Prior Authorization Research Articles

Identifying Implementation Determinants and Strategies for Long-Acting Injectable Cabotegravir-Rilpivirine in People With HIV Who Are Virally Unsuppressed.

Early evidence suggests long-acting injectable cabotegravir and rilpivirine (LA-CAB/RPV) may be beneficial for people with HIV (PWH) who are unable to attain viral suppression (VS) on oral therapy. Limited guidance exists on implementation strategies for this population. Ward 86, a clinic serving publicly insured PWH in San Francisco. We describe multilevel determinants of and strategies for LA-CAB/RPV implementation for PWH without VS, using the Consolidated Framework for Implementation Research. To assess patient and provider-level determinants, we drew on pre-implementation qualitative data. To assess inner and outer context determinants, we undertook a structured mapping process. Key patient-level determinants included perceived ability to adhere to injections despite oral adherence difficulties and care engagement challenges posed by unmet subsistence needs; strategies to address these determinants included a direct-to-inject approach, small financial incentives, and designated drop-in days. Provider-level determinants included lack of time to obtain LA-CAB/RPV, assess injection response, and follow-up late injections; strategies included centralizing eligibility review with the clinic pharmacist, a pharmacy technician to handle procurement and monitoring, regular multidisciplinary review of patients, and development of a clinic protocol. Ward 86 did not experience many outer context barriers because of rapid and unconstrained inclusion of LA-CAB/RPV on local formularies and ability of its affiliated hospital pharmacy to stock the medication. Multilevel strategies to support LA-CAB/RPV implementation for PWH without VS are required, which may necessitate additional resources in some settings to implement safely and effectively. Advocacy to eliminate outer-context barriers, including prior authorizations and specialty pharmacy restrictions, is needed.

SUD records and the machinery of care denial in the new era of relaxed privacy rights

As noted by this recent opinion piece published by The New York Times, “Denying Your Health Care Is Big Business in America,” the process of prior authorization has been around for decades, but has only recently been weaponized by insurers to maximize profits and reduce the provision of health care services. The piece documents people going blind, becoming paralyzed or dying when necessary health care procedures are denied. Around 80% of the time, patients simply give up. Medical care offices have hired huge staffs to battle prior authorization denials. One of the focuses of the piece is on efforts to make prior authorization for medical care by for‐profit companies illegal. It is stalled in Congress.

Abstract 5167: Barriers to tumor mutational burden (TMB) testing in oncology care - U.S. Physician Survey

Abstract Background: Genomic technologies have become increasingly available in oncology; however, barriers remain in terms of TMB use. This study aimed to identify barriers to physicians’ adoption/use of TMB testing. Methods: A cross-sectional online survey was conducted with a representative sample of U.S. general medical, surgical, and/or gynecologic oncologists, including both users and non-users of TMB testing. Physician demographics, practice characteristics, barriers (reimbursement, knowledge, logistics), and approaches to alleviate barriers were collected. Quotas were put in place to ensure a distribution of diverse physician characteristics such as academic affiliations, geography, TMB use, etc. Descriptive analysis was conducted via SASv9.4. Results: Three hundred physicians participated (47.6 mean years of age and 15.2 mean years in clinical practice on average; 50% medical oncologists, 31% surgical oncologists, and 19% gynecologic oncologists). Ninety percent of respondents reported using TMB testing. The most common barrier to TMB testing use was test turnaround time (All: 74.3%; TMB users: 72.3%; non-TMB users: 93.1%). Other commonly reported barriers included unawareness of corresponding therapy and/or clinical trials that may benefit a patient with mutation (All: 68.3%; users: 66.1%; non-users: 89.7%), obtaining prior authorizations (All: 65.7%; users: 62.7%; non-users: 93.1%), and difficulty obtaining a biopsy for testing (All: 57.3%; users: 57.6%, non-users: 55.2%). Increased coverage of TMB testing, access to educational content, and the establishment of minimally acceptable technical standards were reported as key approaches to increasing adoption/use of TMB testing. Conclusions: These results suggest that challenges around reimbursement, knowledge, and logistics are key barriers to use of TMB testing for physicians and provide insights for solutions to alleviate the barriers to TMB testing in oncology. Table 1. Barriers to TMB Test Adoption Reported by Physicians, % AllN=300 TMB userN=271 Non TMB userN=29 p-value Reimbursement Obtain prior authorizations 65.7 62.7 93.1 0.003 TMB not covered by insurance 53.7 53.5 55.2 >0.99 Coverage policy refers to TMB as “experimental”/”unproven” 52.7 51.7 62.1 0.26 Insurance policy restricts genomic tests to particular lab/test provider 51.3 50.6 58.6 0.79 Knowledge/awareness Unaware of therapy/clinical trials that may benefit a patient with mutation 68.3 66.1 89.7 0.03 Unaware of approved indications for TMB 51.3 51.3 51.7 >0.99 Lack of training on TMB 48.7 47.2 62.1 0.28 Logistics Test turnaround time 74.3 72.3 93.1 0.02 Difficulty obtaining biopsy 57.3 57.6 55.2 0.87 Inaccessibility to personnel/lab 49.0 48.3 55.2 0.84 Citation Format: Gieira Jones, Elizabeth Szamreta, Bianca Jackson, Ning Ning, Jennifer Stephens, Arif Hussain. Barriers to tumor mutational burden (TMB) testing in oncology care - U.S. Physician Survey [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5167.

