BACKGROUND: Excess opioid prescribing after surgery can lead to prolonged opioid use and diversion. We interviewed surgeons who were part of a three-group cluster-randomised controlled trial aimed at reducing prescribed opioid quantities after surgery via two versions of a monthly emailed behavioural \'nudge\' (messages encouraging but not mandating compliance with social norms and clinical guidelines around prescribing) at the end of the implementation year in order to understand surgeons\' reasoning for changing or continuing their prescribing behaviour as a result of the intervention and the context for their rationale.
METHODS: The study took place at a large healthcare system in northern California with surgeons from three surgical specialties-orthopaedics, obstetrics/gynaecology and general surgery. Following the intervention period, we conducted semistructured interviews with 36 surgeons who had participated in the trial, ensuring representation across trial arm, specialty and changes in prescribing quantities over the year. Interviews focused on reactions to the nudges, impacts of the nudges on prescribing behaviours and other factors impacting prescribing. Three study team members coded and analysed the transcribed interviews.
RESULTS: Nudges were equally effective in reducing postsurgical opioid prescribing across surgical specialties and between intervention arms. Surgeons were generally receptive to the nudge intervention, noting that it reduced the size of their discharge opioid prescriptions by improving their awareness and intentionality around prescribing. Most were unaware that clinical guidelines around opioid prescribing existed. Some had reservations regarding the accuracy and context of information provided in the nudges, the prescription quantities encouraged by the nudges and feelings of being watched or admonished. A few described discussing the nudges with colleagues. Respondents emphasised that the prescribing behaviours are informed by individual clinical experience and patient-related and procedure-related factors.
CONCLUSIONS: Surgeons were open to learning about their prescribing behaviour through comparisons to guidelines or peer behaviour and incorporating this feedback as one of several factors that guide discharge opioid prescribing. Increasing awareness of clinical guidelines around opioid prescribing is important for curbing postsurgical opioid overprescribing.
BACKGROUND: NCT05070338.

UNASSIGNED: Excess opioid prescribing after surgery can result in prolonged use and diversion. Email feedback based on social norms may reduce the number of pills prescribed.
UNASSIGNED: To assess the effectiveness of 2 social norm-based interventions on reducing guideline-discordant opioid prescribing after surgery.
UNASSIGNED: This cluster randomized clinical trial conducted at a large health care delivery system in northern California between October 2021 and October 2022 included general, obstetric/gynecologic, and orthopedic surgeons with patients aged 18 years or older discharged to home with an oral opioid prescription.
UNASSIGNED: In 19 hospitals, 3 surgical specialties (general, orthopedic, and obstetric/gynecologic) were randomly assigned to a control group or 1 of 2 interventions. The guidelines intervention provided email feedback to surgeons on opioid prescribing relative to institutionally endorsed guidelines; the peer comparison intervention provided email feedback on opioid prescribing relative to that of peer surgeons. Emails were sent to surgeons with at least 2 guideline-discordant prescriptions in the previous month. The control group had no intervention.
UNASSIGNED: The probability that a discharged patient was prescribed a quantity of opioids above the guideline for the respective procedure during the 12 intervention months.
UNASSIGNED: There were 38 235 patients discharged from 640 surgeons during the 12-month intervention period. Control-group surgeons prescribed above guidelines 36.8% of the time during the intervention period compared with 27.5% and 25.4% among surgeons in the peer comparison and guidelines arms, respectively. In adjusted models, the peer comparison intervention reduced guideline-discordant prescribing by 5.8 percentage points (95% CI, -10.5 to -1.1; P = .03) and the guidelines intervention reduced it by 4.7 percentage points (95% CI, -9.4 to -0.1; P = .05). Effects were driven by surgeons who performed more surgeries and had more guideline-discordant prescribing at baseline. There was no significant difference between interventions.
UNASSIGNED: In this cluster randomized clinical trial, email feedback based on either guidelines or peer comparison reduced opioid prescribing after surgery. Guideline-based feedback was as effective as peer comparison-based feedback. These interventions are simple, low-cost, and scalable, and may reduce downstream opioid misuse.
UNASSIGNED: ClinicalTrials.gov NCT05070338.

