1
|
Rogers JL, Clowse MEB, McKenna K, Starling S, Swezey T, Molokwu N, Corneli A, Pisetsky DS, Sun K, Criscione-Schreiber LG, Sadun RE, Maheswaranathan M, Burshell D, Doss J, Eudy AM. Patient and Physician Perspectives of Systemic Lupus Erythematosus Flare: A Qualitative Study. J Rheumatol 2024; 51:488-494. [PMID: 38101916 PMCID: PMC11065621 DOI: 10.3899/jrheum.2023-0721] [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: 12/01/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) flares are associated with increased damage and decreased health-related quality of life. We hypothesized that there is discordance between physicians' and patients' views of SLE flare. In this study, we aimed to explore patient and physician descriptions of SLE flares. METHODS We conducted a qualitative descriptive study using in-depth interviews with a purposeful sample of patients with SLE (who met 1997 American College of Rheumatology or Systemic Lupus International Collaborating Clinics criteria) and practicing rheumatologists. Interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. RESULTS Forty-two patient participants with SLE, representing a range of SLE activity, completed interviews. The majority described flare symptoms as joint pain, fatigue, and skin issues lasting several days. Few included objective signs or laboratory measures, when available, as features of flare. We interviewed 13 rheumatologists from 10 academic and 3 community settings. The majority defined flare as increased or worsening SLE disease activity, with slightly more than half requiring objective findings. Around half of the rheumatologists included fatigue, pain, or other patient-reported symptoms. CONCLUSION Patients and physicians described flare differently. Participants with SLE perceived flares as several days of fatigue, pain, and skin issues. Providers defined flares as periods of increased clinical SLE activity. Our findings suggest the current definition of flare may be insufficient to integrate both perceptions. Further study is needed to understand the pathophysiology of patient flares and the best way to incorporate patients' perspectives into clinical assessments.
Collapse
Affiliation(s)
- Jennifer L Rogers
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Megan E B Clowse
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Kevin McKenna
- K. McKenna, MPH, S. Starling, DrPH, MPH, T. Swezey, PhD, N. Molokwu, MSW, A. Corneli, PhD, MPH, Population Health Sciences, Duke University School of Medicine
| | - Summer Starling
- K. McKenna, MPH, S. Starling, DrPH, MPH, T. Swezey, PhD, N. Molokwu, MSW, A. Corneli, PhD, MPH, Population Health Sciences, Duke University School of Medicine
| | - Teresa Swezey
- K. McKenna, MPH, S. Starling, DrPH, MPH, T. Swezey, PhD, N. Molokwu, MSW, A. Corneli, PhD, MPH, Population Health Sciences, Duke University School of Medicine
| | - Nneka Molokwu
- K. McKenna, MPH, S. Starling, DrPH, MPH, T. Swezey, PhD, N. Molokwu, MSW, A. Corneli, PhD, MPH, Population Health Sciences, Duke University School of Medicine
| | - Amy Corneli
- K. McKenna, MPH, S. Starling, DrPH, MPH, T. Swezey, PhD, N. Molokwu, MSW, A. Corneli, PhD, MPH, Population Health Sciences, Duke University School of Medicine
| | - David S Pisetsky
- D.S. Pisetsky, MD, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine, and Durham VA Medical Center, Durham, North Carolina, USA
| | - Kai Sun
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Lisa G Criscione-Schreiber
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Rebecca E Sadun
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Mithu Maheswaranathan
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Dana Burshell
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Jayanth Doss
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine
| | - Amanda M Eudy
- J.L. Rogers, MD, M.E.B. Clowse, MD, MPH, K. Sun, MD, MS, L.G. Criscione-Schreiber, MD, MEd, R.E. Sadun, MD, PhD, M. Maheswaranathan, MD, D. Burshell, MPH, J. Doss, MD, MPH, A.M. Eudy, PhD, Division of Rheumatology and Immunology, Duke University School of Medicine;
| |
Collapse
|
2
|
Balevic S, Sun K, Rogers JL, Eudy A, Sadun RE, Maheswaranathan M, Doss J, Criscione-Schreiber L, O'Malley T, Clowse M, Weiner D. Interpreting hydroxychloroquine blood levels for medication non-adherence: a pharmacokinetic study. Lupus Sci Med 2024; 11:e001090. [PMID: 38688714 DOI: 10.1136/lupus-2023-001090] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE Characterise the relationship between hydroxychloroquine (HCQ) blood levels and the number of missed doses, accounting for dosage, dose timing and the large variability in pharmacokinetics (PK) between patients. METHODS We externally validated a published PK model and then conducted dosing simulations. We developed a virtual population of 1000 patients for each dosage across a range of body weights and PK variability. Using the model, 10 Monte Carlo simulations for each patient were conducted to derive predicted whole blood concentrations every hour over 24 hours (240 000 HCQ levels at steady state). To determine the impact of missed doses on levels, we randomly deleted a fixed proportion of doses. RESULTS For patients receiving HCQ 400 mg daily, simulated random blood levels <200 ng/mL were exceedingly uncommon in fully adherent patients (<0.1%). In comparison, with 80% of doses missed, approximately 60% of concentrations were <200 ng/mL. However, this cut-off was highly insensitive and would miss many instances of severe non-adherence. Average levels quickly dropped to <200 ng/mL after 2-4 days of missed doses. Additionally, mean levels decreased by 29.9% between peak and trough measurements. CONCLUSIONS We propose an algorithm to optimally interpret HCQ blood levels and approximate the number of missed doses, incorporating the impact of dosage, dose timing and pharmacokinetic variability. No single cut-off has adequate combinations of both sensitivity and specificity, and cut-offs are dependent on the degree of targeted non-adherence. Future studies should measure trough concentrations to better identify target HCQ levels for non-adherence and efficacy.
Collapse
Affiliation(s)
- Stephen Balevic
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kai Sun
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer L Rogers
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amanda Eudy
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebecca Eli Sadun
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mithu Maheswaranathan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jayanth Doss
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Megan Clowse
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Weiner
- UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| |
Collapse
|
3
|
Rogers JL, Clowse MEB, Pisetsky DS, Criscione-Schreiber LG, Sun K, Sadun RE, Maheswaranathan M, Burshell DR, Doss J, Eudy AM. Evaluation of Type 2 SLE symptoms in patients with a range of lupus nephritis activity. Clin Rheumatol 2024; 43:1319-1326. [PMID: 38409491 DOI: 10.1007/s10067-024-06909-4] [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: 11/02/2023] [Revised: 01/12/2024] [Accepted: 02/11/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Type 2 systemic lupus erythematosus (SLE) symptoms, including fatigue, fibromyalgia, and brain fog, contribute to poor health-related quality of life (HRQoL) in patients with lupus. To test the hypothesis that Type 1 (classical inflammatory lupus) activity is associated with Type 2 SLE activity, we characterized the features of Type 2 SLE in patients with a range of lupus nephritis (LN) activity. METHODS This was a cross-sectional study of SLE patients [American College of Rheumatology (ACR) 1997 or Systemic Lupus International Collaborating Clinics (SLICC) 2012 classification criteria] from June 2018 to March 2020. Patients completed the Systemic Lupus Activity Questionnaire (SLAQ) and the Polysymptomatic Distress Scale. Patients were divided into groups based on their renal status. Active nephritis was defined using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) lupus nephritis parameter. Differences across groups were analyzed by Fisher's exact test and ANOVA. RESULTS In this cohort of 244 patients (93% female, mean age 43 years, 58% Black), 10% had active nephritis, 35% had historical nephritis, and 55% never had nephritis (non-nephritis). Active nephritis and non-nephritis patients had a similar burden of Type 2 SLE symptoms, despite a difference in Type 1 SLE activity. Patients with active nephritis had higher Type 2 PGA (Physician Global Assessment) scores and reported more Type 2 SLE symptoms than inactive nephritis patients. Patients with inactive nephritis had the lowest Type 2 SLE activity. CONCLUSIONS While Type 2 SLE symptoms are common in SLE, our findings suggest that patients with active nephritis experience significant Type 2 SLE symptoms that may be ameliorated as nephritis improves. We also observed that non-nephritis patients had a similar burden of Type 2 SLE symptoms as patients with active nephritis, despite having on average lower Type 1 SLE activity. Therefore, the etiology of Type 2 SLE symptoms is likely multifactorial and may be driven by inflammatory and non-inflammatory biopsychosocial factors. Key Points • Patients with active nephritis experienced significant Type 2 symptoms that may be ameliorated as nephritis improves. • Non-nephritis patients had a similar burden of Type 2 SLE symptoms as patients with active nephritis, despite having on average lower Type 1 SLE activity. • Because etiology of Type 2 SLE symptoms is likely multifactorial and may be driven by inflammatory and non-inflammatory biopsychosocial factors.
Collapse
Affiliation(s)
- Jennifer L Rogers
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA.
