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Miller KA, Baier Manwell LM, Bartels CM, Yu TY, Vundamati D, Foertsch M, Brown RL. Implementing an osteoarthritis management program to deliver guideline-driven care for knee and hip osteoarthritis in a U.S. academic health system. Osteoarthr Cartil Open 2024; 6:100452. [PMID: 38495347 PMCID: PMC10940781 DOI: 10.1016/j.ocarto.2024.100452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/26/2024] [Indexed: 03/19/2024] Open
Abstract
Objective Assess implementation feasibility and outcomes for an Osteoarthritis Management Program (OAMP) at an academic center. Design This open study assessed an OAMP designed to deliver care in 1-5 individual or group visits across ≤12 months. Eligibility included adults with knee or hip osteoarthritis with ≥1 visit from 7/1/2017-1/15/2021. A multidisciplinary care team provided: education on osteoarthritis, self-management, exercise, weight loss; pharmacologic management; assessments of mood, sleep, quality of life, and diet. Clinic utilization and growth are reported through 2022. Patient outcomes of body mass index (BMI), pain, and function were analyzed using multivariable general linear models. OAMP outcomes were feasibility and sustainability. Results Most patients were locally referred by primary care. 953 patients attended 2531 visits (average visits 2.16, treatment duration 187.9 days). Most were female (72.6%), older (62.1), white (91.1%), and had medical insurance (95.4%). Obesity was prevalent (84.7% BMI ≥30, average BMI 40.9), mean Charlson Comorbidity Index was 1.89, and functional testing was below average. Longitudinal modeling revealed statistically but not clinically significant pain reduction (4.4-3.9 on 0-10 scale, p = 0.002). BMI did not significantly change (p = 0.87). Higher baseline pain and BMI correlated with greater reductions in each posttreatment. Uninsured patients had shorter treatment duration. Increasing clinic hours (4-24 h weekly) and serving 953 patients over four years demonstrated OAMP sustainability. Conclusions OAMP implementation was feasible and sustainable. Patients with high baseline pain and BMI were more likely to improve. Noninsurance was a barrier. These results contribute to understanding OAMP outcomes in U.S. healthcare.
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Affiliation(s)
- Kathryn A. Miller
- Division of General Internal Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- UW Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Linda M. Baier Manwell
- Division of General Internal Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christie M. Bartels
- Division of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Tommy Yue Yu
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Divya Vundamati
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Marley Foertsch
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Roger L. Brown
- Research Design and Statistics Unit, Schools of Nursing, Medicine, and Public Health, University of Wisconsin-Madison, Madison, WI, USA
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Bartels CM, Chen Y, Powell WR, Rosenkranz MA, Bendlin BB, Kramer J, Busse WW, Kind A. Alzheimer's Incidence and Prevalence with and without Asthma: A Medicare cohort study. J Allergy Clin Immunol 2024:S0091-6749(24)00406-8. [PMID: 38670235 DOI: 10.1016/j.jaci.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 03/22/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND International data suggest that asthma, like other inflammatory diseases, might increase Alzheimer's disease (AD) risk. OBJECTIVE To explore risk pathways and future mitigation strategies by comparing diagnostic claims-based AD incidence and prevalence among US patients with asthma to non-asthma patients. METHODS This cohort study included a national Medicare 20% random sample 2013-2015. Adult patients with >12 months continuous Medicare with asthma were compared to non-asthma subjects overall and as matched. Asthma was defined by one inpatient or two outpatient codes for asthma. The main outcomes were two-year incident or prevalent AD defined as any codes for ICD-9 331.0 or ICD-10 G30.0, G30.1, G30.8, G30.9. RESULTS Among 5,460,732 total beneficiaries, 678,730 patients were identified with baseline asthma and more often identified as Black or Hispanic, were Medicaid eligible, or resided in a highly disadvantaged neighborhood than those without asthma. Two-year incidence of AD was 1.4% with asthma vs 1.1% without; prevalence was 7.8% vs 5.4% (both p=<0.001). Per 100,000 patients over two years, 303 more incident AD diagnoses occurred in asthma, with 2,425 more prevalent cases (p<0.001). Multivariable models showed asthma had greater odds of two-year AD incidence [AOR 1.33 (1.29-1.36); matched 1.2 (1.17-1.24)] and prevalence [AOR 1.48 (1.47-1.50); matched 1.25 (1.22-1.27)). CONCLUSION Asthma was associated with 20-33% increased two-year incidence and 25-48% increased prevalence of claims-based Alzheimer's disease in this nationally representative US sample. Future research should investigate risk pathways of underlying comorbidities and social determinants, as well as whether there are potential asthma treatments that may preserve brain health.
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Affiliation(s)
- Christie M Bartels
- Department of Medicine, Rheumatology Division, University of Wisconsin School of Medicine and Public Health, Madison, WI, US; Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US.
| | - Yi Chen
- Department of Biostatistics and Medical informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - W Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US; Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Melissa A Rosenkranz
- Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, WI, US; Center for Healthy Minds, University of Wisconsin-Madison, Madison, WI, US
| | - Barbara B Bendlin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US; Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Joseph Kramer
- Department of Biostatistics and Medical informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - William W Busse
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine; University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Amy Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US; Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
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Schletzbaum M, Powell WR, Garg S, Kramer J, Astor BC, Gilmore-Bykovskyi A, Kind AJ, Bartels CM. Receipt of rheumatology care and lupus-specific labs among young adults with systemic lupus erythematosus: A US Medicare retention in care cohort study. Lupus 2024:9612033241247905. [PMID: 38631342 DOI: 10.1177/09612033241247905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
OBJECTIVE In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context. METHODS This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18-35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography. RESULTS Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6 months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%-60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71). CONCLUSION Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes.
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Affiliation(s)
- Maria Schletzbaum
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - W Ryan Powell
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Shivani Garg
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Joseph Kramer
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Brad C Astor
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Andrea Gilmore-Bykovskyi
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amy J Kind
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christie M Bartels
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Brandt J, Ramly E, Lim SS, Bao G, Messina ML, Piper ME, Bartels CM. Implementing a Staff-Led Smoking Cessation Intervention in a Diverse Safety-Net Rheumatology Clinic: a pre-post scalability study in a low resource setting. Arthritis Care Res (Hoboken) 2024. [PMID: 38622089 DOI: 10.1002/acr.25349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES Quit Connect (QC), our specialty clinic smoking cessation intervention, supports clinic staff to check, advise, and connect willing patients to a state quit line or class. QC improved tobacco screening and quit line referrals 26-fold in a predominantly White academic healthcare system population. Implementing QC includes education, electronic health record (EHR) reminders, and periodic audit feedback. This study tested QC's feasibility and impact in a safety-net rheumatology clinic with a predominantly Black population. METHODS In this pre-post study, adult rheumatology visits were analyzed 12 months pre- through 18 months post-QC intervention (November 2019 - November 2021, omitting COVID-19 peak April-Nov 2020). EHR data compared process and clinical outcomes, including offers, referrals to resources, completed referrals, and documented cessation. Clinic staff engaged in pre-post focus groups and questionnaires regarding intervention feasibility and acceptability. Cost effectiveness was also assessed. RESULTS Visit-level patients who smoked were 89.8% Black and 69.5% women (n=550). Pre-intervention, clinic staff rarely asked patients about readiness to cut back smoking (< 10% assessment). Post QC intervention, staff assessed quit readiness in 31.8% of visits with patients who smoked (vs 8.1% pre); 58.9% of these endorsed readiness to cut back or quit. Of 102 accepting cessation services, 37% (n = 17) of those reached set a quit date. Staff found the intervention feasible and acceptable. Each quit attempt cost approximately $4-10. CONCLUSIONS In a safety-net rheumatology clinic with a predominantly Black population, QC improved tobacco screening, readiness-to-quit assessment, and referrals and was also feasible and cost-effective.
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Affiliation(s)
- Jennifer Brandt
- Emory University School of Medicine, Atlanta, GA
- Grady Health System, Atlanta, GA
| | - Edmond Ramly
- University of Wisconsin School of Medicine and Public Health, Madison, WI
- University of Wisconsin College of Engineering, Madison, WI
| | - S Sam Lim
- Emory University School of Medicine, Atlanta, GA
- Grady Health System, Atlanta, GA
| | - Gaobin Bao
- Emory University School of Medicine, Atlanta, GA
| | | | - Megan E Piper
- UW Center for Tobacco Research and Intervention, Madison, WI
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Dhital R, Singh NC, Spiker AM, Poudel DR, Pedersen B, Bartels CM. Trends in avascular necrosis and related arthroplasties in hospitalized patients with systemic lupus erythematosus and rheumatoid arthritis. Semin Arthritis Rheum 2024; 66:152444. [PMID: 38604118 DOI: 10.1016/j.semarthrit.2024.152444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/19/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Avascular necrosis (AVN) is a devastating complication often necessitating arthroplasty, particularly common in systemic lupus erythematosus (SLE). Limited research exists on arthroplasty trends since new steroid-sparing agents. We analyzed trends and characteristics associated with AVN and AVN-related arthroplasties among SLE and RA hospitalizations using two decades of data from the U.S. National Inpatient Sample (NIS). METHODS This cross-sectional study used NIS (2000-2019) to identify hospitalized adults with SLE and RA, with or without AVN, using ICD codes. AVN was further grouped by arthroplasty status. Primary outcomes were AVN and AVN-related arthroplasty rates and time trends in SLE and RA. Baseline sociodemographics and comorbidities were compared. Analyses used STATA and Joinpoint regression to calculate annual percent change (APC). RESULTS Overall, 42,728 (1.3 %) SLE and 43,600 (0.5 %) RA hospitalizations had concomitant AVN (SLE-AVN and RA-AVN). Of these, 16,724 (39 %) and 25,210 (58 %) underwent arthroplasties, respectively. RA-AVN increased (APC: 0.98*), with a decrease in arthroplasties (APC: -0.82*). In contrast, SLE-AVN initially increased with a breakpoint in 2011 (APC 2000-2011: 1.94* APC 2011-2019 -2.03), with declining arthroplasties (APC -2.03*). AVN hospitalizations consisted of individuals who were younger and of Black race; while arthroplasties were less likely in individuals of Black race or Medicaid coverage. CONCLUSION We report a breakpoint in rising SLE-AVN after 2011, which may relate to newer steroid-sparing therapies (i.e., belimumab). AVN-associated arthroplasties decreased in SLE and RA. Fewer AVN-associated arthroplasties were noted for Black patients and those with Medicaid, indicating potential disparities. Further research should examine treatment differences impacting AVN and arthroplasty rates.
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Affiliation(s)
- Rashmi Dhital
- Department of Medicine, Division of Rheumatology, Autoimmunity and Inflammation, School of Medicine, University of California San Diego, La Jolla, CA.
| | - Neha Chiruvolu Singh
- Department of Medicine, Division of Rheumatology, Autoimmunity and Inflammation, School of Medicine, University of California San Diego, La Jolla, CA
| | - Andrea M Spiker
- Department of Orthopedic Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Dilli Ram Poudel
- Department of Medicine, Indiana Regional Medical Center, Indiana, PA
| | - Brian Pedersen
- Department of Medicine, Division of Rheumatology, Autoimmunity and Inflammation, School of Medicine, University of California San Diego, La Jolla, CA
| | - Christie M Bartels
- Department of Medicine, Division of Rheumatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
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Ferguson S, Hanlon BM, Ramly E, Messina ML, Ibrahim J, Rake P, Bartels CM. Rheumatology High Blood Pressure Protocol Reduces Disparities, But Delays Remain for External Primary Care. J Clin Rheumatol 2024; 30:00124743-990000000-00196. [PMID: 38446494 DOI: 10.1097/rhu.0000000000002065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
BACKGROUND/OBJECTIVE To address high blood pressure (BP) in rheumatology patients, we previously implemented BP Connect, a brief staff-driven protocol to address high BP. Although timely follow-up and hypertension rates improved for patients with in-system primary care (PC), many receive PC and rheumatology care in separate health systems. In this cohort study, we compared rates of timely PC follow-up for high BP across-system health maintenance organizations (HMOs) before and after BP Connect implementation. METHODS All adult patients with high rheumatology clinic BP and PC in that HMO were eligible. BP Connect's protocol engaged the staff in remeasuring high BP (≥140/90 mm Hg), advising cardiovascular disease risk, and connecting timely PC follow-up, which for patients with PC across system includes written follow-up instructions. After an eligible rheumatology visit, the next HMO PC visit with BP was used to determine rates and odds of timely follow-up before and after using multivariable logistic regression. RESULTS Across 1327 rheumatology visits with high BP and across-system PC (2013-2019), 951 occurred after 2015 BP Connect implementation; 400 had confirmed high BP. Primary care follow-up rose from 20.5% to 23.5%. The odds of timely PC BP follow-up insignificantly changed (odds ratio, 1.19; confidence interval, 0.85-1.68). For visits with Black patients, the odds of timely follow-up did significantly increase (1.95; confidence interval, 1.02-3.79). CONCLUSIONS Timely follow-up for Black patients did improve, highlighting protocol interventions for more equitable health care. In contrast to our prior in-system study, BP Connect did not significantly improve follow-up with an across-system PC, indicating a need for direct scheduling. Future directions include piloting direct across-system scheduling.
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Affiliation(s)
| | - Bret M Hanlon
- Departments of Biostatistics and Medical Informatics
| | | | | | - Jennifer Ibrahim
- Quality Management, Group Health Cooperative of South Central Wisconsin, Madison, WI
| | - Paul Rake
- Quality Management, Group Health Cooperative of South Central Wisconsin, Madison, WI
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Garg S, Chewning B, Hutson P, Astor BC, Bartels CM. Reference Range of Hydroxychloroquine Blood Levels That Can Reduce Odds of Active Lupus and Prevent Flares. Arthritis Care Res (Hoboken) 2024; 76:241-250. [PMID: 37667434 DOI: 10.1002/acr.25228] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/04/2023] [Accepted: 08/31/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE Recent data show that lower hydroxychloroquine (HCQ) doses are associated with a two- to six-fold higher risk of lupus flares. Thus, establishing an effective reference range of HCQ blood levels with upper and lower bounds for efficacy may support individualizing HCQ dosing to prevent flares. METHODS HCQ levels in whole blood and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) were measured during the baseline visit and again during a standard of care routine follow-up visit. Active cross-sectional lupus at baseline was defined as SLEDAI ≥6; a within subject flare was defined as a subsequent three-point increase in SLEDAI with clinical symptoms requiring therapy change. We examined associations between active lupus and HCQ blood levels at baseline and flares and HCQ levels during 6 to 12-month routine lupus follow-up visits using mixed regression analysis. RESULTS Among 158 baseline patient visits, 19% had active lupus. Odds of active lupus were 71% lower in patients with levels within a 750 to 1,200 ng/mL range (adjusted odds ratio 0.29, 95% confidence interval 0.08-0.96). Using convenience sampling strategy during a pandemic, we longitudinally followed 42 patients. Among those patients, 17% flared during their follow-up visit. Maintaining HCQ levels within 750 to 1,200 ng/mL reduced the odds of a flare by 26% over a nine-month median follow-up. CONCLUSION An effective reference range of HCQ blood levels, 750 to 1,200 ng/mL, was associated with 71% lower odds of active lupus, and maintaining levels within this range reduced odds of flares by 26%. These findings could guide clinicians to individualize HCQ doses to maintain HCQ levels within this range to maximize efficacy.
