Trends In Reasons Research Articles

Treatment trends in patients with de novo metastatic prostate cancer in the era of upfront combination therapy.

The objective of this study is to assess the trends in treatment selection for patients with de novo metastatic castration-sensitive prostate cancer in the era of upfront combination therapy. This multicenter retrospective study included 595 patients treated with either upfront combination therapy (upfront novel hormonal therapies and taxane-based chemotherapy) or vintage therapy (androgen deprivation therapy with or without bicalutamide) between 2016 and 2021. High tumor burden metastatic disease was defined when a patient met the CHAARTED or LATITUDE criteria. We evaluated trends in treatment selection and reasons for selecting vintage therapy. Of the 595, 123 and 472 patients were classified as having low and high tumor-burden disease, respectively. The Use of upfront combination therapy was found to be rapidly increasing with utilization rates of 72% and 54% in 2021 for high and low tumor-burden disease, respectively. Multivariable logistic regression analysis found older age, poor performance status, and nonacademic center were significantly associated with the selection of vintage therapy. Of the 163 patients who received vintage hormone therapy after approval of upfront therapy, 74.2% had a specific reason for avoiding upfront therapy. The reasons for selecting vintage therapy included refusal (39.8%), older age (67.6%), frailty (56.3%), and comorbidity (40.8%). Furthermore, 16.9% of patients declined upfront combination therapy due to cost concerns. Upfront combination therapy use has 72% and 54% prevalence among patients with high and low tumor burden diseases, respectively, in this current practice. Older age, poor performance status, and facility bias were negatively associated with the use of upfront combination therapy.

Current trends in retraction of plastic surgery and reconstruction research

Various studies regarding retractions of publications have determined the rate of retraction has increased in recent years. Although this trend may apply to any field, there is a paucity of literature exploring the publication of erroneous studies within plastic and reconstructive surgery. The present study aims to identify trends in frequency and reasons for retraction of plastic and reconstructive surgery studies, with analysis of subspecialty and journals. A database search was conducted for retracted papers within plastic and reconstructive surgery. The initial search yielded 2347 results, which were analyzed by two independent reviewers. 77 studies were jointly identified for data collection. The most common reasons for retractions were duplication (n=20, 25.9%), request of author (n=15, 19.5%), plagiarism (n=9, 11.6%), error (n=9, 11.6%), fraud (n=2, 2.6%), and conflict of interest (n=1, 1.3%). 15 were basic science studies (19.4%), 58 were clinical science studies (75.3%), and 4 were not categorized (5.2%). Subspecialties of retracted papers were maxillofacial (n=29, 37.7%), reconstructive (n=17, 22.0%), wound healing (n=8, 10.4%), burn (n=6, 7.8%), esthetics (n=5, 6.5%), breast (n=3, 3.9%), and trauma (n=1, 1.3%). Mean impact factor was 2.9 and average time from publication to retraction was 32 months. Analysis of retracted plastic surgery studies revealed a recent rise in frequency of retractions, spanning a wide spectrum of journals and subspecialties.

2296. Trends in reasons for hospital admission among adults ≥18 years hospitalized with laboratory-confirmed SARS-CoV-2 infection—COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), 14 U.S. States, June 2020 – January 2023

