Heart failure affects approximately 860,000 Canadians, is associated with reduced survival and quality of life, and is the third leading cause of hospitalization in the country. Heart failure with reduced ejection fraction (HFrEF) accounts for approximately half of these cases.

Despite high-quality evidence supporting the benefits of guideline-directed medical therapy (GDMT) for patients with HFrEF, which entails the rapid initiation of four distinct classes of medication collectively known as quadruple therapy, use of these medications remains suboptimal. This is in part due to inadequate access to heart failure specialists and clinics for many Canadian patients living with HFrEF. This high unmet need underscores the importance of alternative models that expand beyond physician-led GDMT management.

“Heart failure is a serious medical condition that has several effective medications that are underused across Canada,” says lead investigator Ricky Turgeon, BSc(Pharm), ACPR, PharmD, Faculty of Pharmaceutical Sciences, University of British Columbia. “Pharmacists and nurse practitioners are important members of the healthcare team who can help to improve medication use for heart failure.”

The researchers evaluated whether getting pharmacists and nurse practitioners to initiate and manage heart failure medications would be good value for money for the healthcare system by comparing two different scenarios using an economic model.

In the first scenario, patients with heart failure received the usual care currently experienced by most British Columbians with heart failure. In the second scenario, patients with heart failure received the usual care plus additional medication management from pharmacists and nurse practitioners. The investigators then modelled what would happen to these patients over time and tracked how long they would live, how often they would be hospitalized, and how much healthcare resources they would need.

It was estimated that within the first year of implementation, this added service would save approximately 10 lives and prevent 25 hospitalizations per every 1,000 patients who received the pharmacist- or nurse practitioner-led intervention.

“While this service would require additional funding, we demonstrated that this investment would be well justified given what the Canadian healthcare system is generally willing to pay,” notes Dr. Turgeon. “The size of this benefit was far beyond what was anticipated. As a pharmacist caring for people with heart failure, I find these results genuinely empowering. They show that we play an important role in improving patients’ lives while also easing pressure on the healthcare system. We have the evidence; now we need to implement this approach.”

By quantifying the clinical and economic impacts of these additional medication management services, this study provides healthcare system planners with the insights needed to effectively address persistent gaps in care for heart failure patients.

Co-lead investigator Kelly Mackay, MA, Cardiac Services BC, Provincial Health Services Authority, comments, “Our research offers a roadmap to improving patient outcomes while strengthening the sustainability of our health system. The research also provides Cardiac Services BC with the evidence and innovation needed to drive meaningful system change.”

“Expedited and increased access to quadruple therapy has the potential to save lives and reduce some of the pressures in British Columbia’s hospitals. We believe this model could also be successful in other Canadian provinces. We’re thrilled that this research presents such an effective—and feasible—way for more heart failure patients to receive this gold-standard treatment,” concludes co-investigator Nathaniel Hawkins, MBChB, MD, MPH, Cardiac Services BC, Provincial Health Services Authority, and Division of Cardiology, University of British Columbia.

Meanwhile, traditional, in-person visits to the doctor’s office have rebounded since the pandemic. And although digital medicine has become a routine part of healthcare, it is supplementing rather than replacing in-person care. This evolution, researchers say, is reshaping how hospitals and clinics operate daily.

These are the main conclusions of the study, which was led by researchers at NYU Langone Health and represents the largest review ever performed on communications recorded by Epic electronic health records. The team’s analysis involved more than 140 million patient records from 2,067 hospitals and 47,100 health clinics in the US. As part of the study, the researchers evaluated over 8 billion patient-provider interactions that took place between January 2020 and December 2025.

Publishing in the Journal of the American Medical Association (JAMA) online June 22, the study team found that online portal messages more than doubled between 2020 and 2025 (by 153 percent). By contrast, total telephone calls decreased by 6 percent over the same period. The number of Americans with an active Epic health record went from 94 million in 2020 to 140 million in 2025. Thirty percent of active patients on Epic (42 million) sent a portal health app message to their clinician during the first three months of 2025.

Patient portal visits, however, are not replacing in-office visits, which have returned to an average of between two and three per year per patient. Messages from patients to healthcare providers have doubled since the pandemic, from an average pace of 2.2 per year in early 2020 to 5.4 per year in late 2025.

“Our study shows that use of patient portals, health apps, and messaging are now a routine part of everyday patient care across America, not simply side channels used occasionally,” said study senior investigator Michal A. Mankowski, PhD.

Dr. Mankowski, an assistant professor in the Department of Surgery at NYU Grossman School of Medicine, said the study demonstrates that patients now have much more direct access to physicians and other clinicians.

“Our findings reveal that while digital health tools have become a core part of healthcare, delivery is becoming more continuous, timeless, and no longer tied to scheduled appointments during routine work hours,” said Dr. Mankowski.

