The findings were published on March 9, 2026 in the CMAJ/Canadian Medical Association Journal.

“Our findings may reflect improved recognition and treatment of ADHD in adulthood; however, the speed and scale of this growth also raises important questions about how diagnoses are being made, and if this prescribing is always appropriate,” said Dr. Tara Gomes, program director of the Ontario Drug Policy Research Network at St. Michael’s Hospital, Unity Health Toronto and an ICES scientist, Toronto, Ontario.

As background, the researchers noted that, historically, stimulants have been prescribed mainly for pediatric cases of ADHD and some other conditions. But in the past 20 years, ADHD diagnoses and stimulant prescriptions have increased among adults, and data shows that this change accelerated after the start of the pandemic.

“We sought to examine patterns of stimulants dispensed to adults in Ontario and characterize adults who initiated such therapy before and during the pandemic,” the authors said.

The investigators used a regional database to identify monthly rates of new stimulant dispensations among adults in Ontario between January 2016 and June 2024

They found that among 327,053 adults who initiated stimulant therapy, the median age was 31 years and 55.4% were female.

When compared with stimulant prescribing before the COVID-19 pandemic, new adult users during the pandemic were more likely to be aged 25 to 34 years (26.5% v. 32.8%) and female (48.0% v. 59.0%). And the drugs were less likely to be prescribed by psychiatrists (25.5% v. 18.0%).

The rate of new stimulant dispensations rose from 0.16 to 0.44 new monthly dispensations per 1000 people between January 2016 and June 2024.

“Many of these findings are consistent with trends in stimulant prescribing observed globally in the post-pandemic era and are likely influenced by greater awareness of adult ADHD and improved access to care following a historical pattern of underdiagnosis of ADHD in adulthood — particularly among women,” said coauthor Dr. Mina Tadrous, associate professor, Leslie Dan Faculty of Pharmacy, University of Toronto. “However, the rising impact of social media influencers on ADHD awareness in young adults, as well as the rapid evolution of virtual health services that support online assessments and treatment, may also be contributing to misdiagnoses and potential harm.”

The authors concluded, “In Ontario, rates of new prescriptions for stimulants dispensed to adults accelerated rapidly during the COVID-19 pandemic. Monitoring and evaluation are needed to ensure appropriateness of use and safeguard against potential harms.”

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.”

When a lack of proper medication reconciliation (MedRec) led to a sharp deterioration in her father’s health Dr Rita Shane (Vice President and Chief Pharmacy Officer at Cedars Sinai Medical Center, Los Angeles, California) promised herself that she would ‘fix’ the problem before she retired. Just 20 years later she succeeded – MedRec by pharmacy staff became a legal requirement in California.

In 1998 Dr Shane’s father underwent a craniotomy for a brain metastasis associated with lung cancer. He developed “intractable agitation” and was transferred to a geriatric-psychiatric unit where his condition became much worse. When Dr Shane asked about his medication it became apparent that the steroids that he had been prescribed after the craniotomy had been abruptly discontinued when he was transferred.  “I knew you can’t just ‘cold turkey’ discontinue a steroid in a patient. Ultimately, I had him transferred back to Cedars Sinai because he ended up febrile. He was getting a decubitus [ulcer] and I was concerned that he would die of sepsis in a gero-sych unit due to what I considered an iatrogenic issue”, she says.

Medication reconciliation is often viewed as a simple clerical task. In fact, making an accurate record of current medication is an important procedure because the list becomes the basis for future prescribing decisions. Dr Shane has spearheaded a decades-long campaign to transform this process, arguing that pharmacy staff – pharmacists and technicians – are the only professionals with the specific expertise required to ensure medication safety during transitions of care. This effort recently culminated in California law SB 1254 and subsequent regulatory changes that mandate pharmacy-led MedRec for high-risk patients at both admission and discharge.