Abstract Background During the COVID-19 pandemic, hospitals performed widespread screening for SARS-CoV-2, resulting in identification of asymptomatic or mildly ill persons with SARS-CoV-2 who were admitted for other reasons. We examined trends in reasons for admission to identify hospitalized adults with a positive SARS-CoV-2 test likely admitted for COVID-19-related illness. Methods From June 2020–January 2023, hospitalized patients aged ≥ 18 years with a positive screening or clinician-directed SARS-CoV-2 test ≤ 14 days prior to or during hospitalization were identified from > 300 hospitals across 14 states in the population-based COVID-19-Associated Hospitalization Surveillance Network. Trained staff abstracted charts for a representative sample of patients. COVID-19-related admissions were indicated if 1) COVID-19 or 2) COVID-19-associated symptoms or clinical presentations were listed as chief complaint or reason for admission in the history of present illness. Percentages for sampled cases were weighted to account for probability of selection. Results Among 424,047 adults hospitalized with SARS-CoV-2 infection, the proportion aged ≥ 75 years increased over time to > 40% by October 2022 (Figure 1). The proportion of patients among 34,644 sampled hospitalizations admitted with likely COVID-19-related illness declined from 88.0% (June 1, 2020–June 19, 2021) to 72.4% (June 19, 2022–January 31, 2023) (Figure 2). The greatest decline in COVID-19-related admissions occurred in adults aged 18–49 years; the smallest decline occurred in adults aged ≥75 years: > 80% of these admissions in all periods were likely COVID-19-related. Among adults hospitalized from June 2022–January 2023, 27.1% had non-COVID-19 reasons for admission, including planned procedures (2.4%), obstetrics labor and delivery (5.0%), psychiatric admission requiring acute medical care (2.5%), trauma (2.6%), and other reasons likely unrelated to COVID-19 (14.6%).Figure 1.Proportion of laboratory-confirmed SARS-CoV-2 infection-associated hospitalizations by adult age group, June 2020 – January 2023Figure 2.Proportions of hospitalized adults with laboratory-confirmed SARS-CoV-2 infection who had COVID-19 as a likely reason for admission, by age group and variant predominance period — COVID-NET, June 2020 – January 2023 Conclusion While the proportion of COVID-19-related admissions decreased over time among patients hospitalized with laboratory-confirmed SARS-CoV-2, most adults with a positive SARS-CoV-2 test were likely admitted for reasons related to COVID-19. Misclassification of admission reason may occur. Disclosures Art Reingold, MD, GSK: Advisor/Consultant|Takeda: Advisor/Consultant|VBI: Advisor/Consultant

Trends in coping reasons for marijuana use among U.S. adolescents from 2016 to 2022

ObjectiveThis study examines historical trends in coping reasons for marijuana use among adolescents (1976–2022) and explores sociodemographic variations in recent years (2016–2022). MethodData from U.S. national samples of 12th grade adolescents in the Monitoring the Future (MTF) study were used to examine long-term trends (1976–2022, N = 43,237) and recent differences by sociodemographic characteristics (2016–2022, N = 3,816). Measures included marijuana use, coping reasons for use, and sociodemographic characteristics. ResultsThe most prevalent coping reason across time was “relax,” endorsed by 52.9% of past 12-month users. Coping reasons mostly exhibited significant increases over time. Sociodemographic factors were associated with coping reasons. Females had higher odds of using marijuana to escape problems and get through the day (vs. males). Black respondents were more likely to use marijuana to get through the day, and Hispanic respondents were more likely to use to relax (vs. White respondents). Those with lower (vs. higher) parental education were more likely to use due to anger/frustration and to escape problems. Adolescents who used marijuana frequently (vs. less often) had higher odds of endorsing all coping reasons. There was no robust evidence of interactions between sociodemographic characteristics and year. ConclusionsResults indicate a consistent increase in coping reasons for adolescent marijuana use over time, with variations based on sociodemographic characteristics. The findings highlight the importance of understanding subpopulations of adolescents who have higher risk of coping-related marijuana use.

