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Enhancing vaccine uptake is a critical public health challenge 1 . Overcoming vaccine hesitancy 2 , 3 and failure to follow through on vaccination intentions 3 requires effective communication strategies 3 , 4 . Here we present two sequential randomized controlled trials to test the effect of behavioural interventions on the uptake of COVID-19 vaccines. We designed text-based reminders that make vaccination salient and easy, and delivered them to participants drawn from a healthcare system one day (first randomized controlled trial) ( n  = 93,354 participants; clinicaltrials number NCT04800965) and eight days (second randomized controlled trial) ( n  = 67,092 individuals; clinicaltrials number NCT04801524) after they received a notification of vaccine eligibility. The first reminder boosted appointment and vaccination rates within the healthcare system by 6.07 (84%) and 3.57 (26%) percentage points, respectively; the second reminder increased those outcomes by 1.65 and 1.06 percentage points, respectively. The first reminder had a greater effect when it was designed to make participants feel ownership of the vaccine dose. However, we found no evidence that combining the first reminder with a video-based information intervention designed to address vaccine hesitancy heightened its effect. We performed online studies ( n  = 3,181 participants) to examine vaccination intentions, which revealed patterns that diverged from those of the first randomized controlled trial; this underscores the importance of pilot-testing interventions in the field. Our findings inform the design of behavioural nudges for promoting health decisions 5 , and highlight the value of making vaccination easy and inducing feelings of ownership over vaccines. Two randomized controlled trials demonstrate the ability of text-based behavioural ‘nudges’ to improve the uptake of COVID-19 vaccines, especially when designed to make participants feel ownership over their vaccine dose.

In this paper, we demonstrate that the explicit ADER approach as it is used inter alia in Zanotti et al. (Comput Fluids 118:204–224, 2015) can be seen as a special interpretation of the deferred correction (DeC) method as introduced in Dutt et al. (BIT Numer Math 40(2):241–266, 2000). By using this fact, we are able to embed ADER in a theoretical background of time integration schemes and prove the relation between the accuracy order and the number of iterations which are needed to reach the desired order. Next, we extend our investigation to stiff ODEs, treating these source terms implicitly. Some differences in the interpretation and implementation can be found. Using DeC yields typically a much simpler implementation, while ADER benefits from a higher accuracy, at least for our numerical simulations. Then, we also focus on the PDE case and present common space-time discretizations using DeC and ADER in closed forms. Finally, in the numerical section we investigate A-stability for the ADER approach—this is done for the first time up to our knowledge—for different order using several basis functions and compare them with the DeC ansatz. Then, we compare the performance of ADER and DeC for stiff and non-stiff ODEs and verify our analysis focusing on two basic hyperbolic problems.

Heart failure affects people of all ages and is a leading cause of death for both men and women in most racial and ethnic groups in the United States. Infections are common causes of hospitalizations in heart failure, with respiratory infections as the most frequent diagnosis. Vaccinations provide significant protection against preventable respiratory infections. Despite being an easily accessible intervention, prior studies suggest vaccines are underused in patients with heart failure. An observational study of 5089 adults with heart failure was conducted using data from an integrated, multicenter, academic health system in Southern California from 2019 to 2022. Logistic regression models were used to determine the rates of influenza, pneumococcal, and COVID-19 vaccination among a population of patients with heart failure (heart failure preserved ejection fraction [HFpEF], heart failure mildly reduced ejection fraction [HFmrEF], and heart failure reduced ejection fraction [HFrEF], and identify whether heart failure phenotype is associated with vaccination status. Vaccination rates varied between influenza, pneumococcal, and COVID-19 vaccines. Of the three respiratory vaccines, 58.0 % of patients had received an influenza vaccine, 76.2 % had received a pneumococcal vaccine, and 83.3 % had received a COVID-19 vaccine. There were no sex-based differences by vaccination status. Differences were seen within age, race/ethnicity, insurance type, whether the patient was a member of an Accountable Care Organization (ACO), primary language, Social Vulnerability Index (SVI) score, clinician type, and number of comorbidities. Patients with HFpEF and HFmrEF had higher vaccination rates than HFrEF. In adjusted models, patients with HFrEF had lower odds of being vaccinated for influenza (aOR = 0.75, 95 % CI = 0.66–0.86), pneumococcal (aOR = 0.65, 95 % CI = 0.55–0.75), and COVID (aOR = 0.74, 95 % CI = 0.62–0.89) compared to patients with HFpEF. Patients with HFrEF had the lowest levels of respiratory vaccination compared to other specified heart failure categories. Interventions are needed to increase vaccination education and offerings, especially to patients with HFrEF.