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - David S Pisetsky
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
- Durham VA Medical Center, Durham, NC, USA
| | - Lisa G Criscione-Schreiber
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Kai Sun
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Rebecca E Sadun
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Mithu Maheswaranathan
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Dana R Burshell
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Jayanth Doss
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Duke University School of Medicine, Box 3544 DUMC, Durham, NC, 27710, USA
| |
Collapse
|
4
|
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.
Collapse
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
| | | | | | | |
Collapse
|
5
|
Eudy AM, Clowse MEB, Corneli A, McKenna K, Pisetsky DS, Maheswaranathan M, Burshell D, Doss J, Sun K, Sadun RE, Criscione-Schreiber LG, Rogers JL. The Type 1 & 2 systemic lupus erythematosus model: Perspectives of people living with systemic lupus erythematosus. Lupus 2024; 33:266-272. [PMID: 38238905 PMCID: PMC11034781 DOI: 10.1177/09612033241228343] [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: 02/12/2024]
Abstract
OBJECTIVE In the new Type 1 & 2 model for systemic lupus erythematosus (SLE), Type 1 SLE represents classic inflammatory manifestations, such as arthritis, while Type 2 SLE encompasses symptoms such as pain and fatigue where the relationship to inflammation is less clear. The objective of this study was to interview individuals living with SLE to determine the content and face validity of the Type 1 & 2 SLE model. METHODS We conducted a qualitative study using semi-structured interviews with a purposeful sample of participants who met classification criteria for SLE. Participants were asked to describe their experiences with Type 1 & 2 SLE symptoms and treatments, and they indicated if and how their personal experiences aligned with the Type 1 & 2 SLE model. All interviews were audio-recorded and transcribed; applied thematic analysis identified the most frequent and salient themes. RESULTS We interviewed 42 participants with SLE. Type 2 SLE symptoms, such as pain and fatigue, were very common, with almost all participants experiencing some Type 2 symptoms at some point during their disease course. Participants described Type 1 SLE symptoms as being acute flares and life-threatening and Type 2 SLE symptoms as "everyday lupus" that affected their daily lives and were a dominant part of their SLE disease experience. Most participants stated they want their rheumatologists to discuss Type 2 symptoms during clinical appointments in order to address their full symptom experience. CONCLUSION We demonstrated content and face validity of the Type 1 & 2 SLE model with people living with SLE. Participants in our study largely understood the model and felt it accurately reflected their experience living with SLE. Type 2 SLE symptoms are very common in individuals with SLE and impact patients' quality of life. Using the model to address Type 2 SLE symptoms allows the rheumatologist to incorporate the patient's perspective and provide patient-centered care.
Collapse
Affiliation(s)
- Amanda M. Eudy
- Department of Medicine, Duke University School of Medicine
| | | | - Amy Corneli
- Department of Medicine, Duke University School of Medicine
- Department of Population Health Sciences, Duke University School of Medicine
| | - Kevin McKenna
- Department of Population Health Sciences, Duke University School of Medicine
| | - David S. Pisetsky
- Department of Medicine, Duke University School of Medicine
- Durham VA Medical Center
| | | | - Dana Burshell
- Department of Medicine, Duke University School of Medicine
| | - Jayanth Doss
- Department of Medicine, Duke University School of Medicine
| | - Kai Sun
- Department of Medicine, Duke University School of Medicine
| | | | | | | |
Collapse
|
6
|
Herndon S, Corneli A, Dombeck C, Swezey T, Clowse M, Rogers JL, Criscione-Schreiber LG, Sadun RE, Doss J, Eudy AM, Bosworth HB, Sun K. A qualitative study of facilitators of medication adherence in systemic lupus erythematosus: Perspectives from rheumatology providers/staff and patients. Lupus 2024; 33:137-144. [PMID: 38164913 PMCID: PMC10922388 DOI: 10.1177/09612033231225843] [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: 01/03/2024]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) disproportionately affects patients from racial and ethnic minority groups. Medication adherence is lower among these patient populations, and nonadherence is associated with worse health outcomes. We aimed to identify factors that enable adherence to immunosuppressive medications among patients with SLE from racial and ethnic minority groups. METHODS Using a qualitative descriptive study design, we conducted in-depth interviews with purposefully selected (1) patients with SLE from racial and ethnic minority groups who were taking immunosuppressants and (2) lupus providers and staff. We focused on adherence facilitators, asking patients to describe approaches supporting adherence and for overcoming common adherence challenges and providers and staff to describe actions they can take to foster patient adherence. We used applied thematic analysis and categorized themes using the Capability, Opportunity, Motivation, Behavior (COM-B) model. RESULTS We interviewed 12 patients (4 adherent and 8 nonadherent based on medication possession ratio) and 12 providers and staff. Although each patient described a unique set of facilitators, patients most often described social support, physical well-being, reminders, and ability to acquire medications as facilitators. Providers also commonly mentioned reminders and easy medication access as facilitators as well as patient education/communication and empowerment. CONCLUSION Using an established behavioral change model, we categorized a breadth of adherence facilitators within each domain of the COM-B model while highlighting patients' individual approaches. Our findings suggest that an optimal adherence intervention may require a multi-modal and individually tailored approach including components from each behavioral domain-ensuring medication access (Capability) and utilizing reminders and social support (Opportunity), while coupled with internal motivation through improved communication and empowerment (Motivation).
Collapse
Affiliation(s)
- Shannon Herndon
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Amy Corneli
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Clinical Research Institute, Duke University, Durham, NC
| | - Carrie Dombeck
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Teresa Swezey
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Megan Clowse
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | | | - Rebecca E. Sadun
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jayanth Doss
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Amanda M. Eudy
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Hayden B. Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Kai Sun
- Department of Medicine, Duke University School of Medicine, Durham, NC
| |
Collapse
|
7
|
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.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Catherine Howe
- Duke University Hospital and Duke University, Durham, North Carolina
| | | | - Megan Clowse
- Duke University Medical Center, Durham, North Carolina
| | | |
Collapse
|
8
|
Sun K, Eudy AM, Harris N, Pisetsky DS, Criscione-Schreiber LG, Sadun RE, Doss J, Clowse MEB, Rogers JL. Using PROMIS-29 to determine symptom burdens in the context of the Type 1 and 2 systemic lupus erythematosus (SLE) model: a cross sectional study. J Patient Rep Outcomes 2023; 7:136. [PMID: 38127169 PMCID: PMC10739689 DOI: 10.1186/s41687-023-00678-5] [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: 08/25/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE To account for heterogeneity in systemic lupus erythematosus (SLE) and bridge discrepancies between patient- and physician-perceived SLE activity, we developed the Type 1 and 2 SLE model. We examined PROMIS-29 scores, a composite patient-reported outcome (PRO) measure, through the lens of the model. METHODS Patients completed PROMIS-29 and the polysymptomatic distress scale (PSD). Rheumatologists completed the SLE disease activity index (SLEDAI), and physician's global assessments (PGAs) for Type 1 and 2 SLE. We defined Type 1 SLE using SLEDAI, Type 1 PGA, and active nephritis, and Type 2 SLE using PSD and Type 2 PGA. We compared PROMIS-29 T-scores among Type 1 and 2 SLE groups and explored whether PROMIS-29 can predict Type 1 and 2 SLE activity. RESULTS Compared to the general population, patients with isolated Type 1 SLE reported greater pain and physical dysfunction but less depression and improved social functions; patients with high Type 2 SLE (irrespective of Type 1 activity) reported high levels of pain, fatigue, and social and physical limitations. Patients with minimal Type 1 and 2 SLE had less depression and greater physical functioning with other domains similar to national norms. PROMIS-29 predicted Type 2 but not Type 1 SLE activity. CONCLUSION PROMIS-29 similarities in patients with high Type 2 SLE, with and without active Type 1 SLE, demonstrate the challenges of using PROs to assess SLE inflammation. In conjunction with the Type 1 and 2 SLE model, however, PROMIS-29 identified distinct symptom patterns, suggesting that the model may help clinicians interpret PROs.
Collapse
Affiliation(s)
- Kai Sun
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA.
