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.

Primary care practices acquired by private equity tended to see more patients, provide more services to patients, complete more annual wellness visits and expand their staff, according to the study published in Health Affairs. 

“Our prior work has highlighted specific harms from private equity firms acquiring and consolidating physician practices, including higher prices for patients and insurers,” said lead study author Yashaswini Singh, an assistant professor of health services, policy and practice at Brown’s School of Public Health. “This study is a reminder that the relationship between private equity and patient care is more complicated than it first appears, and financial incentives shaped by payment policy play an outsized role in how private equity operates.”

Singh and the team from Brown’s Center for Advancing Health Policy through Research used national Medicare claims to track what happened at 225 primary care practices after they were acquired by private equity firms between 2016 and 2022.

They compared that data with similar primary care practices that remained independently owned to understand how private equity buyouts can change the day-to-day practice of primary care medicine, including physician workload, how many patients doctors see and the services those patients receive.

The team found that while private equity ownership does seem to increase productivity pressures on practices — with physicians billing for about 30% more services — practices saw about 11% more patients overall.

At a time when primary care is increasingly difficult to access nationwide, connecting more patients to primary care is generally viewed as a positive outcome, they said.

That context also applies to the roughly 13% more services received by individual patients in private equity owned practices compared to independent practices. The increase was largely driven by more preventative care, including lab tests and screenings, that can identify problems such as diabetes or high cholesterol before they become serious.

One notable finding was that the Medicare annual wellness visit drove much of the increase in services received. The visit is a comprehensive preventive checkup, which Medicare has long recommended but which independent practices have historically struggled to complete because of documentation requirements. Acquisitions prompted an increase in annual wellness visits by more than 20%.

The study also found that in contrast to other private equity–owned health care settings where staffing cuts are common, primary care practices instead expanded their workforces under private firms.

Compared to independent practices, they hired about 17% more physicians and 40% more nurse practitioners and physician assistants, suggesting the extra work of providing additional services and seeing more patients is likely being spread across larger teams rather than falling on individual doctors.

“Research has documented real harm from staffing cuts following private equity involvement in other settings, as in the case of hospitals and nursing homes, but we must resist a one-size-fits all takeaway,” Singh said. “What we see in primary care is more nuanced: practices grew their teams and drew on both physicians and advanced practice providers in the short term.”

Total Medicare spending per doctor increased by about 15% after private equity firms came in, but spending per patient stayed roughly the same. That means doctors were seeing more patients and billing for more services, researchers said, but individual patients weren’t receiving more expensive care.

For private equity firms, however, that increased volume meant more revenue because of Medicare’s fee-for-service system, where doctors are paid for each service they deliver.

The researchers note a number of limitations to the study, including that it only looked at Medicare patients, followed practices for a relatively short period, and cannot determine whether the changes actually improved patient health. There could also be unexamined harms to patients and doctors that the study does not capture, including reduced clinician autonomy and burnout.

According to the researchers, the biggest takeaway of the study and recent work from the team is that private equity may not operate the same way in every sector of health care.

“In many other settings, my colleagues and I have documented clear harms from private equity,” Singh said. “This study posits a different question: Under what market conditions and incentives can private equity actually deliver on the promises it makes around expanding access and improving care — and how do we create more of those conditions?”

These services are frequently hosted on digital platforms which can be inaccessible to disabled people, the consequences of which can be life-altering.

Blind people, for example, have reported being unable to book vaccinations during the pandemic due to websites that block screen readers. Wheelchair users report having to give their secure card details to strangers when they cannot reach a payment kiosk.

Disabled voters may face challenges accessing online voter registration systems or digital voting platforms that are not designed with accessibility in mind, effectively excluding them from participating in democratic processes.

The new book Digital Accessibility Ethics: Disability Inclusion in all Things Tech, with contributions from a global coalition of experts and advocates, calls for urgent action.

“Digital accessibility is not a luxury, it’s a civil and human right,” the editors Lainey Feingold, Reginé Gilbert and Chancey Fleet argue. “Without it, disabled people are excluded from participating in society, and the digital world cannot be ethical.”

Inequity in the digital age

The team of 39 expert authors demonstrate how the digital accessibility gap, a component of the digital divide, harms disabled people, who make up over 1 billion of the global population according to the World Health Organisation.

The experts argue that inaccessibility is pervasive and a daily challenge. As more services move online and technology continues to advance, without digital accessibility the digital divide will continue to widen.

“Increasingly, everything is digital,” the editors explain. “Our devices help us find our next job, our next love, our community gathering places. Learning and teaching happen online – in and out of the classroom, the workplace, the library. We depend on computers for work, entertainment, shopping, civic participation, and connection. Digital tools allow us to withdraw our own money, listen to music, play games, follow our favourite teams, and participate in local government.

“Legal problems are increasingly handled online. Daily, we look to our phones to find our way. In an emergency, the digital devices in our pockets offer critical safety information and unite us with loved ones.

“None of this is possible for people with disabilities when digital tools and content are not accessible.”

Inaccessibility has economic and social consequences for disabled people, who are more likely to live in poverty, face higher unemployment rates and lack access to critical services due to systemic barriers. Employers also miss out on the skills and creativity of a large section of society when disabled people are blocked from leadership potential by inaccessible workplace tools.

