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Kogut SJ. A primer on quality measurement and reporting in pharmacy benefit plans. J Manag Care Spec Pharm 2024; 30:386-396. [PMID: 38427331 PMCID: PMC10981972 DOI: 10.18553/jmcp.2024.23240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Pharmacy benefit plans in the United States are evaluated on quality measures and other requirements of the government and accrediting organizations. This primer describes the roles of key organizations involved in measuring and reporting quality in pharmacy benefit plans and explains the methods that pharmacy benefit plans use to promote quality of medication use.
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Affiliation(s)
- Stephen J. Kogut
- College of Pharmacy, Department of Pharmacy Practice and Clinical Research, University of Rhode Island, Kingston
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Chisholm-Burns MA, Spivey CA, Tsang CCS, Wang J. Racial and ethnic disparities due to Medicare Part D Star Ratings criteria among kidney transplant patients with diabetes, hypertension, and/or dyslipidemia. J Manag Care Spec Pharm 2022; 28:688-699. [PMID: 35621720 PMCID: PMC9499736 DOI: 10.18553/jmcp.2022.28.6.688] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND: Policies such as Medicare Part D Star Ratings are designed to encourage medication adherence and facilitate positive health outcomes. Patients who have received a kidney transplant not included in assessment of Star Ratings measures may have worse outcomes. OBJECTIVE: To determine if criteria for inclusion in assessment of Star Ratings medication adherence measures among kidney transplant patients with diabetes, hypertension, and dyslipidemia lead to racial and ethnic disparities in who is included in this assessment. METHODS: This was a cross-sectional, secondary analysis of 94,822 adult kidney transplant patients receiving continuous coverage of Medicare Parts A/B/D and filling at least 1 prescription for diabetes, hypertension, or dyslipidemia in 2017. Utilizing 2017 Medicare claims, inclusion in assessment of Star Ratings measures was determined based on criteria for each measure concerning adherence to oral diabetes, hypertension, and dyslipidemia medication. Binary and multinomial logistic regression were conducted. RESULTS: Among kidney transplant patients with diabetes only, Black and Hispanic patients were less likely than White patients to be included in assessment of the Star Ratings adherence measure for oral diabetes medications (P < 0.0001). Among kidney transplant patients with hypertension only and dyslipidemia only, all racial and ethnic minority groups were less likely to be included in assessments of Star Ratings adherence measures for oral hypertension and dyslipidemia medications (P < 0.001). For example, among patients with hypertension, adjusted odds ratios for inclusion of Black, Hispanic, and Asian patients were 0.44 (95% CI = 0.40-0.49), 0.56 (95% CI = 0.49-0.63), and 0.55 (95% = CI 0.45-0.67), respectively. CONCLUSIONS: Disparities exist among patients who have received a kidney transplant qualifying for inclusion in Star Ratings measures, which may ultimately facilitate adverse health outcomes. DISCLOSURES: Marie Chisholm-Burns is a member of the American Society of Transplantation Board of Directors. Christina Spivey has no conflicts of interest to disclose. Chi Chun Tsang has no conflicts of interest to disclose. Junling Wang received funding for this project from the National Institute on Aging/National Institutes of Health; she has also received funding from AbbVie and Pharmaceutical Research and Manufacturers of America (additionally, she has received consulting fees from the latter). Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number R01AG049696 (Principal Investigator: Junling Wang). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The sponsor of the research does not have any role in any aspect of the research, including study design and the collection, analysis, and interpretation of data; the writing of the report; and the decision to submit the manuscript for publication.
