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Howe C, Smith ID, Coles TM, Overton R, Economou-Zavlanos N, Solomon MJ, Doss J, Henao R, Clowse MEB, Leverenz DL. Evaluating Provider Perceptions of Telehealth Utility in Outpatient Rheumatology Telehealth Encounters. J Clin Rheumatol 2024; 30:46-51. [PMID: 38169348 DOI: 10.1097/rhu.0000000000002050] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
OBJECTIVE This study aims to explore the factors associated with rheumatology providers' perceptions of telehealth utility in real-world telehealth encounters. METHODS From September 14, 2020 to January 31, 2021, 6 providers at an academic medical center rated their telehealth visits according to perceived utility in making treatment decisions using the following Telehealth Utility Score (TUS) (1 = very low utility to 5 = very high utility). Modified Poisson regression models were used to assess the association between TUS scores and encounter diagnoses, disease activity measures, and immunomodulatory therapy changes during the encounter. RESULTS A total of 481 telehealth encounters were examined, of which 191 (39.7%) were rated as "low telehealth utility" (TUS 1-3) and 290 (60.3%) were rated as "high telehealth utility" (TUS 4-5). Encounters with a diagnosis of inflammatory arthritis were significantly less likely to be rated as high telehealth utility (adjusted relative risk [aRR], 0.8061; p = 0.004), especially in those with a concurrent noninflammatory musculoskeletal diagnosis (aRR, 0.54; p = 0.006). Other factors significantly associated with low telehealth utility included higher disease activity according to current and prior RAPID3 scores (aRR, 0.87 and aRR, 0.89, respectively; p < 0.001) and provider global scores (aRR, 0.83; p < 0.001), as well as an increase in immunomodulatory therapy (aRR, 0.70; p = 0.015). CONCLUSIONS Provider perceptions of telehealth utility in real-world encounters are significantly associated with patient diagnoses, current and prior disease activity, and the need for changes in immunomodulatory therapy. These findings inform efforts to optimize the appropriate utilization of telehealth in rheumatology.
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Affiliation(s)
| | | | - Theresa M Coles
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | | | | | | | - Jayanth Doss
- Division of Rheumatology and Immunology, Department of Medicine
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2
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Solomon M, Henao R, Economau-Zavlanos N, Smith I, Adagarla B, Overton AJ, Howe C, Doss J, Clowse M, Leverenz DL. Encounter Appropriateness Score for You Model: Development and Pilot Implementation of a Predictive Model to Identify Visits Appropriate for Telehealth in Rheumatology. Arthritis Care Res (Hoboken) 2024; 76:63-71. [PMID: 37781782 DOI: 10.1002/acr.25247] [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: 04/03/2023] [Revised: 08/30/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE We aimed to develop a decision-making tool to predict telehealth appropriateness for future rheumatology visits and expand telehealth care access. METHODS The model was developed using the Encounter Appropriateness Score for You (EASY) and electronic health record data at a single academic rheumatology practice from January 1, 2021, to December 31, 2021. The EASY model is a logistic regression model that includes encounter characteristics, patient sociodemographic and clinical characteristics, and provider characteristics. The goal of pilot implementation was to determine if model recommendations align with provider preferences and influence telehealth scheduling. Four providers were presented with future encounters that the model identified as candidates for a change in encounter modality (true changes), along with an equal number of artificial (false) recommendations. Providers and patients could accept or reject proposed changes. RESULTS The model performs well, with an area under the curve from 0.831 to 0.855 in 21,679 encounters across multiple validation sets. Covariates that contributed most to model performance were provider preference for and frequency of telehealth encounters. Other significant contributors included encounter characteristics (current scheduled encounter modality) and patient factors (age, Routine Assessment of Patient Index Data 3 scores, diagnoses, and medications). The pilot included 201 encounters. Providers were more likely to agree with true versus artificial recommendations (Cohen's κ = 0.45, P < 0.001), and the model increased the number of appropriate telehealth visits. CONCLUSION The EASY model accurately identifies future visits that are appropriate for telehealth. This tool can support shared decision-making between patients and providers in deciding the most appropriate follow-up encounter modality.