Among the study’s other findings was that since 2020, Americans have, as logged in Epic record systems, booked at least 1.77 billion in-person visits to health clinics, sent 1.34 billion messages to their healthcare providers, and received some 3.25 billion online portal messages from providers. Also documented in Epic were 1.59 billion telephone calls and 146 million virtual telehealth portal visits.

Study co-investigator Dorry L. Segev, MD, PhD, said that the digital delivery of healthcare does not replace the old ways of working; it just adds another layer of more steps to existing workflows. To manage this new patient reality, hospitals, clinics, and healthcare workers have to plan future staffing and support.

“Modern delivery of healthcare means increasingly that healthcare providers will have to balance their digital workload on top of their traditional clinical workload,” said Dr. Segev, a professor and vice chair in the Department of Surgery at NYU Grossman School of Medicine. “Clinical staff will need to be trained in mastering the tools of messaging in healthcare; in using AI support programs, including chatbots that can frame content to minimize its complexity; and in making the most effective use of clinician time needed for online billing and online counseling,” said Dr. Segev, who is also a profession in NYU Grossman’s Department of Population Health.

Already, he noted, NYU Langone uses AI support tools to speed up drafting of physician and provider notes.

Dr. Segev said the team next plans to look more specifically at digital-use trends within healthcare systems, including NYU Langone, to break down any regional and outpatient clinic-specific shifts that could affect operational planning.

For the study, the team used Epic Cosmos, a national dataset of the electronic health records of more than 300 million American patients. The dataset includes information from a majority of hospitals and clinics that use Epic, the nation’s largest vendor of electronic health record systems, which had no role in performing the study.

Funding support for the study was provided by NYU Langone.

Along with Drs. Mankowski and Segev, NYU Langone researchers involved in the study were lead investigator Jane J. Long, MD, and co-investigators Mara A. McAdams DeMarco, PhD; Mark D. Schwartz, MD; Joshua Chodosh, MD; and Eric K. Oermann, MD.

Dr. Mankowski was recently elected to serve on the governing board of Epic Cosmos. Dr. Schwartz reported being president-elect of the Society of General Internal Medicine. Dr. Segev has received consulting and/or speaking honoraria from Sanofi, CareDx, Moderna, AstraZeneca, Roche, Optum, OrganOx, Hansa, and Biosidus and is a journal editor for Springer. None of these activities are related to the current JAMA study. NYU Langone is managing the terms and conditions of these relationships in accordance with its policies and procedures.

The population-based retrospective cohort study, which analysed data from more than 1.8 million Canadian adults, examined how initial prescribing patterns influence whether patients go on to use benzodiazepines over the long term. The findings highlight a critical window of opportunity at the point of first prescription, suggesting that the decisions clinicians make early on can have a significant bearing on a patient’s longer-term trajectory.

Benzodiazepines are widely prescribed for conditions including anxiety, insomnia, and seizure disorders, but long-term use carries well-documented risks including dependence, cognitive impairment, and difficulties with withdrawal. Concerns about overprescribing and the potential for harm have made identifying modifiable risk factors a priority for researchers and health systems alike.

The study – funded by a Womenmind Grant to co-principal investigators at the Centre for Addiction and Mental Health (CAMH) – found that three initial prescribing characteristics were associated with earlier discontinuation: keeping the initial course short, prescribing a single benzodiazepine rather than multiple agents, and opting for short-acting formulations over longer-acting ones.

The research team say the results could directly inform prescribing guidelines, offering clinicians practical, evidence-based levers for reducing the risk of patients transitioning from short-term to long-term use.

The full paper, Association between initial benzodiazepine prescribing patterns and time to benzodiazepine discontinuation: A population-based retrospective cohort study, is freely available at https://plos.io/4uxybkF.

Image: Researchers assess long-term benzodiazepine use in Canada.

Credit: Haley Lawrence, Unsplash (CC0, https://creativecommons.org/publicdomain/zero/1.0/)

“Our study findings highlight opportunities to improve patient care and reduce inappropriate testosterone prescribing. Long-term, these findings can lead to quality-improvement efforts and clinical decision support tools that promote consistent, guideline-concordant testosterone prescribing,” said senior author Maria Papaleontiou, M.D., associate professor at the University of Michigan in Ann Arbor, Mich.

The retrospective chart review included a random sample of 200 males assigned at birth (mean age, 52.5 years) with at least one outpatient primary care visit at Michigan Medicine in the past year, who had a diagnosis of hypogonadism, and received an initial testosterone prescription during the study period (2020 to 2025).

The most common coexisting medical conditions in the study population included obesity (63%), hypertension (52%), depression (40%), diabetes (28%) and arthritis (28%).

That data show only 12% of men who received an initial testosterone prescription had two low morning testosterone levels (total testosterone < 300ng/dL), free testosterone < 70pg/mL, or low bioavailable testosterone, between 5 a.m. and 10 a.m.), had their LH and/or FSH measured, and had no contraindications to testosterone therapy.

