Providers' Use of Pharmacogenetic Testing to Inform Antidepressant Prescribing: Results of Qualitative Interviews.

OBJECTIVE: Pharmacogenetic testing (PGx) for patients experiencing depression has been associated with modest improvements in symptoms. However, little is known about providers' use of PGx, including how and for whom providers use the test results in clinical decision making. In this article, results from qualitative interviews on the experience of providers participating in a pragmatic trial of PGx are described; implications of the providers' experiences are highlighted to inform future implementation of PGx. METHODS: Interviews were conducted with providers participating in the trial (N=61) who treated veterans who had depression. Questions were informed by the Consolidated Framework for Implementation Research. A rapid analytic approach was used. RESULTS: Two main themes were identified: perceptions regarding which patients would likely benefit from PGx and approaches to using the test results in prescribing. Providers generally expressed positive experiences with using PGx results. However, the providers varied in application of the test results to clinical decision making regarding medications, were uncertain about how much to rely on the results, and differed in perceptions about which patients would benefit from PGx. CONCLUSIONS: To support future implementation, policies and procedures are needed, as well as mechanisms to support ongoing provider education on PGx.

Absent loading response knee flexion: The impact on gait kinetics and centre of mass motion in individuals with unilateral transfemoral amputation, and the effect of microprocessor controlled knee provision.

BACKGROUND: Individuals with unilateral transfemoral amputation walk with increased levels of asymmetry, and this is associated with reduced gait efficiency, back pain and overuse of the intact limb. This study investigated the effect of walking with a unilateral absence of loading response knee flexion on the symmetry of anterior-posterior kinetics and centre of mass accelerations. METHODS: A retrospective cohort study design was used, assessing three-dimensional gait data from individuals with unilateral transfemoral amputation (n = 56). The anterior-posterior gait variables analysed included; peak ground reaction forces, impulse, centre of mass acceleration, as well as rate of vertical ground reaction force increase in early stance. With respect to these variables, this study assessed the symmetry between intact and prosthetic limbs, compared intact limbs against a healthy unimpaired control group, and evaluated effect on symmetry of microprocessor controlled knee provision. FINDINGS: Significant between-limb asymmetries were found between intact and prosthetic limbs across all variables (p < 0.0001). Intact limbs showed excessive loading when compared with control group limbs after speed normalisation across all variables (p < 0.0001). No improvement in kinetic symmetry following microprocessor controlled knee provision was found. INTERPRETATION: The gait asymmetries for individuals with transfemoral amputation identified in this study suggest that more should be done by developers to address the resultant overloading of the intact limb, as this is thought to have negative long-term effects. The provision of microprocessor controlled knees did not appear to improve the asymmetries faced by individuals with transfemoral amputation, and clinicians should be aware of this when managing patient expectations.

Coping Strategies and Workplace Supports for Peers with Substance Use Disorders.

Introduction: Substance use disorder (SUD) peers provide support and navigation through a fragmented treatment system for people who use drugs (PWUD) and those in recovery. While barriers to peers' work are well established, from role ambiguity to stigma surrounding substance use, little research has focused on factors that facilitate peers' work. Methods: We conducted in-depth semi-structured interviews (N=20) with peers as part of an evaluation of a larger project related to the opioid crisis in Western New York. Participants were recruited from a regional peer network via flyers, emails, and a brief presentation. Interviews were conducted in person or by phone, audio recorded, and transcribed. Transcripts were analyzed using thematic content analysis. Results: Peers emphasized two factors: healthy personal coping strategies and strong workplace supports. Coping strategies included a sense of community, setting appropriate boundaries, and self-care routines. At the workplace, peers valued mental and emotional support, as well as professional relationships and organizational policies that made their work easier and supported self-care. For a few peers, professional relationships included advocating on behalf of PWUD by sharing personal experiences of SUD. Conclusions: Peers valued peer colleagues and peer-led organizations, noting how shared experiences of substance use and recovery enabled a unique support system. For peers who lack such support at work, the authors suggest peer networks as an alternative. We also recommend organizational policies and practices to facilitate peers' work, such as promoting peer input and feedback, but further research is needed to measure effects on peer retention and job satisfaction.

"I just wanna be another person at school": Disclosing veteran identity on campus and effects on campus engagement.

