Deviations from Protocol
REGRESSION
The implementation of the MISSION 507 scribe pilot experienced a few deviations from the protocol registered on ClinicalTrials.gov. Due to challenges in hiring and retaining scribes, the planned number of scribes in both hiring modalities was not reached. Also, one of the sites randomized to implement scribes in its emergency department dropped out of the pilot; however, it was not an intervention site for specialty care and therefore is not a relevant deviation for this analysis. We also made slight variations to the outcomes and covariates included in our regression models. Our protocol specified using scribe FTEs per 1000 patients and quartiles of scribe FTEs per physician FTE; however, given the incomplete fidelity to the dosage of scribe hires that the randomized clinics were able to achieve, we felt that an intent-to-treat approach was better than introducing potential endogeneity (selection bias) by using a measure of intervention dose that would likely be correlated with our outcomes and other factors about each facility (e.g., those that did a better job of hiring and keeping scribes also likely are better in other unobserved ways). We were unable to include several of the prespecified covariates, including age 18–64 male insurance rate, median household income, veteran unemployment rate, and average enrollee driving distance because data for 2021 and 2022 were not yet available at the time of analysis. However, we expect that Medicare Advantage penetration can partially account for variation in insurance coverage, and Zillow Home Value Index and VA priority status can control for variation in the socioeconomic profile of communities and the relevant enrollee population for each clinic. We decided not to include community care wait times for specialty care because of the potential simultaneity with VA wait times.