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Objective To develop an equity extension of the OMERACT Summary of Measurement Properties (SOMP) Table, SOMP Equity to describe whether a patient reported outcome measure (PROM) works well among patients of diverse languages and cultures, education levels, and other population characteristics. Methods We used the PROGRESS-Plus framework to categorize equity characteristics assessed in trials of PROM. PROGRESS refers to Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social Capital, while the ‘plus’ captures additional characteristics, such as age. We pilot tested our SOMP Equity Extension using the Health Assessment Questionnaire (HAQ) as a prototypical PROM. Results The SOMP Equity Extension retains the same columns as the original OMERACT SOMP (domain match, feasibility, construct validity, test-retest reliability, longitudinal construct validity, clinical trial discrimination, thresholds of meaning) but uses the PROGRESS-Plus characteristics as rows. We found several examples of studies of the HAQ which had assessed one or more PROGRESS-Plus characteristics. Conclusions The most commonly reported equity considerations were related to language. OMERACT Equity virtual meeting participants were polled and they indicated that the SOMP Equity Extension is useful for highlighting and tracking equity considerations for OMERACT Core Outcome Measurement Instruments.

Background Despite many studies reporting disparities in coronavirus disease-2019 (COVID-19) incidence and outcomes in Black and Hispanic/Latino populations, mechanisms are not fully understood to inform mitigation strategies. Objective The aim was to test whether neighborhood factors beyond individual patient-level factors are associated with in-hospital mortality from COVID-19. We hypothesized that the Area Deprivation Index (ADI), a neighborhood census-block-level composite measure, was associated with COVID-19 mortality independently of race, ethnicity, and other patient factors. Research design Multicenter retrospective cohort study examining COVID-19 in-hospital mortality. Subjects Inclusion required hospitalization with positive SARS-CoV-2 test or COVID-19 diagnosis at three large Midwestern academic centers. Measures The primary study outcome was COVID-19 in-hospital mortality. Patient-level predictors included age, sex, race, insurance, body mass index, comorbidities, and ventilation. Neighborhoods were examined through the national ADI neighborhood deprivation rank comparing in-hospital mortality across ADI quintiles. Analyses used multivariable logistic regression with fixed site effects. Results Among 5999 COVID-19 patients median age was 61 (interquartile range: 44-73), 48% were male, 30% Black, and 10.8% died. Among patients who died, 32% lived in the most disadvantaged quintile while 11% lived in the least disadvantaged quintile; 52% of Black, 24% of Hispanic/Latino, and 8.5% of White patients lived in the most disadvantaged neighborhoods.Living in the most disadvantaged neighborhood quintile predicted higher mortality (adjusted odds ratio: 1.74; 95% confidence interval: 1.13-2.67) independent of race. Age, male sex, Medicare coverage, and ventilation also predicted mortality. Conclusions Neighborhood disadvantage independently predicted in-hospital COVID-19 mortality. Findings support calls to consider neighborhood measures for vaccine distribution and policies to mitigate disparities.

Trust between healthcare workers is a fundamental component of effective, interprofessional collaboration and teamwork. However, little is known about how this trust is built, particularly when healthcare workers are distributed (i.e., not co-located and lack a shared electronic health record). We interviewed 39 healthcare workers who worked with proximal and distributed colleagues to care for patients with diabetic foot ulcers and analyzed transcripts using content analysis. Generally, building trust was a process that occurred over time, starting with an introduction and proceeding through iterative cycles of communication and working together to coordinate care for shared patients. Proximal, compared to distributed, dyads had more options available for interactions which, in turn, facilitated communication and working together to build trust. Distributed healthcare workers found it more difficult to develop trusting relationships and relied heavily on individual initiative to do so. Few effective tools existed at the level of interprofessional collaborations, teams, or broader healthcare systems to support trust between distributed healthcare workers. With increasing use of distributed interprofessional collaborations and teams, future efforts should focus on fostering this critical attribute.

OBJECTIVE Recognizing smoking as a risk factor for rheumatoid arthritis (RA) severity, the present study was undertaken to evaluate patient- and health care-level predictors of smoking cessation in patients with RA to guide implementation of smoking cessation interventions. METHODS Electronic health record data from 2 health systems were abstracted for patients with at least 2 International Classification of Disease diagnosis codes for RA between 2005 and 2016. Patients missing smoking statuses or with

Objective To determine whether neighborhood socioeconomic disadvantage, as determined by the Area Deprivation Index, increases 30-day hospital re-observation risk. Participants and Methods This retrospective study of 20% Medicare fee-for-service beneficiary observation stays from January 1, 2014, to November 30, 2014, included 319,980 stays among 273,308 beneficiaries. We evaluated risk for a 30-day re-observation following an index observation stay for those living in the 15% most disadvantaged compared with the 85% least disadvantaged neighborhoods. Results Overall, 4.5% (270,600 of 6,080,664) of beneficiaries had index observation stays, which varied by disadvantage (4.3% [232,568 of 5,398,311] in the least disadvantaged 85% compared with 5.6% [38,032 of 682,353] in the most disadvantaged 15%). Patients in the most disadvantaged neighborhoods had a higher 30-day re-observation rate (2857 of 41,975; 6.8%) compared with least disadvantaged neighborhoods (13,543 of 278,005; 4.9%); a 43% increased risk (unadjusted odds ratio [OR], 1.43; 95% CI, 1.31 to 1.55). After adjustment, this risk remained (adjusted OR, 1.13; 95% CI, 1.04 to 1.22). Discharge to a skilled nursing facility reduced 30-day re-observation risk (OR, 0.63; 95% CI, 0.57 to 0.69), whereas index observation length of stay of 4 or more days (3 midnights) conferred increased risk (OR, 1.29; 95% CI, 1.09 to 1.52); those living in disadvantaged neighborhoods were less likely to discharge to skilled nursing facilities and more likely to have long index stays. Beneficiaries with more than one 30-day re-observation (chronic re-observation) had progressively greater disadvantage by number of stays (adjusted incident rate ratio, 1.08; 95% CI, 1.02 to 1.14). Observation prevalence varied nationally. Conclusion Thirty-day re-observation, especially chronic re-observation, is highly associated with socioeconomic neighborhood disadvantage, even after accounting for factors such as race, disability, and Medicaid eligibility. Beneficiaries least able to pay are potentially most vulnerable to costs from serial re-observations and challenges of Medicare observation policy, which may discourage patients from seeking necessary care.

Objective.To define the association between oral and systemic manifestations of Sjögren syndrome (SS) and quality of life (QOL).Methods.We analyzed a cross-sectional survey conducted by the Sjögren’s Foundation in 2016, with 2961 eligible responses. We defined oral symptom and sign exposures as parotid gland swelling, dry mouth, mouth ulcers/sores, oral candidiasis, trouble speaking, choking or dysphagia, sialolithiasis or gland infection, and dental caries. Systemic exposures included interstitial lung disease, purpura/petechiae/cryoglobulinemia, vasculitis, neuropathy, leukopenia, interstitial nephritis, renal tubular acidosis, autoimmune hepatitis, primary biliary cholangitis, or lymphoma. Outcomes included SS-specific QOL questions generated by SS experts and patients.Results.Using multivariable regression models adjusted for age, sex, race, and employment, we observed that mouth ulcers or sores, trouble speaking, and dysphagia were associated with poor quality of life. The following oral aspects had the greatest effect on the following QOL areas: (1) mouth ulcers/sores on the challenge and burden of living with SS (OR 4.26, 95% CI 2.89–6.28); (2) trouble speaking on memory and concentration (OR 4.24, 95% CI 3.28–5.48); and (3) dysphagia on functional interference (OR 4.25, 95% CI 3.13–5.79). In contrast, systemic manifestations were associated with QOL to a lesser extent or not at all.Conclusion.Oral manifestations of SS, particularly mouth ulcers or sores, trouble speaking, and dysphagia, were strongly associated with worse QOL. Further study and targeted treatment of these oral manifestations provides the opportunity to improve quality of life in patients with SS.

We thank Dr. Bitoun and colleagues for their interest and comments regarding our meta-analysis on hydroxychloroquine (HCQ) levels. Bitoun et al. raised an important question about the threshold of HCQ blood levels for clinical efficacy compared to the thresholds that predict the risk of retinal toxicity in lupus.