Objective: To describe how veterans feel about disclosing their military status on campus and impacts on engagement with social and health-related services. Participants: Thirty-one university student veterans who participated in a student veterans' health study. Participants self-identified as White and male (90%) with an average age of 29.5 years and 6.7 years of military service. Methods: Qualitative interviews explored veterans' perceptions of belonging on campus and the impact of veteran identity on educational experiences. Data analysis used an inductive, content-based approach. Results: Themes included: (1) varied feelings around disclosing military service history, with many preferring not to disclose; (2) visibility of resources on campus; and (3) use of resources on campus for social engagement, mental, and physical health. Conclusions: Findings illustrate student veterans' complex experiences, and how feelings about disclosing veteran identity on campus relate to resource use. Campuses should acknowledge and explore this complexity with student veterans' input to ensure that supports meet their needs.

Microcystin-LR Removal from Water via Enzymatic Linearization and Ultrafiltration.

Microcystin-LR (MC-LR) is a toxin produced by cyanobacteria that can bloom in freshwater supplies. This study describes a new strategy for remediation of MC-LR that combines linearization of the toxin using microcystinase A, MlrA, enzyme with rejection of linearized byproducts using membrane filtration. The MlrA enzyme was expressed in Escherichia coli (E. coli) and purified via a His-tag with 95% purity. Additionally, composite membranes made of 95% polysulfone and 5% sulfonated polyether ether ketone (SPEEK) were fabricated and used to filter a solution containing cyclic and linearized MC-LR. Tests were also performed to measure the adsorption and desorption of MC-LR on polysulfone/SPEEK membranes. Liquid chromatography-mass spectrometry (LC-MS) was used to characterize the progress of linearization and removal of MC-LR. Results indicate that the MlrA was successful at linearizing MC-LR. Membrane filtration tests showed rejection of 97% of cyclic MC-LR and virtually all linearized MC-LR, with adsorption to the membranes being the main rejection mechanism. Adsorption/desorption tests indicated that methanol could be used to strip residual MC-LR from membranes to regenerate them. This study demonstrates a novel strategy of remediation of microcystin-tainted water, combining linearization of MC-LR to a low-toxicity byproduct along with removal by membrane filtration.

Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations.

Objectives: Large numbers of older Americans have a history of military service, which may be positively or negatively associated with mental health in late life. We reviewed literature with the aim of better understanding the mental health needs of older Veterans.Methods: Articles included those published in 2009-2018 and focused on prevalence/risk for mental illness and suicide among older Veterans; utilization of mental health services; effectiveness of evidence-based behavioral treatments; and pertinent care delivery models.Results: Older Veterans are generally resilient. A significant minority experience mental health concerns that are associated with poor outcomes including a substantial number of suicides. Most published research is based on the approximately one third of Veterans who use the Veterans Health Administration (VHA) for care. Older Veterans with mental health diagnoses are less likely to utilize mental health services compared to younger Veterans, but as likely to benefit once engaged. Integrated care models in primary and geriatric care settings are promising.Conclusions: Aging Veterans are a large subset of Americans whose mental health needs are complex and deserve attention.Clinical Implications: Clinicians should ask about history of military service (i.e., Veteran status) and utilize available resources when providing care for older Veterans.

Diversity Initiatives and White Americans' Perceptions of Racial Victimhood.

Seven experiments explore whether organizational diversity initiatives heighten White Americans' concerns about the respect and value afforded toward their racial group and increase their perceptions of anti-White bias. The presence (vs. absence) of organizational diversity initiatives (i.e., diversity awards, diversity training, diversity mission statements) caused White Americans to perceive Whites as less respected and valued than Blacks and to blame a White man's rejection for a promotion on anti-White bias. Several moderators were tested, including evidence that Whites were clearly advantaged within the organization, that the rejected White candidate was less meritorious than the Black candidate, that promotion opportunities were abundant (vs. scarce), and individual differences related to support for the status hierarchy and identification with Whites. There was little evidence that these moderators reduced Whites' perceptions of diversity initiatives as harmful to their racial group.

Improving Cancer Screening Rates in Primary Care via Practice Facilitation and Academic Detailing: A Multi-PBRN Quality Improvement Project.