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - Nathaniel Harris
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - David S Pisetsky
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
- Durham VA Medical Center, Durham, NC, USA
| | - Lisa G Criscione-Schreiber
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - Rebecca E Sadun
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - Jayanth Doss
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| | - Jennifer L Rogers
- Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, DUMC 2978, Durham, NC, 27710, USA
| |
Collapse
|
9
|
Clowse MEB, Rogers JL, Coles T, Pisetsky DS, Criscione-Schreiber LG, Burshell D, Doss J, Sadun RE, Sun K, Maheswaranathan M, Eudy AM. Development and psychometric evaluation of a physician global assessment for type 2 systemic lupus erythematosus symptoms. Lupus Sci Med 2023; 10:e001016. [PMID: 38105242 PMCID: PMC10729218 DOI: 10.1136/lupus-2023-001016] [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: 08/08/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE Manifestations of SLE can be categorised as type 1 (classic signs and symptoms of SLE) or type 2 (fatigue, widespread pain and brain fog with an unclear relationship to inflammation). While measures of type 1 SLE activity exist, most current physician-reported measures do not encompass type 2 SLE manifestations. To better evaluate type 2 SLE symptoms, we developed and psychometrically evaluated a physician-reported measure of type 2 symptoms, the Type 2 Physician Global Assessment ('Type 2 PGA'). METHODS AND ANALYSIS The Type 2 PGA was developed and evaluated by six rheumatologists practising in the same academic lupus clinic. The study began with a roundtable discussion to establish consensus guidelines for scoring the Type 2 PGA. Following the roundtable, the Type 2 PGA was psychometrically evaluated using data prospectively collected from 263 patients with SLE enrolled in the Duke Lupus Registry. RESULTS There was strong intra-rater and inter-rater reliability (intraclass correlation coefficient=0.83), indicating the Type 2 PGA scores were consistent within a rheumatologist and across rheumatologists. The Type 2 PGA was correlated with patient-reported symptoms of polysymptomatic distress (r=0.76), fatigue (r=0.68), cognitive dysfunction (r=0.63), waking unrefreshed (r=0.62) and forgetfulness (r=0.60), and weakly correlated with the Type 1 PGA and the Systemic Lupus Erythematosus Disease Activity Index. CONCLUSION The Type 2 PGA performed well as a physician-reported measure of type 2 SLE symptoms. The incorporation of the Type 2 PGA into a routine rheumatology visit may improve patient care by bringing the provider's attention to certain symptoms not well represented in conventional measures of disease activity.
Collapse
Affiliation(s)
- Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer L Rogers
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Theresa Coles
- Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - David S Pisetsky
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
- Durham VA Medical Center, Durham, North Carolina, USA
| | - Lisa G Criscione-Schreiber
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Dana Burshell
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jayanth Doss
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebecca E Sadun
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kai Sun
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mithu Maheswaranathan
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
10
|
Sims CA, Eudy AM, Doss J, Rogers JL, Sadun RE, Criscione-Schreiber L, Sun K, Clowse ME. The impact of pregnancy planning and medical readiness on reproductive outcomes in women with systemic lupus erythematosus. Lupus 2023; 32:1666-1674. [PMID: 37966369 DOI: 10.1177/09612033231216602] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Women with systemic lupus erythematosus (SLE) who get pregnant while SLE is active or while on teratogens have higher risk of poor pregnancy outcomes. The American College of Rheumatology (ACR) Reproductive Health Guidelines recommend women conceive when SLE is well controlled and treated with pregnancy-compatible medications. The Healthy Outcomes in Pregnancy with SLE Through Education of Providers (HOP-STEP) Intervention was created to ascertain pregnancy interest and contraceptive use followed by a personalized pregnancy prevention and/or planning discussion (https://www.LupusPregnancy.org). All study participants were adult females enrolled in a prospective registry who met ACR or SLICC criteria. Women were defined as "not medically ready for pregnancy" if they were currently prescribed a teratogen, had proteinuria ≥500 mg, or had elevated SLE activity according to the physician's global assessment. Two time periods were assessed: 2/2018-12/2019 and 10/2020-4/2021 to evaluate pre- and post-pandemic periods, with some post-pandemic visits taking place via telehealth. The interest in pregnancy was similar between the first time period (17%) and the second time period, whether in-person (18%) or virtual (18%). Pregnancy interest was assessed significantly more frequently during in-person visits (90%) compared to virtual encounters (67%) (p = .02). Contraceptive use was not significantly different during either time period with use of a teratogen or increased SLE activity. Of the 52 women in both time periods who were not medically ready for pregnancy and were not on effective contraception, three women (5.8%) conceived. None of the women who were using moderate or highly effective contraception became pregnant. Pregnancy outcomes were similar between unintended or high-risk and well-timed pregnancies. The HOP-STEP Intervention effectively identified pregnancy interest, giving rheumatologists the opportunity to address patient reproductive goals, optimize disease activity, and adjust medication regimens prior to conception.
Collapse
Affiliation(s)
- Catherine A Sims
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Amanda M Eudy
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Jayanth Doss
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Jennifer L Rogers
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Rebecca E Sadun
- Department of Rheumatology, Duke University, Durham, NC, United States
| | | | - Kai Sun
- Department of Rheumatology, Duke University, Durham, NC, United States
| | - Megan Eb Clowse
- Department of Rheumatology, Duke University, Durham, NC, United States
| |
Collapse
|
11
|
Arps K, Doss J, Geiger K, Flores-Rosario K, DeVore AD, Karra R, Kim HW, Piccini JP, Pokorney SD, Sun AY. Incidence and Predictors of Relapse After Weaning Immune Suppressive Therapy in Cardiac Sarcoidosis. Am J Cardiol 2023; 204:249-256. [PMID: 37556894 DOI: 10.1016/j.amjcard.2023.07.088] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/13/2023] [Indexed: 08/11/2023]
Abstract
Cardiac sarcoidosis (CS) is a relapsing-remitting disease, and immune suppression (IS) is the mainstay of therapy. Predictors of relapse for patients with CS in remission are not well characterized. We assessed incidence of relapse in consecutive patients with CS treated with high-dose steroids and/or steroid-sparing agents (SSA) in our center from 2000 to 2020. Remission was defined as reaching maintenance therapy (no IS, SSA, and/or prednisone ≤5 mg/d) for ≥1 month. Relapse was defined as recurrence of CS syndrome requiring IS intensification: heart failure, ventricular arrhythmia, decrease in left ventricular ejection fraction, or increased disease burden on imaging. Among 68 patients, the mean age was 50.7±9.0 years; 25 (37%) were women, and 32 (47%) were Black. In total, 59 patients (87%) reached remission. Over a median follow-up of 39.5 months (interquartile range 17.6, 92.5), 28 (48%) relapsed. Greater percentage of late gadolinium enhancement (LGE) on pretreatment magnetic resonance imaging corresponded with increased likelihood of relapse (odds ratio 1.396 per 5% increase [95% confidence interval (CI) 1.04 to 1.88]; p = 0.028). LGE ≥11% predicted elevated risk of relapse (adjusted odds ratio 4.998 [1.34 to 18.64]; p = 0.017). Shorter time to relapse was observed with isolated CS (adjusted hazard ratio 4.084 [1.44,11.56]; p = 0.008) and LGE ≥11% (adjusted hazard ratio 3.007 [1.01, 8.98]; p = 0.049). Approximately 1 in 2 patients with CS in remission experienced relapse. Greater burden of LGE on cardiac magnetic resonance imaging and isolated CS are associated with greater risk of relapse. Future work is needed to refine risk stratification for relapse and to optimize surveillance strategies on the basis of the burden of disease.
Collapse
Affiliation(s)
- Kelly Arps
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Jayanth Doss
- Duke University Medical Center, Durham, North Carolina
| | - Kelly Geiger
- Duke University Medical Center, Durham, North Carolina
| | | | - Adam D DeVore
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Ravi Karra
- Duke University Medical Center, Durham, North Carolina
| | - Han W Kim
- Duke University Medical Center, Durham, North Carolina
| | - Jonathan P Piccini
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Sean D Pokorney
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Albert Y Sun
- Duke University Medical Center, Durham, North Carolina; Durham Veterans Affairs Medical Center, Durham, North Carolina
| |
Collapse
|
12
|
Sun K, Eudy AM, Rogers JL, Criscione-Schreiber LG, Sadun RE, Doss J, Maheswaranathan M, Barr AC, Eder L, Corneli AL, Bosworth HB, Clowse ME. Pilot Intervention to Improve Medication Adherence Among Patients With Systemic Lupus Erythematosus Using Pharmacy Refill Data. Arthritis Care Res (Hoboken) 2023; 75:550-558. [PMID: 34739191 PMCID: PMC9068832 DOI: 10.1002/acr.24806] [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: 06/25/2021] [Revised: 09/07/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Despite high rates of medication nonadherence among patients with systemic lupus erythematosus (SLE), effective interventions to improve adherence in SLE are limited. We aimed to assess the feasibility of a pilot intervention and explore its effect on adherence. METHODS The intervention used pharmacy refill data to monitor nonadherence and prompt discussions surrounding SLE medications during clinic encounters. Over 12 weeks, the intervention was delivered through routine clinic visits by providers to patients with SLE who take SLE-specific medications. We measured acceptability, appropriateness, and feasibility using provider surveys. We also measured acceptability by patient surveys and feasibility by medical record documentation. We explored change in adherence by comparing percent of patients with medication possession ratio (MPR) ≥80% 3 months before and after the intervention visit using the McNemar's test. RESULTS Six rheumatologists participated; 130 patients were included in the analysis (median age 43, 95% female, and 59% racial and ethnic minorities). Implementation of the intervention was documented in 89% of clinic notes. Provider surveys showed high scores for feasibility (4.7/5), acceptability (4.4/5), and appropriateness (4.6/5). Among patient surveys, the most common reactions to the intervention visit were feeling determined (32%), empowered (32%), and proud (19%). Proportion of patients with MPR ≥80% increased from 48% to 58% (P = 0.03) after the intervention visit. CONCLUSION Our intervention showed feasibility, acceptability, and appropriateness and led to a statistically significant improvement in adherence. Future work should refine the intervention, assess its efficacy in a controlled setting, and adapt its use among other clinic settings.
