Background: We hypothesized that an electronic health record (EHR) alert grounded in behavioral science could reduce new antipsychotic medication prescriptions for older adults with dementia. Methods: We conducted a pragmatic clinical trial at a large academic health system, randomizing providers to receive the alert (intervention) or not (control) when prescribing new antipsychotic medications to outpatients with dementia. Eligible providers were those who previously signed a new antipsychotic prescription (n = 150). The EHR alert contained: (1) text stating that antipsychotic medications increase mortality risk; (2) a link to an after-visit summary handout describing non-pharmaceutical approaches; (3) a default to a lower dose and pill-days. The primary outcome was mean total pill-days over 19 months. We used provider-level linear regression, controlling for provider characteristics including prior prescribing behavior. Secondary outcomes included order cancellations and exploratory analyses of treatment effects among providers with above-average baseline prescribing patterns. Results: Between 9/15/2021 and 4/11/2023, 28 providers in the intervention and 21 in the control arm initiated prescriptions to eligible patients, resulting in 139 enrolled patients; mean patient age was 83 (SD 9.7); 67% female. After 19 months, raw mean (SD) pill-days were 126 (228) for the intervention and 225 (601) for the control group. Intervention assignment was not significantly associated with total pill-days among enrolled patients (primary outcome, mean difference -113 [95% CI: -256, +30], p = 0.12). Orders were canceled in 12/58 (21%) of intervention encounters. The intervention was estimated to reduce pill-days for providers with average baseline prescribing behavior (-126, 95% CI: -3, -248; p = 0.04); for each additional 10 baseline pill-days, this reduction effect increased by -8.8 pill-days (95% CI: -3.9, -13.6; p < 0.001). Conclusions: This EHR alert did not reduce the primary outcome of antipsychotic pill-days. However, the nonsignificant effect size was substantial, and exploratory analyses revealed that the intervention significantly reduced pill-days for providers with average baseline prescribing. Future alerts should test targeting high prescribers.

We describe a new custom feature within our Epic Systems electronic health record (EHR) that automates stratified randomization at the point-of-care or order. As a demonstration use-case, we conducted a randomized trial of a provider-facing alert for short-interval HbA1c orders. Over 3 months the alert dramatically reduced repeat orders. This transportable clinical informatics application transforms health systems' ability to conduct pragmatic clinical trials and deliver clinical care within the EHR.

Importance:Ambient artificial intelligence (AI) scribes record patient encounters and generate visit notes almost instantaneously, representing a promising solution to documentation burden and associated physician burnout. Despite swift and widespread adoption of AI scribes, their impacts have not been examined in randomized-clinical trials. Objective:To test the effectiveness of two AI scribes in reducing time spent writing notes and associated burnout in a randomized-clinical trial. Design:Parallel three-arm pragmatic randomized-clinical trial where physicians were assigned 1:1:1 via covariate-constrained randomization (balancing on time-in-note, baseline burnout score, and clinic days /week) to either one of two AI scribe applications-Microsoft DAX or Nabla-or a usual-care control group from 11/4/2024-1/3/2025. Setting:A large academic health system in California. Participants:313 outpatient physicians were recruited based on leadership referrals and department-wide emails. 238 participants representing 14 specialties qualified. Intervention:Intervention-arm physicians gained access to an AI scribe for two months. Main Outcomes and Measures:The primary outcome was change from baseline log writing time-in-note. Secondary outcomes measured by surveys included Mini-Z 2.0, 4-item physician task load (TL), and Professional Fulfillment Index-Work Exhaustion (PFI-WE) scores to evaluate aspects of burnout, work environment, and stress, as well as targeted questions addressing safety and accuracy. Results:DAX was used in 33.5% of 24,696 visits; Nabla was used in 29.5% of 23,653 visits. Nabla users experienced a 9.5% [95% CI:-17.2%,-1.8%] (p=.02) decrease in time-in-note versus the control group and a 7.8% [-15.5%,-0.1%] (p=.05) decrease versus DAX users, while DAX users exhibited no significant change versus control (-1.7% [-9.4%,+5.9%]; p=.66). Total Mini-Z, scaled 10-50 with higher scores indicating improvement, increased with users of any scribe (+2.76 [+1.41,+4.10]; p<.001). Reductions in TL (scale 0-400, TL=-35.8 [-63.7, -7.9]; p=.01) and work exhaustion (scale 0-4, PFI-WE=-0.27 [-0.48, -0.07]; p=.01) were seen with users of any scribe. One Grade 1 (mild) adverse event was reported, while clinically-significant inaccuracies were noted "occasionally" on 5-point Likert questions (DAX 2.7 [2.4-3.0] vs. Nabla 2.8 [2.6-3.0]; p=.68). Conclusion and Relevance:Use of Nabla reduced time-in-note, while use of any scribe led to modest improvements in physician burnout, work exhaustion, and task load. Performance was remarkably similar across two distinct vendor platforms, and occasional inaccuracies observed in either scribe require ongoing physician vigilance. Trial Registration:ClinicalTrials.gov Identifier: NCT06792890.

