Safety vs price in the generic drug market: metformin.

OBJECTIVES: Generic medications represent 90% of prescriptions in the US market and provide a tremendous financial benefit for patients. Recently, multiple generic drugs have been recalled due to the presence of carcinogens, predominantly N-nitrosodimethylamine (NDMA), including an extensive recall of extended-release (ER) metformin products in 2020. STUDY DESIGN: Primary pharmaceutical quality testing and database analysis. METHODS: We tested marketed metformin immediate-release (IR) and ER tablets from a wide sample of generic manufacturers for the presence of carcinogenic impurities NDMA and N,N-dimethylformamide (DMF). We examined the association of level of impurity with drug price and the impact of the 2020 FDA recalls on unit price and prescription fill rate. RESULTS: Postrecall NDMA levels were significantly lower in metformin ER samples (standardized mean difference = -2.0; P = .01); however, we found continued presence of carcinogens above the FDA threshold in 2 of 30 IR samples (6.67%). Overall, the presence of contaminant levels was not significantly associated with price for either IR (NDMA: R2 = 0.142; P = .981; DMF: R2 = 0.382; P = .436) or ER (NDMA: R2 = 0.124; P = .142; DMF: R2 = 0.199; P = .073) samples. Despite recalls, metformin ER prescription fills increased by 8.9% while unit price decreased by 19.61% (P < .05). CONCLUSIONS: Recalls of metformin ER medications were effective in lowering NDMA levels below the FDA threshold; however, some samples of generic metformin still contained carcinogens even after FDA-announced recalls. The absence of any correlation with price indicates that potentially safer products are available on the market for the same price as poorer-quality products.

Place of Death Before and During the COVID-19 Pandemic.

This quality improvement study examines the national and ongoing impact of the COVID-19 pandemic with the place of death among individuals in the US.

Does believing something to be fiction allow a form of moral licencing or a 'fictive pass' in understanding others' actions?

Introduction: The human capacity to engage with fictional worlds raises important psychological questions about the mechanisms that make this possible. Of particular interest is whether people respond differently to fictional stories compared to factual ones in terms of how immersed they become and how they view the characters involved and their actions. It has been suggested that fiction provides us with a 'fictive pass' that allows us to evaluate in a more balanced, detached way the morality of a character's behaviour. Methods: We use a randomised controlled experimental design to test this. Results and discussion: We show that, although knowing whether a substantial film clip is fact or fiction does not affect how engaged with ('transported' by) a troubling story an observer becomes, it does grant them a 'fictive pass' to empathise with a moral transgressor. However, a fictive pass does not override the capacity to judge the causes of a character's moral transgression (at least as indexed by a causal attribution task).

Trends and determinants of retail prescription drug costs.

OBJECTIVE: To characterize price trends and variation for US generic and branded drugs at the retail level as they relate to pharmacy acquisition costs and local market factors. DATA SOURCES: Drug pricing data consisting of US pharmacy claims from 2014 to 2019 collected and licensed by GoodRx, an online tool for comparing drug prices. STUDY DESIGN: Time trends of median drug prices and coefficients of variation were measured for generic and branded drugs, including subgroups based on clinical condition (i.e., diabetes and cancer). Pharmacy competition was measured using the Herfindahl-Hirschman Index (HHI) at the zip-code level. Multivariable linear regression analysis assessed the impact of local market-level factors on drug prices and variation. DATA COLLECTION: US drug pricing data consisting of claims filled through a mix of public and private insurance at 58,332 chain and independent pharmacies across 14,421 zip codes in all 50 states. PRINCIPAL FINDINGS: From 2014 to 2019, pharmacy retail markets trended towards greater competition: average HHI by zip code decreased by 15.0% (p < 0.001). Median cash price increased significantly for both generic (6.58%, p < 0.001) and branded (84.10%, p < 0.001) drugs. When normalized to acquisition costs, cash prices for generic drugs rose 22.03% (p < 0.001) while those of branded drugs decreased by 2.31% (p < 0.001). Diabetes drugs showed higher baseline overall markup of cash prices relative to acquisition costs (10.54, Interquartile range (IQR) 3.28-18.43) than cancer drugs (1.88, IQR 1.36-3.08). Neither local pharmacy competition nor median income significantly predicted drug price or variation. CONCLUSION: Measures of generic drug price and price variation are high despite decreased costs earlier in the pharmaceutical supply chain, defying expectations of what would happen in a competitive market. Efforts to bypass the pharmacy benefit model for generic drugs may offer consumers an opportunity for substantial savings.

How Audiences Engage With Drama: Identification, Attribution and Moral Approval.

Fictional storytelling has played an important role in human cultural life since earliest times, and we are willing to invest significant quantities of time, mental effort and money in it. Nonetheless, the psychological mechanisms that make this possible, and how they relate to the mechanisms that underpin real-world social relationships, remain understudied. We explore three factors: identification (the capacity to identify with a character), moral approval and causal attribution with respect to a character's behaviour in live performances of two plays from the European literary canon. There were significant correlations between the extent to which subjects identified with a character and their moral approval of that character's behaviour that was independent of the way the play was directed. However, the subjects' psychological explanations for a character's behaviour (attribution) were independent of whether or not they identified with, or morally approved of, the character. These data extend previous findings by showing that moral approval plays an important role in facilitating identification even in live drama. Despite being transported by an unfolding drama, audiences do not necessarily become biased in their psychological understanding of why characters behaved as they did. The psychology of drama offers significant insights into the psychological processes that underpin our everyday social world.

Emotional arousal when watching drama increases pain threshold and social bonding.

Fiction, whether in the form of storytelling or plays, has a particular attraction for us: we repeatedly return to it and are willing to invest money and time in doing so. Why this is so is an evolutionary enigma that has been surprisingly underexplored. We hypothesize that emotionally arousing drama, in particular, triggers the same neurobiological mechanism (the endorphin system, reflected in increased pain thresholds) that underpins anthropoid primate and human social bonding. We show that, compared to subjects who watch an emotionally neutral film, subjects who watch an emotionally arousing film have increased pain thresholds and an increased sense of group bonding.

A controlled evaluation of comprehensive geriatric assessment in the emergency department: the 'Emergency Frailty Unit'.

BACKGROUND: the ageing demographic means that increasing numbers of older people will be attending emergency departments (EDs). Little previous research has focused on the needs of older people in ED and there have been no evaluations of comprehensive geriatric assessment (CGA) embedded within the ED setting. METHODS: a pre-post cohort study of the impact of embedding CGA within a large ED in the East Midlands, UK. The primary outcome was admission avoidance from the ED, with readmissions, length of stay and bed-day use as secondary outcomes. RESULTS: attendances to ED increased in older people over the study period, whereas the ED conversion rate fell from 69.6 to 61.2% in people aged 85+, and readmission rates in this group fell from 26.0% at 90 days to 19.9%. In-patient bed-day use increased slightly, as did the mean length of stay. DISCUSSION: it is possible to embed CGA within EDs, which is associated with improvements in operational outcomes.