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Kwok TSH, Kuriya B, Hawker G, Eder L, Li P, Choy G, Widdifield J. Adherence and Treat-to-Target Benchmarks in Older Adults With Gout Initiating Urate-Lowering Therapy in Ontario, Canada: A Population-Based Study. Arthritis Care Res (Hoboken) 2024. [PMID: 38831665 DOI: 10.1002/acr.25380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/08/2024] [Accepted: 05/29/2024] [Indexed: 06/05/2024]
Abstract
OBJECTIVE We sought to evaluate urate-lowering therapy (ULT) adherence and treatment-to-target (T2T) serum uric acid (SUA) levels among older adults with gout starting ULT. METHODS We performed a population-based retrospective cohort study in Ontario, Canada in patients with gout aged ≥66 years newly dispensed ULT between 2010 and 2019. We defined successful T2T as patients having SUA levels <360 μmol/L (6 mg/dL) within 12 months after ULT dispensation. We also assessed adherence to ULT. Multilevel logistic regression clustered by ULT prescriber evaluated patient, physician, and prescription factors associated with reaching target SUA levels. RESULTS Among 44,438 patients (mean ± SD age 76.0 ± 7.3 years; 64.4% male), 30,057 (67.6%) patients had ≥1 SUA test completed. Overall, 52.3% patients reached SUA target within 12 months, improving from 45.2% in 2010 to 61.2% in 2019 (P < 0.0001). ULT adherence was 55.3% overall and improved annually. Key factors associated with achieving T2T included febuxostat treatment (odds ratio [OR] 11.40, 95% confidence interval [95% CI] 5.10-25.43) (was only dispensed in 88 patients), ULT adherence (OR 5.17, 95% CI 4.89-5.47), allopurinol starting doses >50 mg (OR 2.53, 95% CI 2.14-2.99), colchicine/oral glucocorticoids co-prescription (OR 1.24, 95% CI 1.14-1.34), and ULT prescription from a rheumatologist. CONCLUSION Only 52.3% of patients achieved an optimal SUA level within 1 year of ULT initiation. ULT adherence was suboptimal, although improving over time. ULT adherence and higher allopurinol starting doses had the strongest associations of achieving a target SUA level. This study highlights room for improvement in gout management and potential strategies to address care gaps.
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Affiliation(s)
- Timothy S H Kwok
- University of Toronto and Sunnybrook Research Institute, Holland Bone & Joint Program, Toronto, Ontario, Canada
| | | | | | - Lihi Eder
- University of Toronto, Toronto, Ontario, Canada
| | - Ping Li
- ICES, Toronto, Ontario, Canada
| | | | - Jessica Widdifield
- University of Toronto, Sunnybrook Research Institute, Holland Bone & Joint Program, and ICES, Toronto, Ontario, Canada
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Tibble H, Sheikh A, Tsanas A. Estimating medication adherence from Electronic Health Records: comparing methods for mining and processing asthma treatment prescriptions. BMC Med Res Methodol 2023; 23:167. [PMID: 37438684 PMCID: PMC10337150 DOI: 10.1186/s12874-023-01935-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 04/26/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Medication adherence is usually defined as the extent of the agreement between the medication regimen agreed to by patients with their healthcare provider and the real-world implementation. Proactive identification of those with poor adherence may be useful to identify those with poor disease control and offers the opportunity for ameliorative action. Adherence can be estimated from Electronic Health Records (EHRs) by comparing medication dispensing records to the prescribed regimen. Several methods have been developed in the literature to infer adherence from EHRs, however there is no clear consensus on what should be considered the gold standard in each use case. Our objectives were to critically evaluate different measures of medication adherence in a large longitudinal Scottish EHR dataset. We used asthma, a chronic condition with high prevalence and high rates of non-adherence, as a case study. METHODS Over 1.6 million asthma controllers were prescribed for our cohort of 91,334 individuals, between January 2009 and March 2017. Eight adherence measures were calculated, and different approaches to estimating the amount of medication supply available at any time were compared. RESULTS Estimates from different measures of adherence varied substantially. Three of the main drivers of the differences between adherence measures were the expected duration (if taken as in accordance with the dose directions), whether there was overlapping supply between prescriptions, and whether treatment had been discontinued. However, there are also wider, study-related, factors which are crucial to consider when comparing the adherence measures. CONCLUSIONS We evaluated the limitations of various medication adherence measures, and highlight key considerations about the underlying data, condition, and population to guide researchers choose appropriate adherence measures. This guidance will enable researchers to make more informed decisions about the methodology they employ, ensuring that adherence is captured in the most meaningful way for their particular application needs.
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Affiliation(s)
- Holly Tibble
- Usher Institute, University of Edinburgh, Edinburgh, Scotland.