Prior Authorization Leads to Administrative Burden and Delays in Treatment in Primary Total Joint Arthroplasty Patients

BackgroundThe prior authorization (PA) process is often criticized by physicians due to increased administrative burden and unnecessary delays in treatment. The effects of PA policies on total hip arthroplasty (THA) and total knee arthroplasty (TKA) have not been well described. The purpose of this study was to analyze the use of PA in a high-volume orthopaedic practice across 4 states. MethodsWe prospectively collected data on 28,725 primary THAs and TKAs performed at our institution between 2020 and 2023. Data collected included patient demographics, payer approval or denial, time to approval or denial, the number of initial denials, the number of peer-to-peer (P2P) or addenda, and the reasons for denial. ResultsSeven thousand five hundred twenty eight (56.4%) patients undergoing THA and 8,283 (54%) patients undergoing TKA required PA, with a mean time to approval of 26.3 ± 34.6 and 33.7 ± 41.5 days, respectively. Addenda were requested in 608 of 7,528 (4.6%) THA patients and 737 of 8,283 (8.9%) TKA patients. From a total of 312 (4.1%) THA patients who had an initial denial, a P2P was requested for 50 (0.7%) patients, and only 27 (0.4%) were upheld after the PA process. From a total of 509 (6.1%) TKA patients who had an initial denial, a P2P was requested for 55 (0.7%) patients, and only 26 (0.3%) were upheld after the PA process. The mean time to denial in the THA group was 64.7 ± 83.5, and the most common reasons for denial were poor clinical documentation (25.9%) and lack of coverage (25.9%). The mean time to denial in the TKA group was 63.4 ± 103.9 days, and the most common reason for denial was not specified by the payer (46.1%). ConclusionsThe use of PA to approve elective THA and TKA led to increased surgical waiting times and a high administrative burden for surgeons and healthcare staff.

Pharmacotherapeutic Considerations in the Treatment of Nontuberculous Mycobacterial Infections: A Primer for Clinicians.

Nontuberculous mycobacteria (NTM) can cause a variety of infections, including serious pulmonary disease. Treatment encompasses polypharmacy, with a targeted regimen of 2-5 active medications, depending on site of infection, species, and clinical characteristics. Medications may include oral, intravenous, and inhalational routes. Medication acquisition can be challenging for numerous reasons, including investigational status, limited distribution models, and insurance prior authorization. Additionally, monitoring and managing adverse reactions and drug interactions is a unique skill set. While NTM is primarily medically managed, clinicians may not be familiar with the intricacies of medication selection, procurement, and monitoring. This review offers insights into the pharmacotherapeutic considerations of this highly complex disease state, including regimen design, medication acquisition, safety monitoring, relevant drug-drug interactions, and adverse drug reactions.

