A window of opportunity for abatacept in RA: is disease duration an independent predictor of low disease activity/remission in clinical practice?

The objective of the study was to examine whether disease duration independently predicts treatment response among biologic-naïve patients with rheumatoid arthritis (RA) initiating abatacept in clinical practice. Using the Corrona RA registry (February 2006–January 2015), biologic-naïve patients with RA initiating abatacept with 12-month (±3 months) follow-up and assessment of disease activity (Clinical Disease Activity Index [CDAI]) at initiation and at 12 months were identified. The primary outcome was mean change in CDAI (ΔCDAI) from baseline to 12 months. Secondary outcomes at 12 months included achievement of low disease activity (LDA; CDAI ≤10 in patients with moderate/high disease activity at initiation) and remission (CDAI ≤2.8 in patients with low, moderate or high disease activity at initiation). Linear and logistic regression analyses were performed to examine the relationship between disease duration and response to abatacept. There were 281 biologic-naïve patients with RA initiating abatacept (disease duration 0–2 years, n = 107; 3–5 years, n = 45; 6–10 years, n = 50; >10 years, n = 79). Increased disease duration was associated with older age (p = 0.047), and the median number of prior conventional disease-modifying antirheumatic drugs used was lowest in the 0- to 2-year duration group (p < 0.001). Mean ΔCDAI (SE) ranged from −10.22 (1.19) for 0–2 years to −4.63 (1.38) for >10 years. In adjusted analyses, shorter disease duration was significantly associated with greater mean ΔCDAI (p = 0.015) and greater likelihood of achieving LDA (p = 0.048). In biologic-naïve patients with RA initiating abatacept, earlier disease (shorter disease duration) was associated with greater ΔCDAI and likelihood of achieving LDA.

Comparative effectiveness of abatacept versus tocilizumab in rheumatoid arthritis patients with prior TNFi exposure in the US Corrona registry

BACKGROUND

We compared the effectiveness of abatacept (ABA) vs tocilizumab (TCA) in tumor necrosis factor inhibitor (TNFi) experienced patients.

METHODS

We identified rheumatoid arthritis (RA) patients from a large observational US cohort (1 January 2010-31 May 2014) who had discontinued at least one TNFi and initiated ABA or TCZ in moderate or high disease activity based on the Clinical Disease Activity Index (CDAI) and had no prior exposure to the comparator drug. Using propensity score matching (1:1) stratified by prior TNF use (1 TNFi vs ≥2 TNFis), effectiveness at 6 months after initiation was evaluated. Mean change in CDAI over 6 months following initiation was the primary outcome, with secondary outcomes of achievement of low disease activity/remission (CDAI ≤ 10) and mean change in modified Health Assessment Questionnaire (mHAQ) score.

RESULTS

The 264 pairs of propensity score-matched ABA and TCZ initiators were well matched with no substantial differences in the baseline characteristics, defined as standardized differences >0.1 in the stratification. Both treatment groups had similar mean change in CDAI at 6 months (-11.3 in ABA vs -9.9 in TCZ; mean difference -1.27, 95% CI -3.65, 1.11). Similar proportions of both treatment groups achieved low disease activity/remission (adjusted odds ratio for ABA vs TCZ 0.99, 95% CI 0.69, 1.43). Mean change in mHAQ was -0.12 in ABA initiators vs -0.11 in TCZ initiations (mean difference -0.01, 95% CI -0.09, 0.06).

CONCLUSIONS

Patients receiving either ABA or TCZ had substantial improvement in clinical disease activity. In this propensity score-matched sample, similar outcomes were observed for both treatment cohorts.

Increased healthcare resource utilization in higher disease activity levels in initiators of TNF inhibitors among US rheumatoid arthritis patients

OBJECTIVE

Determine healthcare resource utilization (HCRU) in biologic-naïve initiators of TNF inhibitors (TNFis) associated with their disease activity from a national cohort of rheumatoid arthritis (RA) patients.

METHODS

RA patients were identified at their first TNFi initiation (index date) in the Corrona registry. Patients with age of RA onset <18, comorbid psoriasis/psoriatic arthritis, fibromyalgia, or osteoarthritis were excluded. Patients were categorized into disease activity (DA) strata by the lowest level of DA (and sustaining low levels for at least two visits) using the Clinical Disease Activity Index (CDAI) across all visits in Corrona while on a TNFi during 1 year after initiation. Rates of all-cause and RA-related hospitalizations, rheumatologist visits, and joint surgeries while on TNFi therapy were reported and compared across DA levels along with the incidence rate ratio (IRR) adjusted for age, gender, and RA duration using Poisson mixed models.

RESULTS

Of 1931 RA patients: 15% achieved sustained remission, 22% remission, 14% sustained low DA, 23% low DA and 27% moderate/high DA (M/HDA). Those in M/HDA had statistically higher rates of hospitalizations (37.3 per 100 patient years (py), 95% CI: 31.6-43.7 and joint surgeries (20.8 per 100 py, 95% CI: 16.6-25.8) compared to the sustained remission cohort, resulting in respective IRRs of 2.3 (p < 0.001) and 1.7 (p = 0.046).

CONCLUSION

Many biologic naïve RA patients initiating TNFi failed to achieve sustained remission during a 1 year period while remaining on TNFi therapy. Patients in higher DA levels had higher HCRU rates vs. patients in sustained remission, suggesting that achieving treat-to-target goals would reduce health care expenses.

Preoperative Pain and Function: Profiles of Patients Selected for Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is an effective treatment to relieve pain and restore function in patients with advanced knee osteoarthritis. TKA utilization is growing rapidly, and the appropriateness of current TKA use is of great interest. We examined patient-reported preoperative pain and function profiles to understand symptom severity at the time of TKA decision.