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Affiliation(s)
- Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Paul Hutson
- University of Wisconsin School of Pharmacy, Madison
| | - Brad C Astor
- University of Wisconsin School of Medicine and Public Health, Madison
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Katz PP, Barber CEH, Duarte-García A, Garg S, Machua W, Rodgers W, Santiago-Casas Y, Suter L, Bartels CM, Yazdany J. Development of the American College of Rheumatology Patient-Reported Outcome Quality Measures for Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2024. [PMID: 38225171 DOI: 10.1002/acr.25301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 11/27/2023] [Accepted: 01/11/2024] [Indexed: 01/17/2024]
Abstract
OBJECTIVE As part of a Centers for Disease Control and Prevention-funded American College of Rheumatology (ACR) initiative, we sought to develop quality measures related to Patient Reported Outcome Measure (PROM) use for systemic lupus erythematosus (SLE) clinical care. METHODS An expert workgroup composed of physician, patient, and researcher representatives convened to identify patient-reported outcome (PRO) domains of greatest importance to people with SLE. A patient advisory panel separately ranked domains. PROMs assessing priority domains were identified through structured literature review, and detailed psychometric reviews were conducted for each PROM. In a Delphi process, the expert workgroup rated PROMs on content validity, psychometric quality, feasibility of implementation, and importance for guiding patient self-management. The patient advisory panel reviewed PROMs in parallel and contributed to the final recommendations. RESULTS Among relevant PRO domains, the workgroup and patient partners ranked depression, physical function, pain, cognition, and fatigue as high-priority domains. The workgroup recommended at least once yearly measurement for (1) assessment of depression using the Patient Health Questionnaire or Patient Reported Outcomes Measurement Information System (PROMIS) depression scales; (2) assessment of physical function using PROMIS physical function scales or the Multi-Dimensional Health Assessment Questionnaire; and (3) optional assessments of fatigue and cognition. Pain scales evaluated were not found to be sufficiently superior to what is already assessed in most SLE clinic visits. CONCLUSION Expert workgroup members and patient partners recommend that clinicians assess depression and physical function at least once yearly in all people with SLE. Additional PROMs addressing cognition and fatigue can also be assessed. Next steps are to incorporate PROM-based quality measures into the ACR The Rheumatology Informatics System for Effectiveness registry.
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Affiliation(s)
| | | | | | - Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Wendy Rodgers
- Lupus Foundation Care and Support Services, Los Angeles, California
| | | | - Lisa Suter
- Yale School of Medicine, New Haven, Connecticut, and Veterans Administration Hospital, West Haven, Connecticut
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Katz J, Bartels CM. Multimorbidity in Rheumatoid Arthritis: Literature Review and Future Directions. Curr Rheumatol Rep 2024; 26:24-35. [PMID: 37995046 DOI: 10.1007/s11926-023-01121-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE OF REVIEW To offer a narrative review of literature and an update on rheumatoid arthritis (RA) multimorbidity research over the past five years as well as future directions. RECENT FINDINGS Patients with RA experience higher prevalence of multimorbidity (31-86% vs 18-71% in non-RA) and faster accumulation of comorbidities. Patients with multimorbidity have worse outcomes compared to non-RA multimorbid patients and RA without multimorbidity including mortality, cardiac events, and hospitalizations. Comorbid disease clusters often included: cardiopulmonary, cardiometabolic, and depression and pain-related conditions. High-frequency comorbidities included interstitial lung disease, asthma, chronic obstructive pulmonary disease, cardiovascular disease, fibromyalgia, osteoarthritis, and osteoporosis, thyroid disorders, hypertension, and cancer. Furthermore, patients with RA and multimorbidity are paradoxically at increased risk of high RA disease activity but experience a lower likelihood of biologic use and more biologic failures. RA patients experience higher prevalence of multimorbidity and worse outcomes versus non-RA and RA without multimorbidity. Findings call for further studies.
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Affiliation(s)
- Jonathan Katz
- Department of Medicine, Rheumatology Division, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave #4132, Madison, WI, 53705, USA
| | - Christie M Bartels
- Department of Medicine, Rheumatology Division, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave #4132, Madison, WI, 53705, USA.
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Bartels CM, Jorge A, Feldman CH, Zell J, Bermas B, Barber CEH, Duarte-García A, Garg S, Haseley L, Jatwani S, Johansson T, Limanni A, Rodgers W, Rovin BH, Santiago-Casas Y, Suter LG, Barnado A, Ude J, Aguirre A, Li J, Schmajuk G, Yazdany J. Development of American College of Rheumatology Quality Measures for Systemic Lupus Erythematosus: A Modified Delphi Process With Rheumatology Informatics System for Effectiveness (RISE) Registry Data Review. Arthritis Care Res (Hoboken) 2023; 75:2295-2305. [PMID: 37165898 PMCID: PMC10615706 DOI: 10.1002/acr.25143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/04/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE We aimed to develop readily measurable digital quality measure statements for clinical care in systemic lupus erythematosus (SLE) using a multistep process guided by consensus methods. METHODS Using a modified Delphi process, an American College of Rheumatology (ACR) workgroup of SLE experts reviewed all North American and European guidelines from 2000 to 2020 on treatment, monitoring, and phenotyping of patients with lupus. Workgroup members extracted quality constructs from guidelines, rated these by importance and feasibility, and generated evidence-based quality measure statements. The ACR Rheumatology Informatics System for Effectiveness (RISE) Registry was queried for measurement data availability. In 3 consecutive Delphi sessions, a multidisciplinary Delphi panel voted on the importance and feasibility of each statement. Proposed measures with consensus on feasibility and importance were ranked to identify the top 3 measures. RESULTS Review of guidelines and distillation of 57 quality constructs resulted in 15 quality measure statements. Among these, 5 met high consensus for importance and feasibility, including 2 on treatment and 3 on laboratory monitoring measures. The 3 highest-ranked statements were recommended for further measure specification as SLE digital quality measures: 1) hydroxychloroquine use, 2) limiting glucocorticoid use >7.5 mg/day to <6 months, and 3) end-organ monitoring of kidney function and urine protein excretion at least every 6 months. CONCLUSION The Delphi process selected 3 quality measures for SLE care on hydroxychloroquine, glucocorticoid reduction, and kidney monitoring. Next, measures will undergo specification and validity testing in RISE and US rheumatology practices as the foundation for national implementation and use in quality improvement programs.
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Affiliation(s)
| | | | | | | | | | | | | | - Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | | | | | | | - Wendy Rodgers
- Lupus Foundation Care and Support Services, Los Angeles, California
| | - Brad H Rovin
- Ohio State University Wexner Medical Center, Columbus
| | | | - Lisa G Suter
- Yale School of Medicine, New Haven, and Veterans Administration Medical Center, West Haven, Connecticut
| | - April Barnado
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer Ude
- American College of Rheumatology, Atlanta, Georgia
| | | | - Jing Li
- University of California San Francisco
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Schletzbaum M, Sweet N, Astor B, Yu A, Powell WR, Gilmore-Bykovskyi A, Kaiksow F, Sheehy A, Kind AJ, Bartels CM. Associations of Postdischarge Follow-Up With Acute Care and Mortality in Lupus: A Medicare Cohort Study. Arthritis Care Res (Hoboken) 2023; 75:1886-1896. [PMID: 36752354 PMCID: PMC10406973 DOI: 10.1002/acr.25097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 12/06/2022] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Patients with systemic lupus erythematosus experience the sixth highest rate of 30-day readmissions among chronic diseases. Timely postdischarge follow-up is a marker of ambulatory care quality that can reduce readmissions in other chronic conditions. Our objective was to test the hypotheses that 1) beneficiaries from populations experiencing health disparities, including patients from disadvantaged neighborhoods, will have lower odds of completed follow-up, and that 2) follow-up will predict longer time without acute care use (readmission, observation stay, or emergency department visit) or mortality. METHODS This observational cohort study included hospitalizations in January-November 2014 from a 20% random sample of Medicare adults. Included hospitalizations had a lupus code, discharge to home without hospice, and continuous Medicare A/B coverage for 1 year before and 1 month after hospitalization. Timely follow-up included visits with primary care or rheumatology within 30 days. Thirty-day survival outcomes were acute care use and mortality adjusted for sociodemographic information and comorbidities. RESULTS Over one-third (35%) of lupus hospitalizations lacked 30-day follow-up. Younger age, living in disadvantaged neighborhoods, and rurality were associated with lower odds of follow-up. Follow-up was not associated with subsequent acute care or mortality in beneficiaries age <65 years. In contrast, follow-up was associated with a 27% higher hazard for acute care use (adjusted hazard ratio [HR] 1.27 [95% confidence interval (95% CI) 1.09-1.47]) and 65% lower mortality (adjusted HR 0.35 [95% CI 0.19-0.67]) among beneficiaries age ≥65 years. CONCLUSION One-third of lupus hospitalizations lacked follow-up, with significant disparities in rural and disadvantaged neighborhoods. Follow-up was associated with increased acute care, but 65% lower mortality in older systemic lupus erythematosus patients. Further development of lupus-specific postdischarge strategies is needed.
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Affiliation(s)
- Maria Schletzbaum
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Nadia Sweet
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Brad Astor
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Ang Yu
- Department of Sociology, University of Wisconsin – Madison, Madison, WI, US
- Center for Demography and Ecology, University of Wisconsin – Madison, Madison, WI, US
| | - W. Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Andrea Gilmore-Bykovskyi
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- School of Nursing, University of Wisconsin – Madison, Madison, WI, US
| | - Farah Kaiksow
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Ann Sheehy
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Amy J Kind
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Christie M Bartels
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI, US
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12
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Taylor L, Gangnon R, Powell WR, Kramer J, Kind AJH, Bartels CM, Brennan MB. Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study. BMJ Open Diabetes Res Care 2023; 11:11/2/e003185. [PMID: 37072336 PMCID: PMC10124219 DOI: 10.1136/bmjdrc-2022-003185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 03/28/2023] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion. RESEARCH DESIGN AND METHODS This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black. RESULTS Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black. CONCLUSIONS A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.
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Affiliation(s)
- Lindsay Taylor
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ronald Gangnon
- Population Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - W Ryan Powell
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- University of Wisconsin Center for Health Disparities Research, Madison, Wisconsin, USA
| | - Joseph Kramer
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- University of Wisconsin Center for Health Disparities Research, Madison, Wisconsin, USA
| | - Amy J H Kind
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- University of Wisconsin Center for Health Disparities Research, Madison, Wisconsin, USA
| | | | - Meghan B Brennan
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
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13
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Gilmore-Bykovskyi A, Zuelsdorff M, Block L, Golden B, Kaiksow F, Sheehy AM, Bartels CM, Kind AJH, Powell WR. Disparities in 30-day readmission rates among Medicare enrollees with dementia. J Am Geriatr Soc 2023. [PMID: 36896859 PMCID: PMC10363234 DOI: 10.1111/jgs.18311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 01/14/2023] [Accepted: 02/14/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Readmissions contribute to excessive care costs and burden for people living with dementia. Assessments of racial disparities in readmissions among dementia populations are lacking, and the role of social and geographic risk factors such as individual-level exposure to greater neighborhood disadvantage is poorly understood. We examined the association between race and 30-day readmissions in a nationally representative sample of Black and non-Hispanic White individuals with dementia diagnoses. METHODS This retrospective cohort study used 100% Medicare fee-for-service claims from all 2014 hospitalizations nationwide among Medicare enrollees with dementia diagnosis linked to patient, stay, and hospital factors. The sample consisted of 1,523,142 hospital stays among 945,481 beneficiaries. The relationship between all cause 30-day readmissions and the explanatory variable of self-reported race (Black, non-Hispanic White) was examined via generalized estimating equations approach adjusting for patient, stay, and hospital-level characteristics to model 30-day readmission odds. RESULTS Black Medicare beneficiaries had 37% higher readmission odds compared to White beneficiaries (unadjusted OR 1.37, CI 1.35-1.39). This heightened readmission risk persisted after adjusting for geographic factors (OR 1.33, CI 1.31-1.34), social factors (OR 1.25, CI 1.23-1.27), hospital characteristics (OR 1.24, CI 1.23-1.26), stay-level factors (OR 1.22, CI 1.21-1.24), demographics (OR 1.21, CI 1.19-1.23), and comorbidities (OR 1.16, CI 1.14-1.17), suggesting racially-patterned disparities in care account for a portion of observed differences. Associations varied by individual-level exposure to neighborhood disadvantage such that the protective effect of living in a less disadvantaged neighborhood was associated with reduced readmissions for White but not Black beneficiaries. Conversely, among White beneficiaries, exposure to the most disadvantaged neighborhoods associated with greater readmission rates compared to White beneficiaries residing in less disadvantaged contexts. CONCLUSIONS There are significant racial and geographic disparities in 30-day readmission rates among Medicare beneficiaries with dementia diagnoses. Findings suggest distinct mechanisms underlying observed disparities differentially influence various subpopulations.
