American Medical Group Association

BackgroundStudies examining the association of chronic kidney disease (CKD) with cancer risk have demonstrated conflicting results.MethodsThis was an individual participant data meta-analysis including 54 international cohorts contributing to the CKD Prognosis Consortium. Included cohorts had data on albuminuria [urine albumin-to-creatinine ratio (ACR)], estimated glomerular filtration rate (eGFR), overall and site-specific cancer incidence, and established risk factors for cancer. Included participants were aged 18 years or older, without previous cancer or kidney failure.ResultsAmong 1,319,308 individuals, the incidence rate of overall cancer was 17.3 per 1000 person-years. Higher ACR was positively associated with cancer risk [adjusted hazard ratio 1.08 (95% CI 1.06–1.10) per 8-fold increase in ACR]. No association of eGFR with overall cancer risk was seen. For site-specific cancers, lower eGFR was associated with urological cancer and multiple myeloma, whereas higher ACR was associated with many cancer types (kidney, head/neck, colorectal, liver, pancreas, bile duct, stomach, larynx, lung, hemolymphatic, leukaemia, and multiple myeloma). Results were similar in a 1-year landmark analysis.DiscussionAlbuminuria, but not necessarily eGFR, was independently associated with the subsequent risk of cancer. Our results warrant an investigation into mechanisms that explain the link between albuminuria and cancer.

Failure to control blood pressure (BP) despite multiple prescribed antihypertensive medications (AHMs) is widespread and leads to worse clinical outcomes. Recent changes to BP targets in US clinical guidelines require an updated evaluation of BP control including evaluations of nonadherence and therapeutic inertia. We leveraged clinical and insurance data sourced from >50 US health care organizations to identify >500 000 patients with established hypertension (>15-month history) concurrently prescribed ≥3 AHM classes in 2019. We characterized the prevalence of uncontrolled hypertension and describe patterns of nonadherence (lack of AHM fills covering >80% of days) and therapeutic inertia (failure to escalate AHM for patients persistently out of BP control). We described the associations with factors including race, ethnicity, sex, and insurance. Among 565 737 patients prescribed ≥3 AHMs, 37.7% met the recommended BP target of <130/80 mm Hg. Black race (odds ratio [OR], 0.71 [95% CI, 0.70-0.73]) and uninsured status (OR, 0.81 [95% CI, 0.76-0.86]) were most associated with lack of BP control relative to White or commercially insured patients. In a subset of insured patients, nonadherence occurred in 52.7%, although BP control remained poor among adherent patients (43.0% versus 39.4% for nonadherent). Therapeutic inertia was widespread; 64.5% of patients persistently above the BP target had no medication escalation within 18 months. An evaluation of a US-based, large, real-world patient cohort demonstrates that most patients prescribed ≥3 AHMs fail to achieve the recommended BP target of <130/80, and both medication nonadherence and therapeutic inertia are widespread.

Abstract The prevalence of people living with dementia (PLWD) is growing and dementia is one of the highest burden, and highest cost chronic conditions in the US. Care management support within primary care practices is one solution to provide patient- and care partner (CP)-centered care, improve patient care outcomes, e.g., hospitalizations, ED visits, polypharmacy, high care partner strain, and reduce healthcare costs. This session describes a collaborative adaptation and implementation of the MIND at Home Dementia Care Coordination Program into two large primary care clinics in two states (e.g., Iowa and North Carolina). The program pilot expanded the skills of existing primary care staff members to the level of Memory Care Coordinators (MCCs), who worked with larger primary care teams on combining the benefits of clinic-based with home-based services that support PLWD, their families, and CPs. 106 primary care patients and their CPs were recruited for a 3-month intervention period and process measures, including identified and addressed needs of the PLWD and CP, were ascertained. This session will discuss the feasibility of program implementation in a racially, economically, and geographically diverse population of PLWD and provide qualitative and quantitative outcomes on patient, provider and MCC program acceptability, program impact, and barriers and facilitators to implementation from the primary care practice perspective. The presentation will reflect on specific issues important to consider in primary care including underdiagnosis of dementia, patient recruitment and outreach, incorporation of home visits, interdisciplinary collaboration and consultation, and outcomes ascertainment.

Abstract Background: We examine pandemic-era quality of care changes associated with telemedicine use among adults with type 2 diabetes and/or hypertension across ten health systems. Methods: Patient-level encounter and laboratory data (n=1,963,563) were analyzed for pre-pandemic (March 13, 2019 to December 31, 2019) and pandemic (March 13, 2020 to December 31, 2020) periods. Generalized linear models with binomial distribution functions and log links estimated the association of telemedicine use with four outcomes: 1) hemoglobin A1c (HbA1c) testing, 2) HbA1c control (&lt;8.0%), 3) blood pressure (BP) testing, and 4) BP control (&lt;140 / 90 mmHg), controlling for patient characteristics, system fixed effects, and with propensity score weights. Results: In adjusted analyses, telemedicine use was associated with lower odds of HbA1c (aOR=0.74, p&lt;0.05) and BP (aOR=0.40, p&lt;0.01) testing for adults with type 2 diabetes, but not HbA1c or BP control. Among hypertension-only patients, telemedicine use was associated with lower odds of BP testing (aOR=0.10, p&lt;0.001), but not BP control. Compared to pre-pandemic telemedicine use, pandemic period telemedicine use was associated with lower odds of HbA1c and BP monitoring. Discussion: Telemedicine use was associated with lower odds of HbA1c monitoring for adults with type 2 diabetes and lower odds of BP testing for adults with type 2 diabetes and/or hypertension. Conclusion: As telemedicine continues to be used for diabetes and hypertension care, remote monitoring, standing orders, and community pharmacy partnerships may be necessary supplements to telemedicine to assure high quality care, especially when in-person care options are limited.