Systemic exclusion

One example where the stakes could not be higher is in emergencies and crises. According to the United Nations, only 20% of disabled individuals can evacuate without support, but less than 40% of emergency plans mention disability at all.

“These statistics are not coincidences,” explains Erin E. Brown, a Bahamian Disability Inclusion Consultant. “They are symptoms of structural ableism, where emergency preparedness frameworks fail to incorporate basic accessibility, digital or otherwise. And in a world increasingly reliant on technology to issue warnings, give directions, and provide services, the absence of digital accessibility is more than a design flaw. It’s an ethical breach.”

Emergency alerts and news updates often fail to include captions, sign language interpretation or screen-reader-friendly formats, leaving deaf, blind and neurodivergent individuals without critical emergency information.

A roadmap for change

The authors introduce a Digital Accessibility Ethics Framework, a tool designed to guide governments, corporations and people in creating inclusive digital environments.

The authors call for immediate action in several key areas, including introducing the Ethics Framework into organisational decision-making before exclusion happens, calling for more government accountability and enforcing compliance with the growing number of digital accessibility legal requirements across the globe.

The authors also suggest organisations should focus on creating digital tools and content that disabled people can use just as easily and independently as everyone else. This means adopting policies to ensure all technologies, whether purchased, licensed, or free, provide equal access to everyone.

They also suggest organisations should provide accurate and current accessibility information about their products and services, including a clear roadmap for addressing accessibility gaps. A robust feedback loop should be established to capture, remediate, and report on issues identified by disabled individuals, ensuring their voices are heard and acted upon, they advise.

“While technology and law are rapidly changing, one thing remains constant: the continued growth of the digital world. In the coming years, more decisions will be made about digital tools and content that impact ever-increasing aspects of our lives. Digital accessibility ethics must be part of that decision‑making,” the editors conclude.

DOI: 10.1201/9781003616702 

The findings are based on a nationally representative survey of more than 5,500 U.S. adults conducted from October through December 2025.

In the past 30 days, did you use an AI tool or chatbot for health-related information or advice for any of the following reasons?

% Yes, among adults who have used AI tools or chatbots for health-related information or advice in the past 30 days

Note. Categories are for descriptive purposes only and were not shown on the survey.

Among Americans who have used AI for health-related information or advice in the past 30 days, the most frequently cited motivations are wanting answers quickly (71%) and wanting additional information (71%). Nearly seven in 10 (67%) say they were curious about what AI would say, and roughly six in 10 report using AI to do research on their own before (59%) or after (56%) seeing a doctor.

Regardless of the reason, almost half (46%) of Americans who used AI for healthcare information say the AI tool or chatbot made them feel more confident talking with or asking questions of a provider. Others say it helped them identify issues earlier (22%) or avoid unnecessary medical tests or procedures (19%).

“Artificial intelligence is already reshaping how Americans seek health information, make decisions and engage with providers, and health systems must keep pace,” said Tim Lash, President, West Health Policy Center, a nonprofit and nonpartisan organization focused on aging and healthcare affordability. “The risk isn’t that AI is moving too fast — it’s that health systems may move too slowly to guide its use in healthcare responsibly.”

A Smaller Share Turn to AI in Place of a Provider

While self-directed research is the primary driver of AI health use, a smaller but notable share of recent users report turning to AI instead of seeing a healthcare provider, particularly when faced with cost, access or quality barriers. Among recent AI health users, 27% say they didn’t want to pay for a doctor’s visit and 14% say they were unable to pay. One in five (21%) say they didn’t have time to make an appointment, and 16% say they couldn’t access a doctor or provider. Another 21% say they felt dismissed or ignored by a provider in the past, and 18% say they were too embarrassed to talk to a person.

In the past 30 days, did you use an AI tool or chatbot for health-related information or advice for any of the following reasons?

% Yes, among adults who have used AI for health-related information and advice in the past 30 days

Among recent AI health users, 84% still saw a healthcare provider, but 14% report not seeing a provider they otherwise would have seen because of information or advice they received from AI. When projected to the full U.S. adult population, this represents roughly 14 million Americans who did not see a provider after receiving AI-generated health information.

Trust in that AI-generated health information, however, remains divided. Among those who consulted it in the past 30 days, roughly one-third say they trust it (33%), one-third neither trust nor distrust it (33%), and about one-third distrust it (34%). However, only 4% say they strongly trust the accuracy, indicating that many Americans are making healthcare decisions based on AI-generated information without full confidence in its accuracy.

About one in 10 (11%) who report using AI for health information or advice in the past 30 days say that AI recommended healthcare information or advice they believed was unsafe.

“This data indicates that while some Americans may be using artificial intelligence as a substitute for going to the doctor’s office, many see it as a tool to complement their healthcare, helping them understand symptoms they might be feeling and clarify any diagnosis they receive from their doctors,” said Joe Daly, Global Managing Partner at Gallup.

Motivations Vary by Age and Income

While information-seeking is the dominant reason Americans turn to AI for health purposes, use patterns differ by demographics. Younger adults are more likely than older adults to use AI for self-directed research — 69% of adults aged 18 to 29 say they do research before seeing a doctor, compared with 43% of those 65 and older.