MP11-02 TREATMENT TRENDS IN PATIENTS WITH DE NOVO METASTATIC PROSTATE CANCER IN THE ERA OF UPFRONT COMBINATION THERAPY

You have accessJournal of UrologyCME1 Apr 2023MP11-02 TREATMENT TRENDS IN PATIENTS WITH DE NOVO METASTATIC PROSTATE CANCER IN THE ERA OF UPFRONT COMBINATION THERAPY Sasaki Daichi, Miura Hikari, Hatakeyama Shingo, Tabata Ryuji, Fujimori Daiji, Kawashima Yohei, Moriyama Shingo, Oishi Takuya, Horiguchi Hirotaka, Soma Osamu, Noro Daisuke, Tanaka Toshikazu, Okamoto Teppei, Hashimoto Yasuhiro, and Ohyama Chikara Sasaki DaichiSasaki Daichi More articles by this author , Miura HikariMiura Hikari More articles by this author , Hatakeyama ShingoHatakeyama Shingo More articles by this author , Tabata RyujiTabata Ryuji More articles by this author , Fujimori DaijiFujimori Daiji More articles by this author , Kawashima YoheiKawashima Yohei More articles by this author , Moriyama ShingoMoriyama Shingo More articles by this author , Oishi TakuyaOishi Takuya More articles by this author , Horiguchi HirotakaHoriguchi Hirotaka More articles by this author , Soma OsamuSoma Osamu More articles by this author , Noro DaisukeNoro Daisuke More articles by this author , Tanaka ToshikazuTanaka Toshikazu More articles by this author , Okamoto TeppeiOkamoto Teppei More articles by this author , Hashimoto YasuhiroHashimoto Yasuhiro More articles by this author , and Ohyama ChikaraOhyama Chikara More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003226.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To assess trends in treatment selection for patients with de novo metastatic castration-sensitive prostate cancer in the era of upfront combination therapy. METHODS: This multicenter retrospective study included 595 patients treated with either upfront combination therapy (upfront novel hormonal therapies and taxane-based chemotherapy) or vintage therapy (androgen deprivation therapy with or without bicalutamide) between 2016 and 2021. High tumor burden metastatic disease was defined when a patient met the CHAARTED or LATITUDE criteria. We evaluated trends in treatment selection and reasons for selecting vintage therapy. RESULTS: Of the 595 included patients, 123 and 472 patients were classified as having low and high tumor burden disease, respectively. Use of upfront combination therapy was found to be rapidly increasing with utilization rates of 72% and 54% in 2021 for high and low tumor burden disease, respectively. Of the 163 patients who were offered upfront combination therapy, 74.2% selected vintage therapy. Reasons for selecting vintage therapy included refusal (39.8%), older age (67.6%), frailty (56.3%), and comorbidity (40.8%). Furthermore, 16.9% of patients declined upfront combination therapy due to cost concerns.Upfront combination therapy use has 72% and 54% prevalence among patients with high and low tumor burden diseases, respectively, in this current practice. CONCLUSIONS: Older age was the most common reason for declining upfront combination therapy. Source of Funding: no © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e123 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sasaki Daichi More articles by this author Miura Hikari More articles by this author Hatakeyama Shingo More articles by this author Tabata Ryuji More articles by this author Fujimori Daiji More articles by this author Kawashima Yohei More articles by this author Moriyama Shingo More articles by this author Oishi Takuya More articles by this author Horiguchi Hirotaka More articles by this author Soma Osamu More articles by this author Noro Daisuke More articles by this author Tanaka Toshikazu More articles by this author Okamoto Teppei More articles by this author Hashimoto Yasuhiro More articles by this author Ohyama Chikara More articles by this author Expand All Advertisement PDF downloadLoading ...

Implementation Science in Surgery: Translating Outcomes to Action.

Implementation Science in Surgery: Translating Outcomes to Action.

How might climate change impact water safety and boil water advisories in Canada?

A boil water advisory (BWA) informs the public that there is an increased level of risk associated with their water and that they should boil it before consuming. Studies show that small communities in Canada are particularly likely to experience repeat and long-term BWAs. Climate change has led to changes in precipitation and temperature patterns, leading to region-specific impacts such as increased frequency, severity, or variance in floods, forest fires, droughts, freezing rain, and sea water intrusion. Academic and non-academic “grey” literature was reviewed to establish the most likely impacts of climate change on water treatment and infrastructure. Anonymized data from public drinking water systems in Canada was analyzed to determine the most common causes of BWAs between 2005 and 2020. Most BWAs reported were related to breakdowns/malfunctions along the distribution, though inadequate disinfection residual and turbidity or coliforms in the treated water were also common. Furthermore, statistical analysis of the data showed seasonal trends in some of these parameters. The results of this study suggest that increased precipitation, flooding, permafrost degradation, and forest fires are likely to have significant impacts on water safety in Canada. Highlights: Climate change effects are expected to worsen many current water challenges. Climate change will disproportionately impact small, rural, and remote water utilities. Water distribution systems are the main source of water safety risk in Canada. Groundwater-supplied systems experience a disproportionate number of BWAs. Seasonal trends in BWA reasons provide opportunities for targeted mitigation.

