The research, led by Michelle S. Rockwell of the Department of Family and Community Medicine at Virginia Tech Carilion School of Medicine together with colleagues across Virginia Tech, Carilion Clinic, the Virginia Center for Health Innovation, the University of Michigan, UCLA, and the RAND Corporation, took an unusual comparative approach. Rather than surveying a random sample of primary care clinicians, the team deliberately sought out the extremes. Within a large health system in the southeastern United States, they ranked 48 primary care practices according to their historical rate of low-value acute low back pain imaging, determined using insurance claims data. From that ranking, they identified the six highest-performing practices, meaning those with the least low-value imaging, and the six lowest-performing practices, meaning those with the most.

From those twelve practices, the researchers invited 93 clinicians, including both physicians and advanced practice providers, to complete a survey. The response rate was 66 percent, a solid figure for clinician survey research. The questionnaire probed several distinct domains: attitudes and beliefs about low-value imaging for back pain, perceptions of the clinicians’ own performance relative to peers, views on what drives low-value imaging and how to fix it, and personal characteristics, including whether the clinician had personally experienced low back pain. The design’s key strength was the linkage of these self-reported attitudes and beliefs to objective, claims-based utilization data, allowing the researchers to see which subjective factors actually tracked with measured performance.

To analyze the results, the team used LASSO regression, a statistical technique well suited to situations where many candidate predictor variables must be winnowed down to a parsimonious set. The method applies a penalty that shrinks the coefficients of less informative variables toward zero, effectively selecting the responses most strongly associated with membership in a highest- versus lowest-performing practice, while controlling for clinician demographics. This approach matters because clinician surveys generate dozens of potential correlates, and naive comparisons can easily produce spurious associations. LASSO’s built-in variable selection provides a more disciplined filter.

The baseline findings were, in some ways, reassuring. Across all respondents, clinicians reported strong agreement with low back pain imaging guidelines, scoring 9.1 out of 10 on average with a standard deviation of 1.7. In other words, almost nobody in the sample believed the guidelines were wrong. Trust in the claims-based performance data used to rank practices was more lukewarm, averaging 4.1 out of 10 with a standard deviation of 1.9. That moderate skepticism is itself informative, because any de-implementation strategy that relies on clinicians accepting feedback from administrative data will have to contend with the fact that many of them do not fully trust that data in the first place.

The statistically significant differences between the groups were more surprising, and arguably more consequential. Two clinician characteristics were associated with lower odds of belonging to a highest-performing practice. The first was a personal history of low back pain, with an odds ratio of 0.70 and a 95 percent confidence interval of 0.64 to 0.76. The second was a greater number of years in practice, with an odds ratio of 0.87 and a 95 percent confidence interval of 0.79 to 0.96. Both confidence intervals exclude one, indicating associations unlikely to be due to chance. The direction of these effects is striking: clinicians who had personally suffered back pain, and clinicians with more experience, were more likely to work in practices that ordered more low-value imaging, not less.

The interpretation of these associations is not settled by the study’s cross-sectional design, which captures a snapshot rather than tracking change over time. One plausible reading is that clinicians who have endured back pain themselves develop a stronger intuitive sense of their patients’ distress and a greater desire to rule out structural causes, even when guidelines say imaging is unnecessary. Similarly, longer-tenured clinicians trained in an era when routine imaging was more accepted may carry ingrained habits that resist guideline updates. Alternatively, the associations could reflect sorting effects, in which clinicians with particular styles gravitate toward particular practices. The study cannot disentangle these mechanisms, but it does establish that experience and personal history are not protective factors against low-value care, and may even be risk factors.

Perhaps the most humbling result concerned self-assessment. Clinicians from the lowest-performing practices were significantly more likely to rate their own performance as better than that of other clinicians in their practice, compared with clinicians from the highest-performing practices, at 57 percent versus 40 percent, a difference the authors report as statistically significant with a p-value of 0.031. This is a textbook illustration of a well-documented cognitive bias: clinicians who order the most low-value care tend to believe they order less than their peers. The finding suggests that simply telling clinicians their raw performance numbers may not be enough, because many will assume the numbers are wrong or that their cases were exceptional. Notably, the overall trust in claims data was only moderate, which compounds the problem of getting accurate self-perceptions to stick.