The “poly problem” and iatrogenic risk

One important reason for specialised pharmacy intervention is what Dr. Shane calls the “poly problem”: poly-disease, poly-doctor, and poly-pharmacy. As patients over 65 tend to have multiple chronic conditions, they often receive prescriptions from multiple providers and pharmacies. This fragmentation can create a chaotic medication history. In many ambulatory settings, medication histories are entered into the electronic health record (EHR) by medical assistants who, while vital to practice support, may lack in-depth training in pharmacology. These entries then become the “source of truth” for hospital admissions. For example, “When we first implemented our electronic health record, we would see orders like “methotrexate daily” [instead of weekly] that the pharmacist would intercept – and that’s really just a lack of knowledge and skills on the part of people that are transcribing orders without the benefit of the clinical knowledge”, she notes. Dr. Shane compares a medication order to a complex sentence: it requires the correct drug, dose, dosage form, route, rate, and duration. The pharmacist serves as a guardian angel over this process, making sure that orders are complete and accurate in the context of the whole patient, she says.

The evidence: Why pharmacy ownership matters

The push for legislative change was based on rigorous research evidence. Dr. Shane and her team conducted a randomised controlled trial in the emergency department, comparing “usual care” (medication histories taken by busy physicians or nurses) with those taken by trained pharmacy staff. The results were stark: pharmacists and technicians were significantly more accurate, identifying up to eight errors per high-risk patient.

The business case for pharmacy-led MedRec

For healthcare administrators, the argument for pharmacy-led MedRec extends beyond clinical outcomes to financial sustainability. Adverse drug events (ADEs) are a primary driver of increased hospital costs and. Data indicates that an ADE can increase a patient’s length of stay (LOS) – and therefore hospital costs – by an average of 3.1 days. At the time of the evaluation, the cost of a single admission or readmission due to these errors was estimated at $12,000 to $14,000.

By leveraging pharmacy technicians to transcribe histories accurately into the EHR, hospitals can achieve significant savings while allowing nurses and physicians to practice at the highest level of their licenses. One organisation demonstrated savings of $830,000 by utilising technicians for this function. Furthermore, reducing the 40 minutes of nursing time typically spent per patient on medication histories provides a major relief to frontline clinical staff.

All of this information was brought together in an infographic that was used to educate the State Board of Pharmacy and the California legislature about the problem. “Timing is everything” says Dr Shane and it turned out that one of the California senators was a pharmacist and he enthusiastically supported Dr Shane’s initiative. After a number of hearings, the bill was signed into law in September 2018, just two years and four days after her father’s death. “It was an exciting journey and really an outstanding opportunity to educate legislators”, she recalls. Moreover, during her discussions with legislators, “Everyone seemed to have an example of a family member having a problem with an inaccurate medication list – and that brought it home”, she adds.

Following the passage of SB 1254 (the bill in question) in 2018, a larger study involving 11 California hospitals (ranging from university-based to community hospitals) further validated these findings. Over a six-week period, the study captured approximately 16,000 errors across 2,300 medication histories. Notably, 94% of medication lists contained at least one error, and 25% of those errors were classified as serious or life-threatening. These findings were verified by independent physician reviews, ensuring that the severity of the errors was not overstated. Reflecting on the findings, Dr Shane says, “We demonstrated that we prevented significant harm in the state of California for the hospitals that implemented this new law”.

Closing the loop: MedRec at discharge

While the 2018 legislation focused on admission, Dr. Shane realised that the “back end” of the hospital stay remained a point of extreme vulnerability. She uses the analogy of a totally wrecked car (the patient) that is painstakingly repaired in a body shop (the hospital), only to be driven off a cliff at discharge because the final medication list was inaccurate.

Studies showed that even with accurate admission medication lists, patients still experienced an average of two medication errors at discharge. Approximately 20% of hospital admissions are medication-related, and at least 40% of patients have an error on their discharge medication list, she says. These errors, such as the inadvertent omission of anticoagulants or antibiotics, are then perpetuated by community pharmacists who, lacking access to patient records, have no way of recognising the mistakes.

To address this, Dr. Shane successfully advocated for a regulatory change through the California State Board of Pharmacy’s “sunset review” process. As of January 1, 2026, the law was expanded to include medication reconciliation at discharge for high-risk patients.

A new paradigm: The “high-alert patient”

Perhaps the most transformative concept proposed by Dr. Shane is the shift from focusing solely on high-alert medications to identifying the “high-alert patient”. This designation would apply to the most vulnerable individuals – those with multiple diseases and complex regimens – who should be “tagged” for prioritised pharmacist attention across all providers.