BACKGROUND:Ambient artificial intelligence (AI) scribes record patient encounters and rapidly generate visit notes, representing a promising solution to documentation burden and physician burnout. However, the scribes' impacts have not been examined in randomized clinical trials. METHODS:In this parallel three-group pragmatic randomized clinical trial, 238 outpatient physicians, representing 14 specialties, were assigned 1:1:1 via covariate-constrained randomization (balancing on time-in-note, baseline burnout score, and clinic days per week) to either one of two AI scribe applications - Microsoft Dragon Ambient eXperience (DAX) Copilot or Nabla - or a usual-care control group from November 4, 2024, to January 3, 2025. The primary outcome was the change from baseline log writing time-in-note. Secondary end points measured by surveys included the Mini-Z 2.0, a four-item physician task load (PTL), and Professional Fulfillment Index - Work Exhaustion (PFI-WE) scores to evaluate aspects of burnout; work environment; stress; and targeted questions addressing safety, accuracy, and usability. RESULTS:DAX was used in 33.5% of 24,696 visits; Nabla was used in 29.5% of 23,653 visits. Nabla users experienced a 9.5% (95% confidence interval [CI], -17.2% to -1.8%; P=0.02) decrease in time-in-note versus the control group, whereas DAX users exhibited no significant change versus the control group (-1.7%; 95% CI, -9.4% to +5.9%; P=0.66). Increases in total Mini-Z (scale 10-50; DAX 2.83 [95% CI, +1.28 to +4.37]; Nabla +2.69 [95% CI, +1.14 to +4.23]) and reductions in PTL (scale 0-400; DAX -39.9 [95% CI, -71.9 to -7.9]; Nabla -31.7 [95% CI, -63.8 to +0.4]), and PFI-WE (scale 0-4; DAX 0.32 [95% CI,-0.55 to -0.08]; Nabla -0.23 [95% CI, -0.46 to +0.01]) scores suggest improvement for users of either scribe versus the control. One grade 1 (mild) adverse event was reported, while clinically significant inaccuracies were noted "occasionally" on five-point Likert questions (DAX 2.7 [95% CI, 2.4 to 3.0]; Nabla 2.8 [95% CI, 2.6 to 3.0]). CONCLUSIONS:Nabla reduced time-in-note versus the control. Both DAX and Nabla resulted in potential improvements in burnout, task load, and work exhaustion, but these secondary end point findings need confirmation in larger, multicenter trials. Clinicians reported that performance was similar across the two distinct platforms, and occasional inaccuracies observed in either scribe require ongoing vigilance. (Funded by the University of California, Los Angeles, Department of Medicine and others; ClinicalTrials.gov number, NCT06792890.).