When asked what drives low-value imaging in the first place, clinicians across both groups converged on the same answer: patient demand was the most frequently identified driver. This attribution is common in the literature on medical overuse, and it frames the clinician as a gatekeeper responding to external pressure rather than an independent decision-maker. Interestingly, the two groups diverged on solutions. Clinicians from the highest-performing practices more frequently recommended health system-focused strategies, such as changes to workflows, decision support, or institutional policies, whereas clinicians from the lowest-performing practices more frequently recommended patient education. That split may reflect a self-serving logic, with lower performers locating the fix outside themselves, but it also carries practical weight: the strategies clinicians are willing to endorse are the strategies most likely to be implemented successfully in their own practices.

The study was conducted as part of the Virginia Center for Health Innovation’s Smarter Care Virginia initiative and a participating health system’s intervention to reduce low-value back pain imaging, both registered on ClinicalTrials.gov, with funding support in part from Arnold Ventures, which had no role in the study’s design, data collection, analysis, or manuscript preparation. The authors conclude that clinician characteristics, perceptions of performance, and preferred de-implementation strategies differ systematically by practice performance, and that these differences can help inform the selection and targeting of strategies to reduce low-value imaging. For health systems, the practical implication is that a one-size-fits-all campaign is unlikely to work. High-performing practices may respond best to system-level nudges, while low-performing practices may need interventions that confront the overconfidence gap directly, build trust in performance data, and address the patient-demand dynamic that clinicians themselves identify as the central pressure. As health systems worldwide grapple with the challenge of de-implementing low-value care, this study offers a reminder that the barriers are not ignorance of guidelines, which clinicians overwhelmingly endorse, but the subtler terrain of personal experience, habit, and self-perception.

Subject of Research: Clinician-level determinants of low-value acute back pain imaging in primary care

Article Title: Clinician-Level determinants of low-value acute back pain imaging in primary care

Article References: Rockwell, M. S., King, M., Mercogliano, E. H., Bortz, B. A., Karanjeet, R., Stewart, J., Fendrick, A. M., Mafi, J. N., & Epling, J. W. (2026). Clinician-Level determinants of low-value acute back pain imaging in primary care. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15609-5

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15609-5

Keywords: low-value care, acute low back pain, primary care, medical imaging, de-implementation, clinician survey, claims data, LASSO regression, health services research, patient demand, guideline adherence, overuse

Atrial fibrillation, the most common sustained cardiac arrhythmia, becomes increasingly prevalent with age, and contemporary patients are typically older, frailer and burdened by multiple chronic conditions. This complexity raises the risk not only of stroke and bleeding but also of non-cardiovascular events and hospital admissions, driving substantial healthcare costs. The ABC pathway was proposed as a structured framework to streamline integrated management: ‘A’ for anticoagulation and stroke risk avoidance, ‘B’ for better symptom control, and ‘C’ for cardiovascular and comorbidity optimisation. Observational studies repeatedly linked adherence to the pathway with lower mortality, stroke and bleeding, and two cluster-randomised trials in Asia—one app-based in largely urban China and one delivered by village doctors with telehealth support in rural settings—had shown that ABC implementation improved guideline adherence and reduced adverse outcomes, including hospitalisations.

What remained unknown was whether the same approach would work in European healthcare systems, specifically among patients aged 65 or older with atrial fibrillation and at least one additional chronic condition. The AFFIRMO investigators, led by Gregory Y.H. Lip and Marco Proietti, designed a multicentre, open-label cluster-randomised trial across Bulgaria, Denmark, Italy, Romania, Serbia and Spain. Clinical centres, not individual patients, were randomised to deliver either the integrated mHealth intervention—dubbed the iABC system—or routine guideline-based care. The intervention combined a patient-facing mobile application with a clinician dashboard, and every intervention patient underwent a comprehensive geriatric assessment at baseline to identify functional domains requiring management.

The AFFIRMO Mobile App collected daily data on vital signs, oral anticoagulant adherence, arrhythmia symptoms and chronic conditions, while dispensing tailored health tips for lifestyle and comorbidity management. Each patient also completed the Patient Health Engagement scale at activation, which determined the level of personalised educational material they received about atrial fibrillation. On the clinical side, the AFFIRMO Clinician Dashboard summarised app usage and patient-entered data, organised by the three ABC pillars, to inform follow-up consultations. Between April 2024 and January 2025, the trial enrolled 1,260 patients, with 634 assigned to the iABC system and 626 to usual care. Follow-up visits occurred at 3, 6 and 12 months, and the primary endpoint was unplanned all-cause hospitalisation during one year of follow-up, adjudicated by a blinded event validation committee.