Has the decline in the intensity of internal migration been accompanied by changes in reasons for migration?

The last few decades have seen the intensity of internal migration decline in Australia and other advanced economies including the United States. Recent evidence suggests that changes in the composition of the population alone do not account for this persistent downward trend. This has led migration scholars to suspect that more profound behavioural changes driven by social, economic, and technological transformations are at play and that shifts in migration behaviour are likely to be reflected in changes in reasons for migration. We use data from the Household, Income and Labour Dynamics in Australia survey to shed new light on the factors driving the decline in internal migration in Australia between 2002 and 2018. This is done by examining annual trends in self-reported reasons for intrastate and interstate migration and applying a series of pooled logistic regressions. Results reveal a decline across all reasons for migration, and not only employment-related migration contrary to explanations proposed in the extant literature. The decline in employment-related migration does not appear to be the result of a rise in alternative forms of mobility such as teleworking or substitution with inter-industry or occupation mobility. Furthermore, we also find that the negative effect of duration of residence has increased for family-related migration. Collectively, these findings suggest that behavioural change, particularly increased place attachment, may have contributed to the decline in internal migration.

Trends in COVID-19 Vaccination Intent, Determinants and Reasons for Vaccine Hesitancy: Results from Repeated Cross-Sectional Surveys in the Adult General Population of Greece during November 2020-June 2021.

Vaccine hesitancy is a major barrier to achieving large-scale COVID-19 vaccination. We report trends in vaccination intention and associated determinants from surveys in the adult general population in Greece. Four cross-sectional phone surveys were conducted in November 2020 and February, April and May 2021 on nationally representative samples of adults in Greece. Multinomial logistic regression was used on the combined data of the surveys to evaluate independent predictors of vaccination unwillingness/uncertainty. Vaccination intention increased from 67.6% in November 2020 to 84.8% in May 2021. Individuals aged 65 years or older were more willing to be vaccinated (May 2021: 92.9% vs. 79.5% in 18–39 years, p < 0.001) but between age-groups differences decreased over time. Vaccination intention increased substantially in both men and women, though earlier among men, and was higher in individuals with prograduate education (May 2021: 91.3% vs. 84.0% up to junior high). From multivariable analysis, unwillingness and/or uncertainty to be vaccinated was associated with younger age, female gender (in particular in the April 2021 survey), lower educational level and living with a child ≤12 years old. Among those with vaccine hesitancy, concerns about vaccine effectiveness declined over time (21.6% in November 2020 vs. 9.6% in May 2021, p = 0.014) and were reported more often by men; safety concerns remained stable over time (66.3% in November 2020 vs. 62.1% in May 2021, p = 0.658) and were reported more often by women. In conclusion, vaccination intention increased substantially over time. Tailored communication is needed to address vaccine hesitancy and concerns regarding vaccine safety.

A different challenge with Benadryl: adolescent diphenhydramine ingestions reported to National Poison Database System, 2007–2020

Background The US Food and Drug Administration released a warning related to potential adverse effects related to intentional misuse or abuse ingestions of diphenhydramine in September 2020. We sought to evaluate adolescent-aged (13–19 y) diphenhydramine ingestions reported to US poison control centers to characterize these exposures, adverse effects, outcomes, and trends in outcomes and reasons for ingestion. Methods The US National Poison Database System was queried for all exposures to diphenhydramine between January 1, 2007 and December 31, 2020. Results 47,644 ingestions were included for analysis. An increase in the number of ingestions, percentage of cases due to an intentional reason for ingestion and suspected suicide was observed. More serious outcomes, cardiac complications, seizures, and deaths were more common following intentional ingestions and specifically suspected suicide over misuse or abuse. Conclusions Adolescent ingestions of diphenhydramine increased between 2007 and 2020. More serious outcomes, intentional reasons, and suspected suicide also increased over the study interval. Suspected suicide was associated with cardiac complications, seizures, coma, and death at higher rates than misuse or abuse. While misuse and abuse remain a concern, public health interventions focusing on the risk that diphenhydramine pose as an agent of suicide attempt may be of higher impact.