Income differences are most visible in barrier-driven motivations. Among adults earning less than $24,000 annually, 32% say they used AI because they could not pay for a doctor’s visit, compared with just 2% among those earning $180,000 or more.

Everyday Health Questions Top the List of AI Use Cases

Americans who used AI for health information or advice in the past 30 days most often report using it to gather information about everyday health concerns, including physical symptoms (58%) and nutrition or exercise (59%). But AI use extends beyond symptom-checking — Americans who used AI in the past 30 days also report using AI to understand medication side effects (46%), interpret medical information (44%), or research a diagnosis or medical condition (38%). Nearly one in four (24%) report using AI to explore mental health or emotional concerns.

Methodology

West Health-Gallup Center on Healthcare, October-December 2025

Results are based on a Gallup Panel study conducted Oct. 27-Dec. 22, 2025, with a sample of 5,660 adults aged 18 and older who are members of the Gallup Panel, a nationally representative, probability-based panel of U.S. adults. Gallup uses random selection methods to recruit Panel members, including random-digit-dial (RDD) phone interviews that cover landlines and cellphones and address-based sampling (ABS) methods. Respondents with internet access completed the questionnaire as a web survey, and those without regular internet access were sent a printed questionnaire to complete and return by mail. The sample for this study was weighted to be demographically representative of the U.S. adult population, using the most recent Current Population Survey figures. For results based on this sample, one can say that the maximum margin of sampling error is ±2.1 percentage points at the 95% confidence level. Margins of error are higher for subsamples. In addition to sampling error, question wording and practical difficulties in conducting surveys can introduce error and bias into the findings of public opinion polls.

DIY test kits for human papillomavirus (HPV) – a group of viruses responsible for more than 90% cervical cancer cases – will be offered to women across the UK who have delayed or been unable to attend their traditional screenings.

Announced as part of the NHS 10-Year Health Plan, the kits contain a vaginal swab similar to a long cotton-wool bud. The scheme is due to be rolled out later this year. Traditional screenings, commonly known as ‘smear tests,’ are generally conducted in person at GP clinics.

The new scheme aims to tackle barriers that discourage women from attending in-person screenings, such as discomfort, embarrassment and cultural sensitivities. While there are currently no plans to routinely offer them as an option for physically Disabled women, at-home kits will be offered to women who are under-screened or have never been screened.

Disabled women often face unique barriers to traditional cervical screening, such as challenges in getting to appointments, a lack of accessible clinic facilities, difficulties in getting into the required position for the test, and a lack of understanding from healthcare providers.

The National Institute for Health and Care Research (NIHR)-funded study, which surveyed 1,493 UK-based women and people with a cervix with physical disabilities or impairments, found a broadly positive response to at-home testing:

• 63 per cent said they would be able to perform the test themselves.
• Over half would choose a home-testing kit over an in-person screening if given the choice.

Sue Sherman, a Professor of Psychology from the University of Sheffield, said: “Physically Disabled women face significant barriers when it comes to accessing healthcare, and cervical screening is no different.

“Our study is the first of its kind to explore the attitudes of physically Disabled women and people with a cervix to self-testing as an alternative to clinician-led cervical screening.

“Our research indicates that many physically Disabled women – particularly those who have delayed, missed or never attended a screening – would find this option easier and preferable.

“Ultimately, introducing self-testing will move us closer to ensuring that everyone has access to potentially life-saving screening, regardless of their physical condition.”

Contributor to the study Alycia Hirani, who lives with Osteogenesis Imperfecta (colloquially known as ‘brittle bone disease’), said: “Disabled women deserve choice in healthcare. Expanding testing options and knowledge of alternatives like HPV screening can give so much more access, autonomy and can be life-saving to so many people.”

The study also found that over 70 per cent of the women surveyed had concerns about performing the test correctly. To help address this, researchers recommend

tailored instructions catering to different physical needs and improved training for clinicians to ensure equitable screening access for all.

Read the study in full in the Journal of Medical Screening.

Why it matters: As hospitals close in some areas, practices consolidate and telehealth expands, older adults may tolerate long trips for care — but not equally. The study suggests socioeconomic status affects willingness to travel.

What’s new: A study published recently in JAMA Network Open finds that many Americans age 65 and older are willing to travel more than an hour for routine or specialized medical care.

What happened: Researchers at the USC Dornsife Center for Economic and Social Research (CESR) surveyed a nationally representative group of older adults.

• Questions centered on how long respondents currently travel for care and how much farther they would be willing to go before deciding to delay or skip an appointment.

Results: On average, respondents would tolerate about an hour or more of travel time, particularly for specialty care.

Growth of telehealth may be impacted by how willing patients are to take long trips for in-person care versus receiving remote clinical care. (Image source: iStock.)

• For primary care visits, they would travel 68 minutes.
• For a diagnostic test, such as an MRI, 113 minutes.
• For a specialist visit, 128 minutes.

What they’re saying: “This shows older adults place a high value on access to care,” said Soeren Mattke, professor (research) of economics, director of the Brain Health Observatory at CESR and study senior author. “They are often willing to travel significant distances before delaying or forgoing care.”

Yes, but: The averages mask important differences.

