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An outdated and burdensome fee-for-service (FFS) reimbursement system has significantly compromised primary care delivery in the US for decades, leading to a dire shortage of primary care workers. Support for primary care must increase from all public and private payers with well-designed value-based primary care payment. Patient care enabled by value-based payment is typically described or "labeled" as value-based care and commonly viewed as distinctly different from other models of care delivery. Unfortunately, labels tend to put individuals in camps that can make the differences seem greater than they are in practice. Achieving the aims of value-based care, aligned with the quintuple aims of health care, is common across many delivery models. The shrinking primary care workforce is too fragile to be fragmented across competing camps. Seeing the alignment across otherwise separate disciplines, such as lifestyle medicine and value-based care, is essential. In this article, we point to the opportunities that arise when we widen the lens to look beyond these labels and make the case that a variety of models and perspectives can meld together in practice to produce the kind of high-quality primary care physicians, care teams, and patients are seeking. [ABSTRACT FROM AUTHOR]

Background: Intersection of gender and race and/or ethnicity in academic medicine is understudied; we aim to understand these factors in relation to scholarly achievements for neurology faculty. Methods: Faculty from 19 US neurology departments completed a survey (2021–2022) to report rank, leadership positions, publications, funded projects, awards, and speaker invitations. Regression analyses examined effects of gender, race, and their intersectionality on these achievements. Women, Black/Indigenous/People of Color (BIPOC), and BIPOC women were comparator groups. Results: Four hundred sixty-two faculty responded: 55% women, 43% men; 31% BIPOC, 63% White; 21% BIPOC women, 12% BIPOC men, 36% White women, 31% White men. Men and White faculty are more likely to be full professors than women and BIPOC faculty. The number of leadership positions, funded projects, awards, and speaker invitations are significantly greater in White compared to BIPOC faculty. Relative to BIPOC women, the number of leadership positions is significantly higher among BIPOC men, White women, and White men. Publication numbers for BIPOC men are lower, number of funded projects and speaker invitations for White women are higher, and number of awards among White men and White women is higher compared to BIPOC women. Discussion: Our study highlights that inequities in academic rank, award number, funded projects, speakership invitations, and leadership roles disproportionately impacted BIPOC women. More studies are needed to evaluate gender and race and/or ethnicity intersectionality effects on faculty achievements, reasons for inequities, recognition, and potential solutions. [ABSTRACT FROM AUTHOR]

Objective: To determine the final outcomes of various types of prior authorizations (PAs), and to quantify the administrative and financial burden of PAs on urology practice. PAs are often required before imaging, procedures or medications can be ordered. However, they can delay timely delivery of patient care and place a significant administrative burden on practices. The impact of PAs has been poorly studied, and no studies on PAs burden on urology practice are available.Methods: Imaging and medications requiring PAs from an outpatient urology clinic from November 2020 to February 2021 were reviewed (n = 267). Authorization outcomes were tracked to resolution. We calculated the time spent on PAs, and the estimated overall financial burden on the practice.Results: Of the PAs required, 60.6% were for imaging and 39.4% were for medications. Initial decision for PAs took a median of 2 days [IQR: 0-6, Range: 0-36], whereas decisions after an appeal (n = 51) took a median of 10 days [IQR: 5-23, range 0-125 days]. Private insurance compared to Medicare or Medicaid, has an earlier time to decision (P =<.001). Initial approval rates were 67.5%, and final approval rates after appeals were 88.2%. Of orders originally denied, a majority (77.3%) were appealed, 13.6% required alternative orders, and 7.6% paid out of pocket. The total cost to the practice was $2206.06, with a $15.11 mean cost of each PA.Conclusion: PAs for imaging studies and medications pose a significant administrative and financial burden to urology patients and practice. [ABSTRACT FROM AUTHOR]