Increasing false positive diagnoses may lead to overestimation of stroke incidence, particularly in the young: a cross-sectional study

BackgroundStroke incidence is reportedly increasing in younger populations, although the reasons for this are not clear. We explored possible reasons by quantifying trends in neurologically focused emergency department (ED) visits, classification of stroke vs. TIA, and imaging use.MethodsWe performed a retrospective, serial, cross-sectional study using the National Hospital Ambulatory Medical Care Survey to examine time trends in age-stratified primary reasons for visit, stroke/TIA diagnoses, and MRI utilization from 1995 to 2000 and 2005–2015.ResultsFive million eight hundred thousand ED visits with a primary diagnosis of stroke (CI 5.3 M–6.4 M) were represented in the data. The incidence of neurologically focused reason for visits (Neuro RFVs) increased over time in both the young and in older adults (young: + 111 Neuro RFVs/100,000 population/year, CI + 94 − + 130; older adults: + 70 Neuro RFVs/100,000 population/year, CI + 34 − + 108). The proportion of combined stroke and TIA diagnoses decreased over time amongst older adults with a Neuro RFV (OR 0.95 per year, p < 0.01, CI 0.94–0.96) but did not change in the young (OR 1.00 per year, p = 0.88, CI 0.95–1.04). Within the stroke/TIA population, no changes in the proportion of stroke or TIA were identified. MRI utilization rates amongst patients with a Neuro RFV increased for both age groups.ConclusionsWe found, but did not anticipate, increased incidence of neurologically focused ED visits in both age groups. Given the lower pre-test probability of a stroke in younger adults, this suggests that false positive stroke diagnoses may be increasing and may be increasing more rapidly in the young than in older adults.

Trends in reasons for emergency calls during the COVID-19 crisis in the department of Gironde, France using artificial neural network for natural language classification

ObjectivesDuring periods such as the COVID-19 crisis, there is a need for responsive public health surveillance indicators in order to monitor both the epidemic growth and potential public health consequences of preventative measures such as lockdown. We assessed whether the automatic classification of the content of calls to emergency medical communication centers could provide relevant and responsive indicators.MethodsWe retrieved all 796,209 free-text call reports from the emergency medical communication center of the Gironde department, France, between 2018 and 2020. We trained a natural language processing neural network model with a mixed unsupervised/supervised method to classify all reasons for calls in 2020. Validation and parameter adjustment were performed using a sample of 39,907 manually-coded free-text reports.ResultsThe number of daily calls for flu-like symptoms began to increase from February 21, 2020 and reached an unprecedented level by February 28, 2020 and peaked on March 14, 2020, 3 days before lockdown. It was strongly correlated with daily emergency room admissions, with a delay of 14 days. Calls for chest pain and stress and anxiety, peaked 12 days later. Calls for malaises with loss of consciousness, non-voluntary injuries and alcohol intoxications sharply decreased, starting one month before lockdown. No noticeable trends in relation to lockdown was found for other groups of reasons including gastroenteritis and abdominal pain, stroke, suicide and self-harm, pregnancy and delivery problems.DiscussionThe first wave of the COVID-19 crisis came along with increased levels of stress and anxiety but no increase in alcohol intoxication and violence. As expected, call related to road traffic crashes sharply decreased. The sharp decrease in the number of calls for malaise was more surprising.ConclusionThe content of calls to emergency medical communication centers is an efficient epidemiological surveillance data source that provides insights into the societal upheavals induced by a health crisis. The use of an automatic classification system using artificial intelligence makes it possible to free itself from the context that could influence a human coder, especially in a crisis situation. The COVID-19 crisis and/or lockdown induced deep modifications in the population health profile.

Assessing Trends in Fellowship Training Among Otolaryngology Residents: A National Survey Study.

