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To develop initial American College of Rheumatology (ACR) guidelines on the use of exercise, rehabilitation, diet, and additional interventions in conjunction with disease‐modifying antirheumatic drugs (DMARDs) as part of an integrative management approach for people with rheumatoid arthritis (RA). An interprofessional guideline development group constructed clinically relevant Population, Intervention, Comparator, and Outcome (PICO) questions. A literature review team then completed a systematic literature review and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the certainty of evidence. An interprofessional Voting Panel (n = 20 participants) that included 3 individuals with RA achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. The Voting Panel achieved consensus on 28 recommendations for the use of integrative interventions in conjunction with DMARDs for the management of RA. Consistent engagement in exercise received a strong recommendation. Of 27 conditional recommendations, 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to additional integrative interventions. These recommendations are specific to RA management, recognizing that other medical indications and general health benefits may exist for many of these interventions. This guideline provides initial ACR recommendations on integrative interventions for the management of RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the importance of an interprofessional, team‐based approach to RA management. The conditional nature of most recommendations requires clinicians to engage persons with RA in shared decision‐making when applying these recommendations.

The COVID‐19 pandemic has impacted the careers of trainees and early career investigators (ECIs). We sought to assess how the American College of Rheumatology (ACR) and the Rheumatology Research Foundation (RRF) can address the needs of those pursuing research careers. The Committee on Research created a survey to assess the impact of COVID‐19 and identify topics for the ACR and the RRF to address. In fall of 2020, we surveyed postdoctoral trainees and ECIs within 9 years of terminal training. Responses were analyzed using descriptive statistics and qualitative content analysis. Twenty‐one percent of invitees responded to the survey (n = 365); of these, 60% were pursuing careers in academic research. Seventy‐five percent of respondents in academic research career paths placed their primary projects on hold during the pandemic. The number of individuals pursuing a research career from 2020 to 2021 decreased by 5%. Respondents reported funding, caregiving, and lack of preliminary data as significant challenges. Suggested impactful interventions included increased funding, funding process reform, and expanding mentoring and networking resources. Major stressors identified during the pandemic included increased caregiving responsibilities and difficulty obtaining data and funding, for which respondents suggested increases and changes in funding programs as well as more mentoring and networking opportunities. Based on these, the Committee on Research proposes 3 priorities: 1) flexible funding mechanisms for ECIs and additional support for those impacted by caregiving; 2) virtual and in‐person programs for career development and networking; and 3) curated content relevant to building a research career available on demand.

To purchase or authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2007.01627.x Byline: Mary E. Tinetti (*[dagger]), Gail J. McAvay (*), Terri R. Fried (*[double dagger]), JoAnne M. Foody (*), Luann Bianco (*), Sandra Ginter (*), Liana Fraenkel (*[double dagger]) Keywords: patient priorities; competing health outcomes; clinical decision-making Abstract: OBJECTIVES: To develop a choice task for eliciting priorities in the face of competing cardiovascular disease (CVD) outcomes, medication-related symptoms, and fall injuries. DESIGN: Conjoint analysis. SETTING: Senior housing site. PARTICIPANTS: Convenience sample of 15 senior housing residents for the pretest, 13 residents for the pilot test. MEASUREMENTS: The final task included 11 sets of choices. In each, one option optimized the risk of one or two of the three outcomes at the expense of the other(s); the second option did the reverse. Relative importance scores for CVD, fall injury, and medication-symptom outcomes were calculated. Reliability was assessed for two administrations using intraclass correlations (ICCs). Wilcoxon rank sum tests were used to evaluate order effects. RESULTS: The ICCs between choice task administrations were 0.70 for fall injuries, 0.73 for medication symptoms, and 0.56 for CVD outcomes. The ICCs with removal of two outliers were 0.84, 0.72, and 0.84, respectively. Whether CVD or fall injuries appeared first had no effect on scores. CONCLUSION: Preliminary evidence of comprehensibility and reliability supports using the choice task to determine whether individuals' priorities differ in the face of competing outcomes. Author Affiliation: (*)Department of Medicine, Section of Geriatrics, New Haven, Connecticut ([dagger])Department of Epidemiology and Public Health, School of Medicine, Yale University, New Haven, Connecticut ([double dagger])Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut. Article note: Address correspondence to Mary E. Tinetti, MD, Department of Internal Medicine/Section of Geriatrics, Yale University School of Medicine, 333 Cedar Street-PO Box 208025, New Haven, CT 06520-8025. E-mail: mary.tinetti@yale.edu

To purchase or authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2007.01232.x Byline: Terri R. Fried (*[dagger]), John O'Leary ([double dagger]), Peter Van Ness ([double dagger]), Liana Fraenkel (*[dagger]) Keywords: decision-making; preferences; life-sustaining treatment Abstract: OBJECTIVES: To determine whether preferences for future attempts at life-sustaining treatment change over time in a consistent and predictable manner. DESIGN: Observational cohort study. SETTING: Community. PARTICIPANTS: One hundred eighty-nine community-dwelling persons ages 60 and older with advanced cancer, heart failure, or chronic obstructive pulmonary disease. MEASUREMENTS: Participants were asked, if faced with an illness exacerbation that would be fatal if untreated, whether they would undergo high-burden therapy for a chance to avoid death and risk an impaired health state to avoid death. Interviews occurred at least every 4 months for up to 2 years. RESULTS: When asked their willingness to undergo high-burden therapy for a chance to avoid death, 35% had an inconsistent preference trajectory (e.g., becoming more and then less willing over time or vice versa). The proportion with inconsistent trajectories increased to 48% and 49% when asked their willingness to risk physical or cognitive disability, respectively, to avoid death. Participants with variable health states over time were more likely to have inconsistent trajectories, although inconsistent trajectories were also common in those with stable health states. CONCLUSION: A large proportion of older persons with advanced illness have inconsistent trajectories of willingness to undergo burdensome therapy or risk an impaired health state for a chance to avoid death. Variability in their health state over time explained this in part, although the frequency of inconsistent trajectories even in those with stable health states suggests that preferences are influenced by transient factors rather than representing stable core values. Author Affiliation: (*)Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut ([dagger])Department of Medicine ([double dagger])Program on Aging, Yale University School of Medicine, New Haven, Connecticut Article note: Address correspondence to Terri R. Fried, MD, CERC 151B, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516. E-mail: terri.fried@yale.edu