BACKGROUND Rheumatologists face time pressures similar to primary care but have not generally benefitted from optimized team-based rooming during the time from the waiting room until the rheumatologist enters the room. OBJECTIVE The aim of this study was to assess current capacity for population management in rheumatology clinics; we aimed to measure the tasks performed by rheumatology clinic staff (medical assistants or nurses) during rooming. METHODS We performed a cross-sectional time-study and work-system analysis to measure rooming workflows at 3 rheumatology clinics in an academic multispecialty practice during 2014-2015. We calculated descriptive statistics and compared frequencies and durations using Fisher exact test and analysis of variance. RESULTS Observing 190 rheumatology clinic previsit rooming sequences (1419 minutes), we found many significant variations. Total rooming duration varied by clinic (median, 6.75-8.25 minutes; p < 0.001). Vital sign measurement and medication reconciliation accounted for more than half of rooming duration. Among 3 clinics, two of 15 tasks varied significantly in duration, and 9 varied in frequency. Findings led clinic leaders to modify policies and procedures regarding 6 high-variation tasks streamlining assessment of weight, height, pain scores, tobacco use, disease activity, and refill needs. CONCLUSIONS Assessing rheumatology rooming tasks identified key opportunities to improve quality and efficiency without burdening providers. This project demonstrated user-friendly methods to identify opportunities to standardize rooming and support data-driven decisions regarding rheumatology clinic practice changes to improve population management in rheumatology.

OBJECTIVE: The objective of this medical record review study is to define the association between smoking and Sjӧgren’s syndrome (SS) in a large RA cohort. METHODS: Electronic health records from a population-based cohort were screened for RA eligibility between 2005– 2018. Inclusion criteria were age ≥ 18 years, two or more RA diagnoses, including two diagnoses by a rheumatologist or a positive rheumatoid factor or anti-CCP antibody. The independent variable, smoking status, was defined as never, current, or past. The outcome, SS, was defined by two or more ICD-9 codes. Multivariable logistic regression was performed to determine odds ratios (ORs) of SS adjusted for age, sex, and race. RESULTS: Among 1,861 patients with RA identified for cohort inclusion, 1,296 patients had a reported smoking status. Current smokers were younger and were less likely female than never and past smokers. Adjusted OR of current compared to never smokers was negatively associated with SS (OR 0.20 [95% Confidence Interval (CI) 0.06-0.65]). Female sex and age were associated with SS (OR 2.70 [95% CI 1.18-6.14]; OR 3.75 [95% CI 1.23-11.4]). CONCLUSIONS: We report that RA patients who currently smoke had 80% lower odds of SS. We found age had a 3.7 fold association and female sex a 2.7 fold association with SS among RA patients. Our data suggest a negative correlation between current smoking and prevalent SS among RA patients. Prospective studies examining pack-year relationships or cessation impacts could further examine risk reduction and causality to follow-up our cross-sectional observational study.

Background: Black, rural, and disadvantaged neighborhood populations are at increased risk of major amputations due to diabetic foot ulcers (DFU). We aimed to determine how the intersection of these health disparity factors is tied to outcomes. Methods: We built a retrospective cohort of 124,487 patients hospitalized with DFU in 2014 with the 100% national Original Medicare population. We used logistic regression and marginal modeling to estimate 30-day composite major amputation/death rates, controlling for other sociodemographics and comorbidities, with interaction terms between the three disparity factors of focus. Results: The predicted rate of major amputation or death for black patients was 19.6% (95% CI 19.0-20.2), compared to 17.3% (17.1-17.6) for white patients, and 17.6% overall. Those living in a disadvantaged neighborhood had a predicated rate of 18.6% (18.1-19.1), compared to 17.4% (17.1-17.6) for those living in a non-disadvantaged neighborhood. Small town residence predicted a 20.2% (19.2-21.1) rate, compared to 16.9% (16.7-17.2) for urban residence. The predicted rate for black patients living in disadvantaged, small towns was 24.2% (20.6-27.8, Figure), with a significant interaction between black race and small town (OR 1.59, p Conclusion: Black patients in small towns face high risk of major amputation or death. Such disparities call for new intervention strategies. Disclosure M. Brennan: None. J. Kramer: None. W. Powell: None. A. J. H. Kind: None. C. M. Bartels: Research Support; Self; Pfizer Foundation. Funding Agency for Healthcare Research and Quality (K08HS02679); National Institute of Diabetes and Digestive and Kidney Diseases; National Institute on Aging (RF1AG057784); National Institute on Minority Health and Health Disparities (R01MD010243)

Objective Cardiovascular disease (CVD) is accelerated in patients with systemic lupus erythematosus and lupus nephritis (LN). Despite the literature suggesting that renal arteriosclerosis predicts CVD in other glomerulonephritis diseases, arteriosclerosis grading and reporting might be particularly overlooked in LN biopsies. Our objective was to examine the burden of renal arteriosclerosis in LN and to assess whether arteriosclerosis is underreported in LN biopsies. Methods We identified all patients with LN undergoing kidney biopsy between 1994 and 2017 at an academic center. We interpreted LN biopsy reports to classify the Banff categories of absent, mild, moderate, or severe renal arteriosclerosis. The prevalence of renal arteriosclerosis was compared with the prevalence published for age-matched healthy peers, and predictors of arteriosclerosis were examined. We overread biopsies for Banff renal arteriosclerosis grading and compared to pathology reports. Results Among 189 incident patients with LN, renal arteriosclerosis prevalence was 2 decades earlier compared to their healthy peers, affecting 40% of patients ages 31-39 years with LN compared to 44% of healthy peers ages 50-59 years. A multivariable analysis showed a 3-fold higher odds of renal arteriosclerosis in patients ages ≥30 years with LN. LN chronicity on biopsy results predicted a 4-fold higher odds of renal arteriosclerosis. The overreads determined that 50% of standard LN biopsy reports missed reporting the presence or absence of renal arteriosclerosis. Conclusion Renal arteriosclerosis is accelerated by 2 decades in patients with LN compared to their healthy peers and is overlooked by pathologists in half of the routine biopsy reports. We propose incorporating Banff renal arteriosclerosis grading in all LN biopsy reports.

OBJECTIVE. Thirty-day hospital readmissions in systemic lupus erythematosus (SLE) approach proportions in Medicare-reported conditions including heart failure (HF). We compared adjusted 30-day readmission and mortality among SLE, HF, and general Medicare to assess predictors informing readmission prevention. METHODS. This database study used a 20% sample of all US Medicare 2014 adult hospitalizations to compare risk of 30-day readmission and mortality among admissions with SLE, HF, and neither per discharge diagnoses (if both SLE and HF, classified as SLE). Inclusion required live discharge and ≥12 months of Medicare A/B before admission to assess baseline covariates including patient, geographic, and hospital factors. Analysis used observed and predicted probabilities, and multivariable GEE models clustered by patient to report adjusted risk ratios (ARRs) of 30-day readmission and mortality. RESULTS. SLE admissions (n=10,868) were younger, predominantly female, more likely to be Black, disabled, and have Medicaid or end-stage renal disease (ESRD). Observed 30-day readmissions of 24% were identical for SLE and HF (p=0.6), and higher than other Medicare (16%, p

The Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP) penalizes hospitals having excess inpatient rehospitalizations within 30 days of index inpatient stays for targeted conditions. Observation hospitalizations are increasing in frequency and may clinically resemble inpatient hospitalizations, yet HRRP excludes observation in index and 30-day rehospitalization counts. Using 100% 2014 Medicare fee-for-service claims and CMS’s 30-day rehospitalization methodology, we modeled how observation hospitalizations impact HRRP metrics when counted as index (denominator) and 30-day (numerator) rehospitalizations. Of 3,806,772 index hospitalizations for HRRP conditions, 418,923 (11%) were observation; 18% (155,553/876,033) of rehospitalizations were invisible to HRRP due to observation hospitalization as index (34%; 63,740/188,430), 30-day outcome (53%; 100,343/188,430), or both (13%; 24,347/188,430). By ignoring observation hospitalizations as index and 30-day events, nearly one of five HRRP rehospitalizations is missed. Policymakers might consider this an opportunity to address broad challenges of the two-tiered observation and inpatient hospital billing distinction.