More than half of the patients (62%) had a prostate-specific antigen (PSA), and 77% had a complete blood count measured in the year before the initial testosterone prescription.

Overall, 55% of the men had obstructive sleep apnea, 4% prostate cancer and 1.5% PSA >4 ng/mL before being prescribed testosterone.

Prescriptions were written by primary care physicians (45%), urologists (35.5%), endocrinologists (18%) and other specialists (1.5%). The most common testosterone prescription was a topical formulation (68.5%).

Sinha and Papaleontiou said improving guideline-concordant testosterone prescribing can help prevent avoidable risks in people who may not have a true clinical need for it.

“Future studies should evaluate whether targeted interventions are needed,” Papaleontiou said.

Dr Deniz Turkmen, a postdoctoral researcher at the University of Exeter AGE Group, Exeter, UK, and colleagues studied data from nearly 38,000 UK Biobank participants who had been prescribed steroids. They calculated how much steroid each one had taken over time; whether higher doses were linked to more side effects; examined whether genetic differences could help explain those who were at risk; and, finally, tested whether adding genetic information improved risk assessment. They found that, in patients treated with steroids, certain genetic variants increased the risk of side effects; CYP3A4 for osteoporosis and CTLA4 for stroke and cataract, among others. “We were also able to show a clear relationship between the dose of steroid and side effects,” says Dr Turkmen. “This precise analysis shows the increased risk associated with long-term treatment”.

Incorporating polygenic risk scores* (PRSs) for osteoporosis enabled the researchers to further improve the steroid risk assessment. This improvement went beyond routinely available factors such as age and sex, and was particularly marked in in younger individuals at the time of their first prescription. “Currently, without efficient prediction methods, clinicians try to reduce risks by using only short courses of steroids, prescribing the lowest possible dose, or switching to alternative steroid-sparing treatments such as biologics. However, biologic treatments are often more expensive and may not be easily accessible to all patients. These strategies may also be insufficient for individuals with chronic conditions who require repeated or long-term steroid treatment. The routine use of genetic information could mean that, in the future, patients at high risk could be identified and given earlier steroid-sparing treatments, or have closer monitoring for side effects,” she says.

Given the widespread use of steroids, large-scale implementation of PRSs in their prescribing will present a major challenge. The most practical application is likely to be targeted to higher risk individuals, and particularly those where steroid use may be longer-term.  The findings also need to be studied in other cohorts to ensure that they are applicable more widely, say the researchers. Larger and ethnically more diverse populations may also enhance predictive performance, since the pharmacogenetic effects observed in the study are consistent with other biological mechanisms that influence steroid metabolism and immune response.

“We anticipated that we would find a clear relationship between dose and adverse outcomes,” says Dr Turkmen, “It was reassuring that the genetic findings involving CYP3A4 and CTLA4 aligned with their roles in steroid metabolism and immune regulation, but the improvement in prediction of osteoporosis when we incorporated polygenic risk scores data was remarkable, especially in younger patients. While single variants had a relatively limited influence on the risk of serious side effects from steroids, adding PRSs for traits such as bone mineral density improved risk prediction. We hope that, in time, greater availability of genetic data at population level will mean that it will be possible to integrate genomics into everyday healthcare and hence into prescribing decisions. That will be a major step on the road to the provision of personalised medicine for all.”

Chair of the conference, Professor Alexandre Reymond, who was not involved in the research, said: “Today we are seeing more and more examples of the predictive value of compounding the risk foreseen for variants that are rare and have a large effect with those of common variants with small effects.”

* A polygenic risk score is the assessment of the risk of specific conditions based on the collective influence of many genetic variants in an individual’s genome.

From the BBC to behaviour change

Kimberly Littlemore spent many years as a documentary filmmaker at the BBC, working across science, health and international topics. For a decade she worked closely with Comic Relief and Sport Relief, collaborating with writer Richard Curtis on fundraising films that reached millions of viewers on Red Nose Day. While travelling in Africa, India and South America for this work, she repeatedly observed community health workers striving to communicate vital health information — about malaria, HIV transmission, and diabetes — to their local populations, often with limited resources.

“I really wanted to make films in local languages for community health workers, to help them train and spread their message as far and wide as possible,” she explains. Before she could pursue this ambition, however, she encountered an opportunity closer to home.

In 2013–2014, while living in Wales, she met Professor Sam Rice, a consultant endocrinologist, who challenged her to address a pressing local problem. Diabetes rates in Wales were high, many people were unaware of their diagnosis, and those referred to diabetes education courses were failing to attend. “The statistics were really poor,” recalls Ms Littlemore. “He said, can you help me?” Together, they produced a series of short films about diabetes management, presented by Dr Jane Gilbert. The results, subsequently published in the European Journal of Diabetes, showed a significant improvement in HbA1c over three months among those who watched the films — an improvement that compared favourably with outcomes seen with metformin and was better than those attending a diabetes course. This early evidence convinced Ms Littlemore that her documentary skills could be powerfully applied to health behaviour change.