Among patients with Alzheimer's disease and its related dementias (ADRD) with behavioral disturbances, antipsychotic prescriptions have limited efficacy and increase the risk of death. Yet, physicians continue to routinely prescribe low-value antipsychotic medications for behavioral disturbances among patients with ADRD. We designed a pragmatic randomized-controlled trial to measure the impact of a behavioral economic electronic health record (EHR) clinical decision support (CDS) intervention to reduce physician prescriptions of new antipsychotic medications among patients with ADRD. Utilizing a pragmatic parallel arm randomized-controlled trial design, the study will randomize eligible physicians from a large academic health system to either receive a EHR CDS intervention or not (control) when they prescribe a new antipsychotic medication during visits with patients with ADRD. The intervention will include three components: 1) alerts prescribers that antipsychotic prescriptions increase mortality risk (motivating physicians' intrinsic desire for non-malfeasance); 2) offers non-pharmacological behavioral resources for caregivers; 3) auto-defaults the prescription to contain the lowest dose and number of pill-days (n = 30) without refills if the prescriber does not cancel the order (appealing to default bias). Over 1 year, we will compare the cumulative total of new antipsychotic pill-days prescribed (primary outcome) by physicians in the intervention group versus in the control group. The study protocol meets international SPIRIT guidelines. Behavioral economics, or the study of human behavior as a function of more than rational incentives, considering a whole host of cognitive and social psychological preferences, tendencies, and biases, is increasingly recognized as an important conceptual framework to improve physician behavior. This pragmatic trial is among the first to combine two distinct behavioral economic principles, a desire for non-malfeasance and default bias, to improve physician prescribing patterns for patients with ADRD. We anticipate this trial will substantially advance understanding of how behavioral-economic informed EHR CDS tools can potentially reduce harmful, low-value care among patients with ADRD.

Objectives Reduction in unnecessary services is one strategy for increasing the value of health care. Reference laboratory, or send-out, tests are associated with considerable costs. We investigated whether displaying cost and turnaround time (TAT), or time-to-result, for reference laboratory tests at the time of order entry in the electronic health record (EHR) system would impact provider ordering practices. Methods Reference laboratory test cost and TAT data were randomized prior to the study and only displayed for the intervention group. A 24-month dataset composed of 12 months each for baseline and study periods was extracted from the clinical data mart. A difference-in-differences (DID) analysis was conducted using a linear mixed-effects model to estimate the association between the intervention and changes in test-ordering patterns. Results In the inpatient setting, the DIDs of aggregate test-order costs and volume were not different among the control and intervention groups (p = 0.31 and p = 0.26, respectively). In the ambulatory setting, the DIDs of aggregate test-order costs and volume were not different among the control and intervention groups (p = 0.82 and p = 0.51, respectively). For both inpatient and ambulatory settings, no significant difference was observed in the DID of aggregate test-order costs and volumes calculated in respect to stratified relative cost and TAT groups (p > 0.05). Conclusion Lack of alternative tests, test orders placed at a late step in patient management, and orders facilitated by trainees or mid-level providers may have limited the efficacy of the intervention. Our randomized study demonstrated no significant association between the display of cost or TAT display and ordering frequency.

