Limited Reimbursement Research Articles

Improving access to gene therapies: a holistic view of current challenges and future policy solutions in the United States.

Gene therapies hold the promise of delivering groundbreaking improvements in health outcomes for previously intractable diseases.These therapies possess unique characteristics that differ from traditional small molecule or biologic treatments, posing new challenges for healthcare stakeholders. While previous analyses have predominantly focused on the payment challenges associated with emerging gene therapies, a more holistic examination reveals numerous obstacles that currently hinder optimal patient access. In the United States (US), these include production and distribution issues, logistical and treatment administration challenges and coverage and reimbursement limitations imposed by US healthcare payers. Several opportunities exist to address these challenges and improve patient access, including the use of appropriate value assessment methods, the development of innovative payment solutions, the removal of inappropriate access barriers imposed by payers and improving education and awareness regarding treatment availability, benefits and risks. Moving forward, we must collectively strive for comprehensive policy and market solutions that are sensitive to the uniqueness of gene therapies to ensure their full potential is realized and these treatments are made available to those in need.

2023 ESC guidelines for management of cardiomyopathies: short review with implications for the clinical practice in Bulgaria

The 2023 European Society of Cardiology guidelines for the management of cardiomyopathies (CM) provide practical recommendations for diagnosis and treatment. They emphasize on the need for a systematic clinical evaluation beginning with clinical suspicion of CM and using a multiparametric approach that leads to classification of CM into one of five distinct phenotypes. А cardiomyopathy mindset, together with a multidisciplinary approach are crucial. Further investigations, including advanced imaging and genetic testing, are needed to make a phenotype-based etiological diagnosis. Detection of pathogenic genetic variants allows risk stratification of sudden cardiac death, where new recommendations are available regarding primary prevention. Therapeutic options are expanded with the approval of a new class of drugs for the treatment of symptomatic hypertrophic cardiomyopathy with left ventricular outflow tract obstruction. Specific exercise recommendations are given and reproductive issues in patients with CM are addressed. The lack of reimbursement by the National Health Insurance Fund (NHIF) of genetic testing and the severely limited reimbursement of some imaging methods are a significant problem in Bulgaria, which leads to difficulties in implementing the new guidelines.

Act for the future of community pharmacy

Community pharmacies serve as a vital gateway to primary care and public health, offering face-to-face pharmacist expert care to assure safe and effective medication use. However, they are disappearing at an alarming rate, with 20%-30% of all community pharmacy locations projected to close within the next year. The objective of this commentary is to highlight the critical need for systemic reforms and collective action within our profession to address the unique challenges faced by community pharmacies, ensuring their sustainability and continued role in providing essential health care services for patients. Key issues and evidence are provided to help pharmacy professionals better articulate why pharmacy closures are happening now and how we can work toward a transformed future. Pharmacy closures stem from an unsustainable business model characterized by declining reimbursement for prescription medications, opaque and anticompetitive pricing practices of pharmacy benefit managers, and limited reimbursement for clinical services. Among these challenges, our profession has the opportunity to create a future for community pharmacy where every person has local access to pharmacist expert care and medications through sustainable, integrated community pharmacy practice. Our profession must embrace community pharmacy teams’ role in patient care, champion opportunities to integrate community pharmacists and their support staff as members of the health care team, and advocate for payment transparency and transformation. Creating this future will take all pharmacists and all pharmacy professionals.

Unlocking the full potential of rare disease drug development: exploring the not-for-profit sector's contributions to drug development and access.

This commentary provides a comprehensive overview of the challenges and opportunities in the field of drug development for rare diseases and especially of gene therapy products for ultra-rare diseases. It discusses the limited market size, reimbursement and scientific complexities that deter pharmaceutical investment in this field. Highlighting the pivotal role of charitable organizations like Fondazione Telethon, it showcases their efforts in funding research and ensuring access to innovative therapies. This commentary also addresses the challenges in therapy distribution, particularly regarding sustainability and global access. It outlines Fondazione Telethon's operational model to try to address these challenges. Finally, it appeals to governments and regulatory bodies to implement policies and incentives aimed at further fostering innovation and accessibility in rare disease drug development and access.