The enrolled population reflected the modern reality of atrial fibrillation care: a mean age of 73 to 74 years, a median CHA2DS2-VASc stroke risk score of 4, and a heavy burden of comorbidity. Roughly 40 percent had more than two chronic conditions, hypertension treated with multiple drugs was nearly universal, and polypharmacy affected 72 percent of participants. Yet the trial’s most consequential baseline finding was how well these patients were already being treated: 97.3 percent were on oral anticoagulation, overwhelmingly direct oral anticoagulants, and use of beta-blockers, anti-arrhythmic drugs and other guideline-directed therapies was uniformly high. Comprehensive geriatric assessment in the intervention arm revealed a largely functionally preserved cohort, with 95.7 percent showing normal cognition, 83.9 percent normal nutritional status, and only about 20 percent reporting meaningful mobility impairment.

After a mean follow-up of 367 days, unplanned all-cause hospitalisation occurred in 17.1 percent of the iABC group versus 18.2 percent of the usual care group—an adjusted odds ratio of 0.95 with a 95 percent confidence interval of 0.61 to 1.49 and a p-value of 0.84. Sensitivity analyses, including a Cox proportional hazards model and a composite endpoint of hospitalisation or death, told the same neutral story. No secondary endpoint differed between groups: all-cause death, any hospitalisation, stroke or cardiovascular death, heart failure events, renal worsening, and major bleeding, which occurred in only 0.7 percent of all participants, were statistically indistinguishable across arms. Subgroup analyses by age, sex, comorbidity count, medication number and country revealed no hidden pockets of benefit.

The investigators attribute the null result to a convergence of factors, each instructive in its own right. First, the trial’s power calculation assumed a 30 percent event rate in usual care and a 25 percent relative reduction with the intervention; instead, usual care produced only an 18.2 percent hospitalisation rate. With such low residual risk, several thousand patients would have been required to detect a statistically significant difference. Second, the baseline quality of care starkly contrasts with the prior Asian trials: in the mAFA trial, oral anticoagulant use at baseline was just 48.4 percent in usual care, and in the MIRACLE-AF rural trial it was around 11 percent. In those settings, the ABC intervention raised anticoagulation dramatically and reduced hospitalisations. In AFFIRMO, with anticoagulation already at 97 percent, there was simply little therapeutic ground left for a digital nudge to reclaim.

Third, and perhaps most telling, patients barely used the app. The median percentage of days on which patients accessed the AFFIRMO Mobile App was 15.1 percent, and 68.5 percent of patients fell into the lowest tertile of use, opening the app on only about one-third or fewer of their study days. The authors point to well-documented implementation barriers—digital literacy in an older population, workflow incompatibility, and difficulty integrating digital tools into complex health systems. Clinical decision support, they note, only works when it is actually used; in the O’CAFÉ trial, modest overall effects sharpened into significant anticoagulation improvements only among clinicians who actively engaged with the tool. Because the mobile app is half of the iABC system, its companion physician dashboard inheriting the consequences of underuse, suboptimal engagement directly undermined the intervention’s theoretical effectiveness.

Fourth, comprehensive geriatric assessment itself ran into a ceiling effect. Although more than half of the intervention patients showed some degree of frailty on the FRAIL scale, most were robust on objective measures of daily functioning, cognition, nutrition and mood. In such high-functioning individuals, geriatric assessment may serve a descriptive rather than an interventional role, and prior evidence suggests little clinical benefit from CGA in robust patients. The trial’s design assumed more functional impairment than it found, constraining the scope for assessment-driven management changes. Not all signals were negative, however: patients in the intervention arm showed numerically higher uptake of several guideline-directed treatments at the final visit, including mineralocorticoid receptor antagonists, SGLT2 inhibitors and anti-arrhythmic drugs, and a significantly lower rate of uncontrolled systolic blood pressure at 12 months (1.5 versus 4.0 percent), hinting at secondary improvements in care quality even without hard outcome benefits.