Collapse
Affiliation(s)
- Kai Sun
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Amanda M. Eudy
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer L. Rogers
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Rebecca E. Sadun
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jayanth Doss
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Mithu Maheswaranathan
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ann Cameron Barr
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Lena Eder
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Amy L. Corneli
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B. Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Megan E.B. Clowse
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
13
|
Doss J, Morrison C. Survey utilization to identify the unmet needs of adolescent and young adult oncology patients. Am J Med Sci 2023. [DOI: 10.1016/s0002-9629(23)00665-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
14
|
Doss J, Collier S, Gardner R, Morrison C. Lumps and bumps: superficial findings with a deeper diagnosis. Am J Med Sci 2023. [DOI: 10.1016/s0002-9629(23)00058-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
15
|
Sun K, Coles TM, Voils CI, Anderson DR, Eudy AM, Sadun RE, Rogers JL, Criscione-Schreiber LG, Doss J, Maheswaranathan M, Clowse MEB. Development and Initial Validation of a Systemic Lupus Erythematosus-Specific Measure of the Extent of and Reasons for Medication Nonadherence. J Rheumatol 2023; 50:296. [PMID: 36724934 DOI: 10.3899/jrheum.220399.c1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
16
|
Barr AC, Clowse M, Maheswaranathan M, Eder L, Eudy AM, Criscione-Schreiber LG, Rogers JL, Sadun RE, Doss J, Sun K. Association of Hurried Communication and Low Patient Self-Efficacy With Persistent Nonadherence to Lupus Medications. Arthritis Care Res (Hoboken) 2023; 75:69-75. [PMID: 36194070 PMCID: PMC9797428 DOI: 10.1002/acr.25030] [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: 04/01/2022] [Revised: 08/17/2022] [Accepted: 09/27/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Medication nonadherence is common among patients with systemic lupus erythematosus (SLE), and adherence often fluctuates with time. Underrepresented racial minorities have disproportionately lower rates of medication adherence and more severe SLE manifestations. We aimed to identify modifiable factors associated with persistent medication nonadherence. METHODS Patients taking ≥1 SLE medication were enrolled. Adherence data were obtained at baseline and at follow-up roughly 1 year later using both self-reported adherence and pharmacy refill data. Covariates included patient-provider interaction, patient self-efficacy, and clinical factors. We compared characteristics of patients in 3 groups using the Kruskal-Wallis H test: persistent nonadherence (low adherence by self-report and refill rates at both time points); persistent adherence (high adherence by self-report and refill rates at both time points); and inconsistent adherence (the remainder). RESULTS Among 77 patients (median age 44 years, 53% Black, 96% female), 48% had persistent nonadherence. Compared with other adherence groups, patients with persistent nonadherence were younger and more likely to be Black, have lower income, take ≥2 SLE medications, have higher SLE-related damage at baseline, and have higher physician global assessment of disease activity at follow-up. Persistently nonadherent patients also rated more hurried communication with providers (particularly fast speech and difficult word choice) and had lower self-efficacy in managing medications. CONCLUSION Potential avenues to improve medication adherence include optimizing patient-provider communication, specifically avoiding difficult vocabulary and fast speech, and enhancing patient self-efficacy, particularly among younger Black patients with lower income who are at higher risk for nonadherence.
Collapse
Affiliation(s)
- Ann Cameron Barr
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Megan Clowse
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Mithu Maheswaranathan
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Lena Eder
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Amanda M. Eudy
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Jennifer L. Rogers
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Rebecca E. Sadun
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jayanth Doss
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Kai Sun
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
17
|
Rosario KF, Brezitski K, Arps K, Milne M, Doss J, Karra R. Cardiac Sarcoidosis: Current Approaches to Diagnosis and Management. Curr Allergy Asthma Rep 2022; 22:171-182. [PMID: 36308680 DOI: 10.1007/s11882-022-01046-x] [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] [Accepted: 10/04/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Cardiac sarcoidosis (CS) is an important cause of non-ischemic cardiomyopathy and has specific diagnostic and therapeutic considerations. With advances in imaging techniques and treatment approaches, the approach to monitoring disease progression and management of CS continues to evolve. The purpose of this review is to highlight advances in CS diagnosis and treatment and present a center's multidisciplinary approach to CS care. RECENT FINDINGS In this review, we highlight advances in granuloma biology along with contemporary diagnostic approaches. Moreover, we expand on current targets of immunosuppression focused on granuloma biology and concurrent advances in the cardiovascular care of CS in light of recent guideline recommendations. Here, we review advances in the understanding of the sarcoidosis granuloma along with contemporary diagnostic and therapeutic considerations for CS. Additionally, we highlight knowledge gaps and areas for future research in CS treatment.
Collapse
Affiliation(s)
- Karen Flores Rosario
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Kyla Brezitski
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Kelly Arps
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Megan Milne
- Division of Rheumatology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Jayanth Doss
- Division of Rheumatology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA
| | - Ravi Karra
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27710, USA. .,Department of Pathology, Duke University Medical Center, Box 102152 DUMC, Durham, NC, 27710, USA.
| |
Collapse
|
18
|
Sun K, Coles TM, Voils CI, Anderson DR, Eudy AM, Sadun RE, Rogers JL, Criscione-Schreiber LG, Doss J, Maheswaranathan M, Clowse MEB. Development and Initial Validation of a Systemic Lupus Erythematosus-Specific Measure of the Extent of and Reasons for Medication Nonadherence. J Rheumatol 2022; 49:1341-1348. [PMID: 36243406 PMCID: PMC9722566 DOI: 10.3899/jrheum.220399] [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: 07/25/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Medication nonadherence is common in patients with systemic lupus erythematosus (SLE) and negatively affects outcomes. To better recognize and address nonadherence in this population, there is a need for an easily implementable tool with interpretable scores. Domains of Subjective Extent of Nonadherence (DOSE-Nonadherence) is a measure that captures both extent of and reasons for nonadherence. We refined and evaluated DOSE-Nonadherence for patients with SLE. METHODS We refined the reasons for the nonadherence domain of DOSE-Nonadherence through rheumatologist feedback and patient cognitive interviewing. We then administered the refined instrument to patients prescribed oral SLE medications and compared the results to the Beliefs About Medicines Questionnaire (BMQ), the Medication Adherence Self-Report Inventory (MASRI), medication possession ratios (MPRs), and hydroxychloroquine (HCQ) blood levels using Pearson correlations. RESULTS Five rheumatologists provided feedback; 16 patients (median age 43 yrs, 100% female, 50% Black) participated in cognitive interviews and 128 (median age 49 yrs, 95% female, 49% Black, 88% on antimalarials, and 59% on immunosuppressants) completed the refined instrument. Items assessing extent of nonadherence produced reliable scores (α 0.89) and identified 47% as nonadherent. They showed convergent validity with MASRI (r = -0.57), HCQ blood levels (r = -0.55), to a lesser extent MPRs (r = -0.34 to -0.40), and discriminant validity with BMQ domains (r = -0.27 to 0.32). Nonadherent patients reported on average 3.5 adherence barriers, the most common being busyness/forgetting (62%), physical fatigue (38%), and pill fatigue (33%). CONCLUSION Our results support the reliability and validity of DOSE-Nonadherence for SLE medications. This refined instrument, DOSE-Nonadherence-SLE, can be used to identify, rigorously study, and guide adherence intervention development in SLE.