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2006.06.007 Byline: Lisa G. Suter (a)(b), Joanne M. Murabito (c)(d), David T. Felson (e), Liana Fraenkel (a)(b) Keywords: Raynaud's phenomenon; Risk factors; Cigarette smoking; Alcohol consumption; Cardiovascular disease; Gender differences Abstract: Data suggest Raynaud's phenomenon shares risk factors with cardiovascular disease. Studies of smoking, alcohol consumption, and Raynaud's have produced conflicting results and were limited by small sample size and failure to adjust for confounders. Our objective was to determine whether smoking and alcohol are independently associated with Raynaud's in a large, community-based cohort. Author Affiliation: (a) VA Connecticut Healthcare System, West Haven, Conn (b) Yale University School of Medicine, New Haven, Conn (c) National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Mass (d) Boston University School of Medicine, Section of General Internal Medicine, Boston, Mass (e) Boston University School of Medicine, Clinical Epidemiology, Boston, Mass. Article Note: (footnote) Dr. Suter was supported by the Veterans Affairs/Robert Wood Johnson Special Fellows Program and an Arthritis Foundation Physician Scientist Development Award. This work was supported by the National Heart Lung and Blood Institute's Framingham Heart Study (Contract No. N01-HC-25195; Drs. Murabito and Felson). Dr. Felson was also supported by National Institutes of Health grant AR47785. Dr. Fraenkel was supported by a K23 Award (National Institutes of Health AR048826-01). Disclosures: Lisa G. Suter: none; Joanne M. Murabito: none; David T. Felson: none; Liana Fraenkel: none.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2005.05.029 Byline: Liana Fraenkel (a)(b), Sarah McGraw (c), Suchat Wongcharatrawee (a)(b)(d), Guadalupe Garcia-Tsao (a)(b)(d) Keywords: Hepatitis C; Decision-making; Pegylated-interferon; Ribavirin Abstract: There are few data describing decision-making in chronic hepatitis C infection from the patient's perspective. In this study, we sought to investigate the factors that influence patients' decisions as they consider treatment for hepatitis C infection. Author Affiliation: (a) Department of Medicine, VA Connecticut Healthcare System, West Haven, Conn (b) Department of Medicine, Yale University School of Medicine, New Haven, Conn (c) New England Research Institutes, Watertown, Mass (d) Hepatitis C Resource Center, VA Connecticut Healthcare System, New Haven, Conn. Article Note: (footnote) This study was funded by the VA Health Services Research Department and the Yale Liver Center Pilot Project Grant DK P3034989. Dr. Fraenkel is also supported by the K23 Award AR048826-01 A1.

Our objective was to elicit clinicians’ and parents’ perspectives about decision-making related to hospitalization for children with bronchiolitis and the use of shared decision-making (SDM) to guide these decisions.We conducted individual, semistructured interviews with purposively sampled clinicians (pediatric emergency medicine physicians and nurses) at 2 children’s hospitals and parents of children age <2 years with bronchiolitis evaluated in the emergency department at 1 hospital. Interviews elicited clinicians’ and parents’ perspectives on decision-making and SDM for bronchiolitis. We conducted an inductive analysis following the principles of grounded theory until data saturation was reached for both groups.We interviewed 24 clinicians (17 physicians, 7 nurses) and 20 parents. Clinicians identified factors in 3 domains that contribute to hospitalization decision-making for children with bronchiolitis: demographics, clinical factors, and social-emotional factors. Although many clinicians supported using SDM for hospitalization decisions, most reported using a clinician-guided decision-making process in practice. Clinicians also identified several barriers to SDM, including the unpredictable course of bronchiolitis, perceptions of parents’ preferences for engaging in SDM, and parents’ emotions, health literacy, preferred language, and comfort with discharge. Parents wanted the opportunity to express their opinions during decision-making about hospitalization, although they often felt comfortable with the clinician’s decision when adequately informed.Although clinicians and parents of children with bronchiolitis are supportive of SDM, most hospitalization decision-making is clinician guided. Future investigation should evaluate how to address barriers and implement SDM in practice, including training clinicians in this SDM approach.

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Background: Hormonal factors may play an important role in the pathophysiology of the Raynaud phenomenon. Experimental studies have shown an increased vasoconstrictor response to estrogen, a response that can be prevented by the addition of progesterone. Objective: To measure the association between estrogen replacement therapy (alone and with progesterone) and the Raynaud phenomenon. Design: Cross-sectional study. Setting: Framingham Offspring Study. Participants: 497 postmenopausal women. Measurements: Prevalence of the Raynaud phenomenon according to hormone use. Covariates measured included age, body mass index, smoking, alcohol consumption, and [Beta]-blocker use. Results: Forty-nine women were classified as having the Raynaud phenomenon (9.9%). The prevalence of this phenomenon was 8.4% among women who did not receive estrogen, 19.1% among women receiving estrogen alone, and 9.8% among women receiving estrogen plus progesterone. The adjusted odds ratio for the Raynaud phenomenon was 2.5 (95% Cl, 1.2 to 5.3) for unopposed estrogen and 0.9 (Cl, 0.3 to 2.6) for estrogen plus progesterone, with nonusers as the reference group. Conclusions: Unopposed estrogen therapy was associated with the Raynaud phenomenon in postmenopausal women. This association was not present in women who were receiving combined hormone therapy., Estrogen replacement therapy with estrogen alone may increase a woman's risk of Raynaud syndrome. Raynaud syndrome causes blood vessels to contract, which increases cold sensitivity, and there is evidence that hormones are involved. In 497 postmenopausal women participating in the Framingham Offspring Study, those who used estrogen alone were 2.5 times more likely to experience symptoms of Raynaud syndrome compared to women who were not using hormone therapy. Women who took estrogen and progesterone had the same risk as non-users.

