Potential solutions to the quality-adjusted life-year, assessing quality, and more.

Read the July Issue of AJAC

This AJMC® Profiles in Care provides an in-depth look into the results of the outcomes-based agreement between Boehringer Ingelheim and Highmark Inc.

AJMC® Profiles in Care Launches

If 2020 was dominated by the news of how COVID-19 spread across the globe, then 2021 has so far been focused on ending the pandemic through vaccine distribution.

A Timeline of COVID-19 Vaccine Developments in 2021

We interview experts on investigational treatments such as liso-cel, and ask how to bring them to community practice.

Spotlight on CAR T-Cell Therapy

The American Journal of Accountable Care® features research and commentary on new payment models.

New Members for AJAC Board

 since 2019 and has a BA in philosophy and journalism & professional writing from The College of New Jersey. 

Some patients with type 1 diabetes have issues that prevent them from having successful telehealth visits, said Leslie Eiland, MD, an endocrinologist at the University of Nebraska Medical Center in Omaha, Nebraska. Eiland's 

, "Use of Diabetes Technologies for Remote Monitoring in Ambulatory/Rural Settings," was presented at the American Diabetes Association's (ADA) 81st Scientific Sessions.

What are some barriers patients with type 1 diabetes (T1D) in rural America face and how can technology address these barriers?

When we started seeing more people with home visits after spring of 2020, we realized that home visits assume a lot, and some of our patients do have issues that prevent them from having successful telehealth visits. Home video visits assume that you have a decent level of tech or digital literacy. They assume that you have not only internet access, but just a stable internet connection that can perform at threshold speeds, able to have a 20-minute video visit with your provider or longer. And they assume that you have access to a connected device with a camera, which not everybody has. During my talk at ADA, I [went] over 6 specific patient examples: who the patients were, what their medical issues were, and then maybe how successful their video visit was and how we responded to some disparities that they had, like lack of internet or lack of smartphone and how we still were able to obtain their diabetes-related data during that visit.

Sometimes we had somebody who didn't have a smartphone, didn't have home internet, but did live close to one of our rural community hospitals, where we had a telehealth visit, where he was able to meet with a local CDCES [certified diabetes care and education specialist] prior to the visit who could upload his diabetes technology. In this case, he was using a CGM, a continuous glucose monitor, she could secure that, email that to me prior to the visit. That way, when we did connect through a visit at his community hospital, I was able to access all of his diabetes data, even though he did not personally have the ability to upload that and share that with me. I have some other elderly patients that live in rural areas. Over the winter, weather was horrible, COVID-19 was raging in their communities, and they had no smartphone, had no home internet. But a couple of my patients did use a Freestyle Libre flash glucose monitor and also used the receiver and I was able to walk them over the phone, through a phone visit, through the receiver, to help me generate a decent amount of glucose data and we were able to make safe changes to their regimen.

Videos

Leslie Eiland, MD, outlines some of the challenges of delivering optimal care to patients with type 1 diabetes (T1D) living in rural America. 

Dr Leslie Eiland Discusses Challenges Faced by Patients With T1D in Rural America 

Peer support interventions that included nursing staff was found to effectively improve lung function and quality of life of nonsmoking patients with chronic obstructive pulmonary disease (

The study highlighted how the professional knowledge and communication skills that nurses possess can provide psychological comfort and encouragement to nonsmoking patients. Nurses can also use their knowledge and skills to guide patients to help them better manage their COPD.

“Peer-support nursing can not only effectively make nonsmoking patients feel positive energy such as respect and trust but also enable nonsmoking patients to get guidance from medical staff in the community, so as to promote the establishment and maintenance of their healthy lifestyle,” wrote the investigators.

Use of long-acting maintenance bronchodilators, inhaled corticosteroids, and pulmonary rehabilitation can decrease symptoms, reduce exacerbation frequency, and improve pulmonary function. However, few actions beyond these therapeutic methods have been taken to reduce disease progression or mortality rates.

Peer support generally involves nonprofessionals who have similar diseases or experience with disease management. If conducted effectively, patients can benefit from disease management assistance, links to clinical care, and social and emotional support that is available at all times.

The investigators enrolled 100 nonsmoking patients with COPD who were admitted at the Human Provincial People’s Hospital in Changsha, China between October 2018 and October 2020. The patients were split into a control group (n = 50), where they were treated with routine care, and an observation group (n = 50), where the patients received routine care and peer support nursing.