PocketMedic: the model

PocketMedic was founded on a core insight: it is not enough to provide information. To drive behaviour change, films must first understand why people fail to do what is good for them. “It’s very easy to be a little bit lazy and just make films about information,” says Ms Littlemore. “But until you really understand what stops people doing things that are going to be good for them, you can’t really get to grips with the challenges that people face.”

She draws on self-determination theory and applies the documentary storytelling techniques she honed at the BBC — filming people in their homes, focusing on relatable human stories, and making content that feels relevant to everyday life. The approach was further refined by a personal experience: after sustaining an injury and looking online for physiotherapy guidance, she found the available content uninspiring. “They were all people in white studios with gym balls. We could do this so much better if we did it in the home,” she says.

The result is a library of short, accessible films on topics ranging from diabetes and COPD to lymphoedema and dementia, all freely available at https://pocketmedic.org. Films are hosted on YouTube, making them easy to watch on a phone or computer at any time. Clinicians routinely refer patients directly to relevant films, and Ms Littlemore personally responds to viewer feedback received through the contact button on each page.

Evidence of impact

PocketMedic has accumulated a growing evidence base across several clinical areas:

• Physiotherapy: An early study found that people who watched PocketMedic physiotherapy films not only improved their ability to perform exercises correctly but also showed better adherence, with fewer missed follow-up appointments.
• Diabetes: The landmark Wales study demonstrated a significant HbA1c improvement over three months in patients who watched the diabetes films, outperforming both metformin and formal diabetes education courses. Only 28% of those offered the films chose to watch them — but among those who did, the clinical benefit was clear.
• COPD: A PhD study by Dr Liam Knox examined the impact of PocketMedic’s COPD self-management films compared with pulmonary rehabilitation. There was no significant difference in outcomes between those who attended the course and those who watched the films alone, suggesting the films are a clinically effective alternative for patients with transport or accessibility barriers. Patients who had completed pulmonary rehabilitation noted that access to the films while waiting for their course would have been particularly valuable.
• Colonoscopy preparation: Working with Professor Tony Rahman at Prince Charles Hospital in Brisbane, Australia, PocketMedic developed a film series to support patients preparing for colonoscopy or endoscopy. Previously, inadequate bowel preparation meant procedures were frequently abandoned. Since the films were introduced, patients arrive better prepared and more confident, the number of appointments required per patient has fallen, and Professor Rahman has noted a positive impact on polyp detection rates — with potential downstream benefits for cancer outcomes. This project received a Royal College of Physicians International Excellence Award.
• Insulin safety for healthcare professionals: In collaboration with the Cambridge Diabetes Education Programme (CDEP), PocketMedic produced a suite of films on the safe use of insulin in hospital, a high-risk area associated with serious prescribing errors. A study led by Professor Gerry Rayman at the University of East Anglia assessed knowledge in 620 healthcare professionals before and two months after watching the films. Staff knowledge improved in nine out of ten assessed areas, and crucially, insulin errors fell from 26% to 14%. The films are embedded in CDEP training courses and have been viewed hundreds of thousands of times.

The films have also been used by a lymphoedema specialist network in Wales, led by Dr Melanie Thomas, to help patients manage complex daily routines involving garments, drainage and skin care — offering what Dr Thomas described as a way of “delivering herself into everybody’s living room.”

Reach: from rural Wales to Saint Helena

One of the most striking examples of PocketMedic’s reach involves the remote island of Saint Helena, in the South Atlantic Ocean. A UK diabetes specialist nurse deployed there found high rates of diabetes among the local population, very limited educational materials, and poor patient engagement with existing resources. Having previously encountered the PocketMedic films at a conference or course, she contacted Ms Littlemore. Because of limited Wi-Fi connectivity on the island, the films were loaded onto a USB drive and installed in clinics across the island. According to reports, the films have been well received and are making a real difference to diabetes education there.

This example illustrates a broader point: the film format is inherently flexible and portable. It can reach patients who cannot or will not attend formal education programmes, those in remote or under-resourced settings, those with learning difficulties, and those who simply prefer to learn in their own time and space.

Expanding into dementia

Ms Littlemore’s most recent work has focused on dementia, driven in part by personal experience: both her parents lived with dementia, and she cared for them during the COVID-19 lockdown period. Unable to find useful filmed content about the lived experience of dementia, she placed fixed cameras in her parents’ home over the course of a year and used the footage as the basis for discussions with clinicians and academics. The resulting material informed a commissioned dementia film series, which is now being used for carer training by the Gloucestershire Integrated Care Board. Since becoming available in February 2025, these films have already been viewed more than 7,000 times.