• Older adults in poorer health, those living in large metropolitan areas and those who had previously struggled with transportation were less willing to travel long durations.
• In contrast, those with higher incomes, more education and reliable access to a car reported greater willingness to spend more time traveling.

Study first author Jeremy Burke, senior economist at CESR, said those gaps matter for health equity.

• “If someone is already dealing with health challenges or transportation barriers, even modest increases in travel time can become a real obstacle,” Burke said. “Those are the patients most at risk of delaying care.”

The big picture: Health systems are consolidating, with some services moving into regional hubs rather than neighborhood clinics. Policymakers often debate how far is “too far” for patients to travel, especially for older adults.

• This study suggests that distance alone isn’t the full story. The type of visit, transportation options and personal resources all shape decisions.

The findings also have implications for telehealth.

• Virtual visits can reduce travel burdens, but they may not fully replace in-person care, especially for diagnostic tests or specialist consultations that require equipment or physical exams.
• “Telehealth is an important tool, but it’s not a cure-all,” Mattke said. “We still need to think carefully about where services are located and how patients physically get there.”

What else? Transportation policy plays a role, too. Programs that offer ride services, improved public transit or partnerships with community organizations could make a meaningful difference for vulnerable seniors.

Between the lines: Older adults living in big cities were less willing to travel long durations.

• This might boil down to traffic, parking and other travel complexities, which make even short drives feel burdensome.
• But rural residents, who often already travel long distances for care, appeared more accepting of extended trips.

Bottom line: Many older Americans are willing to travel surprisingly long distances for medical care — but willingness depends on health, resources and access to transportation.

• As care delivery models evolve, understanding those differences may help health systems and policymakers design services that better match patients’ needs and circumstances.

About the study

The findings are based on data from the Understanding America Study, a nationally representative internet panel administered by CESR. For this study, researchers surveyed a representative sample of 2,650 adults age 65 or older between April 23 and June 8, 2025, about their willingness to travel for primary care, specialty care and one-time diagnostic appointments.

In addition to Mattke and Burke, authors on the study include USC Dornsife researchers Tabasa Ozawa, Ying Liu and Wei Ye, all from the USC Brain Health Observatory based at USC Dornsife.

The study was funded by National Institute on Aging grants 1R01AG083189 and 1U01AG077280.

The emergence of online healthcare via mobile apps has brought about changes in the availability of and demand for health care. The current study, published in The Economic Journal, analyzes the consumption patterns of 19- and 20-year-olds.

The study is based on data from young people in the regions of Stockholm and Västra Götaland. During the study period, 1 9-year-olds were not charged a co-pay for online consultations, while 20-year-olds had to pay a fee..

Price sensitivity among patients was evident. Those who had turned 20 had on average half the number of online consultations compared to 19-year-olds. Women generally had higher consultation rates than men, and experienced a sharper decline once they turned 20.

The value of easing worries

“People often seek online healthcare for simple ailments, a type of care for which price generally matters more,” says Gustav Kjellsson, a researcher in health economics at the University of Gothenburg. “This doesn’t necessarily mean that it is unwarranted care. It’s important to bear in mind that without access to medical expertise, it is difficult to determine which healthcare needs you actually have. Easing people’s worries also has a value.”

The researchers estimate that 45% of the online consultations by 19-year-olds substituted a physical visit, while the remaining 55% represented care that would not have taken place without easy access to online care.

“These often relate to respiratory infections, skin conditions, and healthcare related to sexual and reproductive health, such as contraceptive management, which would typically be handled by a midwife,” he continues. “What we are seeing is a shift toward more care provided by doctors.”

Cost-neutral increase in volume

The researchers found no measurable negative medical effects from the shift toward more online and fewer in-person consultations, either on follow-up care or complication rates. A secondary finding is that young men, who are generally less inclined to seek healthcare, increased their visits to youth clinics.

“This may be an effect of an initial online doctor consultation,” says Gustav Kjellsson. “Accessibility may make it easier to seek help for conditions that are sensitive in nature, such as sexually transmitted diseases.”

The Swedish debate on online doctors involves quality of healthcare, resource allocation, the extent to which the burden on primary care is relieved, and not least how the regions reimburse private online doctor consultations. Against this background, there is another finding in the study that the researchers say stands out: The increased consumption of healthcare among 19- and 20-year-olds did not result in higher total production costs.“Interestingly, our estimates indicate that the increased volume of healthcare is more or less cost neutral. The regions’ costs for digital healthcare are not primarily due to production costs, but to the reimbursement models of private online consultation.”

Uveitis

Uveitis is an umbrella term for inflammation affecting the uvea, the middle layer of the eye. Patients can present with pain, photophobia, blurred vision and floaters. Uveitis can be caused by infections but can also be associated with auto-immune inflammatory diseases such as rheumatoid arthritis, Crohn’s disease or Behcet’s disease. If untreated, uveitis can impair vision permanently; “There is potential for vision loss from this inflammation and the damage that it causes. It can induce macular oedema, which is leaky fluid in the eye and if that fluid accumulates at the macula, which is responsible for your central vision, then it can impact your vision temporarily, but if left untreated can lead to permanent vision loss”, explains Ms Goacher.