Collapse
Affiliation(s)
- Kai Sun
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina;
| | - Theresa M Coles
- T.M. Coles, PhD, Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Corrine I Voils
- C.I. Voils, PhD, William S Middleton Memorial Veterans Hospital and Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - D Ryan Anderson
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Amanda M Eudy
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Rebecca E Sadun
- R.E. Sadun, MD, PhD, Division of Rheumatology and Immunology, Department of Medicine, and Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer L Rogers
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Lisa G Criscione-Schreiber
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jayanth Doss
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Mithu Maheswaranathan
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Megan E B Clowse
- K. Sun, MD, D.R. Anderson, MD, PhD, A.M. Eudy, PhD, J.L. Rogers, MD, L.G. Criscione-Schreiber, MD, MEd, J. Doss, MD, MPH, M. Maheswaranathan, MD, M.E.B. Clowse, MD, MPH, Division of Rheumatology and Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
19
|
Minniti C, Hoppe C, Bradley S, Doss J, Purdie D, Montealegre-Golcher F, Crouch A. THE RANDOMIZED, DOUBLE-BLIND, MULTICENTER, PLACEBO-CONTROLLED PHASE 3 RESOLVE TRIAL INVESTIGATING THE EFFICACY OF VOXELOTOR WITH STANDARD OF CARE IN THE RESOLUTION OF LEG ULCERS IN PATIENTS WITH SICKLE CELL DISEASE. Hematol Transfus Cell Ther 2022. [DOI: 10.1016/j.htct.2022.09.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
20
|
Sun K, Corneli AL, Dombeck C, Swezey T, Rogers JL, Criscione-Schreiber LG, Sadun RE, Eudy AM, Doss J, Bosworth HB, Clowse MEB. Barriers to Taking Medications for Systemic Lupus Erythematosus: A Qualitative Study of Racial Minority Patients, Lupus Providers, and Clinic Staff. Arthritis Care Res (Hoboken) 2022; 74:1459-1467. [PMID: 33662174 PMCID: PMC8417148 DOI: 10.1002/acr.24591] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 09/04/2020] [Revised: 01/18/2021] [Accepted: 03/02/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Underrepresented racial and ethnic minorities are disproportionately affected by systemic lupus erythematosus (SLE). Racial and ethnic minorities also have more severe SLE manifestations that require use of immunosuppressive medications, and often have lower rates of medication adherence. We aimed to explore barriers of adherence to SLE immunosuppressive medications among minority SLE patients. METHODS We conducted a qualitative descriptive study using in-depth interviews with a purposive sample of racial minority SLE patients taking oral immunosuppressants (methotrexate, azathioprine, or mycophenolate), and lupus clinic providers and staff. Interviews were audiorecorded, transcribed, and analyzed using applied thematic analysis. We grouped themes using the Capability, Opportunity, Motivation, Behavior conceptual model. RESULTS We interviewed 12 SLE patients (4 adherent, 8 nonadherent) and 12 providers and staff. We identified capability barriers to include external factors related to acquiring medications, specifically cost-, pharmacy-, and clinic-related issues; opportunity barriers to include external barriers to taking medications, specifically logistic- and medication-related issues; and motivation factors to include intrinsic barriers, encompassing patients' knowledge, beliefs, attitudes, and physical and mental health. The most frequently described barriers were cost, side effects, busyness/forgetting, and lack of understanding, although barriers differed by patient and adherence level, with logistic and intrinsic barriers described predominantly by nonadherent patients and side effects described predominantly by adherent patients. CONCLUSION Our findings suggest that interventions may be most impactful if they are designed to facilitate logistics of taking medications and increase patients' motivation while allowing for personalization to address the individual differences in adherence barriers.
Collapse
Affiliation(s)
- Kai Sun
- Duke University Hospital and Duke University School of Medicine, Durham, North Carolina
| | - Amy L Corneli
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina
| | - Carrie Dombeck
- Duke University School of Medicine, Durham, North Carolina
| | - Teresa Swezey
- Duke University School of Medicine, Durham, North Carolina
| | - Jennifer L Rogers
- Duke University Medical Center and Duke University School of Medicine, Durham, North Carolina
| | | | | | - Amanda M Eudy
- Duke University Medical Center and Duke University School of Medicine, Durham, North Carolina
| | - Jayanth Doss
- Duke University School of Medicine, Durham, North Carolina
| | - Hayden B Bosworth
- Duke University School of Medicine and Durham Veterans Administration Medical Center, Durham, North Carolina
| | - Megan E B Clowse
- Duke University Medical Center and Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
21
|
Eudy AM, Rogers JL, Corneli A, McKenna K, Maheswaranathan M, Pisetsky DS, Criscione-Schreiber LG, Doss J, Sadun RE, Sun K, Clowse MEB. Intermittent and Persistent Type 2 lupus: patient perspectives on two distinct patterns of Type 2 SLE symptoms. Lupus Sci Med 2022; 9:9/1/e000705. [PMID: 36927502 PMCID: PMC9362789 DOI: 10.1136/lupus-2022-000705] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/27/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE We have developed a new conceptual model to characterise the signs and symptoms of SLE: the Type 1 and 2 SLE Model. Within the original model, Type 1 SLE consists of inflammatory manifestations like arthritis, nephritis and rashes; Type 2 SLE includes symptoms of fatigue, myalgia, mood disturbance and cognitive dysfunction. Through in-depth interviews, we explored how the Type 1 and 2 SLE Model fits within the lived experience of patients with SLE, with a focus on the connection between Type 1 and Type 2 SLE symptoms. METHODS Semistructured in-depth interviews were conducted among adult participants meeting 1997 American College of Rheumatology or Systemic Lupus International Collaborating Clinics criteria for SLE. Participants were purposefully selected for age, race, sex and nephritis history. All interviews were audio-recorded and transcribed. Data were analysed through episode profile and thematic analysis. RESULTS Through interviews with 42 patients with SLE, two patterns of Type 2 SLE emerged: Intermittent (n=18) and Persistent (n=24). Participants with Intermittent Type 2 SLE described feeling generally well when Type 1 is inactive; these participants were younger and had more internal SLE manifestations. Participants with Persistent Type 2 described always experiencing Type 2 symptoms despite inactive Type 1, although the severity may fluctuate. Participants with Persistent Type 2 SLE experienced traditional lupus symptoms of joint pain, hair loss and rash, but less often had severe organ system involvement. CONCLUSIONS By listening to the stories of our patients, we found two underlying patterns of Type 2 SLE: Intermittent Type 2 symptoms that resolve in synchrony with Type 1 inflammatory symptoms, and Persistent Type 2 symptoms that continue despite remission of Type 1 symptoms.
Collapse
Affiliation(s)
- Amanda M Eudy
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer L Rogers
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amy Corneli
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin McKenna
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mithu Maheswaranathan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - David S Pisetsky
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Medicine, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | | | - Jayanth Doss
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebecca E Sadun
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kai Sun
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Megan E B Clowse
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Maheswaranathan M, Eudy AM, Barr AC, Howe C, Doss J, Sadun RE, Criscione-Schreiber LG, Sun K, Perrin EM, Bailey SC, Hastings SN, Clowse MEB, Rogers JL. Association of Health Literacy and Numeracy With Lupus Knowledge and the Creation of the Lupus Knowledge Assessment Test. J Rheumatol 2022; 49:585-591. [PMID: 35232802 DOI: 10.3899/jrheum.210708] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Limited health literacy and numeracy are associated with worse patient-reported outcomes and higher disease activity in systemic lupus erythematosus (SLE), but which factors may mediate this association is unknown. We sought to determine the association of health literacy and numeracy with SLE knowledge. METHODS Patients with SLE were recruited from an academic center clinic. Participants completed validated assessments of health literacy (Newest Vital Sign [NVS]; n = 96) and numeracy (Numeracy Understanding in Medicine Instrument, Short Version [S-NUMI]; n = 85). They also completed the Lupus Knowledge Assessment Test (LKAT), which consists of 4 questions assessing SLE knowledge that were determined through consensus expert opinion for their wide applicability and importance related to self-management of the disease. Descriptive statistics and multivariable logistic regression modeling were used to analyze the results. RESULTS In our SLE cohort (n = 125), 33% (32/96) had limited health literacy and 76% (65/85) had limited numeracy. The majority correctly identified that hydroxychloroquine prevented SLE flares (91%); however, only 23% of participants correctly answered a numeracy question assessing which urine protein to creatinine (UPC) ratio was > 1000 mg/g. The mean LKAT score was 2.7 out of 4.0. Limited health literacy, but not numeracy, was associated with lower knowledge about SLE as measured by the LKAT, even after adjusting for education. CONCLUSION Patients with SLE with limited health literacy had lower knowledge about SLE. The LKAT could be further refined and/or used as a screening tool to identify patients with knowledge gaps. Further work is needed to improve patients' understanding of proteinuria and investigate whether literacy-sensitive education can improve care.
