Utibe R. Essien

Background: Angiotensin receptor-neprilysin inhibitors (ARNI) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) are incompletely utilized in heart failure with reduced ejection fraction (HFrEF). The degree to which use varies at the individual level and within specialties is unknown. We aimed to characterize provider-level and specialty-level variation in ARNI and SGLT2i prescribing after HF hospitalization. Methods: This retrospective cohort study included Veterans Affairs (VA) providers seeing patients within 6 months of HFrEF hospitalization 2017-2023. We used descriptive statistics and site-adjusted multilevel logistic regression to examine prescribing by medical specialty, provider type, and provider sex. Adjusted median odds ratios (mOR) and empirical (unadjusted) provider-level rate ratios (RRs) by percentile were used to describe provider-level variation. Clinical pharmacy visits were assessed as an independent factor and as an interaction with specialty. Results: Among 7,946 providers caring for 76,795 patients across 211,267 outpatient encounters, provider-level variation remained substantial after adjustment for patient characteristics and site-level clustering (mOR 1.45 for ARNI; 1.46 for SGLT2i). Within every specialty, providers ranged from near- zero to near-100% use. Relative to the median provider in the same specialty, RRs ranged from 0-0.31 (5th percentile), 0.37-0.71 (25th), 1.38-1.66 (75th), to 1.8-3.2 (95th). Cardiology visits carried the highest adjusted odds of ARNI (OR 2.30, 95% CI 2.18-2.44) and SGLT2i use (OR 1.99, 95% CI 1.88-2.11) and most new starts. Pharmacist visits were independently associated with greater use of ARNI (OR 1.14, 1.06-1.23) and SGLT2i (OR 1.15, 1.06-1.24), with no effect modification by specialty. In early 2023, 58.4% (ARNI) and 40.2% (SGLT2i) of post-hospitalization HF visits had untreated patients. Conclusions: Provider-level variation in ARNI and SGLT2i use after guideline incorporation was large within every specialty and independent of site effects. Though specific specialties have higher use, individual providers, not specialty alone, may be an important target for efforts to close gaps in therapy. CLINICAL PERSPECTIVE: What Is New?: In the years following guideline incorporation, provider-level use of ARNI and SGLT2i after heart failure hospitalization ranged from near 0% to near 100% use within every specialty. Providers at the 95th percentile prescribed at 1.8 to 3.2 times the rate the median provider of the same specialty. Provider-level variation persisted after accounting for patient characteristics and site-level clustering (median odds ratios 1.45 for ARNI and 1.46 for SGLT2i) in a health system with a national formulary and low copayments. What Are the Clinical Implications?: Individual practice patterns within every specialty may be an important target for efforts to close gaps in guideline-directed therapy, and the drivers of this variation warrant study. Visits with cardiology and endocrinology providers were associated with greatest use of both medications, supporting specialty care for HF. Clinical pharmacists could play an important adjunctive role.

Background: Atrial fibrillation (AF) is the most common arrhythmia, affecting up to 6 million in the United States, and is associated with significant morbidity and mortality. Despite higher rates of AF clinical and social risk factors, underrepresented racial and ethnic group individuals have lower AF incidence. Structural factors, such as neighborhood‐level racial and ethnic residential segregation, have been associated with incident cardiometabolic disease, particularly among underrepresented individuals. However, as data on segregation and incident AF are sparse our objective was to examine the association of segregation on AF. Methods: Data from MESA (Multi‐Ethnic Study of Atherosclerosis; baseline 2000–2002) were used to identify those with a diagnosis of AF during follow‐up. Own‐group racial and ethnic segregation was defined by local Gi* statistic, which compares the percentage of each racial and ethnic group in a current census tract to the surrounding area. Racial‐ and ethnic‐stratified Cox proportional hazard models were used to estimate hazard ratios comparing across segregation levels. Models were adjusted for demographic, participant, and neighborhood level socioeconomic, and clinical factors. Results: Our cohort comprised 5375 participants (31% Black, 25% Hispanic/Latino, 44% White). During a median follow‐up of 16.6 years, 1035 participants (19.3%) were diagnosed with AF. Black and Hispanic/Latino participants had the highest prevalence of AF risk factors at baseline and were more likely to reside in segregated neighborhoods than White participants. After adjusting for demographic, socioeconomic, and clinical factors, neighborhood segregation was not found to be associated with AF across racial and ethnic groups. Conclusions: In this longitudinal analysis we did not observe an association between residential segregation and AF incidence for Black, Hispanic/Latino, or White participants in fully adjusted models. Further research is needed to understand how individual factors may intersect with clinical, health care, and structural factors to drive previously described differential risk of AF.

Background: Polypharmacy is increasingly common across all age groups and is often associated with the use of potentially inappropriate medications (PIMs), where harms may outweigh benefits, contributing to increased adverse drug events, reduced quality of life, and rising health care costs. However, existing deprescribing guidelines and PIM criteria, such as the Beers Criteria and STOPP/START (Screening Tool of Older Persons’ Prescriptions/Screening Tool to Alert to Right Treatment), primarily target older adults, overlooking the risks faced by younger populations. Objective: This study aims to develop an international consensus-based list of PIMs for adults aged 18 to 65 years through a modified Delphi process, addressing a critical gap in medication safety and deprescribing guidance. Methods: A 14-member international steering committee developed a preliminary list of candidate PIMs through a literature review and expert input. An international, interdisciplinary Delphi panel of 30 to 40 participants will evaluate this list across 3 survey rounds. Panelists will rate the relevance of potential PIMs using predefined criteria, including the balance of benefits and harms, patient preferences, and the availability of alternatives. Consensus will be defined as a median rating of ≥4 (for inclusion) or ≤2 (for exclusion) on a 5-point Likert scale (1=not relevant to 5=extremely relevant), with an IQR width of ≤1 and at least 70% directional agreement. Items not meeting thresholds will be carried forward to subsequent rounds for reconsideration. Quantitative analyses will summarize ratings and agreement levels, while qualitative free-text responses will undergo content analysis to provide context and capture nuanced perspectives. The process will yield a prioritized list of PIMs for adults aged 18 to 65 years. Results: Panel recruitment was completed between September and October 2025, with 36 participants. Three rounds of data collection were completed between October 2025 and January 2026. Interim analyses were conducted to inform structured feedback between rounds. Final data analysis is ongoing, and consensus results are expected to be reported in late 2026. Conclusions: This Delphi process will yield a consensus-based list of PIMs for adults aged 18 to 65 years, informing the development of an international guideline to support safer prescribing practices and to expand deprescribing efforts beyond geriatric care.

Rheumatoid arthritis (RA) imposes substantial clinical and economic burdens worldwide.¹ Disease-modifying antirheumatic drugs (DMARDs) can control RA symptoms and prevent joint degeneration and organ damage, and they include conventional synthetic DMARDs (csDMARDs; eg, methotrexate), biologic DMARDs (bDMARDs; eg, adalimumab), and targeted synthetic DMARDs (tsDMARDs; eg, tofacitinib).