Ms Littlemore is now developing a dementia awareness app aimed at three groups: people noticing early cognitive changes, those who have recently received a diagnosis, and family carers. Its aim is to broaden understanding of dementia beyond memory loss, addressing its impact on perception, attention and the senses. The app draws on the Alzheimer’s Society finding that 85% of people diagnosed with dementia wish to remain at home for as long as possible. “I’m basically trying to create something that’s currently missing,” she says.

Why it works

Ms Littlemore attributes the success of the PocketMedic approach to a combination of factors. Films are made using the same principles she applied to BBC fundraising content: finding common humanity in individual stories, filming in real homes and environments, and addressing the psychological barriers to behaviour change rather than simply providing instructions. The films are accessible via smartphone, available on demand, and free at the point of use. They can complement — or in some cases substitute for — formal education programmes, particularly where access is difficult.

For healthcare professionals, the films offer a practical tool: a clinician can simply direct a patient to a specific film on the PocketMedic website, or refer them by saying “Go to Google and search PocketMedic and diabetes.” Ms Littlemore is also keen to collaborate with clinicians and organisations interested in developing new content or exploring applications in areas not yet covered.

About Kimberly Littlemore

Kimberly Littlemore is the founder of PocketMedic and Director of eHealth Digital. She is also Honorary Research Associate, Faculty of Medicine, Health and Life Science, Swansea University.

She is a former award-winning BBC documentary filmmaker with extensive experience in health, science and international affairs. Her work on colonoscopy preparation films received a Royal College of Physicians International Excellence Award. She is a member of the International Federation of Aging and works with clinical and academic partners internationally to develop film-based health education content. Clinicians or researchers interested in collaborating can contact her at kim@ehealthdigital.co.uk.

The PocketMedic film library is freely accessible at https://pocketmedic.org or via a Google search for “PocketMedic” and the relevant condition.

Chile ranks among the highest countries globally for rates of childhood overweight and obesity [1]. To combat this issue, in 2016 Chile implemented one of the world’s most comprehensive and ambitious food policies, the Food Labelling and Advertising Law (FLAL) [2].

The FLAL targets foods and drinks high in sugars, saturated fats, salt, or calories through three core measures: mandatory front-of-package warning labels in the form of black octagons (images available here), restrictions on the sale of such products in schools, and limits on food marketing directed at children.

Prof Guillermo Paraje, Professor of Economics, Universidad Adolfo Ibáñez Business School (Chile), says, “Although individual national measures like sugar taxes on soft drinks have been associated with improved health outcomes, this is the first study to plausibly demonstrate that a package of policies can reduce early childhood overweight/obesity risk at the national level.

“These results offer strong evidence for policymakers around the world. They support mandatory front-of-pack nutrition warning labels, restrictions on unhealthy food in schools, and marketing bans as effective, practical ways to tackle the childhood obesity epidemic.”

National data on more than 300,000 schoolchildren aged four to six in Chile was used to compare children’s weight from the years before the introduction of FLAL with the weight and size of children in the same school grades after the first phase of the law came into place in 2016.

The study found that children who had been at school for 18 months after the introduction of FLAL Phase 1 were less likely to be overweight or have obesity than those in the same grades before FLAL. Girls had a 2.9% lower risk of overweight or obesity (a reduction of 1.4 percentage points from a pre-FLAL rate of 47.7%) while boys had a 2.4% lower risk (a reduction of 1.2 percentage points from a pre-FLAL rate of 52%.)

The study also found a plausible causal impact in the cohort of schoolchildren aged four to six after only six months of the FLAL Phase 1; girls had a 1.9% lower risk of overweight or obesity (a reduction of 0.9 percentage points from a pre-FLAL prevalence of 47.4%) and boys a 2.2% lower risk (a reduction of 1.2 percentage points from a pre-FLAL prevalence of 52%).

Phases 2 and 3 of FLAL set stricter limits on sugars, saturated fats, salt, or calories. These phases were introduced in 2018 and 2019, so they did not impact the study’s results.

Dr Nieves Valdes, Associate Professor of Economics, Universidad Adolfo Ibáñez Business School (Chile), says, “Although the reduction in obesity and overweight risk among young school children may seem modest, it is likely that the further tightening of the law in later years will have increased the impact, especially given evidence that there was a greater drop in sales of labelled food products during Phase 2 of the FLAL compared to Phase 1.”

“Additionally, even a small weight reduction for children who have overweight or obesity is likely to bring meaningful long-term health benefits, given the strong links between childhood obesity and later risk of obesity, diabetes, hypertension, and cardiovascular disease, as well as evidence that early prevention can substantially lower these risks.”