Treatment of uveitis

The primary goal of treatment is the control of inflammation to prevent damage such as macular oedema. The clinical approach to uveitis is determined by the anatomical site of the inflammation. Anterior uveitis, affecting the front of the eye, is typically managed with topical steroid or anti-inflammatory drops. However, topical treatments cannot penetrate deeply enough for intermediate, posterior, or panuveitis, and systemic steroids are the standard first-line treatment. “If we can’t control patients on systemic steroids or …. if you can’t get patients off the steroids without them flaring back up with their uveitis you would then move on to secondary immunosuppressive medications. So, commonly we’d use mycophenolate or azathioprine”, says Ms Goacher. The biological, adalimumab is available as a third-line treatment, she adds.  Immunosuppressive treatment is steroid-sparing and can enable patients to transition off systemic steroids and avoid long-term side effects. Despite these options, an unmet need persists for patients who do not tolerate immunosuppressants, those who require maximal treatment but still experience flares, or those for whom systemic steroids are contraindicated.  Fluocinolone acetonide intravitreal implants (Iluvien ®), which provide local treatment, can be useful in these situations.

Fluocinolone intravitreal implants

The fluocinolone acetonide implant is a miniature device, measuring only 3.5 mm in length and 0.37 mm in diameter—roughly the size of a grain of rice. It is designed to be injected into the vitreous (the jelly-like part of the eye), where it slowly elutes the medication over a period of up to three years.

The implantation is performed as an outpatient procedure.  After the administration of numbing drops, the device is injected; the process typically takes 10 to 20 minutes, followed by a course of antibiotic drops. Once implanted, the patient cannot feel the device, and the polymer shell remains in the eye after the drug has been fully eluted.

Real-world clinical outcomes

Ms Goacher conducted an evaluation of 45 eyes (34 patients) treated with fluocinolone implants since 2019. The study group included patients with associated systemic inflammatory diseases, such as rheumatoid arthritis or Crohn’s disease. The findings highlighted several key clinical benefits:

• Visual acuity: 58% of patients experienced an improvement in visual acuity.
• Macular oedema resolution: At the six-month mark, 80% of patients with macular oedema saw the condition resolve.
• Systemic treatment reduction: 84% of patients taking systemic immunosuppressive medication were able to reduce their dosage, and three patients were able to stop systemic treatment entirely.
• Topical treatment reduction: There was a 20% reduction in the need for topical drops among the study group.

While the implant is designed to last three years, the audit found the average time to treatment failure (defined as the need for rescue therapy, such as increased drops or additional implants) was approximately 15 months. However, not all the patients had reached the three-year time point, notes Ms Goacher. Nevertheless, one-third of the patients in the study did reach the three-year mark without requiring further intervention, she says.

Managing complications

The use of local steroids in the eye is associated with known complications, primarily cataract development and increased intraocular pressure (IOP). In this audit,16% of patients developed cataracts post-insertion, with the average time to surgery being 12 months. Furthermore, 11% of patients experienced an IOP rise at the three-month mark. While three patients required surgery to manage this pressure, most cases were manageable with glaucoma drops.

From a clinical perspective, these complications are often viewed as a necessary trade-off; as Ms Goacher notes, cataract surgery is a routine, “bread and butter” procedure, whereas uncontrolled inflammation can lead to permanent, irreversible blindness.

Conclusion and future directions

The real-world data suggests that fluocinolone implants offer a robust option for stabilising uveitis and reducing the systemic medication burden on patients. Current efforts are focused on refining this data by looking at long-term outcomes for patients who have had the implant for two or more years to provide further insights into treatment efficacy.

Ophthalmology specialist pharmacist

The role of the specialist pharmacist in ophthalmology is expanding. Although initially Ms Goacher’s role was concerned with oversight of high-cost drugs, it has since grown considerably. The ophthalmology team at the Sussex Eye Hospital was welcoming and supportive and she soon found that ophthalmology offered many opportunities for pharmacy input. “It may not be that obvious on the outset but as soon as you scratch the surface there’s a lot to do in ophthalmology for pharmacy”, she says. For pharmacists looking to specialise in this important field, Ms Goacher highlights the support available through the UK Ophthalmic Pharmacy Group (UK OPG), which provides a network for advice and collaboration.

Clinical case studies have long been a fixture in medical journals and are a primary way doctors and other health professionals continue learning after their initial training. Typically, case studies are short summaries of a patient’s predicament alongside a clinician’s assessment, diagnosis, and treatment, reviewed exclusively through medical frameworks. But the new series from The Lancet taps experts from the social sciences and humanities to unpack concepts that health care practitioners, leaders, and policymakers can use to address the social and structural causes of global health inequities.

The second case study in the series, published on Thursday, was led by medical anthropologist Carlos Martinez, an assistant professor of Latin American and Latino Studies and core faculty member in the Global and Community Health Program UC Santa Cruz. Martinez and his coauthors describe the difficulties that asylum seekers face when trying to access health care and argue that health system leaders need to know how and when to call in outside resources and organizations to help overcome social, political, and legal challenges in patient care.