Objectives To investigate prevalence estimates and incidence rates (IRs) for SSc and SSc-associated interstitial lung disease (SSc-ILD) cohorts and describe patient characteristics, immunosuppressive therapy (IST) and comorbid outcomes among incident SSc and SSc-ILD cohorts. Methods Data were obtained from the US IBM MarketScan (2008–2017) claims database using algorithms developed with expert consultation. For the SSc cohort, newly diagnosed patients (aged ≥18 years) had one or more diagnostic claim for SSc. For the SSc-ILD cohort, patients had an additional ILD claim. Sensitivity analyses using two or more claims or alternative ILD diagnostic codes were also conducted. Results When requiring one or more diagnostic claim, the prevalence of SSc and SSc-ILD per 100 000 persons was 72.1 and 19.0. The IR for SSc and SSc-ILD per 100 000 person-years was 18.3 and 4.3. Sensitivity analyses requiring two or more claims yielded much lower prevalence (SSc: 41.5; SSc-ILD: 13.3) and IR (SSc: 8.8; SSc-ILD: 1.6) estimates. Patients with SSc-ILD were older, with increased comorbidities and diagnostic procedures at baseline. MTX and MMF were the most common ISTs; 12.7% of the SSc-ILD cohort received therapy at baseline vs 8.2% for SSc. A total of 42.5% and 45.0% of the SSc and SSc-ILD cohorts, respectively, started a stable IST regimen and 21.7% and 19.4% of these had an escalation. Skin disorders were the most common comorbid outcome in both cohorts during follow-up. Conclusions SSc, with or without associated ILD, is a rare disease in the US. Newly diagnosed patients with SSc-ILD had received more IST and had more comorbidities compared with newly diagnosed SSc. [ABSTRACT FROM AUTHOR]

A phytomedicine, or phytopharmacutical, is a complex mixture derived from plant sources that is used as a medicine or drug. The Ministry of Health has begun the standardization of the names of all phytopharmaceutical preparations. The development of phytopharmaceutical products, which might partially substitute some of the conventional medications demanding imported raw materials, and which could be produced by pharmaceutical industries based in developing countries through joint projects. Highest demands are made on clinically proven phyto-pharmaceuticals. Their effect and safety have to be verified in randomized, double-blind, (placebo)-controlled clinical trials. They are developed and scientifically evaluated in the same way as conventional medicinal products. Globally, herbal medicine has been considered an important alternative to modern allopathic medicine. While they have become very popular, only select herbs have been scientifically evaluated for their potential in medical treatment. The new drug Veregen (Polyphenon E) Ointment is the first prescription botanical (herbal) drug approved by the U.S. FDA under the "new" drug amendments of 1962 that required drugs to be proven safe and effective prior to being marketed in the U.S. Because of the unique health benefits and relatively low side effects, natural products such as food/dietary supplements, nutraceuticals and herbal medicines have been gaining popularity all over the world The gap between the popularity of these remedies and the frequently weak scientific basis of their use is striking. In reality, the efficacy and true frequency of side effects for most herbal medicine products is not known because the majority have not yet been tested in large clinical trials and because pharmacovigilance systems are much less extensive than those in place for pharmaceutical products. In contrast to the popularity of herbal medicinal products, physicians and consumers often have a very critical view of robust efficacy and safety profiles. Application of pharmaceutical nanotechnology for plant actives and extracts, is gaining a tremendous growth and interest among the scientist. [ABSTRACT FROM AUTHOR]

Cannabis use among older Americans is increasing. Although much of this growth has been attributed to the entry of a more tolerant baby boom cohort into older age, recent evidence suggests the pathways to cannabis are more complex. Some older persons have responded to changing social and legal environments and are increasingly likely to take cannabis recreationally. Other older persons are experiencing age-related health care needs, and some take cannabis for symptom management, as recommended by a medical doctor. Whether these pathways to recreational and medical cannabis are separate or somewhat tangled remains largely unknown. There have been few studies examining cannabis use among the growing population of Americans aged 65 and older. In this essay, we illuminate what is known about the intersection between cannabis and the aging American population. We review trends concerning cannabis use and apply the age-period-cohort paradigm to explicate varied pathways and outcomes. Then, after considering the public health problems posed by those who misuse or abuse cannabis, we turn our attention to how cannabis may be a viable policy alternative in terms of supporting the health and well-being of a substantial number of aging Americans. On the one hand, cannabis may be an effective substitute for prescription opioids and other misused medications; on the other hand, cannabis has emerged as an alternative for the undertreatment of pain at the end of life. As intriguing as these alternatives may be, policy makers must first address the need for empirically driven, representative research to advance the discourse. [ABSTRACT FROM AUTHOR]