To summarize trends in otolaryngology fellowship applications, fellowships selected, and reasons for pursuing a fellowship. One-page anonymous questionnaire. A survey was completed by examinees at the conclusion of their American Board of Otolaryngology-Head and Neck Surgery oral examination from 2011 to 2019. Data included age, gender, fellowship type, reasons for doing a fellowship, and type of practice that examinees will enter. Spearman correlation and Pearson chi-square tests were completed. Over the 8-year study, 58% of the 2243 responding examinees did fellowships. The most frequently chosen fellowship was facial plastic surgery (25%), followed by pediatric otolaryngology (21%), head and neck surgery (19%), rhinology (13%), laryngology (9%), and neurotology (8%). The 2 most common reasons for doing a fellowship were desire for additional expertise beyond residency training (35%) and intellectual appeal (30%). Over the study period, the number of residents choosing to do a fellowship increased from 45.6% in 2011 to 61.5% in 2019, with a positive correlation between year and number of residents (r = 0.73, P = .036). When the data were stratified by gender, there were statistically significant differences in fellowship selection (P < .001), notably with women selecting pediatric otolaryngology at a higher frequency than men (30.9% vs 15.8%). There is a statistically significant increasing trend of otolaryngology residents who choose to undergo further training in fellowship. These data from a large, long-term study will be valuable in planning for training and workforce needs in the future.

Variation and trends in reasons for knee replacement revision: a multi-registry study of revision burden

Background and purpose — Studies describing time-related change in reasons for knee replacement revision have been limited to single regions or institutions, commonly analyze only 1st revisions, and may not reflect true caseloads or findings from other areas. We used revision procedure data from 3 arthroplasty registries to determine trends and differences in knee replacement revision diagnoses. Patients and methods — We obtained aggregated data for 78,151 revision knee replacement procedures recorded by the Swedish Knee Arthroplasty Register (SKAR), the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), and the Kaiser Permanente Joint Replacement Registry (KPJRR) for the period 2003–2017. Equivalent diagnosis groups were created. We calculated the annual proportions of the most common reasons for revision. Results — Infection, loosening, and instability were among the 5 most common reasons for revision but magnitude and ranking varied between registries. Over time there were increases in proportions of revisions for infection and decreases in revisions for wear. There were inconsistent proportions and trends for the other reasons for revision. The incidence of revision for infection showed a uniform increase. Interpretation — Despite some differences in terminology, comparison of registry-recorded revision diagnoses is possible, but defining a single reason for revision is not always clear-cut. There were common increases in revision for infection and decreases in revision for wear, but variable changes in other categories. This may reflect regional practice differences and therefore generalizability of studies regarding reasons for revision is unwise.

Is Myanmar on the right track after declaring leprosy elimination? Trends in new leprosy cases (2004–2018) and reasons for delay in diagnosis

Background: Myanmar declared leprosy elimination in 2003. In 2018, the country reported 2,214 new leprosy cases of whom 263 had Grade-2 disability (G2D). The country aims to reduce new cases with G2D to <53 cases by 2023 through early diagnosis and treatment. Objectives: To describe the trends (actual and projected) in new leprosy cases from 2004 to 2023 and to explore the reasons for delay in diagnosis. Methods: Mixed-methods study. The quantitative part—ecological study using numbers of new leprosy cases from 2004–2018. For qualitative part, new cases with G2D and health care providers were interviewed. Results: The annual total new cases, new multibacillary cases, new cases with G2D, new child cases are showing a declining trend. Total new cases and new cases with G2D, between 2004 and 2018 have declined by 40% and 28% respectively. If the current trends continue there will be 1,785 (95% CI: 1546-2024) new cases and <53 new cases with G2D in 2023. The interviews of patients and providers yielded the following reasons for delay in diagnosis: incorrect knowledge about leprosy, delay in recognition of symptoms, inappropriate care seeking, and fear of stigma and discrimination. Reduction in health system efforts, lack of local leadership, human resource constraints and decreased funding also contributed to delay in diagnosis. Conclusions: The declining trends and the possibility of achieving the target for new cases with G2D by 2023 is encouraging. The country must address the challenges mentioned by patients and health care providers as a priority, to accelerate the decline in new cases.