Dr. Shane’s vision is to see these California-led successes become a national standard. Through collaboration with the National Association of Boards of Pharmacy (NABP) and the Joint Commission, she continues to advocate for model legislation that designates pharmacy staff as the clear “owners” of the medication list. For health professionals, the message is clear: ensuring an accurate medication list is not a secondary task; it is a foundational element of patient safety that requires the specialised clinical lens of the pharmacy profession.

Defined as the collective ability of a team to generate novel and useful ideas, team creativity has long been studied in business and organizational psychology. However, until now, it had not been explicitly examined or validated in primary health care.

“Primary care teams are under growing strain. Despite being central to delivering high-quality, patient-centered care, these teams face rising burnout and declining job satisfaction,” said Yuna Lee, PhD, assistant professor of Health Policy and Management at Columbia Mailman School, and first author. “Over the past two decades, many interventions have attempted to improve clinician well-being, but most have focused on individual resilience or workload. Our findings suggest that strengthening team-level conditions—specifically creativity—may simultaneously reduce burnout, enhance satisfaction, and improve care.”

The study was conducted within a large New York State health system serving approximately 12 million people, with 85,000 employees, 21 hospitals, and 890 outpatient care centers. The sample included approximately 400 primary care providers and team members.

Among survey respondents, 32 percent had worked in their practice for more than five years; 16 percent were physicians, and 24 percent were registered nurses. Eighty-two percent identified as female, and 56 percent identified as White.

The study makes three key contributions to health services research:

1. Establishes team creativity as a meaningful concept in primary care. This is the first study to show the importance of team creativity to well-being outcomes in a setting that requires optimal teamwork for high-quality, patient-centered care.
2. Introduces and validates a practical measurement tool for measuring team creativity in primary care teams.
3. Advances understanding of how the work life of health care professionals impacts their well-being and, subsequently, patient care.

“Our study highlights the pivotal role of creativity in primary care teams,” said Lee. “Drawing on decades of research in management, organizational behavior, and social psychology, we show that creativity is not just about innovation—it is closely tied to how clinicians experience their work. This has significant implications for how health systems approach burnout.”

Lee continues, “With state policymakers and health system leaders under pressure to improve outcomes while addressing workforce shortages, our findings suggest that fostering team creativity should be viewed as a strategic asset.

Co-authors are Nancy LaVine, Northwell Health and Department of Medicine, Lenox Hill Hospital; Cheryl Rathert, College for Public Health and Social Justice, Saint Louis University; Yulia Kogan, Population Health Analytics, Northwell Health; and Lusine Poghosyan, Stone Foundation and Elise D. Fish Columbia University Professor of Nursing and Professor of Health Policy and Management.

The study was supported by the Agency for Healthcare Research and Quality (Grant 5R03HS027502-02).

The British Medical Association (BMA) says that, by 2040, England should have one  full time equivalent (FTE) GP for every 1,000 patients, to ensure manageable workloads and patient safety.

But new data released last month shows that every one of England’s 42 ICBs is falling far short of meeting this safe threshold, explains Stephanie Santos Paulo.

Nationally, there is one FTE GP for every 2,220 patients, but ICB level data show some regions are facing a far more severe doctor drought than others. The highest reported patient to doctor ratios are in London, Bedfordshire, Luton and Milton Keynes, where there are more than 2,700 patients for every GP.

“No matter where a patient lives in England, the safe limit for patients is being exceeded, with patient demand far outstripping GP capacity,” said Katie Bramall, chair of the BMA’s GP Committee.

Victoria Tzortziou Brown, chair of the Royal College of GPs, added that the findings demonstrated the “troubling picture” of general practice under growing strain. “The pressures on general practice are clearly far beyond what is safe or sustainable,” she said.

But a Department of Health and Social Care (DHSC) spokesperson defended the government’s record on GP numbers, saying, “We currently have the highest number of fully qualified GPs since at least 2015 thanks to actions taken by this government.”

While it is true that England now has 648 more FTE GPs than six years ago, since then around 3.7 million more patients have been registered at GP practices. This represents a 6% rise in patient numbers, against a 2% increase in GPs, leaving practices more thinly spread.

What’s more, since 2019 the gap between the most and least stretched ICBs has hardly changed, suggesting that these workforce shortages are chronic.