Telepsychiatry Current Practice and Implications for Future Trends: A 2023 American Psychiatric Association Member Survey.

Introduction: Although telehealth was a viable means of delivering psychiatric care even before the COVID-19 public health emergency, flexibilities at the federal and state levels during the pandemic prompted mass adoption in a short timeframe. Little is known about how psychiatrists plan to offer care going forward and to what degree services will be offered virtually, in-person, or in a hybrid format. Methods: We conducted a survey of American Psychiatric Association (APA) members regarding telepsychiatry practice and potential barriers. Results: The survey was completed by 1,660 APA members. Most survey respondents (94%) conduct at least some telepsychiatry. Most respondents indicate operating in a hybrid environment in which they maintain a physical practice location, while 16% indicate that they do not have a physical practice and only see patients remotely. Across all setting types, 82% of respondents deliver telehealth via all or mostly video; 11% report conducting telehealth visits via mostly audio-only modalities; and 7% report equal usage of both modalities. Barriers to telepsychiatry noted by respondents include limited reimbursement, state medical licensure, federal and state regulations regarding controlled substance prescribing via telehealth, and technical challenges. Conclusion: Results of this survey of APA members show that the majority conduct at least some telepsychiatry; operate in a hybrid environment; and deliver telehealth via all or mostly video. Reported barriers to telepsychiatry practice include legal, regulatory, reimbursement, and technical issues. The future of telepsychiatry may largely be determined by which legal, regulatory, and reimbursement flexibilities are ended, extended temporarily, or made permanent.

Treatment pattern among patients with relapsed/refractory multiple myeloma (RRMM) who had received pomalidomide-based regimens in Taiwan

ABSTRACT Background/purpose The treatment landscape of relapsed/refractory multiple myeloma (RRMM) is rapidly evolving in Taiwan. The present study aimed to assess the treatment patterns among RRMM patients in Taiwan. Methods This retrospective, chart review-based, non-interventional study collected data on RRMM patients (≥20 years old) receiving pomalidomide-based treatment between January 2017 and December 2020 across five sites in Taiwan. Results Median age of the study population was 65.6 years. Approximately 75% patients received a doublet regimen and 25% were on a triplet regimen. Disease progression was the most common cause for switching to pomalidomide-based treatments in doublet (71.2%) and triplet (58.3%) groups. Patients in doublet and triplet groups (>80%) received 4 mg pomalidomide as a starting dose. Overall response rate (ORR: 31.5% and 45.8%) and median progression-free survival (PFS: 4.7 and 6.8 months) were reported in the doublet and triplet regimen. Doublet regimen was discontinued mainly due to disease progression or death (78.1%); however, triplet regimen patients mainly terminated their treatment due to reimbursement limitations (29.2%). Healthcare resource utilization (HRU) was comparable between doublet and triplet groups. Conclusion In Taiwan, half of RRMM patients received pomalidomide-based triplet regimens. Triplet regimens showed a trend towards better outcomes with longer PFS and higher response rates compared to doublets. Notably, the duration of triplet use is influenced by reimbursement limitations. This study provides insight into RRMM treatment patterns in Taiwan and the findings suggest that triplet regimens may be a better alternative than doublet regimens.

Association of characteristics of cancer, patient, and county with telemedicine services use: Impact of the waiver of reimbursement restrictions on telemedicine.