Objectives To investigate the relationship between smoking history and pack-year exposure on the rate of end-organ damage in systemic lupus erythematosus (SLE). Methods The SLE incident cohort included patients who met American College of Rheumatology (ACR) 1997 or SLE International Collaborating Clinics (SLICC) 2012 SLE criteria and had rheumatology encounters at a US academic institution (2008–16). The primary outcome was median time to SLICC/ACR damage index (SLICC/ACR-DI) increase or death. Main explanatory variables were smoking status and pack-years. Covariates included age, sex, race, ethnicity, receipt of Medicaid, neighborhood area deprivation index, and baseline SLE damage. Damage increase-free survival was evaluated by smoking status and pack-years using Kaplan-Meier and Cox proportional hazards methods. Results Patients of Black race and Medicaid recipients were more commonly current smokers ( p’s 10 pack-year history (HR 2.35; 1.15, 3.64) versus never smokers. Conclusions In this incident SLE cohort, past or current smoking predicted new SLE damage 4-5 years earlier. After adjustment, current smokers and patients with a pack-year history of >10 years accumulated damage at twice the rate of never smokers.

Smoking increases cardiopulmonary and rheumatic disease risk, yet tobacco cessation intervention is rare in rheumatology clinics. This study aimed to implement a rheumatology staff-driven protocol, Quit Connect, to increase the rate of electronic referrals (e-referrals) to free, state-run tobacco quit lines.We conducted a quasi-experimental cohort study of Quit Connect at 3 rheumatology clinics comparing tobacco quit line referrals from 4 baseline years to referrals during a 6-month intervention period. Nurses and medical assistants were trained to use 2 standardized electronic health record (EHR) prompts to check readiness to quit smoking within 30 days, advise cessation, and connect patients using tobacco quit line e-referral orders. Our objective was to use EHR data to examine the primary outcome of tobacco quit line referrals using pre/post design.Across 54,090 pre- and post-protocol rheumatology clinic visits, 4,601 were with current smokers. We compared outcomes between 4,078 eligible pre-implementation visits and 523 intervention period visits. Post-implementation, the odds of tobacco quit line referral were 26-fold higher compared to our pre-implementation rate (unadjusted odds ratio [OR] 26 [95% confidence interval (95% CI) 6-106]). Adjusted odds of checking readiness to quit in the next 30 days increased over 100-fold compared to pre-implementation (adjusted OR 132 [95% CI 99-177]). Intervention led to e-referrals for 71% of quit-ready patients in90 seconds; 24% of referred patients reported a quit attempt.Implementing Quit Connect in rheumatology clinics was feasible and improved referrals to a state-run tobacco quit line. Given the importance of smoking cessation to reduce cardiopulmonary and rheumatic disease risk, future studies should investigate disseminating cessation protocols like Quit Connect that leverage tobacco quit lines.

BackgroundRural Americans with diabetic foot ulcers (DFUs) face a 50% increased risk of major amputation compared to their urban counterparts. We sought to identify health system barriers contributing to this disparity.MethodsWe interviewed 44 participants involved in the care of rural patients with DFUs: 6 rural primary care providers (PCPs), 12 rural specialists, 12 urban specialists, 9 support staff, and 5 patients/caregivers. Directed content analysis was performed guided by a conceptual model describing how PCPs and specialists collaborate to care for shared patients.ResultsRural PCPs reported lack of training in wound care and quickly referred patients with DFUs to local podiatrists or wound care providers. Timely referrals to, and subsequent collaborations with, rural specialists were facilitated by professional connections. However, these connections often were lacking between rural providers and urban specialists, whose skills were needed to optimally treat patients with high acuity ulcers. Urban referrals, particularly to vascular surgery or infectious disease, were stymied by 1) time-consuming processes, 2) negative provider interactions, and 3) multiple, disconnected electronic health record systems. Such barriers ultimately detracted from rural PCPs’ ability to focus on medical management, as well as urban specialists’ ability to appropriately triage referrals due to lacking information. Subsequent collaboration between providers also suffered as a result.ConclusionsPoor connections across rural and urban healthcare systems was described as the primary health system barrier driving the rural disparity in major amputations. Future interventions focusing on mitigating this barrier could reduce the rural disparity in major amputations.

Background: Rural patients with diabetic foot ulcers (DFUs) face a 40% increased risk of major amputation. We aimed to identify health system barriers contributing to this disparity. Methods: We interviewed 44 participants involved in the care of rural patients with DFUs: 6 rural PCPs, 12 rural specialists, 12 urban specialists, 9 support staff, and 5 patients/caregivers. Directed content analysis of transcripts was guided by a conceptual model describing how PCPs and specialists co-manage patients. We adapted the model to describe how rural patients receive care for DFUs. Results: When caring for rural patients with DFUs, collaboration between rural PCPs and rural specialists was strong. However, collaboration broke down when urban specialists were needed. Urban referrals were hindered by 1) time-consuming processes, 2) negative provider interactions, and 3) multiple, disconnected electronic health records (Fig). Time needed to finesse referrals detracted from rural clinicians’ focus on medical care. Urban specialists struggled to triage referrals due to incomplete data. Subsequent communication between rural and urban providers was also suboptimal. Conclusion: Poor collaboration across rural and urban health systems was described as the main health system barrier driving the rural disparity in major amputations. Fostering collaboration between rural and urban providers may reduce the rural disparity in major amputations. Disclosure M. Brennan: None. B. Sutherland: None. K. Pecanac: None. Funding University of Wisconsin Institute for Clinical and Translational Research (WPP3086)

Background Systemic lupus erythematous (SLE) disproportionately impacts patients of color and socioeconomically disadvantaged patients. Similar disparities in HIV were reduced through a World Health Organization-endorsed Care Continuum strategy targeting “retention in care,” defined as having at least two annual visits or viral load lab tests. Using similar definitions, this study aimed to examine predictors of lupus retention in care, to develop an SLE Care Continuum and inform interventions to reduce disparities. We hypothesized that Black patients and those residing in disadvantaged neighborhoods would have lower retention in care. Methods Abstractors manually validated 545 potential adult cases with SLE codes in 2013–2014 using 1997 American College of Rheumatology (ACR) or 2012 Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) criteria. We identified 397 SLE patients who met ACR or SLICC criteria for definite lupus, had at least one baseline rheumatology visit, and were alive through 2015. Retention in care was defined as having two ambulatory rheumatology visits or SLE labs (e.g., complement tests) during the outcome year 2015, analogous to HIV retention definitions. Explanatory variables included age, sex, race, ethnicity, smoking status, neighborhood area deprivation index (ADI), number of SLE criteria, and nephritis. We used multivariable logistic regression to test our hypothesis and model predictors of SLE retention in care. Results Among 397 SLE patients, 91% were female, 56% White, 39% Black, and 5% Hispanic. Notably, 51% of Black versus 5% of White SLE patients resided in the most disadvantaged ADI neighborhood quartile. Overall, 60% met visit-defined retention and 27% met complement lab-defined retention in 2015. Retention was 59% lower for patients in the most disadvantaged neighborhood quartile (adjusted OR 0.41, CI 0.18, 0.93). No statistical difference was seen based on age, sex, race, or ethnicity. More SLE criteria and non-smoking predicted greater retention. Conclusions Disadvantaged neighborhood residence was the strongest factor predicting poor SLE retention in care. Future interventions could geo-target disadvantaged neighborhoods and design retention programs with vulnerable populations to improve retention in care and reduce SLE outcome disparities.

OBJECTIVE: Despite a growing prevalence of hypertension, young adults (18–39 year-olds) have lower hypertension control rates compared to older adults. The purpose of this study was to evaluate the role of sociodemographic factors in hypertension control among young adults with regular primary care access. METHODS: A retrospective analysis included 3208 patients, 18–39 years old, who met clinical criteria for an initial (incident) hypertension diagnosis in a large, Midwestern, academic practice from 2008 to 2011. Patients with a prior antihypertensive medication prescription were excluded. Kaplan-Meier analysis was used to estimate the probability of achieving hypertension control over 24 months by gender. Cox proportional hazard models were fit to identify sociodemographic predictors of delays in hypertension control. RESULTS: Among the 3208 young adults with incident hypertension, 48% achieved hypertension control within 24 months. Kaplan-Meier analysis demonstrated that young women had a higher hypertension control rate at 24 months (57%) compared to young men (41%). According to adjusted hazard models, young men had a 39% lower rate of hypertension control (hazard ratio 0.61; 95% confidence interval 0.55–0.69) compared to women. Being unmarried (0.87; 0.78–0.98) and a non-English primary language speaker (0.47; 0.37–0.60) also predicted lower hypertension control rates. CONCLUSIONS: Gender disparities, being unmarried, and non-English primary language are important barriers to hypertension control among young adults with regular primary care use. Interventions tailored to sociodemographic characteristics may improve hypertension control in this challenging population.

