buprenorphine in different practice settings. Conclusion: These results indicate that buprenorphine access may be expanded by increasing support for DATA waivered providers from other parts of the healthcare system such as behavioral health providers and pharmacists. Implications for clinical practice and future research will be discussed.

EP-213 An Audit on the Initial Management of Acute Cholecystitis: A Single Centre Experience

Abstract Aim Acute cholecystitis (AC) accounts for up to one third of emergency surgical admissions. The initial management of AC includes fluid resuscitation and appropriate antibiotic therapy. The aim of this study is to audit compliance with local microbiology guidelines for the treatment of AC and to develop interventions that improve compliance rates. Method All patients admitted from September to December 2020 with radiologically confirmed AC were included in an initial prospective audit (n=39 patients). Antibiotic prescriptions, patient demographics, presence of fever (&amp;gt;38°C), inflammatory markers and liver function tests were recorded. The results were disseminated, educational material produced, and antibiotic “champions” appointed to improve adherence to antibiotic guidelines. A prospective re-audit was conducted from May to June 2021 to establish the effectiveness of the interventions (n=49 patients). Compliance rates before and after the interventions were compared using a Chi-squared test. Binomial logistic regression was carried out to establish whether any patient demographic or clinical parameters were independent predictors of prescribing behaviour. Results Compliance to antibiotic guidelines for AC significantly improved following the interventions (12.8% vs 57.1%; p&amp;lt;0.001). Age, gender, temperature, inflammatory markers and liver function tests were comparable in both groups and were not found to be independent predictors of non-compliant antibiotic prescription. Conclusions Adherence to antibiotic guidelines for AC can be improved with educational interventions and the appointment of individuals responsible for ensuring correct prescribing behaviour. Interestingly, patient demographics, signs of sepsis or liver function did not influence prescribing behaviour, suggesting that divergence from antibiotic guidelines may be due to ingrained prescribing dogma.

Exploring the Use of Antibiotics for Dental Patients in a Middle-Income Country: Interviews with Clinicians in Two Ghanaian Hospitals.

Background: Antimicrobial resistance is a global problem driven by the overuse of antibiotics. Dentists are responsible for about 10% of antibiotics usage across healthcare worldwide. Factors influencing dental antibiotic prescribing are numerous, with some differences in low- and middle-income countries compared with high-income countries. This study aimed to explore the antibiotic prescribing behaviour and knowledge of teams treating dental patients in two Ghanaian hospitals. Methods: Qualitative interviews were undertaken with dentists, pharmacists, and other healthcare team members at two hospitals in urban and rural locations. Thematic and behaviour analyses using the Actor, Action, Context, Target, Time framework were undertaken. Results: Knowledge about ‘antimicrobial resistance and antibiotic stewardship’ and ‘people and places’ were identified themes. Influences on dental prescribing decisions related to the organisational context (such as the hierarchical influence of colleagues and availability of specific antibiotics in the hospital setting), clinical issues (such as therapeutic versus prophylactic indications and availability of sterile dental instruments), and patient issues such as hygiene in the home environment, delays in seeking professional help, ability to access antibiotics in the community without a prescription and patient’s ability to pay for the complete prescription. Conclusions: This work provides new evidence on behavioural factors influencing dental antibiotic prescribing, including resource constraints which affect the availability of certain antibiotics and diagnostic tests. Further research is required to fully understand their influence and inform the development of new approaches to optimising antibiotic use by dentists in Ghana and potentially other low- and middle-income countries.

The Effect of Online Prescription Drug Monitoring on Opioid Prescription Habits After Elective Single-level Lumbar Fusion.