11058 Background: Telemedicine services have great potential to improve access to care of cancer patients who are vulnerable in health status and may experience financial hardship due to the cost of their care. However, very little is known about how the Centers for Medicare and Medicaid Services’ waiver of reimbursement restrictions on telemedicine and characteristics of cancer affected their use of telemedicine services. We examined the changes in frequency of telemedicine use before and after the waiver and, after the waiver, the determinants of telemedicine use across medical provider types. Methods: We used the 5% Surveillance, Epidemiology and End Results registry file linked to Medicare data among patients who had a newly diagnosed cancer in 2019 and were enrolled in Medicare Parts A and B during 2019-2020, and Area Health Resources File. Our outcomes were binary variables of telemedicine services use in outpatient (OP), office-based clinics (OB), and emergency department (ED), respectively, and for detailed provider types in OB. Primary independent variables included the ten most frequently observed cancer sites (reference: all other sites), sequence of cancer, stage of diagnosis, and quarter of diagnosis in 2019. Analysis was by a multilevel mixed effects logistic regression model, adjusting characteristics of cancer, patient and county. Results: Among eligible patients (n = 14,226), telemedicine services use for all provider types increased from 4.3% in pre-waiver period to 40.3% (5.2% in OP, 39.3% in OB, and 0.2% in ED) in post-waiver period. Telemedicine services use varied by primary cancer site, but was higher for those with a cancer recurrence (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.16-1.60) and advanced cancer stage (OR 1.24, 95% CI 1.03-1.48). For visits to oncologists, cancer characteristics such as recurrence (OR 1.67, 95% CI 1.34-2.08), advanced stage (OR 5.52, 95% CI 4.12-7.40) and diagnosis in the last quarter in 2019 (OR 1.39, 95% CI 1.20-1.61) were associated with greater use of telemedicine. Patients of older age and minority race/ethnicity and in non-Northeast regions were less likely to use telemedicine, while women, patients with dual eligibility for Medicaid, and those living in a county with high median household income and high availability of hospital beds were more likely to use telemedicine. Conclusions: Cancer patients used telemedicine services more frequently after the waiver and their cancer characteristics were most strongly associated with that use, implying their greater need for, and benefit from, telemedicine. Disparities in telemedicine use related to individual and county-level socio-demographics and medical supply suggest health policy changes to improve equitable access to telemedicine and efficient cancer care planning.

Breaking Sound Barriers: Exploring Tele-Audiology's Impact on Hearing Healthcare.

Hearing impairment is a global issue, affecting billions of people; however, there is a gap between the population affected by hearing loss and those able to access hearing healthcare. Tele-audiology, the application of telemedicine in audiology, serves as a new form of technology which aims to provide synchronous or asynchronous hearing healthcare. In this article, we reviewed some recent studies of tele-audiology-related topics to have a glimpse of the current development, associated challenges, and future advancement. Through the utilization of tele-audiology, patients can conveniently access hearing healthcare, and thus save travel costs and time. Recent studies indicate that remote hearing screening and intervention are non-inferior to the performance of traditional clinical pathways. However, despite its potential benefits, the implementation of tele-audiology faces numerous challenges, and audiologists have varying attitudes on this technology. Overcoming obstacles such as high infrastructure costs, limited reimbursement, and the lack of quality standards calls for concerted efforts to develop effective strategies. Ethical concerns, reimbursement, and patient privacy are all crucial aspects requiring in-depth discussion. Enhancing the education and training of students and healthcare workers, along with providing relevant resources, will contribute to a more efficient, systematic hearing healthcare. Future research will aim to develop integrated models with evidence-based protocols and incorporating AI to enhance the affordability and accessibility of hearing healthcare.

Chronopharmacology: Optimizing drug therapy through biological rhythms

Digital therapeutics are evidence-based therapeutic interventions that utilize digital technologies to prevent, manage, or treat medical disorders. These interventions utilize digital technologies such as mobile applications or online platforms to deliver evidence-based therapeutic interventions and treatments for various health conditions. Digital therapeutics undergo rigorous clinical validation and regulatory processes to ensure their safety and efficacy. Digital therapeutics offer several benefits in health care, including improved accessibility, personalized treatment, cost-effectiveness, continuous monitoring and feedback, enhanced patient engagement, scalability, and support for various health conditions. They have practical applications in areas such as psychiatry, drug development, substance abuse treatment, chronic insomnia, Parkinson’s disease, cardiac rehabilitation, and oncology care. Digital therapeutics can significantly improve the quality of life for individuals across different populations by providing tailored interventions for mental health disorders and addressing health conditions related to different age groups. However, challenges to the widespread adoption of digital therapeutics include resistance to change within health-care systems, interoperability issues, privacy concerns, and limited reimbursement policies. Collaboration among health-care providers, regulators, technology developers, and patients is necessary to address these challenges and ensure the safety and effectiveness of digital therapeutics.