PURPOSE: In the United States, cancer screening rates are often below national targets. This project implemented practice facilitation and academic detailing aimed at increasing breast, cervical, and colorectal cancer screening rates in safety-net primary care practices. METHODS: Three practice-based research networks across western and central New York State partnered to provide quality improvement strategies on breast, cervical, and colorectal cancer screening. Pre/postintervention screening rates for all participating practices were collected annually, as were means across all practices over 7 years. Simple ordinary least squares linear regression was used to calculate the trend for each cancer type and test for statistical significance (ie, P≤0.05), using the ordinal time point as a fixed effect. RESULTS: An overall increase in mean screening rates was seen over the duration of this project for colorectal (24.6% preintervention to 48.0% in year 7 of intervention; P<0.001) and breast cancer (37.0% preintervention to 48.6% in year 7; P=0.460). Mean cervical cancer screening rates decreased (35.5% preintervention to 31.4% in year 7; P=0.209). Success in increasing screening rates varied across regions of New York State. CONCLUSIONS: Practice facilitation and academic detailing were successful in significantly increasing, on average, colorectal cancer screening rate. Cervical cancer screening showed an overall decrease, likely due to difficulties for primary care practices in tracking and implementation, as many patients seek this service at outside gynecology facilities. Regional differences, guideline changes, and practice reorganization each may have played a part in observed trends. A standardization of queries being used to pull screening rates is an important step in increasing the reliability of these data.

Increasing Breast, Cervical, and Colorectal Cancer Screenings: A Qualitative Assessment of Barriers and Promoters in Safety-Net Practices.

PURPOSE: Breast, cervical, and colorectal cancer screening rates are suboptimal in underserved populations. A 7-year quality improvement (QI) project implemented academic detailing and practice facilitation in safety-net primary care practices to increase cancer screening rates. This manuscript assesses barriers and promoters. METHODS: Primary care practices providing care to underserved patients were recruited in New York cities Buffalo, Rochester, and Syracuse. Enrollment totaled 31 practices, with 12 practices participating throughout. Annually, each practice received 6 months of practice facilitation support for development and implementation of evidence-based interventions to increase screening rates for the three cancer types. At the end of each practice facilitation period, focus groups and key informant interviews were conducted with participating personnel. Content analysis was performed annually to identify barriers and promoters. A comprehensive final analysis was performed at project end. RESULTS: Barriers included system-level (inconsistent communication with specialists, electronic health record system transitions, ownership changes) and practice-level challenges (staff turnover, inconsistent data entry, QI fatigue) that compound patient-level challenges of transportation, cost, and health literacy. Cyclical barriers like staff turnover returned despite attempts to resolve them, while successful implementation was promoted by reducing patients' structural barriers, adapting interventions to existing practice priorities, and enacting officewide policies. During the QI project, practices became aware of the impact of social determinants of health on patients' screening decisions. CONCLUSIONS: The project's longitudinal design enabled identification of key barriers that reduced accuracy of practices' screening rates and increased risk of patients falling through the cracks. Identified promoters can help sustain interventions to increase screenings.

Impact of COVID-19 on Screening Rates for Colorectal, Breast, and Cervical Cancer: Practice Feedback From a Quality Improvement Project in Primary Care.

PURPOSE: Three New York State practice-based research networks provided quality improvement strategies to improve screening rates for breast, cervical, and colorectal (BCC) cancers in safety-net primary care, over 7 years. In the final year (Y7), the United States experienced the COVID-19 pandemic. The impact of the COVID-19 pandemic on BCC cancer screening rates was assessed qualitatively. METHODS: A total of 12 primary care practices participated in Y7 of the quality improvement project. BCC cancer screening rates at year beginning and end were assessed. Practice staff were asked about how COVID-19 impacted screening. Average pre/postintervention screening rates and qualitative thematic analysis regarding how COVID-19 impacted cancer screening were ascertained. RESULTS: In Y7, there was an increase in breast cancer and a decrease in colorectal and cervical cancer screening rates compared to the previous project year. Many practices were able to continue pre-COVID-19 cancer screening processes. Overall, practices reported loss of staff, changes in data entry, and a shift from preventive screening to care of sick patients. Telehealth was vital for practices to continue serving patients but had a less positive impact on patients with financial/technological disadvantages. BCC cancer screenings were impacted at various levels. CONCLUSIONS: The COVID-19 pandemic negatively impacted primary care practice cancer screening; however, some practices were able to mitigate effects by shifting focus to processes supporting screening outside of in-person office visits.

Minimal clinically important difference in walking velocity, gait profile score and two minute walk test for individuals with lower limb amputation.