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To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. The guideline addresses treatment with disease‐modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high‐risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). This clinical practice guideline is intended to serve as a tool to support clinician and patient decision‐making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision‐making process based on patients’ values, goals, preferences, and comorbidities.

Aim:Research regarding decisions patients make about total knee arthroplasty, apart from having the procedure or not, are limited. Understanding patient decision making and related information needs is essential for shared decision making. Methods:Focus groups with an online community-based sample identified decisions about total knee arthroplasty beyond the decision to have the surgery itself. An online survey was used to determine relative importance of five major decisions and evaluate related information available. Results:Patients did not feel they have enough information to make important decisions of surgeon, device type, surgical approach, facility, or timing, for their total knee arthroplasty. Conclusion:Although further research is needed to generalize these findings, physicians should consider these questions during shared decision making with patients considering total knee arthroplasty.

IMPORTANCE: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for knee osteoarthritis. However, they are associated with uncertain long-term clinical benefit and significant toxic effects. OBJECTIVE: To evaluate whether discontinuing NSAIDs and engaging in a telephone-based cognitive behavioral therapy (CBT) program is noninferior to continuing NSAIDs for patients with knee osteoarthritis. DESIGN, SETTING, AND PARTICIPANTS: The Stopping NSAIDs for Arthritis Pain multicenter randomized withdrawal trial was conducted for 364 patients taking NSAIDs for knee osteoarthritis pain on most days of the week for at least 3 months between September 1, 2013, and September 30, 2018. Analysis was performed on an intent-to-treat basis. INTERVENTIONS: Participants discontinued their current NSAID and took 15 mg per day of meloxicam daily during a 2-week run-in period. Those who remained eligible were randomized in a 1:1 ratio to receive meloxicam or placebo for 4 weeks (blinded phase 1). Participants receiving meloxicam then continued this medication for 10 weeks, while those receiving placebo participated in a 10-week CBT program (unblinded phase 2). MAIN OUTCOMES AND MEASURES: The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score at 4 weeks with the noninferiority margin set at 1. Secondary outcomes included the area under the curve of the pain score after 4 weeks as well as the WOMAC pain score, area under the curve of the pain score, WOMAC disability score, and global impression of change after treatment at 14 weeks. RESULTS: A total of 180 participants (161 men; mean [SD] age, 58. 2 [11.8] years) were randomized to receive placebo followed by CBT, and a total of 184 participants (154 men; mean [SD] age, 58.5 [10.0] years) were randomized to receive meloxicam. After adjustment for baseline pain and study site, the estimated mean difference in WOMAC pain score between the placebo and meloxicam groups after 4 weeks was 1.4 (95% CI, 0.8-2.0; noninferiority test P = .92). At week 14, the adjusted mean difference in WOMAC pain score between the placebo (followed by CBT) and meloxicam groups was 0.8 (95% CI, 0.2-1.4; noninferiority P = .28). There was no statistically significant difference in the global impression of change (mean difference in scores, –0.2; 95% CI, –0.4 to 0.1; P = .15) or lower extremity disability (mean difference in scores, 0.9; 95% CI, –1.4 to 3.2; P = .45) between the 2 groups after 14 weeks. CONCLUSIONS AND RELEVANCE: Among patients with knee osteoarthritis, placebo and CBT (after placebo) are inferior to meloxicam. However, the WOMAC pain score differences between the 2 groups were small, and there were no statistically significant differences in participants’ global impression of change or function after 14 weeks. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01799213

Treat‐to‐target implementation in rheumatoid arthritis (RA) requires a shared decision‐making (SDM) process. However, ability to pay is a major determinant of patient choice, but how this factor affects SDMis under‐explored. Visits at 4 RAclinics during which patients faced a decision to change their treatment were audiotaped between May 2016 and June 2017. Audiotapes were transcribed verbatim and analyzed using qualitative framework analysis. A total of 156 visits were analyzed. Most patients with RA, except those with effective insurance coverage, had deliberations disrupted or sidelined by third‐party insurance providers having power to authorize the preferred disease‐modifying antirheumatic drug choice. This triangulated SDMcomplicated efficiency in deliberations and timely treatment and was a barrier to shared engagement about health risks and symptom improvement typically found in patient‐provider dyads. Rheumatology care providers should aim to incorporate treatment costs and ability to pay into their deliberations so that individualized out‐of‐pocket estimates can be considered during triangulated SDMat the point‐of‐care.