The United States opioid epidemic is a well-documented crisis stemming from increased prescriptions of narcotics. Online prescription drug monitoring programs (PDMPs) are a potential resource to mitigate narcotic misuse by tracking controlled substance prescriptions. Therefore, the purpose of this study was to evaluate opioid prescription trends after implementation of an online PDMP in patients who underwent single-level lumbar fusion. Patients who underwent a single-level lumbar fusion between August 27, 2017, and August 31, 2020, were identified and placed categorically into one of two cohorts: an "early adoption" cohort, September 1, 2017, to August 31, 2018, and a "late adoption" cohort, September 1, 2019, to August 31, 2020. This allowed for a 1-year washout period after Pennsylvania PDMP implementation on August 26, 2016. Opioid use data were obtained by searching for each patient in the state government's online PDMP and recording data from the year before and the year after the patient's procedure. No significant difference was observed in preoperative opioid prescriptions between the early and late adoption cohorts. The late adoption group independently predicted decreased postoperative opioid prescriptions (β, 0.78; 95% confidence interval [CI], 0.65 to 0.93; P = 0.007), opioid prescribers (β, 0.81; 95% CI, 0.72 to 0.90; P < 0.001), pharmacies used (β, 0.90; 95% CI, 0.83 to 0.97; P = 0.006), opioid pills (β, 0.61; 95% CI, 0.50 to 0.74; P < 0.001), days of opioid prescription (β, 0.57; 95% CI, 0.45 to 0.72; P < 0.001), and morphine milligram equivalents prescribed (β, 0.53; 95% CI, 0.43 to 0.66; P < 0.001). PDMP implementation was associated with decreased postoperative opioid prescription patterns but not preoperative opioid prescribing behaviors. 4.

Parallel cognition: hybrid intelligence for human-machine interaction and management

As an interdisciplinary research approach, traditional cognitive science adopts mainly the experiment, induction, modeling, and validation paradigm. Such models are sometimes not applicable in cyber-physical-social-systems (CPSSs), where the large number of human users involves severe heterogeneity and dynamics. To reduce the decision-making conflicts between people and machines in human-centered systems, we propose a new research paradigm called parallel cognition that uses the system of intelligent techniques to investigate cognitive activities and functionals in three stages: descriptive cognition based on artificial cognitive systems (ACSs), predictive cognition with computational deliberation experiments, and prescriptive cognition via parallel behavioral prescription. To make iteration of these stages constantly on-line, a hybrid learning method based on both a psychological model and user behavioral data is further proposed to adaptively learn an individual’s cognitive knowledge. Preliminary experiments on two representative scenarios, urban travel behavioral prescription and cognitive visual reasoning, indicate that our parallel cognition learning is effective and feasible for human behavioral prescription, and can thus facilitate human-machine cooperation in both complex engineering and social systems.

Does diagnostic testing always decrease antibiotics prescriptions?

BackgroundEmpiric prescription to treat infectious diseases in community care settings has caused antibiotics to be overprescribed, increasing antimicrobial resistance (AMR). To reduce antibiotics prescription, the use of point-of-care diagnostic testing (POCT) has been suggested.MethodsWe present a stylized static theoretical economic model to analyse whether the use of POCT always decreases antibiotics prescriptions. We consider the interaction of a group of doctors who differ in their level of concern about AMR when prescribing with a firm selling a POCT, and we characterize the price set by the manufacturer and doctors’ decision to employ POCT.ResultsWe found that the number of antibiotics prescriptions is not always lower. This result depends on the distribution of the doctors’ concern about AMR as there is a proportion of doctors who use POCT and then prescribe antibiotics while other doctors change their prescribing behaviour after using POCT and stop giving antibiotics to patients who do not benefit from them. When the proportion of patients who need antibiotic treatment is higher than the proportion of doctors who use POCT and stop prescribing unnecessary antibiotics, the number of antibiotics prescriptions is larger. Our analysis also shows that the use of POCT improves health outcomes.ConclusionsWe should be very careful when we assert that POCT reduces antibiotics prescriptions as there are situations in which the opposite effect occurs.

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.

Aiding the prescriber: developing a machine learning approach to personalized risk modeling for chronic opioid therapy amongst US Army soldiers.

The opioid epidemic is a major policy concern. The widespread availability of opioids, which is fueled by physician prescribing patterns, medication diversion, and the interaction with potential illicit opioid use, has been implicated as proximal cause for subsequent opioid dependence and mortality. Risk indicators related to chronic opioid therapy (COT) at the point of care may influence physicians' prescribing decisions, potentially reducing rates of dependency and abuse. In this paper, we investigate the performance of machine learning algorithms for predicting the risk of COT. Using data on over 12 million observations of active duty US Army soldiers, we apply machine learning models to predict the risk of COT in the initial months of prescription. We use the area under the curve (AUC) as an overall measure of model performance, and we focus on the positive predictive value (PPV), which reflects the models' ability to accurately target military members for intervention. Of the many models tested, AUC ranges between 0.83 and 0.87. When we focus on the top 1% of members at highest risk, we observe a PPV value of 8.4% and 20.3% for months 1 and 3, respectively. We further investigate the performance of sparse models that can be implemented in sparse data environments. We find that when the goal is to identify patients at the highest risk of chronic use, these sparse linear models achieve a performance similar to models trained on hundreds of variables. Our predictive models exhibit high accuracy and can alert prescribers to the risk of COT for the highest risk patients. Optimized sparse models identify a parsimonious set of factors to predict COT: initial supply of opioids, the supply of opioids in the month being studied, and the number of prescriptions for psychotropic medications. Future research should investigate the possible effects of these tools on prescriber behavior (e.g., the benefit of clinician nudging at the point of care in outpatient settings).