- Asthma UK Centre for Applied Research, University of Edinburgh, Edinburgh, Scotland.
| | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Asthma UK Centre for Applied Research, University of Edinburgh, Edinburgh, Scotland
| | - Athanasios Tsanas
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Asthma UK Centre for Applied Research, University of Edinburgh, Edinburgh, Scotland
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Pietersen E, Anderson K, Cox H, Dheda K, Bian A, Shepherd BE, Sterling TR, Warren RM, van der Heijden YF. Variation in missed doses and reasons for discontinuation of anti-tuberculosis drugs during hospital treatment for drug-resistant tuberculosis in South Africa. PLoS One 2023; 18:e0281097. [PMID: 36780443 PMCID: PMC9925007 DOI: 10.1371/journal.pone.0281097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 01/15/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Updated World Health Organization (WHO) treatment guidelines prioritize all-oral drug-resistant tuberculosis (DR-TB) regimens. Several poorly tolerated drugs, such as amikacin and para-aminosalicylic acid (PAS), remain treatment options for DR-TB in WHO-recommended longer regimens as Group C drugs. Incomplete treatment with anti-TB drugs increases the risk of treatment failure, relapse, and death. We determined whether missed doses of individual anti-TB drugs, and reasons for their discontinuation, varied in closely monitored hospital settings prior to the 2020 WHO DR-TB treatment guideline updates. METHODS We collected retrospective data on adult patients with microbiologically confirmed DR-TB between 2008 and 2015 who were selected for a study of acquired drug resistance in the Western Cape Province of South Africa. Medical records through mid-2017 were reviewed. Patients received directly observed treatment during hospitalization at specialized DR-TB hospitals. Incomplete treatment with individual anti-TB drugs, defined as the failure to take medication as prescribed, regardless of reason, was determined by comparing percent missed doses, stratified by HIV status and DR-TB regimen. We applied a generalized mixed effects model. RESULTS Among 242 patients, 131 (54%) were male, 97 (40%) were living with HIV, 175 (72%) received second-line treatment prior to first hospitalization, and 191 (79%) died during the study period. At initial hospitalization, 134 (55%) patients had Mycobacterium tuberculosis with resistance to rifampicin and isoniazid (multidrug-resistant TB [MDR-TB]) without resistance to ofloxacin or amikacin, and 102 (42%) had resistance to ofloxacin and/or amikacin. Most patients (129 [53%]) had multiple hospitalizations and DST changes occurred in 146 (60%) by the end of their last hospital discharge. Incomplete treatment was significantly higher for amikacin (18%), capreomycin (18%), PAS (17%) and kanamycin (16%) than other DR-TB drugs (P<0.001), including ethionamide (8%), moxifloxacin (7%), terizidone (7%), ethambutol (7%), and pyrazinamide (6%). Among the most frequently prescribed drugs, second-line injectables had the highest rates of discontinuation for adverse events (range 0.56-1.02 events per year follow-up), while amikacin, PAS and ethionamide had the highest rates of discontinuation for patient refusal (range 0.51-0.68 events per year follow-up). Missed doses did not differ according to HIV status or anti-TB drug combinations. CONCLUSION We found that incomplete treatment for second-line injectables and PAS during hospitalization was higher than for other anti-TB drugs. To maximize treatment success, interventions to improve person-centered care and mitigate adverse events may be necessary in cases when PAS or amikacin (2020 WHO recommended Group C drugs) are needed.
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Affiliation(s)
- Elize Pietersen
- Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, Division of Pulmonology, Centre for Lung Infection and Immunity, University of Cape Town, Cape Town, South Africa
| | - Kim Anderson
- Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, Division of Pulmonology, Centre for Lung Infection and Immunity, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen Cox
- Wellcome Centre for Infectious Diseases Research in Africa and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, Division of Pulmonology, Centre for Lung Infection and Immunity, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Timothy R. Sterling
- Vanderbilt Tuberculosis Center, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Robin M. Warren
- Division of Molecular Biology and Human Genetics, NRF-DSI Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Yuri F. van der Heijden
- Vanderbilt Tuberculosis Center, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- The Aurum Institute, Johannesburg, South Africa
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Ni K, Tampe CA, Sol K, Richardson DB, Pereira RI. Effect of CGM Access Expansion on Uptake Among Patients on Medicaid With Diabetes. Diabetes Care 2023; 46:391-398. [PMID: 36480729 PMCID: PMC9887615 DOI: 10.2337/dc22-1287] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/07/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Current studies on continuous glucose monitor (CGM) uptake are revealing for significant barriers and inequities for CGM use among patients from socially underprivileged communities. This study explores the effect of full subsidies regardless of diabetes type on CGM uptake and HbA1c outcomes in a U.S. adult patient population on Medicaid. RESEARCH DESIGN AND METHODS This retrospective cohort study examined 3,036 adults with diabetes enrolled in a U.S. Medicaid program that fully subsidized CGM. CGM uptake and adherence were assessed by CGM prescription and dispense data, including more than one fill and adherence by medication possession ratio (MPR). Multivariate logistic regression evaluated predictors of CGM uptake. Pre- and post-CGM use HbA1c were compared. RESULTS CGM were very well received by both individuals with type 1 diabetes and individuals with type 2 diabetes with similar high fill adherence levels (mean MPR 0.78 vs. 0.72; P = 0.06). No significant difference in CGM uptake outcomes were noted among major racial/ethnic groups. CGM use was associated with improved HbA1c among those with type 2 diabetes (-1.2% [13.1 mmol/mol]; P < 0.001) that was comparable between major racial/ethnic groups and those with higher fill adherence achieved greater HbA1c reduction (-1.4% [15.3 mmol/mol]; P < 0.001) compared with those with lower adherence (-1.0% [10.9 mmol/mol]; P < 0.001). CONCLUSIONS CGM uptake disparities can largely be overcome by eliminating CGM cost barriers. CGM use was associated with improved HbA1c across all major racial/ethnic groups, highlighting broad CGM appeal, utilization, and effectiveness across an underprivileged patient population.