METHODS

Data were from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement. We included patients undergoing primary, unilateral TKAs between 2011 and 2014 for osteoarthritis and had data on the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain and Short-Form 36-item Physical Component Summary (PCS) score. We compared patient profiles across groupings by symptoms: (1) little pain and high function (KOOS ≥70, PCS ≥40); (2) little pain but poor function (KOOS ≥70, PCS <40); (3) high pain but high function (KOOS <70, PCS ≥40); and (4) high pain and poor function (KOOS <70, PCS <40).

RESULTS

Of 6936 patients, 77% had high pain and poor function (group 4), 19% had high pain "or" poor function (groups 2-3), and 5% had little pain and high function before TKA (group 1). In group 1, 86% were constantly aware of their knee problem, 48% reported pain daily yet 5% experienced severe or extreme pain on stairs, and 1% pain in bed. Over half had a lot of limitations in vigorous activities. Compared with group 4, group 1 were older, less obese, more educated, and included more men and people reporting being healthy, less disabled, and happy (P < .05 for all).

CONCLUSION

Most patients undergoing TKAs had significant pain and/or poor function. Our results provide critical information given the current debate of potentially inappropriate TKA utilization in the United States.

Diagnostic Prevalence of Ankylosing Spondylitis Using Computerized Health Care Data, 1996 to 2009: Underrecognition in a US Health Care Setting

INTRODUCTION

Few studies have assessed the prevalence and features of axial spondyloarthritis (axSpA) and ankylosing spondylitis in diverse, population-based, community settings.

OBJECTIVES

We used computerized diagnoses to estimate the prevalence of axSpA and ankylosing spondylitis in Kaiser Permanente Northern California (KPNC).

METHODS

We identified persons aged 18 years or older with 1 or more International Classification of Diseases, Ninth Revision (ICD-9) diagnosis Code 720.X (ankylosing spondylitis and other inflammatory spondylopathies) in clinical encounter data from 1996 through 2009 to estimate the prevalence of axSpA and ankylosing spondylitis. We reviewed medical records to confirm the diagnosis in a random sample and estimated the positive predictive value of computerized data to identify confirmed cases using various case definitions.

RESULTS

In the computerized data, 5568 adults had diagnostic codes indicating axSpA. On the basis of our case-finding approach using a single physician diagnosis code for ICD-9 720.X, the point prevalence of these conditions, standardized to the 2000 US Census, was 2.26 per 1000 persons for axSpA and 1.07 per 1000 for ankylosing spondylitis. Less than half of suspected cases saw a rheumatologist. The most specific algorithm for confirmed ankylosing spondylitis required 2 or more computerized diagnoses assigned by a rheumatologist, with 67% sensitivity (95% confidence interval, 64%-69%) and 81% positive predictive value (95% confidence interval, 79%-83%).

CONCLUSIONS

Observed prevalence in the KPNC population, compared with national estimates for axSpA and ankylosing spondylitis, suggests there is substantial underrecognition of these conditions in routine clinical practice. However, use of computerized data is able to identify true cases of ankylosing spondylitis, facilitating population-based research.

A Prospective Evaluation of the Effects of Prevalent Depressive Symptoms on Disease Activity in Rheumatoid Arthritis Patients Treated With Biologic Response Modifiers

PURPOSE

Depressive symptoms are common in rheumatoid arthritis (RA) and may affect disease activity and treatment outcomes. The objective of this study was to determine if prevalent depressive symptoms modify biologic treatment response through their effect on RA disease activity.

METHODS

RA patients with depressive symptoms, initiating biologic treatment, were identified from a US RA registry sample. Patients with depression were compared with control subjects (ie, those patients with no reports of depressive symptoms at, or before, initiating therapy) in terms of clinical disease activity index (CDAI) remission and low disease activity (LDA), and the changes in the component measures that comprise this scale at 6 and 12 months of follow-up. Inverse probability weighting was used to account for differences in baseline disease severity, concomitant treatment characteristics, and other possible confounders. Logistic and linear regression models estimated differences in response rates and changes in component disease activity measures.

FINDINGS

Depressive symptoms were associated with a decreased likelihood of CDAI remission at 6 months (odds ratio, 0.43 [95% CI, 0.19-0.96]) but not at 12 months (odds ratio, 0.83 [95% CI, 0.43-1.60]), and there was no effect on CDAI LDA. Adjusted core component measurement changes showed smaller decreases in global assessment ratings in patients with depressive symptoms; these associations were not statistically significant.

IMPLICATIONS

Poorer treatment outcomes among RA patients with depressive symptoms may be a result of higher baseline disease severity. Adjusted estimates indicated symptoms of depression only affected remission at 6 months' follow-up through patient and physician global assessments. Thus, any impact of depressive symptoms during biologic treatment might not be due to a definitive impact on joint swelling and tenderness.

Objectively Measured Physical Activity and Symptoms Change in Knee Osteoarthritis

OBJECTIVE

The study objective was to quantify the association between daily physical activity measured by accelerometer and 1-year changes in symptoms among people with knee osteoarthritis.

METHODS

Participants from the Osteoarthritis Initiative had knee radiographs and physical activity assessed using GT1M ActiGraph (Pensacola, FL) uniaxial accelerometers at the 48-month visit. Physical activity was calculated and categorized as tertiles of average daily minutes in light and moderate-to-vigorous activity. Outcomes were 1-year change in symptoms measured by Western Ontario and McMaster Universities scales, including pain, stiffness, and physical function. Adjusted multivariable linear models estimated the relationship between tertiles of light or moderate-to-vigorous physical activity and changes in knee symptoms.