The broader lesson echoes the recent STEEER-AF trial, in which an electronic education programme for clinicians also yielded only marginal improvements because guideline adherence was already high in both arms. The authors emphasise that the results do not disqualify integrated care or the ABC pathway, which remains embedded in European Society of Cardiology guidance through the 2020 ABC framework and the 2024 AF-CARE scheme. Rather, they argue, integrated care interventions and digital health tools must be targeted at settings with genuine unmet clinical need—populations with low baseline guideline adherence, higher residual risk, or greater functional impairment. Future studies may also need easier-to-use apps, co-designed with older patients, and more selected populations in which the theoretical benefit of holistic optimisation has room to translate into fewer hospitalisations. For now, AFFIRMO stands as a rigorous, well-conducted demonstration that in medicine, as in engineering, the marginal return on optimisation shrinks as the system approaches its ceiling—and that digital tools, however elegantly engineered, cannot multiply benefit that better baseline care has already claimed.

Subject of Research: A cluster-randomised trial of mHealth-based integrated care and comprehensive geriatric assessment in older multimorbid patients with atrial fibrillation.

Article Title: Integrated care management and comprehensive geriatric assessment using a mHealth-based approach in older multimorbid patients with atrial fibrillation: the AFFIRMO cluster-randomised trial

Article References: Lip, G. Y., Proietti, M., Ainsworth, J., Dan, G.-A., Frost, L., Graffigna, G., Lane, D. A., Lucci, D., Fabbri, G., Marin, F., O'Flaherty, M., Petrovic, M., Potpara, T. S., Proietti, R., Sanaullah, A., Tokmakova, M., Vetrano, D. L., Johnsen, S. P., Maggioni, A. P., … Tokmakova, M. (2026). Integrated care management and comprehensive geriatric assessment using a mHealth-based approach in older multimorbid patients with atrial fibrillation: the AFFIRMO cluster-randomised trial. The Lancet Regional Health – Europe, 70, Article 101832. https://doi.org/10.1016/j.lanepe.2026.101832

Image Credits: AI Generated

DOI: 10.1016/j.lanepe.2026.101832

Keywords: atrial fibrillation, AFFIRMO trial, mHealth, integrated care, ABC pathway, comprehensive geriatric assessment, multimorbidity, cluster-randomised trial, unplanned hospitalisation, digital health, older adults, guideline adherence

The study, conducted by researchers affiliated with Moffitt Cancer Center in collaboration with CAN Community Health, a Ryan White-funded clinic network predominantly based in Florida, was published in the journal Cancer Causes & Control. It set out to identify the sociodemographic, health, and social predictors of anal and cervical cancer screening uptake among adults with and without HIV. The stakes are considerable: high-risk HPV causes more than ninety percent of anal and cervical cancers, and people with HIV are roughly seventeen times more likely to develop anal cancer than people without the virus, while women with HIV face about a fourfold increase in cervical cancer risk. HIV-related immunosuppression allows HPV infection to persist and progress more readily toward malignancy, and health system barriers contribute to later-stage diagnoses and higher mortality among this population.

Both anal and cervical cancers are unusual among malignancies in that they progress through well-defined, detectable precancerous lesions. Removing high-grade squamous intraepithelial lesions can halt progression before invasive cancer develops, which makes screening an unusually powerful prevention tool. For cervical cancer, established guidelines exist: the U.S. Preventive Services Task Force recommends screening every three years for women without HIV aged 21 to 65, while the Infectious Diseases Society of America advises annual screening for women with HIV beginning at age 21. Anal cancer screening guidance is more recent. The landmark ANCHOR study showed that treating anal high-grade lesions in people with HIV significantly reduced anal cancer incidence compared with active monitoring, and those findings underpin the International Anal Neoplasia Society consensus guidelines, which recommend screening for HIV-positive men who have sex with men and transgender women aged 35 and older, and for HIV-negative people in high-risk groups aged 45 and older.

To measure how these recommendations translate into real-world care, the research team implemented a cross-sectional survey between April and June 2024 among adult patients of the CAN clinic network, which serves more than 31,100 unique patients annually, a population that is 35 percent White, 35 percent Black, and 18 percent Hispanic or Latino. The questionnaire, distributed anonymously through the clinic’s electronic patient intake system and offered in English and Spanish, collected information on demographics, health history, cancer prevention behaviors, experiences with the health system, and social exposures including HIV-related stigma. Participants received a twenty-five dollar gift card. From the responses, 412 participants were eligible for anal cancer screening and 294 women were eligible for cervical cancer screening based on current guidelines.