Trends and Factors Associated With Insurer Approval of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor Prescriptions

ObjectivesProprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is)—innovative yet costly cholesterol-lowering agents—have been subject to substantial prior authorization (PA) requirements and low approval rates. We aimed to investigate trends in insurer approval and reasons for rejection for PCSK9i prescriptions as well as associations between patients’ demographic, clinical, pharmacy, payer, and PCSK9i-specific plan/coverage factors and approval. MethodsWe examined trends in PCSK9i approval rates and reasons for rejection using medical and prescription claims from 2015 to 2017 for individuals who received a PCSK9i prescription. We used multinomial logistic regression to estimate quarterly risk-adjusted approval rates for initial PCSK9i prescriptions and approval for any PCSK9i prescription within 30, 90, and 180 days of the initial PCSK9i prescription. For a 2016 subsample for whom we had PCSK9i-specific plan policy data, we examined factors associated with approval including PCSK9i-specific plan formulary coverage, step therapy requirements, and number of PA criteria. ResultsThe main sample included 12 309 patients (mean age 64.8 years [SD = 10.8], 52.1% female, 51.5% receiving Medicare) and was similar in characteristics to the 2016 subsample (n = 6091). Approval rates varied across quarters but remained low (initial prescription, 13%-23%; within 90 days, 28%-44%). Over time, rejections owing to a lack of formulary coverage decreased and rejections owing to PA requirements increased. Lack of formulary coverage and having ≥11 PA criteria in the plan policy were associated with lower odds of PCSK9i prescription approval. ConclusionsThese findings confirm ongoing PCSK9i access issues and offer a baseline for comparison in future studies examining the impact of recent efforts to improve PCSK9i access.

Missed Opportunities for HPV Vaccination Among Vaccine-Eligible Women with High Grade Cervical Lesions

BackgroundIncidence of high-grade cervical lesions (HGCL) has declined in the U.S following the introduction of the human papillomavirus (HPV) vaccine in 2006. However, many women continue to be diagnosed with HGCLs, including those eligible to receive the vaccine but did not. We determined self-reported barriers to and correlates of HPV vaccination in vaccine-eligible women diagnosed with cervical intraepithelial neoplasia grades 2, 2/3, 3 and adenocarcinoma in situ (CIN2+). MethodsData from a statewide surveillance system in Connecticut for CIN 2+ during 2008–2015 were used for this analysis. Enhanced surveillance data were collected for women residing in New Haven County, including HPV vaccine history and demographic factors, through chart review and patient interviews. Women who reported being unvaccinated were asked why they did not receive the vaccine. We evaluated trends in reasons for not receiving the vaccine using a two-sided Cochran Armitage trend test. Log-binomial analysis was used to assess associations between sociodemographic characteristics and vaccination status. ResultsBetween 2008 and 2015, 1625 vaccine-eligible women were diagnosed with CIN2+, with 882 of these women reporting never receiving the HPV vaccine. The proportion of unvaccinated vaccine-eligible women did not significantly change from 2008 to 2015 (p = 0.18, range 49.1% to 60.0%). The most commonly reported reason for being unvaccinated was age/too old, followed by previous HPV diagnosis and no provider recommendation. Women who had public or no insurance were significantly more likely than privately insured women to report being unvaccinated (p = <0.001, p = 0.0034). ConclusionsCommonly cited barriers to vaccination, such as age/too old and previous HPV diagnosis, are not contraindications for vaccination. Furthermore, frequent reporting of no provider recommendation underscores the important role providers play in the immunization of their patients. These results indicate the need for greater efforts by providers to dispel myths about HPV vaccine eligibility and to promote vaccination for all of their eligible patients.

Dynamic stagnation: reasons for contraceptive non-use in context of fertility stall.