RESULTS

Among 1059 participants (55% were women; mean age, 66 ± 9 years), greater time in light activity was associated with a trend toward declined physical function (P = .01). Greater time in daily moderate-to-vigorous activity also was associated with declined physical function (P = .01) and increased pain (P = .08). None of these average changes in symptoms reached minimally important clinical differences. However, greater daily time in both activities was associated with a higher probability of worsening symptoms among persons with Kellgren-Lawrence grade 4 osteoarthritis.

CONCLUSIONS

Objectively measured daily activity was not associated with 1-year symptom improvements among community-dwelling adults with knee osteoarthritis. In those with advanced disease (Kellgren-Lawrence grade 4), greater daily minutes in physical activity were associated with worsening symptoms. How best to implement exercise regimens in persons with advanced knee osteoarthritis to reduce the deleterious impact on symptoms needs to be explored.

Identifying factors associated with concordance with the American College of Rheumatology rheumatoid arthritis treatment recommendations

BACKGROUND

Factors associated with care concordant with the American College of Rheumatology (ACR) recommendations for the use of disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) are unknown.

METHODS

We identified a national cohort of biologic-naive patients with RA with visits between December 2008 and February 2013. Treatment acceleration (initiation or dose escalation of biologic and nonbiologic DMARDs) in response to moderate to high disease activity (using the Clinical Disease Activity Index) was assessed. The population was divided into two subcohorts: (1) methotrexate (MTX)-only users and (2) multiple nonbiologic DMARD users. In both subcohorts, we compared the characteristics of patients who received care consistent with the ACR recommendations (e.g., prescriptions for treatment acceleration) and their providers with the characteristics of those who did not at the conclusion of one visit and over two visits, using logistic regression and adjusting for clustering of patients by rheumatologist.

RESULTS

Our study included 741 MTX monotherapy and 995 multiple nonbiologic DMARD users cared for by 139 providers. Only 36.2 % of MTX monotherapy users and 39.6 % of multiple nonbiologic DMARD users received care consistent with the recommendations after one visit, which increased over two visits to 78.3 % and 76.2 %, respectively (25-30 % achieved low disease activity by the second visit without DMARD acceleration). Increasing time since the ACR publication on RA treatment recommendations was not associated with improved adherence.

CONCLUSIONS

Allowing two encounters for treatment acceleration was associated with an increase in care concordant with the recommendations; however, time since publication was not.

Gout Prophylaxis Evaluated According to the 2012 American College of Rheumatology Guidelines: Analysis from the CORRONA Gout Registry

OBJECTIVE

To analyze prophylaxis using the CORRONA (COnsortium of Rheumatology Researchers Of North America) Gout Registry according to the American College of Rheumatology (ACR) guidelines, and to evaluate whether differences in disease characteristics influenced prophylaxis.

METHODS

All patients with gout in the CORRONA Gout Registry between November 1, 2012, and November 26, 2013, were included. They were divided into 2 groups: "receiving prophylaxis" versus "not receiving prophylaxis" at the time of enrollment. Patients having a flare at time of visit were excluded. Descriptive statistics and multivariable logistic regression models were performed to evaluate the factors associated with prophylaxis.

RESULTS

There were 1049 patients with gout available for analysis. There were 441 patients (42%) receiving prophylaxis and 608 (58%) not receiving prophylaxis. The most common drugs used for prophylaxis were colchicine (78%) and nonsteroidal antiinflammatory drugs (32%). Prophylaxis drug combination was used by 45 patients (10.2%). Patients in the "receiving prophylaxis" group were more likely to have a gout duration of ≤ 1 year (n = 68, p < 0.001), ≥ 1 flare in the year previous to enrollment (p < 0.001), ≥ 1 healthcare uses in the last year [Emergency Department (p = 0.029); outpatient visit to primary care, rheumatologist, or urgent care clinic (p < 0.001)], have tophi (p < 0.001), report pain > 3 (p = 0.001), and have disease activity > 10 (p < 0.001) compared with patients in the "not receiving prophylaxis" group.

CONCLUSION

Forty-two percent of patients with gout in the CORRONA Gout Registry were receiving prophylaxis. Prophylaxis was significantly more common in patients with a higher disease burden and activity, which is in agreement with the ACR guidelines. Our study highlights disease characteristics influencing prophylaxis and furthers our knowledge on current use of flare prophylaxis.

Comparative effectiveness and safety of rituximab versus subsequent anti-tumor necrosis factor therapy in patients with rheumatoid arthritis with prior exposure to anti-tumor necrosis factor therapies in the United States Corrona registry

Introduction

Patients with active rheumatoid arthritis (RA) despite anti–tumor necrosis factor(anti-TNF)agent treatment can switch to either a subsequent anti-TNF agent or a biologic with an alternative mechanism of action, such as rituximab; however, there are limited data available to help physicians decide between these 2 strategies. The objective of this analysis was to examine the effectiveness and safety of rituximab versus a subsequent anti-TNF agent in anti-TNF–experienced patients with RA using clinical practice data from the Corrona registry.

Methods

Rituximab-naive patients from the Corrona registry with prior exposure to ≥1 anti-TNF agent who initiated rituximab or anti-TNF agents (2/28/2006-10/31/2012) were included. Two cohorts were analyzed: the trimmed population (excluding patients who fell outside the propensity score distribution overlap) and the stratified-matched population (stratified by 1 vs ≥2 anti-TNF agents, then matched based on propensity score). The primary effectiveness outcome was achievement of low disease activity (LDA)/remission (Clinical Disease Activity Index ≤10) at 1 year. Secondary outcomes included achievement of modified American College of Rheumatology (mACR) 20/50/70 responses and meaningful improvement (≥0.25) in modified Health Assessment Questionnaire (mHAQ) score at 1 year. New cardiovascular, infectious and cancer events were reported.