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Affiliation(s)
- Kevin Ni
- Medicine Service–Endocrinology, Denver Health, Denver, CO
- Department of Medicine, University of Colorado, Aurora, CO
| | | | - Kayce Sol
- Medicine Service–Endocrinology, Denver Health, Denver, CO
| | | | - Rocio I. Pereira
- Medicine Service–Endocrinology, Denver Health, Denver, CO
- Department of Medicine, University of Colorado, Aurora, CO
- Corresponding author: Rocio I. Pereira,
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Bhatt AS, Vaduganathan M, Solomon SD, Schneeweiss S, Lauffenburger JC, Desai RJ. Sacubitril/valsartan use patterns among older adults with heart failure in clinical practice: a population-based cohort study of >25 000 Medicare beneficiaries. Eur J Heart Fail 2022; 24:1506-1515. [PMID: 35689603 DOI: 10.1002/ejhf.2572] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/13/2022] [Accepted: 06/07/2022] [Indexed: 12/11/2022] Open
Abstract
AIMS Sacubitril/valsartan is strongly supported in guidelines for the management of heart failure, but suboptimal adherence and treatment non-persistence may limit the population-level benefit that this therapy might otherwise offer. METHODS AND RESULTS We identified a cohort of Medicare beneficiaries (2014-2017) initiating sacubitril/valsartan after ≥6 months of continuous enrolment. We assessed adherence as the proportion of days covered (PDC) and proportion of patients non-persistent (having no prescription available) at 180 days after initiation. We fit a multivariable negative binomial model with a count of adherent days to evaluate independent factors associated with of sacubitril/valsartan adherence. Among 27 063 new sacubitril/valsartan users, most (n = 17 663, 65%) were prescribed low-dose at 24 mg/26 mg and most (n = 19 984, 74%) were switched from prior angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) rather than being RASi treatment naïve. Median 180-day PDC was 86% (25th-75th percentiles 58-98%). Black patients, those with high comorbid disease burden (≥8 comorbidities), and patients with recent hospitalization within 30 days had fewer adherent days, while those treated with preceding ACEi/ARB had more adherent days. Thirty-four percent of patients did not have an active sacubitril/valsartan prescription at day 180. Among these, few had preceding dose down-titrations (6% among patients on 49 mg/51 mg and 9% among patients on 97 mg/103 mg) and 68% did not have a subsequent ACEi/ARB prescription. Among patients who remained persistent, dose up-titrations occurred in 29% of patients who started on 24 mg/26 mg and 27% of patients on 49 mg/51 mg. CONCLUSIONS Overall adherence to sacubitril/valsartan among Medicare beneficiaries is acceptable, but is lower in Black patients, those with higher comorbidities or those who started therapy after recent hospitalization. While broad implementation of guideline-directed medical therapy is a key priority, additional focused efforts to improve adherence early after hospitalization and among at-risk patients are needed in parallel.