Sara S McCoy,1 Zubin Mukadam,2 Keith C Meyer,2 Jeffrey P Kanne,3 Cristopher A Meyer,3 Maria D Martin,3 Emmanuel Sampene,4 Scott W Aesif,5 Laurie N Rice,6 Christie M Bartels1 1Division of Rheumatology, Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA; 2Division of Pulmonary and Critical Care, Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53705, USA; 3Department of Radiology, University of Wisconsin, Madison, WI 53792-3252, USA; 4Department of Biostatistics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA; 5Department of Pathology, University of Wisconsin, Madison, WI 53792-3252, USA; 6Department of Pulmonology, SSM Health Dean Medical Group, Madison, WI53715, USA Objectives: International experts recently characterized interstitial pneumonia with autoimmune features (IPAF) as a provisional diagnosis for patients with interstitial lung disease who have characteristics of autoimmune disease but do not meet criteria for a specific autoimmune disease. We describe clinical characteristics of IPAF patients and examine responses to mycophenolate as a therapy for IPAF.Methods: This retrospective cohort included adult patients meeting European Respiratory Society/American Thoracic Society classification criteria for IPAF. Sociodemographic, clinical, and pulmonary function test data were abstracted for patients with and without mycophenolate treatment and followed longitudinally from interstitial lung disease diagnosis for change in pulmonary function test results.Results: We identified 52 patients who met criteria for IPAF. Of 52 IPAF patients, 24 did not receive mycophenolate and 28 did, with median time to mycophenolate treatment 22 months. Changes in FVC% and percentage predicted lung diffusion capacity for carbon monoxide (DLCO%) between the mycophenolate-treated and untreated groups were not significantly different (FVC% change P=0.08, DLCO% change P=0.17). However, there was a trend toward more rapid baseline decline of both FVC% and DLCO% in the mycophenolate-treated cohort before vs after mycophenolate therapy. The slope of both FVC% and DLCO% values improved after onset of mycophenolate exposure for the treated group, although this finding was not statistically significant.Conclusion: Patients with IPAF might benefit from mycophenolate therapy. Larger prospective clinical trials are needed to evaluate the efficacy of mycophenolate for patients who meet criteria for IPAF. Keywords: interstitial lung disease, autoimmune disease, connective tissue disease, myco­phenolate

BACKGROUND/OBJECTIVE: Given heightened cardiovascular (CVD) risk in rheumatoid arthritis (RA) and that higher blood pressure (BP) represents greater CVD risk, we hypothesized that higher BP would predict more BP-related communication in rheumatology visits. We examined predictors of documented BP communication during RA clinic visits. METHODS: Retrospective cohort study of RA patients identified in EHR records with uncontrolled hypertension receiving both primary and rheumatology care. Trained abstractors reviewed RA visit notes for “BP-communication” using a standardized tool to elicit documentation about BP or hypertension beyond recording vital signs. We used multivariate logistic regression to examine the impact of BP category (American Heart Association: ideal normotension, prehypertension, stage I and stage II hypertension) on odds ratios (OR, 95% confidence intervals) of BP-communication. RESULTS: Among 1,267 RA patients, 40% experienced BP elevations meeting the definition of uncontrolled hypertension. Of 2,677 eligible RA visits, 22% contained any documented BP communication. After adjustment, models predicted only 31% of visits with markedly high BPs ≥160/100 would contain BP-communication. Compared to stage I, stage II elevation did not significantly increase communication (OR 2.0, 1.4–2.8 vs. 1.5, 1.2–2.2), although both groups’ odds exceeded prehypertension and normotension. Less than 10% of eligible visits resulted in documented action steps recommending follow-up of high BP. CONCLUSIONS: Regardless of BP magnitude, most RA clinic visits lacked documented communication about blood pressure despite compounded CVD risk. Future work should study how rheumatology clinics can facilitate follow-up of high BPs to address hypertension as the most common and reversible CVD risk factor.

Objective.Despite advances integrating patient-centered outcomes into rheumatologic studies, concerns remain regarding their representativeness across diverse patient groups and how this affects equity. The Outcome Measures in Rheumatology (OMERACT) Equity Working Group aims to determine whether and how to address equity issues within the core outcome sets of domains and instruments.Methods.We surveyed current and previous OMERACT meeting attendees and members of the Campbell and Cochrane Equity Group regarding whether to address equity issues within the OMERACT Filter 2.0 Core Outcome Sets and how to assess the appropriateness of domains, instruments, and measurement properties among diverse patients. At OMERACT 2016, results of the survey and a narrative review of differential psychosocial effects of rheumatoid arthritis (i.e., on men) were presented to stimulate discussion and develop a research agenda.Results.We proposed 6 moments for which an equity lens could be added to the development, selection, or testing of patient-reported outcome measures (PROM): (1) recruitment, (2) domain selection, (3) feasibility in diverse settings, (4) instrument validity, (5) thresholds of meaning, and (6) consideration of statistical power of subgroup analyses for outcome reporting.Conclusion.There is a need to (1) conduct a systematic review to assess how equity and population characteristics have been considered in PROM development and whether these differences influence the ranking of importance of outcome domains or a patient’s response to questionnaire items, and (2) conduct the same survey described above with patients representing groups experiencing health inequities.

Young adults (aged 18 to 39years) have the lowest hypertension control rates compared with older adults. Shorter follow-up encounter intervals are associated with faster hypertension control rates in older adults; however, optimal intervals are unknown for young adults. The study objective was to evaluate the relationship between ambulatory blood pressure encounter intervals (average number of provider visits with blood pressures over time) and hypertension control rates among young adults with incident hypertension. A retrospective analysis was conducted of patients aged 18 to 39 years (n = 2990) with incident hypertension using Kaplan-Meier survival and Cox proportional hazards analyses over 24months. Shorter encounter intervals were associated with higher hypertension control: 6months (13%). Young adults with shorter encounter intervals also had lower medication initiation, supporting the effectiveness of lifestyle modifications. Sustainable interventions for timely young adult follow-up are essential to improve hypertension control in this hard-to-reach population.

Objective: Calcium pyrophosphate crystal deposition disease (CPDD) is a common cause of acute and chronic arthritis, yet there are few large epidemiologic studies of CPDD. We sought to characterize CPDD in the national Veterans Affairs (VA) population. Methods: Patients with International Classification of Diseases, ninth revision (ICD-9) codes for CPDD seen at any VA medical center from 2010 through 2014 were matched by age and gender with control patients without CPDD, using data from the Department of Veterans Affairs Corporate Data Warehouse. We used multivariate analysis to compare the prevalence and odds ratios (OR; 95% confidence intervals [CI]) of various co-morbidities, substance use, medication exposures, and arthroplasties among patients with and without CPDD. Results: We identified 25,157 patients with CPDD yielding a point prevalence of 5.2 per 1000. The average age was 68.1 ±12.3 years old and 95% were male. The strongest positive associations with CPDD were hyperparathyroidism (OR 3.35; 95% CI 2.96, 3.79), gout (2.82; 2.69, 2.95), osteoarthritis (2.26; 2.15, 2.37), rheumatoid arthritis (1.88; 1.74, 2.03), and hemochromatosis (1.87; 1.57, 2.24). Positive associations were also seen with higher odds for osteoporosis (1.26; 1.16, 1.36), hypomagnesemia (1.23; 1.16, 1.30), chronic kidney disease (1.12; 1.07, 1.18), and calcium supplementation (1.15; 1.06, 1.24). Negative associations were seen with proton pump inhibitors (0.58; 0.55, 0.60) and loop diuretics (0.80; 0.76, 0.84). Conclusion: Using a large national dataset, we confirmed known CPDD associations, provided support for positive associations with rheumatoid arthritis, hypomagnesemia, and osteoporosis, and suggest potential novel negative associations with commonly used medications. This article is protected by copyright. All rights reserved.