“Addressing these nonbiological determinants of health is increasingly being recognized as the most significant way to improve patient health outcomes, particularly among marginalized communities,” Martinez explained. “But clinicians are still not being provided with the knowledge base and tools they need to act on these determinants. Our case study encourages clinicians to partner with community-based advocacy and mutual aid organizations that are already doing a lot of the heavy lifting in supporting marginalized communities and to become familiar with and draw from their expertise in order to better serve patients.”

Revealing the health risks of a broken asylum system

Martinez’s case study focuses on a 45-year-old man seeking asylum in the U.S. who was suffering from kidney stone complications. A volunteer doctor at a clinic in Tijuana diagnosed the man and explained that he would need treatment with a specialized medical procedure called lithotripsy, which neither the clinic nor the public health system in Mexico could provide. The doctor prescribed medication to temporarily stabilize the condition, and the man then crossed into the U.S., where both he and his doctor assumed he would be able to get prompt medical care. Unfortunately, that’s not what happened.

The man was placed in an Immigration and Customs Enforcement (ICE) detention facility, where he was held for three weeks without a medical consultation, despite experiencing extreme pain. He then called a hotline telephone number operated by non-profit human rights organization Migrant Advocates. The organization submitted complaints to the facility’s warden, after which ICE offered a medical consultation from a jail physician but still did not provide adequate pain control, medication, or a specialist referral. That’s when the nonprofit reached out to the doctor in Tijuana who had initially diagnosed the man to request his medical records.

The doctor had never worked with an advocacy organization in this manner before and was worried about potentially running afoul of privacy laws by sharing patient medical information. But he also knew that his patient was at risk of infection and permanent kidney damage if the kidney stone was left untreated. The doctor decided to work with Migrant Advocates, contributing to a series of letters and court petitions advocating for the man to receive appropriate specialty care. The process took more than a year. The patient was eventually released from ICE custody and received the procedure he needed 5 months afterward at a hospital in Los Angeles. But treatment delays left him with moderate permanent kidney damage.

The whole ordeal took place back in 2022, when strict COVID-era public health rules initially implemented by the first Trump Administration were still in effect, reducing entry into the U.S. and allowing for quick expulsion of would-be immigrants, including asylum seekers. The situation has further deteriorated under the second Trump Administration, Martinez says, and migrants with medical needs now face more threats than ever.

“As Amnesty International has documented, all pathways to legally request asylum at the border are now blocked,” he said. “As a result, asylum seekers at the border are now stuck in permanent limbo in highly precarious environments, requiring more long-term support and medical care. This requires more collaborations between medical professionals, social service organizations, and legal groups documenting these experiences who are seeking to challenge the Trump Administration’s policies in court.”

Teaching clinicians how to call for backup

Martinez’s case study demonstrates the need for health care providers to develop what he and his coauthors call “structural intercompetency.” The term refers to both having a strong awareness of social, political, legal, and economic impacts on patient health and being ready and able to effectively collaborate with non-clinicians, such as legal and community advocates, to improve patient outcomes.

The practice is valuable in any setting where health care providers are working with marginalized populations, ranging from asylum seekers to patients who experience negative health impacts associated with racial or gender-based discrimination, political persecution, domestic violence, homelessness, incarceration, or occupational-related harms. Martinez and his coauthors lay out several pathways to supporting structural intercompetency in these cases.

First, doctors, hospital administrators, and public health officials can focus on developing and funding medical-legal partnerships, in which legal professionals are embedded in health care settings. These types of partnerships can reduce patient stress, readmission rates, and emergency department visits by helping patients access essential services, rights, and benefits. Health care leaders should also seek to expand partnerships to grassroots organizations, which can often provide both immediate material support for patients and lead advocacy efforts to advance long-term policy change.

“Currently, the partnership-building work of structural intercompetency is often being led by clinicians themselves, rather than by hospital administrators,” Martinez said. “Providers across California are currently collaborating with lawyers and community organizations to develop and advocate for the adoption of hospital policies and protocols that better protect undocumented patients and those who are being brought to hospitals by ICE officials.”

Medical schools also have a role to play. The case study argues that medical schools should integrate experts and practitioners beyond the health professions throughout their curricula, so that students build an awareness of the work of these experts, how it impacts patients, and how physicians can collaborate with them to advance health. This type of training could help students understand the limitations of clinical medicine and the need to work constructively with patients, communities, and outside experts to respond to social and political inequalities.

“Despite the benefits, many medical schools are currently rolling back curricula that address the social determinants of health amidst a political crackdown on so-called DEI in higher education,” Martinez said. “Our hope is that this series on global social medicine in The Lancet, considered one of medicine’s most prestigious journals, will encourage medical schools to restore and expand this kind of curriculum. By better preparing providers to engage collaboratively around social issues, medical schools and health systems could have broader impacts in improving patient and community outcomes and reducing strain on health systems.”

Early results from the community pharmacy independent prescribing (IP) pathfinder programme show that the community pharmacy is increasing patient access to advice and medicines for acute and long-term conditions, according to an audit presented by Paula Wilson (Strategic Pharmacy Leader, NHS Midlands and Lancashire Commissioning Support Unit).