IMPORTANCE Few stroke survivors meet recommended cardiovascular goals, particularly among racial/ethnic minority populations, such as Black or Hispanic individuals, or socioeconomically disadvantaged populations. OBJECTIVE To determine if a chronic care model-based, community health worker (CHW), advanced practice clinician (APC; including nurse practitioners or physician assistants), and physician team intervention improves risk factor control after stroke in a safety-net setting (ie, health care setting where all individuals receive care, regardless of health insurance status or ability to pay). DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included participants recruited from 5 hospitals serving low-income populations in Los Angeles County, California, as part of the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) clinical trial. Inclusion criteria were age 40 years or older; experience of ischemic or hemorrhagic stroke or transient ischemic attack (TIA) no more than 90 days prior; systolic blood pressure (BP) of 130 mm Hg or greater or 120 to 130 mm Hg with history of hypertension or using hypertensive medications; and English or Spanish language proficiency. The exclusion criterion was inability to consent. Among 887 individuals screened for eligibility, 542 individuals were eligible, and 487 individuals were enrolled and randomized, stratified by stroke type (ischemic or TIA vs hemorrhagic), language (English vs Spanish), and site to usual care vs intervention in a 1:1 fashion. The study was conducted from February 2014 to September 2018, and data were analyzed from October 2018 to November 2020. INTERVENTIONS Participants randomized to intervention were offered a multimodal coordinated care intervention, including hypothesized core components (ie, >= 3 APC clinic visits, >= 3 CHW home visits, and Chronic Disease Self-Management Program workshops), and additional telephone visits, protocol-driven risk factor management, culturally and linguistically tailored education materials, and self-management tools. Participants randomized to the control group received usual care, which varied by site but frequently included a free BP monitor, self-management tools, and linguistically tailored information materials. MAIN OUTCOMES AND MEASURES The primary outcome was change in systolic BP at 12 months. Secondary outcomes were non-high density lipoprotein cholesterol, hemoglobin A(1c), and C-reactive protein (CRP) levels, body mass index, antithrombotic adherence, physical activity level, diet, and smoking status at 12 months. Potential mediators assessed included access to care, health and stroke literacy, self-efficacy, perceptions of care, and BP monitor use. RESULTS Among 487 participants included, the mean (SD) age was 57.1 (8.9) years; 317 (65.1%) were men, and 347 participants (71.3%) were Hispanic, 87 participants (18.3%) were Black, and 30 participants (6.3%) were Asian. A total of 246 participants were randomized to usual care, and 241 participants were randomized to the intervention. Mean (SD) systolic BP improved from 143 (17) mm Hg at baseline to 133 (20) mm Hg at 12 months in the intervention group and from 146 (19) mm Hg at baseline to 137 (22) mm Hg at 12 months in the usual care group, with no significant differences in the change between groups. Compared with the control group, participants in the intervention group had greater improvements in self-reported salt intake (difference, 15.4 [95% CI, 4.4 to 26.0]; P = .004) and serum CRP level (difference in log CRP, -0.4 [95% CI, -0.7 to -0.1] mg/dL; P = .003); there were no differences in other secondary outcomes. Although 216 participants (89.6%) in the intervention group received some of the 3 core components, only 35 participants (14.5%) received the intended full dose. CONCLUSIONS AND RELEVANCE This randomized clinical trial of a complex multilevel, multimodal intervention did not find vascular risk factor improvements beyond that of usual care; however, further studies may consider testing the SUCCEED intervention with modifications to enhance implementation and participant engagement.

Introduction Robust randomised trial data have shown that routine preoperative (pre-op) testing for cataract surgery patients is inappropriate. While guidelines have discouraged testing since 2002, cataract pre-op testing rates have remained unchanged since the 1990s. Given the challenges of reducing low-value care despite strong consensus around the evidence, innovative approaches are needed to promote high-value care. This trial evaluates the impact of an interdisciplinary electronic health record (EHR) intervention that is informed by behavioural economic theory. Methods and analysis This pragmatic randomised trial is being conducted at UCLA Health between June 2021 and June 2022 with a 12-month follow-up period. We are randomising all UCLA Health physicians who perform pre-op visits during the study period to one of the three nudge arms or usual care. These three nudge alerts address (1) patient harm, (2) increased out-of-pocket costs for patients and (3) psychological harm to the patients related to pre-op testing. The nudges are triggered when a physician starts to order a pre-op test. We hypothesise that receipt of a nudge will be associated with reduced pre-op testing. The primary outcome will be the change in the percentage of patients undergoing pre-op testing at 12 months. Secondary outcomes will include the percentage of patients undergoing specific categories of pre-op tests (labs, EKGs, chest X-rays (CXRs)), the efficacy of each nudge, same-day surgery cancellations and cost savings. Ethics and dissemination The study protocol was approved by the institutional review board of the University of California, Los Angeles as well as a nominated Data Safety Monitoring Board. If successful, we will have created a tool that can be disseminated rapidly to EHR vendors across the nation to reduce inappropriate testing for the most common low-risk surgical procedures in the country. Trial registration number ClinicalTrials.gov identifier: NCT04104256 .

