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Sjögren's disease (SjD), a highly female predominant systemic autoimmune disease, peaks in perimenopause. Prior studies lack details on timing or type of sex hormone exposure. We examined SjD risk using endogenous and exogenous hormone exposure and related comorbidities.We performed a retrospective case-control study of adult women, nested within a population cohort. Cases had SjD diagnosed by a rheumatology provider or two SjD diagnoses from a non-rheumatology provider with a positive anti-SSA antibody or salivary gland biopsy. Cases were age-matched to three SjD-free controls. We calculated modified composite estrogen scores (mCES) and collected demographics, comorbidities, and endogenous and exogenous hormone exposures. Risk ratios were adjusted for demographics.Of 546 SjD cases and 1637 age-matched controls, mCES was not significantly associated with SjD in adjusted models. The top individual hormone exposures associated with SjD included estrogen replacement therapy (ERT; RR 1.78 [95% CI 1.47-2.14]), polycystic ovarian syndrome (1.65 [1.28-2.12]), and hysterectomy without bilateral oophorectomy (1.51 [1.13-2.03]). We identified comorbidities preceding SjD including fibromyalgia, pulmonary disease, diabetes, lymphoma, osteoporosis, peripheral vascular disease, and renal disease. Taking comorbidities into account, we developed a predictive model for SjD that included fibromyalgia (2.50 [1.93-3.25]), osteoporosis (1.84 [1.27-2.66]), hormone replacement therapy (HRT) (1.61 [1.22-2.12]), diabetes (0.27 [0.13-0.50]), and body mass index (BMI) (0.97 [0.95-0.99]).We report a novel algorithm to improve identifying patients at risk for SjD and describe sex hormone association with SjD. Finally, we report new comorbidities associated with SjD decrease, BMI and diabetes, and increase, lymphoma and osteoporosis.. Key Points •Given female predominance and typical perimenopausal onset, sex hormones should be considered when studying comorbidities in Sjögren's disease. •The top exposures associated with developing Sjögren's disease included fibromyalgia, osteoporosis, and use of hormone replacement therapy. Possible protective factors included prior diabetes and higher body mass index. •We used our newly identified exposures to generate a predictive algorithm, which has potential to improve diagnosis and pathogenic insights into Sjögren's disease.

Patients with rheumatologic conditions are at elevated risk of cardiovascular disease (CVD) due to inflammatory and traditional risk factors, such as high blood pressure (BP) and smoking. However, rheumatology clinics rarely address traditional risk factors, although they are routinely assessed and modifiable in primary care. The present study sought to (1) characterize rheumatology clinic staff's work process for addressing high BP and smoking and (2) identify barriers and strategies for effective management of these risk factors.We conducted 7 focus groups with medical assistants, nurses, and scheduling staff from 4 adult rheumatology clinics across 2 health systems (BP focus groups, n = 23; smoking, n = 20). Transcripts were analyzed using thematic analysis to elucidate barriers and strategies.We found 3 clinic work processes for the management of high BP and smoking risk: (1) risk identification, (2) follow-up within the clinic, and (3) follow-up with primary care and community resources. Within these processes, we identified barriers and strategies grouped into themes: (1) time, (2) clinic workflows, (3) technology and resources, (4) staff's attitudes and knowledge, and (5) staff's perceptions of patients. The most pervasive barriers were (1) no structured system for follow-up and (2) staff confidence and skill in initiating conversations about health-related behavior change.Our study identified generalizable gaps in rheumatology staff's work processes and competencies for addressing high BP and smoking in patients. Future efforts to support staff needs should target (1) systems for follow-up within and outside the clinic and (2) conversation support tools.

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.

Cutaneous lupus erythematosus (CLE) with or without systemic lupus erythematosus (SLE), can be debilitating and cause psychological distress. Belimumab, a monoclonal antibody that inhibits B-cell activation, is an FDA-approved SLE medication, but less is known on its use in CLE. Moreover, the time to response after starting belimumab in CLE is unknown, which may lead to premature discontinuation in the absence of early perceivable benefits. Thus, objectives of this meta-analysis were to examine: a) the efficacy of belimumab; b) time to response after starting belimumab in patients with CLE with or without SLE.A comprehensive literature search was performed to include studies that examined clinical response in patients with CLE with or without SLE receiving belimumab. Clinical response at 52 weeks in belimumab users vs. non-users was summarized in a random effects model. Additionally, we calculated the pooled odds ratio for each consecutive 4-week observation interval to trend clinical response time in CLE with or without SLE after starting belimumab.Among 747 screened studies, 14 studies were included. Pooled odds of clinical response at 52 weeks in belimumab users were 44% higher compared to non-users (OR 1.44, 95% CI 1.20-1.74, IFindings support belimumab as an effective therapy for CLE with SLE. Likewise, they inform patient counseling regarding estimates of 20 weeks to achieve response.