Collapse
Affiliation(s)
- Mithu Maheswaranathan
- M. Maheswaranathan, MD, Fellow, A.M. Eudy, PhD, Assistant Professor, J. Doss, MD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Professor, K. Sun, MD, Assistant Professor, M.E.B. Clowse, MD, MPH, Associate Professor, J.L. Rogers, MD, Assistant Professor, Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina;
| | - Amanda M Eudy
- M. Maheswaranathan, MD, Fellow, A.M. Eudy, PhD, Assistant Professor, J. Doss, MD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Professor, K. Sun, MD, Assistant Professor, M.E.B. Clowse, MD, MPH, Associate Professor, J.L. Rogers, MD, Assistant Professor, Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ann Cameron Barr
- A.C. Barr, MD, Resident, C. Howe, MD, Resident, Department of Medicine, Duke University Hospital, Durham, North Carolina
| | - Catherine Howe
- A.C. Barr, MD, Resident, C. Howe, MD, Resident, Department of Medicine, Duke University Hospital, Durham, North Carolina
| | - Jayanth Doss
- M. Maheswaranathan, MD, Fellow, A.M. Eudy, PhD, Assistant Professor, J. Doss, MD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Professor, K. Sun, MD, Assistant Professor, M.E.B. Clowse, MD, MPH, Associate Professor, J.L. Rogers, MD, Assistant Professor, Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Rebecca E Sadun
- R.E. Sadun, MD, PhD, Assistant Professor, Division of Rheumatology, Departments of Medicine and Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Lisa G Criscione-Schreiber
- M. Maheswaranathan, MD, Fellow, A.M. Eudy, PhD, Assistant Professor, J. Doss, MD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Professor, K. Sun, MD, Assistant Professor, M.E.B. Clowse, MD, MPH, Associate Professor, J.L. Rogers, MD, Assistant Professor, Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Kai Sun
- M. Maheswaranathan, MD, Fellow, A.M. Eudy, PhD, Assistant Professor, J. Doss, MD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Professor, K. Sun, MD, Assistant Professor, M.E.B. Clowse, MD, MPH, Associate Professor, J.L. Rogers, MD, Assistant Professor, Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Eliana M Perrin
- E.M. Perrin, MD, MPH, Professor, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Stacy C Bailey
- S.C. Bailey, PhD, MPH, Associate Professor of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, Illinois
| | - Susan N Hastings
- S.N. Hastings, MD, Departments of Medicine & Population Health Sciences and Center for the Study of Aging, Duke University, and Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Megan E B Clowse
- M. Maheswaranathan, MD, Fellow, A.M. Eudy, PhD, Assistant Professor, J. Doss, MD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Professor, K. Sun, MD, Assistant Professor, M.E.B. Clowse, MD, MPH, Associate Professor, J.L. Rogers, MD, Assistant Professor, Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer L Rogers
- M. Maheswaranathan, MD, Fellow, A.M. Eudy, PhD, Assistant Professor, J. Doss, MD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Professor, K. Sun, MD, Assistant Professor, M.E.B. Clowse, MD, MPH, Associate Professor, J.L. Rogers, MD, Assistant Professor, Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
24
|
Arps K, Geiger K, Devore AD, Doss J, Karra R, Kim HW, Piccini JP, Pokorney SD, Sun AY. PO-638-06 TEMPORAL RELATIONSHIP OF ATRIAL ARRHYTHMIAS WITH THE DIAGNOSIS OF CARDIAC SARCOIDOSIS. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
25
|
Eudy AM, Reeve BB, Coles T, Lin L, Rogers JL, Pisetsky DS, Criscione-Schreiber LG, Doss J, Sadun R, Sun K, Clowse MEB. The use of patient-reported outcome measures to classify type 1 and 2 systemic lupus erythematosus activity. Lupus 2022; 31:697-705. [PMID: 35343853 PMCID: PMC9348758 DOI: 10.1177/09612033221090885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 12/31/2022]
Abstract
OBJECTIVE We developed a model that categorizes systemic lupus erythematosus (SLE) activity into two dimensions: Type 1 SLE consists of inflammatory activity, including arthritis, nephritis, and rashes; Type 2 SLE includes fatigue, myalgia, mood disturbance, and cognitive dysfunction. Patient-reported outcome (PRO) measures have received attention as a way to capture symptomatology of SLE. The objective of this study was to explore the use of existing PRO measures to classify Type 1 and 2 SLE activity. METHODS Systemic lupus erythematosus patients completed three questionnaires: Systemic Lupus Activity Questionnaire (SLAQ), Polysymptomatic Distress Scale (PSD), and Patient Health Questionnaire (PHQ-2). SLE Disease Activity Index (SLEDAI) and physician global assessments (PGA; 0-3) for Type 1 and Type 2 activity were also recorded. High Type 1 SLE activity was defined as cSLEDAI ≥4 (scored without labs), SLEDAI ≥6, active nephritis, or Type 1 PGA ≥1.0. High Type 2 SLE activity was defined as Type 2 PGA ≥1.0. Patients with both high Type 1 and 2 activity were defined as Mixed SLE, and patients with low Type 1 and 2 activity were defined as Minimal SLE. Data were reduced with a factor analysis. Using a reduced set of 13 variables, multinomial logistic regression models estimated the probability of Minimal, Type 1, Type 2, and Mixed SLE classification. RESULTS The study included 208 patients with SLE. The model accurately predicted the clinician-based Type 1 and 2 SLE classification in 63% of patients; 73% of patients had their Type 1 SLE activity accurately predicted; and 83% had their Type 2 SLE activity accurately predicted. Performance varied by group: 87% of Minimal patients were correctly predicted to be in the Minimal SLE group, yet only about one-third of patients in the Type 1 group were correctly predicted to be in the Type 1 group. CONCLUSIONS Our findings indicate Type 2 SLE activity can be identified by patient-reported data. The use of PROs was not as accurate at predicting Type 1 activity. These findings highlight the challenges of using PROs to categorize and classify SLE symptoms since some manifestations of Type 1 activity (e.g., nephritis) may be essentially clinically silent while other Type 1 manifestations may cause severe symptoms.
Collapse
Affiliation(s)
- Amanda M. Eudy
- Department of Medicine, Duke University School of Medicine
| | - Bryce B. Reeve
- Department of Population Health Sciences, Duke University School of Medicine
| | - Theresa Coles
- Department of Population Health Sciences, Duke University School of Medicine
| | - Li Lin
- Department of Population Health Sciences, Duke University School of Medicine
| | | | - David S. Pisetsky
- Department of Medicine, Duke University School of Medicine,Medical Research Service Durham VAMC
| | | | - Jayanth Doss
- Department of Medicine, Duke University School of Medicine
| | - Rebecca Sadun
- Department of Medicine, Duke University School of Medicine
| | - Kai Sun
- Department of Medicine, Duke University School of Medicine
| | | |
Collapse
|
26
|
Sun K, Eudy AM, Criscione-Schreiber LG, Sadun RE, Rogers JL, Doss J, Corneli AL, Bosworth HB, Clowse MEB. Racial Differences in Patient-provider Communication, Patient Self-efficacy, and Their Associations With Systemic Lupus Erythematosus-related Damage: A Cross-sectional Survey. J Rheumatol 2021; 48:1022-1028. [PMID: 33259332 PMCID: PMC10698393 DOI: 10.3899/jrheum.200682] [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] [Accepted: 08/13/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Despite significant racial disparities in systemic lupus erythematosus (SLE) outcomes, few studies have examined how disparities may be perpetuated in clinical encounters. We aimed to explore associations between areas of clinical encounters - patient-provider communication and patient self-efficacy - with SLE-related damage, in order to identify potential areas for intervention to reduce SLE outcome disparities. METHODS We collected cross-sectional data from a tertiary SLE clinic including patient-provider communication, general self-efficacy, self-efficacy for managing medications and treatments, patient-reported health status, and clinical information. We compared racial groups and used logistic regression to assess race-stratified association of patient-provider communication and patient self-efficacy with having SLE-related damage. RESULTS Among 121 patients (37% White, 63% African American), African Americans were younger, more likely to be on Medicaid, and less likely to be college educated, married, or living with a partner or spouse. African Americans reported less fatigue and better social function, took more complex SLE medication regimens, had lower fibromyalgia (FM) scores, and had higher SLE disease activity and SLE-related damage scores. African Americans reported similar self-efficacy compared to White patients, but they reported more hurried communication with providers, which was reflected in their perception that providers used words that were difficult to understand. Perceiving providers use difficult words and lower general self-efficacy were associated with having SLE-related damage among African American but not White patients. CONCLUSION African Americans had more severe SLE and perceived more hurried communication with providers. Both worse communication and lower self-efficacy were associated with having SLE-related damage among African American but not White patients, suggesting that these factors should be investigated as potential interventions to reduce SLE racial disparities.