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Affiliation(s)
- Andrea Gilmore-Bykovskyi
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Megan Zuelsdorff
- School of Nursing, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Laura Block
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA.,School of Nursing, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Blair Golden
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Farah Kaiksow
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Ann M Sheehy
- Division of Hospital Medicine, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Christie M Bartels
- Division of Rheumatology, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
| | - Amy J H Kind
- Center for Health Disparities Research, University of Wisconsin-Madison, Madison, WI, USA
| | - W Ryan Powell
- Division of Geriatrics, Department of Medicine, University of Wisconsin-Madison School of Medicine & Public Health, Madison, Wisconsin, USA
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14
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Schletzbaum M, Kind AJ, Chen Y, Astor BC, Ardoin SP, Gilmore-Bykovskyi A, Sheehy AM, Kaiksow FA, Powell WR, Bartels CM. Age-Stratified 30-day Rehospitalization and Mortality and Predictors of Rehospitalization Among Patients With Systemic Lupus Erythematosus: A Medicare Cohort Study. J Rheumatol 2023; 50:359-367. [PMID: 35970523 PMCID: PMC9929023 DOI: 10.3899/jrheum.220025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Recent studies suggest young adults with systemic lupus erythematosus (SLE) have high 30-day readmission rates, which may necessitate tailored readmission reduction strategies. To aid in risk stratification for future strategies, we measured 30-day rehospitalization and mortality rates among Medicare beneficiaries with SLE and determined rehospitalization predictors by age. METHODS In a 2014 20% national Medicare sample of hospitalizations, rehospitalization risk and mortality within 30 days of discharge were calculated for young (aged 18-35 yrs), middle-aged (aged 36-64 yrs), and older (aged 65+ yrs) beneficiaries with and without SLE. Multivariable generalized estimating equation models were used to predict rehospitalization rates among patients with SLE by age group using patient, hospital, and geographic factors. RESULTS Among 1.39 million Medicare hospitalizations, 10,868 involved beneficiaries with SLE. Hospitalized young adult beneficiaries with SLE were more racially diverse, were living in more disadvantaged areas, and had more comorbidities than older beneficiaries with SLE and those without SLE. Thirty-day rehospitalization was 36% among young adult beneficiaries with SLE-40% higher than peers without SLE and 85% higher than older beneficiaries with SLE. Longer length of stay and higher comorbidity risk score increased odds of rehospitalization in all age groups, whereas specific comorbid condition predictors and their effect varied. Our models, which incorporated neighborhood-level socioeconomic disadvantage, had moderate-to-good predictive value (C statistics 0.67-0.77), outperforming administrative data models lacking comprehensive social determinants in other conditions. CONCLUSION Young adults with SLE on Medicare had very high 30-day rehospitalization at 36%. Considering socioeconomic disadvantage and comorbidities provided good prediction of rehospitalization risk, particularly in young adults. Young beneficiaries with SLE with comorbidities should be a focus of programs aimed at reducing rehospitalizations.
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Affiliation(s)
- Maria Schletzbaum
- M. Schletzbaum, PhD, B.C. Astor, PhD, MPH, Department of Population Health Sciences, and Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Amy J Kind
- A.J. Kind, MD, PhD, A.M. Sheehy, MD, MS, F.A. Kaiksow MD, MPP, W. Ryan Powell, PhD, MA, C.M. Bartels, MD, MS, Department of Medicine, and Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Yi Chen
- Y. Chen, MS, Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brad C Astor
- M. Schletzbaum, PhD, B.C. Astor, PhD, MPH, Department of Population Health Sciences, and Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Stacy P Ardoin
- S.P. Ardoin, MD, MS, Division of Pediatric Rheumatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Andrea Gilmore-Bykovskyi
- A. Gilmore-Bykovskyi, PhD, RN, Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, and School of Nursing, University of Wisconsin, Madison, Wisconsin, USA
| | - Ann M Sheehy
- A.J. Kind, MD, PhD, A.M. Sheehy, MD, MS, F.A. Kaiksow MD, MPP, W. Ryan Powell, PhD, MA, C.M. Bartels, MD, MS, Department of Medicine, and Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Farah A Kaiksow
- A.J. Kind, MD, PhD, A.M. Sheehy, MD, MS, F.A. Kaiksow MD, MPP, W. Ryan Powell, PhD, MA, C.M. Bartels, MD, MS, Department of Medicine, and Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - W Ryan Powell
- A.J. Kind, MD, PhD, A.M. Sheehy, MD, MS, F.A. Kaiksow MD, MPP, W. Ryan Powell, PhD, MA, C.M. Bartels, MD, MS, Department of Medicine, and Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Christie M Bartels
- A.J. Kind, MD, PhD, A.M. Sheehy, MD, MS, F.A. Kaiksow MD, MPP, W. Ryan Powell, PhD, MA, C.M. Bartels, MD, MS, Department of Medicine, and Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin;
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15
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Barber CEH, Bartels CM. Making Sense of Multimorbidity in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2023; 75:207-209. [PMID: 35876632 DOI: 10.1002/acr.24986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/06/2022] [Accepted: 07/21/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Claire E H Barber
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christie M Bartels
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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16
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Garg S, Bartels CM, Bao G, Helmick CG, Drenkard C, Lim SS. Timing and Predictors of Incident Cardiovascular Disease in Systemic Lupus Erythematosus: Risk Occurs Early and Highlights Racial Disparities. J Rheumatol 2023; 50:84-92. [PMID: 35914786 PMCID: PMC10773489 DOI: 10.3899/jrheum.220279] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) affects Black people 2 to 3 times more frequently than non-Black people and is associated with higher morbidity and mortality. In total, 4 studies with predominantly non-Black SLE cohorts highlighted that cardiovascular disease (CVD) is no longer primarily a late complication of SLE. This study assessed the timing and predictors of incident CVD in a predominantly Black population-based SLE cohort. METHODS Incident SLE cases from the population-based Georgia Lupus Registry were validated as having a CVD event through review of medical records and matching with the Georgia Hospital Discharge Database and the National Death Index. The surveillance period for an incident CVD event spanned a 15-year period, starting from 2 years prior to SLE diagnosis. RESULTS Among 336 people with SLE, 253 (75%) were Black and 56 (17%) had an incident CVD event. The frequency of CVD events peaked in years 2 and 11 after SLE diagnosis. There was a 7-fold higher risk of incident CVD over the entire 15-year period; this risk was 19-fold higher in the first 12 years in Black people as compared to non-Black people with SLE. Black people with SLE (P < 0.001) and those with discoid rash (hazard ratio 3.2, 95% CI 1.4-7.1) had a higher risk of incident CVD events. CONCLUSION The frequency of incident CVD events peaked in years 2 and 11 after SLE diagnosis. Being Black or having a discoid rash were strong predictors of an incident CVD event. Surveillance for CVD and preventive interventions, directed particularly toward Black people with recent SLE diagnoses, are needed to reduce racial disparities.
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Affiliation(s)
- Shivani Garg
- S. Garg, MD, MS, Assistant Professor, C.M. Bartels, MD, MS, Associate Professor, Rheumatology Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin;
| | - Christie M Bartels
- S. Garg, MD, MS, Assistant Professor, C.M. Bartels, MD, MS, Associate Professor, Rheumatology Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gaobin Bao
- G. Bao, MPH, Senior Statistician, Division of Rheumatology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Charles G Helmick
- C.G. Helmick, MD, Professor, Division of Population Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cristina Drenkard
- C. Drenkard, MD, PhD, Associate Professor, S.S. Lim, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, Emory University School of Medicine, and Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - S Sam Lim
- C. Drenkard, MD, PhD, Associate Professor, S.S. Lim, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, Emory University School of Medicine, and Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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17
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Mbonu I, Tai S, Bartels CM, Putman M. Association Between Neighborhood Deprivation and Number of Rheumatology Providers. Arthritis Care Res (Hoboken) 2023; 75:9-13. [PMID: 36205227 DOI: 10.1002/acr.25036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Geographic disparities in the distribution and practice patterns of rheumatology providers may negatively impact patients with rheumatic diseases. The objective of this study was to describe the distribution of rheumatologists with respect to the Area Deprivation Index (ADI) and to identify differences in practice patterns among Medicare Part D rheumatologist prescribers. METHODS We identified 5,882 rheumatologists who served a mean ± SD of 280 ± 208 Medicare Part D beneficiaries per year. In a Poisson regression model of the number of rheumatologists and the ADI of their practice location, for every increase of 10 on the ADI scale (range 0-100; higher = higher deprivation), there were 20.3% fewer rheumatologists (P < 0.001), resulting in 2.1 times as many rheumatologists per 100,000 people in the first ADI quintile when compared to the fifth ADI quintile. RESULTS The number of rheumatologists peaked in 2016 and decreased steadily thereafter across all quintiles. The prescribing rate per 100 beneficiaries was significantly different between quintiles across all studied drug classes except for opioids, but the trends were inconsistent and of unclear clinical significance. CONCLUSION Rheumatologists tended to practice in areas with less deprivation, resulting in twice as many rheumatologists per 100,000 people in the quintile of lowest deprivation as opposed to the quintile with the highest deprivation. Public policy makers should be aware of these data and take steps to mitigate disparities in access to care as the rheumatology workforce shrinks.
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18
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Kipp R, Kalscheur M, Sheehy AM, Bartels CM, Kind AJH, Powell WR. Race, Sex, and Neighborhood Socioeconomic Disparities in Ablation of Ventricular Tachycardia Within a National Medicare Cohort. J Am Heart Assoc 2022; 11:e027093. [PMID: 36515242 PMCID: PMC9798800 DOI: 10.1161/jaha.122.027093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Ventricular tachycardia (VT) ablation significantly improves our ability to control VT, yet little is known about whether disparities exist in delivery of this technology. Methods and Results Using a national 100% Medicare inpatient data set of beneficiaries admitted with VT from January 1, 2014, through November 30, 2014, multivariable logistic regression techniques were used to examine the sociodemographic and clinical characteristics associated with receiving ablation. Census block group-level neighborhood socioeconomic disadvantage was measured for each patient by the Area Deprivation Index, a composite measure of socioeconomic disadvantage consisting of education, income, housing, and employment factors. Among 131 645 patients admitted with VT, 2190 (1.66%) received ablation. After adjustment for comorbidities, hospital characteristics, and sociodemographics, female sex (odds ratio [OR], 0.75 [95% CI, 0.67-0.84]), identifying as Black race (OR, 0.75 [95% CI, 0.62-0.90] compared with identifying as White race), and living in a highly socioeconomically disadvantaged neighborhood (national Area Deprivation Index percentile of >85%) (OR, 0.81 [95% CI, 0.69-0.95] versus Area Deprivation Index ≤85%) were associated with significantly lower odds of receiving ablation. Conclusions Female patients, patients identifying as Black race, and patients living in the most disadvantaged neighborhoods are 19% to 25% less likely to receive ablation during hospitalization with VT. The cause of and solutions for these disparities require further investigation.
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Affiliation(s)
- Ryan Kipp
- Division of Cardiovascular Medicine, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI,William S. Middleton Memorial Veterans HospitalMadisonWI
| | - Matthew Kalscheur
- Division of Cardiovascular Medicine, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI,William S. Middleton Memorial Veterans HospitalMadisonWI
| | - Ann M. Sheehy
- Division of Hospitalist Medicine, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI
| | - Christie M. Bartels
- Division of Rheumatology, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI
| | - Amy J. H. Kind
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public HealthMadisonWI,Division of Geriatric Medicine, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWI
| | - W. Ryan Powell
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public HealthMadisonWI
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19
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Kneeland R, Montes D, Endo J, Shields B, Bartels CM, Garg S. Improvement in Cutaneous Lupus Erythematosus After Twenty Weeks of Belimumab Use: A Systematic Review and Meta-Analysis. Arthritis Care Res (Hoboken) 2022. [PMID: 36358025 DOI: 10.1002/acr.25058] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/11/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Cutaneous lupus erythematosus (CLE), with or without systemic lupus erythematosus (SLE), can be debilitating and cause psychological distress. Belimumab, a monoclonal antibody that inhibits B cell activation, is a Federal Drug Administration-approved SLE medication, but less is known on its use in CLE. Moreover, the time to response after starting belimumab in CLE is unknown, which may lead to premature discontinuation in the absence of early perceivable benefits. Thus, the objectives of this meta-analysis were to examine the efficacy of belimumab, as well as the time to response after starting belimumab in patients with CLE with or without SLE. METHODS A comprehensive literature search was performed to include studies that examined clinical response in patients with CLE with or without SLE receiving belimumab. A clinical response at 52 weeks in belimumab users versus nonusers was summarized in a random-effects model. Additionally, we calculated the pooled odds ratio (OR) for each consecutive 4-week observation interval to identify time to a clinical response in CLE with or without SLE after starting belimumab. RESULTS Among 747 screened studies, 14 were included. The pooled odds of clinical response at 52 weeks in belimumab users were 44% higher compared to nonusers (OR 1.44 [95% confidence interval (95% CI) 1.20-1.74], I2 = 0%). A clinical response was first noted after 20 weeks of starting belimumab (OR 1.35 [95% CI 1.01-1.81], I2 = 0%), with a sustained clinical response through 1 year. CONCLUSION The findings support belimumab as an effective therapy for CLE with SLE. Likewise, the findings inform patient counseling regarding estimates of 20 weeks to achieve a response.
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Affiliation(s)
- Rachel Kneeland
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Daniel Montes
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Justin Endo
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Bridget Shields
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Madison
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Tong M, Gilmore-Bykovskyi A, Block L, Ramly E, White DW, Messina ML, Bartels CM. Rheumatology Clinic Staff Needs: Barriers and Strategies to Addressing High Blood Pressure and Smoking Risk. J Clin Rheumatol 2022; 28:354-361. [PMID: 35696986 PMCID: PMC9529788 DOI: 10.1097/rhu.0000000000001868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Patients with rheumatologic conditions are at elevated risk of cardiovascular disease (CVD) due to inflammatory and traditional risk factors, such as high blood pressure (BP) and smoking. However, rheumatology clinics rarely address traditional risk factors, although they are routinely assessed and modifiable in primary care. The present study sought to (1) characterize rheumatology clinic staff's work process for addressing high BP and smoking and (2) identify barriers and strategies for effective management of these risk factors. METHODS We conducted 7 focus groups with medical assistants, nurses, and scheduling staff from 4 adult rheumatology clinics across 2 health systems (BP focus groups, n = 23; smoking, n = 20). Transcripts were analyzed using thematic analysis to elucidate barriers and strategies. RESULTS We found 3 clinic work processes for the management of high BP and smoking risk: (1) risk identification, (2) follow-up within the clinic, and (3) follow-up with primary care and community resources. Within these processes, we identified barriers and strategies grouped into themes: (1) time, (2) clinic workflows, (3) technology and resources, (4) staff's attitudes and knowledge, and (5) staff's perceptions of patients. The most pervasive barriers were (1) no structured system for follow-up and (2) staff confidence and skill in initiating conversations about health-related behavior change. CONCLUSIONS Our study identified generalizable gaps in rheumatology staff's work processes and competencies for addressing high BP and smoking in patients. Future efforts to support staff needs should target (1) systems for follow-up within and outside the clinic and (2) conversation support tools.