Background Medicare measures readmissions within 30 days of hospitalization as a marker of care quality across several conditions, although beyond hospital quality, neighborhood disadvantage is a known predictor of readmission. While not a reporting condition, a 2010 study noting 27% lupus readmissions led to our interest in examining readmission in lupus versus general Medicare including the impact of neighborhood disadvantage. Methods Using a 20% US national Medicare sample, we identified all patients with inpatient hospitalizations 2013–14 to compare odds of 30 day readmission among patients with SLE to the general Medicare population. Inclusion required age >18 y.o., 12 mos. Medicare Part A/B (30d. post discharge), and being alive at discharge. Covariates included age, gender, race, ethnicity, prior Medicaid, comorbidity, prior hospitalization, length of stay, hospital volume, medical school affiliation, rural urban commuter area, and area deprivation index (ADI)a measure of neighborhood disadvantage derived from patients census block group (www.neighborhoodatlas.medicine.wisc.edu). Analysis used multivariable logistic regression clustered by patient. Results Nearly 1.4 million acute Medicare hospitalizations were analyzed including 10 868 lupus hospitalizations. Patients with lupus were younger (55% of hospitalizations in 18- Lupus readmissions ranged from 20% within lower disadvantage to 27% within the greatest decile of ADI neighborhood disadvantage, compared to 17%–21% in general Medicare regardless of ADI decile (Figure 1). Before adjustment, patients with SLE were 60% more likely to be readmitted than non-lupus Medicare patients (Unadj. OR 1.61 (1.51, 1.71)). Lupus remained a readmission risk in adjusted models (Adj. OR 1.28 (1.20, 1.36)). SLE patients with 30 day readmissions were more likely to be Conclusions Among nationally representative Medicare hospitalizations, having lupus was a major readmission risk factor. Hospitalized patients with lupus who lived in a neighborhood with greatest disadvantage had higher 30 day readmissions, impacting nearly 1 in 3 patients. Future studies are needed to examine readmission causes and interventions to systematically reduce readmissions among vulnerable hospitalized patients with lupus. Funding Source(s): None

OBJECTIVE Recognizing high blood pressure (BP) as the most prevalent cardiovascular risk factor in patients with rheumatic diseases and all adults, experts recommend clinic protocols to improve BP control. The aim of this study was to adapt and implement a specialty clinic protocol, "BP Connect," to improve timely primary care follow-up after high BP measurements in rheumatology clinics. METHODS We examined BP Connect in a 6-month preimplementation and postimplementation quasi-experimental design with 24-month follow-up in 3 academic rheumatology clinics. Medical assistants and nurses were trained to 1) check (re-measuring BPs ≥140/90 mm Hg), 2) advise (linking rheumatic and cardiovascular diseases), and 3) connect (timely [

Background Patients of color are more likely to have systemic lupus erythematosus (SLE) and a smoking history. Prior literature notes that both smoking and race impact odds of cutaneous manifestations. Therefore, we sought to examine the impact of cumulative smoking and race on cutaneous manifestations of SLE. Methods Our cohort study included 631 consecutive SLE patients at a single academic center. Adults with at least one ambulatory rheumatology encounter with an SLE ICD- 9 or 10 code from 2008–16 were identified. Electronic health records were manually abstracted to include patients meeting ACR 1997 or SLICC 2012 classification criteria. The primary outcomes were ACR or SLICC cutaneous criteria and SLICC Damage Index (DI) cutaneous criteria. The primary explanatory variable was smoking exposure defined as low ( 10 pack-years), compared to nonsmokers. Covariates included age category at diagnosis (early onset 50 years), sex, and race. Analysis was performed using multivariate logistic regression to calculate odds ratios and 95% confidence intervals (OR, (95% CI)). Results Among 631 SLE patients, mean age was 42, 91% female, 82% white, and 40% ever smokers. Patients with low smoking exposure were nine times more likely to develop any mucocutaneous manifestations (OR 9.0, (1.2, 67.7)), four times more likely to meet any SLICC cutaneous criteria (OR 3.7, (OR 1.3, 10.6)), and twice as likely to meet ACR cutaneous criteria (OR 2.0 (1.0, 3.8)) compared to non-smokers (table 1). Patients with medium smoking exposure were twice as likely to meet acute cutaneous SLICC criteria (OR 2.3, (1.1, 5.1)), whereas those with high smoking exposure had two-fold higher odds of discoid lupus (OR 2.1, (1.1, 4.1) data not shown). Chronic cutaneous SLICC criteria and DI cutaneous criteria showed linear pack-year trends that met significance with high smoking exposure (OR 2.2, (1.2, 4.2); OR 4.2, (0.9, 9.2)). Patients of color had increased risk for alopecia, discoid lupus, chronic cutaneous lupus, and DI skin damage. Limitations included sample size and just 18% patients of color. Conclusions Any smoking exposure was an independent risk factor for nearly all cutaneous SLE manifestations whereas high smoking exposure and patients of color had significantly increased risk of chronic cutaneous manifestations and skin damage. Findings suggest a dose relationship between smoking exposure and cutaneous manifestations/damage, making cessation an important strategy to potentially reduce disparities and improve cutaneous outcomes in SLE. Funding Source(s): Support: Rheumatology Research Foundation

Background Despite the pivotal role hydroxychloroquine (HCQ) plays in treating SLE, less than 50% of patients take HCQ as prescribed. Non-adherence versus lack of effect to HCQ are difficult to distinguish, underscoring the importance of measuring HCQ blood levels to assess adherence. Despite this, information and consensus on the clinical impact of incorporating routine testing of HCQ blood levels is lacking. Therefore, we systematically reviewed publications examining the correlation between 1) HCQ levels and adherence, and 2) HCQ levels and SLEDAI scores, in SLE patients. We hypothesized that low HCQ levels would correlate with non-adherence and higher SLEDAI scores. Methods A comprehensive search was performed using MeSH heading and keywords in Medline, Embase, CINHL and Web of Science databases. We selected observational and interventional studies that measured HCQ levels and assessed adherence and/or SLEDAI scores in adults with SLE. Newcastle Ottawa Scale and Cochrane Collaboration Risk Assessment tools were used to rate the quality of observational and intervention studies, respectively. We used Forest plots to compare pooled estimates (95% CI) of correlations between HCQ levels and patient or physician reported nonadherence and SLEDAI scores. Heterogeneity was assessed using I2. Results From 306 manually reviewed studies, four studies analyzing correlation between HCQ levels and adherence, and five studies examining the correlation between SLEDAI and HCQ blood levels, met inclusion criteria. The odds of nonadherence measured by physician or reported by the patient was 3 times higher in patients with below threshold HCQ levels, compared to those with higher HCQ levels (OR 2.95, 95% CI 1.63, 5.35, p Conclusions We found good correlation between HCQ levels and non-adherence. Low HCQ levels showed higher mean SLEDAI scores but due to the limited number of studies and heterogeneity we did not find significant correlation. Findings support the clinical utility of measuring HCQ levels in SLE patients. Future larger studies should investigate standards for HCQ level interpretation and target levels needed to minimize SLEDAI scores. Funding Source(s): n/a

Objectives: To examine the prevalence and incidence of cardiovascular risk factors (CVRFs) including hypertension (HTN), hyperlipidemia (HL), diabetes mellitus (DM), and obesity among patients with psoriatic arthritis (PsA) and rheumatoid arthritis (RA) compared to the general population, and to examine the treatment of incident CVRFs in PsA and RA compared to controls. Methods: A cohort study was conducted within The Health Improvement Network, a medical record database in the United Kingdom, using data from 1994 to 2014. Patients age 18-89 with PsA or RA were matched to controls on practice and start date. The prevalence and incidence of CVRFs identified by diagnostic codes were calculated. Cox proportional hazards models were used to examine the relative incidence of these cardiovascular risk factors. Finally, pharmacologic therapies for incident CVRFs were examined. Results: Study subjects included patients with PsA (N=12,548), RA (N=53,215), and controls (N=389,269). The prevalence of all CVRFs was significantly elevated in PsA. Only the prevalence of DM and obesity was increased in RA. Incidence of HTN, HL, and DM was elevated in PsA and RA. Receipt of therapy within one year following incident diagnosis of CVRFs was not substantially different between the groups; approximately 85%, 65%, and 45% of patients received prescriptions for HTN, HL, and DM, respectively. Conclusion: Patients with PsA have an increased prevalence of CVRFs, and both patients with PsA and RA have increased incidence of new diagnosis of CVRFs. Pharmacologic treatment of CVRFs in patients with PsA and RA was similar to controls in the UK. This article is protected by copyright. All rights reserved.