To determine the proportion of primary lipid screening among patients with rheumatoid arthritis (RA) and compare it with those among patients with diabetes mellitus (DM) and patients with neither RA nor DM, and to assess whether primary lipid screening varied according to the health care provider (rheumatologist versus non‐rheumatologist). We analyzed claims data from US private and public health plans from 2006–2010. Eligibility requirements included continuous medical and pharmacy coverage for ≥12 months (baseline period) and >2 physician diagnoses and relevant medications to define RA, DM, RA and DM, or neither condition. Among the 330,695 eligible participants, we calculated the proportion with a lipid profile ordered during the 2 years following baseline. Time‐varying Cox proportional hazard models were used to determine the probability of hyperlipidemia screening in participants with RA according to provider specialty. More than half of the patients were ages 41–71 years. Among patients with RA (n = 12,182), DM (n = 62,834), RA and DM (n = 1,082), and those who did not have either condition (n = 167,811), the proportion screened for hyperlipidemia was 37%, 60%, 55%, and 41%, respectively. Patients with RA who visited a rheumatologist and a non‐rheumatology clinician during follow‐up had a 55% (95% confidence interval 1.36–1.78) higher screening probability than those who only visited a rheumatologist. Primary lipid screening was suboptimal among patients with RA. It was also lower for patients with DM and minimally different from the general population. Screening was higher for RA patients who received care from both a rheumatologist and a non‐rheumatologist (e.g., primary care physician).

In order to identify opportunities to improve outpatient care, we evaluated patients with systemic lupus erythematosus (SLE) who persistently frequent the emergency department (ED). We conducted a retrospective study of patients with SLE who frequented the ED for ≥3 visits in a calendar year, from 2013 to 2016. Persistent users were those who met criteria for persistent use for at least 2 of the 4 years, and limited users for 1 of the 4 years. Each ED encounter was categorized as SLE‐related, infection‐related, pain‐related, or other. We compared ED use between persistent and limited users, and analyzed factors associated with pain‐related encounters among persistent users through multivariate logistic regression. We identified 77 participants who had 1,143 encounters as persistent users, and 52 participants who had 335 encounters as limited users. Persistent users accounted for 77% of ED use by patients with SLE who frequented the ED. Pain‐related ED visits were more common among persistent users (32%) than limited users (18%). Among persistent users, most pain‐related encounters were discharged from the ED (69%) or within 48 hours of admission (20%). Persistent users with pain‐related encounters accounting for >10% of ED use were more likely to be obese, have fewer comorbid conditions, and be on long‐term opioid therapy. Pain is a major cause of ED use. Patients with SLE who persistently utilize the ED for pain are likely to be noncritically ill, as evidenced by frequent discharges from the ED and short‐stay admissions. Patients with SLE who persistently frequent the ED for pain represent a viable target for interventions to improve outpatient quality of care.

Treat‐to‐target (TTT) is an accepted paradigm for care of patients with rheumatoid arthritis (RA). Because TTT can be associated with more medication switches, concerns arise regarding whether implementing TTT may increase adverse events and/or resource use. The aim of this study was to examine adverse events and resource use during the preintervention and intervention periods of the TTT intervention trial. We used data from 6 practices enrolled in an 18‐month cluster‐randomized controlled trial to compare adverse events and resource use before (months 1–9) and during (months 10–18) a TTT intervention. The outcomes of interest, adverse events and resource use, were based on medical record review of all rheumatology visits for RA patients before and during the intervention. We examined records for 321 patients before the intervention and 315 during the intervention. An adverse event was recorded in 10.2% of visits before the intervention and 8.8% of visits during the intervention (P= 0.41). Biologic disease‐modifying antirheumatic drugs were taken by 53.6% of patients before the intervention and 49.8% of patients during the intervention (P= 0.73). Rheumatology visits were more frequent before the intervention (mean ± SD 4.0 ± 1.4) than during the intervention (mean ± SD 3.6 ± 1.2; P= 0.02). More visits were accompanied by monitoring laboratory tests before the intervention (90.0%) compared with during the intervention (52.7%; P< 0.001). A greater percentage of visits before the intervention included diagnostic imaging (15.4%) versus during the intervention (8.9%; P< 0.001). We observed similar rates of adverse events before and during the implementation of TTT for RA. Rheumatology visits, use of laboratory monitoring, and diagnostic imaging did not increase during the TTT intervention.

In this proof‐of‐concept study, we sought to evaluate whether a value clarification tool enabling patients to view a set of rheumatoid arthritis (RA) treatment preference phenotypes could be used to support shared decision‐making at the point‐of‐care. We conducted a pretest/post test study. English‐speaking patients with RA presenting to their scheduled outpatient visits were asked to participate. Visits for patients with active RA were transcribed. Shared decision‐making components were measured using a quantitative coding scheme based on an established model of shared decision‐making. Forty‐six visits were included in the pretest and 40 in the post test phases. Providers offered more disease‐modifying antirheumatic drugs (DMARDs) (2 or more) in the post test visits (60%) compared to the pretest visits (47.8%). Overall, more patients vocalized their values and/or preferences in the post test visits compared to the pretest visits for treatment escalation decisions including a choice of 1 new DMARD (90.9% versus 56.3%), 2 or more new DMARDs (95.8% versus 86.4%), as well as prednisone (87.5% versus 66.7%). Providers were also more likely to base their recommendations on patients’ values and/or preferences in the post test (100% of 6 visits) than the pretest (64.3% of 14 visits) phases during visits in which a recommendation was made. The mean ± SD length of the visit was 29.9 ± 11.6 minutes and 25.1 ± 10.7 minutes in the pretest and post test phases, respectively. This study provides an early indication that a value clarification tool allowing patients to consider a set of preference phenotypes can support shared decision‐making at the point‐of‐care without extending visit time.