Adapting prescribing criteria for amyloid-targeted antibodies for adults with Down syndrome.

Prior authorization criteria for Federal Drug Administration (FDA) approved immunotherapeutics, among the class of anti-amyloid monoclonal antibodies (mAbs), established by state drug formulary committees, are tailored for adults with late-onset Alzheimer's disease. This overlooks adults with Down syndrome (DS), who often experience dementia at a younger age and with different diagnostic assessment outcomes. This exclusion may deny DS adults access to potential disease-modifying treatments. To address this issue, an international expert panel convened to establish adaptations of prescribing criteria suitable for DS patients and parameters for access to Centers for Medicare & Medicaid Services (CMS) registries. The panel proposed mitigating disparities by modifying CMS and payer criteria to account for younger onset age, using alternative language and assessment instruments validated for cognitive decline in the DS population. The panel also recommended enhancing prescribing clinicians' diagnostic capabilities for DS and initiated awareness-raising activities within healthcare organizations. These efforts facilitated discussions with federal officials, aimed at achieving equity in access to anti-amyloid immunotherapeutics, with implications for national authorities worldwide evaluating these and other new disease-modifying therapeutics for Alzheimer's disease.

Prior Authorization and Association With Delayed or Discontinued Prescription Fills.

Prior authorization requirements are increasing but little is known about their effects on access to care. We examined the association of a new prior authorization policy with delayed or discontinued prescription fills for oral anticancer drugs among Medicare Part D beneficiaries. Using Medicare part D claims data from 2010 to 2020, we studied beneficiaries regularly filling one of 11 oral anticancer drugs, defined as three 30-day fills in 120 days preceding the plan's prior authorization policy change on that drug and continuously enrolled in the same plan for 120 days before and after the policy change at the start of a new year. The control group consisted of beneficiaries meeting the same utilization criteria, but who were enrolled in plans at the same time that did not implement a prior authorization policy change. The outcomes of interest were discontinuation of the drug within 120 days (analyzed with regression analyses) and time (in days) to next fill after a prior authorization policy change (analyzed using a quasi-experimental difference-in-differences event study). The introduction of a new prior authorization on an established drug increased the odds of discontinuation within 120 days (adjusted odds ratio, 7.1 [95% CI, 6.0 to 8.5]; P < .001) and increased time to next fill by 9.7 days (95% CI, 8.2 to 11.2; P < .001), relative to patients whose plans did not have a prior authorization policy change. Introduction of a new prior authorization policy on an established drug regimen is associated with increased probability of discontinued and delayed care. For some conditions, this may represent a clinically consequential barrier to access. Waiving prior authorization for patients already established on a drug may improve adherence.

Harnessing RNA Interference for Cholesterol Lowering: The Bench-to-Bedside Story ofInclisiran.

Lowering low-density lipoprotein cholesterol (LDL-C) is a cornerstone of reducing risk for atherosclerotic cardiovascular disease. Despite the approval of nonstatin therapies for LDL-C lowering over the past 2 decades, these medications are underused, and most patients are still not at guideline-recommended LDL-C goals. Barriers include poor adherence, clinical inertia, concern for side effects, cost, and complex prior authorization processes. With atherosclerotic cardiovascular disease-related mortality increasing globally, there remains a need for additional therapeutic options for lowering LDL-C as part of an atherosclerotic cardiovascular disease prevention strategy. Following the identification of PCSK9 (proprotein convertase subtilisin/kexin type 9) as a promising therapeutic target, inclisiran was developed using the natural process of RNA interference for robust, sustained prevention of hepatic PCSK9 synthesis. Twice-yearly maintenance subcutaneous inclisiran (following initial loading doses at Day 1 and Day 90) reduces circulating LDL-C levels by ≈50% versus placebo when added to maximally tolerated statins. Long-term safety and tolerability of inclisiran have been assessed, with studies underway to evaluate the effects of inclisiran on cardiovascular outcomes and to provide additional safety and effectiveness data. In 2021, <20 years after the discovery of PCSK9, inclisiran became the first RNA interference therapeutic approved in the United States for LDL-C lowering in patients with established atherosclerotic cardiovascular disease or familial hypercholesterolemia and has since been approved for use in patients with primary hyperlipidemia. This article reviews the journey of inclisiran from bench to bedside, including early development, the clinical trial program, key characteristics of inclisiran, and practical points for its use in the clinic.