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Affiliation(s)
- Michelle Tong
- From the Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Laura Block
- School of Nursing, University of Wisconsin-Madison
| | | | | | - Monica L Messina
- Rheumatology Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Christie M Bartels
- Rheumatology Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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21
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Williams M, Brown HW, Ramly E, Messina ML, Hanlon BM, Carlson AM, Bartels CM. Improving primary care follow-up for gynecologic patients with hypertension: an implementation science pilot study. Am J Obstet Gynecol 2022; 227:650-652. [PMID: 35613649 PMCID: PMC10197919 DOI: 10.1016/j.ajog.2022.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/18/2022] [Indexed: 11/20/2022]
Affiliation(s)
- Makeba Williams
- Division of Academic Specialists in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, 1010 Mound St., Madison, WI 53715.
| | - Heidi W Brown
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Edmond Ramly
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Monica L Messina
- Division of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Bret M Hanlon
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Anisa M Carlson
- Division of Academic Specialists in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Christie M Bartels
- Division of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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22
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McCoy SS, Hetzel S, VanWormer JJ, Bartels CM. Sex hormones, body mass index, and related comorbidities associated with developing Sjögren's disease: a nested case-control study. Clin Rheumatol 2022; 41:3065-3074. [PMID: 35701626 PMCID: PMC9610811 DOI: 10.1007/s10067-022-06226-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Sjögren's disease (SjD), a highly female predominant systemic autoimmune disease, peaks in perimenopause. Prior studies lack details on timing or type of sex hormone exposure. We examined SjD risk using endogenous and exogenous hormone exposure and related comorbidities. METHODS We performed a retrospective case-control study of adult women, nested within a population cohort. Cases had SjD diagnosed by a rheumatology provider or two SjD diagnoses from a non-rheumatology provider with a positive anti-SSA antibody or salivary gland biopsy. Cases were age-matched to three SjD-free controls. We calculated modified composite estrogen scores (mCES) and collected demographics, comorbidities, and endogenous and exogenous hormone exposures. Risk ratios were adjusted for demographics. RESULTS Of 546 SjD cases and 1637 age-matched controls, mCES was not significantly associated with SjD in adjusted models. The top individual hormone exposures associated with SjD included estrogen replacement therapy (ERT; RR 1.78 [95% CI 1.47-2.14]), polycystic ovarian syndrome (1.65 [1.28-2.12]), and hysterectomy without bilateral oophorectomy (1.51 [1.13-2.03]). We identified comorbidities preceding SjD including fibromyalgia, pulmonary disease, diabetes, lymphoma, osteoporosis, peripheral vascular disease, and renal disease. Taking comorbidities into account, we developed a predictive model for SjD that included fibromyalgia (2.50 [1.93-3.25]), osteoporosis (1.84 [1.27-2.66]), hormone replacement therapy (HRT) (1.61 [1.22-2.12]), diabetes (0.27 [0.13-0.50]), and body mass index (BMI) (0.97 [0.95-0.99]). CONCLUSIONS We report a novel algorithm to improve identifying patients at risk for SjD and describe sex hormone association with SjD. Finally, we report new comorbidities associated with SjD decrease, BMI and diabetes, and increase, lymphoma and osteoporosis.. Key Points •Given female predominance and typical perimenopausal onset, sex hormones should be considered when studying comorbidities in Sjögren's disease. •The top exposures associated with developing Sjögren's disease included fibromyalgia, osteoporosis, and use of hormone replacement therapy. Possible protective factors included prior diabetes and higher body mass index. •We used our newly identified exposures to generate a predictive algorithm, which has potential to improve diagnosis and pathogenic insights into Sjögren's disease.
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Affiliation(s)
- Sara S McCoy
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705-2281, USA.
| | - Scott Hetzel
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
- Department of Population Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Jeffrey J VanWormer
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - Christie M Bartels
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705-2281, USA
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23
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Bartels CM, Johnson L, Ramly E, Panyard DJ, Gilmore-Bykovskyi A, Johnson HM, McBride P, Li Z, Sampene E, Lauver DR, Lewicki K, Piper ME. Impact of a Rheumatology Clinic Protocol on Tobacco Cessation Quit Line Referrals. Arthritis Care Res (Hoboken) 2022; 74:1421-1429. [PMID: 33825349 PMCID: PMC8492788 DOI: 10.1002/acr.24589] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/23/2020] [Accepted: 03/02/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Smoking increases cardiopulmonary and rheumatic disease risk, yet tobacco cessation intervention is rare in rheumatology clinics. This study aimed to implement a rheumatology staff-driven protocol, Quit Connect, to increase the rate of electronic referrals (e-referrals) to free, state-run tobacco quit lines. METHODS We conducted a quasi-experimental cohort study of Quit Connect at 3 rheumatology clinics comparing tobacco quit line referrals from 4 baseline years to referrals during a 6-month intervention period. Nurses and medical assistants were trained to use 2 standardized electronic health record (EHR) prompts to check readiness to quit smoking within 30 days, advise cessation, and connect patients using tobacco quit line e-referral orders. Our objective was to use EHR data to examine the primary outcome of tobacco quit line referrals using pre/post design. RESULTS Across 54,090 pre- and post-protocol rheumatology clinic visits, 4,601 were with current smokers. We compared outcomes between 4,078 eligible pre-implementation visits and 523 intervention period visits. Post-implementation, the odds of tobacco quit line referral were 26-fold higher compared to our pre-implementation rate (unadjusted odds ratio [OR] 26 [95% confidence interval (95% CI) 6-106]). Adjusted odds of checking readiness to quit in the next 30 days increased over 100-fold compared to pre-implementation (adjusted OR 132 [95% CI 99-177]). Intervention led to e-referrals for 71% of quit-ready patients in <90 seconds; 24% of referred patients reported a quit attempt. CONCLUSION Implementing Quit Connect in rheumatology clinics was feasible and improved referrals to a state-run tobacco quit line. Given the importance of smoking cessation to reduce cardiopulmonary and rheumatic disease risk, future studies should investigate disseminating cessation protocols like Quit Connect that leverage tobacco quit lines.
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Affiliation(s)
| | - Lauren Johnson
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Edmond Ramly
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Daniel J Panyard
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Heather M Johnson
- Charles E. Schmidt College of Medicine, Florida Atlantic University and Boca Raton Regional Hospital/Baptist Health South Florida, Boca Raton
| | - Patrick McBride
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Zhanhai Li
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Emmanuel Sampene
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Kristin Lewicki
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Megan E Piper
- University of Wisconsin School of Medicine and Public Health, Madison
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24
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McCoy SS, Woodham M, Bartels CM, Saldanha IJ, Bunya VY, Maerz N, Akpek EK, Makara MA, Baer AN. Symptom-Based Cluster Analysis Categorizes Sjögren's Disease Subtypes: An International Cohort Study Highlighting Disease Severity and Treatment Discordance. Arthritis Rheumatol 2022; 74:1569-1579. [PMID: 35594474 PMCID: PMC9427679 DOI: 10.1002/art.42238] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/21/2022] [Accepted: 05/12/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Although symptom relief is a critical aspect for successful drug development in Sjögren's disease, patient experiences with Sjögren's-related symptoms are understudied. Our objective was to determine how pain, dryness, and fatigue, the cardinal symptoms of Sjögren's disease, drive cluster phenotypes. METHODS We used data from the Sjögren's International Collaborative Clinical Alliance (SICCA) Registry and a Sjögren's Foundation survey. We performed hierarchical clustering of symptoms by levels of dryness, fatigue, and pain. Using international and US cohorts, we performed multiple logistic regression analysis to compare the clusters, which included comparisons of differences in symptoms, quality of life (QoL), medication use, and systemic manifestations. RESULTS Four similar clusters were identified among 1,454 SICCA registrants and 2,920 Sjögren's Foundation survey participants: 1) low symptom burden in all categories (LSB); 2) dry with low pain and low fatigue (DLP); 3) dry with high pain and low to moderate fatigue (DHP); and 4) high symptom burden in all categories (HSB). Distribution of SICCA registrants matching the symptom profile for each cluster was 10% in the LSB cluster, 30% in the DLP cluster, 23% in the DHP cluster, and 37% in the HSB cluster. Distribution of survey participants matching the symptom profile for each cluster was 23% in the LSB cluster, 14% in the DLP cluster, 21% in the DHP cluster, and 42% in the HSB cluster. Individuals in the HSB cluster had more total symptoms and lower QoL but lower disease severity than those in the other clusters. Despite having milder disease as measured by laboratory tests and organ involvement, individuals in the HSB cluster received immunomodulatory treatment most often. CONCLUSION We identified 4 symptom-based Sjögren's clusters and showed that symptom burden and immunomodulatory medication use do not correlate with Sjögren's end-organ or laboratory abnormalities. Findings highlight a discordance between objective measures and treatments and offer updates to proposed symptom-based clustering approaches.
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25
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Garg S, Raval AN, Hansen KE, Zhong W, Huang Y, Smith M, Panzer SE, Bartels CM. Association of Renal Arteriosclerosis With Atherosclerotic Cardiovascular Disease Risk in Lupus Nephritis. Arthritis Care Res (Hoboken) 2022; 74:1105-1112. [PMID: 33421305 PMCID: PMC10637686 DOI: 10.1002/acr.24552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/16/2020] [Accepted: 01/05/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Lupus nephritis (LN) predicts a 9-fold higher atherosclerosis cardiovascular disease (ASCVD) risk, highlighting the urgent need to target ASCVD prevention. Studies in IgA nephropathy reported that severe renal arteriosclerosis (r-ASCL) in diagnostic biopsies strongly predicted ASCVD risk. We recently found that 50% of LN pathology reports overlooked r-ASCL reporting, which could explain prior negative LN ASCVD risk studies. The present study was undertaken to examine associations between a composite of reported and overread r-ASCL and ASCVD events in LN. METHODS Data were abstracted from all LN patients who underwent diagnostic biopsy between 1994 and 2017, including demographic information, ASCVD risk factors, and pathology reports at the time of LN diagnosis. We manually validated all incident ASCVD events. We overread 25% of the biopsies to grade r-ASCL using the Banff criteria. We supplemented the overread r-ASCL grade, when available, to determine the composite of reported and overread r-ASCL grade. RESULTS Among 189 incident LN patients, 78% were female, 73% White, and the median age was 25 years. Overall, 31% had any reported r-ASCL, and 7% had moderate-to-severe r-ASCL. After incorporating systematically re-examined r-ASCL grade, the prevalence of any and moderate-to-severe r-ASCL increased to 39% and 12%, respectively. We found 22 incident ASCVD events over 11 years of follow-up. Using a composite of reported and overread r-ASCL grade, we found that severe r-ASCL in diagnostic LN biopsies was associated with 9-fold higher odds of ASCVD. CONCLUSION Severe r-ASCL can predict ASCVD in LN; therefore, larger studies are required to systematically report r-ASCL and examine ASCVD associations.
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Affiliation(s)
| | | | | | | | - Yabing Huang
- RenMin Hospital of Wuhan University, Hubei, China
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26
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Garg S, Singh T, Panzer SE, Astor BC, Bartels CM. Multidisciplinary Lupus Nephritis Clinic Reduces Time to Renal Biopsy and Improves Care Quality. ACR Open Rheumatol 2022; 4:581-586. [PMID: 35396828 PMCID: PMC9274336 DOI: 10.1002/acr2.11435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/24/2022] [Accepted: 03/04/2022] [Indexed: 11/16/2022] Open
Abstract
Objective Patients with lupus nephritis (LN) have a 26‐fold higher mortality rate compared with their peers. Kidney biopsy, the gold standard diagnostic method for LN, may have an average wait time of more than 50 days. Other gaps in quality process measures during LN visits have also been reported. A subspecialty multidisciplinary clinic (MDC) can provide better care and quality in LN; therefore, we aimed to examine how an LN MDC impacted time to biopsy, time to treatment, and other quality measures. Methods We included all validated patients with LN who underwent diagnostic kidney biopsies between the 2011 to 2017 pre‐MDC period and the 2018 to 2020 post‐MDC period. We compared time to biopsy and treatment and quality measures between the two periods and examined factors associated with timely LN diagnosis, defined as a biopsy within 21 days. Results During the pre‐ and post‐MDC periods, 53 and 21 patients with LN underwent a diagnostic biopsy, respectively. We found a decrease in the median time to biopsy from 26 days to 16 days after starting the LN clinic (P = 0.014). Beyond clinical factors, the presence of social factors, such as being of a non‐White race and having food insecurity, were associated with 54% lower odds of timely diagnosis (adjusted Hazards Ratio [aHR] = 0.46; 95% confidence interval: 0.22‐0.93; P = 0.031). We found higher odds of quality measure performance during the post‐ versus pre‐MDC period. Conclusion Wait times to diagnose LN decreased by 40% and higher quality measure performance was noted after establishing an LN MDC. Systemic and social barriers predicted delays in diagnosis that may be addressed by MDCs.