As behavioural science is increasingly adopted by organizations, there is a growing need to assess the robustness and transferability of empirical findings. Here, we investigate the transferability of insights from various sources of behavioural science knowledge to field settings. Across three pre-registered randomized controlled trials (RCTs, N  = 314,824) involving a critical policy domain—COVID-19 booster uptake—we field tested text-based interventions that either increased vaccinations in prior field work (RCT1, NCT05586204), elevated vaccination intentions in an online study (RCT2, NCT05586178) or were favoured by scientists and non-experts (RCT3, NCT05586165). Despite repeated exposure to COVID-19 vaccination messaging in our population, reminders and psychological ownership language increased booster uptake, replicating prior findings. However, strategies deemed effective by prediction or intention surveys, such as encouraging the bundling of COVID-19 boosters and flu shots or addressing misconceptions, yielded no detectable benefits over simple reminders. These findings underscore the importance of testing interventions’ transferability to real-world settings. The authors field test the transferability of behavioural science knowledge on promoting COVID-19 booster uptake. Interventions effective in past field work improve uptake, but those deemed effective in surveys measuring intentions or predictions do not.

Objective Quality improvement efforts have aimed to improve annual diabetic retinopathy screening at our institution, but rates remain well below goal. To better understand facilitators, barriers and operational issues unique to our health system and to develop a comprehensive understanding of the care pathway, the Patient Voice toolkit was applied.Methods In-depth interviews were conducted individually with patients and care team members in a large urban academic medical centre with multiple satellite community clinics. Interviews with patients focused on facilitators and barriers to annual diabetic retinopathy screening. These interviews were transcribed and organised into discrete codes to identify initial themes. We interviewed clinic staff involved in diabetic retinopathy examination scheduling, execution or quality assurance. Interviews with care team members focused on training materials, camera operations and workflow.Results Through analysis of 15 patient interviews, we found that facilitators included internal motivation, automated examination reminders, reminders from providers and utilisation of local optometry offices. Barriers included competing demands, distant retinal camera locations, limited appointment access and financial and insurance issues. Interviews with 13 care team members resulted in the creation of a process map, and areas of opportunity were identified in the training and operational workflows.Conclusions The inclusion of different stakeholder perspectives provides in-depth insight into facilitators and barriers to completing annual diabetic retinopathy screening, allowing for recommendations tailored to our specific health system and operations. Suggested operational improvements include expanding clinics that can perform this examination, increasing appointment flexibility, partnering with local optometry clinics and enhancing annual examination reminders to include more details about the examination. Recommendations suggested by staff include increasing patient education, setting expectations around the examination and implementing real-time feedback on image quality.