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Affiliation(s)
| | | | | | | | | | | | - Catherine Howe
- Duke University Hospital and Duke University, Durham, North Carolina
| | | | - Megan Clowse
- Duke University Medical Center, Durham, North Carolina
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3
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Leverenz DL, Garren AU, Katz G, Saygin D, Witt A, Harper R, Sparks MA, Criscione-Schreiber L. RheumMadness: Creating an Online Community of Inquiry in Rheumatology. Arthritis Care Res (Hoboken) 2023; 75:2248-2258. [PMID: 36847710 DOI: 10.1002/acr.25108] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/17/2023] [Accepted: 02/23/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVE To evaluate the educational impact of RheumMadness, an online tournament of rheumatology concepts grounded in social constructivist theory, as viewed through the community of inquiry (CoI) framework. METHODS The curricular scaffold of RheumMadness was a bracket of 16 rheumatology concepts competing as "teams" in a tournament. Participants could create and review "scouting reports" about each team, listen to a RheumMadness podcast, discuss on social media, and submit a bracket predicting tournament outcomes according to the perceived importance of each team. Engagement was measured with direct analytics and through self-report on a survey. The survey also assessed participants' educational experience using an adapted 34-item CoI survey, which describes the cognitive, social, and teaching presences in a learning activity. RESULTS One hundred brackets were submitted. On average, each scouting report was viewed 92 times, each podcast episode was downloaded 163 times, and 486 tweets were sent about #RheumMadness from 105 users. The survey received 58 of 107 responses (54%). Respondent agreement with prompts related to each CoI presence was: 70.3% cognitive, 61.7% social, 84.9% teaching. Reported engagement in RheumMadness correlated strongly with overall CoI survey scores (r = 0.72, P < 0.001). CONCLUSION RheumMadness created an online CoI that fostered social constructivist learning about rheumatology.
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Affiliation(s)
| | - Akrithi U Garren
- MedStar Health and Georgetown Washington Hospital Center, Washington, DC
| | - Guy Katz
- Massachusetts General Hospital, Boston
| | - Didem Saygin
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Allen Witt
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Robert Harper
- University of Cincinnati College of Medicine, Cincinnati, Ohio
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4
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Azar NS, Ruiz-Lozano RE, Quiroga-Garza ME, Soifer M, Mousa HM, Komai S, Leverenz DL, Perez VL. Delayed presentation of surgically induced scleral necrosis after I-BRITE procedure treated with immunosuppressive therapy. Digit J Ophthalmol 2023; 29:77-82. [PMID: 37780039 PMCID: PMC10539002 DOI: 10.5693/djo.02.2023.04.005] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Surgically induced scleral necrosis (SISN) is an uncommon complication of ocular procedures. Cosmetic eye-whitening surgery involves conjunctival and Tenon's capsule dissection, cautery, and mitomycin C application. We report the case of a 36-year-old white woman referred to our clinic for severe pain, scleral inflammation, and necrosis in both eyes 9 years after I-BRITE, an elective eye-whitening procedure. An extensive workup yielded negative results. The patient improved with aggressive lubrication and topical and high-dose systemic prednisone (60 mg), with recurrence upon steroid tapering. Concomitant weekly methotrexate was added, resulting in inflammatory control and allowing discontinuance of topical and oral steroids.
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Affiliation(s)
- Nadim S. Azar
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Raul E. Ruiz-Lozano
- Tecnologico de Monterrey, School of M and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Mexico
| | - Manuel E. Quiroga-Garza
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Matias Soifer
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Hazem M. Mousa
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Seitaro Komai
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - David L. Leverenz
- Department of Medicine, Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina
| | - Victor L. Perez
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
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5
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Milne ME, Kimball J, Tarrant TK, Al-Rohil RN, Leverenz DL. The Role of T Helper Type 2 (Th2) Cytokines in the Pathogenesis of Eosinophilic Granulomatosis with Polyangiitis (eGPA): an Illustrative Case and Discussion. Curr Allergy Asthma Rep 2022; 22:141-150. [PMID: 36103081 PMCID: PMC9471022 DOI: 10.1007/s11882-022-01039-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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/26/2022]
Abstract
Purposeof Review The pathogenesis of eosinophilic granulomatosis with polyangiitis (eGPA) is driven largely by CD4 + type 2 helper T cells (Th2), B cells, and eosinophils. Interleukin (IL)-4 and IL-13 are critical cytokines in Th2 cell–mediated inflammation; however, inhibition of IL-4 and IL-13 does not reduce serum eosinophil counts and has even been associated with hypereosinophilia. This review explores the role of IL-4, IL-5, and IL-13 in Th2-mediated inflammation to consider the potential clinical consequences of inhibiting these individual cytokines in eGPA. Recent Findings Treatments for eosinophilic granulomatosis with polyangiitis (eGPA) are rapidly evolving through using biologic therapies to modulate the Th2 inflammatory response via eosinophil inhibition. While IL-4, IL-5, IL-13, and IL-25 can all affect eosinophils, only IL-5 inhibition has demonstrated therapeutic benefit to-date. In this review, we report a clinical vignette of a patient with adult-onset asthma who developed severe manifestations of eGPA after switching from mepolizumab (an IL-5 inhibitor) to dupilumab (an inhibitor of IL-4 and IL-13). Summary By understanding the role of IL-4, IL-5, and IL-13 in Th2-mediated vasculitis, we can start to understand how eGPA might respond differently to focused cytokine inhibition.