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27
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Brennan MB, Powell WR, Kaiksow F, Kramer J, Liu Y, Kind AJH, Bartels CM. Association of Race, Ethnicity, and Rurality With Major Leg Amputation or Death Among Medicare Beneficiaries Hospitalized With Diabetic Foot Ulcers. JAMA Netw Open 2022; 5:e228399. [PMID: 35446395 PMCID: PMC9024392 DOI: 10.1001/jamanetworkopen.2022.8399] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Patients identifying as Black and those living in rural and disadvantaged neighborhoods are at increased risk of major (above-ankle) leg amputations owing to diabetic foot ulcers. Intersectionality emphasizes that the disparities faced by multiply marginalized people (eg, rural US individuals identifying as Black) are greater than the sum of each individual disparity. OBJECTIVE To assess whether intersecting identities of Black race, ethnicity, rural residence, or living in a disadvantaged neighborhood are associated with increased risk in major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used 2013-2014 data from the US National Medicare Claims Data Database on all adult Medicare patients hospitalized with a diabetic foot ulcer. Statistical analysis was conducted from August 1 to October 27, 2021. EXPOSURES Race was categorized using Research Triangle Institute variables. Rurality was assigned using Rural-Urban Commuting Area codes. Residents of disadvantaged neighborhoods comprised those living in neighborhoods at or above the national 80th percentile Area Deprivation Index. MAIN OUTCOMES AND MEASURES Major leg amputation or death during hospitalization or within 30 days of hospital discharge. Logistic regression was used to explore interactions among race, ethnicity, rurality, and neighborhood disadvantage, controlling for sociodemographic characteristics, comorbidities, and ulcer severity. RESULTS The cohort included 124 487 patients, with a mean (SD) age of 71.5 (13.0) years, of whom 71 286 (57.3%) were men, 13 100 (10.5%) were rural, and 21 649 (17.4%) identified as Black. Overall, 17.6% of the cohort (n = 21 919), 18.3% of rural patients (2402 of 13 100), and 21.9% of patients identifying as Black (4732 of 21 649) underwent major leg amputation or died. Among 1239 rural patients identifying as Black, this proportion was 28.0% (n = 347). This proportion exceeded the expected excess for rural patients (18.3% - 17.6% = 0.7%) plus those identifying as Black (21.9% - 17.6% = 4.3%) by more than 2-fold (28.0% - 17.6% = 10.4% vs 0.7% + 4.3% = 5.0%). The adjusted predicted probability of major leg amputation or death remained high at 24.7% (95% CI, 22.4%-26.9%), with a significant interaction between race and rurality. CONCLUSIONS AND RELEVANCE Rural patients identifying as Black had a more than 10% absolute increased risk of major leg amputation or death compared with the overall cohort. This study suggests that racial and rural disparities interacted, amplifying risk. Findings support using an intersectionality lens to investigate and address disparities in major leg amputation and mortality for patients with diabetic foot ulcers.
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Affiliation(s)
| | - W. Ryan Powell
- Department of Medicine, University of Wisconsin, Madison
| | - Farah Kaiksow
- Department of Medicine, University of Wisconsin, Madison
| | - Joseph Kramer
- Department of Medicine, University of Wisconsin, Madison
| | - Yao Liu
- Department of Ophthalmology, University of Wisconsin, Madison
| | - Amy J. H. Kind
- Department of Medicine, University of Wisconsin, Madison
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison
- Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Hospital, Department of Veterans Affairs, Madison, Wisconsin
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28
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McCoy SS, Greenlee RT, VanWormer JJ, Schletzbaum M, Bartels CM. Smoking associated with reduced odds of Sjögren's syndrome among rheumatoid arthritis patients. Scand J Rheumatol 2022; 51:97-101. [PMID: 34169792 PMCID: PMC8709876 DOI: 10.1080/03009742.2021.1925584] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The objective of this medical record review study is to define the association between smoking and Sjӧgren's syndrome (SS) in a large rheumatoid arthritis (RA) cohort. METHODS Electronic health records from a population-based cohort were screened for RA eligibility between 2005 and 2018. Inclusion criteria were age ≥ 18 years, two or more RA diagnoses, including two diagnoses by a rheumatologist, or positive rheumatoid factor or anti-cyclic citrullinated peptide (anti-CCP) antibody. The independent variable, smoking status, was defined as never, current, or past. The outcome, SS, was defined by two or more ICD-9 codes. Multivariable logistic regression was performed to determine odds ratios (ORs) of SS adjusted for age, sex, and race. RESULTS Among 1861 patients with RA identified for cohort inclusion, 1296 had a reported smoking status. Current smokers were younger and less likely to be female than never smokers. The adjusted OR of current compared to never smokers was negatively associated with SS [OR 0.20, 95% confidence interval (CI) 0.06-0.65]. Female sex and age were associated with SS (OR 2.70, 95% CI 1.18-6.14; OR 3.75, 95% CI 1.23-11.4). CONCLUSION We report that RA patients who currently smoke had 80% lower odds of SS. Age had a 3.7-fold association and female sex a 2.7-fold association with SS among RA patients. Our data suggest a negative correlation between current smoking and prevalent SS among RA patients. Prospective studies examining pack-year relationships or smoking cessation could further examine risk reduction and causality to follow-up our cross-sectional observational study.
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Affiliation(s)
- Sara S. McCoy
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Robert T. Greenlee
- Marshfield Clinic Research Institute, Center for Clinical Epidemiology and Population Health, Marshfield, WI, USA
| | - Jeffrey J. VanWormer
- Marshfield Clinic Research Institute, Center for Clinical Epidemiology and Population Health, Marshfield, WI, USA
| | - Maria Schletzbaum
- University of Wisconsin School of Medicine and Public Health, Department of Population Health Sciences, Madison, WI, USA
| | - Christie M. Bartels
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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29
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Abstract
BACKGROUND Despite many studies reporting disparities in coronavirus disease-2019 (COVID-19) incidence and outcomes in Black and Hispanic/Latino populations, mechanisms are not fully understood to inform mitigation strategies. OBJECTIVE The aim was to test whether neighborhood factors beyond individual patient-level factors are associated with in-hospital mortality from COVID-19. We hypothesized that the Area Deprivation Index (ADI), a neighborhood census-block-level composite measure, was associated with COVID-19 mortality independently of race, ethnicity, and other patient factors. RESEARCH DESIGN Multicenter retrospective cohort study examining COVID-19 in-hospital mortality. SUBJECTS Inclusion required hospitalization with positive SARS-CoV-2 test or COVID-19 diagnosis at three large Midwestern academic centers. MEASURES The primary study outcome was COVID-19 in-hospital mortality. Patient-level predictors included age, sex, race, insurance, body mass index, comorbidities, and ventilation. Neighborhoods were examined through the national ADI neighborhood deprivation rank comparing in-hospital mortality across ADI quintiles. Analyses used multivariable logistic regression with fixed site effects. RESULTS Among 5999 COVID-19 patients median age was 61 (interquartile range: 44-73), 48% were male, 30% Black, and 10.8% died. Among patients who died, 32% lived in the most disadvantaged quintile while 11% lived in the least disadvantaged quintile; 52% of Black, 24% of Hispanic/Latino, and 8.5% of White patients lived in the most disadvantaged neighborhoods.Living in the most disadvantaged neighborhood quintile predicted higher mortality (adjusted odds ratio: 1.74; 95% confidence interval: 1.13-2.67) independent of race. Age, male sex, Medicare coverage, and ventilation also predicted mortality. CONCLUSIONS Neighborhood disadvantage independently predicted in-hospital COVID-19 mortality. Findings support calls to consider neighborhood measures for vaccine distribution and policies to mitigate disparities.
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Affiliation(s)
| | - Christie M Bartels
- Department of Medicine, Health Services and Care Research Program
- Division of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Laura E Lamb
- Beaumont Health System, Royal Oak, MI
- Oakland University William Beaumont School of Medicine, Rochester, MI
| | - Amy J H Kind
- Department of Medicine, Health Services and Care Research Program
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health
- Department of Veterans Affairs Geriatrics Research Education and Clinical Center, Madison, WI
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30
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Lepak AJ, Buys A, Stevens L, LeClair-Netzel M, Anderson L, Osman F, Brennan MB, Bartels CM, Safdar N. COVID-19 in Health Care Personnel: Significance of Health Care Role, Contact History, and Symptoms in Those Who Test Positive for SARS-CoV-2 Infection. Mayo Clin Proc 2021; 96:2312-2322. [PMID: 34366140 PMCID: PMC8249700 DOI: 10.1016/j.mayocp.2021.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/14/2021] [Accepted: 06/25/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify significant factors that help predict whether health care personnel (HCP) will test positive for severe acute respiratory coronavirus 2 (SARS-CoV-2). PATIENTS AND METHODS We conducted a prospective cohort study among 7015 symptomatic HCP from March 25, 2020, through November 11, 2020. We analyzed the associations between health care role, contact history, symptoms, and a positive nasopharyngeal swab SARS-CoV-2 polymerase chain reaction test results, using univariate and multivariable modelling. RESULTS Of the symptomatic HCP, 624 (8.9%) were positive over the study period. On multivariable analysis, having a health care role other than physician or advanced practice provider, contact with family or community member with known or suspected coronavirus disease 2019 (COVID-19), and seven individual symptoms (cough, anosmia, ageusia, fever, myalgia, chills, and headache) were significantly associated with higher adjusted odds ratios for testing positive for SARS-CoV-2. For each increase in symptom number, the odds of testing positive nearly doubled (odds ratio, 1.93; 95% CI, 1.82 to 2.07, P<.001). CONCLUSION Symptomatic HCP have higher adjusted odds of testing positive for SARS-CoV-2 based on three distinct factors: (1) nonphysician/advanced practice provider role, (2) contact with a family or community member with suspected or known COVID-19, and (3) specific symptoms and symptom number. Differences among health care roles, which persisted after controlling for contacts, may reflect the influence of social determinants. Contacts with COVID-19-positive patients and/or HCP were not associated with higher odds of testing positive, supporting current infection control efforts. Targeted symptom and contact questionnaires may streamline symptomatic HCP testing for COVID-19.
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Key Words
- app, advanced practice provider
- astm, american society for testing and materials (formerly)
- cdc, centers for disease control and prevention
- covid-19, coronavirus disease 2019
- hcp, health care personnel
- irb, institutional review board
- ma, medical assistant
- np, nasopharyngeal
- or, odds ratio
- pcr, polymerase chain reaction
- ppe, personal protective equipment
- rt-pcr, real-time polymerase chain reaction
- sars-cov-2, severe acute respiratory syndrome coronavirus 2
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Affiliation(s)
- Alexander J Lepak
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Ashley Buys
- Infection Control Department, UW Health University Hospital, Madison, WI, USA
| | - Linda Stevens
- Nursing Quality and Safety, UW Health University Hospital, Madison, WI, USA
| | | | - Laura Anderson
- Infection Control, University of Wisconsin Medical Foundation, Inc, Madison, WI, USA
| | - Fauzia Osman
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Meghan B Brennan
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christie M Bartels
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; William S. Middleton Memorial Veterans Affairs Medical Center, Madison, WI, USA
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Garg S, Bartels CM, Lenfant T, Costedoat-Chalumeau N. Reply. Arthritis Care Res (Hoboken) 2021; 74:162-163. [PMID: 34459149 DOI: 10.1002/acr.24775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/26/2021] [Indexed: 11/06/2022]
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Sheehy AM, Kaiksow F, Powell WR, Bykovskyi AG, Bartels CM, Golden B, Kind AJH. The Hospital Readmissions Reduction Program and Observation Hospitalizations. J Hosp Med 2021; 16:409-411. [PMID: 34197304 PMCID: PMC8248819 DOI: 10.12788/jhm.3634] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/02/2021] [Indexed: 11/20/2022]
Abstract
The Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP) penalizes hospitals having excess inpatient rehospitalizations within 30 days of index inpatient stays for targeted conditions. Observation hospitalizations are increasing in frequency and may clinically resemble inpatient hospitalizations, yet HRRP excludes observation in index and 30-day rehospitalization counts. Using 100% 2014 Medicare fee-for-service claims and CMS's 30-day rehospitalization methodology, we modeled how observation hospitalizations impact HRRP metrics when counted as index (denominator) and 30-day (numerator) rehospitalizations. Of 3,806,772 index hospitalizations for HRRP conditions, 418,923 (11%) were observation; 18% (155,553/876,033) of rehospitalizations were invisible to HRRP due to observation hospitalization as index (34%; 63,740/188,430), 30-day outcome (53%; 100,343/188,430), or both (13%; 24,347/188,430). By ignoring observation hospitalizations as index and 30-day events, nearly one of five HRRP rehospitalizations is missed. Policymakers might consider this an opportunity to address broad challenges of the two-tiered observation and inpatient hospital billing distinction.
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Affiliation(s)
- Ann M Sheehy
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Medicine, Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Corresponding Author: Ann M Sheehy, MD, MS; ; Telephone: 608-261-1571; Twitter: @SheehyAnn
| | - Farah Kaiksow
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Department of Medicine, Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - W Ryan Powell
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Andrea Gilmore Bykovskyi
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- School of Nursing, University of Wisconsin, Madison, Wisconsin
| | - Christie M Bartels
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Department of Medicine, Division of Rheumatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Blair Golden
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Department of Medicine, Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Amy JH Kind
- Health Services and Care Research Program, University of Wisconsin Department of Medicine, Madison, Wisconsin
- Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Veterans Affairs Geriatrics Research Education and Clinical Center, Madison, Wisconsin
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McCoy SS, Bartels CM, Saldanha IJ, Bunya VY, Akpek EK, Makara MA, Baer AN. National Sjögren's Foundation Survey: Burden of Oral and Systemic Involvement on Quality of Life. J Rheumatol 2021; 48:1029-1036. [PMID: 32934136 PMCID: PMC7956920 DOI: 10.3899/jrheum.200733] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To define the association between oral and systemic manifestations of Sjögren syndrome (SS) and quality of life (QOL). METHODS We analyzed a cross-sectional survey conducted by the Sjögren's Foundation in 2016, with 2961 eligible responses. We defined oral symptom and sign exposures as parotid gland swelling, dry mouth, mouth ulcers/sores, oral candidiasis, trouble speaking, choking or dysphagia, sialolithiasis or gland infection, and dental caries. Systemic exposures included interstitial lung disease, purpura/petechiae/cryoglobulinemia, vasculitis, neuropathy, leukopenia, interstitial nephritis, renal tubular acidosis, autoimmune hepatitis, primary biliary cholangitis, or lymphoma. Outcomes included SS-specific QOL questions generated by SS experts and patients. RESULTS Using multivariable regression models adjusted for age, sex, race, and employment, we observed that mouth ulcers or sores, trouble speaking, and dysphagia were associated with poor quality of life. The following oral aspects had the greatest effect on the following QOL areas: (1) mouth ulcers/sores on the challenge and burden of living with SS (OR 4.26, 95% CI 2.89-6.28); (2) trouble speaking on memory and concentration (OR 4.24, 95% CI 3.28-5.48); and (3) dysphagia on functional interference (OR 4.25, 95% CI 3.13-5.79). In contrast, systemic manifestations were associated with QOL to a lesser extent or not at all. CONCLUSION Oral manifestations of SS, particularly mouth ulcers or sores, trouble speaking, and dysphagia, were strongly associated with worse QOL. Further study and targeted treatment of these oral manifestations provides the opportunity to improve quality of life in patients with SS.