The observation and control groups had a mean (SD) age of 45.36 (15.68) years and 46.25 (14.65) years, respectively. Both groups had a higher number of male than female patients (observation group, n = 28 vs 22; control group; n = 27 vs 23).

Before the study, the researchers recruited nurses and peers to interact with the patients. Nurses had to have at least a bachelor degree and more than 5 years of experience working in a 

 department, at least 3 of which they had to be working as a senior nurse.

The observation group were given health education training through group interaction and situational dialogue. Peers functioned as group leaders to demonstrate pulmonary function exercises and share rehabilitation knowledge. Patients were added to a peer support group chat, where disease rehabilitation knowledge and psychological counseling were provided.

The groups were evaluated before the intervention and 3 months after the interventions. The patients were given a social support rating scale featuring a 5-point Likert scale. When tallied, the scored demonstrated the impact that the intervention had on patient lifestyle. The higher the score, the more improved the lifestyle.

Prior to the intervention, the groups did not differ much in values depicting subjective support, objective support, utilization of support, and total scores (

 > .05). However, scores for subjective support and support utilization were significantly higher in the observation group compared with the control group 3 months after receiving the intervention (

The groups also did not have significant different in scores for positive attitude, stress reduction, self-decision making, and total score prior to the intervention (

 > .05). Three months after the intervention, the values shifted to be significantly higher in the observation group than the control group (

There were also no differences prior to the intervention between the groups regarding health responsibility, self-realization, interpersonal support, and stress management (

 > .05), but the observation group had significantly higher scores than the control group for these values after the intervention (

After the intervention, the observation group performed better during the 6-minute walk test than the control group (

 < .05). Before the intervention, both groups performed similarly (

A limitation of the study was that the investigators did not look at the potential impact that family cooperation in nursing could have on the results. The investigators said that follow-up studies need to be conducted and should focus on formulating relevant intervention programs.

Yao X, Wang X, Tuan J, Huang Z, Wu D, Xu H

Benefits conferred by peer-support nursing intervention to pulmonary function and quality of life in nonsmoking patients with COPD. 

. Published online June 16, 2021. doi: 10.1155/2021/7450979

Articles

Peer support nursing intervention produced significant benefits in lung function and quality of life (QOL) in patients with chronic obstructive pulmonary disease (COPD), highlighting the importance that nurses can play in improving disease management.

Nurse-Led Peer Support Proves Effective at Improving Lung Function, QOL in COPD

Lower Vaccine Antibody Levels Seen in Juvenile Idiopathic Arthritis 

A recent study of children with juvenile idiopathic arthritis (JIA) illustrates the pressing need for continued routine vaccinations. A report in 

 found that these patients were more likely to have lower anti-vaccine antibody levels due in part to incomplete vaccination, arthritis, and immunosuppressive drugs like biologics and methotrexate; many patients stop the vaccinations at diagnosis despite their safety and efficacy. The study, published in 

analyzed 170 children, aged 2 to 17 years with JIA, who had received routine vaccinations, including measles, rubella, mumps (MMR), diphtheria, and hepatitis B. Patients were divided into 2 categories: complete and incomplete vaccination. Incomplete vaccination was defined as having fewer vaccines or doses by age. Post-vaccination antibodies (IgG) were measured using ELISA.

The study found that protective levels of antibodies for those with incomplete vaccinations ranged from 50% for hepatitis B, 52% for diphtheria, 58% for measles, 80% for mumps, and 98% for rubella.

Fifty patients did not achieve a complete vaccine dosing schedule against MMR. Among those, 39% were treated with biologics, 22% with methotrexate, and 14% with nonsteroidal anti-inflammatory drugs.

When comparing patients with complete and incomplete vaccinations, those with incomplete status had a lower level of antibodies against mumps and diphtheria; treatment with methotrexate and biologics were strong indicators of diphtheria revaccination omission. Incomplete vaccination was also a risk factor for nonprotective levels of antibodies against measles.

Study Highlights Need for Cardiovascular Disease Prevention in RA, T2D

In patients with rheumatoid arthritis (RA) with type 2 diabetes (T2D), the use of cardiovascular disease (CVD) medication and prevalence of atherosclerotic cardiovascular disease (ASCVD) were doubled compared with patients with RA who did not have T2D, according to a 

Both RA and T2D are historically associated with increased risk of ASCVD. The 

 suggested that increased awareness of ASCVD is needed as patients with both conditions more frequently reached lipid targets compared with patients with RA without T2D.