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Affiliation(s)
- Megan E Milne
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, 40 Duke Medicine Circle, Clinic 1J, Durham, NC, 27710, USA.
| | - Jack Kimball
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, 40 Duke Medicine Circle, Clinic 1J, Durham, NC, 27710, USA
| | | | - David L Leverenz
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, 40 Duke Medicine Circle, Clinic 1J, Durham, NC, 27710, USA
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6
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Smith ID, Coles TM, Howe C, Overton R, Economou‐Zavlanos N, Solomon MJ, Zhao R, Adagarla B, Doss J, Henao R, Clowse MEB, Leverenz DL. Telehealth Made
EASY
: Understanding Provider Perceptions of Telehealth Appropriateness in Outpatient Rheumatology Encounters. ACR Open Rheumatol 2022; 4:845-852. [PMID: 35855564 PMCID: PMC9555194 DOI: 10.1002/acr2.11470] [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: 01/18/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 11/22/2022] Open
Abstract
Objective The purpose of this study was to evaluate a novel scoring system, the Encounter Appropriateness Score for You (EASY), to assess provider perceptions of telehealth appropriateness in rheumatology encounters. Methods The EASY scoring system prompts providers to rate their own encounters as follows: in‐person or telehealth acceptable, EASY = 1; in‐person preferred, EASY = 2; or telehealth preferred, EASY = 3. Assessment of the EASY scoring system occurred at a single academic institution from January 1, 2021, to August 31, 2021. Data were collected in three rounds: 1) initial survey (31 providers) assessing EASY responsiveness to five hypothetical scenarios, 2) follow‐up survey (34 providers) exploring EASY responsiveness to 11 scenario modifications, and 3) assessment of EASYs documented in clinic care. Results The initial and follow‐up surveys demonstrated responsiveness of EASYs to different clinical and nonclinical factors. For instance, less than 20% of providers accepted telehealth when starting a biologic for active rheumatoid arthritis, although more than 35% accepted telehealth in the same scenario if the patient lived far away or was well known to the provider. Regarding EASY documentation, 27 providers provided EASYs for 12,381 encounters. According to these scores, telehealth was acceptable or preferred for 29.7% of all encounters, including 21.4% of in‐person encounters. Conversely, 24.4% of telehealth encounters were scored as in‐person preferred. Conclusion EASY is simple, understandable, and responsive to changes in the clinical scenario. We have successfully accumulated 12,381 EASYs that can be studied in future work to better understand telehealth utility and optimize telehealth triage.