Background Broadband access has been highlighted as a national policy priority to improve access to care in rural communities. Objective To determine whether broadband internet availability was associated with telemedicine adoption among a rural patient population in western Tennessee. Methods Observational study using electronic medical record data from March 13th, 2019 to March 13th, 2021. Multivariable logistic regression incorporating individual-level characteristics with broadband availability, income, educational attainment, and primary care physician supply at the zip code level, and rural status as determined at the county level. Setting Single health system in western Tennessee. Participants Adult patients with one or more in-person or remote encounter in a health system in western Tennessee and residing in western Tennessee between March 13th, 2019 and March 13th, 2021 ( N  = 54,688). Outcome measures Completion of one or more video encounters in the year following March 13th, 2020 ( N  = 3199; 7%). Our primary characteristic of interest was the proportion of residents in each zip code with access to the internet meeting the Federal Communications Commission definition of broadband access, adjusting for age, gender, race, income, educational attainment, insurance type, rural status, and primary care provider supply. Results Patients in a rural western Tennessee health system were predominantly white (79%), residing in rural zip codes (73%) with median household incomes ($52,085) less than state and national averages. Patients residing in a zip code where there is 80 to 100% broadband access compared to 0 to 20% were more likely in the year following March 13th, 2020 to have completed both telemedicine and in-person visits ([OR; 95% CI] 1.57; 1.29, 1.94), completed only telemedicine visits (2.26; 1.71, 2.97), less likely to have only completed in-person visits (0.81; 0.74, 0.89), but no more or less likely to have accessed no care (1.07; 0.97, 1.18). Discussion The availability of broadband internet was shown to be one of many factors associated with the utilization of telemedicine for a rural, working-class community after March 13th, 2020. Conclusions Access to broadband internet is a determinant of access to telemedicine for patients in rural communities and should be a priority for policymakers interested in improving health and access to care for rural patients.

Little information exists on how COVID-19 testing influences intentions to engage in risky behavior. Understanding the behavioral effects of diagnostic testing may highlight the role of adequate testing on controlling viral transmission. In order to evaluate these effects, simulated scenarios were conducted evaluating participant intentions to self-isolate based on COVID-19 diagnostic testing availability and results. Participants from the United States were recruited through an online survey platform (Amazon Mechanical Turk) and randomized to one of three hypothetical scenarios. Each scenario asked participants to imagine having symptoms consistent with COVID-19 along with a clinical diagnosis from their physician. However, scenarios differed in either testing availability (testing available v. unavailable) or testing result (positive v. negative test). The primary outcome was intention to engage in high-risk COVID-19 behaviors, measured using an 11-item mean score (range 1-7) that was pre-registered prior to data collection. Multi-variable linear regression was used to compare the mean composite scores between conditions. The randomized survey was conducted between July 23rd to July 29th, 2020. A total of 1400 participants were recruited through a national, online, opt-in survey. Out of 1194 respondents (41.6% male, 58.4% female) with a median age of 38.5 years, participants who had no testing available in their clinical scenario showed significantly greater intentions to engage in behavior facilitating COVID-19 transmission compared to those who received a positive confirmatory test result scenario (mean absolute difference (SE): 0.14 (0.06), P = 0.016), equating to an 11.1% increase in mean score risky behavior intentions. Intention to engage in behaviors that can spread COVID-19 were also positively associated with male gender, poor health status, and Republican party affiliation. Testing availability appears to play an independent role in influencing behaviors facilitating COVID-19 transmission. Such findings shed light on the possible negative externalities of testing unavailability. Effect of Availability of COVID-19 Testing on Choice to Isolate and Socially Distance, NCT04459520, https://clinicaltrials.gov/ct2/show/NCT04459520.

ObjectiveThe study aimed to evaluate the top large language models (LLMs) in validated medical knowledge tests in Portuguese.MethodsThis study compared 31 LLMs in the context of solving the national Brazilian medical examination test. The research compared the performance of 23 open-source and 8 proprietary models across 399 multiple-choice questions.ResultsAmong the smaller models, Llama 3 8B exhibited the highest success rate, achieving 53.9%, while the medium-sized model Mixtral 8×7B attained a success rate of 63.7%. Conversely, larger models like Llama 3 70B achieved a success rate of 77.5%. Among the proprietary models, GPT-4o and Claude Opus demonstrated superior accuracy, scoring 86.8% and 83.8%, respectively.Conclusions10 out of the 31 LLMs attained better than human level of performance in the Revalida benchmark, with 9 failing to provide coherent answers to the task. Larger models exhibited superior performance overall. However, certain medium-sized LLMs surpassed the performance of some of the larger LLMs.