Patients have a poor understanding of outcomes related to total knee replacement (TKR) surgery, with most patients underestimating the potential benefits and overestimating the risk of complications. In this study, we sought to compare the impacts of descriptive information alone or in combination with an icon array, experience condition (images), or spinner on participants’ preference for TKR. A total of 648 members of an online arthritis network were randomized to 1 of 4 outcome presentation formats: numeric only, numeric with an icon array, numeric with a set of 50 images, or numeric with a functional spinner. Preferences for TKRwere measured before and immediately after viewing the outcome information using an 11‐point numeric rating scale. Knowledge was assessed by asking participants to report the frequency of each outcome. Participants randomized to the icon array, images, and spinner had stronger preferences for TKR(after controlling for baseline preferences) compared to those viewing the numeric only format (P< 0.05 for all mean differences). Knowledge scores were highest in participants randomized to the icon array; however, knowledge did not mediate the association between format and change in preference for TKR. Decision support at the point‐of‐care is being increasingly recognized as a vital component of care. Our findings suggest that adding graphic information to descriptive statistics strengthens preferences for TKR. Although experience formats using images may be too complex to use in clinical practice, icon arrays and spinners may be a viable and easily adaptable decision aid to support communication of probabilistic information.

Objective.The Outcome Measures in Rheumatology (OMERACT) Shared Decision Making (SDM) Working Group aims to determine the core outcome domain set for measuring the effectiveness of SDM interventions in rheumatology trials.Methods.A white paper was developed to clarify the draft core domain set. It was then used to prepare for interviews to investigate reasons for lack of consensus on it and to suggest further improvements.Results.OMERACT scientists/clinicians (n = 13) and patients (n = 10) suggested limiting the core domain set to outcome domains, removing process domains, and clarifying remaining domains.Conclusion.A revised core domain set will undergo further consensus-building.

To identify the perspectives of patients with rheumatoid arthritis (RA) on electronic recording of between‐visit disease activity and other patient‐reported outcomes (PROs) and on sharing this information with health care providers or peers. Patients with RA were recruited to participate in focus groups from December 2014 to April 2015. The topic guide and analysis were based on the Andersen–Newman framework. Sessions were audiorecorded, transcribed, independently coded, and analyzed for themes. Thirty‐one patients participated in 7 focus groups. Their mean ± SD age was 51 ± 13.1 years, 94% were women, 52% were African American, 11% were Hispanic, and 37% were white. Three themes emerged: provider communication, information‐seeking about RA, and social and peer support. Participants expressed a willingness to track disease activity data to share with health care providers electronically if providers would act on the information. Participants envisioned symptom tracking and information sharing as a mechanism to relay and obtain reliable information about RA. Participants were also interested in electronic communication between visits if it facilitated learning about symptom management and enhanced opportunities for social support among patients with RA. Patients with RA may be amenable to electronic collection and sharing of PRO‐type data between clinical encounters if it facilitates communication with health care providers and provides access to reliable information about RA. Providing patients with social support was important for enhancing PROs collection by helping them overcome barriers by using electronic devices and overcome reservations about the value of these data.

The aim of this study was to examine whether providing patients with a series of balance scales (BS), depicting a reciprocal relationship between achieving disease control and increasing the risk of infection, influences treatment preference. Participants were randomized to receive a description of a medication in which risk of infection was relayed using 1 of 4 formats, including numbers only, numbers + icon array (IA), numbers + BS, or numbers + IA+ BS(i.e., combination). We compared the likelihood of starting the medication across the 4 formats, and evaluated whether the influence of risk formats varied by numeracy and gist risk appraisals. The mean ± SElikelihood of starting the medication was higher among participants randomized to the combination format (3.85 ± 0.09) compared to those who viewed the BS(3.56 ± 0.09; P= 0.0222) or numbers‐only formats (3.51 ± 0.09; P= 0.0069). Viewing an IAalone was associated with a lower likelihood of starting the medication among participants lower in numeracy and endorsing a risk‐avoidant noncompensatory gist risk appraisal. Conversely, viewing an IA(with or without the BS) was associated with a greater likelihood of starting the medication among patients with higher numeracy and compensatory risk appraisals. Adding explanatory images to IAs increases patient likelihood to take a medication in those with low numeracy and a noncompensatory gist risk appraisal. Explanatory images may be a feasible approach to improve willingness to try medication among subjects who are especially risk averse and believe that any risk is unacceptable.

To explore the factors that influence risk tolerance among women from different racial/ethnic groups. In‐depth individual interviews of non‐Hispanic African American, non‐Hispanic white, and Hispanic women ages 20–45 years were conducted by a trained interviewer using a semi‐structured interview guide to elicit the factors that influence risk tolerance among minority women. The interviews were audiotaped and professionally transcribed, with a final sample size of 36 determined by thematic saturation. The members of the research team used open coding to review and develop a list of codes, which was modified as new codes emerged. A final list of 35 codes was applied to the transcripts and combined into broader themes. The study included 30.6% non‐Hispanic African American, 33.3% non‐Hispanic white, and 36.1% Hispanic women, with a mean ± SDage of 34.8 ± 6.8 years. Several major themes explaining risk aversion among minority women emerged: discrepancies in quality of health care, perceived prejudice, lack of knowledge and education, medication beliefs, risk perception, and constrained resources. The latter was discussed most frequently. While our findings identify several concerns that may be addressed through implementation of more effective communication strategies by medical providers, they also highlight that disparities are strongly influenced by the complex ways financial and social constraints impact health care decisions of minority women.

We conducted a 2‐phase randomized controlled trial of a learning collaborative to facilitate implementation of treat‐to‐target (T2T) to manage rheumatoid arthritis (RA). We found substantial improvement in implementation of T2T in phase I. Here, we report on a second 9 months (phase II), where we examined the maintenance of response in phase I and predictors of greater improvement in T2T adherence. We recruited patients from 11 rheumatology sites and randomized them to either receive the learning collaborative during phase I or to a wait‐list control group that received the learning collaborative intervention during phase II. The outcome was change in T2T implementation score (0–100, where 100 = best) from pre‐ to postintervention. The T2T implementation score was defined as a percent of components documented in visit notes. Analyses examined the extent to which the phase‐I intervention teams sustained improvement in T2T, as well as predictors of T2T improvement. The analysis included 636 RApatients. At baseline, the mean T2T implementation score was 11% in phase I intervention sites and 13% in phase IIsites. After the intervention, T2T implementation score improved to 57% in the phase I intervention sites and to 58% in the phase IIsites. Intervention sites from phase I sustained the improvement during the phase II(52%). Predictors of greater T2T improvement included having only rheumatologist providers at the site, academic affiliation of the site, having fewer providers per site, and the rheumatologist provider being a trainee. Improvement in T2T remained relatively stable over a postintervention period.

