Modernizing clinical practice guidelines for the American Academy of Dermatology.

The American Academy of Dermatology is modernizing its clinical practice guidelines to be more timely and easily interpretable, while decreasing the influence of conflicts of interest in guideline generation. The main changes include the transition from SORT to GRADE methodology and the requirement that nonconflicted members of the guideline work groups remain nonconflicted throughout the entire guidelines process.

An early examination of access to select orphan drugs treating rare diseases in health insurance exchange plans.

BACKGROUND: Patients with rare diseases often face significant health care access challenges, particularly since the number of available treatment options for rare diseases is limited. The implementation of health insurance exchanges promises improved access to health care. However, when purchasing a plan, patients with rare diseases need to consider multiple factors, such as insurance premium, access to providers, coverage of a specific medication or treatment, tier placement of drug, and out-of-pocket costs.  OBJECTIVE: To provide an early snapshot of the exchange plan landscape from the perspective of patients with select rare diseases by evaluating the degree of access to medications in a subset of exchange plans based on coverage, tier placement, associated cost sharing, and utilization management (UM) applied.  METHODS: The selection of drugs for this analysis began by identifying rare diseases with FDA-approved treatment options using the National Institutes of Health Office of Rare Diseases' webpage and further identification of a subset of drugs based on select criteria to ensure a varied sample, including the characteristics and prevalence of the condition. The medications were categorized based on whether alternative therapies have FDA approval for the same indication and whether there are comparators based on class or therapeutic area. The list was narrowed to 11 medications across 7 diseases, and the analysis was based on how these drugs are listed in exchange plan outpatient pharmacy benefit formularies. This analysis focused on 84 plans in 15 states with the highest expected exchange enrollment and included a variety of plan types to ensure that variability in the marketplace was represented. To best approximate plans that will have the greatest enrollment, the analysis focused on silver and bronze plan formularies because consumers in this market are expected to be sensitive to premiums. Data on drug coverage, tier placement, cost, and UM were collected from these plans beginning October 1, 2013, with the launch of the open enrollment period. RESULTS: Coverage and use of UM for selected medications vary within and across states. This study found that bronze plans were far less likely than silver plans to cover the 11 products included in this analysis. Results also showed that select drugs identified as the only FDA-approved product indicated for a certain rare disease experienced relatively robust coverage (at least 65% of plans) but often included some form of UM. However, coverage of selected rare disease therapies also is complicated by the fact that plans cover certain products under the medical benefit versus the pharmacy benefit. At the time of this analysis, transparency of medical benefit coverage for these products in exchange plans was limited.Selected medications are most likely to appear on the highest tiers of 4-tier formularies or are not covered at all. Although there are no requirements to designate certain tiers as "specialty tiers," more than 70% of plans in this study use coinsurance for the highest tiers of their formularies. Rates of coinsurance for medications on highest tiers range from 10% to 50% in silver plans and 15% to 50% in bronze plans. Among those plans utilizing copayments rather than coinsurance, ranges of copayments for these select products vary between $20 and $250 per prescription across both silver plans and bronze plans. CONCLUSIONS: This preliminary analysis of access to treatments for patients with select rare diseases revealed the complexities involved for patients with specific needs when selecting a plan with appropriate coverage. For patients with rare diseases, the process of identifying and selecting a plan centers on understanding if and how the plan covers a specific treatment or set of treatments. Access factors will likely vary substantially across plans, as demonstrated by the findings from this analysis. With limited treatment options and the potential for cost sharing and UM barriers, increased data transparency to assist patients in navigating formularies will be a critical step for patients to fully understand their access to needed therapies in each plan.

Cultural mismatch and the education of Aboriginal youths: the interplay of cultural identities and teacher ratings.

In response to the enduring "deficit" approach to the educational attainment of Aboriginal students in North America, we hypothesized that academic underperformance is related to a cultural mismatch between Aboriginal students' cultural background, which emphasizes connectedness and interdependence, and the mainstream White model of education, which focuses on independence and assertiveness. The participants included virtually all the secondary students (N = 115) in the Naskapi community of Kawawachikamach, Quebec, Canada. We obtained self-reports of identification with Aboriginal and White culture, teacher reports of assertiveness, and official grades. We found that high identification with either Aboriginal or White culture was related to higher grades, regardless of whether the students were perceived as assertive by their teacher. Conversely, at low levels of cultural identification toward Aboriginal or White culture, being perceived as low in assertiveness by one's teacher predicted lower grades. This suggests that both high cultural identification and assertiveness can contribute to enhancing the educational outcomes of Aboriginal students, but that Aboriginal students with low levels of both cultural identification and assertiveness are at particular risk as they are mismatched with the culture of mainstream schools and do not benefit from the protective effects of identity. The relationships among identity, cultural values, and academic performance point to the need to reject the notion of an inherent deficit in education among Aboriginal youths in favor of a different framework in which success can be attained when alternative ways of being are fostered and nurtured in schools.

Reduced ratings of physical and relational aggression for youths with a strong cultural identity: evidence from the Naskapi people.

PURPOSE: Minority youth in general, and Aboriginal youth in particular, are at increased statistical risk for being perpetrators or victims of aggression. METHODS: We examined the potential protective aspect of cultural identity in relation to peer ratings of physical and relational aggression and factors typically associated with each among almost the entire cohort of Naskapi youths from Kawawachikamach, Québec. RESULTS: Hierarchical multiple regressions revealed that a strong identity with their own Native culture predicted less perceived physical and social aggression by their peers. CONCLUSION: These findings are discussed in the context of the role of a positive affiliation with ancestral culture for the diminishment of adolescent aggression and for general adaptive development and well-being.