Tzortziou Brown said the “stark disparities” between ICBs were worrying. “We know that areas facing higher deprivation often have the highest ratios of patients to GPs, as well as the most difficulty recruiting and retaining GPs,” she said.

A spokesperson for Bedfordshire, Luton and Milton Keynes ICB said, “We presently have over 140 GPs in training roles, many of whom we expect to contribute to improving our GP to patient ratio when they qualify.” But they acknowledged that a low number of GP vacancies could make it difficult for trainees to secure posts once they qualified.

The data underline what GP leaders describe as a paradox in the workforce crisis, with qualified GPs unable to find work while their employed counterparts struggle to keep pace with growing patient lists, writes Santos Paulo.

The DHSC says it has recruited more than 2,000 extra GPs in the past year, and health and social care secretary Wes Streeting has also pledged to expand training numbers further.

But expansion of GP training places would need to be considerable to keep up with growing demand, argues Santos Paulo. In 2025, there were 20,995 applications for 4,726 GP specialty training posts, a ratio of almost five applicants per post. This competition ratio has more than tripled since 2019, when there were just 1.34 applications per post.

She also points out that despite workforce pressures, the monthly number of GP appointments rose by more than 10 million between December 2018 and December 2025, reaching a record high last year.

The DHSC spokesperson said that GPs are “at the heart” of the government’s “historic shift” from hospital to community and will benefit from a growing share of NHS funding.

But Tzortziou Brown said the health secretary’s promises to support general practice and deliver “thousands more GPs” must be backed by a clear and robust 10 year workforce plan.

“General practice is the bedrock of the NHS,” she says. “With the right investment and meaningful initiatives to recruit and retain GPs we can turn this ar

For years, drug companies and industry allies have argued that the U.S. gets faster and wider access because its government moves quicker than foreign regulators, but the new analysis suggests the U.S. advantage in drug access is driven less by faster government review and more by when companies apply for review and the type of drugs they submit.

The study, published in Health Affairs, looked at every new prescription drug approved between 2014 and 2018 in the U.S., and Europe, and then tracked submission delays and review times for these products across regulators in Canada, Japan and Australia through the end of 2022. The analysis assessed the speed of the review process and the timing of submissions for approval, with results broken down by drug characteristics, including therapeutic value of the drugs.

Specifically, the researchers explored whether different patterns in submission and review times emerged for drugs that offered little added medical benefit over drugs that were already on the market.

“Some commentators have argued that foreign regulators take too long to review drugs and should do more to ensure timely access to new therapies, often pointing to limited availability of new cancer therapies in Europe and other rich markets relative to what’s on the market in the United States, as evidence that regulatory red tape is getting in the way of timely patient access,” said lead author Irene Papanicolas, a professor of health services, policy and practice at the Brown University School of Public Health. “Where we’re coming at this from is saying that broader availability of new medicines is generally a great thing — we want patients to get access to new meds — but not all new medications are equally important from a medical standpoint.”

In fact, what stood out most was how companies handled drugs that provide little therapeutic advantage over existing treatments, which the authors referred to as “low-value” drugs in their analysis. The researchers found these drugs were typically submitted to U.S. regulators months or even years before companies sought approval in other high-income countries, giving Americans earlier and wider access to expensive drugs that may not significantly improve patient outcomes.

The findings likely reflect a mix of business incentives and policy choices, according to the research team which along with Papanicolas and other Brown co-authors Olivier Wouters and Tania Sawaya also includes health policy experts from Vanderbilt University and the London School of Economics and Political Science.

The U.S. is the world’s largest drug market, and manufacturers can generally set prices freely when a drug launches. In contrast, many other countries evaluate how much a new drug improves health compared with existing treatments and use that information to negotiate prices or limit coverage, said Wouters, an associate professor in the Department of Health Services, Policy, and Practice.

“There are many drugs that enter the U.S. market that frankly aren’t much better than what’s already available,” Wouters said. “Companies generally seem to submit these lower-value products for approval  earlier in the United States than in other markets. This may reflect the fact that governments in other countries tend to drive a tougher bargain than U.S. payers, which could influence companies’ decisions about where and when to seek approval.”

