Search

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 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.

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)

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.

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.

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.

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 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.

A1 Introduction to the 8th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health David Chambers1, Lisa Simpson2 1Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD, 20850, USA; 2AcademyHealth, Washington, DC, 20036, USA For the second year in a row, we are pleased to be able to share the proceedings of the Annual Conference on the Science of Dissemination and Implementation in Health, a large meeting reflecting the expanding and evolving research field that seeks to optimize the use of evidence, interventions, and tools from health research within the myriad of settings where people receive health care, make health-related decisions, and increase knowledge of influences on the health of the population. We once again benefitted from a strong partnership, co-led by AcademyHealth and the National Institutes of Health (NIH), with co-sponsorship from the Agency for Healthcare Research and Quality (AHRQ), the Patient Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation (RWJF), the US Department of Veterans Affairs (VA), and the WT Grant Foundation. In addition, we benefitted from the collaboration of staff from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). NIH and AcademyHealth again co-led the program planning committee, which focused on the development of the plenary sessions, and convened a scientific advisory panel to suggest speakers and advise on the overall conference development. The planning committee identified four key areas around which to focus the plenary panels and keynote address. Dr. America Bracho, M.D., M.P.H., Executive Director of Latino Health Access in Orange County, California, spoke about the opportunities for implementation science to inform efforts to improve community health and engage underserved populations. The three plenary panels each focused on a significant future direction for dissemination and implementation (D & I) research: the interface between D&I science and population health, emerging opportunities for global implementation science, and the challenges around implementation of precision medicine. The plenary sessions were complemented by facilitated lunchtime discussions on the same three topics, which offered participants an opportunity to identify key research questions for each and brainstorm next steps. Synopses of the lunchtime discussions are included in this supplement. Given the overwhelming success of the 2014 conference and the large number of abstracts received in 2014 (660), the program planning committee identified eight program tracks for abstract submitters to respond to, and through which the concurrent sessions of the conference would be organized. These tracks—Behavioral Health, Big Data and Technology for Dissemination and Implementation Research, Clinical Care Settings, Global Dissemination and Implementation, Promoting Health Equity and Eliminating Disparities, Health Policy Dissemination and Implementation, Prevention and Public Health, and Models, Measures and Methods— were designed to enable conference participants to follow a consistent theme across the multiple sessions of the conference and form the structure of this supplement. The call for abstracts, including individual paper presentations, individual posters and panel presentations, resulted in 515 submissions, spread across the eight thematic tracks. Over one hundred reviewers devoted their time to ensuring a comprehensive and expert review, and reviews were conducted within each track and coordinated by the track leads. For the final program, 64 oral presentations, 12 panels, and 263 posters were presented over the two-day meeting. Slides for the oral presentations and panels (with the agreement of the authors) were posted on the conference website (http://diconference.academyhealth.org/archives/2015archives) and all abstracts were included on the conference webapp (https://academyhealth.confex.com/academyhealth/2015di/meetingapp.cgi). This supplement has compiled the abstracts for presented papers, panel sessions, and lunchtime discussions from the 8th Annual Meeting on the Science of Dissemination and Implementation in Health: Optimizing Personal and Population Health. We are pleased to have the abstracts from the conference together in one volume once again, and look forward to the 9th Annual meeting, scheduled for December in Washington, D.C.

Background Among adults with hypertension, obesity independently contributes to cardiovascular disease. Weight loss and hypertension control are critical to reduce cardiovascular events. The purpose of this study was to evaluate rates and predictors of achieving weight loss among adults who achieved hypertension control within 1 year of developing incident hypertension. Methods Retrospective electronic health record analysis was performed of ≥18 year olds with a body mass index ≥30.0kg/m(2), who received regular primary care from 2008 to 2011 and achieved hypertension control. Exclusions were less than 60 days follow-up, prior hypertension diagnosis, prior antihypertensive prescription, or pregnancy. The primary outcome was clinically significant weight loss (≥5kg); the secondary outcome was modest (2.0-4.9kg) weight loss. Multinomial logistic regression identified predictors of achieving weight loss (≥5 or 2.0-4.9kg) compared to no significant weight loss ( Results Of the 2,906 obese patients who achieved hypertension control, 72% (n = 2,089) did not achieve at least 2.0kg weight loss. Overall, 12% (n = 351) achieved ≥5kg weight loss. Young adults (18-39 year olds; odds ratio (OR): 2.47, 95% confidence interval (CI): 1.63-3.47), middle-aged adults (40-59 year olds; OR: 2.32, 95% CI: 1.59-3.37), and patients prescribed antihypertensive medication (OR: 1.37, 95% CI: 1.07-1.76) were more likely to achieve clinically significant weight loss and hypertension control. Age remained a significant predictor for 2.0-4.9kg weight loss. Conclusions Despite achieving hypertension control, the majority of obese patients did not achieve clinically significant weight loss. Effective weight loss interventions with dedicated hypertension treatment are needed to decrease cardiovascular events in this high-risk population.