A treat‐to‐target (TTT) strategy is recommended in rheumatoid arthritis (RA). However, health care providers’ adherence to TTTin clinical practice remains unclear. We examined adherence to TTTin RAat USrheumatology sites. We used baseline information from the randomized controlled Treat‐to‐Target in RA: Collaboration to Improve Adoption and Adherence trial, which recruited 641 patients from 46 providers practicing at 11 USsites. We obtained data on the implementation of TTT, patient covariates, provider characteristics, and site variables. We examined the implementation of TTTusing 4 cardinal features: recording a disease target, recording a disease activity measure, engaging in shared decision‐making, and changing treatment if not at disease target. These features were assessed across sites and providers. We calculated a TTTimplementation score as the percentage of features noted. We examined the association between patient, provider, and site covariates and TTTimplementation score using proportional odds models. The implementation of TTTat baseline was suboptimal: 64.3% of visits had none of the TTTcomponents present, 33.1% had 1 component, 2.3% had 2 components, and 0.3% had all components. The implementation of TTTwas significantly different across providers and sites (P< 0.0001 for all). In the multivariable model, we observed that more experience as a rheumatologist was associated with a higher implementation score (P= 0.01 for trend). Compared with fellows, providers with >20 years of experience in practice were more likely to have more TTTcomponents recorded (odds ratio 7.68 [95% confidence interval 1.46–40.52]). We found that adherence to a TTTstrategy in RAwas suboptimal, and it differed across providers and sites.

The need for kidneys for transplantation continues to far surpass the number of donors. Although studies have shown that most people are aware of and support the idea of living donation, it remains unclear what motivates individuals who are aware, knowledgeable, and in support of donation to actually donate, or conversely, what deters them from donating. Utilizing nominal group technique, 30 individuals participated in 4 groups in which they brainstormed factors that would impact willingness to be a living donor and voted on which factors they deemed most important. Responses were analyzed and categorized into themes. Factors that influence the donation decision, from most to least important as rated by participants, were altruism, relationship to recipient, knowledge, personal risk/impact, convenience/access, cost, support, personal benefit, and religion. Participants reported a significant lack of information about donation as well as lack of knowledge about where and how to obtain information that would motivate them to donate or help make the decision to donate. Findings suggest that public campaign efforts seeking to increase rates of living donation should appeal to altruism and increase knowledge about the impact (or lack thereof) of donation on lifestyle factors and future health, and transplant programs should aim to maximize convenience and minimize donor burden. Future research should examine whether tailoring public campaigns to address factors perceived as most salient by potential donors reduces the significant gap in supply of and demand for kidneys.

Shared decision-making (SDM) has mostly been used with adults and parents in the primary care setting, and there is limited knowledge on the use of SDM with parents of acutely ill children. The objective of this study was to review the literature on SDM with parents in the management of acutely ill children.

To identify and summarize the published and gray literature on the use of telemedicine for the diagnosis and management of inflammatory and/or autoimmune rheumatic disease. We performed a registered systematic search (CRD42015025382) for studies using MEDLINE (1946 to July 2015), Embase (1974 to July 2015), Web of Science (1900 to July 2015), and Scopus (1946 to July 2015) databases. We included studies that demonstrated the use of telemedicine for diagnosis and/or management of inflammatory/autoimmune rheumatic disease. Following data extraction, we performed a descriptive analysis. Our literature search identified 1,468 potentially eligible studies. Of these studies, 20 were ultimately included in this review. Studies varied significantly in publication type, quality of evidence, and the reporting of methods. Most demonstrated a high risk of bias. Rheumatoid arthritis was the most commonly studied rheumatic disease (42% of patients). Studies demonstrated conflicting results regarding the effectiveness of telemedicine (18 found it effective, 1 found it effective but possibly harmful, and 1 found it ineffective). A limited number of studies included some component of a cost analysis (n = 6; 16% of patients); all of these found telemedicine to be cost‐effective. Studies identified by this systematic review generally found telemedicine to be effective for the diagnosis and management of autoimmune/inflammatory rheumatic disease; however, there is limited evidence to support this conclusion. Further studies are needed to determine the best uses of telemedicine for the diagnosis and management of these conditions.

There is a need to consider the impact of the new resident-hours regulations on the variety of aspects of medical education and patient care. Most existing literature about this subject has focused on the role of fatigue in resident performance, education, and health care delivery. However, there are other possible consequences of these new regulations, including a negative impact on decision ownership. Our main assumption of is that increased shift work in medicine can decrease ownership of treatment decisions and impact negatively on quality of care. We review some potential components of decision ownership in treatment context and suggest possible ways in which the absence of decision ownership may decrease the quality of medical decision making. The article opens with the definition of decision ownership and the overview of some contextual factors that may contribute to the development of ownership in medical residency. The following section discusses decision ownership in medical care from the perspective of "diffusion of responsibility." We question the quality of choices made within narrow decisional frames. We also compare isolated and interrelated choices, assuming that residents make more isolated decisions during their shifts. Lastly, we discuss the consequences of decreased decision ownership impacting the delivery of health care. [ABSTRACT FROM AUTHOR]