BACKGROUND: Individuals with lower limb amputation are routinely assessed with a variety outcome measures, however there is a lack of published data to indicate minimal clinically important differences (MCID) for many of these outcome measures. Three such important gait-specific outcome measures include walking velocity, gait profile score (GPS) and the two minute walk test (2MWT). RESEARCH QUESTION: Determine the MCIDs for walking velocity, GPS and 2MWT for individuals with lower limb amputation. METHODS: Walking velocity and GPS (n = 60), and 2MWT (n = 119) data for individuals with unilateral transfemoral or knee disarticulation were identified retrospectively from a database held at the study centre. An anchor-based method was used with Medicare functional classification level (MFCL) acting as the impairment-related criterion, and a least-squares linear regression approach was used to calculate the gradient required for a change between MFCL levels. RESULTS: An increase of 0.21 m/s (95 % CI: 0.13,0.29) for walking velocity, a reduction of 1.7° (95 % CI: -2.449,-1.097) for GPS and an increase of 37.2 m (95 % CI: 28.8,45.5) for 2MWT were found to correspond to an increase in MFCL of one level. Walking velocity, GPS and 2MWT correlated with MFCL with R2 values of 0.333, 0.322 and 0.398 respectively (p < 0.00001). The authors propose that 0.21 m/s for walking velocity, 1.7° for GPS and 37.2 m for 2MWT be used as MCID values for individuals with lower limb amputation. SIGNIFICANCE: The results of this study can be used to help both researchers and clinicians to objectively evaluate if interventions for individuals with lower limb amputation are effective.

Target 5000: a standardized all-Ireland pathway for the diagnosis and management of inherited retinal degenerations.

INTRODUCTION: Inherited retinal degenerations (IRD) are rare genetic disorders with > 300 known genetic loci, manifesting variably progressive visual dysfunction. IRDs were historically underserved due to lack of effective interventions. Many novel therapies will require accurate diagnosis (phenotype and genotype), thus an efficient and effective pathway for assessment and management is required. METHODS: Using surveys of existing practice patterns and advice from international experts, an all-Ireland IRD service (Target 5000) was designed. Detailed phenotyping was followed by next generation genetic sequencing in both a research and accredited laboratory. Unresolved pedigrees underwent further studies (whole gene/whole exome/whole genome sequencing). Novel variants were interrogated for pathogenicity (cascade screening, in silico analysis, functional studies). A multidisciplinary team (MDT; ophthalmologists, physicians, geneticists, genetic counsellors) reconciled phenotype with genotype. A bespoke care plan was created for each patient comprising supports, existing interventions, and novel therapies/clinical trials. RESULTS AND DISCUSSION: Prior to Target 5000, a significant cohort of patients were not engaged with healthcare/support services due to lack of effective interventions. Pathogenic or likely pathogenic variants in IRD-associated genes were detected in 62.3%, with 11.6% having variants of unknown significance. The genotyping arm of Target 5000 allowed a 42.73% cost saving over independent testing, plus the value of MDT expertise/processing. Partial funding has transferred from charitable sources to government resources. CONCLUSION: Target 5000 demonstrates efficacious and efficient clinical/genetic diagnosis, while discovering novel IRD-implicated genes/variants and investigating mechanisms of disease and avenues of intervention. This model could be used to develop similar IRD programmes in small/medium-sized nations.

Evaluation of gait outcomes for individuals with established unilateral transfemoral amputation following the provision of microprocessor controlled knees in the context of a clinical service.

BACKGROUND: Microprocessor controlled knees (MPKs) have been shown to improve gait outcomes for individuals with unilateral transfemoral amputation (TFA); however, previous studies have limitations, which may affect their applicability. OBJECTIVES: To compare gait outcomes between non-MPK and MPK conditions within a large and diverse cohort of established TFAs in the pragmatic context of an operational clinical service and to identify any demographic variables that correlate with changes in gait outcomes. STUDY DESIGN: This is a retrospective cohort study. METHODS: Full-body three-dimensional motion capture and a portable breath gas analyser were used to evaluate gait-specific outcomes both pre-MPK and 6 months post-MPK provisions in TFAs (n = 32). The primary outcome measure was gait profile score, along with the following secondary outcome measures: walking velocity, step length, step length symmetry ratio, step time symmetry ratio, vertical ground reaction force symmetry index, base of support, center of mass deviation, and oxygen cost of walking. RESULTS: Data showed statistically significant improvement in gait profile score from 11.2° ± 2.2° to 10.1° ± 2.1° (p < 0.01) between non-MPK and MPK conditions. Other outcomes which showed significant improvement were walking velocity (p < 0.01), step length (p < 0.01), vertical ground reaction force symmetry index (p < 0.01), and center of mass deviation (p < 0.05). CONCLUSIONS: MPK provision offered significant gait improvements to this cohort of TFAs in an operational clinical setting. There still remains a large gap in gait outcomes between this cohort and those of healthy unimpaired adults. Improvements in socket design, prosthetic foot design, and physiotherapy intervention could further reduce this gap.