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Affiliation(s)
- Sara S McCoy
- S.S. McCoy, MD, MS, C.M. Bartels, MD, MS, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin;
| | - Christie M Bartels
- S.S. McCoy, MD, MS, C.M. Bartels, MD, MS, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ian J Saldanha
- I.J. Saldanha, MBBS, MPH, PhD, Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice and Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Vatinee Y Bunya
- V.Y. Bunya, MD, MSCE, Department of Ophthalmology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Esen K Akpek
- E.K. Akpek, MD, Department of Ophthalmology, Johns Hopkins University School of Medicine
| | | | - Alan N Baer
- A.N. Baer, MD, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Sutherland BL, Pecanac K, LaBorde TM, Bartels CM, Brennan MB. Good working relationships: how healthcare system proximity influences trust between healthcare workers. J Interprof Care 2021; 36:331-339. [PMID: 34126853 PMCID: PMC8669032 DOI: 10.1080/13561820.2021.1920897] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Trust between healthcare workers is a fundamental component of effective, interprofessional collaboration and teamwork. However, little is known about how this trust is built, particularly when healthcare workers are distributed (i.e., not co-located and lack a shared electronic health record). We interviewed 39 healthcare workers who worked with proximal and distributed colleagues to care for patients with diabetic foot ulcers and analyzed transcripts using content analysis. Generally, building trust was a process that occurred over time, starting with an introduction and proceeding through iterative cycles of communication and working together to coordinate care for shared patients. Proximal, compared to distributed, dyads had more options available for interactions which, in turn, facilitated communication and working together to build trust. Distributed healthcare workers found it more difficult to develop trusting relationships and relied heavily on individual initiative to do so. Few effective tools existed at the level of interprofessional collaborations, teams, or broader healthcare systems to support trust between distributed healthcare workers. With increasing use of distributed interprofessional collaborations and teams, future efforts should focus on fostering this critical attribute.
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Affiliation(s)
- Bryn L Sutherland
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kristin Pecanac
- School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
| | - Taylor M LaBorde
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christie M Bartels
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Meghan B Brennan
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Ramly E, Lauver DR, Gilmore-Bykovskyi A, Bartels CM. Interactive and Participatory Audit and Feedback (IPAF): theory-based development and multi-site implementation outcomes with specialty clinic staff. Implement Sci Commun 2021; 2:58. [PMID: 34059154 PMCID: PMC8167954 DOI: 10.1186/s43058-021-00155-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 05/04/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Theory-based implementation strategies, such as audit and feedback (A&F), can improve the adoption of evidence-based practices. However, few strategies have been developed and tested to meet the needs of specialty clinics. In particular, frontline staff can execute cardiovascular disease (CVD) risk reduction protocols, but A&F strategies to support them are not well examined. Our objective was to develop and evaluate a theory-based approach to A&F, Interactive and Participatory A&F (IPAF). METHODS We developed IPAF informed by two complementary theories, self-regulation theory (SRT) and self-determination theory (SDT). IPAF applies concepts from these theories to inform (1) what to address with staff to improve rates of best practices (SRT) and (2) how to interact with staff to improve behaviors aligned with best practices (SDT). We promoted IPAF fidelity by developing a semi-structured guide to facilitate staff discussion of target behaviors, perceived barriers, goals, and action plans. We evaluated IPAF in the context of eight quasi-experimental implementations in specialty clinics across two health systems. Following a hybrid type 2 effectiveness-implementation design, we reported intervention outcomes for CVD risk reduction elsewhere. This paper reports implementation outcomes associated with IPAF, focusing on feasibility, appropriateness, acceptability, fidelity, and adoption. We evaluated implementation outcomes using mixed-methods data including electronic health record (EHR) data, team records, and staff questionnaire responses. RESULTS Eighteen staff participated in 99 monthly, individual, synchronous (face-to-face or phone) IPAF sessions during the first 6 months of implementation. Subsequently, we provided over 375 monthly feedback emails. Feasibility data revealed high staff attendance (90-93%) and engagement in IPAF sessions. Staff highly rated questionnaire items about IPAF acceptability. Team records and staff responses demonstrated fidelity of IPAF delivery and receipt. Adoption of target behaviors increased significantly (all P values < 0.05), and adoption or behaviors were maintained for over 24 months. CONCLUSIONS We developed and evaluated a theory-based approach to A&F with frontline staff in specialty clinics to improve the implementation of evidence-based interventions. The findings support feasibility, appropriateness, acceptability, and fidelity of IPAF, and staff adoption and maintenance of target behaviors. By evaluating multi-site implementation outcomes, we extended prior research on clinic protocols and A&F beyond primary care settings and providers.
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Affiliation(s)
- Edmond Ramly
- Department of Family and Community Medicine, School of Medicine & Public Health, University of Wisconsin-Madison, Madison, WI, USA.,Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Diane R Lauver
- School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Christie M Bartels
- Department of Medicine, School of Medicine & Public Health, University of Wisconsin-Madison, 1685 Highland Ave, Rm 4132, Madison, WI, 53705-2281, USA.
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McKown T, Schletzbaum M, Unnithan R, Wang X, Ezeh N, Bartels CM. The effect of smoking on cumulative damage in systemic lupus erythematosus: An incident cohort study. Lupus 2021; 30:620-629. [PMID: 33470148 PMCID: PMC7969411 DOI: 10.1177/0961203320988603] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To investigate the relationship between smoking history and pack-year exposure on the rate of end-organ damage in systemic lupus erythematosus (SLE). METHODS The SLE incident cohort included patients who met American College of Rheumatology (ACR) 1997 or SLE International Collaborating Clinics (SLICC) 2012 SLE criteria and had rheumatology encounters at a US academic institution (2008-16). The primary outcome was median time to SLICC/ACR damage index (SLICC/ACR-DI) increase or death. Main explanatory variables were smoking status and pack-years. Covariates included age, sex, race, ethnicity, receipt of Medicaid, neighborhood area deprivation index, and baseline SLE damage. Damage increase-free survival was evaluated by smoking status and pack-years using Kaplan-Meier and Cox proportional hazards methods. RESULTS Patients of Black race and Medicaid recipients were more commonly current smokers (p's < 0.05). Former smokers were older and more likely to have late-onset SLE (54% versus 33% of never and 29% of current smokers, p = 0.001). Median time to SLICC/ACR-DI increase or death was earlier in current or former compared to never smokers (4.5 and 3.4 versus 9.0 yrs; p = 0.002). In multivariable models, the rate of damage accumulation was twice as fast in current smokers (HR 2.18; 1.33, 3.57) and smokers with a >10 pack-year history (HR 2.35; 1.15, 3.64) versus never smokers. CONCLUSIONS In this incident SLE cohort, past or current smoking predicted new SLE damage 4-5 years earlier. After adjustment, current smokers and patients with a pack-year history of >10 years accumulated damage at twice the rate of never smokers.
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Affiliation(s)
- Trevor McKown
- Department of Medicine, University of Wisconsin School of Medicine and Public Health (UW-SMPH), Madison, USA
- William S. Middleton Memorial Veterans Hospital, Madison, USA
| | | | - Rachna Unnithan
- Department of Medicine, University of Wisconsin School of Medicine and Public Health (UW-SMPH), Madison, USA
| | - Xing Wang
- Department of Biostatistics and Medical Informatics, UW-SMPH, Madison, USA
- Seattle Children's Hospital, Seattle, USA
| | - Nnenna Ezeh
- Department of Medicine, University of Wisconsin School of Medicine and Public Health (UW-SMPH), Madison, USA
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Garg S, Unnithan R, Hansen KE, Costedoat-Chalumeau N, Bartels CM. Clinical Significance of Monitoring Hydroxychloroquine Levels in Patients With Systemic Lupus Erythematosus: A Systematic Review and Meta-Analysis. Arthritis Care Res (Hoboken) 2021; 73:707-716. [PMID: 32004406 DOI: 10.1002/acr.24155] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 01/21/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Despite the pivotal role that hydroxychloroquine (HCQ) plays in treating systemic lupus erythematosus (SLE), less than 50% of patients take HCQ as prescribed. Measurement of HCQ blood levels can help clinicians distinguish nonadherence versus lack of efficacy of HCQ. Our objective was to systematically review publications and perform a meta-analysis to examine the correlation between HCQ levels and 1) nonadherence and 2) Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores, in SLE. METHODS A comprehensive search was performed. We included observational and interventional studies that measured HCQ levels and assessed adherence or SLEDAI scores in adults with SLE. Forest plots compared pooled estimates of correlations between HCQ levels and reported nonadherence or SLEDAI scores. RESULTS Among 604 studies screened, 17 were reviewed. We found 3-times higher odds of reported nonadherence in patients with low HCQ levels (odds ratio 2.95 [95% confidence interval (95% CI) 1.63, 5.35], P < 0.001). The mean SLEDAI score was 3.14 points higher in groups with below-threshold HCQ levels on a priori analysis (δ = 3.14 [95% CI -0.05, 6.23], P = 0.053), and 1.4 points higher in groups with HCQ levels of <500 ng/ml (δ = 1.42 [95% CI 0.07, 2.76], P = 0.039). Among 1,223 patients, those with HCQ levels ≥750 ng/ml had a 58% lower risk of active disease, and their SLEDAI score was 3.2 points lower. CONCLUSION We found a strong association between low HCQ levels and reported nonadherence. Our results suggest that HCQ levels of ≥750 ng/ml might be a potential therapeutic target.
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Affiliation(s)
- Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Rachna Unnithan
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Karen E Hansen
- University of Wisconsin School of Medicine and Public Health, Madison
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Garg S, Bartels CM, Hansen KE, Zhong W, Huang Y, Semanik MG, Smith M, Panzer SE. High Burden of Premature Arteriosclerosis on Renal Biopsy Results in Incident Lupus Nephritis. Arthritis Care Res (Hoboken) 2021; 73:394-401. [PMID: 31909878 DOI: 10.1002/acr.24138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 12/31/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Cardiovascular disease (CVD) is accelerated in patients with systemic lupus erythematosus and lupus nephritis (LN). Despite the literature suggesting that renal arteriosclerosis predicts CVD in other glomerulonephritis diseases, arteriosclerosis grading and reporting might be particularly overlooked in LN biopsies. Our objective was to examine the burden of renal arteriosclerosis in LN and to assess whether arteriosclerosis is underreported in LN biopsies. METHODS We identified all patients with LN undergoing kidney biopsy between 1994 and 2017 at an academic center. We interpreted LN biopsy reports to classify the Banff categories of absent, mild, moderate, or severe renal arteriosclerosis. The prevalence of renal arteriosclerosis was compared with the prevalence published for age-matched healthy peers, and predictors of arteriosclerosis were examined. We overread biopsies for Banff renal arteriosclerosis grading and compared to pathology reports. RESULTS Among 189 incident patients with LN, renal arteriosclerosis prevalence was 2 decades earlier compared to their healthy peers, affecting 40% of patients ages 31-39 years with LN compared to 44% of healthy peers ages 50-59 years. A multivariable analysis showed a 3-fold higher odds of renal arteriosclerosis in patients ages ≥30 years with LN. LN chronicity on biopsy results predicted a 4-fold higher odds of renal arteriosclerosis. The overreads determined that 50% of standard LN biopsy reports missed reporting the presence or absence of renal arteriosclerosis. CONCLUSION Renal arteriosclerosis is accelerated by 2 decades in patients with LN compared to their healthy peers and is overlooked by pathologists in half of the routine biopsy reports. We propose incorporating Banff renal arteriosclerosis grading in all LN biopsy reports.
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Affiliation(s)
| | | | | | | | - Yabing Huang
- RenMin Hospital of Wuhan University, Wuhan, China
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Ezeh N, McKown T, Garg S, Bartels CM. Smoking exposure in pack-years predicts cutaneous manifestations and damage in systemic lupus erythematosus. Lupus 2021; 30:961203321995257. [PMID: 33626970 PMCID: PMC8382776 DOI: 10.1177/0961203321995257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the impact of cumulative smoking in pack-years on systemic lupus erythematosus (SLE) cutaneous manifestations and damage. METHODS Our cohort study included 632 adult SLE patients at an academic center, meeting 1997 ACR or 2012 SLICC classification criteria. Outcomes were: (1) cutaneous SLICC Damage Index (SDI), (2) ACR and SLICC criteria. Smoking exposure was defined as low (<5 pack-years), medium (5-10), and high (>10), compared to non-smokers. Analysis used multivariable logistic regression to calculate odds ratios and confidence intervals (OR, (95% CI)). RESULTS Among 632 SLE patients, mean age 42 ± 14, 91% were female, 82% White, and 40% were ever smokers. Black patients were more likely to have smoked (51% vs. 41% White, 11% Other). Chronic SLICC and SDI cutaneous criteria showed linear pack-year trends, meeting significance with high smoking exposure (OR 2.2, (1.2, 4.2); OR 4.2, (1.9, 9.2)). Those with medium exposure were more likely to meet acute SLICC cutaneous criteria (OR 2.3, (1.1, 5.1)). Low exposure predicted any cutaneous SLICC and ACR criteria (OR 3.7, (1.3, 10.6); OR 2.0 (1.03, 3.8)). Patients of color had more chronic SLICC cutaneous criteria (Other Race OR 3.6 (1.6, 8.1)) and SDI skin damage (Black OR 2.6 (1.1, 5.9)) even controlling for smoking exposure. CONCLUSIONS Smoking was an independent risk factor for cutaneous SLE. High pack-year exposure and non-White race increased chronic skin manifestations and SDI damage. Findings suggested a dose relationship between smoking and cutaneous SLE damage, making cessation messaging important to potentially improve outcomes and reduce some disparities.