Results

Estimates for LDA/remission, mACR response and mHAQ improvement were consistently better for rituximab than for anti-TNF agent users in adjusted analyses. The odds ratio for likelihood of LDA/remission in rituximab versus anti-TNF patients was 1.35 (95 % CI, 0.95-1.91) in the trimmed population and 1.54 (95 % CI, 1.01-2.35) in the stratified-matched population. Rituximab patients were significantly more likely than anti-TNF patients to achieve mACR20/50 and mHAQ improvement in the trimmed population and mACR20 and mHAQ in the stratified-matched population. The rate of new adverse events per 100 patient-years was similar between groups.

Conclusions

In anti-TNF–experienced patients with RA, rituximab was associated with an increased likelihood of achieving LDA/remission, mACR response and physical function improvement, with a comparable safety profile, versus subsequent anti-TNF agent users.

Trial registration

ClinicalTrials.gov NCT01402661. Registered 25 July 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0776-1) contains supplementary material, which is available to authorized users.

Disease activity in rheumatoid arthritis and the risk of cardiovascular events

OBJECTIVE

Use of several immunomodulatory agents has been associated with reduced numbers of cardiovascular (CV) events in epidemiologic studies of rheumatoid arthritis (RA). However, it is unknown whether time-averaged disease activity in RA correlates with CV events.

METHODS

We studied patients with RA whose cases were followed in a longitudinal US-based registry. Time-averaged disease activity was assessed during followup using the area under the curve of the Clinical Disease Activity Index (CDAI), a validated measure of RA disease activity. Age, sex, presence of diabetes mellitus, hypertension, or hyperlipidemia, body mass index, family history of myocardial infarction (MI), use of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), presence of CV disease, and baseline use of an immunomodulator were assessed at baseline. Cox proportional hazards regression models were examined to determine the risk of a composite CV end point that included MI, stroke, and death from CV causes.

RESULTS

A total of 24,989 patients who had been followed up for a median of 2.7 years were included in these analyses. During followup, we observed 534 confirmed CV end points, for an incidence rate of 7.8 per 1,000 person-years (95% confidence interval [95% CI] 6.7-8.9). In models adjusted for variables noted above, a 10-point reduction in the time-averaged CDAI was associated with a 21% reduction in CV risk (95% CI 13-29). These results were robust in subgroup analyses stratified by the presence of CV disease, use of corticosteroids, use of NSAIDs or selective cyclooxygenase 2 inhibitors, and change in RA treatment, as well as when restricted to events adjudicated as definite or probable.

CONCLUSION

Our findings showed that reduced time-averaged disease activity in RA is associated with fewer CV events.

Temporal effect of depressive symptoms on the longitudinal evolution of rheumatoid arthritis disease activity

OBJECTIVE

Depression is common in the rheumatoid arthritis (RA) population, yet little is known of its effect on the course of disease activity. The aim of our study was to determine if prevalent and incident depressive symptoms influenced longitudinal changes in RA disease activity.

METHODS

RA patients with and without depressive symptoms were identified using single-item questions from an existing registry sample. Mixed-effects models were used to examine changes in disease activity over 2 years in those with and without prevalent and incident depressive symptoms. Outcome variables included composite disease activity, joint counts, global assessments, pain, function, and acute-phase reactants. Model-based outcome estimations at the index dates and corresponding 1- and 2-year changes were calculated.

RESULTS

Rates of disease activity change were significantly different in patients with a lifetime prevalence of symptomology, but not incident depressive symptoms, when compared to controls. Prior symptoms were associated with slower rates of disease activity decline, evidenced by the estimated 1-year Clinical Disease Activity Index changes: -3.0 (-3.3, -2.6) and -4.0 (-4.3, -3.6) in patients with and without lifetime prevalence, respectively. Analogous results were obtained for most of the other disease activity outcomes; although, there was no temporal effect of prevalent symptoms of depression on swollen joints and acute-phase reactants.

CONCLUSION

Depressive symptoms temporally influence the evolution of RA disease activity, and the magnitude is dependent on the time of symptomatic onset. However, the effect is limited to patient-reported pain, global assessment, and function, as well as physician-reported global assessment and tender joints.

Effectiveness of Rituximab for the Treatment of Rheumatoid Arthritis in Patients with Prior Exposure to Anti-TNF: Results from the CORRONA Registry

Objective.

To characterize the real-world effectiveness of rituximab (RTX) in patients with rheumatoid arthritis.

Methods.

Clinical effectiveness at 12 months was assessed in patients who were prescribed RTX based on the Clinical Disease Activity Index (CDAI). Change in CDAI was calculated (CDAI at 12 mos minus at initiation). Achievement of remission or low disease activity (LDA; CDAI ≤ 10) among those with moderate/high disease activity at the time of RTX initiation was compared based on prior anti-tumor necrosis factor agent (anti-TNF) use (1 vs ≥ 2) using logistic regression models.

Results.

Patients (n = 265) were followed for 12 months with a mean change in CDAI of −8.1 (95% CI −9.8 – −6.4). Of the 218 patients with moderate/high disease activity at baseline, patients with 1 prior anti-TNF (baseline CDAI 25.0) demonstrated a mean change in CDAI of −10.1 (95% CI −13.2 – −7.0); patients with ≥ 2 prior anti-TNF (baseline CDAI 30.0) demonstrated a mean change of −10.5 (95% CI −12.9 – −8.0). The unadjusted OR for achieving LDA/remission in patients with moderate/high disease activity at baseline exposed to ≥ 2 versus 1 prior anti-TNF was 0.40 (95% CI 0.22–0.73), which was robust to 4 different adjusted models (OR range 0.38–0.44).