The characteristics of the two screening-eligible groups reflected the populations most at risk. Among those eligible for anal cancer screening, the median age was 56 years, 88.8 percent were living with HIV, and 82.3 percent were men, with roughly two-thirds identifying as gay or lesbian. Among women eligible for cervical cancer screening, the median age was 38 and 43.5 percent were living with HIV. The researchers computed adjusted prevalence ratios using multivariable Poisson regression, guided by the Andersen Behavioral Model of health services use, with models stratified by HIV status and sex to account for documented differences in cancer risk and screening outcomes across these subpopulations.

The anal cancer findings delivered a cautiously optimistic signal. Overall, 58.6 percent of screening-eligible participants reported ever having been screened, most commonly through an anal Pap test or high-resolution anoscopy. After statistical adjustment, men with HIV were 57 percent more likely to have received anal cancer screening than men without HIV. Within the group of men with HIV, uptake was higher among those who had been diagnosed with any precancer and those living with three or more comorbidities, a pattern the authors attribute to more frequent medical encounters creating more opportunities for preventive services. Living in a household of three or more people was associated with significantly lower uptake among these men, possibly reflecting caregiving responsibilities, competing demands, or limited economic means that crowd out preventive visits.

The cervical cancer picture was far less reassuring. Only 47 percent of women with HIV had received guideline-adherent cervical screening, compared with 71 percent of women without HIV, a gap that persisted after adjustment, leaving women with HIV 40 percent less likely to be screened on time. This shortfall is particularly troubling because U.S. guidelines call for more frequent, annual screening in this higher-risk group, not less. The study also identified a psychosocial driver: among women with HIV, greater concerns about disclosing their HIV status were independently associated with lower guideline-adherent cervical screening uptake. This finding reinforces a growing body of evidence that stigma is not merely an abstract social burden but a concrete mechanism that undermines preventive care, engagement with health services, and trust in medical systems.

The researchers point to several practical implications. Community-based, culturally sensitive screening programs embedded in clinics that patients already trust appear to pay dividends, and the integrated social services offered by Ryan White-funded networks may help explain why anal cancer screening among men with HIV exceeded that of their HIV-negative counterparts. For cervical cancer, proven strategies exist to close the gap, including provider reminders, patient education campaigns, and HPV self-collection kits that can overcome geographic barriers, limited access, and the discomfort or stigma associated with pelvic examinations. The authors also note that clinician awareness matters, since gaps in provider knowledge and training about screening recommendations for people with HIV remain documented barriers alongside fragmented care, unstable housing, and transportation difficulties.

The study carries limitations worth noting. It was conducted within a single, highly diverse clinic network in Florida, so results may not generalize everywhere; it captured only patient-reported characteristics rather than provider-level factors; it assessed Pap testing rather than high-risk HPV testing for cervical screening adherence; and its cross-sectional design precludes conclusions about cause and effect, including the timing of precancer diagnoses relative to screening. Small sample sizes in some stratified models may also have limited statistical power. Still, the divergent findings, with anal screening lagging among women even as it advances among men, and cervical screening falling short precisely among the women who need it most, offer clinicians and public health planners a specific map of where targeted interventions, from stigma reduction to self-sampling, could save lives among one of the nation’s most cancer-vulnerable populations.

Subject of Research: Predictors of anal and cervical cancer screening uptake among adults with and without HIV

Article Title: Predictors of anal and cervical cancer screening uptake among adults with and without HIV: survey of a community-based health clinic network

Article References: Lin, Y. C., Hume, E., Boxtha, C., Commaroto, S. A., Lael, M., Christy, S. M., Vadaparampil, S. T., Giuliano, A. R., Coghill, A. E., Schabath, M. B., Vidrine, D. J., Peterson, J., DiPalmo, S., Joshi, H., Shukla, P., Vidrine, J. I., & Islam, J. Y. (2026). Predictors of anal and cervical cancer screening uptake among adults with and without HIV: survey of a community-based health clinic network. Cancer Causes & Control, 37(10), Article 159. https://doi.org/10.1007/s10552-026-02239-9

Image Credits: AI Generated

DOI: 10.1007/s10552-026-02239-9

Keywords: HIV, anal cancer screening, cervical cancer screening, HPV, cancer prevention, health disparities, HIV stigma, Pap test, community health clinics, guideline adherence, Cancer Causes & Control, Ryan White clinics