The study also showed that drugs offering clear medical benefits over existing treatments tended to reach most high-income countries at roughly the same time. This is because drugmakers typically submit those products for approval simultaneously across the high-income countries the researchers looked at. The Food and Drug Administration was only slightly faster than its counterparts abroad in approving the drugs by a few weeks or a month on average, the researchers said.

“Historically, yes, the U.S. gets more new drugs and gets them faster than other countries but a lot of what is driving this pattern aren’t the drugs that have this meaningful therapeutic gain for patients,” Papanicolas said. “Everybody’s getting those important new drugs quickly.”

Overall, the study helps add nuance to the question of why the U.S. spends far more on prescription drugs than other high-income countries without consistently better health outcomes. It also paints a more complicated picture as policymakers debate proposals such as the “most favored nation” approach, to bring down drug spending, which proposes linking U.S. drug prices to those paid in peer countries.

“It’s not clear how this is going to work,” Papanicolas said. “How will the US authorities handle products that haven’t yet been marketed abroad? Will the policy affect where and when companies decide to submit drugs abroad? No one really knows yet.”

The program is the first of its kind to combine population health and pharmacoepidemiology in the Houston metropolitan area, one of the nation’s largest and most culturally rich healthcare markets.

“The program positions the UH College of Pharmacy as a hub for advanced training at the intersection of pharmacy, data science and population health,” said Arash Bashirullah, dean of the UH College of Pharmacy. “Graduates will be prepared for research and leadership positions in healthcare systems, government, industry, and academia, and benefit from UH’s Tier One research environment and proximity to the Texas Medical Center.”

Population health shifts the focus from managing illness in individuals to proactively improving health outcomes in specific populations. Pharmacoepidemiology is one of the tools used by population health to study the impact of medications and improve health outcomes in large groups of people. It combines many different fields to study, connecting clinical sciences, data science and epidemiology.

“The program is a timely and strategic initiative that aligns with the growing demand for graduate training in these fields to fill a critical workforce gap while enhancing the college’s educational portfolio,” said Bashirullah. “Houston’s expansive healthcare systems and academic medical centers provide a unique opportunity for the University of Houston to establish leadership in this field.”

The degree track offers students training in epidemiologic methods, biostatistics, health data science and pharmacoepidemiology to generate evidence that informs clinical practice, health policy and healthcare system decision-making.

The new degree tracks will be housed in the Department of Pharmaceutical Health Outcomes and Policy.

“The new program combines the unique strengths of this department with emerging data sciences specialization at UH and the University’s population health initiatives,” said Rajender Aparasu, Mustafa F. & Sanober Lokhandwala Professor and chair of the Department of Pharmaceutical Health Outcomes and Policy.

Applicants to the MS and PhD in Pharmaceutical Sciences with a concentration in Population Health & Pharmacoepidemiology must hold a bachelor’s degree in a relevant field with a minimum GPA of 3.0 on a 4-point scale. Preference is given to applicants with pharmacy, biomedical, or other health-related backgrounds.

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.

“This is important given the rise in vaccine hesitancy, which has resulted in a downward trend in flu vaccination that coincided with a high rate of hospitalization this flu season,” said the study’s lead author, Shivan Mehta, MD, MBA, MSHP, associate chief innovation officer at Penn Medicine. “Many nudge interventions directed to patients only on vaccinations have shown limited effectiveness in the United States, so we wanted to make sure that we addressed both sides of the exam room: the patient and the clinician.”

The researchers believe these results might point to some strategies that could help boost how many people get the shot every year for an illness that has hospitalized up to 710,000 people each year since 2010—and killed as many as 52,000 Americans annually.

Nudging versus standard care 

The study tested several forms of “nudging,” a behavioral science concept that means small tweaks that make the healthiest choices the easiest ones. Patients who were eligible for the vaccine received flu shot reminder texts (or automated voice recordings), had automatic orders for a flu shot waiting for their clinician to approve, and monthly personalized messages were sent to providers that compared their patients’ vaccination rates to their clinician peers.

More than 52,000 people were randomly assigned to two groups: one that received all of the nudges or a “standard care” control group at either the University of Pennsylvania Health System or the University of Washington’s health system, UW Medicine The standard care team didn’t get any of the nudges and followed the usual path for getting a flu vaccine, which relies largely on the clinician remembering to offer the vaccine based on information in the electronic health records. Researchers found that almost 3,000 more people got flu shots when they were nudged than would have been expected if they got normal care.