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

ObjectiveSystemic lupus erythematosus (SLE) affects Black people 2 to 3 times more frequently than non-Black people and is associated with higher morbidity and mortality. In total, 4 studies with predominantly non-Black SLE cohorts highlighted that cardiovascular disease (CVD) is no longer primarily a late complication of SLE. This study assessed the timing and predictors of incident CVD in a predominantly Black population-based SLE cohort.MethodsIncident SLE cases from the population-based Georgia Lupus Registry were validated as having a CVD event through review of medical records and matching with the Georgia Hospital Discharge Database and the National Death Index. The surveillance period for an incident CVD event spanned a 15-year period, starting from 2 years prior to SLE diagnosis.ResultsAmong 336 people with SLE, 253 (75%) were Black and 56 (17%) had an incident CVD event. The frequency of CVD events peaked in years 2 and 11 after SLE diagnosis. There was a 7-fold higher risk of incident CVD over the entire 15-year period; this risk was 19-fold higher in the first 12 years in Black people as compared to non-Black people with SLE. Black people with SLE (P< 0.001) and those with discoid rash (hazard ratio 3.2, 95% CI 1.4-7.1) had a higher risk of incident CVD events.ConclusionThe frequency of incident CVD events peaked in years 2 and 11 after SLE diagnosis. Being Black or having a discoid rash were strong predictors of an incident CVD event. Surveillance for CVD and preventive interventions, directed particularly toward Black people with recent SLE diagnoses, are needed to reduce racial disparities.

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.

Although symptom relief is a critical aspect for successful drug development in Sjögren's disease, patient experiences with Sjögren's-related symptoms are understudied. Our objective was to determine how pain, dryness, and fatigue, the cardinal symptoms of Sjögren's disease, drive cluster phenotypes.We used data from the Sjögren's International Collaborative Clinical Alliance (SICCA) Registry and a Sjögren's Foundation survey. We performed hierarchical clustering of symptoms by levels of dryness, fatigue, and pain. Using international and US cohorts, we performed multiple logistic regression analysis to compare the clusters, which included comparisons of differences in symptoms, quality of life (QoL), medication use, and systemic manifestations.Four similar clusters were identified among 1,454 SICCA registrants and 2,920 Sjögren's Foundation survey participants: 1) low symptom burden in all categories (LSB); 2) dry with low pain and low fatigue (DLP); 3) dry with high pain and low to moderate fatigue (DHP); and 4) high symptom burden in all categories (HSB). Distribution of SICCA registrants matching the symptom profile for each cluster was 10% in the LSB cluster, 30% in the DLP cluster, 23% in the DHP cluster, and 37% in the HSB cluster. Distribution of survey participants matching the symptom profile for each cluster was 23% in the LSB cluster, 14% in the DLP cluster, 21% in the DHP cluster, and 42% in the HSB cluster. Individuals in the HSB cluster had more total symptoms and lower QoL but lower disease severity than those in the other clusters. Despite having milder disease as measured by laboratory tests and organ involvement, individuals in the HSB cluster received immunomodulatory treatment most often.We identified 4 symptom-based Sjögren's clusters and showed that symptom burden and immunomodulatory medication use do not correlate with Sjögren's end-organ or laboratory abnormalities. Findings highlight a discordance between objective measures and treatments and offer updates to proposed symptom-based clustering approaches.