Social workers are key to addressing social determinants of health in integrated care settings

ABSTRACT Social workers play an important role in assessing social determinants of health (SDH) and providing behavioral health services in integrated care settings. Evidence suggests that integrated care interventions improve quality of life and other patient outcomes. However, the ambiguous role of social workers on the interdisciplinary team, the lack of protocol in SDH screening and intervention, and restrictions due to healthcare reimbursement limit social workers’ ability to intervene. Future directions include standardizing integrated care models, evaluating integrated care’s efficacy to address SDH, incorporating SDH into interprofessional training including role clarification and reimbursing for SDH assessment and intervention.

Goal attainment with integrated upper limb spasticity management including botulinum toxin-A (BoNT-A): Subanalysis of Australian data from the ULIS-III study

Background: Primary results from the international upper limb international spasticity-III study provided robust evidence for the benefit of repeated cycles of botulinum toxin-A (BoNT-A) for upper limb spasticity. Objectives: Internationally, patients with active function goals tended to require more frequent injections, and we hypothesized that reimbursement restrictions in Australia (which typically limited the number of injections received) may have adversely impacted outcomes compared with the international cohort. Methods: Upper Limb International Spasticity-III was a prospective, observational study following adults living with spasticity over 2 years of goal-directed upper limb spasticity management including repeated BoNT-A treatment. Results: The Australian subgroup included 115 patients (mean±SD age 53.8±16.9 years, 56% male, 79% stroke etiology), of whom 74% had previously been treated with BoNT-A. Australian participants had fewer injection cycles [2.7 (2.3, 3.0) vs. 4.1 (4.0, 4.3)] with longer injection intervals [330.6 (280.3, 381.0) vs. 200.3 (189.4, 211.1) days] than the international cohort. Across each evaluation cycle, patients in the Australian subgroup showed a change from baseline in Goal Attainment Scaling (GAS) T scores of >10, confirming relevant improvement. At 2 years, cumulated GAS T scores were 47.9 (46.4, 49.4) for the Australian subgroup versus 49.7 (49.3, 50.1) in the international cohort. Active function goals were generally underachieved in the Australian subgroup (mean cumulated GAS-T-score 43.6 (41.6, 45.6) vs. 47.4 (46.5, 48.3) internationally]. Conclusions: As anticipated, the Australian cohort had fewer injection cycles with longer intervals than seen internationally. Their overall goal attainment was lower than for the total cohort, which appeared to be driven by less active function goal attainment. Among other possible factors, these data support the idea that restricted reimbursement may have impacted BoNT-A injection frequency and consequently, patient outcomes.

From diagnosis to treatment in genetic epilepsies: Implementation of precision medicine in real-world clinical practice

The implementation of whole exome sequencing (WES) has had a major impact on the diagnostic yield of genetic testing in individuals with epilepsy. The identification of a genetic etiology paves the way to precision medicine: an individualized treatment approach, based on the disease pathophysiology. The aim of this retrospective cohort study was to: (1) determine the diagnostic yield of WES in a heterogeneous cohort of individuals with epilepsy referred for genetic testing in a real-world clinical setting, (2) investigate the influence of epilepsy characteristics on the diagnostic yield, (3) determine the theoretical yield of treatment changes based on genetic diagnosis and (4) explore the barriers to implementation of precision medicine. WES was performed in 247 individuals with epilepsy, aged between 7 months and 68 years. In 34/247 (14 %) a (likely) pathogenic variant was identified. In 7/34 (21 %) of these individuals the variant was found using a HPO-based filtering. Diagnostic yield was highest for individuals with an early onset of epilepsy (39 %) or in those with a developmental and epileptic encephalopathy (34 %). Precision medicine was a theoretical possibility in 20/34 (59 %) of the individuals with a (likely) pathogenic variant but implemented in only 11/34 (32 %). The major barrier to implementation of precision treatment was the limited availability or reimbursement of a given drug. These results confirm the potential impact of genetic analysis on treatment choices, but also highlight the hurdles to the implementation of precision medicine. To optimize precision medicine in real-world practice, additional endeavors are needed: unifying definitions of precision medicine, establishment of publicly accessible databases that include data on the functional effect of gene variants, increasing availability and reimbursement of precision therapeutics, and broadening access to innovative clinical trials.