From 2026 onwards, all newly-registered pharmacists will be qualified as Independent Prescribers. In preparation for this development the Independent Prescribing in Community Pharmacy Pathfinder programme was set up, in selected sites, and went live in September 2024.  The purpose of the programme was to explore how community pharmacists and their teams could deliver integrated clinical services aligning prescribing activity with general practices and the population needs of local communities. The results from the pathfinder sites will be used to inform a commissioning framework for IP.

The data from 171 pathfinder sites were analysed for the period August 2024 to July 2025. A total of 30,351 consultations was recorded with 55% resulting in a prescribing decision – starting (42.3%), changing (10.2%), or stopping (2.9%) a prescription.  In total, 98.6% cases were closed by the pharmacist.  A number of different of clinical models or services were involved. By far the most common was for minor ailments (68%) followed by prescription management (8.4%), hypertension (7.5%) and lipid management (5.6%). The majority (79.7%) of consultations were completed face-to-face. Telephone consultations accounted for 17.8%. The average time taken for completion of a consultation was 22 minutes.

The authors concluded that the IP programme offered patients convenient appointments of longer duration than typical GP appointments and comparable to those offered by PCN pharmacists. As a result of the service, many patients did not need appointments with GPs. It is anticipated that a national roll-out will increase prescribing capacity in primary care, potentially increasing patient services, access and choice in the future.

Wilson P, Baqir W, Sidhu J, Titterton J, Dance J, Hampshaw S, Haydar G, Crouch T, Pearson H, Dulay M, Hobbs C Joshua A, Horgan J. Wearly findings from the Community Pharmacy Independent Prescribing Pathfinder Programme in England. Clinical Pharmacy Congress North, November 2025

Photo: Paula Wilson

HRT Safety: Disentangling Breast Cancer Risk

One common query is whether hormone replacement therapy (HRT) increases the risk of developing breast cancer. The direct answer is often no, but the distinction between hormone types is crucial: the only type of HRT shown to be associated with a non-statistically significant increased risk is medroxyprogesterone acetate (a synthetic progestogen). Oestradiol, progesterone, and testosterone have not been shown to be associated with an increased risk of breast cancer.

The use of HRT in women with a history of breast cancer is challenging because comprehensive studies are lacking and historical data often included synthetic hormones such as tibolone. Moreover, many women have been told that they cannot have hormones because they’ve had breast cancer. However, “an oestrogen receptor positive breast cancer doesn’t mean it’s been caused by oestrogen and it doesn’t mean that oestrogen per se is all bad”, says Dr Newson. She often prescribes testosterone for women who have had oestrogen receptor positive breast cancer, and this can significantly improve symptoms and potentially improve prognosis.

Women who are BRCA-gene positive and have undergone prophylactic bilateral mastectomy or bilateral oophorectomy, can usually safely receive body-identical hormones. Studies, though small, suggest that women with the BRCA gene who have undergone oophorectomy and receive HRT may have a better prognosis, possibly due to the anti-inflammatory actions of hormones. “It’s really sad when I see women who have the BRCA gene [and] they’ve been told they can’t have hormones”, comments Dr Newson. Synthetic hormones should not be prescribed, she adds.

Genitourinary Syndrome of Menopause (GSM)

Genitourinary Syndrome of Menopause (GSM), formerly known as vulvovaginal atrophy (VVA), describes symptoms affecting the genital and urinary tracts. The term VVA is being phased out as “atrophy” means “withered and wasting away”, which may be seen as unduly negative.

GSM is very common, affecting 70–80% of menopausal women, but it is critical to recognise that it is not exclusive to menopausal women. It can also occur during perimenopause, in young women, those using oral contraceptives, or those breastfeeding, says Dr Newson. Beyond genital symptoms like dryness, soreness, and pain during intercourse, GSM includes significant urinary symptoms such as incontinence, urgency, and increased frequency. Most importantly, GSM is strongly linked to recurrent urinary tract infections (UTIs). Considering that urosepsis causes 30% of all sepsis cases, prevention is vital. Decades of data, dating back to the 1980s, show that the incidence of UTIs significantly reduces when women use vaginal hormones. Despite this powerful evidence, only a minority of women with GSM are prescribed these “transformational hormones,” which can also be safely used by women who have had breast cancer.

Neurokinin receptor antagonists (NK3RAs) for hot flushes

The neurokinin receptor antagonists elinzanetant and fezolinetant have been marketed to treat vasomotor symptoms (hot flushes). Originally developed as neuroleptics to help with psychosis, NK3RAs were found to reduce the frequency of hot flushes in women participating in trials. NK3RAs work by affecting the thermoregulatory zone in the hypothalamus and have been shown to reduce hot flushes compared to placebo.

However, significant caution is advised regarding their use. They have not been compared against the gold standard treatment (HRT) in clinical studies, which is unusual. Furthermore, because neurokinin receptors exist throughout the entire body, blocking them raises concerns about unknown long-term effects, explains Dr Newson.

Key concerns include:

1. Hormone inhibition:NK3RAs may inhibit natural hormone production, potentially reducing oestradiol, progesterone, and testosterone levels, especially in the brain, which is the site of the commonest menopausal symptoms.
2. Kisspeptin blockage:These drugs block kisspeptin, a protein known to inhibit metastatic spread. Given that NK3RAs are marketed heavily toward women with breast cancer, inhibiting this protective protein is a major concern regarding potential metastatic disease.
3. Safety Data:Long-term data is lacking. One small study has raised concerns about an increased incidence of epithelial cancers in women taking these drugs and fezolinetant received a black box warning from the FDA related to deranged liver function.