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Affiliation(s)
| | - Christina A. Spivey
- University of Tennessee Health Science Center College of Pharmacy, Department of Clinical Pharmacy and Translational Science, 901-448-7141
| | - Chi Chun Steve Tsang
- University of Tennessee Health Science Center College of Pharmacy, Department of Clinical Pharmacy and Translational Science, 901-448-6047
| | - Junling Wang
- University of Tennessee Health Science Center College of Pharmacy, Department of Clinical Pharmacy and Translational Science, 901-448-3601
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Parekh N, Munshi KD, Hernandez I, Gellad WF, Henderson R, Shrank WH. Impact of Star Rating Medication Adherence Measures on Adherence for Targeted and Nontargeted Medications. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1266-1274. [PMID: 31708063 DOI: 10.1016/j.jval.2019.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/14/2019] [Accepted: 06/19/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND In 2012, Medicare incorporated medication adherence targeting oral antidiabetic medications, renin-angiotensin system (RAS) antagonists, and statins as highly weighted components in its Star Ratings Program. In the same year, health plans began receiving quality bonus payments for higher star ratings. OBJECTIVE We aimed to assess how these policy changes affected adherence to targeted and other chronic disease medications in the United States. METHODS We performed interrupted time series analyses to assess monthly changes in medication adherence from 2010 to 2016 using health plans' Medicare claims submitted to a large pharmacy benefits manager. We conducted 2 sets of analyses. The first examined whether policy changes affected adherence to the 3 targeted therapy classes, and the second assessed the association between policy changes and adherence to 5 chronic disease classes not targeted by star ratings. For the second analysis, we further compared adherence between members who concomitantly used and did not use targeted medications. RESULTS For star-ratings analyses, we studied 240 811 members on oral antidiabetic medications, 500 958 on RAS antagonists, and 471 135 on statins. Adherence for all star rating-targeted and nontargeted medications increased after 2012 (P < .001). Oral antidiabetic, statin, and RAS antagonist adherence was, respectively, 11.2%, 3.7%, and 8.1% higher than adherence without policy changes (P < .001). Nontargeted antihypertensive and antihyperlipidemic adherence trends were higher among those concomitantly on star rating-targeted medications compared with those who were not (P < .001). CONCLUSIONS As policy makers strive to identify optimal quality measures for improving healthcare delivery, it is important to consider that incentives can promote improved performance in both targeted measures and related outcomes.
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Affiliation(s)
- Natasha Parekh
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA; UPMC Centers for High-Value Health Care and Value-Based Pharmacy Initiatives, UPMC Insurance Services Division, Pittsburgh, PA, USA.
| | | | - Inmaculada Hernandez
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Walid F Gellad
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - William H Shrank
- UPMC Centers for High-Value Health Care and Value-Based Pharmacy Initiatives, UPMC Insurance Services Division, Pittsburgh, PA, USA
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Hohmann N, Hansen R, Garza KB, Harris I, Kiptanui Z, Qian J. Association between Higher Generic Drug Use and Medicare Part D Star Ratings: An Observational Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1186-1191. [PMID: 30314619 DOI: 10.1016/j.jval.2018.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/22/2018] [Accepted: 03/10/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Increasing generic drug use, due to potential for cost savings and drug access, is a viable consideration for Medicare prescription drug plans to achieve high star ratings and improve quality of plan offerings for Medicare beneficiaries. OBJECTIVE To examine the association between contract-level proportion of generic drugs dispensed (pGDD) and Medicare Part D star ratings. METHODS This was a retrospective study of linked 2011 Medicare Part D star rating data with contract-level pGDD data. A total of 477 individual Medicare prescription contracts were included, representing 75% of total Prescription Drug Plans and more than 65% of total Medicare Advantage Prescription Drug Plans available by the end of 2010. Primary outcomes were Medicare Part D summary and domain star ratings (1-5 indicating lowest to highest performance), incorporating a range of quality measures for access, cost, beneficiary satisfaction, and health services outcomes and processes. Ordinal logistic regression models were used to examine associations between pGDD and Medicare Part D summary and domain star ratings, controlling for contract type and number of beneficiary enrollment. RESULTS Higher pGDD was associated with higher summary star ratings (adjusted odds ratio 1.08 with 95% confidence interval 1.04-1.12) and higher "member experience with drug plan" domain ratings (adjusted odds ratio 1.07 with 95% confidence interval 1.03-1.11). CONCLUSIONS Prescription formulary benefit design targeting increasing generic drug use appears to be associated with improved member experience and higher plan star ratings. Consideration may be given to incorporating pGDD into Medicare Part D star rating measures to improve quality of prescription plans.