The extent and growth of prior authorization in Medicare Advantage.

To assess trends in the use of prior authorization requirements among Medicare Advantage (MA)plans. Descriptive quantitative analysis. Data were from the CMS MA benefit and enrollment files for 2009-2019, supplemented with area-level data on demographic and provider market characteristics. For each service category, we calculated the annual share of MA enrollees in plans requiring at least some prior authorization and plotted trends over time. We mapped the county-level share of MA enrollees exposed to prior authorization in 2009 vs 2019. We quantified the association between local share of MA enrollees exposed to prior authorization and characteristics of that county in the same year. Finally, we plotted the share of MA enrollees exposed to prior authorization requirements over time for the 6 largest MA carriers. From 2009 to 2019, the share of MA enrollees in plans requiring prior authorization for any service remained stable. By service category, the share of MA enrollees exposed to prior authorization ranged from 30.7% (physician specialist services) to 72.2% (durable medical equipment) in 2019, with most service categories requiring prior authorization more often over time. Several area-level demographic and provider market characteristics were associated with prior authorization requirements, but these associations weakened over time. The use of prior authorization varied widely across plans. In 2019, roughly 3 in 4 MA enrollees were in a plan requiring prior authorization. Service-level, area-level, and carrier-level patterns suggest a wide range of approaches to prior authorization requirements.

Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage

ObjectiveTo measure and compare the scope of US insurers’ policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences...

Overactive Bladder Medication Access.

The price range, insurance coverage, and side effect burden of overactive bladder medications is broad and varied. An internal quality improvement project was undertaken to improve patient ability to access and ultimately adhere to preferred medication therapy for treatment of overactive bladder. Our objective was to increase the percentage of patients per month at an academic Urogynecology practice who receive their preferred overactive bladder medication from baseline 39.5% to 45%. Data were extracted via Epic report. Manual chart review and calls to patients and/or pharmacy were completed to obtain status of medication access and reasons why medications were not taken. A targeted intervention was implemented with creation of a written document to help guide patients with options to decrease prescription costs. After this document was embedded into Epic after visit summary documentation, a repeat analysis was performed. The most common barrier to medication access was cost; specifically, the medication was not covered and a prior authorization was not initiated. Before the intervention, more than 60% of patients did not persist with their initially prescribed overactive bladder medication at a 6-month follow-up interval from office visit. Following implementation of a cost-navigation guide, persistence increased to 45.5% at a 3-month follow-up interval. A targeted intervention on cost navigation of prescriptions can have a positive effect on patient access and persistence of using overactive bladder medications. Our practice continues to use our prescription navigation handout.

Atmospheric effects on the propagation of sonic booms utilizing ray tracing methods

The aviation industry’s push towards a return of supersonic flight has some hurdles in the United States due to the regulation restricting overland supersonic use of civil aircraft without prior authorization. This regulation was put in place in response to the public's concerns over property damage from the boom front as well as the audible nuisance complaints in the path of the boom carpet. The physical behavior of the boom is understood well enough that NASA is in the testing stage of the X-59 QueSST to test the feasibility of overland flight. The boom characteristics are affected by the temperature, direction, and wind speed of the atmosphere as the signature propagates through the atmosphere. Our research plan is to implement atmospheric profiles from NCAR CFSv2 into a ray tracing Python code in order to model the behavior of the boom front in urban areas through different atmospheres. Several atmospheric conditions will be modeled and the resulting signatures around large structures will be compared.

Medicare Part D Plans Greatly Increased Utilization Restrictions On Prescription Drugs, 2011-20.