Objective.The aim of this Outcome Measures in Rheumatology (OMERACT) Working Group was to determine the core set of outcome domains and subdomains for measuring the effectiveness of shared decision-making (SDM) interventions in rheumatology clinical trials.Methods.Following the OMERACT Filter 2.0, and based on a previous literature review of SDM outcome domains and a nominal group process at OMERACT 2014, (1) an online Delphi survey was conducted to gather feedback on the draft core set and refine its domains and subdomains, and (2) a workshop was held at the OMERACT 2016 meeting to gain consensus on the draft core set.Results.A total of 170 participants completed Round 1 of the Delphi survey, and 116 completed Round 2. Respondents came from 29 countries, with 49% being patients/caregivers. Results showed that 14 out of the 17 subdomains within the 7 domains exceeded the 70% criterion (endorsement ranged from 83% to 100% of respondents). At OMERACT 2016, only 8% of the 96 attendees were patients/caregivers. Despite initial votes of support in breakout groups, there was insufficient comfort about the conceptualization of these 7 domains and 17 subdomains for these to be endorsed at OMERACT 2016 (endorsement ranged from 17% to 68% of participants).Conclusion.Differences between the Delphi survey and consensus meeting may be explained by the manner in which the outcomes were presented, variations in participant characteristics, and the context of voting. Further efforts are needed to address the limited understanding of SDM and its outcomes among OMERACT participants.

Cardiac and pulmonary rehabilitation programs are grossly underutilized, and participation is particularly low in rural regions.

The opioid epidemic continues to be a public health crisis that has worsened during the COVID-19 pandemic. Medications for opioid use disorder (MOUD) are the most effective way to reduce complications from opioid use disorder (OUD), but uptake is limited by both structural and individual factors. To inform strategies addressing individual factors, we evaluated patients' preferences and trade-offs in treatment decisions using conjoint analysis.

To develop an innovative and effective educational intervention to inform patients about the need for osteoporosis treatment and to determine factors associated with its online uptake.

Numerous factors can impede or facilitate patients’ medication decision‐making and adherence to physicians’ recommendations. Little is known about how patients and physicians jointly view issues that affect the decision‐making process. Our objective was to derive an empirical framework of patient‐identified facilitators to lupus medication decision‐making from key stakeholders (including 15 physicians, 5 patients/patient advocates, and 8 medical professionals) using a patient‐centered cognitive mapping approach. We used nominal group patient panels to identify facilitators to lupus treatment decision‐making. Stakeholders independently sorted the identified facilitators (n = 98) based on their similarities and rated the importance of each facilitator in patient decision‐making. Data were analyzed using multidimensional scaling and hierarchical cluster analysis. A cognitive map was derived that represents an empirical framework of facilitators for lupus treatment decisions from multiple stakeholders’ perspectives. The facilitator clusters were 1) hope for a normal/healthy life, 2) understand benefits and effectiveness of taking medications, 3) desire to minimize side effects, 4) medication‐related data, 5) medication effectiveness for “me,” 6) family focus, 7) confidence in physician, 8) medication research, 9) reassurance about medication, and 10) medication economics. Consideration of how different stakeholders perceive the relative importance of lupus medication decision‐making clusters is an important step toward improving patient‐physician communication and effective shared decision‐making. The empirically derived framework of medication decision‐making facilitators can be used as a guide to develop a lupus decision aid that focuses on improving physician‐patient communication.

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How best to involve patients in the development of clinical practice guideline (CPG) recommendations is not known. We sought to determine the feasibility and value of developing CPG recommendations based on a voting panel composed entirely of patients, with the ultimate goal of comparing the patients’ recommendations to ones developed by a physician‐dominated voting panel on the same clinical questions. Ten patients with rheumatoid arthritis completed 8 hours of training on evidence‐based medicine and guideline development. They constituted a voting panel and, with 2 American College of Rheumatology staff with expertise in CPG development and a physician facilitator, subsequently met at a face‐to‐face meeting to develop recommendations. They applied the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology to formulate recommendations on 18 questions for which there was evidence warranting moderate or high confidence. The patient panel developed recommendations for 16 of the 18 questions; for the other 2, the panel thought there were insufficient data to support a recommendation. For 13 of the 16 questions, the patient panel recommended the same course of action as did the physician‐dominated panel. Differences were due to how the 2 panels valued the balance between benefits and harms. Patient and physician‐dominated panels developed the same recommendations for most questions for which there was evidence warranting moderate to high confidence. Additional experiences are necessary to advance the evidence necessary to determine what panel composition is optimal to produce the best guidelines.

The Affordable Care Act proposes wider use of nurse practitioners (NPs) and physician assistants (PAs), but little is known about outcomes of care provided by them in medical specialties. We compared the outcomes of care for patients with rheumatoid arthritis (RA) seen in practices with NPs or PAs and rheumatologists versus practices with rheumatologists only. We enrolled 7 rheumatology practices in the US (4 with NPs or PAs and 3 without). RA disease activity (categorized as in remission, low, moderate, or high, using standardized measures) was abstracted from medical records from the most recent 2 years. We performed a repeated‐measures analysis using generalized linear regression to compare disease activity for visits to practices with NPs or PAs versus rheumatologist‐only practices, adjusting for disease duration, serologic status, RA treatments, and disease activity measures. Records from 301 patients, representing 1,982 visits, were reviewed. The patients’ mean age was 61 years and 77% were female. In the primary adjusted analysis, patients seen in practices with NPs or PAs were less likely to have higher disease activity (odds ratio 0.32, 95% confidence interval 0.17–0.60; P= 0.004) than those seen in rheumatologist‐only practices. However, there were no differences in the change in disease activity. Patients seen in practices with NPs or PAs had lower RA disease activity over 2 years compared to those seen in rheumatologist‐only practices; no differences were observed in the change in disease activity between visits either within or between the different types of provider practice.