Economic theory suggests that medical spending risk affects the extent to which households are willing to accept financial risk, and consequently their investment portfolios. In this study, we focus on the elderly for whom medical spending represents a substantial risk. We exploit the exogenous reduction in prescription drug spending risk because of the introduction of Medicare Part D in the U.S. in 2006 to identify the causal effect of medical spending risk on portfolio choice. Consistent with theory, we find that Medicare-eligible persons increased risky investment after the introduction of prescription drug coverage, relative to a younger, ineligible cohort. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Tracking the dissemination of specific Mycobacterium tuberculosis (Mtb) strains using genotyped Mtb isolates from tuberculosis patients is a routine public health practice in the United States. The present study proposes a standardized cluster investigation method to identify epidemiologic-linked patients in Mtb genotype clusters. The study also attempts to determine the proportion of epidemiologic-linked patients the proposed method would identify beyond the outcome of the conventional contact investigation. Methods: The study population included Mtb culture positive patients from Georgia, Maryland, Massachusetts and Houston, Texas. Mtb isolates were genotyped by CDC's National TB Genotyping Service (NTGS) from January 2006 to October 2010. Mtb cluster investigations (CLIs) were conducted for patients whose isolates matched exactly by spoligotyping and 12-locus MIRU-VNTR. CLIs were carried out in four sequential steps: (1) Public Health Worker (PHW) Interview, (2) Contact Investigation (CI) Evaluation, (3) Public Health Records Review, and (4) CLI TB Patient Interviews. Comparison between patients whose links were identified through the study's CLI interviews (Step 4) and patients whose links were identified earlier in CLI (Steps 1-3) was conducted using logistic regression. Results: Forty-four clusters were randomly selected from the four study sites (401 patients in total). Epidemiologic links were identified for 189/401 (47%) study patients in a total of 201 linked patient-pairs. The numbers of linked patients identified in each CLI steps were: Step 1 - 105/401 (26.2%), Step 2 - 15/388 (3.9%), Step 3 - 41/281 (14.6%), and Step 4 - 28/119 (30%). Among the 189 linked patients, 28 (14.8%) were not identified in previous CI. No epidemiologic links were identified in 13/44 (30%) clusters. Conclusions: We validated a standardized and practical method to systematically identify epidemiologic links among patients in Mtb genotype clusters, which can be integrated into the TB control and prevention programs in public health settings. The CLI interview identified additional epidemiologic links that were not identified in previous CI. One-third of the clusters showed no epidemiologic links despite being extensively investigated, suggesting that some improvement in the interviewing methods is still needed. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the Affordable Care Act's dependent coverage mandate impact on insurance take-up and health services use through the second full year of implementation.Data: Medical Expenditure Panel Survey from 2006 to 2012.Study Design: Difference-in-difference regressions comparing pre-/postpolicy-outcome changes between 19- to 25-year-olds and 27- to 34-year-olds.Principal Findings: Following significant increases in 2011, insurance take-up among 19- to 25-year-olds leveled off overall in 2012. However, increases in coverage for Black young adults were higher in 2012 compared to 2011. Despite increased coverage, there is little evidence of an overall effect on health services use postmandate. Evidence points to increased doctor visits and emergency department visits among Hispanics in the first year postmandate.Conclusions: The Affordable Care Act young adult mandate led to significant gains in insurance take-up, though evidence suggests that the bulk of the gains occurred in the first year after the mandate. Gains for Black young adults appear to have picked up in 2012. [ABSTRACT FROM AUTHOR]

Abstract: Although the importance of expectations is well documented in the decision-making literature, a key shortcoming of the empirical research into effects of involuntary job loss on depression is perhaps its neglect of the subjective expectations of job loss. Using data from the US Health and Retirement Study surveys we examine whether the impact of job loss on mental health is influenced by an individual’s subjective expectations regarding future displacement. Our results imply that, among older workers in the age range of 55–65 year, subjective expectations are as significant predictors of depression as job loss itself, and ignoring them can bias the estimate of the impact of job loss on mental health. [Copyright &y& Elsevier]