Development of video animations to encourage patient-driven deprescribing: A Team Alice Study.

OBJECTIVE: Patient-driven deprescribing initiatives aim to increase patient knowledge and strengthen self-advocacy skills. This article describes the development of three animated videos designed to educate older adults about unsafe prescribing and medication harm, based on the actionable lessons from the death, by polypharmacy, of an older adult in our community. METHODS: Using a community based participatory research approach (CBPR), members of three senior centers (n = 53) and the Deprescribing Partnership of Western New York (n = 30) were recruited and participated in two rounds of focus groups to guide the video development. RESULTS: Stakeholder input led to changes in content, wording, and visual presentation. The final versions of the videos emphasize the following messages (1) "New medications and what you should know about the risks", (2) "What you should do when a doctor tells you never to take a certain medication", (3) "What you should know about medications when you are in the hospital." CONCLUSION: The study highlights the successful process of using CBPR to develop a series of videos designed to provide information on the risks of polypharmacy, and empower older adults to advocate for themselves. PRACTICE IMPLICATIONS: Animated educational videos are a novel strategy to address medication harm in older adults. This research is a critical first step to increasing patient-led discussions that reduce the incidence of medication harm and inappropriate medication use among older adults.

Variations in Risk and Motivations for Substance Use over the Course of Military Service.

BACKGROUND: Epidemiological data identify risk factors related to substance use among military service members to inform prevention and treatment. Less is known about how motivations and risks for substance use vary over a military service career. The study goal was to explore substance use patterns and motivations among a sample of United States undergraduate student veterans in order to identify periods of risk. Methods: Qualitative interviews were conducted (n = 31) between December 2018 and April 2019. Transcripts were coded in ATLAS.ti using thematic content analysis. Results: Interviews revealed complex motivations around substance use and identified key periods of risk. 1) Pre-service: Participants reported using alcohol and marijuana, primarily during social activities. 2) During service: Participants described a culture of heavy alcohol and tobacco use in social contexts, but little use of other substances. Post-deployment was a notable exception, when some reported heavier alcohol use and use of other drugs, including opiates, cocaine, and ecstasy. 3) Post-service: Transitioning out of the military was described as difficult; some participants reported heavier use of substances during this period. Some participants quit smoking after military service, or switched to vaping. Others reported use of alcohol and/or marijuana to calm themselves, relieve stress, and enable sleep. Conclusions: These data indicate that the periods immediately following deployment and transition out of the military may be especially high-risk for heavy substance use and use of a broader range of substances. This highlights the need for tailored interventions and messaging at different points of military service, particularly during periods of greatest risk.

#NotAllWhites: Liberal-Leaning White Americans Racially Disidentify and Increase Support for Racial Equity.

Donald Trump won the 2016 presidential election largely due to support from White Americans. This win created a new sociopolitical reality in which White Americans as a group became associated with Trump and his anti-egalitarianism. Four studies (N = 3,245) explored how liberal-leaning White Americans negotiate their racial identity to contend with group-image threat arising from the association between their racial ingroup and Trump. Trump-related group-image threat (i.e., White Americans' support for Trump's anti-egalitarianism or his continuation in office) led liberal-leaning White Americans to disidentify from their racial ingroup. In turn, racial disidentification predicted greater signaling of egalitarian beliefs (i.e., expressing intentions to advocate for racial equity and supporting policies designed to benefit racially minoritized groups) and behaviors (i.e., donating money to racial equity-focused organizations). These results suggest that the process of negotiating Trump-related group-image threat has implications for both White Americans' racial identities and ongoing efforts to achieve racial equity.

Primary care and mental health providers' perceptions of implementation of pharmacogenetics testing for depression prescribing.