Collapse
Affiliation(s)
- Kai Sun
- K. Sun, MD, MS, Assistant Professor, A.E. Eudy, PhD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Associate Professor, R.E. Sadun, MD, PhD, Assistant Professor, J.L. Rogers, MD, Assistant Professor, J. Doss, MD, MPH, Assistant Professor, M.E. Clowse, Associate Professor, Division of Rheumatology, Department of Medicine, Duke University School of Medicine;
| | - Amanda M Eudy
- K. Sun, MD, MS, Assistant Professor, A.E. Eudy, PhD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Associate Professor, R.E. Sadun, MD, PhD, Assistant Professor, J.L. Rogers, MD, Assistant Professor, J. Doss, MD, MPH, Assistant Professor, M.E. Clowse, Associate Professor, Division of Rheumatology, Department of Medicine, Duke University School of Medicine
| | - Lisa G Criscione-Schreiber
- K. Sun, MD, MS, Assistant Professor, A.E. Eudy, PhD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Associate Professor, R.E. Sadun, MD, PhD, Assistant Professor, J.L. Rogers, MD, Assistant Professor, J. Doss, MD, MPH, Assistant Professor, M.E. Clowse, Associate Professor, Division of Rheumatology, Department of Medicine, Duke University School of Medicine
| | - Rebecca E Sadun
- K. Sun, MD, MS, Assistant Professor, A.E. Eudy, PhD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Associate Professor, R.E. Sadun, MD, PhD, Assistant Professor, J.L. Rogers, MD, Assistant Professor, J. Doss, MD, MPH, Assistant Professor, M.E. Clowse, Associate Professor, Division of Rheumatology, Department of Medicine, Duke University School of Medicine
| | - Jennifer L Rogers
- K. Sun, MD, MS, Assistant Professor, A.E. Eudy, PhD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Associate Professor, R.E. Sadun, MD, PhD, Assistant Professor, J.L. Rogers, MD, Assistant Professor, J. Doss, MD, MPH, Assistant Professor, M.E. Clowse, Associate Professor, Division of Rheumatology, Department of Medicine, Duke University School of Medicine
| | - Jayanth Doss
- K. Sun, MD, MS, Assistant Professor, A.E. Eudy, PhD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Associate Professor, R.E. Sadun, MD, PhD, Assistant Professor, J.L. Rogers, MD, Assistant Professor, J. Doss, MD, MPH, Assistant Professor, M.E. Clowse, Associate Professor, Division of Rheumatology, Department of Medicine, Duke University School of Medicine
| | - Amy L Corneli
- A.L. Corneli, PhD, Associate Professor, H.B. Bosworth, PhD, Professor, Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hayden B Bosworth
- A.L. Corneli, PhD, Associate Professor, H.B. Bosworth, PhD, Professor, Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Megan E B Clowse
- K. Sun, MD, MS, Assistant Professor, A.E. Eudy, PhD, Assistant Professor, L.G. Criscione-Schreiber, MD, MEd, Associate Professor, R.E. Sadun, MD, PhD, Assistant Professor, J.L. Rogers, MD, Assistant Professor, J. Doss, MD, MPH, Assistant Professor, M.E. Clowse, Associate Professor, Division of Rheumatology, Department of Medicine, Duke University School of Medicine
| |
Collapse
|
27
|
Sun K, Eudy AM, Criscione-Schreiber LG, Sadun RE, Rogers JL, Doss J, Corneli AL, Bosworth HB, Clowse MEB. Racial Disparities in Medication Adherence between African American and Caucasian Patients With Systemic Lupus Erythematosus and Their Associated Factors. ACR Open Rheumatol 2020; 2:430-437. [PMID: 32584516 PMCID: PMC7368138 DOI: 10.1002/acr2.11160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/14/2020] [Indexed: 01/19/2023] Open
Abstract
Objective Medication nonadherence is more common in African Americans compared with Caucasians. We examined the racial adherence gaps among patients with systemic lupus erythematosus (SLE) and explored factors associated with nonadherence. Methods Cross‐sectional data were obtained from consecutive patients prescribed SLE medications seen at an academic lupus clinic between August 2018 and February 2019. Adherence was measured using both self‐report and pharmacy refill data. High composite adherence was defined as having both high self‐reported adherence and high refill rates. Covariates were patient‐provider interaction, patient‐reported health status, and clinical factors. We compared adherence rates by race and used race‐stratified analyses to identify factors associated with low composite adherence. Results Among 121 patients (37% Caucasian, 63% African American), the median age was 44 years (range 22‐72), 95% were female, 51% had a college education or more, 46% had private insurance, and 38% had high composite adherence. Those with low composite adherence had higher damage scores, patient‐reported disease activity scores, and more acute care visits. High composite adherence rate was lower among African Americans compared with Caucasians (30% vs 51%, P = 0.02), and the gap was largest for those taking mycophenolate (26% vs 75%, P = 0.01). Among African Americans, low composite adherence was associated with perceiving fewer “Compassionate respectful” interactions with providers and worse anxiety and negative affect. In contrast, among Caucasians, low composite adherence was only associated with higher SLE medication regimen burden and fibromyalgia pain score. Conclusion Significant racial disparities exist in SLE medication adherence, which likely contributes to racial disparities in SLE outcomes. Interventions may be more effective if tailored by race, such as improving patient‐provider interaction and mental health among African Americans.
Collapse
Affiliation(s)
- Kai Sun
- Department of Medicine, Division of Rheumatology and Immunology, Duke University Medical Center, Durham, USA
| | - Amanda M Eudy
- Department of Medicine, Division of Rheumatology and Immunology, Duke University Medical Center, Durham, USA
| | - Lisa G Criscione-Schreiber
- Department of Medicine, Division of Rheumatology and Immunology, Duke University Medical Center, Durham, USA
| | - Rebecca E Sadun
- Department of Medicine, Division of Rheumatology and Immunology, Duke University Medical Center, Durham, USA
| | - Jennifer L Rogers
- Department of Medicine, Division of Rheumatology and Immunology, Duke University Medical Center, Durham, USA
| | - Jayanth Doss
- Department of Medicine, Division of Rheumatology and Immunology, Duke University Medical Center, Durham, USA
| | - Amy L Corneli
- Department of Population Health Sciences and Department of Medicine, Duke University, Durham, USA
| | - Hayden B Bosworth
- Department of Population Health Sciences and Department of Medicine, Duke University, Durham, USA
| | - Megan E B Clowse
- Department of Medicine, Division of Rheumatology and Immunology, Duke University Medical Center, Durham, USA
| |
Collapse
|
28
|
Rogers JL, Eudy AM, Pisetsky D, Criscione-Schreiber LG, Sun K, Doss J, Clowse MEB. Using Clinical Characteristics and Patient-Reported Outcome Measures to Categorize Systemic Lupus Erythematosus Subtypes. Arthritis Care Res (Hoboken) 2020; 73:386-393. [PMID: 31909888 DOI: 10.1002/acr.24135] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 12/31/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The type 1 and type 2 systemic lupus erythematosus (SLE) categorization system was recently proposed to validate the patients' perspective of disease and to capture a more comprehensive spectrum of symptoms. The objective of this study was to characterize the clinical manifestations of SLE subtypes and to determine the correlation between the patient- and physician-reported measures used in the model. METHODS This was a cross-sectional study of patients with SLE in a university clinic. Patients completed the Systemic Lupus Activity Questionnaire (SLAQ) and 2011 American College of Rheumatology fibromyalgia (FM) criteria. Active SLE was defined as Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score ≥6, clinical SLEDAI score ≥4, or active lupus nephritis. We identified 4 groups: type 1 SLE (active SLE without FM), type 2 SLE (inactive SLE with FM), mixed SLE (active SLE with FM), and minimal SLE (inactive SLE without FM). RESULTS In this cohort of 212 patients (92% female, mean age 45 years), 30% had type 1 SLE, 8% had type 2 SLE, 13% had mixed SLE, and 49% had minimal SLE. Regardless of SLE disease activity, patients with FM (21%), reported higher SLAQ scores, patient global assessment scores, and self-reported lupus flare that resulted in discordance between patient- and physician-reported measures. CONCLUSION Fatigue, widespread pain, sleep dysfunction, and mood disorders are common symptoms in SLE. Identifying these symptoms as type 2 SLE may be a method to improve patient communication and understanding. The level of type 2 SLE impacts patients' perception of disease and self-reported symptoms. The SLAQ may need to be reinterpreted based on the FM severity scale.