Drug utilization management tools can be employed to ensure that medicines are prescribed cost-effectively, but they can also be implemented in ways that reduce adherence and harm patient health. We examined trends in the prevalence of utilization restrictions on non-protected-class compounds in Medicare Part D plans during the period 2011-20, including prior authorization and step therapy requirements as well as formulary exclusions. Part D plans became significantly more restrictive over time, rising from an average of 31.9percent of compounds restricted in 2011 to 44.4percent restricted in 2020. The prevalence of formulary exclusions grew particularly fast: By 2020, plan formularies excluded an average of 44.7percent of brand-name-only compounds. Formulary restrictions were more common among brand-name-only compared with generic-available compounds, among more expensive compounds, and in stand-alone compared with Medicare Advantage prescription drug plans.

Differences in Home Health Services and Outcomes Between Traditional Medicare and Medicare Advantage

Private Medicare Advantage (MA) plans recently surpassed traditional Medicare (TM) in enrollment. However, MA plans are facing scrutiny for burdensome prior authorization and potential rationing of care, including home health. MA beneficiaries are less likely to receive home health, but recent evidence on differences in service intensity and outcomes among home health patients is lacking. To examine differences in home health service intensity and patient outcomes between MA and TM. This cross-sectional study was conducted from January 2019 to December 2022 in 102 home health locations in 19 states and included 178 195 TM and 107 102 MA patients 65 years or older with 2 or fewer 60-day home health episodes. It included a secondary analysis of standardized assessment and visit data. Inverse probability of treatment weighting regression compared service intensity and patient outcomes between MA and TM episodes, accounting for differences in demographic characteristics, medical complexity, functional and cognitive impairments, social environment, caregiver support, and local community factors. Models included office location, year, and reimbursement policy fixed effects. Data were analyzed between September 2023 and July 2024. TM vs MA plan. Home health length of stay and number of visits from nursing, physical, occupational, and speech therapy, social work, and home health aides. Patient outcomes included improvement in self-care and mobility function, discharge to the community, and transfer to an inpatient facility during home health. Of 285 297 total patients, 180 283 (63.2%) were female; 586 (0.2%) were American Indian/Alaska Native, 8957 (3.1%) Asian, 28 694 (10.1%) Black, 7406 (2.6%) Hispanic, 1959 (0.7%) Native Hawaiian/Pacific Islander, 237 017 (83.1%) non-Hispanic White, and 678 (0.2%) multiracial individuals. MA patients had shorter home health length of stay by 1.62 days (95% CI, -1.82 to 1.42) and received fewer visits from all disciplines except social work. There were no differences in inpatient transfers. MA patients had 3% and 4% lower adjusted odds of improving in mobility and self-care, respectively (mobility odds ratio [OR], 0.97; 95% CI, 0.94-0.99; self-care OR, 0.96; 95% CI, 0.92-0.99). MA patients were 5% more likely to discharge to the community compared with TM (OR, 1.05; 95% CI, 1.01-1.08). The results of this cross-sectional study suggest that MA patients receive shorter and less intensive home health care vs TM patients with similar needs. Differences may be due to the administrative burden and cost-limiting incentives of MA plans. MA patients experienced slightly worse functional outcomes but were more likely to discharge to the community, which may have negative implications for MA patients, including reduced functional independence or increased caregiver burden.

National institute of hygiene, epidemiology and microbiology Adolescent violence exposure survey

A survey was prepared based on an instrument designed and validated for the study of exposure to violence in adolescents with the objective of exploring the variables of physical, psychological, sexual and neglect/abandonment violence in home, school and community settings., cyber violence is included. The survey will be completed anonymously by adolescents from Basic Secondary Education, Pre-University, Technical and Professional Education and Special Conduct Schools Categories 1 and 2 with prior authorization from parents and/or guardians.