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Affiliation(s)
- Isaac D. Smith
- Department of Medicine, Duke University Hospital Duke University Hospital and Duke University School of Medicine Durham North Carolina USA
- Department of Medicine, Division of Rheumatology and Immunology Duke University School of Medicine Durham North Carolina USA
| | - Theresa M. Coles
- Department of Population Health Sciences Duke University School of Medicine Durham North Carolina USA
| | - Catherine Howe
- Department of Medicine, Duke University Hospital Duke University Hospital and Duke University School of Medicine Durham North Carolina USA
| | - Robert Overton
- Duke Clinical Research Institute Duke University School of Medicine Durham North Carolina USA
| | - Nicoleta Economou‐Zavlanos
- AI Health Duke University School of Medicine Durham North Carolina USA
- Office of Academic Solutions and Information Systems Duke Health Technology Solutions, Duke Health Durham North Carolina USA
| | - Mary J. Solomon
- AI Health Duke University School of Medicine Durham North Carolina USA
- Department of Biostatistics and Bioinformatics Duke University School of Medicine Durham North Carolina USA
| | - Rong Zhao
- Department of Biostatistics and Bioinformatics Duke University School of Medicine Durham North Carolina USA
| | - Bhargav Adagarla
- Duke Clinical Research Institute Duke University School of Medicine Durham North Carolina USA
| | - Jayanth Doss
- Department of Medicine, Division of Rheumatology and Immunology Duke University School of Medicine Durham North Carolina USA
| | - Ricardo Henao
- Duke Clinical Research Institute Duke University School of Medicine Durham North Carolina USA
- Department of Biostatistics and Bioinformatics Duke University School of Medicine Durham North Carolina USA
| | - Megan E. B. Clowse
- Department of Medicine, Division of Rheumatology and Immunology Duke University School of Medicine Durham North Carolina USA
| | - David L. Leverenz
- Department of Medicine, Division of Rheumatology and Immunology Duke University School of Medicine Durham North Carolina USA
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7
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Maheswaranathan M, Chu P, Johannemann A, Criscione-Schreiber L, Clowse M, Leverenz DL. The Impact of the COVID-19 Pandemic and Telemedicine Implementation on Practice Patterns and Electronic Health Record Utilization in an Academic Rheumatology Practice. J Clin Rheumatol 2022; 28:e612-e615. [PMID: 33843775 DOI: 10.1097/rhu.0000000000001751] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Mithu Maheswaranathan
- From the Division of Rheumatology and Immunology, Department of Medicine, Duke University, Durham, NC
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8
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Qian ET, Leverenz DL, McPherson JA, Kroop SF. An Internal Medicine Residency Podcast: Impact on the Educational Experience and Care Practices of Medical Residents. J Gen Intern Med 2021; 36:1457-1459. [PMID: 32524251 PMCID: PMC8131423 DOI: 10.1007/s11606-020-05939-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Edward T Qian
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - David L Leverenz
- Department of Medicine, Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, NC, USA
| | - John A McPherson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan F Kroop
- Department of Medicine, Division of Rheumatology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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9
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Leverenz DL, Eudy AM, Criscione-Schreiber LG. What do internal medicine residents know about rheumatology? A needs assessment for curriculum design. Clin Rheumatol 2020; 40:2021-2026. [PMID: 33201328 DOI: 10.1007/s10067-020-05506-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 11/27/2022]
Abstract
We sought to determine if analyzing internal medicine (IM) resident performance on the in-training exam (ITE) might reveal curricular needs in rheumatology education beyond those intuitive to learners and educators from their perceptions and experience. We analyzed ITE scores of post-graduate year (PGY) 2 IM residents at our institution from 2010 to 2017. We sorted rheumatology-related educational objectives on the ITEs into 10 disease categories and calculated average scores. We then surveyed our IM residents' self-reported confidence and rheumatology educators' perceptions of IM resident proficiency in the 10 categories on a 10-point Likert scale. Finally, we tallied diagnoses in each category encountered by IM residents in rheumatology clinic. Pearson's correlation coefficients were calculated for the relationship between these data. The ITEs exposed 402 residents to 63 rheumatology-related educational objectives in the 10 categories; 24 objectives were categorized as "other." Survey respondents included 38 residents and 22 educators. There was no correlation between ITE scores in the 10 categories and resident confidence (r = - 0.226, p = 0.530), educator perception (r = - 0.274, p = 0.445), or diagnoses encountered (r = - 0.310, p = 0.383). There was a strong positive correlation between resident confidence and educator perception (r = 0.934, p < 0.001). ITE performance was low in crystalline arthritis and osteoarthritis despite high resident confidence, educator perception, and number of diagnoses seen. Our analysis of IM resident ITE performance identified curricular gaps not apparent in surveys of learner and educator perceptions or an assessment of learner experience. Key Points • In this study, we demonstrate how a systematic analysis of internal medicine resident performance on the in-training exam can identify important curricular gaps in rheumatology education that are not apparent in assessments of learners and educator perceptions or learner experience in rheumatology clinic. • In-training exam performance was low in crystalline arthritis and osteoarthritis despite high resident confidence, educator perception of proficiency, and number of diagnoses seen in these categories. • When rheumatology curricula for internal medicine residents are developed solely on the basis of learner and educator perceptions, common disorders traditionally considered "easy" may be overlooked.