The AAMC (Association of American Medical Colleges) is a nonprofit association dedicated to transforming health through medical education, health care, medical research, and community collaborations.Its members are all 155 accredited U.S. and 17 accredited Canadian medical schools; approximately 400 teaching hospitals and health systems, including Department of Veterans Affairs medical centers; and more than 70 academic societies.Through these institutions and organizations, the AAMC leads and serves America's medical schools and teaching hospitals and the millions of individuals employed across academic medicine, including more than

Abstract BackgroundAn intensive lifestyle modification program or metformin pharmacotherapy reduced the risk of developing diabetes in patients at high risk, but are not widely used in the 88 million American adults with prediabetes.ObjectiveDevelop an electronic health record (EHR)-based risk tool that provides point-of-care estimates of diabetes risk to support targeting interventions to patients most likely to benefit.DesignCross-design synthesis: risk prediction model developed and validated in large observational database, treatment effect estimates from risk-based reanalysis of clinical trial data.SettingOutpatient clinics in US.PatientsRisk model development cohort: 1.1 million patients with prediabetes from the OptumLabs Data Warehouse (OLDW); validation cohort: distinct sample of 1.1 million patients in OLDW. Randomized clinical trial cohort: 3081 people from the Diabetes Prevention Program (DPP) study.InterventionsRandomization in the DPP: 1) an intensive program of lifestyle modification; 2) standard lifestyle recommendations plus 850 mg metformin twice daily; or 3) standard lifestyle recommendations plus placebo twice daily.ResultsEleven variables reliably obtainable from the EHR were used to predict diabetes risk. This model validated well in the OLDW (c-statistic = 0.76; observed 3-year diabetes rate was 1.8% in lowest-risk quarter and 19.6% in highest-risk quarter). In the DPP, the hazard ratio for lifestyle modification was constant across all levels of risk (HR = 0.43, 95% CI 0.35 – 0.53); while the HR for metformin was highly risk-dependent (HR HR = 1.1 [95% CI: 0.61 - 2.0] in the lowest-risk quarter vs. HR=0.45 [95% CI: 0.35 0.59] in the highest risk quarter). Fifty-three percent of the benefits of population-wide dissemination of the DPP lifestyle modification, and 76% of the benefits of population-wide metformin therapy can be obtained targeting the highest risk quarter of patients.LimitationsDifferences in variable definitions and in missingness across observational and trial settings may introduce estimation error in risk-based treatment effects.ConclusionAn EHR-compatible risk model might support targeted diabetes prevention to more efficiently realize the benefits of the DPP interventions.

Managed care pharmacy has a relatively short history, but one that is defined by significant achievements. Since the late 1960s, managed care pharmacists have applied their unique skills to formulary management, clinical programs, benefit design, and contract negotiations to support patient access to life-saving therapies, while also ensuring cost-effective use of limited health care resources. Key milestones include establishing the pharmacy benefit as an essential component of the U.S. health care system, launching the Medicare Part D program, and expanding medication therapy management services. The year 2020 brings another milestone-the 25th anniversary of AMCP's flagship publication, the Journal of Managed Care + Specialty Pharmacy. This year also serves as an inflection point. As managed care pharmacy professionals prepare for change and the challenges ahead-including the imperative to address the rising costs of health care and health disparities-the use of evidence, utilization management strategies, and innovation will support our continued success. DISCLOSURES: No funding supported the writing of this commentary. The authors have nothing to disclose.

\n Os métodos tradicionais microbiológicos descritos nas farmacopéias mais comumente utilizadas pelas indústrias farmacêuticas são de fácil execução e os custos são acessíveis, mas exigem longos períodos de tempo para obtenção dos resultados e muitas vezes não apresentam sensibilidade para recuperação de microrganismos em estados fisiológicos vulneráveis conhecidos como viáveis e não cultiváveis. Há intensa motivação na busca de métodos microbiológicos alternativos que apresentem maior sensibilidade, exatidão e especificidade nas análises realizadas, garantindo maior segurança ao paciente, além de permitir que resultados sejam obtidos em um curto período de tempo, contribuindo para a antecipação de investigações sobre possíveis falhas de processo e produto. Assim, os objetivos deste estudo foram avaliar a potencial aplicabilidade da citometria de fluxo em produtos farmacêuticos não estéreis, além de executar as etapas de validação analítica, analisando o método compendial em paralelo com o método alternativo por citometria de fluxo no equipamento BactiFlow ALS®. Os resultados indicaram que não houve diferenças significativas entre os métodos em relação à capacidade de detectar contaminação microbiana, entretanto, a detecção com o método de citometria de fluxo apresentou maior rapidez comparada ao método tradicional, o que indica que esta tecnologia é uma alternativa viável a ser implementada.\n