Although systemic lupus erythematosus (SLE) most commonly occurs in reproductive-age women, some are diagnosed after the age of 50. Recognizing that greater than one-third of SLE criteria are cutaneous, we undertook a systematic review and meta-analysis to evaluate differences in cutaneous manifestations in early- and late-onset SLE patients.We searched the literature using PubMed, CINAHL, Web of Science, and Cochrane Library. We excluded studies that did not include ACR SLE classification criteria, early-onset controls, that defined late-onset SLE as50 years of age, or were not written in English. Two authors rated study quality using the Newcastle Ottawa Quality Scale. We used Forest plots to compare odds ratios (95% CI) of cutaneous manifestations by age. Study heterogeneity was assessed using I(2).Overall, 35 studies, representing 11,189 early-onset and 1727 late-onset patients with SLE, met eligibility criteria. The female:male ratio was lower in the late-onset group (5:1 versus 8:1). Most cutaneous manifestations were less prevalent in the late-onset group. In particular, malar rash [OR = 0.43 (0.35, 0.52)], photosensitivity [OR = 0.72 (0.59, 0.88)], and livedo reticularis [OR = 0.33 (0.17, 0.64)] were less common in late-onset patients. In contrast, sicca symptoms were more common [OR = 2.45 (1.91, 3.14)]. The mean Newcastle Ottawa Quality Scale score was 6.3 ± 0.5 (scale: 0-9) with high inter-rater reliability for the score (0.96).Overall, cutaneous manifestations are less common in late-onset SLE patients, except sicca symptoms. Future studies should investigate etiologies for this phenomenon including roles of immune senescence, environment, gender, and immunogenetics.

Rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) patient populations face similar risks of chronic immunosuppression including corticosteroid use. We compared the receipt of preventive services between IBD and RA populations according to published quality metrics.We defined a single-center cohort of patients with IBD or RA receiving specialty and primary care. Electronic health record abstraction assessed quality metrics, sociodemographics, comorbidity, and utilization. Comparisons used multivariate odds ratios and Student's t-tests.218 RA and 190 IBD patients were included. In multivariate analysis, IBD patients were less likely to receive pneumococcal vaccination (OR=0.29, 95% CI: 0.11-0.85), while RA patients underwent glucocorticoid-induced osteoporosis screening more often (100% vs. 82.5%, p = 0.023).Gastroenterologists can improve care quality for IBD patients by assuming greater responsibility for preventive care in IBD patients and/or collaborating with primary care and health systems to improve preventive care delivery.

Objective Despite increased cardiovascular disease (CVD) risk, rheumatoid arthritis (RA) patients often lack CVD preventive care. We examined CVD preventive care processes from RA patient and provider perspectives to develop a process map for identifying targets for future interventions to improve CVD preventive care. Methods Thirty-one participants (15 patients, 7 rheumatologists, and 9 primary care physicians [PCPs]) participated in interviews that were coded using NVivo software and analyzed using grounded theory techniques. Results Patients and providers reported that receipt of preventive care depends upon identifying and acting on risk factors, although most noted that both processes rarely occurred. Engagement in these processes was influenced by various provider-, system-, visit-, and patient-related conditions, such as patient activation or patients’ knowledge about their risk. While nearly half of patients and PCPs were unaware of RA-CVD risk, all rheumatologists were aware of risk. Rheumatologists reported not systematically identifying risk factors, or, if identified, they described communicating about CVD risk factors via clinic notes to PCPs instead of acting directly due to perceived role boundaries. PCPs suggested that scheduling PCP visits could improve CVD risk management, and all participants viewed comanagement positively. Conclusion Findings from this study illustrate important gaps and opportunities to support identifying and acting on CVD risk factors in RA patients from the provider, system, visit, and patient levels. Future work should investigate professional role support through improved guidelines, patient activation, and system-based RA-CVD preventive care strategies.

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

Objective Although smoking is a risk factor for cardiovascular and rheumatic disease severity, only 10% of rheumatology visits document cessation counseling. After implementing a rheumatology clinic protocol that increased tobacco quitline referrals 20-fold, we undertook this study to examine patients' barriers and facilitators to smoking cessation based on prior rheumatology experiences, to solicit reactions to the new cessation protocol, and to identify patient-centered outcomes or signs of cessation progress following improved care. Methods We recruited 19 patients who smoke (12 with rheumatoid arthritis [RA] and 7 with systemic lupus erythematosus [SLE]) to participate in 1 of 3 semistructured focus groups. Transcripts of the focus group discussions were analyzed using thematic analysis to classify barriers, facilitators, and signs of cessation progress. Results Participant-reported barriers and facilitators to cessation involved psychological, health-related, and social and economic factors, as well as health care messaging and resources. Commonly discussed barriers included viewing smoking as a crutch amid rheumatic disease, rarely receiving cessation counseling in rheumatology clinics, and very limited awareness that smoking can worsen rheumatic diseases or reduce efficacy of some rheumatic disease medications. Participants endorsed our cessation protocol with rheumatology-specific education and accessible resources, such as a quitline. Beyond quitting, participants prioritized knowing why and how to quit as signs of progress outcomes. Conclusion Focus groups identified themes and categories of facilitators/barriers to smoking cessation at the levels of patient and health system. Two key outcomes of improving cessation care for patients with RA and SLE were knowing why and how to quit. Emphasizing rheumatologic health benefits and cessation resources is essential when designing and evaluating rheumatology smoking cessation interventions.

Rehospitalizations are prevalent and associated with decreased quality of life. Although hospice has been advocated to reduce rehospitalizations, it is not known how area-level hospice utilization patterns affect rehospitalization risk.The study objective was to examine the association between hospice enrollment, local hospice utilization patterns, and 30-day rehospitalization in Medicare patients.With a retrospective cohort design, 1,997,506 hospitalizations were assessed between 2005 and 2009 from a 5% national sample of Medicare beneficiaries. Local hospice utilization was defined using tertiles representing the percentage of all deaths occurring in hospice within each Hospital Service Area (HSA). Cox proportional hazard models were used to assess the relationship between 30-day rehospitalization, hospice enrollment, and local hospice utilization, adjusting for patient sociodemographics, medical history, and hospital characteristics.Rates of patients dying in hospice were 27% in the lowest hospice utilization tertile, 41% in the middle tertile, and 53% in the highest tertile. Patients enrolled in hospice had lower rates of 30-day rehospitalization than those not enrolled (2.2% versus 18.8%; adjusted hazard ratio [HR], 0.12; 95% confidence interval [CI], 0.118-0.131). Patients residing in areas of low hospice utilization were at greater rehospitalization risk than those residing in areas of high utilization (19.1% versus 17.5%; HR, 1.05; 95% CI, 1.04-1.06), which persisted beyond that accounted for by individual hospice enrollment.Area-level hospice utilization is inversely proportional to rehospitalization rates. This relationship is not fully explained by direct hospice enrollment, and may reflect a spillover effect of the benefits of hospice extending to nonenrollees.