Objectives. We sought to assess whether the disparity in mortality rates between Black and White men decreased from the beginning to the end of the 20th century. Methods. We used Cox proportional hazard models for mortality to estimate differences in longevity between Black and White Civil War veterans from 1900 to 1914 (using data from a pension program) and a later cohort of male participants (using data from the 1992 to 2006 Health and Retirement Study). In sensitivity analysis, we compared relative survival of veterans for alternative baseline years through 1914. Results. In our survival analysis, the Black-White male difference in mortality, both unadjusted and adjusted for other influences, did not decrease from the beginning to the end of the 20th century. A 17% difference in Black-White mortality remained for the later cohort even after we controlled for other influences. Although we could control for fewer other influences on longevity, the Black-White differences in mortality for the earlier cohort was 18%. Conclusions. In spite of overall improvements in longevity, a major difference in Black-White male mortality persists. (Am J Public Health. 2010;100:357-363. doi:10.2105/AJPH. 2008.158188) [ABSTRACT FROM AUTHOR]

The article focuses on the impact of the Drug Price Competition and Patent Term Restoration Act (DPCPTRA) in the pharmaceutical industry of India. The provision of the Act entails the simplification of U.S. Food and Drug Administration (FDA) approval process for generic drugs via Abbreviated New Drug Applications (ANDAs). The Act modifies the Patent Act of 1952 as it provides incentives to innovators and generic companies through patent extension based on 180-day exclusivity to generic firms.

Study Objectives. To review the labels of United States Food and Drug Administration (FDA)-approved drugs to identify those that contain pharmacogenomic biomarker information, and to collect prevalence information on the use of those drugs for which pharmacogenomic information is included in the drug labeling. Design. Retrospective analysis. Data Sources. The Physicians' Desk Reference Web site, Drugs@FDA Web site, and manufacturers' Web sites were used to identify drug labels containing pharmacogenomic information, and the prescription claims database of a large pharmacy benefits manager (insuring > 55 million individuals in the United States) was used to obtain drug utilization data. Measurements and Main Results. Pharmacogenomic biomarkers were defined, FDA-approved drug labels containing this information were identified, and utilization of these drugs was determined. Of 1200 drug labels reviewed for the years 1945-2005, 121 drug labels contained pharmacogenomic information based on a key word search and follow-up screening. Of those, 69 labels referred to human genomic biomarkers, and 52 referred to microbial genomic biomarkers. Of the labels referring to human biomarkers, 43 (62%) pertained to polymorphisms in cytochrome P450 (CYP) enzyme metabolism, with CYP2D6 being most common. Of 36.1 million patients whose prescriptions were processed by a large pharmacy benefits manager in 2006, about 8.8 million (24.3%) received one or more drugs with human genomic biomarker information in the drug label. Conclusion. Nearly one fourth of all outpatients received one or more drugs that have pharmacogenomic information in the label for that drug. The incorporation and appropriate use of pharmacogenomic information in drug labels should be tested for its ability to improve drug use and safety in the United States. [ABSTRACT FROM AUTHOR]