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Affiliation(s)
- Ankeet S Bhatt
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Delta T, a Useful Indicator for Pharmacy Dispensing Data to Monitor Medication Adherence. Pharmaceutics 2022; 14:pharmaceutics14010103. [PMID: 35056999 PMCID: PMC8778707 DOI: 10.3390/pharmaceutics14010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Calculating patients' medication availability from dispensing or refill data is a common method to estimate adherence. The most often used measures, such as the medication possession ratio (MPR), average medication supplies over an arbitrary period. Averaging masks the variability of refill behavior over time. GOAL To derive a new absolute adherence estimate from dispensing data. METHOD Dispensing histories of patients with 19 refills of direct oral anticoagulants (DOAC) between 1 January 2008 and 31 December 2017 were extracted from 39 community pharmacies in Switzerland. The difference between the calculated and effective refill day (ΔT) was determined for each refill event. We graphed ΔT and its dichotomized version (dΔT) against the MPR, calculated mean ΔT and mean dΔT per refill, and applied cluster analysis. RESULTS We characterized 2204 refill events from 116 DOAC patients. MPR was high (0.975 ± 0.129) and showed a positive correlation with mean ΔT. Refills occurred on average 17.8 ± 27.9 days "too early", with a mean of 75.8 ± 20.2 refills being "on time". Four refill behavior patterns were identified including constant gaps within or at the end of the observation period, which were critical. CONCLUSION We introduce a new absolute adherence estimate ΔT that characterizes every refill event and shows that the refill behavior of DOAC patients is dynamic.
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Loucks J, Zuckerman AD, Berni A, Saulles A, Thomas G, Alonzo A. Proportion of days covered as a measure of medication adherence. Am J Health Syst Pharm 2021; 79:492-496. [PMID: 34637496 DOI: 10.1093/ajhp/zxab392] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
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Affiliation(s)
- Jennifer Loucks
- The University of Kansas Health System, Kansas City, KS, USA
| | - Autumn D Zuckerman
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Adam Saulles
- Credena Health-Providence St. Joseph Health System, Portland, OR, USA
| | | | - Amy Alonzo
- Texas Children's Hospital Specialty Pharmacy, Houston, TX, USA
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Kibbons AM, Peter M, DeClercq J, Choi L, Bell J, Jolly J, Cherry E, Alhashemi B, Shah NB, Zuckerman AD. Pharmacist Interventions to Improve Specialty Medication Adherence: Study Protocol for a Randomized Controlled Trial. Drugs Real World Outcomes 2020; 7:1-11. [PMID: 32983839 PMCID: PMC7503429 DOI: 10.1007/s40801-020-00213-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The effectiveness of specialty medications in complicated clinical conditions depends on adherence to therapy. However, specialty medications pose unique barriers to adherence. OBJECTIVE This study aims to determine whether pharmacist interventions improve specialty medication adherence. METHODS This is a single-center, pragmatic, randomized controlled trial ongoing since 10 May 2019 at an integrated health system specialty pharmacy. This study evaluates usual care compared with usual care plus patient-tailored adherence interventions. Study design and procedures were informed by focus groups with patients and specialty pharmacists. Patients at Vanderbilt Specialty Pharmacy with a proportion of days covered (PDC) < 90% in the previous 4 months are identified by a daily query of the electronic pharmacy database. A pharmacist reviews these patients' electronic health records to identify and exclude ineligible patients. Eligible patients are randomized evenly to the control or intervention arm and stratified by historical clinic nonadherence rates. Patients randomized to the intervention arm undergo a baseline assessment to clarify reasons for nonadherence and subsequently receive patient-tailored interventions based on their specific reasons. Interventions and follow-up are provided at the discretion of the intervening pharmacist. The primary outcome is PDC calculated at 8 months post-enrollment. Enrollment of 438 participants will provide 90% power to detect a 5% difference in PDC between the two arms within each nonadherence risk stratum. DISCUSSION This trial will evaluate the effect of patient-tailored interventions on specialty medication adherence and will inform how often and why patients are misidentified as nonadherent. REGISTRATION The trial was deemed a quality improvement initiative by the Vanderbilt University Institutional Review Board. It was registered in ClinicalTrials.gov (NCT03709277) on 17 October 2018.
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Affiliation(s)
- Amanda M. Kibbons
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, 726 Melrose Avenue, Nashville, TN 37211 USA
| | - Megan Peter
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, 726 Melrose Avenue, Nashville, TN 37211 USA
| | - Josh DeClercq
- The Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN USA
| | - Leena Choi
- The Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN USA
| | - Jacob Bell
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, 726 Melrose Avenue, Nashville, TN 37211 USA
| | - Jacob Jolly
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, 726 Melrose Avenue, Nashville, TN 37211 USA
- Blue Fin Group, Nashville, TN USA
| | - Elizabeth Cherry
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, 726 Melrose Avenue, Nashville, TN 37211 USA
| | - Bassel Alhashemi
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, 726 Melrose Avenue, Nashville, TN 37211 USA
| | - Nisha B. Shah
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, 726 Melrose Avenue, Nashville, TN 37211 USA
| | - Autumn D. Zuckerman
- Vanderbilt Specialty Pharmacy, Vanderbilt University Medical Center, 726 Melrose Avenue, Nashville, TN 37211 USA
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