Why nudging patients and clinicians worked 

Mehta and his colleagues are encouraged by their findings, driven mainly by the importance of communication and trust.

“We think the automatic order encouraged primary care physicians to have a conversation with their patients, and we know these clinicians still have a lot of trust from their communities,” said co-senior author Amol Navathe, MD, PhD, a professor of Medical Ethics and Health Policy, as well as a professor of Health Care Management in the Wharton School.

The work continues at scale 

The team has replicated their work at Lancaster General Health in the University of Pennsylvania Health System, which serves a rural and suburban patient base that looks somewhat different than the study populations in this study drawn largely from Philadelphia and Seattle. They are still analyzing the results of this replication study.

Since the work leverages existing tools in the electronic health record along with other available technologies but no additional staffing or human effort, it could be particularly attractive to health systems looking to augment their flu shot efforts.

“Future interventions could be more successful by complementing the automated communication with clinical staff to engage with patients that are still hesitant, and integrating flu vaccine nudges with other interventions focused on preventive health, like cancer screening,” Mehta said.

Defining the clinical burden

Insomnia is more than a few sleepless nights. Diagnosis requires three components: difficulty falling asleep, difficulty staying asleep, and significant next-day consequences. Chronic insomnia is defined by these symptoms occurring at least three times a week for more than three months.

The epidemiological data is sobering. Chronic insomnia affects 5% to 10% of the adult population and is strongly associated with chronic physical illnesses involving pain or respiratory distress, as well as psychiatric disorders such as major depression.

The consequences of sleeping less than five or six hours a night are significant:

• The risk of type 2 diabetes trebles
• The risk of hypertension increases fivefold
• The risk of vascular dementia and impaired cognitive functioning more than doubles.

Furthermore, even a small reduction in sleep (less than six hours compared to seven to nine) is associated with a 13% increase in mortality risk due to accidents, stroke, cardiovascular disease and cancer.

In mental health, insomnia acts as a “multiplier” of poor outcomes. A landmark study using big data found that in patients with major depression, those with comorbid insomnia had more GP appointments, higher medication consumption, more psychiatric admissions, and increased rates of attempted suicide.

The limitations of traditional pharmacotherapy

Both benzodiazepines and the “Z-drugs” (e.g. zopiclone) are used for the short-term management of insomnia. Both classes of drug promote the actions of the inhibitory neurotransmitter gamma amino butyric acid (GABA) in the central nervous system. In effect, they “dial up” the effects of GABA. Benzodiazepines are non-selective; they affect pathways relating to sleep and also those relating to anxiety and memory. “In addition to inducing sleep, they’re anxiolytic but they also have an amnesic effect which is quite common with benzodiazepines, particularly [for] short-term memory” explains Mr Donoghue. The Z-drugs lack the anxiolytic effects and generally have shorter half-lives than benzodiazepines, making them less likely to have next day hangover effects.

A NICE appraisal concluded that there was no compelling evidence of a clinically useful advantage with Z drugs and recommended that short-acting benzodiazepines should continue to be the treatments of choice. Mr Donoghue noted that the commonly-used (short-acting) temazepam has a half life of 10-20 hours, meaning that after a 20mg night-time dose,10 mgs could still be in the body the next morning. “And here’s one of the things that pharmacists must advise patients – not ‘be careful when you’re driving’, but simply ‘do not drive’. Do not operate dangerous machinery of any kind, because even the short acting benzodiazepines have significant hangover effects” says Mr Donoghue.

Antihistamines (e.g. diphenhydramine), antidepressants and antipsychotics are also sometimes used for insomnia. Although over-the-counter antihistamines are often recommended for insomnia but they are commonly associated with side effects such as ataxia, blurred vision, constipation and dizziness. “So, diphenhydramine and drugs like promethazine are not the benign drugs that we think they are, and they do need to be used cautiously, and patients should be warned about particularly the danger involved with driving after they’ve been taking them”, he says. Antidepressants and antipsychotics should be avoided as hypnotics, he adds.