Patients With Lupus, Cardiovascular Autonomic Neuropathy Report Lower QOL

Patients with systemic lupus erythematosus (SLE) had more self-reported cardiovascular autonomic neuropathy, along with impaired health-related quality of life (QOL) and parasympathetic function, when compared with a control group that had cardiovascular autonomic neuropathy but not SLE, according to a report published in 

The relationship of autonomic dysfunction as it relates to QOL has been studied in other diseases but not in SLE, the report said. 

, a bit more than half of patients with SLE presented with signs of autonomic dysfunction, characterized mostly by parasympathetic impairment and in more severe cases by sympathetic impairment. Even without cardiovascular autonomic neuropathy, patient with SLE had impaired parasympathetic function. The finding adds credence to evidence of autonomic dysfunction as a distinct disease mechanism in SLE that may suggest new targets for therapies.

The latest news in rheumatology includes the need for robust vaccinations in juvenile idiopathic arthritis; new findings about rheumatoid arthritis (RA) and type 2 diabetes; and quality of life in  systemic lupus erythematosus.




Rheumatology Rundown: Vaccinations in JIA; RA and T2D; SLE Quality of Life

® since 2019 after receiving his Bachelor's degree at Rutgers University–New Brunswick in journalism and economics.

As health care utilization experienced marked 

 in 2020 due to the COVID-19 pandemic, the impact of deferred cancer screening and treatment is expected to contribute to 

 cancer morbidity and mortality in the future.

In examining these delays, the impact on underserved communities and at-risk populations across the United States cannot be understated, as 

 in cancer diagnoses and surgery were apparent long before the pandemic began, according to experts interviewed by 

Although early cancer screening and diagnosis provides patients with the best chance of positive outcomes, eligibility for screening, particularly 

, has historically overlooked the increased risk associated with minority populations.

 of cancer-related deaths, data has demonstrated that Black men and women are at increased risk for lung cancer at a younger age, despite having smoked less than White men.

In fact, these concerns were the focus of recently 

 US Preventive Services Task Force (USPSTF) recommendations for lung cancer screening, in which 2 notable changes were made to expand eligibility for more high-risk patients:

Yearly low-dose computed tomography (LDCT) scans for people aged 50 to 80 years old, rather than starting at 55

Individuals with 20 pack-years of smoking history now eligible, expanding from 30 pack-years

Reviewing the potential impact of these updated guidelines, M. Patricia Rivera, MD, professor of medicine, Division of Pulmonary Diseases and Critical Care Medicine, director, Multidisciplinary Lung Cancer Screening Program, and codirector, North Carolina Lung Screening Registry, at University of North Carolina at Chapel Hill, discussed in an email exchange with 

what will be achieved and what unmet needs persist in managing lung cancer care disparities.

“The new recommendations of lowering the age and pack year requirement actually results in a higher relative increase in eligibility for women versus men, and for Blacks, Hispanics, and Native Americans versus whites,” said Rivera, who also served as a coauthor of an editorial published in 

 on the updated recommendations. “An important observation is that while these new recommendations will result in a higher relative increase in eligibility, it does not mean that the disparities will be eliminated.”

 examining the updated guidelines, Rivera said that although screening eligibility will be improved for women and minorities, odds ratio findings suggest that eligibility will still favor White men.

“It is expected that now 14.5 million US adults will be eligible for screening, with the 2013 recommendations it was 8 million. So, I think it's like an 81% increase of individuals–many more patients are now eligible,” said Rivera. “But the barriers still remain–just because you've lowered the age and the smoking history doesn't mean that the rate is going to increase. It means you've improved eligibility or access to lung cancer screening by eligibility, but not necessarily access to care.”

Ultimately, there are several underlying factors contributing to the inequities present in lung cancer care. In assessing one of the major 

 of lung cancer, non-small cell lung cancer (NSCLC), a recent study published in the 

 examined differences in outcomes by race and residential segregation, measured by a proxy of historic housing discrimination and related structural racism, in 100 of the most populous US counties.

Deriving data from the Surveillance, Epidemiology and End Results program on Black and White patients diagnosed with NSCLC from 2004 to 2016, results indicated that Black patients with NSCLC who lived in the most segregated US counties were 49% more likely to be diagnosed at an advanced stage, compared with those living in the least segregated counties—a trend that was not found in White patients.

In addition to being more likely than White patients of being diagnosed at an advanced stage, despite having lower incidence overall, Black patients from highly segregated counties who were diagnosed with NSCLC at an early stage were found to be 47% less likely to receive surgery.