HISTORICALLY, THE BENZODIAZEPINES AND PHENYTOIN have been used as first-line therapy in aborting status epilepticus (SE). The rationale for use of these two agents mainly rests on the 1998 results of the Veterans Affairs Cooperative Trial. The greatest response rate was seen in those patients who received benzodiazepines in addition to phenytoin (PHT), rather than PHT alone. Although the intravenous formulation of valproic acid (VPA) was officially approved by the FDA in 1996, the agent was not included in the Veterans Affairs Cooperative Trial and still has not received approval by the FDA for use in SE. Nevertheless, despite the lack of FDA approval, IV VPA continues to be used off-label by clinicians. Therefore, papers such as this one by Gilad et al are critical in defining the exact role of VPA in both acute repetitive seizures (ARS) and SE. Seventy-four adult patients with either ARS or SE older than age 18 were included in this open-label study. Patients with baseline abnormal liver function tests or previous toxic serum levels of VPA were excluded from the study. For this study, SE was defined as greater than 30 minutes of continuous seizure activity or two or more sequential seizures without clinical recovery. ARS was defined as two or more repetitive seizures with clinical recovery between seizures during a 5- to 6-hour period. The primary endpoint was cessation of clinical seizure activity within 20 minutes of either VPA or PHT infusion, without rescue medication intervention. The secondary endpoint was assessment of infusion tolerability over the subsequent 24 hours. The IV VPA patient group received 30 mg/kg given over 20 minutes. The PHT patient group received an infusion of 18 mg/kg also given over 20 minutes. Patients were treated randomly in the emergency room in a 2:1 ratio of either VPA or PHT infusion. If seizure control was not achieved by infusion of the first study drug, then patients were treated with the other study drug. Patients who failed both study drug infusions were then treated with IV midazolam at a dosage of 0.2 mg/kg and were then subsequently transferred to the intensive care unit. Electroencephalography was performed in select cases of clinically suspected nonconvulsive status where patients did not regain consciousness. Forty-nine patients were treated with IV VPA and 25 patients were treated with PHT. Nearly two-thirds of patients in the study experienced breakthrough seizures secondary to subtherapeutic anti-epileptic drug levels or non-compliance. Post-stroke epilepsy made up approximately 25% of patients. Twelve percent of both the IV VPA and IV PHT groups required rescue medication. No significant side effects were found in the VPA group. One patient in the PHT group (no prior cardiac history) experienced ventricular premature beats during the infusion, one experienced vertigo, and one was noted to develop hyponatremia. [ABSTRACT FROM AUTHOR]

Abstract: This paper examines the impact of job loss due to business closings on body mass index (BMI) and alcohol consumption. We suggest that the ambiguous findings in the extant literature may be due in part to unobserved heterogeneity in response and in part due to an overly broad measure of job loss that is partially endogenous (e.g., layoffs). We improve upon this literature using: exogenously determined business closings, a sophisticated estimation approach (finite mixture models) to deal with complex heterogeneity, and national, longitudinal data from the Health and Retirement Study. For both alcohol consumption and BMI, we find evidence that individuals who are more likely to respond to job loss by increasing unhealthy behaviors are already in the problematic range for these behaviors before losing their jobs. These results suggest the health effects of job loss could be concentrated among “at risk” individuals and could lead to negative outcomes for the individuals, their families, and society at large. [Copyright &y& Elsevier]

Post-traumatic stress disorder (PTSD), characterized by abnormally persistent and distressing memories, is a chronic debilitating condition in need of new treatment options. Current treatment guidelines recommend psychotherapy as first line management with only two drugs, sertraline and paroxetine, approved by U.S. Food and Drug Administration (FDA) for treatment of PTSD. These drugs have limited efficacy as they only reduce symptoms related to depression and anxiety without producing permanent remission. PTSD remains a significant public health problem with high morbidity and mortality requiring major advances in therapeutics. Early evidence has emerged for the beneficial effects of psychedelics particularly in combination with psychotherapy for management of PTSD, including psilocybin, MDMA, LSD, cannabinoids, ayahuasca and ketamine. MDMA and psilocybin reduce barrier to therapy by increasing trust between therapist and patient, thus allowing for modification of trauma related memories. Furthermore, research into the memory reconsolidation mechanisms has allowed for identification of various pharmacological targets to disrupt abnormally persistent memories. A number of pre-clinical and clinical studies have investigated novel and re-purposed pharmacological agents to disrupt fear memory in PTSD. Novel therapeutic approaches like neuropeptide Y, oxytocin, cannabinoids and neuroactive steroids have also shown potential for PTSD treatment. Here, we focus on the role of fear memory in the pathophysiology of PTSD and propose that many of these new therapeutic strategies produce benefits through the effect on fear memory. Evaluation of recent research findings suggests that while a number of drugs have shown promising results in preclinical studies and pilot clinical trials, the evidence from large scale clinical trials would be needed for these drugs to be incorporated in clinical practice., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)