Conclusion.

A good clinical response was observed in all patients; however, patients previously treated with 1 anti-TNF, who had lower baseline CDAI and a greater opportunity for clinical improvement compared with patients previously treated with ≥ 2 anti-TNF, were more likely to achieve LDA/remission.

Use of atypical antipsychotics in nursing homes and pharmaceutical marketing

OBJECTIVES

To describe the current extent and type of pharmaceutical marketing in nursing homes (NHs) in one state and to provide preliminary evidence for the potential influence of pharmaceutical marketing on the use of atypical antipsychotics in NHs.

DESIGN

Nested mixed-methods, cross-sectional study of NHs in a cluster randomized trial.

SETTING

Forty-one NHs in Connecticut.

PARTICIPANTS

NH administrators, directors of nursing, and medical directors (n = 93, response rate 75.6%).

MEASUREMENTS

Quantitative data, including prescription drug dispensing data (September 2009-August 2010) linked with Nursing Home Compare data (April 2011), were used to determine facility-level prevalence of atypical antipsychotic use, facility-level characteristics, NH staffing, and NH quality. Qualitative data, including semistructured interviews and surveys of NH leaders conducted in the first quarter of 2011, were used to determine encounters with pharmaceutical marketing.

RESULTS

Leadership at 46.3% of NHs (n = 19) reported pharmaceutical marketing encounters, consisting of educational training, written and Internet-based materials, and sponsored training. No association was detected between level of atypical antipsychotic prescribing and reports of any pharmaceutical marketing by at least one NH leader.

CONCLUSION

NH leaders frequently encounter pharmaceutical marketing through a variety of ways, although the impact on atypical antipsychotic prescribing is unclear.

The rheumatoid arthritis treat-to-target trial: a cluster randomized trial within the Corrona rheumatology network

Background

The treat-to-target (T2T) approach to the care of patients with rheumatoid arthritis involves using validated metrics to measure disease activity, frequent follow-up visits for patients with moderate to high disease activity, and escalation of therapy when patients have inadequate therapeutic response as assessed by standard disease activity scores. The study described is a newly launched cluster-randomized behavioral intervention to assess the feasibility and effectiveness of the T2T approach in US rheumatology practices. It is designed to identify patient and provider barriers to implementing T2T management. This initial paper focuses on the novel study design and methods created to provide these insights.

Methods/Design

This trial cluster-randomizes rheumatology practices from the existing Corrona network of private and academic sites rather than patients within sites or individual investigators to provide either T2T or usual care (UC) for qualified patients who meet the 2010 revised American College of Rheumatology criteria for the diagnosis of rheumatoid arthritis and have moderate to high disease activity. Specific medication choices are left to the investigator and patient, rather than being specified in the protocol. Enrollment is expected to be completed by the end of 2013, with 30 practices randomized and enrolling a minimum of 530 patients. During the 12-month follow-up, visits are mandated as frequently as monthly in patients with active disease in the T2T group and every 3 months for the UC group. Safety data are collected at each visit. The coprimary endpoints include a comparison of the proportion of patients achieving low disease activity in the T2T and UC groups and assessment of the feasibility of implementing T2T in rheumatology practices, specifically assessment of the rates of treatment acceleration, frequency of visits, time to next visit conditional on disease activity, and probability of acceleration conditional on disease activity in the 2 groups.

Discussion

This cluster-randomized behavioral intervention study will provide valuable insights on the outcomes and feasibility of employing a T2T treatment approach in clinical practice in the United States.

Trial registration

NCT01407419

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-389) contains supplementary material, which is available to authorized users.

Temporal associations between the different domains of rheumatoid arthritis disease activity and the onset of patient-reported depressive symptoms

BACKGROUND

Depression is a frequently occurring comorbid condition in patients with rheumatoid arthritis (RA), and research into the temporal relationships regarding its onset has mainly focused on functional status. The study aim was to examine temporal associations of the diverse measures of RA disease activity with incident self-reports of depressive symptoms.

METHODS

RA patients from the Consortium of Rheumatology Researchers of North America (CORRONA) registry were utilized. Cox regression was used to assess the lagged time-varying association of RA disease activity with the incident onset of depressive symptoms as measured using a single-item depression question. Predictor variables included joint counts, global assessments, pain, function, serum biomarkers, and composite disease activity. Hazard ratios (HRs) comparing categorical quintiles were estimated with 95 % confidence intervals.

RESULTS

Every metric of disease activity, except inflammatory markers, were significantly associated with the self-reported onset of depressive symptoms. Adjusted HRs comparing fifth quintiles to first quintiles were the following: CDAI = 2.3 [2.1-2.7]; pain = 2.3 [2.0-2.6]; SJC = 1.4 [1.4-1.6]. When examining successive self-reports (two consecutive), the magnitude of the associations greatly increased: CDAI = 3.6 [2.5-5.0].

CONCLUSIONS

The data suggest depressive symptom onset in RA patients is related to measures reported by the patient: pain, functional status, and global disease activity; and measures reported by providers, rather than biological markers. The magnitude of the associations, however, were greater for the patient-reported measures when compared to physician assessments, implying that patients' experience of their disease activity may be a precipitating factor of depression onset.

A description of patient- and rheumatologist-reported depression symptoms in an American rheumatoid arthritis registry population

OBJECTIVES

Depression is a common and important comorbidity in patients with rheumatoid arthritis (RA). The study aim was to describe rates of depressive symptoms and their associations with RA disease activity using measures reported from patients and rheumatologists.