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BACKGROUND:A recent nurse-led proactive care management intervention, Care Coordination for Health Promotion and Activities in Parkinson Disease (CHAPS), improved care quality when compared to usual care in a randomized controlled trial. Therefore, stakeholder (patient participants, nurse care managers, and Parkinson disease (PD) specialists) perceptions of key intervention components merit evaluation to inform decisions about dissemination.METHODS:This multi-site study occurred in five southwest United States Veterans Health Administration medical centers. Stakeholders were surveyed on their perceptions of CHAPS including the CHAPS Assessment, CHAPS nurse care managers, the Siebens Domain Management Model™ (a practical clinical model), and the Siebens Health Care Notebook (Notebook) (self-care tool). Participants' electronic medical records were abstracted for perceptions of the Notebook. Statistical analysis software was used to provide summary statistics; open card sorting methodology was used to identify themes and attributes in qualitative data including usability of some components.RESULTS:Participants, overall, highly rated their medication self-management, acknowledged some challenges with the CHAPS self-care tools, reported knowledge of PD specialist follow-up and PD red flags, and rated CHAPS nurse care managers as helpful. Nurse care manager responses indicated the CHAPS Assessment and Program highly facilitated care of their patients. Most all PD specialists would refer other patients to CHAPS. Nurse care manager and PD specialist responses indicated improved participant management of their PD. Three themes emerged in participant perceptions of the Notebook: Notebook Assets (e.g., benefits and features-liked); Deferring Notebook Review (e.g., no time to review); and Reasons for Not Using (e.g., participant preference). Shared attributes regarding the Siebens Domain Management Model and Notebook usability, reported by nurse care managers, were user-friendly, person/patient-centered, and organized. Some challenges to their use were also reported.CONCLUSIONS:Overall, stakeholder perceptions of the proactive nurse-led CHAPS intervention indicated its value in the care of individuals with PD. Responses about the CHAPS Assessment, Siebens Domain Management Model, and Notebook self-care tool signified their usefulness. Stakeholders' constructive suggestions indicated their engagement in CHAPS. These findings support CHAPS dissemination and contribute to research in care management.TRIAL REGISTRATION:ClinicalTrials.gov as NCT01532986 , registered on January 13, 2012.

Parkinson’s disease (PD) complexity poses challenges for individuals with Parkinson’s, providers, and researchers. A recent multisite randomized trial of a proactive, telephone-based, nurse-led care management intervention - Care Coordination for Health Promotion and Activities in Parkinson’s Disease (CHAPS) - demonstrated improved PD care quality. Implementation details and supportive stakeholder feedback were subsequently published. To inform decisions on dissemination, CHAPS Model components require evaluations of their fidelity to the Chronic Care Model and to their implementation. Additionally, assessment is needed on whether CHAPS addresses care challenges cited in recent literature. These analyses are based on data from a subset of 140 intervention arm participants and other CHAPS data. To examine CHAPS Model fidelity, we identified CHAPS components corresponding to the Chronic Care Model’s six essential elements. To assess implementation fidelity of these components, we examined data corresponding to Hasson’s modified implementation fidelity framework. Finally, we identified challenges cited in current Parkinson’s care management literature, grouped these into themes using open card sorting techniques, and examined CHAPS data for evidence that CHAPS met these challenges. All Chronic Care Model essential elements were addressed by 17 CHAPS components, thus achieving CHAPS Model fidelity. CHAPS implementation fidelity was demonstrated by adherence to content, frequency, and duration with partial fidelity to telephone encounter frequency. We identified potential fidelity moderators for all six of Hasson’s moderator types. Through card sorting, four Parkinson’s care management challenge themes emerged: unmet needs and suggestions for providers (by patient and/or care partner), patient characteristics needing consideration, and standardizing models for Parkinson’s care management. CHAPS activities and stakeholder perceptions addressed all these themes. CHAPS, a supportive nurse-led proactive Parkinson’s care management program, improved care quality and is designed to be reproducible and supportive to clinicians. Findings indicated CHAPS Model fidelity occurred to the Chronic Care Model and fidelity to implementation of the CHAPS components was demonstrated. Current Parkinson’s care management challenges were met through CHAPS activities. Thus, dissemination of CHAPS merits consideration by those responsible for implementing changes in clinical practice and reaching people in need. ClinicalTrials.gov as NCT01532986 , registered on January 13, 2012.