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Affiliation(s)
- David L Leverenz
- Division of Rheumatology & Immunology Department of Medicine, Duke University School of Medicine, 40 Duke Medicine Circle, DUMC, Box 2918, Durham, NC, 27710, USA.
| | - Amanda M Eudy
- Division of Rheumatology & Immunology Department of Medicine, Duke University School of Medicine, 40 Duke Medicine Circle, DUMC, Box 2918, Durham, NC, 27710, USA
| | - Lisa G Criscione-Schreiber
- Division of Rheumatology & Immunology Department of Medicine, Duke University School of Medicine, 40 Duke Medicine Circle, DUMC, Box 2918, Durham, NC, 27710, USA
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10
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Affiliation(s)
- David L Leverenz
- Duke University School of Medicine, Department of Medicine, Division of Rheumatology and Immunology, Durham NC 27710, USA.
| | - Teresa K Tarrant
- Duke University School of Medicine, Department of Medicine, Division of Rheumatology and Immunology, Durham NC 27710, USA
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11
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Leverenz DL, Criscione-Schreiber LG. A Fuzzy Cause of Hip Pain. Am J Med 2020; 133:580-581. [PMID: 31715162 DOI: 10.1016/j.amjmed.2019.10.026] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/04/2019] [Indexed: 11/30/2022]
Affiliation(s)
- David L Leverenz
- Department of Internal Medicine, Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, N.C.
| | - Lisa G Criscione-Schreiber
- Department of Internal Medicine, Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, N.C
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12
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Abstract
Primary Sjögren's syndrome is a chronic autoimmune disease characterized by salivary and lacrimal gland dysfunction, leading to substantial morbidity and reduced quality of life. Many patients with primary Sjögren's syndrome also have extraglandular systemic complications, some of which can be organ- or life-threatening. Over the last decade, numerous targeted immunomodulatory therapies for primary Sjögren's syndrome have failed to show a benefit in clinical trials, and as yet no disease-modifying therapy has been approved for this disease. Herein, we provide an updated review of the clinical trial landscape for primary Sjögren's syndrome and the numerous efforts to move the field forward, including the development of new classification criteria and outcome measures, the results of recent clinical trials in this field, the challenges faced in the search for effective therapies, and the expanding pipeline of novel therapies under development.
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Affiliation(s)
- David L. Leverenz
- Department of Medicine, Division of Rheumatology and Immunology, School of Medicine, Duke University, 40 Duke Medicine Circle, Durham, NC, 27110, USA
| | - E. William St. Clair
- Department of Medicine, Division of Rheumatology and Immunology, School of Medicine, Duke University, 40 Duke Medicine Circle, Durham, NC, 27110, USA
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13
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Kozak PM, Trumbo SP, Christensen BW, Leverenz DL, Shotwell MS, Kingeter AJ. Addition of price transparency to an education and feedback intervention reduces utilization of inpatient echocardiography by resident physicians. Int J Cardiovasc Imaging 2019; 35:1259-1263. [DOI: 10.1007/s10554-019-01572-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/23/2019] [Indexed: 10/27/2022]
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14
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Trumbo SP, Iams WT, Limper HM, Goggins K, Gibson J, Oliver L, Leverenz DL, Samuels LR, Brady DW, Kripalani S. Deimplementation of Routine Chest X-rays in Adult Intensive Care Units. J Hosp Med 2019; 14:83-89. [PMID: 30785415 PMCID: PMC8102033 DOI: 10.12788/jhm.3129] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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] [Indexed: 12/27/2022]
Abstract
BACKGROUND Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns. OBJECTIVE We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. DESIGN We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies. SETTING The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016. PARTICIPANTS The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists). INTERVENTION COMPONENTS We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates. MEASUREMENTS We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation. RESULTS Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities. CONCLUSIONS Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.
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Affiliation(s)
- Silas P Trumbo
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wade T Iams
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Heather M Limper
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathryn Goggins
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jayme Gibson
- Cardiovascular Intensive Care Unit, Vanderbilt University Medical Center, Nashville Tennessee, USA
| | - Lauren Oliver
- Cardiovascular Intensive Care Unit, Vanderbilt University Medical Center, Nashville Tennessee, USA
| | - David L Leverenz
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lauren R Samuels
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Donald W Brady
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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