METHODS

The Consortium of Rheumatology Researchers of North America (CORRONA) registry is an observational cohort with data on more than 33,000 RA patients. Using depression symptom measures reported separately by patients and rheumatologists, lifetime prevalence, 12-month prevalence, and annualised incidence rates (IR) were estimated. Additionally, cross-sectional associations between RA disease and a history of depressive symptoms were examined.

RESULTS

Lifetime prevalence estimates of 26.5% and 12.9% were reported by patients and rheumatologists, respectively. The 12-month prevalence rates reported by CORRONA patients and rheumatologists were 11.7% and 1.0%, respectively. The annualised IR from the self-reported depressive symptom measure was approximately 7.8 per 100 patient-years, compared to 0.4 per 100 patient-years reported by their rheumatologists. Increased disease activity at study entry was associated with a higher probability of reporting a history of depressive symptoms.

CONCLUSIONS

RA patients have a high likelihood of experiencing symptoms of depression, while treating rheumatologists under-report them and disease estimates based on their reports were much lower when compared to healthy individuals. Thus, estimates of prevalence and the impact of these symptoms need to be interpreted based on the source of the diagnosis. Collectively, the findings of this study suggest that depressive symptoms are an important comorbidity that practicing rheumatologists should be aware of during clinical encounters.

An electronic health record-based intervention to increase follow-up office visits and decrease rehospitalization in older adults

OBJECTIVES

To assess the effect of an electronic health record-based transitional care intervention involving automated alerts to primary care providers and staff when older adults were discharged from the hospital.

DESIGN

Randomized controlled trial.

SETTING

Large multispecialty group practice.

PARTICIPANTS

Individuals aged 65 and older discharged from hospital to home.

INTERVENTION

In addition to notifying primary care providers about the individual's recent discharge, the system provided information about new drugs added during the inpatient stay, warnings about drug-drug interactions, recommendations for dose changes and laboratory monitoring of high-risk medications, and alerts to the primary care provider's support staff to schedule a posthospitalization office visit.

MEASUREMENTS

An outpatient office visit with a primary care provider after discharge and rehospitalization within 30 days after discharge.

RESULTS

Of the 1,870 discharges in the intervention group, 27.7% had an office visit with a primary care provider within 7 days of discharge. Of the 1,791 discharges in the control group, 28.3% had an office visit with a primary care provider within 7 days of discharge. In the intervention group, 18.8% experienced a rehospitalization within the 30-day period after discharge, compared with 19.9% in the control group. The hazard ratio for an office visit with a primary care physician did not significantly differ between the intervention and control groups. The hazard ratio for rehospitalization in the 30-day period after hospital discharge in the intervention versus the control group was 0.94 (95% confidence interval = 0.81-1.1).

CONCLUSION

This electronic health record-based intervention did not have a significant effect on the timeliness of office visits to primary care providers after hospitalization or risk of rehospitalization.

The comparative effectiveness of abatacept versus anti-tumour necrosis factor switching for rheumatoid arthritis patients previously treated with an anti-tumour necrosis factor

Objective

We compared the effectiveness of abatacept (ABA) versus a subsequent anti-tumour necrosis factor inhibitor (anti-TNF) in rheumatoid arthritis (RA) patients with prior anti-TNF use.

Methods

We identified RA patients from a large observational US cohort (2/1/2000–8/7/2011) who had discontinued at least one anti-TNF and initiated either ABA or a subsequent anti-TNF. Using propensity score (PS) matching (n:1 match), effectiveness was measured at 6 and 12 months after initiation based on mean change in Clinical Disease Activity Index (CDAI), modified American College of Rheumatology (mACR) 20, 50 and 70 responses, modified Health Assessment Questionnaire (mHAQ) and CDAI remission in adjusted regression models.

Results

The PS-matched groups included 431 ABA and 746 anti-TNF users at 6 months and 311 ABA and 493 anti-TNF users at 12 months. In adjusted analyses comparing response following treatment with ABA and anti-TNF, the difference in weighted mean change in CDAI (range 6–8) at 6 months (0.46, 95% CI −0.82 to 1.73) and 12 months was similar (−1.64, 95% CI −3.47 to 0.19). The mACR20 responses were similar at 6 (28–32%, p=0.73) and 12 months (35–37%, p=0.48) as were the mACR50 and mACR70 (12 months: 20–22%, p=0.25 and 10–12%, p=0.49, respectively). Meaningful change in mHAQ was similar at 6 and 12 months (30–33%, p=0.41 and 29–30%, p=0.39, respectively) as was CDAI remission rates (9–10%, p=0.42 and 12–13%, p=0.91, respectively).

Conclusions

RA patients with prior anti-TNF exposures had similar outcomes if they switched to a new anti-TNF as compared with initiation of ABA.

Knowledge of and perceived need for evidence-based education about antipsychotic medications among nursing home leadership and staff

BACKGROUND/OBJECTIVES

Antipsychotic use is common in US nursing homes, despite evidence of increased risk of morbidity and mortality, and limited efficacy in older adults with dementia. Knowledge, attitudes, and beliefs regarding antipsychotic use among nursing home staff are unclear. The study aim was to describe nursing home leadership and direct care staff members' knowledge of antipsychotic risks, beliefs and attitudes about the effectiveness of antipsychotics and nonpharmacologic management of dementia-related behaviors, and perceived need for evidence-based training about antipsychotic medication safety.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

Survey of leadership and direct care staff of nursing homes in Connecticut was conducted in June 2011. Questionnaire domains included knowledge of antipsychotic risks, attitudes about caring for residents with dementia, satisfaction with current behavior management training, beliefs about antipsychotic effectiveness, and need for staff training about antipsychotics and behavior management.