BACKGROUND: Acute uncomplicated urinary tract infections are common in outpatient settings but are not treated optimally. Few studies of the outpatient use of antibiotics for specific diagnoses have been done in sub-Saharan Africa, so little is known about the prescribing patterns of medical officers in the region.
METHODS: Aga Khan University has 16 outpatient clinics throughout the Nairobi metro area with a medical officer specifically assigned to that clinic. A baseline assessment of evaluation and treatment of suspected UTI was performed from medical records in these clinics. Then the medical officer from each of the 16 clinics was recruited from each clinic was recruited with eight each randomized to control vs. feedback groups. Both groups were given a multimodal educational session including locally adapted UTI guidelines and emphasis on problems identified in the baseline assessment Each record was scored using a scoring system that was developed for the study according to adequacy of history, physical examination, clinical diagnosis matching recorded data, diagnostic workup and treatment. Three audits were done for both groups; baseline (audit 1), post-CME (audit 2), and a final audit, which was after feedback for the feedback group (audit 3). The primary analysis assessed overall guideline adherence in the feedback group versus the CME only group.
RESULTS: The overall scores in both groups showed significant improvement after the CME in comparison to baseline and for each group, the scores in most domains also improved. However, audit 3 showed persistence of the gains attained after the CME but no additional benefit from the feedback. Some deficiencies that persisted throughout the study included lack of workup of possible STI and excess use of non-UTI laboratory tests such as CBC, stool culture and H. pylori Ag. After the CME, the use of nitrofurantoin rose from only 4% to 8% and cephalosporin use increased from 49 to 67%, accompanied by a drop in quinolone use.
CONCLUSIONS: The CME led to modest improvements in patient care in the categories of history taking, treatment and investigations, but feedback had no additional effect. Future studies should consider an enforcement element or a more intensive feedback approach.

OBJECTIVE: Sense of agency is associated with a sense of responsibility, which is essential to performing goal-directed occupations.
OBJECTIVE: To reach consensus on a set of extrinsic feedback statements that have the potential to create a sense of responsibility among patients with neurological disorders in the course of performing daily or social occupations.
METHODS: Anonymous Delphi study with two rounds with international experts and one round with Irani patients with Parkinson\'s disease (PD).
METHODS: Electronic survey.
METHODS: One hundred experts and 73 patients with idiopathic PD.
METHODS: Experts and patients anonymously rated (5 = strongly agree/very effective, 4 = agree/effective, 3 = neither agree nor disagree/uncertain, 2 = disagree/ineffective, 1 = strongly disagree/very ineffective) their level of agreement with each survey statement and the effectiveness of each statement in creating a sense of responsibility in the course of performing daily or social occupations. Consensus was set as an interquartile range of ≤1 and ≥70% agreement in two adjacent categories of a Likert scale.
RESULTS: In the experts\' first round, consensus was reached on the level of agreement and effectiveness of 18 statements. In the second round, final consensus was achieved on all statements. In the one patient round, patients reached consensus on all statements. Finally, 34 statements were rated as 4 or 5 in terms of agreement and effectiveness, based on the opinions of experts and patients.
CONCLUSIONS: This study has produced a collection of feedback statements that might be useful in occupation-based interventions. What This Article Adds: Extrinsic responsibility feedback delivered while administering occupation-based interventions may increase volition, motivation, and engagement.

This paper is concerned with the problem of fixed-time consensus tracking for a class of nonlinear multi-agent systems subject to unknown disturbances. Firstly, a modified fixed-time disturbance observer is devised to estimate the unknown mismatched disturbance. Secondly, a distributed fixed-time neural network control protocol is designed, in which neural network is employed to approximate the uncertain nonlinear function. Simultaneously, the technique of command filter is applied to fixed-time control, which circumvents the \"explosion of complexity\" problem. Under the proposed control strategy, all agents are enable to track the desired trajectory in fixed-time, and the consensus tracking error and disturbance estimation error converge to an arbitrarily small neighborhood of the origin, meanwhile, all signals in the closed-loop system remain bounded. Finally, a simulation example is provided to validate the effectiveness of the presented design method.

Incidental research findings pose a considerable challenge to hospital-based research biobanks since they are acting as intermediaries between healthcare and research. In a joint action the centralized biobank ibdw (Interdisciplinary Bank of Biomaterials and Data Wuerzburg) together with local authorities drafted a coherent concept to manage incidental research findings in full compliance with relevant ethical and data privacy regulations. The concept was developed and elaborated in close collaboration with the German Biobank Alliance (GBA). Comprehensive documentation of all steps guarantees the traceability of the process. By a mandatory assessment of the findings prior to re-identification of the individual concerned, unnecessary measures can be avoided. The individual\'s \"right not to know\" is respected according to the stipulations of the informed consent. As a general principle any communication with the individual occurs exclusively through the hospital and by competent physicians with appropriate knowledge and communication skills. We propose this scheme as a blueprint for reporting workflows for incidental research findings at hospital-based biobanks.

This paper is concerned with the sampled-data consensus of networked Euler-Lagrange systems. The Euler-Lagrange system has enormous advantages in analyzing and designing dynamical systems. Yet, some problems arise in the Euler-Lagrange equation-based control laws when they contain sampled-data feedbacks. The control law differentiates the discontinuous sampled-data signals to generate its control input. In this process, infinities in the control inputs are generated inevitably. The main goal of this work is to eliminate these infinities and make the control inputs applicable. To reach this goal, a class of differentiable pulse functions is designed for the controllers. The pulse functions work as multipliers on the sampled-data signals to make them differentiable, hence avoid the infinities. A new consensus condition compatible with the pulse function is also obtained through rigorous consensus analysis. The condition is proved to be less conservative compared with that of the existing method. Finally, numerical examples are given to illustrate the findings and theoretical results.