Patients identifying as Black and those living in rural and disadvantaged neighborhoods are at increased risk of major (above-ankle) leg amputations owing to diabetic foot ulcers. Intersectionality emphasizes that the disparities faced by multiply marginalized people (eg, rural US individuals identifying as Black) are greater than the sum of each individual disparity.To assess whether intersecting identities of Black race, ethnicity, rural residence, or living in a disadvantaged neighborhood are associated with increased risk in major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers.This retrospective cohort study used 2013-2014 data from the US National Medicare Claims Data Database on all adult Medicare patients hospitalized with a diabetic foot ulcer. Statistical analysis was conducted from August 1 to October 27, 2021.Race was categorized using Research Triangle Institute variables. Rurality was assigned using Rural-Urban Commuting Area codes. Residents of disadvantaged neighborhoods comprised those living in neighborhoods at or above the national 80th percentile Area Deprivation Index.Major leg amputation or death during hospitalization or within 30 days of hospital discharge. Logistic regression was used to explore interactions among race, ethnicity, rurality, and neighborhood disadvantage, controlling for sociodemographic characteristics, comorbidities, and ulcer severity.The cohort included 124 487 patients, with a mean (SD) age of 71.5 (13.0) years, of whom 71 286 (57.3%) were men, 13 100 (10.5%) were rural, and 21 649 (17.4%) identified as Black. Overall, 17.6% of the cohort (n = 21 919), 18.3% of rural patients (2402 of 13 100), and 21.9% of patients identifying as Black (4732 of 21 649) underwent major leg amputation or died. Among 1239 rural patients identifying as Black, this proportion was 28.0% (n = 347). This proportion exceeded the expected excess for rural patients (18.3% - 17.6% = 0.7%) plus those identifying as Black (21.9% - 17.6% = 4.3%) by more than 2-fold (28.0% - 17.6% = 10.4% vs 0.7% + 4.3% = 5.0%). The adjusted predicted probability of major leg amputation or death remained high at 24.7% (95% CI, 22.4%-26.9%), with a significant interaction between race and rurality.Rural patients identifying as Black had a more than 10% absolute increased risk of major leg amputation or death compared with the overall cohort. This study suggests that racial and rural disparities interacted, amplifying risk. Findings support using an intersectionality lens to investigate and address disparities in major leg amputation and mortality for patients with diabetic foot ulcers.

IntroductionRural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion.Research design and methodsThis 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013–2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black.ResultsOverall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black.ConclusionsA smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.

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 Recent studies suggest young adults with systemic lupus erythematosus (SLE) have high 30-day readmission rates, which may necessitate tailored readmission reduction strategies. To aid in risk stratification for future strategies, we measured 30-day rehospitalization and mortality rates among Medicare beneficiaries with SLE and determined rehospitalization predictors by age. Methods In a 2014 20% national Medicare sample of hospitalizations, rehospitalization risk and mortality within 30 days of discharge were calculated for young (aged 18-35 yrs), middle-aged (aged 36-64 yrs), and older (aged 65+ yrs) beneficiaries with and without SLE. Multivariable generalized estimating equation models were used to predict rehospitalization rates among patients with SLE by age group using patient, hospital, and geographic factors. Results Among 1.39 million Medicare hospitalizations, 10,868 involved beneficiaries with SLE. Hospitalized young adult beneficiaries with SLE were more racially diverse, were living in more disadvantaged areas, and had more comorbidities than older beneficiaries with SLE and those without SLE. Thirty-day rehospitalization was 36% among young adult beneficiaries with SLE—40% higher than peers without SLE and 85% higher than older beneficiaries with SLE. Longer length of stay and higher comorbidity risk score increased odds of rehospitalization in all age groups, whereas specific comorbid condition predictors and their effect varied. Our models, which incorporated neighborhood-level socioeconomic disadvantage, had moderate-to-good predictive value (C statistics 0.67-0.77), outperforming administrative data models lacking comprehensive social determinants in other conditions. Conclusion Young adults with SLE on Medicare had very high 30-day rehospitalization at 36%. Considering socioeconomic disadvantage and comorbidities provided good prediction of rehospitalization risk, particularly in young adults. Young beneficiaries with SLE with comorbidities should be a focus of programs aimed at reducing rehospitalizations.

To identify significant factors that help predict whether health care personnel (HCP) will test positive for severe acute respiratory coronavirus 2 (SARS-CoV-2).We conducted a prospective cohort study among 7015 symptomatic HCP from March 25, 2020, through November 11, 2020. We analyzed the associations between health care role, contact history, symptoms, and a positive nasopharyngeal swab SARS-CoV-2 polymerase chain reaction test results, using univariate and multivariable modelling.Of the symptomatic HCP, 624 (8.9%) were positive over the study period. On multivariable analysis, having a health care role other than physician or advanced practice provider, contact with family or community member with known or suspected coronavirus disease 2019 (COVID-19), and seven individual symptoms (cough, anosmia, ageusia, fever, myalgia, chills, and headache) were significantly associated with higher adjusted odds ratios for testing positive for SARS-CoV-2. For each increase in symptom number, the odds of testing positive nearly doubled (odds ratio, 1.93; 95% CI, 1.82 to 2.07, P.001).Symptomatic HCP have higher adjusted odds of testing positive for SARS-CoV-2 based on three distinct factors: (1) nonphysician/advanced practice provider role, (2) contact with a family or community member with suspected or known COVID-19, and (3) specific symptoms and symptom number. Differences among health care roles, which persisted after controlling for contacts, may reflect the influence of social determinants. Contacts with COVID-19-positive patients and/or HCP were not associated with higher odds of testing positive, supporting current infection control efforts. Targeted symptom and contact questionnaires may streamline symptomatic HCP testing for COVID-19.