White Paper: American Gastroenterological Association Position Statement: The Future of IBD Care in the United States–Removing Barriers and Embracing Opportunities

Despite incredible growth in systems of care and rapidly expanding therapeutic options for people with inflammatory bowel disease, there are significant barriers that prevent patients from benefiting from these advances. These barriers include restrictions in the form of prior authorization, step therapy, and prescription drug coverage. Furthermore, inadequate use of multidisciplinary care and inflammatory bowel disease specialists limits patient access to high-quality care, particularly for medically vulnerable populations. However, there are opportunities to improve access to high-quality, patient-centered care. This position statement outlines the policy and advocacy goals that the American Gastroenterological Association will prioritize for collaborative efforts with patients, providers, and payors.

A Comparison of Amyloid Deposition in Endoscopic and Open Carpal Tunnel Release

Previous investigations assessing the incidence of amyloidosis detected with biopsy during carpal tunnel release (CTR) have focused on open CTR (OCTR). Prior authors have suggested that biopsy may be more technically challenging during endoscopic carpal tunnel release (ECTR). Our purpose was to compare differences in the incidence of amyloid deposition detected during ECTR versus OCTR. We reviewed all primary ECTR and OCTR during which a biopsy for amyloid was obtained between February 2022 and June 2023. All procedures were performed by five upper-extremity surgeons from a single institution. Congo red staining was used to determine the presence of amyloid deposition in either the transverse carpal ligament (TCL) or tenosynovium. All positive cases underwent subtype analysis and protein identification through liquid chromatography-tandem mass spectrometry. Baseline demographics were recorded for each case, and the incidence of positive biopsy was compared between ECTR and OCTR cases. A total of 282 cases were included for analysis (143 ECTR and 139 OCTR). The mean age was 67 years, and 45% of cases were women. Baseline demographics were similar except for a significantly higher incidence of diabetes in OCTR cases (13% vs 33%). Overall, 13% of CTR cases had a positive biopsy. There was a statistically significant difference in the incidence of amyloid deposition detected during biopsy in ECTR cases (3.5%) compared with OCTR cases (23%). Biopsy performed during ECTR may result in a lower incidence of amyloid detection. Future basic science investigation may be necessary to determine histologic differences between tenosynovium proximal and distal to the leading edge of the TCL. When surgeons plan a biopsy during surgical release of the carpal tunnel, an open approach may be advantageous. Prognostic II.

Prior authorization for FDA-approved PARP inhibitors in ovarian cancer

ObjectivesPARP inhibitors (PARP-I) improve survival in ovarian cancer, especially in patients with germline or somatic BRCA mutations or other homologous recombination deficiency (HRD). With high efficacy and costs, insurers may enact barriers or facilitators to PARP-I. Our objective was to examine the prevalence of prior authorization for PARP-I in ovarian cancer. MethodsWe performed a retrospective cross-sectional study of patients with ovarian cancer prescribed a PARP-I within the University of Pennsylvania practices from December 2018 through May 2021. We assessed prevalence of prior authorization for PARP-I overall, by frontline or recurrent maintenance, and by genetic status. We then assessed approval and appeal rates and time to PARP-I start. ResultsOf 180 patients with a PARP-I prescription and information regarding prior authorization, 116 (64 %, 95 % CI 57–71) experienced prior authorization. Of patients in the frontline setting, 60 of 90 (67 %, 95 % CI 56–76) experienced prior authorization. Of patients prescribed PARP-I in recurrence, 55 of 85 (65 %, 95 % CI 54–74) experienced prior authorization. Having a germline or somatic genetic mutation was associated with higher risk of prior authorization (adjusted risk ratio 1.35, 95 %CI 1.09–1.67). 102 patients (89 %, 95 % CI 83–94) required one appeal, 8 required two appeals and 5 cases required 3 appeals. Five patients were denied. Mean time from PARP-I prescription to PARP-I start was 10 days longer for patients who experienced prior authorization. Conclusions64% of patients experienced prior authorization for PARP-I. Risk of prior authorization was increased for patients with BRCA, despite greater clinical benefit. Prior authorization contributes to delays in care, and reform is needed.