ObjectiveThe impact of geographic isolation on abdominal aortic aneurysm (AAA) care in the United States is unknown. It has been postulated but not proven that rural patients have less access to endovascular aneurysm repair (EVAR), vascular surgeons, and high-volume treatment centers than their urban counterparts, resulting in inferior AAA care. The purpose of this study was to compare the national experience for treatment of intact AAA for patients living in rural areas or towns with those living in urban areas.MethodsPatients who underwent intact AAA repair in 2005 to 2006 were identified from a standard 5% random sample of all Medicare beneficiaries. Data on patient demographics, comorbidities, type of repair, and specialty of operating surgeon were collected. Hospitals were stratified into quintiles by yearly AAA volume. Primary outcomes included 30-day mortality and rehospitalization.ResultsA total of 2616 patients had repair for intact AAA (40% open, 60% EVAR). Patients from rural and urban areas were equally likely to receive EVAR (rural 60% vs urban 61%; P = .99) and be treated by a vascular surgeon (rural 48% vs urban 50%; P = .82). Most rural patients (86%) received care in urban centers. Primary outcomes occurred in 11.6% of rural patients (1.3% 30-day mortality; 10.3% rehospitalization) vs 16.0% of urban patients (3% 30-day mortality, 13% rehospitalization; P = .04). In multivariate analyses, rural residence was independently associated with treatment at high-volume centers (odds ratio, 1.64; 95% confidence interval, 1.34-2.01; P < .0001) and decreased death or rehospitalization (odds ratio, 0.69; 95% confidence interval, 0.49-0.97; P = .03).ConclusionsDespite geographic isolation, patients in rural areas needing treatment for intact AAAs have equivalent access to EVAR and vascular surgeons, increased referral to high-volume hospitals, and improved outcomes after repair. This suggests that urban patients may be disadvantaged even with nearby access to high-quality centers. This study supports the need for criteria that define centers of excellence to extend the benefit of regionalization to all patients.

Objective For patients with rheumatoid arthritis (RA) and comorbid cardiovascular disease (CVD), diabetes, or hyperlipidemia, annual lipid testing is recommended to reduce morbidity and mortality from comorbidities. Given trends encouraging complex patients to receive care in "medical homes," we examined associations between regularly seeing a primary care provider (PCP) and lipid testing in RA patients with cardiovascular-related comorbidities. Methods We performed a retrospective cohort study examining a 5% random USA Medicare sample (2004-06) of beneficiaries over 65 years old with RA and concomitant CVD, diabetes, or hyperlipidemia ( n = 16,893). We examined the relationship between receiving lipid testing in 2006 and having at least 1 PCP visit per year in 2004, 2005, and 2006 using multivariate regression. Results Ninety percent of patients had prevalent CVD; 46% had diabetes, and 64% had hyperlipidemia. However, annual lipid testing was only performed in 63% of these RA patients. Thirty percent of patients saw a PCP less than once per year, despite frequent visits (mean >9) with other providers. Patients without at least 1 annual PCP visit were 16% less likely to have lipid testing. Increased age, complexity scores, hospitalization, and large town residence predicted decreased lipid testing. Conclusions Despite comorbid CVD, diabetes, or hyperlipidemia, 30% of Medicare RA patients saw a PCP less than once per year, and 1 in 3 lacked annual lipid testing. Findings support advocating primary care visits at least once per year. Remaining gaps in lipid testing suggest the need for additional strategies to improve lipid testing in at-risk RA patients.