Multiple Reasons Underpinning Disparities

Addressing these disparities in surgery, corresponding study author Kei Suzuki, MD, assistant professor of Surgery, Boston University School of Medicine, told 

 that while the study was not designed to identify the details and causes of the association, he and fellow authors consider reasons for the link to be multifactorial.

“This could be due to system issues such as access to care—could be an issue on the providers’ side as they may be less likely to recommend surgery for Black patients,” Suzuki said via email. “This could be due to factors on the patients’ side, whether that be mistrust or that patients’ physiologic condition may not allow for surgery….using our local data with patients being seen at Boston Medical Center, we have further shown association with residential segregation in the form of 

 and disparity in lung cancer screening.”

Perceiving updates to the USPSTF lung cancer screening guidelines as an important step in improving screening of at-risk populations, Suzuki noted that further research on risk factors is warranted, with another significant issue residing in screening uptake.

“Published screening rate/uptake in the country is in the range of 5% to 10%, meaning of those who meet the criteria, only a handful are actually receiving the screening LDCT scans. It’s one thing to expand the criteria, but an unanswered question remains: how do we better screen those who meet the criteria?”

Closing the Medicaid Screening Coverage Gap, Potential of Targeted Screening

As Rivera noted, there are several issues contributing to the lack of adherence nationwide to the USPSTF lung cancer screening guidelines, namely endorsement from prominent health care organizations and socioeconomic barriers such as insurance status.

Medicare is currently reviewing the updated USPSTF guidelines, and had endorsed screening in 2015, but for Medicaid, where recipients are 

 to be current smokers than those with private insurance, the program is not required to cover screening. Even if it does cover it, programs may use different criteria than what guidelines recommend.

“There are [9] states that did not expand the Medicaid coverage for lung cancer screening. So, we have a large number of individuals in this country at risk for lung cancer because of smoking, who are either uninsured or underinsured with Medicaid and may be in an area where Medicaid doesn't cover—that remains a significant barrier within our health care system,” said Rivera.

With disparities in screening access potentially exacerbated by the updated guidelines due to the lack of applicability for a significant proportion of US residents covered by Medicaid, a recent 

 developed for the Lung Ambition Alliance by The Health Policy Partnership suggests that targeted screening with LDCT scans in high-risk populations can significantly reduce mortality and the economic burden tied to it.

Endorsed by the International Association for the Study of Lung Cancer (IASLC), the review was based on findings of the 

, which showed that among a cohort of over 13,000 European people indicated as high-risk for lung cancer, mortality rates were significantly reduced in the intervention group who underwent LDCT scans (18.4%) compared with those of the control group who were not scanned (24.4%) after a 10-year follow-up.

, Giorgio Scagliotti, past president and interim chief science officer, IASLC, and professor of Medical Oncology, University of Turin School of Medicine, highlighted that while screening recommendations focus primarily on current or former heavy smokers and age, there is growing evidence suggesting that risk factors such as family history of cancer or pneumonia, occupational exposures, and ethnicity are paramount in determining risk of lung cancer.

“Early-stage lung cancer can be managed with less complex, less costly clinical pathways than when it is diagnosed at later stages,” said Scagliotti via email. “As lung cancer progresses, health care costs rise from increased frequency of hospital admissions, additional rounds of treatment, additional care requirements and greater likelihood of palliative care.”

As underserved populations and people of lower socioeconomic status have been shown in data to be less likely to participate in cancer screening programs, the report assessed barriers that patients may face and opportunities for reform in 3 key areas:

Reducing physical and financial barriers to access

Dismantling psychological and social barriers that prevent attendance at screening

“Screening with LDCT technology is the next big opportunity to increase survival from cancer, and wide scale implementation will bring us closer to our goal of eliminating lung cancer as a cause of death,” added Scagliotti.

Catching Cancer Earlier May Warrant Federal Intervention

Although a scaled LDCT screening approach would be optimal in expanding reach to high-risk populations, Rivera noted that simply revising guidelines to include requirements such as shared decision-making would potentially exacerbate 

 for already time-constrained physicians, and may limit uptake as a result.

“In thinking of strategies that might expedite workflow, doing televisits of shared decision-making prior to patients coming in to see their doctors can be very helpful,” suggested Rivera. “But probably one of the most important interventions is that health care systems really need to provide the resources like the nurse navigators that can help facilitate the screening process. And in addition to navigators, community navigators deploying nurse navigators into communities to reach 

 of individuals in low socioeconomic areas would be very helpful.”