Value of PET imaging in head and neck cancer

The combination of positron-emission tomography (PET) with cross-sectional imaging in particular is becoming increasingly important in the diagnosis of head and neck tumors because, in addition to pure anatomy, the metabolic activity of tissue can be visualized and assessed. The combination of PET and computed tomography (CT) is already an established procedure in head and neck tumor patients in some indications, e.g., for primary tumor detection in cancer of unknown primary (CUP) syndrome or also after completed primary radio(chemo)therapy for evaluation of response, especially also with regard to nodal status. In some cases, salvage neck dissection can thus be avoided in the case of PET-negative findings. In the context of primary diagnosis, PET/CT imaging can be used primarily to evaluate distant metastasis. According to current guidelines, PET-based imaging is not (yet) of value in determining the local extent at initial diagnosis. Achallenge is the still limited reimbursement by health insurance companies, which currently allow only certain indications, and the still lack of nationwide coverage.

Issues Related to Children-Faced by Armed Forces Families When Caring for Patients in Palliative Care - A Qualitative Study.

Access to palliative care is limited, especially in rural India. Children needing care by palliative teams may themselves be patients, or siblings and children of patients. Armed forces families face characteristic lifestyle challenges - frequent transfers, living in difficult and remote areas, serving personnel staying apart from families for long periods - very different from issues faced by civilians. Military service increases the risk of psychosocial burden for serving personnel as well as families. Most depend on private and state medical services for palliative care so it is important for the palliative community to understand their issues. This study aimed to explore the issues related to children - faced by armed forces families when caring for patients in palliative care. Qualitative study based on thematic analysis of semi-structured interviews with caregivers - either serving personnel or their dependents, in three centres. Analysis of the 15 interviews showed that armed forces families face complex challenges related to children when caring for the palliative patient due to frequent movement, lack of paediatric palliative services in far-flung areas, disruption of the continuity of care, social isolation, language, and cultural barriers when living in non-native areas, inability to build and access family and community support and financial burden due to restrictive reimbursement policies. Although medical and administrative support within the organisation provides a cushion, wives have to manage alone in the father's prolonged absence, and safety is a concern for children when living outside the campuses and serving personnel report guilt, anger, and helplessness at not being present when needed. Awareness of these issues can enable palliative workers to provide more meaningful support tailored to the needs of service families.

Cost-Effectiveness of Pharmacist Prescribing for Managing Hypertension in the United States