ObjectivesComplications after abdominal aortic aneurysm (AAA) repair resulting in reintervention increase mortality risk, but have not been well studied. Mortality after reintervention is termed failure to rescue and may reflect differences related to quality management of the complication. This study describes the relationship between reoperation and mortality and examines the effect of physician speciality on reintervention rates and failure to rescue after AAA repair.MethodsData were extracted for 2616 patients who underwent intact AAA repair in 2005 to 2006 from a standard 5% random sample of all Medicare beneficiaries. Patient demographics, comorbidities, hospital characteristics, repair type, and speciality of operating surgeon were collected. Primary outcomes were 30-day reoperation and 30-day mortality. Logistic regression analysis identified characteristics predicting reoperation.ResultsA total of 156 reoperations were required in 142 (4.2%) patients. Early mortality was far more likely for patients requiring reintervention than for those who did not (22.5% vs 1.5%; P < .0001). Of patients requiring reoperation, those requiring two or more interventions had an even higher mortality (54% vs 20%; P = .0007). Despite equivalent reoperation rates between specialities (vascular surgeons, 5.2%; others, 5.6%, P = .67), the mortality after reoperation was nearly half for vascular surgeons compared with other specialities (16.2% vs 32.3%; P = .04). The most common reason for reoperation was arterial complications (35.8%) accounting for the largest difference in mortality between vascular surgeons (30.7%) and other specialities (52.0%).ConclusionsPostoperative complications requiring reoperation dramatically increase mortality after AAA repair. Despite similar complication rates, vascular surgeons showed lower mortality rates after reoperation.

Objectives. The purpose of this study was to examine prevalence trends of serious extra-articular manifestations (EAMs) in a data set representing both hospitalized and ambulatory patients with RA. Methods. This retrospective cohort study used serial cross-sectional data to examine the prevalence of serious EAMs in patients with RA from 1985 to 2006 across the United States (US) Veteran’s Health Administration system. Serious EAMs included rheumatoid carditis, RA lung disease, FS and pooled EAM rates included previously reported vasculitis prevalence as queried by ICD-9 searches. Statistical analysis employed auto-regression and time series analysis using the Chow and Durbin–Watson tests to detect breakpoints and linear time-trends. Results. Among 3 million veterans, including >35 000 RA patients annually, we noted declining RA hospitalizations emphasizing the importance of examining both the inpatient and outpatient settings to assess EAM prevalence. Individual EAM trends varied, demonstrating linear declines in FS, increases in RA lung disease and significant breakpoint declines in carditis and pooled serious EAMs. Pooled EAM prevalence dropped around 2000, from an early linear trend peak of 10% among inpatients, to

Objective To examine trends in the prevalence of rheumatoid vasculitis in a national US population comprising both hospitalized and ambulatory patients with rheumatoid arthritis (RA). Methods In this serial cross-sectional study, we analyzed data on hospitalized and ambulatory patients spanning 22 years (1985–2006) and 10 years (1997–2006), respectively, to determine the prevalence of rheumatoid vasculitis, as defined by the International Classification of Diseases, Ninth Revision. Our search encompassed data collected on a predominantly male study population during 10 million hospitalizations and outpatient visits, and included annual data on >37,000 RA patients. To test for a decrease in rheumatoid vasculitis prevalence, breakpoint analysis was performed using stepwise Chow and Durbin-Watson tests. Results There was a clear decline in the prevalence of rheumatoid vasculitis, and this decline remained evident even after accounting for a decreased number of hospitalizations among RA patients. Peak prevalence occurred among hospitalized patients in the 1980s, and prevalence gradually declined throughout the 1990s. Furthermore, simultaneous breakpoints representing a significant drop in rheumatoid vasculitis prevalence between the years 2000 and 2001 were demonstrated for both inpatients (P < 0.000) and outpatients (P < 0.003). The prevalence of vasculitis dropped 53% among inpatients and 31% among outpatients between 2000 and 2001. Conclusion Our results demonstrate a significant decline in rheumatoid vasculitis prevalence after 2000 in this nationwide sample of hospitalized and ambulatory patients. The clear, consistent drop in prevalence provides an opportunity for the formulation of causal hypotheses, including consideration of the impact of biologic agents used to treat RA, on rheumatoid vasculitis.