Memory clinics (MCs) play a key role in accurate and timely diagnoses and treatment of dementia and mild cognitive impairment. However, within Australia, there are little data available on current practices in MCs, which hinder international comparisons for best practice, harmonisation efforts and national coordination. Here, we aimed to characterise current service profiles of Australian MCs.
The \'Australian Dementia Network Survey of Expert Opinion on Best Practice and the Current Clinical Landscape\' was conducted between August-September 2020 as part of a larger-scale Delphi process deployed to develop national MC guidelines. In this study, we report on the subset of questions pertaining to current practice including wait-times and post-diagnostic care.
Responses were received from 100 health professionals representing 60 separate clinics (45 public, 11 private, and 4 university/research clinics). The majority of participants were from clinics in metropolitan areas (79%) and in general were from high socioeconomic areas. While wait-times varied, only 28.3% of clinics were able to offer an appointment within 1-2 weeks for urgent referrals, with significantly more private clinics (58.3%) compared to public clinics (19.5%) being able to do so. Wait-times were less than 8 weeks for 34.5% of non-urgent referrals. Only 20.0 and 30.9% of clinics provided cognitive interventions or post-diagnostic support respectively, with 7.3% offering home-based reablement programs, and only 12.7% offering access to group-based education. Metropolitan clinics utilised neuropsychological assessments for a broader range of cases and were more likely to offer clinical trials and access to research opportunities.
In comparison to similar countries with comprehensive government-funded public healthcare systems (i.e., United Kingdom, Ireland and Canada), wait-times for Australian MCs are long, and post-diagnostic support or evidence-based strategies targeting cognition are not common practice. The timely and important results of this study highlight a need for Australian MCs to adopt a more holistic service of multidisciplinary assessment and post-diagnostic support, as well as the need for the number of Australian MCs to be increased to match the rising number of dementia cases.

Surgical antibiotic prophylaxis (SAP) has been proved to decrease the rate of surgical site infections (SSI), but compliance to SAP guidelines remains suboptimal.
This study evaluated the impact of periodically sending individualized feedback letters to surgeons and anesthesiologists on their compliance rate to SAP guidelines.
A total of 1491 surgeries were evaluated by retrospective chart review during the pre-intervention period and 668 surgeries were evaluated by prospective chart review during the per-intervention period. Finally, 295 letters were sent to 64 surgeons and 45 anesthesiologists. Compliance rate was assessed as an outcome composed of: indication for SAP, choice of antibiotic agent, antibiotic dose, postoperative duration, timing of the preoperative dose and intraoperative redosing. An interrupted time series design was used to assess a difference on compliance rates before and during the intervention period.
Sending individualized feedback letters to surgeons and anesthesiologists did not significantly improve the overall compliance to local SAP guidelines.
Individualized feedback letters could be part of future interventions directed at improving compliance to SAP guidelines, but are likely insufficient by themselves to provide significant results.

National Dutch guidelines have been introduced to improve suboptimal perioperative care. A multifaceted implementation programme (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) has been developed to support hospitals in applying these guidelines. This study evaluated the effectiveness of IMPROVE on guideline adherence and the association between guideline adherence and patient safety.
Nine hospitals participated in this unblinded, superiority, stepped-wedge, cluster RCT in patients with major noncardiac surgery (mortality risk ≥1%). IMPROVE consisted of educational activities, audit and feedback, reminders, organisational, team-directed, and patient-mediated activities. The primary outcome of the study was guideline adherence measured by nine patient safety indicators on the process (stop moments from the composite STOP bundle, and timely administration of antibiotics) and on the structure of perioperative care. Secondary safety outcomes included in-hospital complications, postoperative wound infections, mortality, length of hospital stay, and unplanned care.
Data were analysed for 1934 patients. The IMPROVE programme improved one stop moment: \'discharge from recovery room\' (+16%; 95% confidence interval [CI], 9-23%). This stop moment was related to decreased mortality (-3%; 95% CI, -4% to -1%), fewer complications (-8%; 95% CI, -13% to -3%), and fewer unscheduled transfers to the ICU (-6%; 95% CI, -9% to -3%). IMPROVE negatively affected one other stop moment - \'discharge from the hospital\' - possibly because of the limited resources of hospitals to improve all stop moments together.
Mixed implementation effects of IMPROVE were found. We found some positive associations between guideline adherence and patient safety (i.e. mortality, complications, and unscheduled transfers to the ICU) except for the timely administration of antibiotics.
NTR3568 (Dutch Trial Registry).