Differential rates of diagnosis and treatment by hypertension (HTN) type may contribute to poor HTN control in young adults. The objective of this study was to compare rates of receiving a hypertension diagnosis and antihypertensive agent among young adults with (1) isolated systolic, (2) isolated diastolic, and (3) combined systolic/diastolic HTN. A retrospective analysis was conducted in patients aged 18 to 39 years (n=3003) with incident HTN. Kaplan-Meier survival and Cox proportional hazards analyses were performed. Only 56% with isolated systolic HTN received a diagnosis compared with 63% (systolic/diastolic); 32% with isolated systolic HTN received an initial antihypertensive compared with 52% (systolic/diastolic). Compared with patients with systolic/diastolic HTN, those with isolated systolic HTN had a 50% slower diagnosis rate (hazard ratio [HR], 0.50; 95% confidence interval [CI], 0.41-0.60) and those with isolated diastolic HTN had a 26% slower rate (HR, 0.74; CI, 0.60-0.92). Patients with isolated systolic HTN had 58% slower medication initiation (HR, 0.42; CI, 0.34-0.51) and those with isolated diastolic HTN had 31% slower rates (HR, 0.69; CI, 0.55-0.86). Young adults with isolated systolic HTN have lower diagnosis and treatment rates.

Background Traditional productivity-based compensation models do not align well with newer population-based approaches to primary care. There are few published examples of academic general internal medicine compensation models that explicitly reward population health management, including care for patients between visits.

Objective. RA increases vascular disease and angiogenesis, yet a 1964 Lancet report paradoxically linked RA to lower diabetic retinopathy. Our objective was to examine RA as a risk factor for diabetic retinopathy compared with other vascular risk factors. Methods. This cohort study compared the prevalence of diabetic retinopathy in diabetes patients with and without RA in a 5% Medicare sample. We analysed the impact of RA on the prevalence of diabetic retinopathy using multivariate logistic regression calculating adjusted rate ratios (ARRs) controlling for sociodemographics, co-morbidity and health utilization. Sensitivity analysis examined eye exam rates. Results. Among 256 331 Medicare diabetes patients, 5572 (2%) had RA. Diabetic retinopathy was less prevalent in patients with RA compared with those without RA (13.7% vs 16.1%, P ≤ 0.01). Compared with patients without RA, the adjusted model demonstrated that patients with diabetes and RA were 28% less likely to have diabetic retinopathy and 4% more likely to receive an eye exam [ARR 0.72 (95% CI 0.67, 0.77), ARR 1.04 (95% CI 1.02, 1.06)]. Conclusion. Findings support the 1964 paradox observing decreased diabetic retinopathy in patients with RA. These findings pose new questions regarding whether RA physiology or treatments protect against diabetic retinopathy and how intraocular factors vary in contrast to adverse vascular changes elsewhere.

Most patients with diabetes have comorbid chronic conditions that could support (concordant) or compete with (discordant) diabetes care. We sought to determine the impact of the number of concordant and discordant chronic conditions on diabetes care quality.Logistic regression analysis of electronic health record data from 7 health systems on 24,430 patients with diabetes aged 18-75 years. Diabetes testing and control quality care goals were the outcome variables. The number of diabetes-concordant and the number of diabetes-discordant conditions were the main explanatory variables. Analysis was adjusted for health care utilization, health system and patient demographics.A higher number of concordant conditions were associated with higher odds of achieving testing and control goals for all outcomes except blood pressure control. There was no to minimal positive association between the number of discordant conditions and outcomes, except for cholesterol testing which was less likely with 4+ discordant conditions.Having more concordant conditions makes diabetes care goal achievement more likely. The number of discordant conditions has a smaller, inconsistently significant impact on diabetes goal achievement. Interventions to improve diabetes care need to align with a patient's comorbidities, including the absence of comorbidities, especially concordant comorbidities.

Purpose We present a case report detailing a challenge in health information technology (HIT) project implementations we term “stakeholder creep”: not thoroughly identifying which stakeholders need to be involved and why before starting a project, consequently not understanding the true effort, skill sets, social capital, and time required to complete the project. Methods A root cause analysis was performed post-implementation to understand what led to stakeholder creep. HIT project stakeholders were given a questionnaire to comment on these misconceptions and a proposed implementation tool to help mitigate stakeholder creep. Findings Stakeholder creep contributed to an unexpected increase in time (3-month delayed go-live) and effort (68% over expected HIT work hours). Four main clinician/researcher misconceptions were identified that contributed to the development of stakeholder creep: 1) that EHR IT is a single group; 2) that all EHR IT members know the entire EHR functionality; 3) that changes to an EHR need the input of just a single EHR IT member; and 4) that the technological complexity of a project mirrors the clinical complexity. HIT project stakeholders similarly perceived clinicians/researchers to hold these misconceptions. The proposed stakeholder planning tool was perceived to be feasible and helpful. Conclusions Stakeholder creep can negatively affect HIT project implementations. Projects may be susceptible to stakeholder creep when clinicians/researchers hold misconceptions related to HIT organization and processes. Implementation tools, such as the proposed stakeholder checklist, could be helpful in preempting and mitigating the effect of stakeholder creep.

OBJECTIVES: Phenotypes differ between late and early-onset systemic lupus erythematosus (SLE). Prior studies suggested that there may be more pulmonary disease among late-onset patients. Our objective was to perform a systematic review and meta-analysis to evaluate the differences in pulmonary manifestations in late- versus early-onset SLE. METHODS: We searched the literature using PubMed, CINAHL, Web of Science, Cochrane Library, and EMBASE. We excluded studies that did not include American College of Rheumatology SLE classification criteria, an early-onset SLE comparison group, or those that defined late-onset SLE as

ᅟ: The increase in cardiovascular disease (CVD) risk in rheumatoid arthritis (RA) is well known; however, appropriate management of this elevated risk in rheumatology clinics is less clear.By critically reviewing literature published within the past 5 years, we aim to clarify current knowledge and gaps regarding CVD risk management in RA.We examine recent guidelines, recommendations, and evidence and discuss three approaches: (1) RA-specific management including treat-to-target and medication management, (2) assessment of comprehensive individual risk, and (3) targeting traditional CVD risk factors (hypertension, smoking, hyperlipidemia, diabetes, obesity, and physical inactivity) at a population level. Considering that 75% of US RA visits occur in specialty clinics, further research is needed regarding evidence-based strategies to manage and reduce CVD risk in RA. This review highlights clinical updates including US cardiology and international professional society guidelines, successful evidence-based population approaches from primary care, and novel opportunities in rheumatology care to reduce CVD risk in RA.

Background: Young adults (18-39 years old) have the lowest rates of hypertension control compared to middle-aged and older adults. Shorter follow-up encounter intervals have been associated with faster rates of hypertension control in middle-aged and older adults. However, the optimal follow-up interval is not defined in younger adults. The objective was to evaluate the relationship between ambulatory follow-up intervals, defined as the average number of provider-patient blood pressure encounters over time, and rates of hypertension control among young adults with incident hypertension. Methods: This was a retrospective analysis of 3,150 young adults receiving regular primary care in a large, Midwestern, academic group practice from 2008-2011. Patients were included upon meeting JNC7 clinical criteria for hypertension (≥140/90 mmHg) and followed for 24 months. Young adults with a previous hypertension diagnosis or prior antihypertensive medication were excluded. We calculated the average blood pressure encounter interval over 24 months and categorized the intervals using established categories of 6 month intervals. Summary statistics were constructed using frequencies and proportions for categorical data and median (25 th , 75 th percentile) for continuous variables. Univariate associations between continuous variables were assessed using two-sided t-test. The probability of achieving hypertension control ( Results: Among young adults with newly diagnosed hypertension (59% male, 83% White), those with the shortest average encounter interval (6 months (13%), pth -75 th percentile) by encounter intervals was: 2.8 (1.8-3.9), 7.1 (5.1-11.3), 10.5 (8.5-14.4), 16.4 (12.4-22.6), and 23.9 (22.5-24.1) months. Young adults with 2-3 month and 3-6 month encounter intervals had higher rates of antihypertensive medication initiation within 24 months, 28% (884/3150) and 27% (850/3150) respectively, compared to 21% (661/3150) with Conclusions: A shorter encounter interval (

Objective Despite numerous studies reporting increased cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA), the impact of RA on managing modifiable CVD risk factors remains understudied. We tested the hypothesis that RA is a risk factor for not receiving a hypertension diagnosis. Methods Using a cohort design, we studied adult patients with and without RA/inflammatory arthritis from a large academic multispecialty practice. All were seen regularly in primary care and met clinical guideline hypertension criteria, but lacked prior hypertension diagnosis/treatment. The primary outcome was time to International Classification of Diseases, Ninth Revision code for hypertension or elevated blood pressure, or antihypertensive medication prescription. Kaplan-Meier survival curve analysis and Cox proportional hazards modeling were used to examine the impact of RA on diagnosis of hypertension. Results Among 14,974 patients with undiagnosed hypertension, 201 patients had RA codes. RA patients had equivalent primary care visits and more total visits compared to patients without RA. At the end of the study, the likelihood of hypertension diagnosis was 36% in RA patients compared to 51% in patients without RA. In adjusted Cox models, RA patients had a 29% lower hypertension diagnosis hazard (hazard ratio 0.71, 95% confidence interval 0.55–0.93), reflecting more undiagnosed hypertension than with other comorbidities. Conclusion Among patients meeting guideline-based hypertension criteria, RA patients were less likely to be diagnosed despite more visits than those without RA. Given heightened CVD risks in RA and the importance of hypertension diagnosis as a first step toward controlling risk, rheumatologists should collaborate to improve rates of diagnosis for this modifiable CVD risk factor.