Background: While most countries have experienced reductions in the total fertility rate (TFR), there are countries where the fertility transition has not begun and others where the fertility transition has stalled with TFR still well above replacement level. We use these contexts of "fertility stagnation" to explore reasons behind contraceptive non-use among women who desire to delay or avoid a future birth. Specifically, we explore whether women's reasons for not using contraception are stagnant as the population-level indicator, TFR, suggests or are more dynamic. This nuanced understanding can inform programmatic direction for countries especially in need. Methods: Using Demographic and Health Survey (DHS) data from the two most recent surveys of ten study countries-five countries that have not yet experienced a fertility transition ("pre-transitional") and five countries that began the fertility transition but stalled ("transitional")-we explore trends in reasons for non-use. Results: We find that that reasons for non-use are changing. Specifically, in pre-transition study countries, women are increasingly citing attitudes opposing contraception as reasons for non-use. In transition countries, women are increasingly citing reasons related to service quality and method side effects. Perceived low fecundability is increasingly cited among both pre-transition and transition study countries. Geographical access and cost are not prominent frequently cited at either time point. Conclusions: These findings highlight the need for prioritized programmatic attention aimed at: reducing opposition to contraception in pre-transitional countries; improving service quality and addressing issues of side-effects, both experienced and perceived, in transitional countries; and addressing fecundability perceptions in both types of country contexts. We remind policy makers that even in contexts of fertility stagnation, underlying attitudes, norms, and barriers to contraceptive uptake are shifting. Lack of change at the population-level can mask important changes at the individual-level that must be accounted for in program development and implementation.

National Trends in Parental Human Papillomavirus Vaccination Intentions and Reasons for Hesitancy, 2010-2015.

Human papillomavirus (HPV) vaccination uptake remains lower than other recommended adolescent vaccines in the United States. Parental attitudes are important predictors of vaccine uptake, yet little is known about how they have changed over time. Participants included US residents aged 13-17 years with documented vaccination status who had received <3 doses of HPV vaccine whose parents responded to the National Immunization Survey-Teen, 2010-2015. Of the 76971 participants, 63.0% were male, 58.8% were non-Hispanic white, and 14.4 years was the median age. The percentage of unvaccinated teens decreased from 2010 to 2015, yet, annually, parents of unvaccinated teens of both sexes most often reported that they were "not likely at all" to vaccinate their teen. The percentage decreased significantly from 41.5% to 31.2% (P < .001) for parents of unvaccinated females from 2010 to 2015 but did not change among parents of males from 2012 to 2015. Conversely, parents of undervaccinated teens of both sexes reported higher and increasing vaccination intent over time. In 2015, nearly one-third of parents of unvaccinated teens reported that the vaccine was "not needed/necessary." Concerns about vaccine safety and side effects declined among parents of unvaccinated females but increased among parents of males (7.3% to 14.8%; P < .001). Although parental vaccination intent and knowledge improved over time, intent remains low and many parents still have significant concerns about HPV vaccination, even after series initiation. Multiple strategies are needed to improve series initiation and completion in the United States.

Diagnosing the Decades-Long Rise in the Deceased Donor Kidney Discard Rate in the United States.

The proportion of deceased donor kidneys recovered for transplant but discarded increased steadily in the United States over 2 decades, from 5.1% in 1988 to 19.2% by 2009. Over 100 000 patients are waiting for a kidney transplant, yet 3159 kidneys were discarded in 2015. We evaluated trends in donor characteristics, discard reasons, and Organ Procurement Organization-specific discard rates. Multivariable regression and propensity analysis were used to estimate the proportion of the discard rate rise in the 2000s attributable to changes in donor factors and decisions to biopsy and pump kidneys. This study found that at least 80% of the discard rate rise can be explained by the recovery of kidneys from an expanding donor pool and changes in biopsy and pumping practices. However, a residual discard rate increase could not be explained by changes in these factors. From 1987 to 2009, median donor age rose from 26 to 43 years; median Kidney Donor Risk Index increased from 1.1 in 1994 to 1.3 in 2009. Our findings suggest that the increase from 10% to 30% in the proportion of kidneys pumped during the 2000s served as a buffer, keeping the discard rate from rising even higher than it did. The majority of the kidney discard rate rise can be explained by the broadening donor pool. However, the presence of an unexplained, residual increase suggests behavioral factors (eg, increased risk aversion) and/or allocation inefficiencies may have played a role. Reducing risk aversion, improving allocation, and more often pumping less-than-ideal, yet potentially transplantable kidneys, may help reverse the trend.