Ultimately, Scagliotti, Rivera, and Suzuki all agree that to make a significant impact on lung cancer care disparities, federal intervention from policymakers is needed.


In fact, Rivera said that similar action was taken decades ago for breast and cervical cancer, in which federal mandates, such as the 

Breast and Cervical Cancer Mortality Prevention Act of 1990

, were instituted to ensure availability and quality of screening for these cancers were provided by each state to all women, regardless of financial status.

“We need state involvement and individual state mandates like expansion of Medicaid across all states, so that all individuals have a chance to access this important preventive service,” added Rivera.

In looking at recent data on rates of screening across the United States per state, Kentucky has the 

 nationwide, with the smoking rate shown to be significantly higher than the national rate. 

In response, the state has implemented a very aggressive lung cancer screening initiative that Rivera noted was spearheaded years ago primarily through family practice physicians. Through this initiative, Kentucky’s lung cancer screening rate rose to 15% in 2018, vastly greater than North Carolina, where the screening rate was 4% in the same year, underscoring potentially undiagnosed and advancing lung cancers.

“By having these initiatives that get screening into the communities where it's needed most and learning/trying to mimic or expand those kinds of initiatives across other states can be very helpful,” she concluded.

On World Lung Cancer Day, we explore current guidelines for lung cancer screening in the United States, implications of the COVID-19 pandemic, and disparities in mortality and access to care by race and socioeconomic status.

An Inside Look at Disparities in Lung Cancer Care for At-Risk Populations

Gary Lyman, MD, MPH, is an oncologist, hematologist, and public health researcher who has long been an advocate for biosimilars. He has also developed guidelines in support of using biosimilars in the oncology space.

Do you believe that changes in biosimilars reimbursement or incentives for biosimilar use will help uptake?

Depends on the level at which they are likely to impact, like if it's at the health system level or the provider level in a small practice. I think ultimately, our concern is about the patient. If all else is equal, cost drivers will generally went out. If either the health system pays less for a specific favored biosimilar or if patients are not left with as much out-of-pocket costs, because the agent is not fully reimbursed, I think those will be strong motivators to utilize 1 biosimilar or another.

In the end, everyone, including patients, providers, and the health system, should all consider patient safety and efficacy as the primary concern. If you're not convinced with all that I've said and others have said about why we believe that these FDA-approved alternatives are just as good as the originator across disease settings, then you need to find out more. I've talked about this for many years and major meetings like the ones for ASCO [American Society of Clinical Oncology], and ASH [American Society of Hematology], and NCCN [ National Commprehensive Cancer Network]. I think once clinicians take the time to be fully educated on these issues around drift and extrapolation, and so forth, they will accept and utilize the version of biosimilar that is preferred and available.

Where there's still some issues for discussion is the process of interchangeability that that the FDA has set up that only exists in the United States. It's not something that exists in Europe or elsewhere in the world. [Only 1] biologic that is a biosimilar version [Semglee, insulin glargine biosimilar] has been granted [interchangeability]. In principle, it's a higher level of approval, that is once a biologic has been approved as a biosimilar, [companies have] the option, with additional comparative clinical trial data showing that switching back and forth between the reference product and the biosimilar doesn't impact on safety and efficacy, for a biosimilar to be granted a higher level approval as an interchangeable biosimilar. And perhaps some company will feel this provides them with some market advantage or as a reason to choose their agent over another. So far, that [marketing has] not been done.

One provision in that regulation is that if a drug is granted this higher level of approval, that substitution for their agent could be made without intervention of the provider automatically, and there would be no requirement for notification. Well, this has led more than half the states in the country to put together their own laws to intervene to say, "We don't fully accept that process and we do think providers need to be notified." That's ASCO's position as well. Clinicians may not have a choice as to which agent is used for their patient, but they at least need to be informed of what their patient has been given. If you prescribe 1 agent, and they're given another agent, even if there's strong evidence that is just as safe and effective, you want to know which agent they're receiving. If for no other reason for pharmacovigilance to make sure if there's any new, rare, unexpected effect that you can report exactly what agent so that it can be linked back to in their reporting. So, it's really important that clinicians know what patients are getting, even if they don't necessarily have control over the switching or substitution that takes place.

Gary Lyman, MD, MPH, an oncologist and hematologist, discusses how financial incentives, concerns for patients, and interchangeability impact biosimilar prescribing patterns.