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Affiliation(s)
- Natalie Hohmann
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | - Richard Hansen
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | - Kimberly B Garza
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | | | | | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Auburn University Harrison School of Pharmacy, Auburn, AL, USA.
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Haviland AM, Damberg CL, Mathews M, Paddock SM, Elliott MN. Shifting From Passive Quality Reporting to Active Nudging to Influence Consumer Choice of Health Plan. Med Care Res Rev 2018; 77:345-356. [PMID: 30255721 DOI: 10.1177/1077558718798534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Comparative quality information on health plan and provider performance is increasingly available in the form of quality report cards, but consumers rarely make use of these passively provided decision support tools. In 2012-2013, the Centers for Medicare & Medicaid Services (CMS) initiated quality-based nudges designed to encourage beneficiaries to move into higher quality Medicare Advantage (MA) plans. We assess the impacts of CMS' targeted quality-based nudges with longitudinal analysis of 2009-2014 MA plan enrollment trends. Nudges are associated with 17% reductions in enrollment in the lowest-performing plans and 3% increases in enrollment in the highest performing plans (annually, p < .01 for both), occurring at the time of nudge implementation and relative to trends for plans with moderate performance that were not targeted by nudges. These findings suggest that quality-based nudges can successfully steer consumers into higher quality plans and provide opportunities for purchasers and payers to increase consumers' use of quality information.
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Affiliation(s)
- Amelia M Haviland
- Carnegie Mellon University, Pittsburgh, PA, USA.,RAND Corporation, Pittsburgh, PA, USA
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Almodovar AS, Axon DR, Coleman AM, Warholak T, Nahata MC. The Effect of Plan Type and Comprehensive Medication Reviews on High-Risk Medication Use. J Manag Care Spec Pharm 2018; 24:416-422. [PMID: 29694292 PMCID: PMC10397681 DOI: 10.18553/jmcp.2018.24.5.416] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In 2007, the Centers for Medicare & Medicaid Services (CMS) instituted a star rating system using performance outcome measures to assess Medicare Advantage Prescription Drug (MAPD) and Prescription Drug Plan (PDP) providers. OBJECTIVE To assess the relationship between 2 performance outcome measures for Medicare insurance providers, comprehensive medication reviews (CMRs), and high-risk medication use. METHODS This cross-sectional study included Medicare Part C and Part D performance data from the 2014 and 2015 calendar years. Performance data were downloaded per Medicare contract from the CMS. We matched Medicare insurance provider performance data with the enrollment data of each contract. Mann Whitney U and Spearman rho tests and a hierarchical linear regression model assessed the relationship between provider characteristics, high-risk medication use, and CMR completion rate outcome measures. RESULTS In 2014, an inverse correlation between CMR completion rate and high-risk medication use was identified among MAPD plan providers. This relationship was further strengthened in 2015. No correlation was detected between the CMR completion rate and high-risk medication use among PDP plan providers in either year. A multivariate regression found an inverse association with high-risk medication use among MAPD plan providers in comparison with PDP plan providers in 2014 (beta = -0.358, P < 0.001) and 2015 (beta = -0.350, P < 0.001), the CMR completion rate in 2015 (beta = -0.221, P < 0.001), and enrollee population size in 2015 (beta = -0.203, P = 0.001). CONCLUSIONS This study found that MAPD plan providers and higher CMR completion rates were associated with lower use of high-risk medications among beneficiaries. DISCLOSURES No outside funding supported this study. Silva Almodovar reports a fellowship funded by SinfoniaRx, Tucson, Arizona, during the time of this study. The other authors have nothing to disclose.