Background Interpreting clinical guideline adherence and the appropriateness of medication regimens requires consideration of individual patient and caregiver factors. Factors leading to initiation of a medication may differ from those determining continued use. We believe this is the case for systemic steroid therapy in inflammatory bowel disease (IBD), resulting in a need to apply methods that separately consider factors associated with initiation and duration of therapy. To evaluate the relationship between patient characteristics and the frequency and duration of incident steroid use we apply a 2-part hurdle model to Medicare data. We do so in older patients with tumor necrosis factor antagonist (anti-TNFs) contraindications, as they are of special interest for compliance with Medicare-adopted, quality metrics calling for anti-TNFs and nonbiologic immune therapies to reduce steroid utilization. Many older patients have contraindications to anti-TNFs. However, nonbiologics cause adverse events that are concerning in older adults, limiting their use in this population and increasing reliance on systemic steroids. Methods We used a national Medicare sample for 2006–2009 including patients with 12 months or greater of Parts A and B and 6 months or greater of Part D coverage, IBD confirmed with at least 2 claims for ICD-9CM 555.xx or 556.xx, anti-TNF contraindications and without contraindications to nonbiologic agents. We applied a negative binomial-logit hurdle model to examine patient characteristics associated with systemic steroid utilization. Results Among the 1,216 IBD patients without baseline steroid use, 21 % used systemic steroids. Odds of receiving systemic steroids were greater in those younger, rural, and those receiving other agents. Available patient characteristics failed to predict longer steroid treatment duration. Conclusions Our study identified differences in predictors of frequency and duration of medication use and suggests the utility of two-part models to examine drug utilization patterns. Applying such a model to Medicare data, we determined that despite medical consensus that systemic steroid use should be minimized, its use was substantial. Findings indicate anticipated difficulties in implementing recently adopted quality measures to avoid systemic steroids.

Objectives To examine the frequency and predictors of antitumour necrosis factor (TNF) use, and to describe steroid utilisation among US patients with inflammatory bowel disease (IBD) aged 65 years and older prior to the publication of a new Medicare quality measure calling for the use of anti-TNFs and other steroid-sparing agents. Design Retrospective cohort study. Setting This study utilised 2006–2009 claims data for a national sample of Medicare beneficiaries. Participants Patients with IBD (>1 claim for ICD codes 555.xx, 556.xx) without anti-TNF contraindications, enrolled in Medicare parts A and B ≥12 months and part D ≥6 months were included (n=8502). Outcome measures We estimated incidence rate ratios (IRR) and 95% CIs predicting new anti-TNF therapy using multivariable Poisson regression. Results This nationally representative study of older patients with IBD estimated that only 3.7% received anti-TNFs. New anti-TNF use (1.4%) was associated with younger age, absence of Medicaid coverage, hospitalisation, and higher preceding use of burst (IRR=2.35, CI 1.59 to 3.47) and maintenance steroids (IRR=2.40, CI 1.05 to 5.48). Among anti-TNF users, we observed high rates of concurrent maintenance steroid use (19%). Conclusions Anti-TNF use was very low in this population of older patients with IBD and, importantly, was often combined with maintenance steroid use despite guidelines suggesting reduced needs. Expanding IBD-specific quality measures to include steroid taper plans may cue appropriate maintenance regimens that include anti-TNFs and other steroid sparing agents while reducing protracted concomitant steroid use as intended by current quality measures.

Background Rheumatoid arthritis (RA) has been associated with an increased risk of cardiovascular morbidity and mortality but this has not translated to optimal management of traditional cardiovascular risk factors such as hyperlipidemia. The objectives of this study were to 1) determine the prevalence of screening for hyperlipidemia in patients with RA followed by primary care practitioners (PCP); 2) examine initiation of lipid-lowering therapy in patients with an indication, and 3) assess whether proposed modifications to cardiovascular risk calculations change the percentage of RA patients with an indication for therapy. Methods We performed a retrospective cohort study using an academic medical center-based medical record database in the United States. Patients with RA defined by the presence of at least one ICD-9 code between 2005–2010 and followed by a PCP within the health care system were included. The positive predictive value of ICD-9 codes for accurately identifying patients with RA was 96.7 %. Descriptive statistics were used to report the prevalence of screening and use of lipid-lowering therapy among those with an indication. Factors associated with not receiving lipid screening were examined using logistic regression models. Indication for and receipt of therapy were then assessed before and after the application of the European Union League Against Rheumatism (EULAR) recommended multiplier to the Framingham risk score. Results Among 1,056 patients with RA followed by PCPs and eligible for lipid screening, lipid screening was ordered for 539 (51 %) within the 3-year follow-up period. Patients with diabetes, hypertension, chronic kidney disease, obesity or age >50 were more likely to be screened. Of those with lipid results (N = 290), 25 (9 %) patients had an indication for lipid-lowering therapy based on Adult Treatment Panel III guidelines. Ten (40 %) patients with an indication for lipid-lowering therapy received therapy did not receive therapy. Applying the EULAR multiplier only changed the indication for lipid-lowering therapy in two patients. Conclusions Screening and management of traditional cardiovascular risk factors, including hyperlipidemia, need to be optimized.