Dr Gary Lyman: Do Financial Incentives or Policies Have a Greater Influence on Biosimilar Uptake?

Patients with treatment-naive chronic lymphocytic leukemia (CLL) or small lymphocytic leukemia (SLL) had superior progression-free survival (PFS) when treated with zanubrutinib (Brukinsa) vs bendamustine and rituximab (B+R), according to an interim analysis of a phase 3 trial.

SEQUOIA is a randomized, multicenter, global phase 3 trial comparing the efficacy and safety of zanubrutinib against B+R in patients with treatment-naive CLL and SLL whose tumor did not exhibit del(17p). The primary end point of the trial was PFS as assessed by independent review committee, and there was a median follow-up of 25.8 months.

Cohort 1 has 479 patients randomized 1:1 to receive zanubrutinib or B+R until disease progression or unacceptable toxicity. This cohort does not include patients with del(17p).

Cohort 2 has 110 patients with del(17p) receiving zanubrutinib as a monotherapy.

Cohort 3 is currently enrolling patients with del(17p) or pathogenic TP53 variant to receive zanubrutinib in combination with venetoclax.

SEQUOIA also showed that zanubrutinib was generally well tolerated. Previous data have highlighted that the therapy has 

. As a second-generation Bruton tyrosine kinase inhibitor, zanubrutinib has fewer off-target effects.

 at the European Hematology Association Virtual Congress 2021, showed that zanubrutinib has a superior response rate, improved PFS, and lower rate of atrial fibrillation/flutter compared with ibrutinib in patients with relapsed/refractory CLL/SLL.

“The combined clinical evidence from SEQUOIA, ALPINE, the 205 trial, and the AU-003 trial validates our confidence in Brukinsa as a regimen which can offer improvements in treatment outcomes for hundreds of thousands of patients living with CLL,” Jane Huang, MD, chief medical officer, hematology at BeiGene, 

. “We are pleased to see that at the interim analysis of the SEQUOIA trial, Brukinsa significantly prolonged progression-free survival for treatment-naïve CLL patients, and that the demonstrated safety profile was consistent with what we have observed in its global development program with more than 2300 patients treated with Brukinsa to date.”

In an interim analyses of the phase 3 SEQUOIA trial, zanubrutinib had superior progression-free survival compared with bendamustine plus rituximab in patients with treatment-naive chronic lymphocytic leukemia (CLL) or small lymphocytic leukemia (SLL).

Positive Results From SEQUOIA Analyses for Zanubrutinib in Treatment-Naive CLL and SLL 

Polypharmacy in older adults has implications for safety and economics, as well as posing clinical risks, and 

 is one of the cornerstones in geriatrics.

 examined the effect of drug rationalization on comprehensive geriatric assessment (CGA) parameters, in which a detailed medication review is conducted, as well as the Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults. The Beers criteria, a tool developed by the American Geriatrics Society, is a list of PIMs that are typically best avoided.

The retrospective and longitudinal study examined the records of patients visiting geriatric outpatient clinics between February 2015 and October 2018 in Turkey. Of 1741 patients seen, 515 were included in the analysis and had been followed for 6 months after a medication review, according to Beers and CGA. Patient mean age [SD] was 74.13 [7.29]; most were female.

Detailed medication history, laboratory findings, comorbidities, socioeconomic characteristics, and CGA parameters were recorded at the first visit, and polypharmacy was defined as the concurrent use of 5 or more drugs. These were then compared with follow-up data.

Drug therapy was individualized by the same geriatrician who assessed patients in the outpatient clinic, and patients whose total drug numbers fell were reevaluated separately after 6 months.

Patients were divided into 2 groups: less than 5 drugs, or 5 or more. Patients in the former group numbered 246 (47.8%) and 269 individuals (52.2%) were in the latter. There was no statistically significant difference between the 2 groups in terms of gender.

The baseline mean number of drugs was 5.11 [3.34], but after prescriptions were optimized by a physician, that number fell to 4.76 [2.72].

The patients whose total drug numbers fell were reevaluated separately after 6 months.

Results showed that the polypharmacy group had a higher rate of geriatric syndromes and lower CGA scores. They were also more likely to be married and suffer from hypertension, depression, and type 2 diabetes.

At the end of 6 months, depression, mobility, and nutritional scores improved for patients who were taking fewer drugs, without a decline in cognition, activities of daily living scores, and gait speed.

However, as the number of drugs increased, mobility and functionality decreased, showing that “medication reviews have key importance in the management of older patients,” the authors noted.