To assess the quality of medication optimization for transient ischemic attack (TIA) and minor stroke patients across the Veterans Health Administration (VHA), and to identify characteristics predicting medication optimization for hypertension, hyperlipidemia, and diabetes. The scope of this study focuses on these three medication‐related conditions and defines optimization as medication changes or additions made within a guideline‐defined timeframe.

Background: Minority and socioeconomically disadvantaged individuals are underrepresented in secondary stroke prevention trials. Little is known about factors associated with study retention in these populations. Objective: To evaluate the impact of sociodemographic characteristics on retention in the Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED) trial. Methods: 487 participants ≥40 years with stroke/TIA were recruited from 4 safety-net hospitals and 1 stroke center serving low income zip codes. Strategies for boosting retention included: having bilingual research assistants from similar cultures establish rapport and follow participants; culturally and linguistically tailoring materials; arranging visits around participants’ schedules; offering transportation, and conducting assessments in the home and community. We compared sociodemographic characteristics among those retained at 12 months (n=412) vs. those not retained (n=75) using t-test, Chi Square, and Fisher exact tests. Independent factors associated with retention were determined using logistic regression. Results: Average age was 57 years, 18% were black, 71% were Hispanic, 58% were Spanish-speaking, and 72% were born outside the US. 12-month retention was 85%. On bivariate analysis, factors associated with retention were: Spanish-speaking, Hispanic ethnicity, younger age, born outside the US, and married status (all p<0.05). After multivariate analysis, study site, younger age (<64 vs ≥65 years OR 2.2, 95% CI 1.1,4.4), married status (OR 2.0, 1.0,4.2), government insurance (vs uninsured OR 25.1, 1.2,5.1), private insurance (vs uninsured, OR 4.6, 1.3,16.4), and inability to afford medical care (OR 2.9, 1.3,6.7) were associated with retention. Discussion: In this secondary prevention trial of stroke survivors from predominantly minority backgrounds, younger age, marriage, and insurance were associated with retention, suggesting that addressing barriers in the elderly, and those without insurance or spousal support may be beneficial. Financial constraints were associated with retention suggesting that study participation appealed to more socioeconomically vulnerable individuals.

ABSTRACT IMPACT: We report a novel metric for assessing clinical informatics fellows relative to their personal goals, using standardized milestones that have been approved for the field by ACGME. OBJECTIVES/GOALS: ACGME has defined 20 milestones that serve as the goals for fellows in clinical informatics. Each fellow is rated from 1 to 5 on the achievement of each milestone, where 1 is entry-level, 4 is the level expected of a graduating fellow, and 5 is aspirational. We assessed fellows’ progress toward the personal goal levels that they set for each milestone. METHODS/STUDY POPULATION: At the start of the fellowship, we asked each fellow to rate the personal target levels that they want to achieve for each milestone. Since the default target level of achievement for a graduating fellow is a 4, we asked fellows to document exceptions from this target. We calculated a metric for each fellow’s achievement of each milestone as their achievement rating (assigned by mentors and rotation leaders during the semi-annual Clinical Competency Committee meeting) divided by the fellow’s desired level of achievement. In summarizing across the milestones, we counted those milestones having achievement metrics >=1.0 as ‘achieved,’ and then for milestones that were not achieved, we calculated an average for the fellow. RESULTS/ANTICIPATED RESULTS: As of June, 2020, our two graduating 2nd-year fellows had fully met 9/20 and 18/20 milestones, respectively. For the unmet milestones they averaged 81% and 85% achievement. The largest shortfalls were 75% achievements in Assessing User Needs for one fellow, and in Recognition of Errors for the other. One of our three 1st-year fellows had fully met 3/20 milestones; the other two had met none at 1st-year’s end. For unmet milestones, the 1st-year fellows’ average achievement metrics were 69%, 67%, and 52%. The greatest shortfalls were in Resource Utilization (creating job descriptions, budgeting etc.) and in Communication with Patients and Families. However, the rotations that would expose them to project management and to patient-facing systems such as MyChart come in our 2nd-year. DISCUSSION/SIGNIFICANCE OF FINDINGS: Assessing milestones met plus the percent achievement for those not yet met provides a useful metric for comparing fellows and identifying areas in need of more training. Although milestones will soon change to reflect the recent practice analysis for clinical informatics, we expect that this approach to assessing fellows will remain equally useful.