Collapse
Affiliation(s)
| | - Amanda M Eudy
- Duke University Medical Center, Durham, North Carolina
| | - David Pisetsky
- Durham Veterans Affairs Hospital and Duke University Medical Center, Durham, North Carolina
| | | | - Kai Sun
- Duke University Medical Center, Durham, North Carolina
| | - Jayanth Doss
- Duke University Medical Center, Durham, North Carolina
| | | |
Collapse
|
29
|
Rini B, Huseni M, Atkins M, McDermott D, Powles T, Escudier B, Banchereau R, Liu LF, Leng N, Fan J, Doss J, Nalle S, Carroll S, Li S, Schiff C, Green M, Motzer R. Molecular correlates differentiate response to atezolizumab (atezo) + bevacizumab (bev) vs sunitinib (sun): Results from a phase III study (IMmotion151) in untreated metastatic renal cell carcinoma (mRCC). Ann Oncol 2018. [DOI: 10.1093/annonc/mdy424.037] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
30
|
Alobaidi F, Doss J, Abmurat N. Multi-Disciplinary Team (MDT) Approach in Oral Cancer Management: An Exploratory Study. J Glob Oncol 2018. [DOI: 10.1200/jgo.18.33500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Treatment of oral cancer has evolved throughout the past decades which has led to the introduction of the multi-disciplinary team approach (MDT). The MDT concept has been endorsed as the main approach to ensure holistic care for oral cancer patients worldwide. In Malaysia, the MDT concept has been introduced in few hospitals throughout the country. According to the available literature, the MDT approach has improved coordination of care for oral cancer patients, communication between the different disciplines, decision making to obtain the best treatment plan, provided educational opportunities for development of the members, and improved staff and patient well-being. However, little evidence is available to support the fact that the MDT approach has improved patient survival and outcome. Aim: The aim of this study was to explore the MDT approach in the management of oral cancer patients. To our knowledge this is the first study on head and neck MDTs in Malaysia. Methods: The study was conducted at University of Malaya. A mixed-method study was commenced including both quantitative and qualitative designs. The quantitative part assessed the MDT members' attitude toward the role and use of the MDT approach in oral cancer patient management, while the qualitative part assessed the perception of the MDT members regarding the MDT approach in terms of: team structure, team process, decision making, barriers and suggestions for improvement of the MDT approach. The quantitative study was conducted through a structured self-administered questionnaire which were both content and face validated, and distributed to the members of the head and neck MDT. The qualitative study was commenced through two focus group discussions (FGDs) conducted separately. Results: The study was conducted among the head and neck MDT members at University Malaya which received a 100% response rate. The majority of the MDT members showed positive attitudes toward the MDT approach, with the seniors being more positive than the juniors. The MDT approach has improved team dynamics in terms of communication, care coordination and decision making. However, there were a few issues of miscommunication as well as long waiting lists for oncological radiotherapy machines and radiologic scanning. Conclusion: The MDT approach is certainly the preferable mode of care for oral cancer patients in University of Malaya. However, there is a need for further improvement with regards to communication between the team members, expansion of the current team composition, training of the MDT members with regards to clinical and nonclinical skills, guidelines, protocols and certain facilities. Teamwork is a fundamental perspective which is crucial for an effective MDT. As such, a better understanding of each other's roles and responsibilities within the team is essential to ensure optimum patient care and management.
Collapse
|
31
|
Doss J, Mo H, Carroll RJ, Crofford LJ, Denny JC. Phenome-Wide Association Study of Rheumatoid Arthritis Subgroups Identifies Association Between Seronegative Disease and Fibromyalgia. Arthritis Rheumatol 2017; 69:291-300. [PMID: 27589350 DOI: 10.1002/art.39851] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 08/11/2016] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The differences between seronegative and seropositive rheumatoid arthritis (RA) have not been widely reported. We performed electronic health record (EHR)-based phenome-wide association studies (PheWAS) to identify disease associations in seropositive and seronegative RA. METHODS A validated algorithm identified RA subjects from the de-identified version of the Vanderbilt University Medical Center EHR. Serotypes were determined by rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) values. We tested EHR-derived phenotypes using PheWAS comparing seropositive RA and seronegative RA, yielding disease associations. PheWAS was also performed in RF-positive versus RF-negative subjects and ACPA-positive versus ACPA-negative subjects. Following PheWAS, select phenotypes were then manually reviewed, and fibromyalgia was specifically evaluated using a validated algorithm. RESULTS A total of 2,199 RA individuals with either RF or ACPA testing were identified. Of these, 1,382 patients (63%) were classified as seropositive. Seronegative RA was associated with myalgia and myositis (odds ratio [OR] 2.1, P = 3.7 × 10-10 ) and back pain. A manual review of the health record showed that among subjects coded for Myalgia and Myositis, ∼80% had fibromyalgia. Follow-up with a specific EHR algorithm for fibromyalgia confirmed that seronegative RA was associated with fibromyalgia (OR 1.8, P = 4.0 × 10-6 ). Seropositive RA was associated with chronic airway obstruction (OR 2.2, P = 1.4 × 10-4 ) and tobacco use (OR 2.2, P = 7.0 × 10-4 ). CONCLUSION This PheWAS of RA patients identifies a strong association between seronegativity and fibromyalgia. It also affirms relationships between seropositivity and chronic airway obstruction and between seropositivity and tobacco use. These findings demonstrate the utility of the PheWAS approach to discover novel phenotype associations within different subgroups of a disease.
Collapse
Affiliation(s)
| | - Huan Mo
- Loma Linda University Medical Center, Loma Linda, California
| | | | | | | |
Collapse
|
32
|
Doss J, Mo H, Carroll RJ, Crofford LJ, Denny JC. Reply. Arthritis Rheumatol 2016; 69:680-681. [PMID: 27860419 DOI: 10.1002/art.39997] [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: 11/04/2016] [Accepted: 11/10/2016] [Indexed: 11/09/2022]
Affiliation(s)
| | - Huan Mo
- Loma Linda University School of Medicine, Loma Linda, CA
| | | | | | | |
Collapse
|
33
|
Affiliation(s)
- Jayanth Doss
- Division of Rheumatology, Vanderbilt University, Nashville, Tenn.
| | - James England
- Department of Medicine, Vanderbilt University, Nashville, Tenn
| | - Howard Fuchs
- Division of Rheumatology, Vanderbilt University, Nashville, Tenn
| |
Collapse
|
34
|
Borchardt KA, Ortega H, Mahood JD, Newman J, Delay PR, Doss J, Hipkins K, Schecter G, Gelber RH. Intestinal parasites in Southeast Asian refugees. West J Med 1981; 135:93-6. [PMID: 7281655 PMCID: PMC1273023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
A survey of intestinal parasitism in 6,241 Southeast Asian refugees (3,576 males and 2,665 females) indicated that 32.9 percent of the refugees had one or more intestinal parasites. A total of 1,178 (57.3 percent) males and 878 (42.7 percent) females harbored the parasites, with helminths representing the most frequent isolate. Intestinal parasitic infections may be considered minimal public health threats in the United States because of effective hygienic practices and sanitation facilities. However, it is important to emphasize that the attack rate also will be influenced by continued health education, job activities, and diagnosis and treatment of the refugees for these parasites.
Collapse
|
35
|
Pulido JI, Doss J, Twieg D, Blomqvist GC, Faulkner D, Horn V, DeBates D, Tobey M, Parkey RW, Willerson JT. Submaximal exercise testing after acute myocardial infarction: myocardial scintigraphic and electrocardiographic observations. Am J Cardiol 1978; 42:19-28. [PMID: 354368 DOI: 10.1016/0002-9149(78)90979-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The relation between global and regional left ventricular function and electrocardiographic signs of ischemia at rest and during submaximal supine exercise was studied in 27 patients 2 to 3 weeks after acute myocardial infarction. Dynamic myocardial scintigraphy was performed at rest and during submaximal exercise utilizing an in vivo method of labeling red blood cells with technetium-99m pertechnetate. Gated radionuclide blood pool scintigrams were obtained in a modified left anterior oblique, and in some patients also in the right anterior oblique projection, to measure left ventricular ejection fraction and segmental wall motion. Electrocardiographic monitoring of heart rate and rhythm was provided during the exercise. The submaximal exercise test was terminated when the patient's heart rate reached 125 beats/min or if angina, malignant ventricular ectopy or electrocardiographic evidence of myocardial ischemia developed before this rate was reached. The data demonstrate that patients with a recent anterior myocardial infarct, in contrast to patients with a recent inferior or nontransmural infarct, manifest a significant reduction in left ventricular ejection fraction with submaximal exercise. Of the eight patients with an anterior infarct, seven had segmental wall motion abnormalities at rest. Four of these eight manifested more severe abnormalities with submaximal exercise; three had abnormalities at rest that did not change with exercise. Four of the eight had a positive electrocardiographic response during exercise (two were taking digoxin). Of these four, only two had more marked wall motion abnormalities with effort. Of the 13 patients with an inferior infarct, 11 had apparently normal wall motion in the modified left anterior oblique projection at rest, including 2 who manifested segmental wall motion abnormalities with submaximal exercise; the 2 remaining patients had wall motion abnormalities at rest that, on exercise, became more marked in one and were unchanged in one. Four of the 13 had a positive electrocardiographic response with exercise (one was taking digoxin); only one of these had a detectably more severe wall motion abnormality with exercise. Of the six patients with a nontransmural infarct, four had no identifiable wall motion abnormalities at rest; in one of these, an abnormality developed with exercise. The remaining two patients had wall motion abnormalities at rest; in one, a positive electrocardiographic ischemic response developed with exercise. Patients with an anterior infarct appear to have a different functional ventricular response to submaximal exercise at the time of hospital discharge than patients with an inferior or nontransmural infarct. To identify ischemic responses with submaximal exercise in these patients one should ideally use both electrocardiographic monitoring and dynamic myocardial scintigraphy.
Collapse
|
36
|
Keshavan H, Nardizzi L, Srinath M, Doss J. Noninvasive radioisotope cardiographic images with digital prefiltering and boundary detection for measuring left ventricular parameters. Math Biosci 1977. [DOI: 10.1016/0025-5564(77)90094-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
37
|
Doss J, van Zweiten PA. Cholinergic receptors involved in the production of gastric acid. Arch Int Pharmacodyn Ther 1972; 197:245-60. [PMID: 5031139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|