Idil E, Ekrem Aydin A, Bulut EA, Isik, AT. Rationally decreasing the number of drugs seems to be a useful therapeutic approach in older adults: 6-month follow-up study. 

Published online June 30, 2021. doi: 10.1016/j.archger.2021.104472

Drug optimization in older adults improved outcomes in this retrospective study.

Reducing Number of Drugs in Older Adults Shows Benefit 6 Months Later

Occurring naturally over time, cataracts can develop in both older and younger populations, particularly those with diabetes or prior eye injuries, said Rajesh Rajpal, MD, chief medical officer, global head of clinical medical affairs, Johnson & Johnson Vision.

Can you discuss the prevalence of cataracts among adults in the United States?

, as you probably know, are a natural clouding of the lens of the eye. It happens naturally as we age, and it's estimated that by age 75, approximately half of all Americans have cataracts. And cataracts continue to develop as we get older.

There are some reasons that a cataract can develop at an earlier age. For example, if patients are on certain medications, if they're diabetic, if they have a family history of cataracts, or sometimes if they've had significant injuries around the eyes. There are multiple reasons that we look for cataracts at an earlier age, as well.

What trends are you seeing in the development of cataracts?

Certainly, as we all have greater visual needs, we are finding that the age for cataract surgery is occurring at an earlier age in life, because ultimately cataracts decrease vision. So, if we're doing more visually, then we notice that earlier, but the trends in general are still similar.

It's related to those medical conditions or family history at an early age, but otherwise, it's primarily related to age. And it's thought that it’s that natural process of the lens becoming more dense and cloudy, which is really what a cataract is.

Rajesh Rajpal, MD, chief medical officer, global head of clinical medical affairs, Johnson & Johnson Vision, discusses the process of cataract development and its prevalence in both older and younger populations.

Dr Rajesh Rajpal on US Prevalence of Cataracts, Risk Factors for Younger Populations

A recent study reviewed the interaction between autoimmune hepatitis (AIH) and metabolic-associated fatty liver disease (MAFLD), which affects about 25% of people worldwide.

Both conditions may coexist and may react to each other in a synergistic fashion, impacting both progression and response to therapies. One challenge in diagnosing the 2 

 is that there is no specific biomarker, either for the diseases alone or together.

 the prevalence of MAFLD among patients with AIH is unknown, but that estimates range from 17% to 30%. Even less is known about the prevalence of AIH in MAFLD, and in both of the available studies available for analysis, the number of patients with a confirmed diagnosis of AIH after a liver biopsy fell.

The higher prevalence of coexistent MAFLD/AIH in patients with AIH can be explained by the higher prevalence of MAFLD overall as compared with the generally lower prevalence of AIH, they said.

MAFLD appears to have an effect on AIH. A small retrospective US study showed that patients with MAFLD/AIH were more likely to have cirrhosis and had worse clinical outcomes when compared with patients with AIH alone. Having both conditions was linked to a relative risk for liver-related mortality of 7.65 in patients with MAFLD/AIH and 2.55 for liver-related adverse outcomes compared with AIH alone. Worse outcomes were also seen with both conditions in larger studies conducted in the United States and Japan.

There is a lack of data about treatment when the 2 conditions are present, the authors said. In one of the aforementioned studies, patients with MAFLD and AIH were significantly more likely to receive ursodeoxycholic acid, while they were less likely to receive prednisolone, compared with AIH alone.

While the presence of autoantibodies are required to diagnose AIH, their effect on MAFLD is unclear. Patients with MAFLD have been reported to have a higher presence of autoantibodies than the general population, but the clinical significance of that is not know. The authors said the while the topic needs more research, “the available evidence suggests that patients with MAFLD/AIH have differential natural history, with potential bidirectional synergistic interaction between both conditions.”

In addition, more studies are needed to understand “the shared genetic basis between AIH and MAFLD.” One study in AIH has shown that 

-rs738409 variant GG, a strong risk variant for MAFLD, is a strong predictor for time to liver transplantation or death. The same study showed that 

-rs58542926 was linked with steatosis in AIH patients, but not with fibrosis progression.

Treatment requires a multidisciplinary approach tailored to each patient and may involve corticosteroids, prednisolone, budesonide, and immunosupressive agents, the authors said. Therapy must also include dietary changes, weight loss, exercise, and abstaining from alcohol.