The researchers note some limitations of their studies, including that the plausible causality of the relationship relies on the assumption that, if the FLAL hadn’t been introduced, the two cohorts of school children would have followed the same nutrition trends, which cannot be tested although support for the assumption was provided through pre-policy trends. Additionally, the children’s weight was collected by school staff who, although trained for this task, may not achieve the same precision typically found in primary health care settings.

Writing in a linked Comment, Professor Simone Pettigrew and Dr Daisy Coyle, The George Institute for Global Health (Australia), who were not involved in the study, say, “In a policy environment where industry opposition constitutes a formidable obstacle to the implementation of health-promoting policies, high-quality, real-world evidence is critical. […] the research results strengthen the case for governments to move beyond incremental, single-policy approaches and to instead implement comprehensive, integrated strategies to improve food environments. In particular, the results highlight the potential for policy suites including mandatory warning labels and marketing restrictions on unhealthy foods and school food minimum standards to produce meaningful outcomes.”

Researchers used two behavioral science-backed methods to prompt clinicians to prescribe the medication, called naltrexone, to qualified patients, resulting in a 15-fold increase in the likelihood that a patient would leave the emergency department with a prescription. The research from the Perelman School of Medicine at the University of Pennsylvania was recently published in the Annals of Emergency Medicine.

“Nationally, because of stigma and a lack of awareness, we are missing out on a huge opportunity to offer effective treatment to patients who struggle with alcohol,” said first author Jeffrey Ebert, PhD, the director of Applied Behavioral Science at Penn Medicine’s Nudge Unit. “Our work shows that it only takes a small adjustment to make a huge impact on who gets the medicine they need.”

Demonstrating an effective medication with few prescriptions

A 2023 national study found that only 1.9 percent of people with AUD received medication to treat their condition. The initiation of naltrexone in the emergency department is significantly lower: Just 0.5 percent of patients presenting with alcohol use disorder received a prescription from the emergency department.

But, the positive effects of naltrexone have been demonstrated: Compared to those taking placebos, 1 in 11 patients with alcohol use disorder quit drinking altogether when taking naltrexone, with the typical patient reducing their heavy drinking days­­­—characterized as four-plus drinks a day for women, and five-plus for men—by one to two days per month.

With this in mind, the Nudge Unit researchers decided to use Penn Medicine’s own emergency departments to establish a potential solution to spur higher naltrexone prescription numbers.

They employed nudges in two phases:

• The first phase, initiated in March 2024 involved establishing a standardized set of steps for caring for a patient potentially presenting with alcohol use disorder or other forms of problematic drinking, and a formatted discharge order that included a prepopulated order for a naltrexone prescription.
• The second phase began three months later, in August 2024. This phase added questions about alcohol to the typical triage questions nurses asked, and a banner alert in patients’ electronic health records if they had screened potentially positive for harmful drinking. Clicking on it immediately sent the physician to the standardized steps for treating these types of patients and the naltrexone order.

“We were very cognizant of the ‘alert fatigue’ that clinicians experience, so we were sure to make the emergency department electronic health record screening prompts and pre-populated orders seamless, user-friendly, and removed some dated components to make sure there was no extra clutter or time burden,” said senior author M. Kit Delgado, MD, MS, faculty director of the Nudge Unit and an associate professor of Emergency Medicine.

Seeing big increases

The nudges were implemented in four hospitals across the University of Pennsylvania Health System, with two others serving as controls.

At baseline, which included data from two-and-a-half years before the nudges started, only 13 (0.2 percent) of patients with an alcohol-related diagnosis received a naltrexone prescription from the emergency department.

When the nudges began, however, 2.7 percent of these patients were prescribed naltrexone during Phase 1. In Phase 2, that rate increased to 3.2 percent, resulting in 99 patients being prescribed naltrexone in just over a year.

In comparison, at the hospitals with no nudging, naltrexone prescribing remained close to 0 (just 0.3 percent of patients with an alcohol-related diagnosis received a prescription).

The jumps in ordering at the nudge hospitals translated to a 12-fold increase in the likelihood of receiving a naltrexone prescription in the Phase 1 period, and a 15-fold increase during Phase 2.

“Before our intervention, only a handful of experts prescribed naltrexone, and only one patient every couple months left with a prescription,” Ebert explained. “It just wasn’t something routinely done in the emergency department. After our intervention, 46 different clinicians prescribed it, with two patients each week, on average, getting a prescription.”

Implemented elsewhere in Philly…and Bhutan

Amid their findings, study-co-author Jeanmarie Perrone, MD, a professor of Emergency Medicine and the founding director of the Penn Medicine Center for Addiction Medicine and Policy, emphasized the opportunity for spreading the word to other physicians about naltrexone.

“There are highly effective, underutilized, low-cost medications for alcohol use disorder, a disease that affects roughly one in 10 Americans,” said Perrone. “It’s something that, likely, many in our own community have been affected by in their loved ones or personally, so it would be helpful to spread information about these good, accessible treatments.”