To examine the potential value of a theory‐based, interactive decision support tool in clinical practice for patients with rheumatoid arthritis who are candidates for biologic agents. We conducted an 8‐week, 2‐arm, parallel, single‐blind pilot trial in which candidates for treatment escalation with a biologic agent were randomized to receive either a link to a web‐based tool or usual care. Outcomes included changes in objective knowledge, subjective knowledge, values clarification, and satisfaction with risk communication as well as the proportion of subjects defined as making an informed choice to escalate care at 2 weeks. A total of 125 subjects were randomized. Significant between‐group differences at 2 weeks favoring the intervention group were seen for changes in objective knowledge, subjective knowledge, and values clarification. No significant between‐group differences were found in subjects’ satisfaction with risk communication. Among those deciding to escalate care, a greater percentage met the criteria for an informed choice at 2 weeks in the intervention group compared to the control group (32% versus 13%; P= 0.02). Improvements in subjective knowledge and values clarification persisted at 8 weeks. There were no between‐group differences in objective knowledge at 8 weeks. In this study, use of a decision support tool at the time of decision‐making resulted in improved objective and subjective knowledge, as well as values clarity, compared to usual care. Not all improvements were sustained, emphasizing the need to offer educational support should additional escalation of care be required over the course of the illness.

Objective.Despite the importance of shared decision making for delivering patient-centered care in rheumatology, there is no consensus on how to measure its process and outcomes. The aim of this Outcome Measures in Rheumatology (OMERACT) working group is to determine the core set of domains for measuring shared decision making in intervention studies in adults with osteoarthritis (OA), from the perspectives of patients, health professionals, and researchers.Methods.We followed the OMERACT Filter 2.0 method to develop a draft core domain set by (1) forming an OMERACT working group; (2) conducting a review of domains of shared decision making; and (3) obtaining opinions of all those involved using a modified nominal group process held at a session activity at the OMERACT 12 meeting.Results.In all, 26 people from Europe, North America, and Australia, including 5 patient research partners, participated in the session activity. Participants identified the following domains for measuring shared decision making to be included as part of the draft core set: (1) identifying the decision, (2) exchanging information, (3) clarifying views, (4) deliberating, (5) making the decision, (6) putting the decision into practice, and (7) assessing the effect of the decision. Contextual factors were also suggested.Conclusion.We proposed a draft core set of shared decision-making domains for OA intervention research studies. Next steps include a workshop at OMERACT 13 to reach consensus on these proposed domains in the wider OMERACT group, as well as to detail subdomains and assess instruments to develop a core outcome measurement set.

Objective.The most rapidly growing population of patients undergoing total knee arthroplasty (TKA) is under the age of 65. The objective of our study was to gain insight into the factors influencing physicians’ recommendations for persons in this age group with moderate osteoarthritis (OA).Methods.Rheumatologists and orthopedic surgeons attending national meetings were asked to complete a survey including a standardized scenario of a 62-year-old person with knee OA who has moderate knee pain limiting strenuous activity despite medical management. We used an experimental 2 × 2 × 2 design to examine the effects of sex, employment status, and severity of radiographic OA on physicians’ recommendations. Each physician was asked to rate a single scenario.Results.The percentage of physicians recommending TKA varied from 30% to 55% for scenarios describing a patient with mild radiographic OA, and from 39% to 71% for scenarios describing a patient with moderate radiographic OA. Surgeons were less likely to recommend TKA for women compared to men of the same age, employment status, symptom severity, and functional status, and radiographs. Rheumatologists practicing in academic settings were more likely to recommend TKA compared to those practicing in nonacademic settings, and American surgeons were more likely to recommend TKA compared to their European counterparts.Conclusion.Orthopedic surgeons and rheumatologists vary significantly in their recommendations for patients with moderate knee pain and functional limitations. Both patient and physician characteristics influence physicians’ recommendations, and rheumatologists and orthopedic surgeons display different patterns of decision making.

Objective.Patients vary in their beliefs related to the cause of serious illness. The effect of these beliefs among patients with systemic vasculitis is not known. Our study aimed to describe causal attributions about disease onset and relapse in systemic vasculitis and to examine whether causal beliefs differ by type of vasculitis or are associated with negative health outcomes.Methods.Patients with vasculitis were recruited to complete an online questionnaire. Categories of causal beliefs were assessed with the Revised Illness Perception Questionnaire (IPQ-R). Differences in beliefs about disease onset versus relapse were compared across different forms of vasculitis. Causal beliefs were assessed in association with several health outcomes including fatigue, functional impairments, and personal understanding of the condition.Results.The questionnaire was completed by 692 patients representing 9 forms of vasculitis. The majority (90%) of patients had beliefs about the cause of their illness. Causal attributions were highly variable, but altered immunity and stress were the most commonly agreed-upon causal beliefs. Frequencies of causal beliefs were strikingly similar across different forms of vasculitis, with a few notable exceptions primarily in Behçet disease. Beliefs differed about causes of disease onset versus relapse. Specific beliefs about disease onset and relapse were weakly associated with fatigue, functional impairments, and understanding of the condition.Conclusion.Patient beliefs related to the cause of systemic vasculitis are highly variable. Patterns of causal beliefs are associated with important negative health outcomes. Clinicians who care for patients with vasculitis should be mindful of these associations and consider asking about patients’ causal beliefs.

There are insufficient toxicity data available to guide treatment decisions in patients with ANCA (antineutrophil cytoplasmic antibody)–associated vasculitis. The objective of this study was to obtain expert input related to available treatment options.