RESULTS

A total of 138 nursing home leaders and 779 direct care staff provided useable questionnaires. Only 24% of nursing home leaders identified at least 1 severe adverse effect of antipsychotics; 13% of LPNs and 12% of RNs listed at least 1 severe adverse effect. Fifty-six percent of direct care staff believed that medications worked well to manage resident behavior. Leaders were satisfied with the training that staff received to manage residents with challenging behaviors (62%). Fifty-five percent of direct care staff felt that they had enough training on how to handle difficult residents; only 37% felt they could do so without using medications.

CONCLUSIONS

Findings suggest that a comprehensive multifaceted intervention designed for nursing homes should aim to improve knowledge of antipsychotic medication risks, change beliefs about appropriateness and effectiveness of antipsychotics for behavior management, and impart strategies and approaches for nonpharmacologic behavior management.

Racial and ethnic disparities in disease activity in patients with rheumatoid arthritis

BACKGROUND

Observational studies of patients with rheumatoid arthritis have suggested that racial and ethnic disparities exist for minority populations. We compared disease activity and clinical outcomes across racial and ethnic groups using data from a large, contemporary US registry.

METHODS

We analyzed data from 2 time periods (2005-2007 and 2010-2012). The Clinical Disease Activity Index was examined as both a continuous measure and a dichotomous measure of disease activity states. Outcomes were compared in a series of cross-sectional and longitudinal multivariable regression models.

RESULTS

For 2005-2007, significant differences of mean disease activity level (P < .001) were observed across racial and ethnic groups. Over the 5-year period, modest improvements in disease activity were observed across all groups, including whites (3.7; 95% confidence interval [CI], 3.2-4.1) compared with African Americans (4.3; 95% CI, 2.7-5.8) and Hispanics (2.7; 95% CI, 1.2-4.3). For 2010-2012, significant differences of mean disease activity level persisted (P < .046) across racial and ethnic groups, ranging from 11.6 (95% CI, 10.4-12.8) in Hispanics to 10.7 (95% CI, 9.6-11.7) in whites. Remission rates remained significantly different across racial/ethnic groups across all models for 2010-2012, ranging from 22.7 (95% CI, 19.5-25.8) in African Americans to 27.4 (95% CI, 24.9-29.8) in whites.

CONCLUSIONS

Despite improvements in disease activity across racial and ethnic groups over a 5-year period, disparities persist in disease activity and clinical outcomes for minority groups versus white patients.

Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers Criteria Medications

OBJECTIVES

To characterize adverse drug events (ADEs) occurring within the high-risk 45-day period after hospitalization in older adults.

DESIGN

Clinical pharmacists reviewed the ambulatory records of 1,000 consecutive discharges.

SETTING

A large multispecialty group practice closely aligned with a Massachusetts-based health plan.

PARTICIPANTS

Hospitalized individuals aged 65 and older discharged home.

MEASUREMENTS

Possible drug-related incidents occurring during the 45-day period after hospitalization were identified and presented to a pair of physician-reviewers who classified incidents as to whether an ADE was present, whether the event was preventable, and the severity of the event. Medications implicated in ADEs were further characterized according to their inclusion in the 2012 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

RESULTS

At least one ADE was identified during the 45-day period in 18.7% (n = 187) of the 1,000 discharges. Of the 242 ADEs identified, 35% (n = 84) were deemed preventable, of which 32% (n = 27) were characterized as serious, and 5% (n = 4) as life threatening. More than half of all ADEs occurred within the first 14 days after hospitalization. The percentage of ADEs in which Beers Criteria medications were implicated was 16.5% (n = 40). Beers criteria medications with both a high quality of evidence and strong strength of recommendation were implicated in 6.6% (n = 16) of the ADEs.

CONCLUSION

ADEs are common and often preventable in older adults after hospital discharge, underscoring the need to address medication safety during this high-risk period in this vulnerable population. Beers criteria medications played a small role in these events, suggesting that efforts to improve the quality and safety of medication use during this critical transition period must extend beyond a singular focus on Beers criteria medications.

Cardiovascular risk in rheumatoid arthritis: comparing TNF-α blockade with nonbiologic DMARDs

BACKGROUND

Elevated tumor necrosis factor (TNF)-α likely contributes to the excess cardiovascular risk observed in rheumatoid arthritis. We compared the cardiovascular risk in rheumatoid arthritis patients starting a TNF-α blocking agent versus a nonbiologic disease-modifying antirheumatic drug (nbDMARD).

METHODS

Subjects with rheumatoid arthritis participating in several different US insurance programs between 1998 and 2007 who received methotrexate were eligible. Those who added a TNF-α blocking agent were compared with subjects who added a nbDMARD in Cox regression models stratified by propensity score decile and adjusted for oral glucocorticoid dosage. We examined the composite cardiovascular end point of myocardial infarction, stroke, or coronary re-vascularization after 6 months.

RESULTS

We compared 8656 new users of a nbDMARD with 11,587 new users of a TNF-α blocking agent with similar baseline covariates. Incidence rates per 100 person-years for the composite cardiovascular end point were 3.05 (95% confidence interval [CI], 2.54-3.65) for nbDMARDs and 2.52 (95% CI, 2.12-2.98) for TNF-α blocking agents. The hazard ratio (HR) for the TNF-α blocking agent compared with nbDMARD carrying the first exposure forward was 0.80 (95%, CI 0.62-1.04), while the HR for the as-treated analysis was 0.71 (95% CI, 0.52-0.97). The potential cardiovascular benefit of TNF-α blocking agents was strongest among individuals ≥65 years of age (HR 0.52; 95% CI, 0.34 -0.77; P for interaction = 0.075).

CONCLUSION

Among subjects with rheumatoid arthritis, TNF-α blocking agents may be associated with a reduced risk of cardiovascular events compared with an nbDMARD. Randomized controlled clinical trials should be considered to test this hypothesis.