Already, the team is working to apply their methods to other emergency departments in the health system that didn’t originally get the nudges.

The team was also called upon to implement their work in low-resource settings like Philadelphia’s Puentes de Salud. The learnings are also being applied further afield: Emergency departments in Bhutan are adopting the nudges, too.

The researchers are also exploring how they could expand screening for alcohol misuse in primary care and effectively connect people to treatment.

This study was supported by philanthropic donations directed to the Penn Medicine Nudge Unit.

For patients with religious or ethical beliefs — including Muslims, Jews, Sikhs, Buddhists, and vegans — the animal origin of a medicine can directly affect whether they accept or adhere to treatment. However, a survey by Abdalla Alkhateeb, Trainee Pharmacist at University Hospitals Plymouth NHS Trust, suggests that pharmacy staff may not always know enough about animal products in medicines to discuss the issues with patients. It is estimated that about 2% of the population could be affected.

Animal-derived ingredients are present in many commonly prescribed medicines – and while animal-free alternatives exist, their usage varies considerably. For example, at University Hospitals Plymouth the low molecular weight heparin (LMWH) of choice is enoxaparin, a product that is derived from porcine intestinal mucosa cells. Fondaparinux, which contains no animal products, is reserved for patients with acute coronary syndrome.

Survey findings

An anonymised survey of 62 pharmacists, pharmacy technicians and trainees at University Hospitals Plymouth NHS Trust Derriford Hospital was conducted over a two-month period. A total of 30 people responded and the results showed that:

• 85% of respondents did not realise that gelatine can be used as an excipient in tablets as well as capsules
• 85% did not know how to check for dietary preferences or restrictions in patient notes
• 66% were unaware that some commonly used injectables – including enoxaparin (LMWH), alteplase, and chimeric monoclonal antibodies – are animal-derived.
• 45% did not know that fondaparinux is animal product-free
• 35% could not identify which patient groups might wish to avoid animal-derived medicines

Notably, there was no correlation between years of experience and knowledge in this area, suggesting this is a systemic gap rather than one resolved simply by time in practice. The existing organisational prescribing protocol also does not currently suggest alternatives.

Mr Alkhateeb explained that an easy way to identify people who may wish to avoid animal products in medicines would be to ask about dietary restrictions when conducting medication reconciliation interviews.

Action taken

In response to these findings the medicine reconciliation protocol has been revised to incorporate dietary restrictions. A Drug and Therapeutics Committee application has been submitted to enable fondaparinux as an alternative to enoxaparin where appropriate.

Future work includes reviewing medicine management policies in the next PDSA cycle and surveying inpatients prescribed LMWH about their dietary preferences to assess the real-world impact of these changes.

High cholesterol is a key modifiable risk factor for cardiovascular disease, but many eligible patients are not receiving lipid-lowering therapy. A service evaluation by Ankush Sareen (Clinical Pharmacist, Long Lane Surgery, North West Leicestershire GP Federation) demonstrates how a pharmacist-led group consultation model can address this gap — improving patient engagement, increasing treatment uptake, and delivering meaningful clinical outcomes.

Conventional one-to-one appointments often leave insufficient time for education and shared decision-making, contributing to patient misconceptions about statins and low treatment uptake. The group consultation model was designed to tackle these barriers directly.

Method

Patients with a QRISK2 score ≥10% and LDL-C cholesterol >1.8 mmol/L who were not yet on lipid-lowering therapy were identified via a SystmOne and invited by Accurx with a self-booking link. The pharmacist-led group session covered cardiovascular risk, lifestyle modification, and the benefits and safety of statins. Common misconceptions were also addressed. A post-session Accurx questionnaire captured treatment preferences and automatically coded responses in the clinical record. Each patient then received an individual clinical review prior to prescribing, with a repeat lipid profile and liver function tests at eight weeks.

FIndings

Attendance was high, with 88% of invited patients (n=35) taking up the invitation to the group consultation. Following the session, 23 patients opted to start statin therapy and 7 declined.  At eight weeks, results among biochemical responders were clinically significant: 63% achieved a ≥40% reduction in LDL cholesterol, and 32% reached the target of LDL <1.8 mmol/L. The average LDL reduction was 1.52 mmol/L. The authors noted that each 1 mmol/L LDL reduction is associated with a 20–25% relative reduction in major cardiovascular events. Mr Sareen commented that the feedback from patients had been particularly favourable, saying that their questions had been answered.

Managing the same cohort through individual 15-minute appointments would have required approximately eight hours and 45 minutes of pharmacist time. The group model took around two and a half hours — releasing over six hours of clinical capacity for other long-term condition work.