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)

Background Theory-based implementation strategies, such as audit and feedback (A&F), can improve the adoption of evidence-based practices. However, few strategies have been developed and tested to meet the needs of specialty clinics. In particular, frontline staff can execute cardiovascular disease (CVD) risk reduction protocols, but A&F strategies to support them are not well examined. Our objective was to develop and evaluate a theory-based approach to A&F, Interactive and Participatory A&F (IPAF). Methods We developed IPAF informed by two complementary theories, self-regulation theory (SRT) and self-determination theory (SDT). IPAF applies concepts from these theories to inform (1) what to address with staff to improve rates of best practices (SRT) and (2) how to interact with staff to improve behaviors aligned with best practices (SDT). We promoted IPAF fidelity by developing a semi-structured guide to facilitate staff discussion of target behaviors, perceived barriers, goals, and action plans. We evaluated IPAF in the context of eight quasi-experimental implementations in specialty clinics across two health systems. Following a hybrid type 2 effectiveness-implementation design, we reported intervention outcomes for CVD risk reduction elsewhere. This paper reports implementation outcomes associated with IPAF, focusing on feasibility, appropriateness, acceptability, fidelity, and adoption. We evaluated implementation outcomes using mixed-methods data including electronic health record (EHR) data, team records, and staff questionnaire responses. Results Eighteen staff participated in 99 monthly, individual, synchronous (face-to-face or phone) IPAF sessions during the first 6 months of implementation. Subsequently, we provided over 375 monthly feedback emails. Feasibility data revealed high staff attendance (90–93%) and engagement in IPAF sessions. Staff highly rated questionnaire items about IPAF acceptability. Team records and staff responses demonstrated fidelity of IPAF delivery and receipt. Adoption of target behaviors increased significantly (all P values < 0.05), and adoption or behaviors were maintained for over 24 months. Conclusions We developed and evaluated a theory-based approach to A&F with frontline staff in specialty clinics to improve the implementation of evidence-based interventions. The findings support feasibility, appropriateness, acceptability, and fidelity of IPAF, and staff adoption and maintenance of target behaviors. By evaluating multi-site implementation outcomes, we extended prior research on clinic protocols and A&F beyond primary care settings and providers.

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.

Background: Theory-based implementation strategies, such as audit and feedback (A&F), can improve adoption of evidence-based practices. However, few strategies have been developed and tested to meet the needs of specialty clinics. In particular, frontline staff can execute CVD risk-reduction protocols, but A&F strategies to support them have not been well examined. Our objective was to develop and evaluate a novel A&F strategy, Interactive Participatory A&F (IPAF). Methods: We developed IPAF by combining theories to inform staff goals (Self-Regulation Theory) and address their psychological needs for relatedness, autonomy, and confidence (Self-Determination Theory). We facilitated IPAF fidelity by developing a theory-based facilitation tool: a semi-structured worksheet to guide flexible discussion of target behaviors, perceived barriers, goals, and action plans. We evaluated IPAF in the context of eight quasi-experimental implementations in specialty clinics across two health systems. Following a Hybrid Type 2 effectiveness-implementation design, we reported intervention outcomes for CVD risk-reduction elsewhere. This paper reports implementation outcomes associated with IPAF, focusing on feasibility, acceptability, fidelity, and adoption. We evaluated implementation outcomes using mixed-methods data including Electronic Health Records (EHR) data, team records, IPAF worksheets, and staff questionnaire responses. Results: Eighteen staff participated in 99 monthly, individual, synchronous (face-to-face or by phone) IPAF sessions during the first six months of implementation. Subsequently, we provided over 375 monthly feedback emails. Feasibility data revealed high staff attendance (90-93%) and engagement in IPAF sessions. Staff rated questionnaire items about acceptability of IPAF highly. IPAF records and staff responses demonstrated fidelity of delivery and receipt of IPAF. Adoption of target behaviors increased significantly (all P-values < 0.05) and was maintained for over 24 months. Conclusions: We developed and evaluated an interactive participatory A&F strategy with frontline staff in specialty clinics to improve implementation of evidence-based interventions. The IPAF toolkit combines two complementary theories: Self-Regulation Theory and Self-Determination Theory. Findings support feasibility, acceptability, and fidelity of IPAF, and staff adoption and maintenance of target behaviors. By evaluating multi-site implementation outcomes, we have extended prior research on clinic protocols and A&F beyond primary care settings and providers.

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