CG-MS, Radical Scavenging, Acetylcholinesterase Inhibition, Antifungal and Molecular Docking Studies of Essential Oil from the Leaves of Tapirira guianensis Aubl

The species Tapirira guianensis Aubl is used in folk medicine to treat leprosy, diarrhea, and syphilis. The present study aims to evaluate the chemical composition and the antioxidant, anticholinesterase, and antifungal potential of the essential oil from T. guianensis leaves. The plant material was collected at Arco Estadual do Cocó, with prior authorization from the Municipal Environment Department. The essential oil was extracted through the hydrodistillation process with a Clevenger-type apparatus, and the constituents were evaluated through Gas Chromatography coupled to Mass Spectrometry (GC-MS). The antioxidant potential was assessed through free radicals: DPPH (2,2-diphenyl-1-picrylhydrazyl) and ABTS+ (2,2-azinobis(3-ethylbenzothiazoline-6-sulfonic acid)) in a 96-well plate. Antifungal activity was evaluated using the Clinical Laboratory Standards Institute - M38-A protocol (CLSI, 2018). Gas chromatography coupled with mass spectrometry revealed the presence of constituents such as eugenol (59.00%), α-copaene (0.40%), β-caryophyllene (29.91%), α-humulene in T. guianensis. The essential oil demonstrated very promising antioxidant and anticholinesterase potential in In vitro studies. Molecular docking regarding acetylcholinesterase enzyme inhibition revealed that α-copaene has superior action compared to the drug physostigmine. The results of molecular docking for Candida albicans showed that α-copaene and α-humulene interacted in the same binding region as the PepA inhibitor against SAP5. This indicates their action is similar to the aspartic protease inhibitor, in addition to the possibility of a synergistic effect with the drug fluconazole. This is the first study of the biological potential of the essential oil from T. guianensis leaves, thus revealing its high potential for future studies in the scientific community. Therefore, we can infer that the essential oil of T. guianensis is a source of antioxidant, anticholinesterase, and antifungal constituents, with promising therapeutic potential in the management of Alzheimer's disease and Candida infections.

Association of Economic Policies With Hypertension Management and Control

Economic policies have the potential to impact management and control of hypertension. To review the evidence on the association between economic policies and hypertension management and control among adults with hypertension in the US. A search was carried out of PubMed/MEDLINE, Cochrane Library, Embase, PsycINFO, CINAHL, EconLit, Sociological Abstracts, and Scopus from January 1, 2000, through November 1, 2023. Included were randomized clinical trials, difference-in-differences, and interrupted time series studies that evaluated the association of economic policies with hypertension management. Economic policies were grouped into 3 categories: insurance coverage expansion such as Medicaid expansion, cost sharing in health care such as increased drug copayments, and financial incentives for quality such as pay-for-performance. Antihypertensive treatment was measured as taking antihypertensive medications or medication adherence among those who have a hypertension diagnosis; and hypertension control, measured as blood pressure (BP) lower than 140/90 mm Hg or a reduction in BP. Evidence was extracted and synthesized through dual review of titles, abstracts, full-text articles, study quality, and policy effects. In total, 31 articles were included. None of the studies examined economic policies outside of the health care system. Of these, 16 (52%) assessed policies for insurance coverage expansion, 8 (26%) evaluated policies related to patient cost sharing for prescription drugs, and 7 (22%) evaluated financial incentive programs for improving health care quality. Of the 16 studies that evaluated coverage expansion policies, all but 1 found that policies such as Medicare Part D and Medicaid expansion were associated with significant improvement in antihypertensive treatment and BP control. Among the 8 studies that examined patient cost sharing, 4 found that measures such as prior authorization and increased copayments were associated with decreased adherence to antihypertensive medication. Finally, all 7 studies evaluating financial incentives aimed at improving quality found that they were associated with improved antihypertensive treatment and BP control. Overall, most studies had a moderate or low risk of bias in their policy evaluation. The findings of this systematic review suggest that economic policies aimed at expanding insurance coverage or improving health care quality successfully improved medication use and BP control among US adults with hypertension. Future research is needed to investigate the potential effects of non-health care economic policies on hypertension control.