Pharmacist-led interventions can significantly improve blood pressure (BP) control. The long-term cost-effectiveness of pharmacist-prescribing interventions implemented on a large scale in the US remains unclear. To estimate the cost-effectiveness of implementing a pharmacist-prescribing intervention to improve BP control in the US. This economic evaluation included a 5-state Markov model based on the pharmacist-prescribing intervention used in The Alberta Clinical Trial in Optimizing Hypertension (or RxACTION) (2009 to 2013). In the trial, control group patients received an active intervention, including a BP wallet card, education, and usual care. Data were analyzed from January to June 2023. Cardiovascular (CV) events, end-stage kidney disease events, life years, quality-adjusted life years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio (ICER). CV risk was calculated using Framingham risk equations. Costs were based on the reimbursement rate for level 1 encounters, medication costs from published literature, and event costs from national surveys and pricing data sets. Quality of life was determined using a published catalog of EQ-5D utility values. One-way sensitivity analyses were used to assess alternative reimbursement values, a reduced time horizon of 5 years, alternative assumptions for BP reduction, and the assumption of no benefit to the intervention after 10 years. The model was expanded to the US population to estimate population-level cost and health impacts. Assumed demographics were mean (SD) age, 64 (12.5) years, 121 (49%) male, and a mean (SD) baseline BP of 150/84 (13.9/11.5) mm Hg. Over a 30-year time horizon, the pharmacist-prescribing intervention yielded 2100 fewer cases of CV disease and 8 fewer cases of kidney disease per 10 000 patients. The intervention was also associated with 0.34 (2.5th-97.5th percentiles, 0.23-0.45) additional life years and 0.62 (2.5th-97.5th percentiles, 0.53-0.73) additional QALYs. The cost savings were $10 162 (2.5th-97.5th percentiles, $6636-$13 581) per person due to fewer CV events with the pharmacist-prescribing intervention, even after the cost of the visits and medication adjustments. The intervention continued to produce benefits in more conservative analyses despite increased costs as the ICER ranged from $2093 to $24 076. At the population level, a 50% intervention uptake was associated with a $1.137 trillion in cost savings and would save an estimated 30.2 million life years over 30 years. These findings suggest that a pharmacist-prescribing intervention to improve BP control may provide high economic value. The necessary tools and resources are readily available to implement pharmacist-prescribing interventions across the US; however, reimbursement limitations remain a barrier.

Answering the Call: Experiences of Implementing Antiracist Interventions in Health Care

Abstract: Since 2020, when the Covid-19 pandemic and police violence against Black Americans made undeniably visible inequities in health outcomes based on race, health professionals have issued calls for their colleagues to practice antiracism. Yet few studies have qualitatively described the experiences of health professionals who have implemented antiracist interventions to identify the factors that make them successful. I conducted semi-structured interviews with 51 health professionals and administrators who had introduced changes in their clinical practices explicitly to address health inequities based on race. The interventions focused on removing barriers to access for patients who lack the linguistic, economic, or cultural resources to navigate a complicated health care system. Interprofessional collaboration, leadership support, and community trust facilitated the success of the interventions. Restrictive insurance reimbursement policy was the most cited barrier. The experiences of these health professionals illustrate possibilities for implementing antiracist interventions at the point of care.

Mapping barriers to midwives’ educational role in Cyprus guided by the Theoretical Domains Framework

Abstract Issue The high caesarean section (C/S) rate in Cyprus (>60%) led to the formation of a National Committee to address this Public Health priority. Among WHO recommendations for C/S reduction are midwifery-led educational interventions; yet, medicalization of birth in Cyprus is curtailing the autonomous role of midwives. Description of problem While midwives could “make every contact count” during routine appointments, antenatal education (AE) is reduced to a formal activity within the antenatal class space with documented low attendance. This formative research mapped barriers to the educational role of Cypriot midwives guided by behaviour theory. A context-specific understanding is needed to shape an appropriate intervention and promote a common understanding among stakeholders. Results One in three midwives islandwide (N = 119, response: 34%) rated 83 determinants (from 1=more to 6=less problematic), guided by the Theoretical Domains Framework (TDF). “Beliefs about AE importance” (M = 5.57, SD = 0.96) and “Professional role” (M = 5.58, SD = 0.57) received the highest scores. Lack of organizational resources (M = 3.39, SD = 0.97), institutional and inter-professional support (M = 3.77, SD = 1.4) and acceptance (M = 4.25, SD = 0.85) were identified as problematic. While perceived capabilities and intentions were rated favourably, achieving “Goals” was difficult, mainly due to competing priorities (M = 3.86, SD = 0.84). Self-efficacy and behavioural control were lower among less experienced midwives (p < 0.01) and in the private sector (p = 0.08), which accounts for >70% of births. Lessons Beyond the antenatal class, AE is a ‘bad fit’ with routine practice. The phenomenon pertains to organizational arrangements but also norms and perceptions of other providers and service users. While current Healthcare reforms present prospects in re-defining the role of midwives, the educational role is not adequately supported or promoted given the limited number of visits and reimbursement restrictions imposed. Key messages • Barriers to routine antenatal education originate from an unsupportive system and socio-cultural norms which alienate midwives in an already medicalized environment. • This theory-driven formative study described the issue in behaviour terms in the context of shaping an intervention to strengthen the health education role of midwives.