Orexin and chronic insomnia

The discovery of orexin in the late 1990s changed the understanding of the sleep-wake cycle. Orexin is an excitatory neurotransmitter that acts as the brain’s “wake signal,” released in response to daylight to kickstart alertness.

Current thinking suggests that chronic insomnia is not necessarily a lack of “sleep pressure” but rather a disorder of orexin overactivity. Essentially, the wake signal is being released inappropriately during the night. This explains why simple sleep hygiene measures often fail in chronic cases; sleep hygiene measures cannot suppress the inappropriate release of orexin.

Daridorexant: A dual orexin receptor antagonist (DORA)

Daridorexant represents a new class of treatment approved by NICE for chronic insomnia in adults. Unlike traditional hypnotics that induce sleep by “closing down” the brain, Daridorexant is a DORA that blocks the wake signal from reaching excitatory pathways. It suppresses both the wake signal (Orexin 2 receptor) and the motivation/reward signal (Orexin 1 receptor), allowing sleep to occur naturally while maintaining normal background brain activity.

Clinical evidence and safety

Two large randomised controlled trials published in The Lancet Neurology highlight several key findings for clinicians¹:

• Efficacy: At the 50mg dose, patients gained approximately one hour of extra sleep per night after three months, falling asleep 30 minutes faster and waking up for 30 minutes less.
• Daytime alertness: Critically, daridorexant showed a significant improvement in daytime alertness, with no “hangover” effects observed.
• Long-term profile: In a 12-month extension study, there was no evidence of loss of effect over time and, remarkably, no withdrawal symptoms upon discontinuation.
• Tolerability: The side effect profile is “remarkably benign,” with only fatigue occurring more frequently than placebo (affecting only 1 in 25 patients).

Responding to symptoms of insomnia

NICE recommends daridorexant as a second-line treatment following cognitive behavioural therapy for insomnia (CBTI). However, if CBTI is unavailable or the patient refuses it, daridorexant can be considered first-line.²

When patients seek help for insomnia in primary care Mr Donoghue suggests five key questions should be asked:

1. What are the sleep problems (getting to/staying asleep)?
2. Are there external factors (noise, shift work)?
3. How long has it been going on (the 3-month threshold)?
4. How often does it occur (the 3-times-a-week threshold)?
5. How do you feel the next day?

Patients who meet the criteria for chronic insomnia should either be referred to their GP or a prescribing pharmacist, who may consider prescribing daridorexant.

Regarding the cost – a common barrier to prescribing – Mr Donoghue points out that at £42 per month, the treatment costs less than half a cup of coffee per day. Given the serious consequences of chronic insomnia for people’s emotional, mental and physical well-being, this makes it a highly cost-effective intervention.

About John Donoghue

John Donoghue is the Director of Medicines in Mental Health Ltd. His work involves:

• The provision of continuing education related to the treatment of severe mental illness. His key interest is schizophrenia, but he also covers major depression and bipolar disorder. He provides medical education to psychiatrists, pharmacists, mental health nurses, psychologists and social workers.
• Pharmaco-epidemiology research. He was an early adopter of big data and has been involved in landmark studies using big data to follow outcomes in major depression.
• Consultancy He provides consultancy services, mostly to the pharmaceutical industry but also occasionally to the National Health Service.

Mr Donoghue is also a published novelist. His debut novel, The Death’s Head Chess Club was published in 2015. His new novel, Not Alive, Not Dead, was published in 2025.

References

1. Mignot E, Mayleben D, Fietze I, Leger D, Zammit G, Bassetti CLA, Pain S, Kinter DS, Roth T; investigators. Safety and efficacy of daridorexant in patients with insomnia disorder: results from two multicentre, randomised, double-blind, placebo-controlled, phase 3 trials. Lancet Neurol. 2022 Feb;21(2):125-139. doi: 10.1016/S1474-4422(21)00436-1.
2. NICE Technology appraisal guidance (TA 922) Daridorexant for treating long-term insomnia. October 2023

A new University of Oxford-led study, published in The Lancet Planetary Health, is the first to link daily temperature data to health-care use and costs across primary and secondary care in England.

Using linked patient records from 4,366,981 people registered at 244 English GP practices between April 2007 and June 2019, the researchers estimate that exposure to average daily temperatures outside a mild reference range (18°C to 21°C) accounts for around 3.0% of recorded health-care costs in their dataset.