BackgroundThe antibody response to pertussis vaccination in rheumatoid arthritis is unknown, a concerning omission given the relatively low efficacy of the pertussis vaccine, a rise in pertussis infections, and a general increased susceptibility to infection in rheumatoid arthritis. Additionally, the contributions from an intrinsically dysregulated immune system in rheumatoid arthritis and immune-suppressing medications to the response to pertussis vaccination is poorly defined. This study examines antibody titers against pertussis in vaccinated rheumatoid arthritis patients and controls as well as evaluates potential contributions from demographic factors, immune suppressing medications, and reactivity against citrullinated pertussis.MethodsSerum IgG titers against native and citrullinated pertussis and tetanus were quantified by enzyme-linked immunosorbent assay in rheumatoid arthritis subjects and controls who were vaccinated within 10 years. Titers were compared by t-test and percent immunity by Fisher's exact test. Multivariable logistic regression was used to identify clinical factors that correlate with native pertussis titers.ResultsCompared to controls, rheumatoid arthritis subjects had lower titers against pertussis, but not tetanus, and reduced immunity to pertussis. These results were even more prominent at 5-10 years post-vaccination, when rheumatoid arthritis patients had 50% lower titers than controls and 2.5x more rheumatoid arthritis subjects were not considered immune to pertussis. Multiple logistic regression demonstrated that female sex and methotrexate use, but not TNF inhibiting medications, correlated with reduced immunity to pertussis. Finally, rheumatoid arthritis patients had higher IgG titers against citrullinated pertussis than native pertussis.ConclusionsPertussis titers are lower in vaccinated rheumatoid arthritis patients with evidence for contributions from female sex, a citrulline-biased immune response, and methotrexate use.

Objective: Young adults meeting hypertension diagnostic criteria have a lower prevalence of a hypertension diagnosis than middle-aged and older adults. The purpose of this study was to compare the rates of a new hypertension diagnosis for different age groups and identify predictors of delays in the initial diagnosis among young adults who regularly use primary care. Methods: A 4-year retrospective analysis included 14 970 patients, at least 18 years old, who met clinical criteria for an initial hypertension diagnosis in a large, Midwestern, academic practice from 2008 to 2011. Patients with a previous hypertension diagnosis or prior antihypertensive medication prescription were excluded. The probability of diagnosis at specific time points was estimated by Kaplan–Meier analysis. Cox proportional hazard models (hazard ratio; 95% confidence interval) were fit to identify predictors of delays to an initial diagnosis, with a subsequent subset analysis for young adults (18–39 years old). Results: After 4 years, 56% of 18–24-year-olds received a diagnosis compared with 62% (25–31-year-olds), 68% (32–39-year-olds), and more than 70% (≥40-year-olds). After adjustment, 18–31-year-olds had a 33% slower rate of receiving a diagnosis (18–24 years hazard ratio 0.66, 0.53–0.83; 25–31 years hazard ratio 0.68, 0.58–0.79) compared with adults at least 60 years. Other predictors of a slower diagnosis rate among young adults were current tobacco use, white ethnicity, and non-English primary language. Young adults with diabetes, higher blood pressures, or a female provider had a faster diagnosis rate. Conclusion: Provider and patient factors are critical determinants of poor hypertension diagnosis rates among young adults with regular primary care use.

One approach to the patient-centered medical home, particularly for patients with chronic illnesses, is to include physician assistants (PAs) and nurse practitioners (NPs) on primary care teams. Using Medicare claims and electronic health record data from a large physician group, we compared outcomes for two groups of adult Medicare patients with diabetes whose conditions were at various levels of complexity: those whose care teams included PAs or NPs in various roles, and those who received care from physicians only. Outcomes were generally equivalent in thirteen comparisons. In four comparisons, outcomes were superior for the patients receiving care from PAs or NPs, but in three other comparisons the outcomes were superior for patients receiving care from physicians only. Specific roles performed by PAs and NPs were associated with different patterns in the measure of the quality of diabetes care and use of health care services. No role was best for all outcomes. Our findings suggest that patient characteristics, as well as patients' and organizations' goals, should be considered when determining when and how to deploy PAs and NPs on primary care teams. Accordingly, training and policy should continue to support role flexibility for these health professionals.

Background Young adults (18–39 year-olds) have the lowest hypertension control rates among adults with hypertension in the United States. Unique barriers to hypertension management in young adults with primary care access compared to older adults have not been evaluated. Understanding these differences will inform the development of hypertension interventions tailored to young adults. The goals of this multicenter study were to explore primary care providers’ perspectives on barriers to diagnosing, treating, and controlling hypertension among young adults with regular primary care. Methods Primary care providers (physicians and advanced practice providers) actively managing young adults with uncontrolled hypertension were recruited by the Wisconsin Research & Education Network (WREN), a statewide practice-based research network. Semi-structured qualitative interviews were conducted in three diverse Midwestern clinical practices (academic, rural, and urban clinics) using a semi-structured interview guide, and content analysis was performed. Results Primary care providers identified unique barriers across standard hypertension healthcare delivery practices for young adults. Altered self-identity, greater blood pressure variability, and unintended consequences of medication initiation were critical hypertension control barriers among young adults. Gender differences among young adults were also noted as barriers to hypertension follow-up and antihypertensive medication initiation. Conclusions Tailored interventions addressing the unique barriers of young adults are needed to improve population hypertension control. Augmenting traditional clinic structure to support the “health identity” of young adults and self-management skills are promising next steps to improve hypertension healthcare delivery. Electronic supplementary material The online version of this article (doi:10.1186/s13104-016-2332-8) contains supplementary material, which is available to authorized users.

Background In the United States, young adults (18-39 year-olds) have the lowest hypertension control rates (35%) compared to middle-aged (58%) and older (54%) adults. Ambulatory care for hypertension management often focuses on medication with little time for self-management and behavioral counseling. This study was designed to evaluate the feasibility of MyHEART, a telephone-based health coach self-management intervention for young adults. The goals were to determine the intervention's ability to: 1) recruit young adults with uncontrolled hypertension, 2) maintain ongoing communication between the coach and participants, 3) increase participants' engagement in self-management, 4) document coach-patient communication in the electronic health record, and 5) assess patient acceptability. Methods Eligible participants were identified through the electronic health record. Inclusion criteria included 18-39 year-olds, with ICD-9 hypertension diagnoses and uncontrolled hypertension (≥ 140/90 mmHg), receiving regular primary care at a large multispecialty group practice. The intervention consisted of 6 telephone self-management sessions by a health coach targeting lifestyle modifications. Patients completed an open-ended acceptability survey. Results Study uptake was 47% (9 enrolled/19 eligible). Mean (SD) age was 35.8 (2.6) years, 78% male, and 33% Black. Over 85% of enrolled young adults maintained communication with their health coach. At baseline, 11% reported checking their blood pressure outside of clinic; 44% reported blood pressure monitoring after the study. All coach-patient encounters were successfully documented in the electronic health record for primary care provider review. Open-ended responses from all surveys indicated that participants had a positive experience with the MyHEART intervention. Conclusions This study demonstrated that MyHEART was feasible and acceptable to young adults with uncontrolled hypertension. Health coaches can effectively maintain ongoing communication with young adults, document communication in the electronic health record, and increase engagement with home blood pressure monitoring. The results of this study will inform a multi-center young adult randomized controlled trial of MyHEART.