Objectives: Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) trial evaluated the implementation of a quality improvement (QI) program aligned with Learning Healthcare System principles to improve TIA care. Methods: A facility-based, stepped-wedge trial was conducted at six diverse sites. The intervention included five components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. Implementation strategies included: team activation via audit and feedback, goal setting, reflecting and evaluating, and planning; external facilitation; and building a community of practice. The primary effectiveness outcome was the Without Fail rate (WFR); proportion of TIA patients who received all processes of care for which they were eligible among: brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, high/moderate potency statins. The primary implementation outcomes were the number of improvement activities completed and the Group Organization (GO) scores for providing and improving care (scale of 1-10). Results: The 6 PREVENT facilities cared for N=162 control period TIA patients and N=191 intervention period TIA patients. The mean facility WFR increased from 36.7% (baseline) to 53.9% (active implementation); p=0.002 (adjusted for temporal trend, hospital admission). The mean number of improvement activities completed during the 1-year implementation period was 26 (range 11-39). The mean facility GO scores increased: providing care, 1.2 to 6.5; improving care, 1.0 to 6.7. Conclusions: PREVENT advances three aspects of a learning healthcare system: Learning from Data (teams interacted with their facility’s performance data to explore hypotheses, plan QI activities, and evaluate change over time); Learning from Each Other (teams participated in monthly virtual collaborative conferences), and Sharing Best Practices (teams shared tools and protocols).

Objective A growing body of evidence suggests that testing for influenza virus alone is more appropriate than multiplex respiratory viral panel (RVP) testing for general populations of patients with respiratory tract infections. We aimed to decrease the proportion of RVPs out of total respiratory viral testing ordered during influenza season. Methods We implemented two consecutive interventions: reflex testing for RVPs only after a negative influenza test, and noninterruptive clinical decision support (CDS) including modifications of the computerized physician order entry search behavior and cost display. We conducted an interrupted time series of RVPs and influenza polymerase chain reaction tests pre- and postintervention, and performed a mixed-effects logistic regression analysis with a primary outcome of proportion of RVPs out of total respiratory viral tests. The primary predictor was the intervention period, and covariates included the provider, clinical setting, associated diagnoses, and influenza incidence. Results From March 2013 to April 2019, there were 24,294 RVPs and 26,012 influenza tests ( n = 50,306). Odds of ordering an RVP decreased during the reflex testing period (odds ratio: 0.432, 95% confidence interval: 0.397-0.469), and decreased more dramatically during the noninterruptive CDS period (odds ratio: 0.291, 95% confidence interval: 0.259-0.327). Discussion The odds of ordering an RVP were 71% less with the noninterruptive CDS intervention, which projected 4,773 fewer RVPs compared with baseline. Assuming a cost equal to Medicare reimbursement rates for RVPs and influenza tests, this would generate an estimated averted cost of $1,259,474 per year. Conclusion Noninterruptive CDS interventions are effective in reducing unnecessary and expensive testing, and avoid typical pitfalls such as alert fatigue.