Using illustrative budget figures detailed below, this may amount to £3 billion in costs for NHS England and be of the same order of magnitude as spending on dentistry.

As NHS leaders plan for winter pressures and wider service resilience, the study provides new evidence on how temperature-related demand and costs sit across the health system in England.

The UK frequently experiences cold conditions, with days averaging 0°C to 9°C accounting for around 64.4% of the estimated burden, reflecting cumulative increases in NHS use across the winter period. The study also raises a practical concern in extreme cold: when average temperatures fell below 0°C, health-care use declined in the data. This suggests barriers to seeking care in hazardous cold conditions such as snow and black ice.

However, the study also highlights that hot weather, which is becoming more frequent under climate change, also conveys concerning health risks. Very hot days were rare in the study period, which limits precision, but the data reports sharp, same-day surges in parts of the system – including A&E attendances and prescribing – when temperatures are unusually high.

In other words, while cold is linked to a larger cumulative burden on the NHS, heat is linked to sudden spikes that can challenge day-to-day service delivery. Older adults were consistently the most affected group across the findings.

Dr Patrick Fahr, Senior Health Economist at the Nuffield Department of Primary Health Care Sciences, University of Oxford, and a lead author of the study, said:
‘Temperature affects the NHS every day, but until now nobody knew how costly this was. Three percent is both a small and a large figure, because these costs are concentrated on cold and hot days only when demand is spiking. Historically, the winter season has been and remains associated with additional health risks, which occur routinely each year, however heatwaves are emerging as a new challenge.

‘In the data, heat tends to be associated with short, same day increases in demand and pressure on services, requiring a rapid response. Overall, the practical implication is that planning for temperature-related variation in service use is a year-round issue. Vulnerable people, such as older adults, can be particularly at risk.’

Illustrative budget impact

The study estimates the share of recorded healthcare costs associated with non-optimal temperature exposure (relative to a reference temperature), rather than producing a national budget total. As an illustration, if a similar proportion applied to NHS England’s planned 2023/24 spending on acute services, specialised services and primary medical care (combined £101.4bn), this would correspond to costs on the order of £3bn per year across those categories.

For context, that illustrative figure is above the £2.899bn spent on NHS dentistry reported in DHSC annual accounts for 2022/23, as highlighted by the British Dental Association.

Study title: ‘Quantifying the health-care burden of temperature in the National Health Service in England: an economic analysis of resource use and costs’

Journal: The Lancet Planetary Health

URL: https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(25)00251-7/fulltext

A new three-year project, funded by the National Institute for Health and Care Research (NIHR), aims to identify the precise reasons behind that, exploring why some international medical graduates see their careers blossom once they reach the UK and start working in the NHS while others do not.

It will also seek solutions at an individual, trust/practice and national level, identifying the types of tailored support international medical graduates might need over the course of their careers if they are to become consultants or GPs in the NHS.

The ‘SUP IMG’ project started this summer and runs until 2028. It is being led by researchers from the University of Plymouth’s Peninsula Medical School, working with colleagues at the University of Oxford, University College London and Imperial College London.

They will engage with international medical graduates currently working in the NHS, educational supervisors, training programme leads, professional support staff, other healthcare professionals and patient representatives.

The project is building on research carried out for the General Medical Council in 2021, which found that international medical graduates’ main drivers for coming to work in the UK include employment, training and development opportunities.

However, less than 5% of them join specialist or GP registers on arrival, and few – 11.6% within five years and 27.2% within 10 years – go on to become consultants or GPs. By contrast, around 75% of UK graduates become consultants or GPs over the same timeframe.

Dr Nicola Brennan, Associate Professor in Medical Education at the University of Plymouth, led the study for the GMC and is the new project’s chief investigator.

She said: “As things stand, around 40% of the medical workforce is made up of international medical graduates. That means a lot of foreign doctors want to work here, and have the necessary qualifications and skills to do so. But for various reasons – including language and cultural differences, and direct or indirect discrimination or racism – once they get here their careers are more likely to stagnate. We know the government’s 10-year health plan for England calls for reduced future reliance on international graduates but for the time being, and potentially the future too, they are critical to the running of the NHS. It is really important that we help them succeed and progress.”