Colorectal cancer (CRC) screening reduces CRC mortality; however, screening rates remain well below the national benchmark of 80%. To determine whether an electronic primer message delivered through the patient portal increases the completion rate of CRC screening in a mailed fecal immunochemical test (FIT) outreach program. In this randomized clinical quality improvement trial at the University of California, Los Angeles Health of 2339 patients enrolled in a FIT mailing program from August 28, 2019, to September 20, 2020, patients were randomly assigned to either the control or intervention group, and the screening completion rate was measured at 6 months. Participants were average-risk managed care patients aged 50 to 75 years, with a valid mailing address, no mailed CRC outreach in the previous 6 months, and an active electronic health record (EHR) patient portal who were due for CRC screening. Data were analyzed on an intention-to-treat basis. Eligible patients were randomly assigned to receive either (1) the standard FIT mailed outreach (control group) or (2) the standard FIT mailed outreach plus an automated primer to notify patients of the upcoming mailed FIT sent through the electronic patient portal (intervention group). The primary outcome was the screening completion rate (ie, returning the FIT). Secondary outcomes were (1) were the time to CRC screening from the FIT mailing date, (2) screening modality completed, and (3) the effect of opening the electronic primer on screening completion rate. The study included 2339 patients (1346 women [57.5%]; mean [SD] age, 58.9 [7.5] years). The screening completion rate was higher in the intervention group than in the control group (37.6% [445 of 1182] vs 32.1% [371 of 1157]; P = .005). The time to screening was shorter in the intervention group than in the control group (adjusted hazard ratio, 1.24; 95% CI, 1.08-1.42; P = .003). The proportion of each screening test modality completed was similar in both groups. In a subanalysis of the 900 of 1182 patients (76.1%) in the intervention group who opened the patient portal primer message, there was a 7.3-percentage point (95% CI, 2.3-12.4 percentage points) increase in CRC screening (local mean treatment effect; P = .004). Implementation of an electronic patient portal primer message in a mailed FIT outreach program led to a significant increase in CRC screening and improvement in the time to screening completion. The findings provide an evidence base for additional refinements to mailed FIT outreach quality improvement programs in large health systems. ClinicalTrials.gov Identifier: NCT05115916.

IMPORTANCE:Patients treated outside of their Medicare Shared Savings Program (MSSP) accountable care organization (ACO) likely benefit less from the ACO’s integration of care. Consequently, the MSSP’s open-network design may preclude ACOs from improving value in care. OBJECTIVES:Quantify out-of-ACO care in a single urban ACO and examine associations between patient-level predictors and out-of-ACO expenditures. RESEARCH DESIGN:Secondary data analysis using Centers for Medicare and Medicaid ACO Program Claim and Claim Line Feed dataset (dates of service January 1, 2013–December 31, 2013). Two-part modeling was used to examine associations between patient-level predictors and likelihood and level of out-of-ACO expenditures. SUBJECTS:Patients were included if they were prospectively assigned to the MSSP in 2013. Patients were excluded if they declined to share data with the ACO, were not retrospectively confirmed to be in the ACO, or had missing data on covariates. Analytic sample included 11,922 patients. MEASURES:Total out-of-ACO expenditures and out-of-ACO expenditures by place of service. RESULTS:Of total expenditures, 32.9% were paid to out-of-ACO providers, and 89.8% of beneficiaries had out-of-ACO expenditures. The presence of almost all medical comorbidities increased out-of-ACO expenditures ($800–$3000 per comorbidity) across the study population. Racial/ethnic minority groups spent between $1076 and $1422 less outside of the ACO than white patients, which was driven by less out-of-ACO outpatient office expenditures ($417–$517 less for each racial/ethnic minority group). CONCLUSIONS:Out-of-ACO expenditures represented a significant portion of expenditures for the study population. Medically complex patients spent more outside of the ACO and represent an important population to study further.