Next steps

For primary care teams looking to improve cardiovascular outcomes efficiently, this approach offers a replicable template. Plans are now underway to scale this model across a 12-practice GP federation, with potential expansion into hypertension and diabetes management.

Photo: Ankush Sareen, Clinical Pharmacist, Long Lane Surgery, North West Leicestershire GP Federation

Electronic prescribing (EP) systems are now firmly embedded in modern clinical practice, promising safer, more efficient and more accountable medication management. Yet implementation alone is not enough. Research using the Electronic Prescribing Risk and Safety Evaluation (ePRaSE) tool has revealed considerable variation across NHS trusts in how EP systems are configured to mitigate known prescribing risks — highlighting significant room for improvement.

In response, the ePRaSE team, sponsored by NHS England, has developed the Electronic Prescribing Learning Lab (EP Learning Lab): a practical, evidence-based toolkit designed to help trusts optimise their EP systems and realise their full clinical benefit.

Poster presenter, Michelle Haddock commented:

“The Lab is really useful if people have not understood the concept of system optimisation. It’s an evidence-based approach, it’s not a step-by-step guide”.

What is the EP Learning Lab?

Developed by the ePRaSE Programme Board and NHS Midlands & Lancashire CSU — with contributions from clinical pharmacology, informatics and innovation — the EP Learning Lab is an interactive PDF resource structured around a core framework of optimisation themes. These include system configuration, integration, clinical decision support (CDS), governance and reporting, workforce and culture, and drug–drug interactions, among others.

The resource draws on a comprehensive literature review, analysis of ePRaSE 2024–25 campaign data, AI-assisted knowledge synthesis, and real-world case studies covering areas such as anticoagulation, insulin prescribing, paediatrics and mental health.

Crucially, the EP Learning Lab is system-agnostic — designed to be applicable across different EP platforms, hardware environments and clinical protocols, making it relevant to a wide range of NHS settings.

Why it matters

For health professionals involved in medicines management, digital transformation or patient safety, the EP Learning Lab offers a structured starting point for identifying and addressing gaps in EP system performance. It supports trusts to strengthen clinical decision support tools, reduce alert fatigue, improve data quality and drive workflow optimisation.

The toolkit’s principles extend beyond EP systems, offering value to any team engaged in broader digital systems improvement across the NHS.

Access the EP Learning Lab at www.eprase.info/lab/ or via NHS Futures.

Photo: Michelle Haddock Lead Pharmacist, NHS Midlands & Lancashire Commissioning Support Unit (MLCSU) / NHS Arden & Greater East Midlands Commissioning Support Unit (Arden & GEM)

Published in JAMA Health Forum, the study is the first to quantify patient cost impacts after B.C. introduced free prescription contraception in April 2023.

The highest payers gain the most

Before the policy, the pill averaged about $25 per month, while IUDs ranged from $75 to more than $500 up front—and for long-term pill users, lifetime costs could reach $10,000.

Nearly 40 per cent of prescription contraception was not covered by insurance, but was paid out of pocket by patients—the highest rate in Canada and well above most other prescription drugs. Among young adults, that figure was even higher at about 45 per cent. After implementation, their out-of-pocket share fell by roughly 33 percentage points. Across all patient groups, the share of prescriptions with any patient cost dropped to under 10 per cent and to five per cent for prescription contraceptives that were fully covered.

Two years later, patient spending was 83 per cent lower than expected, translating to average savings of $43 per contraceptive user per year.

“People in their 20s are often in a coverage gap. They’re off a parent’s plan but not yet in jobs with benefits,” said lead author Dr. Elizabeth Nethery, a postdoctoral researcher at UBC’s faculty of pharmaceutical sciences. “This policy was particularly important for this group who were most likely to be paying out of pocket.”

System costs stable as access expands

The study analyzed pharmacy data from all 10 provinces, using jurisdictions without universal coverage as a comparison. While patient costs fell sharply, total contraceptive spending across patients, insurers and the public system remained essentially unchanged after two years. Researchers also found increased uptake of long-acting reversible contraceptives, including IUDs and implants.

“Universal coverage works,” said senior author Dr. Laura Schummers, an assistant professor at UBC. “Removing cost barriers increased uptake of the most effective methods, which helps reduce unintended pregnancy and inequality—adding to strong evidence that universal contraception coverage is essential in Canada.”

In Canada, roughly two out of five pregnancies are unintended, disproportionately affecting people with fewer financial resources.

Policy momentum across Canada

Manitoba introduced a similar program in October 2024, with early results consistent with B.C.’s. At the federal level, Canada passed pharmacare legislation in 2024 committing to public coverage of contraception, although implementation agreements currently involve only three provinces and one territory.

The study was funded by the Canadian Institutes of Health Research and included researchers from UBC, the University of Calgary, the University of Manitoba, Simon Fraser University and the University of Ottawa.

Interview language(s): English (Nethery, Schummers), French (Nethery)