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Schneider JE, Parikh A, Stojanovic I. Impact of a Novel Insulin Management Service on Non-insulin Pharmaceutical Expenses. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2018; 6:53-62. [PMID: 32685571 PMCID: PMC7309958 DOI: 10.36469/9783] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Studies have shown that improvements in glycemic control are associated with avoidance or delayed onset of diabetes complications, improvements in health-related quality of life, and reductions in diabetes-related health care costs. Clinical practice guidelines recommend maintaining a hemoglobin A1c (HbA1c) level less than 7%, but among type 2 diabetes patients using insulin, two-thirds have HbA1c above 7% and one-third have HbA1c above 9%. OBJECTIVES This study examined the use of insulin management services to enable patients to optimize insulin dosing to achieve HbA1c targets and subsequently reduce health care costs. Cost savings may be achieved through reduced complications and hospitalizations, as well as reduced outpatient, physician, and clinic costs. This study quantified the reduction in pharmaceutical expenses related to the use of an enhanced insulin management service to improve glycemic control. METHODS Two hundred seventeen insulin-reliant patients were enrolled in the d-Nav® Insulin Guidance Service through a participating insurance group. A prospective cost analysis was conducted using data from enrolled patients who completed the first 90 days of follow up. RESULTS Of the 192 patients who completed the 90-day study period, 54 (28.13%) were prescribed one or more expensive medications at baseline, but 45 (83.33%) of those patients were eligible for medication discontinuation after 90 days. At baseline, the annual cost of expensive medications per patient was $7564 (CI: $5191-$9938) and $1483 (CI: -$1463-$4429) at 90 days (p<0.001). Direct savings from medication elimination was estimated to be $145 per patient per month (PPPM) or $1736 per patient per year (PPPY) for all patients and $514 PPPM/$6172 PPPY for the target group. Patients that completed the 90-day period significantly reduced HbA1c levels from 9.37% (CI:7.72%-11.03%) at baseline to 7.71% (CI: 6.70%-8.73%) (p<0.001). A total of 170 (88.54%) patients had improved HbA1c at 90 days. CONCLUSIONS Use of the insulin guidance service achieved improved glycemic control by optimizing insulin dosing, which enabled most patients using the service to reduce or eliminate the use of expensive diabetes medications. Further study is needed to assess the impact of optimized insulin dosing on other diabetes-related health care costs in a usual practice setting.
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Lewey J, Wei W, Lauffenburger JC, Makanji S, Chant A, DiGeronimo J, Nanchanatt G, Jan S, Choudhry NK. Targeted Adherence Intervention to Reach Glycemic Control with Insulin Therapy for patients with Diabetes (TARGIT-Diabetes): rationale and design of a pragmatic randomised clinical trial. BMJ Open 2017; 7:e016551. [PMID: 29084790 PMCID: PMC5665263 DOI: 10.1136/bmjopen-2017-016551] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Adherence to and persistence of medications for chronic diseases remains poor and many interventions to improve medication use have only been modestly effective. Targeting interventions to patients who are most likely to benefit should improve their efficiency and clinical impact. This study aims to test the impact of three cost-equivalent pharmacist-led interventions on insulin persistence and glycaemic control among patients with diabetes. METHODS AND ANALYSIS TARGIT-Diabetes (Targeted Adherence Intervention to Reach Glycemic Control with Insulin Therapy for patients with Diabetes) is a randomised controlled trial that will evaluate three different multifaceted pharmacist-outreach strategies for improving long-term insulin use among individuals with diabetes. We will randomise 6000 patients in a large insurer to one of three arms. The arms are designed to deliver an increasingly intensive intervention to a progressively targeted population, identified using predictive analytics. The central component of the intervention in all arms is a tailored telephone consultation with a pharmacist which varies across arms based on the: (A) proportion of patients offered the intervention and (B) intervention intensity, including follow-up frequency and cointerventions such as text reminders and interactions with patients' providers. The primary outcome is insulin persistence, assessed using pharmacy claims data, and the secondary outcomes are glycaemic control as measured by glycosylated haemoglobin values, healthcare utilisation and healthcare spending. ETHICS AND DISSEMINATION This protocol has been approved by the Institutional Review Board of Brigham and Women's Hospital and the Privacy Board of Horizon Blue Cross Blue Shield of New Jersey. We plan to present the results of this trial at national meetings and in manuscripts submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT 02846779.