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Affiliation(s)
- Nnenna Ezeh
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Trevor McKown
- University of Wisconsin Hospitals and Clinics, Madison, WI, USA
| | - Shivani Garg
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christie M Bartels
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Bartels CM, Chodara A, Chen Y, Wang X, Powell WR, Shi F, Schletzbaum M, Sheehy AM, Kaiksow FA, Gilmore-Bykovskyi AL, Garg S, Yu M, Kind AJ. One Quarter of Medicare Hospitalizations in Patients with Systemic Lupus Erythematosus Readmitted within Thirty Days. Semin Arthritis Rheum 2021; 51:477-485. [PMID: 33813261 DOI: 10.1016/j.semarthrit.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/09/2021] [Accepted: 02/15/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Thirty-day hospital readmissions in systemic lupus erythematosus (SLE) approach proportions in Medicare-reported conditions including heart failure (HF). We compared adjusted 30-day readmission and mortality among SLE, HF, and general Medicare to assess predictors informing readmission prevention. METHODS This database study used a 20% sample of all US Medicare 2014 adult hospitalizations to compare risk of 30-day readmission and mortality among admissions with SLE, HF, and neither per discharge diagnoses (if both SLE and HF, classified as SLE). Inclusion required live discharge and ≥12 months of Medicare A/B before admission to assess baseline covariates including patient, geographic, and hospital factors. Analysis used observed and predicted probabilities, and multivariable GEE models clustered by patient to report adjusted risk ratios (ARRs) of 30-day readmission and mortality. RESULTS SLE admissions (n=10,868) were younger, predominantly female, more likely to be Black, disabled, and have Medicaid or end-stage renal disease (ESRD). Observed 30-day readmissions of 24% were identical for SLE and HF (p = 0.6), and higher than other Medicare (16%, p < 0.001). Both SLE and HF had elevated readmission risk (ARR 1.08, (95% CI (1.04, 1.13)); 1.11, (1.09, 1.13)). SLE readmissions were higher for Black (30%) versus White (21%) populations, and highest in ages 18-33 (39%) and ESRD (37%). Admissions of Black patients with SLE from least disadvantaged neighborhoods had highest 30-day mortality (9% versus 3% White). CONCLUSION Thirty-day SLE readmissions rivaled HF at 24%. Readmission prevention programs should engage young, ESRD patients with SLE and examine potential causal gaps in SLE care and transitions.
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Affiliation(s)
- Christie M Bartels
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Rheumatology Division, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA.
| | - Ann Chodara
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Rheumatology Division, Madison, WI, USA; University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Yi Chen
- University of Wisconsin School of Medicine and Public Health, Department of Biostatistics and Medical Informatics, Madison, WI, USA
| | - Xing Wang
- University of Wisconsin School of Medicine and Public Health, Department of Biostatistics and Medical Informatics, Madison, WI, USA
| | - W Ryan Powell
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Geriatrics Division, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA
| | - Fangfang Shi
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Geriatrics Division, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA
| | - Maria Schletzbaum
- University of Wisconsin School of Medicine and Public Health, Department of Population Health Sciences, Madison, WI, USA
| | - Ann M Sheehy
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Hospital Medicine Division, Madison, WI, USA
| | - Farah A Kaiksow
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Hospital Medicine Division, Madison, WI, USA
| | - Andrea L Gilmore-Bykovskyi
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Geriatrics Division, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA; University of Wisconsin-Madison, School of Nursing, Madison, WI, USA
| | - Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Rheumatology Division, Madison, WI, USA
| | - Menggang Yu
- University of Wisconsin School of Medicine and Public Health, Department of Biostatistics and Medical Informatics, Madison, WI, USA
| | - Amy J Kind
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Geriatrics Division, Madison, WI, USA; University of Wisconsin School of Medicine and Public Health, Department of Medicine, Health Services & Care Research Program, Madison, WI, USA; VA Geriatrics Research Education and Clinical Center, William S Middleton VA Hospital, Madison, WI, USA
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Sheehy AM, Powell WR, Kaiksow FA, Buckingham WR, Bartels CM, Birstler J, Yu M, Bykovskyi AG, Shi F, Kind AJH. Thirty-Day Re-observation, Chronic Re-observation, and Neighborhood Disadvantage. Mayo Clin Proc 2020; 95:2644-2654. [PMID: 33276837 PMCID: PMC7720926 DOI: 10.1016/j.mayocp.2020.06.059] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/28/2020] [Accepted: 06/25/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine whether neighborhood socioeconomic disadvantage, as determined by the Area Deprivation Index, increases 30-day hospital re-observation risk. PARTICIPANTS AND METHODS This retrospective study of 20% Medicare fee-for-service beneficiary observation stays from January 1, 2014, to November 30, 2014, included 319,980 stays among 273,308 beneficiaries. We evaluated risk for a 30-day re-observation following an index observation stay for those living in the 15% most disadvantaged compared with the 85% least disadvantaged neighborhoods. RESULTS Overall, 4.5% (270,600 of 6,080,664) of beneficiaries had index observation stays, which varied by disadvantage (4.3% [232,568 of 5,398,311] in the least disadvantaged 85% compared with 5.6% [38,032 of 682,353] in the most disadvantaged 15%). Patients in the most disadvantaged neighborhoods had a higher 30-day re-observation rate (2857 of 41,975; 6.8%) compared with least disadvantaged neighborhoods (13,543 of 278,005; 4.9%); a 43% increased risk (unadjusted odds ratio [OR], 1.43; 95% CI, 1.31 to 1.55). After adjustment, this risk remained (adjusted OR, 1.13; 95% CI, 1.04 to 1.22). Discharge to a skilled nursing facility reduced 30-day re-observation risk (OR, 0.63; 95% CI, 0.57 to 0.69), whereas index observation length of stay of 4 or more days (3 midnights) conferred increased risk (OR, 1.29; 95% CI, 1.09 to 1.52); those living in disadvantaged neighborhoods were less likely to discharge to skilled nursing facilities and more likely to have long index stays. Beneficiaries with more than one 30-day re-observation (chronic re-observation) had progressively greater disadvantage by number of stays (adjusted incident rate ratio, 1.08; 95% CI, 1.02 to 1.14). Observation prevalence varied nationally. CONCLUSION Thirty-day re-observation, especially chronic re-observation, is highly associated with socioeconomic neighborhood disadvantage, even after accounting for factors such as race, disability, and Medicaid eligibility. Beneficiaries least able to pay are potentially most vulnerable to costs from serial re-observations and challenges of Medicare observation policy, which may discourage patients from seeking necessary care.
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Affiliation(s)
- Ann M Sheehy
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI.
| | - W Ryan Powell
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Farah A Kaiksow
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Hospital Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - William R Buckingham
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Applied Population Laboratory, University of Wisconsin, Madison, WI
| | - Christie M Bartels
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Division of Rheumatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jen Birstler
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI
| | - Menggang Yu
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison, WI
| | - Andrea Gilmore Bykovskyi
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; School of Nursing, University of Wisconsin, Madison, WI
| | - Fangfang Shi
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Amy J H Kind
- Health Services and Care Research Program, Department of Medicine, University of Wisconsin, Madison, WI; Divisions of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; Department of Veterans Affairs Geriatrics Research Education and Clinical Center, Madison, WI
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Wattiaux A, Bettendorf B, Block L, Gilmore-Bykovskyi A, Ramly E, Piper ME, Rosenthal A, Sadusky J, Cox E, Chewning B, Bartels CM. Patient Perspectives on Smoking Cessation and Interventions in Rheumatology Clinics. Arthritis Care Res (Hoboken) 2020; 72:369-377. [PMID: 30768768 DOI: 10.1002/acr.23858] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 02/12/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Although smoking is a risk factor for cardiovascular and rheumatic disease severity, only 10% of rheumatology visits document cessation counseling. After implementing a rheumatology clinic protocol that increased tobacco quitline referrals 20-fold, we undertook this study to examine patients' barriers and facilitators to smoking cessation based on prior rheumatology experiences, to solicit reactions to the new cessation protocol, and to identify patient-centered outcomes or signs of cessation progress following improved care. METHODS We recruited 19 patients who smoke (12 with rheumatoid arthritis [RA] and 7 with systemic lupus erythematosus [SLE]) to participate in 1 of 3 semistructured focus groups. Transcripts of the focus group discussions were analyzed using thematic analysis to classify barriers, facilitators, and signs of cessation progress. RESULTS Participant-reported barriers and facilitators to cessation involved psychological, health-related, and social and economic factors, as well as health care messaging and resources. Commonly discussed barriers included viewing smoking as a crutch amid rheumatic disease, rarely receiving cessation counseling in rheumatology clinics, and very limited awareness that smoking can worsen rheumatic diseases or reduce efficacy of some rheumatic disease medications. Participants endorsed our cessation protocol with rheumatology-specific education and accessible resources, such as a quitline. Beyond quitting, participants prioritized knowing why and how to quit as signs of progress outcomes. CONCLUSION Focus groups identified themes and categories of facilitators/barriers to smoking cessation at the levels of patient and health system. Two key outcomes of improving cessation care for patients with RA and SLE were knowing why and how to quit. Emphasizing rheumatologic health benefits and cessation resources is essential when designing and evaluating rheumatology smoking cessation interventions.
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Affiliation(s)
| | | | | | | | | | - Megan E Piper
- University of Wisconsin, Center for Tobacco Research and Intervention, Madison
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Sutherland BL, Pecanac K, Bartels CM, Brennan MB. Expect delays: poor connections between rural and urban health systems challenge multidisciplinary care for rural Americans with diabetic foot ulcers. J Foot Ankle Res 2020; 13:32. [PMID: 32513221 PMCID: PMC7278184 DOI: 10.1186/s13047-020-00395-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/19/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Rural Americans with diabetic foot ulcers (DFUs) face a 50% increased risk of major amputation compared to their urban counterparts. We sought to identify health system barriers contributing to this disparity. METHODS We interviewed 44 participants involved in the care of rural patients with DFUs: 6 rural primary care providers (PCPs), 12 rural specialists, 12 urban specialists, 9 support staff, and 5 patients/caregivers. Directed content analysis was performed guided by a conceptual model describing how PCPs and specialists collaborate to care for shared patients. RESULTS Rural PCPs reported lack of training in wound care and quickly referred patients with DFUs to local podiatrists or wound care providers. Timely referrals to, and subsequent collaborations with, rural specialists were facilitated by professional connections. However, these connections often were lacking between rural providers and urban specialists, whose skills were needed to optimally treat patients with high acuity ulcers. Urban referrals, particularly to vascular surgery or infectious disease, were stymied by 1) time-consuming processes, 2) negative provider interactions, and 3) multiple, disconnected electronic health record systems. Such barriers ultimately detracted from rural PCPs' ability to focus on medical management, as well as urban specialists' ability to appropriately triage referrals due to lacking information. Subsequent collaboration between providers also suffered as a result. CONCLUSIONS Poor connections across rural and urban healthcare systems was described as the primary health system barrier driving the rural disparity in major amputations. Future interventions focusing on mitigating this barrier could reduce the rural disparity in major amputations.
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Affiliation(s)
- Bryn L Sutherland
- Department of Medicine, University of Wisconsin School of Medicine and Public Health (UWSMPH), 800 University Bay Dr. Suite 210, Madison, WI, 53705-2299, USA
| | - Kristen Pecanac
- School of Nursing, University of Wisconsin-Madison, 4167 Signe Skott Cooper Hall, 701 Highland Ave, Madison, WI, 53705-2299, USA
| | - Christie M Bartels
- Department of Medicine, University of Wisconsin School of Medicine and Public Health (UWSMPH), 800 University Bay Dr. Suite 210, Madison, WI, 53705-2299, USA
| | - Meghan B Brennan
- Department of Medicine, University of Wisconsin School of Medicine and Public Health (UWSMPH), 800 University Bay Dr. Suite 210, Madison, WI, 53705-2299, USA.
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Navarro-Millán I, Yang S, Chen L, Yun H, Jagpal A, Bartels CM, Fraenkel L, Safford MM, Curtis JR. Screening of Hyperlipidemia Among Patients With Rheumatoid Arthritis in the United States. Arthritis Care Res (Hoboken) 2020; 71:1593-1599. [PMID: 30414353 PMCID: PMC6510643 DOI: 10.1002/acr.23810] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 11/06/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To determine the proportion of primary lipid screening among patients with rheumatoid arthritis (RA) and compare it with those among patients with diabetes mellitus (DM) and patients with neither RA nor DM, and to assess whether primary lipid screening varied according to the health care provider (rheumatologist versus non-rheumatologist). METHODS We analyzed claims data from US private and public health plans from 2006-2010. Eligibility requirements included continuous medical and pharmacy coverage for ≥12 months (baseline period) and >2 physician diagnoses and relevant medications to define RA, DM, RA and DM, or neither condition. Among the 330,695 eligible participants, we calculated the proportion with a lipid profile ordered during the 2 years following baseline. Time-varying Cox proportional hazard models were used to determine the probability of hyperlipidemia screening in participants with RA according to provider specialty. RESULTS More than half of the patients were ages 41-71 years. Among patients with RA (n = 12,182), DM (n = 62,834), RA and DM (n = 1,082), and those who did not have either condition (n = 167,811), the proportion screened for hyperlipidemia was 37%, 60%, 55%, and 41%, respectively. Patients with RA who visited a rheumatologist and a non-rheumatology clinician during follow-up had a 55% (95% confidence interval 1.36-1.78) higher screening probability than those who only visited a rheumatologist. CONCLUSION Primary lipid screening was suboptimal among patients with RA. It was also lower for patients with DM and minimally different from the general population. Screening was higher for RA patients who received care from both a rheumatologist and a non-rheumatologist (e.g., primary care physician).
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Affiliation(s)
- Iris Navarro-Millán
- Weill Cornell Medicine and the Hospital for Special Surgery, New York, New York
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45
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Schletzbaum M, Wang X, Greenlee R, Piper ME, Bartels CM. Predictors of Smoking Cessation in Patients With Rheumatoid Arthritis in Two Cohorts: Most Predictive Health Care Factors. Arthritis Care Res (Hoboken) 2020; 73:633-639. [PMID: 32128996 DOI: 10.1002/acr.24154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recognizing smoking as a risk factor for rheumatoid arthritis (RA) severity, the present study was undertaken to evaluate patient- and health care-level predictors of smoking cessation in patients with RA to guide implementation of smoking cessation interventions. METHODS Electronic health record data from 2 health systems were abstracted for patients with at least 2 International Classification of Disease diagnosis codes for RA between 2005 and 2016. Patients missing smoking statuses or with <6 months of follow-up were excluded. Multivariable logistic regression was used to determine predictors of smoking cessation. RESULTS Among 3,577 patients with RA, 507 smoked at baseline, and 29% quit over a median of 4.75 years. Black male patients, ages 40-59 years and enrolled in Medicaid, were significantly more likely to be baseline smokers; however, none of these factors predicted cessation. Instead, patients new to rheumatology care were 60% more likely to quit (adjusted odds ratio [ORadj ] 1.60 [95% confidence interval (95% CI) 1.02-2.50]), and patients in the rural community health system were 66% more likely to quit (ORadj 1.66 [95% CI 1.03-2.69]). Seropositive patients were 43% less likely to quit smoking (ORadj 0.57 [95% CI 0.35-0.91]). CONCLUSION Health care factors, including health system and being new to rheumatology care, were more predictive of smoking cessation in patients with RA than patient sociodemographic factors, suggesting an important role for health system cessation efforts for patients with RA. Seropositive patients were less likely to quit and may particularly benefit from cessation support. Emphasizing smoking cessation with new or seropositive RA patients and leveraging health system interventions could improve smoking cessation and outcomes in RA.