Effect of Smartphone App–Based Education on Clinician Prescribing Habits in a Learning Health Care System

Effective methods for engaging clinicians in continuing education for learning-based practice improvement remain unknown. To determine whether a smartphone-based app using spaced education with retrieval practice is an effective method to increase evidence-based practice. A prospective, unblinded, single-center, crossover randomized clinical trial was conducted at a single academic medical center from January 6 to April 24, 2020. Vanderbilt University Medical Center clinicians prescribing intravenous fluids were invited to participate in this study. All clinicians received two 4-week education modules: 1 on prescribing intravenous fluids and 1 on prescribing opioid and nonopioid medications (counterbalancing measure), over a 12-week period. The order of delivery was randomized 1:1 such that 1 group received the fluid management module first, followed by the pain management module after a 4-week break, and the other group received the pain management module first, followed by the fluid management module after a 4-week break. The primary outcome was evidence-based clinician prescribing behavior concerning intravenous fluids in the inpatient setting and pain medication prescribing on discharge from the hospital. A total of 354 participants were enrolled and randomized, with 177 in group 1 (fluid then pain management education) and 177 in group 2 (pain management then fluid education). During the overall study period, 16 868 questions were sent to 349 learners, with 11 783 (70.0%) being opened: 10 885 (92.4%) of those opened were answered and 7175 (65.9%) of those answered were answered correctly. The differences between groups changed significantly over time, indicated by the significant interaction between educational intervention and time (P = .002). Briefly, at baseline evidence-concordant IV fluid ordered 7.2% less frequently in group 1 than group 2 (95% CI, -19.2% to 4.9%). This was reversed after training at 4% higher (95% CI, -8.2% to 16.0%) in group 1 than group 2, a more than doubling in the odds of evidence-concordant ordering (OR, 2.56, 95% CI, 0.80-8.21). Postintervention, all gains had been reversed with less frequent ordering in group 1 than group 2 (-9.5%, 95% CI, -21.6% to 2.7%). There was no measurable change in opioid prescribing behaviors at any time point. In this randomized clinical trial, use of smartphone app learning modules resulted in statistically significant short-term improvement in some prescribing behaviors. However, this effect was not sustained over the long-term. Additional research is needed to understand how to sustain improvements in care delivery as a result of continuous professional development at the institutional level. ClinicalTrials.gov Identifier: NCT03771482.

Opioid prescribing patterns among oculofacial plastic surgeons.

Oculofacial plastic surgeons (OPS) prescribe narcotic pain prescriptions at a rate four times higher than that of other ophthalmologists. We conducted a cross-sectional survey to understand trends in opioid prescriptions among oculofacial plastic surgeons after common oculoplastic surgeries. This cross-sectional survey was sent to OPS in the USA between June 19, 2020 and December 1, 2020. Participants were asked about their training and practice as well as their top two choices for post-operative pain management both overall and for seven common oculoplastic surgeries. Fisher's exact and chi-square tests were performed to analyze relationships between categorical variables. The two most common opioid medications, in percentage of respondents (n = 82), prescribed overall by OPS were hydrocodone-acetaminophen (35%) and tramadol (21%). Between OPS completed training before 1990(16%) and those who completed training from 1991 to 2000 (12%), the latter cohort is 4.9 times more likely to prescribe opioids overall ([95% CI = 1.3-15.4], p = .01). Additionally, OPS who are currently practicing in the Southeast USA are 4.2 times more likely to prescribe opioids overall than those practicing in the Northeast USA ([95% CI: 1.4-12.8], p = .02). This study has helped identify patterns in opioid prescribing behavior among OPS based on demographic information and common oculoplastic surgeries. This knowledge will help bring awareness of prescribing behavior to the oculoplastics community and identify areas of improvement to reduce opioid prescriptions. Kindly check and confirm the OD and ON has been correctly identified in 2nd affiliationYes.