Addressing the age myth and guidelines

The notion that women can be “too old” for HRT is a misconception stemming from the findings of the Women’s Health Initiative (WHI) study. The WHI study reported an increased incidence of cardiovascular disease (CVD) in women over 60. However, the study used synthetic hormones (conjugated equine oestrogens) and high doses in women often already suffering from established CVD. “It was really giving the wrong type of hormone, the wrong dose to the wrong woman”, says Dr Newson.

It is illogical to assume that the body responds differently to oestradiol at age 59 versus age 61. Synthetic hormones are pro-inflammatory, which is detrimental, especially to older individuals or those with established CVD.

When starting HRT for older women who have “missed out”, Dr Newson advocates beginning with a low-dose transdermal oestradiol and progesterone, sometimes adding testosterone, and then allowing the patient to choose. While randomised controlled trials (RCTs) for natural hormones will never be available (because they would be considered unethical given the known benefits), personalised care and patient choice remain paramount, emphasises Dr Newson.

Finally, HCPs must critically assess guidelines. The latest NICE guidelines state that first-line treatment for the majority of women is hormones. However, the analysis failed to distinguish between synthetic and natural hormones due to a perceived lack of RCT data, meaning the guidelines conflate treatments with different risk profiles. Furthermore, a word search of the guidelines reveals a disproportionate focus on the word “risk” and the topic of “breast cancer” compared to “benefit” and “osteoporosis,” reflecting a potential bias. Effective menopause management requires applying the guidelines while prioritising the art of medicine and individualisation of care, says Dr Newson.

About Dr Louise Newson

Dr Louise Newson is a GP and menopause specialist.  She is the founder of Newson Health and Newson Education. She developed the Balance app (a menopause support app) and the Confidence in Menopause course for health care professionals.  She is the author of the best-seller, The Definitive Guide to the Perimenopause and Menopause and hosts a website that provides a wealth of articles, podcasts and other information.

The study, “Investigating the Impact of Advertising on Smoking Cessation: The Role of Direct-to-Consumer Prescription Drug Advertising,” was authored by Erfan Loghmani of the University of Washington and Ali Goli of the University of Rochester.

The study authors examined nearly a decade of U.S. market-level data, combining advertising exposure with prescription records and retail sales of cigarettes, e-cigarettes and nicotine replacement therapies (NRTs).

They found that prescription ads do help reduce smoking. Chantix advertising—the leading prescription cessation drug—boosted prescriptions for both Chantix and Bupropion (an older prescription option) and led to lower cigarette sales across markets.

On the flip side, ads for OTC smoking cessation products did not reduce cigarette use. They shifted some smokers toward options such as nicotine patches, gums and lozenges and away from prescription therapies that have been shown to be more effective. This pattern suggests that OTC advertising may have unintended consequences for overall cessation efforts.

There were some spillover effects. Ads for prescription smoking cessation products spilled over to increased demand for alternative cessation methods, including Bupropion and even e-cigarettes.

Insurance coverage played a critical role in shaping how advertising influenced behavior. In markets where health plans offered strong coverage for prescription cessation drugs, advertising translated into higher declines in cigarette sales. In contrast, in markets with limited coverage, the same advertising often pushed smokers toward OTC products or even e-cigarettes, which might be less effective at supporting long-term cessation. This finding underscores that the public health benefits of advertising depend on the accessibility and affordability of the promoted therapies, as well as the availability of substitutes. The same advertising investment yields very different public health outcomes depending on these structural factors.

“We find that Direct-to-Consumer advertising for prescription smoking-cessation drugs reduces cigarette sales, there is no question,” said Loghmani. “But direct-to-consumer advertising of OTC smoking-cessation products can have unintended consequences and shift some smokers away from prescription therapies that are shown to be more effective. This distinction is crucial for policymakers considering whether to restrict pharmaceutical advertising.”

The research team analyzed advertising expenditures, prescription fills, and retail sales for cigarettes and cessation products across multiple U.S. markets between 2010 and 2020. Using econometric models, they estimated both direct effects (advertising on its target product) and indirect effects (spillovers to substitutes and complements).

They then conducted simulations to test the effect of reduced DTCA advertising on cigarette sales. They found that a 10% reduction in DTCA leads to a 0.23% increase in cigarette sales and an equivalent decrease of 21.3 million packs of cigarettes in total nicotine content consumption.

“Our analysis shows that prescription drug advertising reduces cigarette consumption through multiple pathways,” said Goli.  “The primary mechanism is increased prescriptions for the effective prescription cessation medications, but we also observe spillover effects to other cessation products. However, these spillovers vary in effectiveness, which is why insurance coverage matters so much – when people can access the prescription drugs, we see the strongest public health benefits.” This result adds to the ongoing debate on how DTCA of prescription drugs affects public health. Although policymaking bodies like the American Medical Association (AMA) have advocated for a ban on all DTCA, the study shows that DTCA is net positive for smoking cessation.

Read the full study here: https://pubsonline.informs.org/doi/10.1287/mksc.2024.0848