BACKGROUND: Pharmacogenetic testing (PGx) has the potential to improve the quality of psychiatric prescribing by considering patients' genetic profile. However, there is limited scientific evidence supporting its efficacy or guiding its implementation. The Precision Medicine in Mental Health (PRIME) Care study is a pragmatic randomized controlled trial evaluating the effectiveness of a specific commercially-available pharmacogenetic (PGx) test to inform antidepressant prescribing at 22 sites across the U.S. Simultaneous implementation science methods using the Consolidated Framework for Implementation Research (CFIR) are integrated throughout the trial to identify contextual factors likely to be important in future implementation of PGx. The goal of this study was to understand providers' perceptions of PGx for antidepressant prescribing and implications for future implementation. METHODS: Qualitative focus groups (n = 10) were conducted at the beginning of the trial with Primary Care and Mental Health providers (n = 31) from six PRIME Care sites. Focus groups were audio-recorded and transcribed and data were analyzed using rapid analytic procedures organized by CFIR domains. RESULTS: Analysis revealed themes in the CFIR Intervention Characteristics domain constructs of Evidence, Relative Advantage, Adaptability, Trialability, Complexity, and Design that are important for understanding providers' perceptions of PGx testing. Results indicate: 1) providers had limited experience and knowledge of PGx testing and its evidence base, particularly for psychiatric medications; 2) providers were hopeful that PGx could increase their precision in depression prescribing and improve patient engagement, but were uncertain about how results would influence treatment; 3) providers were concerned about potential misinterpretation of PGx results and how to incorporate testing into their workflow; 4) primary care providers were less familiar and comfortable with application of PGx testing to antidepressant prescribing than psychiatric providers. CONCLUSIONS: Provider perceptions may serve as facilitators or barriers to implementation of PGx for psychiatric prescribing. Incorporating implementation science into the conduct of the RCT adds value by uncovering factors to be addressed in preparing for future implementation, should the practice prove effective. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03170362 ; Registered 31 May 2017.

Opportunities and Recommendations for Improving Medication Safety: Understanding the Medication Management System in Primary Care Through an Abstraction Hierarchy.

BACKGROUND: Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system. OBJECTIVE: This paper aims to refine our understanding of the primary care office in relation to a patient's medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care. METHODS: The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. RESULTS: This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved. CONCLUSIONS: Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.

The Impact of Inherited Retinal Diseases in the Republic of Ireland (ROI) and the United Kingdom (UK) from a Cost-of-Illness Perspective.

To date, there has been a global lack of data regarding the prevalence of conditions falling under the Inherited Retinal Diseases (IRD) classification, the impact on the individuals and families affected, and the cost burden to economies. The absence of an international patient registry, and equitable access to genetic testing, compounds this matter. The resulting incomplete knowledge of the impact of IRDs hinders the development and commissioning of clinical services, provision of treatments, and planning and implementation of clinical trials. Thus, there is a need for stronger evidence to support value for money to regulatory bodies for treatments approved, and progressing through clinical trials. To ensure a strategic approach to future research and service provision, it is necessary to learn more about the IRD landscape. This review highlights two recent cost-of-illness reports on the socio-economic impact of 10 IRDs in the Republic of Ireland (ROI) and the United Kingdom (UK), which demonstrate the comprehensive impact of IRDs on individuals affected, their families, friends and society. Total costs attributable to IRDs in the ROI were estimated to be £42.6 million in 2019, comprising economic (£28.8 million) and wellbeing costs (£13.8 million). Wellbeing costs were estimated using the World Health Organization (WHO) burden of disease methodology, a non-financial approach, where pain, suffering and premature mortality are measured in terms of disability-adjusted-life-years (DALYs). In the UK, wellbeing costs attributable to IRDs were £196.1 million, and economic costs were £327.2 million amounting to £523.3 million total costs in 2019. Accounting for over one-third of total costs, the wellbeing burden of persons affected by IRDs should be emphasized and factored into reimbursement processes for therapies and care pathways. This targeted review presents the most current and relevant data on IRD prevalence in the ROI and the UK, and the impacts (financial and non-financial) of IRDs in terms of diagnosis, wellbeing, employment, formal and informal care, health system costs, deadweight losses and issues surrounding payers and reimbursement. This review demonstrates IRD patients and their families have common issues including, the need for timely equitable access to genetic testing and counselling, equality in accessing employment, and a revision of the assessment process for reimbursement of therapies currently focused on the cost-of-illness to the healthcare system. This review reveals that IRD patients do not frequently engage the healthcare system and as such suggests a cost-of-illness model from a societal perspective may be a better format.