Metabolic-associated fatty liver disease and autoimmune hepatitis: An overlooked interaction. Gabera Y, AbdAllah M, Salamac A, Sayedd M, Alem SA, Nafadyc S. 

l. Published online July 15, 2021. doi: 10.1080/17474124.2021.1952867

One diagnosis challenge is that there is no specific biomarker, either for autoimmune hepatitis (AIH) or metabolic-associated fatty liver disease (MAFLD), either alone or if they exist concurrently.

Review Examines Interaction Between 2 Distinct Liver Diseases

William "Andy" Nish, MD, is a medical director and provider with a specialty in allergy and immunology at Northeast Georgia Physicians Group in Gainesville, Georgia.

What are some of the factors to consider when deciding whether to start a patient with asthma on a biologic?

Basically, biologics come into play when they're not doing well with other medicines, like maximal medical therapy. These days, maximum medical therapy would be double or combination medical therapy, like inhaled steroids with long-acting beta agonists, or even triple medical therapy, including anti-muscarinic or anticholinergic inhalers like Trelegy [fluticasone furoate, umeclidinium, and vilanterol]. So, we have 3 arrows of asthma treatment, if you will. Back in the day—and I'm dating myself when I say this—when I was training, we had theophen, albuterol, and steroids by mouth. Then, inhaled steroids came out and that was a huge advancement. And then, combination medicines came out when Advair [fluticasone propionate and salmeterol] came out and that was another huge advancement. Then, the biologics came out and gave us another treatment.

Whenever we have options like that, where we can treat people who otherwise weren't doing well, it's hard to serves as a tremendous advancement. Basically, it's based on the severity of their asthma. So, if they're doing well currently, for sure they don't need biologic. [But what] if they're not doing well in terms of severity and recurrent exacerbations? For instance, if they have 1 or more exacerbations and they go into the ER, they go into the acute care, or they're coming into the office acutely and/or they typically need steroids by mouth a couple times a year—that's not well controlled—if they can't sleep at night, if they can't exercise, if they're missing school, if they're missing work, those are all things that say that they're not well controlled.

William "Andy" Nish, MD, an allergist and immunologist at Northeast Georgia Physicians Group, discusses the factors that influence whether patients with asthma should be prescribed a biologic therapy.

Dr William "Andy" Nish on When a Patient With Asthma Should Start a Biologic

Here are some of the latest developments in 

 assessed the occurrence of MS and neuromyelitis optica spectrum disorder (NMOSD) among indigenous populations in New Zealand and Australia. Although results showed the Māori indigenous population in New Zealand had higher rates of NMOSD, MS was intermediate between those living in New Zealand with Southeast Asian and European ancestry. Both conditions appeared to be uncommon in Australia’s indigenous populations.

“One advantage of our comparison of ethnic ancestry between NMOSD, suspected NMOSD, and MS is that the process of case ascertainment and data collection was the same for all 3 groups,” researchers explained.

“There was also good consistency between our clinically collected MS cohort and the previously collected ethnic ancestry specific prevalence data. The relative prevalence in those of Asian ancestry was 1% of the overall European MS prevalence,” they said.

 at the virtual Institutional Perspectives in Neurology: Multiple Sclerosis program focused on the latest approved therapies in the sphingosine phosphate 1 (S1P) targeting class of oral medications for MS.

The talk, given by Jessica L. Stulc, MD, MPH, the director of the Multiple Sclerosis Treatment and Research Center at the Minneapolis Clinic of Neurology, discussed the mechanisms of action for the new entries in the S1P class, ozanimod (Zeposia; BMS) and ponesimod (Ponvory; Janssen). These drugs were approved in March 2020 and March 2021, respectively.

“These are G protein couple receptors that work as a signaling molecule. Primarily, for MS, the function we’re aware of is that it keeps the lymphocytes in the lymph nodes—you have to have signaling to allow egress of the lymphocytes out into the peripheral tissues,” Stulc said.

She noted drug sequencing, timing and mechanisms of action should all be taken into consideration is providers choose to recommend these medications.

, experts discussed considerations for the use of fumarates among patients with relapsing MS.

Fumarates as a class were first introduced in the United States around 2011 and 2012, explained Ravi Dukkipati, MD. “Initially there was dimethyl fumarate, and then there was a newer iteration of dimethyl fumarate, diroximel fumarate. These have established themselves quite well, in the United States and internationally, as a viable oral option for patients with relapsing remitting MS,” he said.

Here are some of the latest developments in multiple sclerosis (MS) from our sister publication, NeurologyLive®.