Overall drug treatment of idiopathic pulmonary fibrosis patients from national registries – a real-world study from Finland

BackgroundCurrently, two disease-modifying antifibrotic drugs are indicated for the treatment of idiopathic pulmonary fibrosis. The objective of this study was to analyse antifibrotic and overall prescription medication use of IPF patients in the real world.MethodsData was collected from the FinnishIPF registry and the Registry of the Social Insurance Institution of Finland (SII). Purchases of all prescription medicines were assessed. The frequency, the initiation interval, the duration, and the breaks of the antifibrotic treatments were defined. The association between the prescription of antifibrotic therapy and different patient-related clinical parameters was studied. Accordingly, the relationships between the delay in starting therapy and patient-related variables were analysed.ResultsOf the 263 IPF patients, 132 (50.2%) had started antifibrotic treatment during the study period 2011–2018. The mean interval from the diagnosis to the first purchase was 367 (SD 429) days. The antifibrotic drug was switched in 14% of patients. Discontinuation of therapy occurred most commonly during the first year of the treatment. The one-year persistence was 77.1% for pirfenidone and 78.9% for nintedanib. A tendency of treating patients under 75 years was noticed. Low forced vital capacity predicted earlier initiation of medication.ConclusionsThe initiation of antifibrotics after diagnosis was slow, probably due to reimbursement limitations. Younger age at diagnosis affected treatment initiation although it is unknown which patients benefit most from these medications. The reasons for discontinuation of the antifibrotic therapy during the first year should be a focus in clinical work and further studies.

Value of PET imaging in head and neck cancer

The combination of positron-emission tomography (PET) with cross-sectional imaging in particular is becoming increasingly important in the diagnosis of head and neck tumors because, in addition to pure anatomy, the metabolic activity of tissue can be visualized and assessed. The combination of PET and computed tomography (CT) is already an established procedure in head and neck tumor patients in some indications, e.g., for primary tumor detection in cancer of unknown primary (CUP) syndrome or also after completed primary radio(chemo)therapy for evaluation of response, especially also with regard to nodal status. In some cases, salvage neck dissection can thus be avoided in the case of PET-negative findings. In the context of primary diagnosis, PET/CT imaging can be used primarily to evaluate distant metastasis. According to current guidelines, PET-based imaging is not (yet) of value in determining the local extent at initial diagnosis. Achallenge is the still limited reimbursement by health insurance companies, which currently allow only certain indications, and the still lack of nationwide coverage.

Policy and Strategy for Hepatitis C Virus Elimination at the National Level: Experience in Taiwan.

The estimated prevalence of anti-HCV was 3.1% in Taiwan. Studies have shown iatrogenic behavior was the major transmission route. It is highest in specific populations including patients with end stage renal disease (ESRD), human immunodeficiency virus infection, who inject drug (PWID), and under opioid substitution treatment. Approximately 405,160 patients were seropositive for HCV RNA and in need of treatment. Taiwan government claims to reach WHO's 2030 goal of HCV elimination by 2025 and works hard to resolve several barriers of HCV elimination including political commitment, sustainable financing, minimize reimbursement restrictions, instituted monitoring, and perform micro-elimination of specific populations. The last stage of HCV elimination is to accelerate the universal HCV screening program of populations aged 45-79 years and resolve the unawareness issue of HCV infection. Hopefully, we can achieve the targets of HCV elimination set by WHO and reach the goal earlier in 2025.