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Affiliation(s)
- Maria Schletzbaum
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Xing Wang
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Megan E Piper
- University of Wisconsin School of Medicine and Public Health, Madison
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46
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Bartels CM, Rosenthal A, Wang X, Ahmad U, Chang I, Ezeh N, Garg S, Schletzbaum M, Kind A. Investigating lupus retention in care to inform interventions for disparities reduction: an observational cohort study. Arthritis Res Ther 2020; 22:35. [PMID: 32087763 PMCID: PMC7036188 DOI: 10.1186/s13075-020-2123-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 02/06/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Systemic lupus erythematous (SLE) disproportionately impacts patients of color and socioeconomically disadvantaged patients. Similar disparities in HIV were reduced through a World Health Organization-endorsed Care Continuum strategy targeting "retention in care," defined as having at least two annual visits or viral load lab tests. Using similar definitions, this study aimed to examine predictors of lupus retention in care, to develop an SLE Care Continuum and inform interventions to reduce disparities. We hypothesized that Black patients and those residing in disadvantaged neighborhoods would have lower retention in care. METHODS Abstractors manually validated 545 potential adult cases with SLE codes in 2013-2014 using 1997 American College of Rheumatology (ACR) or 2012 Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) criteria. We identified 397 SLE patients who met ACR or SLICC criteria for definite lupus, had at least one baseline rheumatology visit, and were alive through 2015. Retention in care was defined as having two ambulatory rheumatology visits or SLE labs (e.g., complement tests) during the outcome year 2015, analogous to HIV retention definitions. Explanatory variables included age, sex, race, ethnicity, smoking status, neighborhood area deprivation index (ADI), number of SLE criteria, and nephritis. We used multivariable logistic regression to test our hypothesis and model predictors of SLE retention in care. RESULTS Among 397 SLE patients, 91% were female, 56% White, 39% Black, and 5% Hispanic. Notably, 51% of Black versus 5% of White SLE patients resided in the most disadvantaged ADI neighborhood quartile. Overall, 60% met visit-defined retention and 27% met complement lab-defined retention in 2015. Retention was 59% lower for patients in the most disadvantaged neighborhood quartile (adjusted OR 0.41, CI 0.18, 0.93). No statistical difference was seen based on age, sex, race, or ethnicity. More SLE criteria and non-smoking predicted greater retention. CONCLUSIONS Disadvantaged neighborhood residence was the strongest factor predicting poor SLE retention in care. Future interventions could geo-target disadvantaged neighborhoods and design retention programs with vulnerable populations to improve retention in care and reduce SLE outcome disparities.
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Affiliation(s)
- Christie M Bartels
- Department of Medicine, Rheumatology Division, University of Wisconsin School of Medicine and Public Health, 1485 Highland Ave, Rm 4132, Madison, WI, 53705, USA. .,Health Services & Care Research Program, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Ann Rosenthal
- Medical College of Wisconsin, Milwaukee, WI, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA
| | - Xing Wang
- Department of Biostatistics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Seattle Children's Hospital, Seattle, WI, USA
| | - Umber Ahmad
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ian Chang
- Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Medicine, Rheumatology, University of California Irvine Medical Center, Orange County, CA, USA
| | - Nnenna Ezeh
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Shivani Garg
- Department of Medicine, Rheumatology Division, University of Wisconsin School of Medicine and Public Health, 1485 Highland Ave, Rm 4132, Madison, WI, 53705, USA
| | - Maria Schletzbaum
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amy Kind
- Health Services & Care Research Program, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.,Geriatrics Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, USA.,VA Geriatrics Research Education and Clinical Center, William S Middleton VA Hospital, Madison, WI, USA
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Bartels CM, Ramly E, Johnson HM, Lauver DR, Panyard DJ, Li Z, Sampene E, Lewicki K, McBride PE. Connecting Rheumatology Patients to Primary Care for High Blood Pressure: Specialty Clinic Protocol Improves Follow-up and Population Blood Pressures. Arthritis Care Res (Hoboken) 2020; 71:461-470. [PMID: 29856134 DOI: 10.1002/acr.23612] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/11/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Recognizing high blood pressure (BP) as the most prevalent cardiovascular risk factor in patients with rheumatic diseases and all adults, experts recommend clinic protocols to improve BP control. The aim of this study was to adapt and implement a specialty clinic protocol, "BP Connect," to improve timely primary care follow-up after high BP measurements in rheumatology clinics. METHODS We examined BP Connect in a 6-month preimplementation and postimplementation quasi-experimental design with 24-month follow-up in 3 academic rheumatology clinics. Medical assistants and nurses were trained to 1) check (re-measuring BPs ≥140/90 mm Hg), 2) advise (linking rheumatic and cardiovascular diseases), and 3) connect (timely [<4 weeks] primary care follow-up using protocoled electronic health record [EHR] orders). We used EHR data and multivariable logistic regression analysis to examine the primary outcome of timely primary care follow-up for patients with in-network primary care. Staff surveys were used to assess perceptions. Interrupted time series analysis was performed to examine sustainability and BP trends in the clinic populations. RESULTS Across both 4,683 preimplementation and 689 postimplementation rheumatology visits by patients with high BP, 2,789 (57%) encounters were eligible for in-network primary care follow-up. Postimplementation, the odds of timely primary care BP measurement follow-up doubled (odds ratio 2.0, 95% confidence interval 1.4-2.9). Median time to follow-up decreased from 71 days to 38 days. Moreover, rheumatology visits by patients with high BP decreased from 17% to 8% over 24 months, suggesting significant population-level declines (P < 0.01). CONCLUSION Implementing the BP Connect specialty clinic protocol in rheumatology clinics improved timely follow-up and demonstrated reduced population-level rates of high BP. These findings highlight a timely strategy to improve BP follow-up amid new guidelines and quality measures.
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Affiliation(s)
| | - Edmond Ramly
- University of Wisconsin School of Medicine and Public Health and College of Engineering, Madison
| | - Heather M Johnson
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Daniel J Panyard
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Zhanhai Li
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Emmanuel Sampene
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Kristin Lewicki
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Patrick E McBride
- University of Wisconsin School of Medicine and Public Health, Madison
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McCoy SS, Mukadam Z, Meyer KC, Kanne JP, Meyer CA, Martin MD, Sampene E, Aesif SW, Rice LN, Bartels CM. Mycophenolate therapy in interstitial pneumonia with autoimmune features: a cohort study. Ther Clin Risk Manag 2018; 14:2171-2181. [PMID: 30464490 PMCID: PMC6219314 DOI: 10.2147/tcrm.s173154] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives International experts recently characterized interstitial pneumonia with autoimmune features (IPAF) as a provisional diagnosis for patients with interstitial lung disease who have characteristics of autoimmune disease but do not meet criteria for a specific autoimmune disease. We describe clinical characteristics of IPAF patients and examine responses to mycophenolate as a therapy for IPAF. Methods This retrospective cohort included adult patients meeting European Respiratory Society/American Thoracic Society classification criteria for IPAF. Sociodemographic, clinical, and pulmonary function test data were abstracted for patients with and without mycophenolate treatment and followed longitudinally from interstitial lung disease diagnosis for change in pulmonary function test results. Results We identified 52 patients who met criteria for IPAF. Of 52 IPAF patients, 24 did not receive mycophenolate and 28 did, with median time to mycophenolate treatment 22 months. Changes in FVC% and percentage predicted lung diffusion capacity for carbon monoxide (DLCO%) between the mycophenolate-treated and untreated groups were not significantly different (FVC% change P=0.08, DLCO% change P=0.17). However, there was a trend toward more rapid baseline decline of both FVC% and DLCO% in the mycophenolate-treated cohort before vs after mycophenolate therapy. The slope of both FVC% and DLCO% values improved after onset of mycophenolate exposure for the treated group, although this finding was not statistically significant. Conclusion Patients with IPAF might benefit from mycophenolate therapy. Larger prospective clinical trials are needed to evaluate the efficacy of mycophenolate for patients who meet criteria for IPAF.
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Affiliation(s)
- Sara S McCoy
- Division of Rheumatology, Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA,
| | - Zubin Mukadam
- Division of Pulmonary and Critical Care, Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
| | - Keith C Meyer
- Division of Pulmonary and Critical Care, Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA
| | - Jeffrey P Kanne
- Department of Radiology, University of Wisconsin, Madison, WI 53792-3252, USA
| | - Cristopher A Meyer
- Department of Radiology, University of Wisconsin, Madison, WI 53792-3252, USA
| | - Maria D Martin
- Department of Radiology, University of Wisconsin, Madison, WI 53792-3252, USA
| | - Emmanuel Sampene
- Department of Biostatistics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Scott W Aesif
- Department of Pathology, University of Wisconsin, Madison, WI 53792-3252, USA
| | - Laurie N Rice
- Department of Pulmonology, SSM Health Dean Medical Group, Madison, WI 53715, USA
| | - Christie M Bartels
- Division of Rheumatology, Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA,
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Rebernick R, Fahmy L, Glover C, Bawadekar M, Shim D, Holmes CL, Rademacher N, Potluri H, Bartels CM, Shelef MA. DNA Area and NETosis Analysis (DANA): a High-Throughput Method to Quantify Neutrophil Extracellular Traps in Fluorescent Microscope Images. Biol Proced Online 2018; 20:7. [PMID: 29618953 PMCID: PMC5878938 DOI: 10.1186/s12575-018-0072-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 02/14/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Neutrophil extracellular traps (NETs), extracellular structures composed of decondensed chromatin and antimicrobial molecules, are released in a process called NETosis. NETs, which are part of normal host defense, have also been implicated in multiple human diseases. Unfortunately, methods for quantifying NETs have limitations which constrain the study of NETs in disease. Establishing optimal methods for NET quantification holds the potential to further elucidate the role of NETs in normal and pathologic processes. RESULTS To better quantify NETs and NET-like structures, we created DNA Area and NETosis Analysis (DANA), a novel ImageJ/Java based program which provides a simple, semi-automated approach to quantify NET-like structures and DNA area. DANA can analyze many fluorescent microscope images at once and provides data on a per cell, per image, and per sample basis. Using fluorescent microscope images of Sytox-stained human neutrophils, DANA quantified a similar frequency of NET-like structures to the frequency determined by two different individuals counting by eye, and in a fraction of the time. As expected, DANA also detected increased DNA area and frequency of NET-like structures in neutrophils from subjects with rheumatoid arthritis as compared to control subjects. Using images of DAPI-stained murine neutrophils, DANA (installed by an individual with no programming background) gave similar frequencies of NET-like structures as the frequency of NETs determined by two individuals counting by eye. Further, DANA quantified more NETs in stimulated murine neutrophils compared to unstimulated, as expected. CONCLUSIONS DANA provides a means to quantify DNA decondensation and the frequency of NET-like structures using a variety of different fluorescent markers in a rapid, reliable, simple, high-throughput, and cost-effective manner making it optimal to assess NETosis in a variety of conditions.
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Affiliation(s)
- Ryan Rebernick
- Department of Medicine, University of Wisconsin, Madison, WI USA
| | - Lauren Fahmy
- Department of Medicine, University of Wisconsin, Madison, WI USA
| | | | - Mandar Bawadekar
- Department of Medicine, University of Wisconsin, Madison, WI USA
| | - Daeun Shim
- Department of Medicine, University of Wisconsin, Madison, WI USA
| | - Caitlyn L. Holmes
- Department of Medicine, University of Wisconsin, Madison, WI USA
- Department of Pathology & Laboratory Medicine, University of Wisconsin, Madison, WI USA
| | | | - Hemanth Potluri
- Department of Medicine, University of Wisconsin, Madison, WI USA
| | | | - Miriam A. Shelef
- Department of Medicine, University of Wisconsin, Madison, WI USA
- William S. Middleton Memorial Veterans Hospital, Madison, WI USA
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Medlin JL, Hansen KE, McCoy SS, Bartels CM. Pulmonary manifestations in late versus early systemic lupus erythematosus: A systematic review and meta-analysis. Semin Arthritis Rheum 2018; 48:198-204. [PMID: 29550111 DOI: 10.1016/j.semarthrit.2018.01.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 01/15/2018] [Accepted: 01/22/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Phenotypes differ between late- and early-onset systemic lupus erythematosus (SLE). Prior studies suggested that there may be more pulmonary disease among late-onset patients. Our objective was to perform a systematic review and meta-analysis to evaluate the differences in pulmonary manifestations in late- versus early-onset SLE. METHODS We searched the literature using PubMed, CINAHL, Web of Science, Cochrane Library, and EMBASE. We excluded studies that did not include American College of Rheumatology SLE classification criteria, an early-onset SLE comparison group, or those that defined late-onset SLE as <50 years of age. We rated study quality using the Newcastle-Ottawa Quality Scale. We used Forest plots to compare odds ratios (95% confidence intervals) of pulmonary manifestations by age. Study heterogeneity was assessed using I2. RESULTS Thirty-nine studies, representing 10,963 early-onset and 1656 late-onset patients with SLE, met eligibility criteria. The odds of developing several pulmonary manifestations were higher in the late-onset group. Interstitial lung disease (ILD) was nearly three times more common (OR = 2.56 (1.27, 5.16)). Pleuritis (OR = 1.53 (1.19, 1.96)) and serositis (OR = 1.31 (1.05, 1.65)) were also more common in the late-onset group. The mean Newcastle-Ottawa Quality Scale score for study quality was moderate (6.3 ± 0.7, scale 0-9). CONCLUSIONS Pulmonary manifestations of SLE were more common in late-onset SLE patients compared to their younger peers, in particular ILD and serositis. Age-related changes of the immune system, tobacco exposure, race, and possible overlap with Sjögren's syndrome should be examined in future studies.
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Affiliation(s)
| | - Karen E Hansen
- Department of Medicine, Rheumatology Division, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, Rm 4132, Madison, WI
| | - Sara S McCoy
- Department of Medicine, Rheumatology Division, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, Rm 4132, Madison, WI
| | - Christie M Bartels
- Department of Medicine, Rheumatology Division, University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, Rm 4132, Madison, WI.
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