Background: Approximately 25 million people in the US are Limited English Proficient (LEP). LEP individuals are more likely to feel dissatisfied with the quality of healthcare when compared to the English proficient, but little is known about LEP stroke survivors. Objective: To evaluate differences in stroke literacy, self-efficacy, and perceptions of healthcare delivery in English and Spanish-speaking individuals enrolled in the Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED) trial. Methods: SUCCEED participants were given the option of receiving the intervention in English or Spanish. Baseline differences in stroke literacy (Schneider et al), self-efficacy (General Self-Efficacy Scale), and perceptions of care (Patient Assessment of Chronic Illness Care and Consumer Assessment of Healthcare Providers and Systems) were compared using T-test, Chi Square, and Fisher Exact in individuals who chose Spanish vs. English. Results: Of 487 participants, 207 preferred English and 280 chose Spanish. Despite feeling more worried about having a stroke (77 % vs. 67%), and feeling at risk of having a stroke (63% vs. 45%), Spanish-speakers were less likely to identify 3 stroke risk factors (19% vs. 33%, all p<0.05). Half of Spanish-speakers had difficulty understanding what was being told to them (50% vs. 30%), and less than half felt confident filling out medical forms (40% vs. 70%, both p<0.05). Spanish-speakers responded favorably about the ease of hospital admission or accessing medical care (80% vs. 55% and 72% vs. 53%), but responded negatively about providers spending enough time with them or explaining things in a way that was easy to understand (56% vs. 24% and 52% vs. 28%, all p<0.05). Spanish-speakers were more likely to feel that providers did not listen or respect what they had to say (52% vs. 22% and 44% vs. 17%, both p<0.05). Conclusion: Among stroke survivors, Spanish-speakers were more likely to have low stroke literacy, low self-efficacy, and a negative perception of healthcare delivery despite feeling that healthcare was accessible. Recognizing language barriers as a contributor to healthcare disparities, and tailoring interventions to address these barriers are crucial.

OBJECTIVES:Although healthy lifestyle practices mitigate recurrent stroke risk and mortality, few stroke survivors adhere to them, particularly among socioeconomically disadvantaged communities. We developed and pilot tested a occupational therapy-based lifestyle management intervention, Healthy Eating And Lifestyle after Stroke (HEALS), to improve stroke survivors' self-management skills relating to diet and physical activity and evaluated it in a diverse safety-net population. MATERIALS AND METHODS:One hundred English- or Spanish-speaking participants with stroke or transient ischemic attack were randomized to a 6-week occupational therapist-led group lifestyle intervention vs. usual care. Each of the six 2-h group sessions included didactic presentations on diet and physical activity, peer exchange, personal exploration with goal setting, and direct experience through participation in a relevant activity. Primary outcomes at 6 months were change in body mass index, fruit/vegetable intake, and physical activity. Secondary outcomes included change in waist circumference, smoking, blood pressure, high-density lipoprotein, low-density lipoprotein, triglyceride, total cholesterol, glycosylated hemoglobin levels, quality of care, and perceptions of care. Effect sizes were determined in preparation for a larger randomized controlled trial powered to detect a difference in primary outcomes. A nested formative evaluation assessed facilitators and barriers to implementation, acceptance, and intervention adherence. RESULTS:There were no significant changes in primary or secondary outcomes at 6 months. Effect sizes for all outcomes were small (< 0.2). Focus group participants recommended extending the intervention program duration with more sessions, additional information on stroke and vascular risk factors, an interdisciplinary approach, additional family involvement, and incentives. Providers recommended longer program duration, more training, fidelity checks to ensure standardized program delivery, and additional incentives for participants. CONCLUSIONS:The HEALS intervention was feasible in a safety-net setting, but effect sizes were small. A longer-duration intervention, with intervener fidelity checks may be warranted. TRIAL REGISTRATION:NCT01550822.