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Affiliation(s)
- Jennifer Lewey
- Division of Pharmacoepidemiology and Pharmacoeconomics, Center for Healthcare Delivery Sciences, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wenhui Wei
- Clinical Health Outcomes, Sanofi U.S., Inc, Bridgewater, New Jersey, USA
| | - Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Center for Healthcare Delivery Sciences, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sagar Makanji
- Clinical Programs, Magellan Rx Management, Newport, Rhode Island, USA
| | - Alan Chant
- Clinical Health Outcomes, Sanofi U.S., Inc, Bridgewater, New Jersey, USA
| | | | - Gina Nanchanatt
- Pharmacy Strategy and Clinical Integration, Horizon Healthcare Services Inc, Newark, New Jersey, USA
| | - Saira Jan
- Pharmacy Strategy and Clinical Integration, Horizon Healthcare Services Inc, Newark, New Jersey, USA
- School of Pharmacy, Rutgers State University of New Jersey, New Brunswick, New Jersey, USA
| | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Center for Healthcare Delivery Sciences, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Sussell J, Bognar K, Schwartz TT, Shafrin J, Sheehan JJ, Aubry W, Scanlon D. Value-Based Payments and Incentives to Improve Care: A Case Study of Patients with Type 2 Diabetes in Medicare Advantage. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:1216-1220. [PMID: 28964455 DOI: 10.1016/j.jval.2017.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/17/2017] [Accepted: 03/28/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To estimate the impact of increased glycated hemoglobin (A1C) monitoring and treatment intensification for patients with type 2 diabetes (T2D) on quality measures and reimbursement within the Medicare Advantage Star (MA Star) program. METHODS The primary endpoint was the share of patients with T2D with adequate A1C control (A1C ≤ 9%). We conducted a simulation of how increased A1C monitoring and treatment intensification affected this end point using data from the National Health and Nutrition Examination Survey and clinical trials. Using the estimated changes in measured A1C levels, we calculated corresponding changes in the plan-level A1C quality measure, overall star rating, and reimbursement. RESULTS At baseline, 24.4% of patients with T2D in the average plan had poor A1C control. The share of plans receiving the highest A1C rating increased from 27% at baseline to 49.5% (increased monitoring), 36.2% (intensification), and 57.1% (joint implementation of both interventions). However, overall star ratings increased for only 3.6%, 1.3%, and 4.8% of plans, respectively, by intervention. Projected per-member per-year rebate increases under the MA Star program were $7.71 (monitoring), $2.66 (intensification), and $10.55 (joint implementation). CONCLUSIONS The simulation showed that increased monitoring and treatment intensification would improve A1C levels; however, the resulting average increases in reimbursement would be small.
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Affiliation(s)
- Jesse Sussell
- Precision Health Economics, Oakland, CA, USA, at the time the research was conducted.
| | - Kata Bognar
- Precision Health Economics, Oakland, CA, USA, at the time the research was conducted
| | - Taylor T Schwartz
- Precision Health Economics, Oakland, CA, USA, at the time the research was conducted
| | - Jason Shafrin
- Precision Health Economics, Oakland, CA, USA, at the time the research was conducted
| | - John J Sheehan
- AstraZeneca Pharmaceuticals, LP (at the time the research was conducted), Wilmington, DE; current affiliation: Janssen Scientific Affairs, LLC, Titusville, NJ
| | - Wade Aubry
- University of California, San Francisco, CA, USA
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