Validity of diagnostic codes and prevalence of psoriasis and psoriatic arthritis in a managed care population, 1996-2009

BACKGROUND

Few population-based studies have reported the prevalence of psoriatic disease.

OBJECTIVE

We validated computerized diagnoses to estimate the prevalence of psoriasis and psoriatic arthritis.

METHOD

We identified adults with ≥1 ICD-9 diagnosis codes of 696.0 (psoriatic arthritis) or 696.1 (psoriasis) in clinical encounter data during 1996-2009 and used chart review to confirm the diagnoses in random samples of patients. We then used the best performing case-finding algorithms to estimate the point prevalence of psoriasis and psoriatic arthritis.

RESULTS

The number of persons with a diagnosis for psoriasis (ICD-9 code 696.1) was 87 827. Chart review of a random sample of 101 cases with at least one dermatologist-rendered psoriasis code revealed a positive predictive value (PPV) of 90% (95% CI, 83-95) with sensitivity of 88% (95% CI, 80-93). Psoriatic arthritis (code 696.0) was recorded for 5187 patients, with the best performing algorithm requiring ≥2 diagnoses recorded by a rheumatologist or ≥1 diagnosis recorded by a rheumatologist together with ≥1 psoriasis diagnoses recorded by a dermatologist; the PPV was 80% (95% CI, 70-88) with sensitivity 73% (95% CI, 63-82). Among KPNC adults, the point prevalence of psoriasis, with or without psoriatic arthritis, was 939 (95% CI, 765-1142) per 100 000, and the overall prevalence of psoriatic arthritis, with or without psoriasis, was 68 (95% CI, 54-84) per 100 000.

CONCLUSION

Within an integrated health care delivery system, the use of computerized diagnoses rendered by relevant disease specialists is a valid method for identifying individuals with psoriatic disease.

Primary care providers' knowledge, beliefs and treatment practices for gout: results of a physician questionnaire

OBJECTIVE

We sought to examine primary care providers' gout knowledge and reported treatment patterns in comparison with current treatment recommendations.

METHODS

We conducted a national survey of a random sample of US primary care physicians to assess their treatment of acute, intercritical and tophaceous gout using published European and American gout treatment recommendations and guidelines as a gold standard.

RESULTS

There were 838 respondents (response rate of 41%), most of whom worked in private practice (63%) with >16 years experience (52%). Inappropriate dosing of medications in the setting of renal disease and lack of prophylaxis when initiating urate-lowering therapy (ULT) accounted for much of the lack of compliance with treatment recommendations. Specifically for acute podagra, 53% reported avoidance of anti-inflammatory drugs in the setting of renal insufficiency, use of colchicine at a dose of ≤2.4 mg/day and no initiation of a ULT during an acute attack. For intercritical gout in the setting of renal disease, 3% would provide care consistent with the recommendations, including initiating a ULT at the appropriate dose with dosing titration to a serum urate level of ≤6 mg/dl and providing prophylaxis. For tophaceous gout, 17% reported care consistent with the recommendations, including ULT use with dosing titration to a serum urate level of ≤6 mg/dl and prophylaxis.

CONCLUSION

Only half of primary care providers reported optimal treatment practices for the management of acute gout and <20% for intercritical or tophaceous gout, suggesting that care deficiencies are common.

Incidence and prevalence of juvenile idiopathic arthritis among children in a managed care population, 1996-2009

OBJECTIVE

Few studies based in well-defined North American populations have examined the occurrence of juvenile idiopathic arthritis (JIA), and none has been based in an ethnically diverse population. We used computerized healthcare information from the Kaiser Permanente Northern California membership to validate JIA diagnoses and estimate the incidence and prevalence of the disease in this well-characterized population.

METHODS

We identified children aged ≤ 15 years with ≥ 1 relevant International Classification of Diseases, 9th edition, diagnosis code of 696.0, 714, or 720 in computerized clinical encounter data during 1996-2009. In a random sample, we then reviewed the medical records to confirm the diagnosis and diagnosis date and to identify the best-performing case-finding algorithms. Finally, we used the case-finding algorithms to estimate the incidence rate and point prevalence of JIA.

RESULTS

A diagnosis of JIA was confirmed in 69% of individuals with at least 1 relevant code. Forty-five percent were newly diagnosed during the study period. The age- and sex-standardized incidence rate of JIA per 100,000 person-years was 11.9 (95% CI 10.9-12.9). It was 16.4 (95% CI 14.6-18.1) in girls and 7.7 (95% CI 6.5-8.9) in boys. The peak incidence rate occurred in children aged 11-15 years. The prevalence of JIA per 100,000 persons was 44.7 (95% CI 39.1-50.2) on December 31, 2009.

CONCLUSION

The incidence rate of JIA observed in the Kaiser Permanente population, 1996-2009, was similar to that reported in Rochester, Minnesota, USA, but 2 to 3 times higher than Canadian estimates.

Dementia and risk of adverse warfarin-related events in the nursing home setting

BACKGROUND

Little attention has been focused on the safety of medications administered to treat non illnesses in nursing home residents with dementia. It is unclear whether this population is at increased risk of adverse drug events.

OBJECTIVES

To test the hypotheses that in nursing home residents with dementia prescribed warfarin have less time in therapeutic range and a higher incidence of nonpreventable and preventable adverse warfarin events compared to nursing home residents without dementia after controlling for facility and patient characteristics.

METHODS

A prospective cohort embedded in a clinical trial of nursing home residents prescribed warfarin in 26 nursing homes in Connecticut was observed for up to 12 months. The primary outcome measures included adverse warfarin events (AWEs) (injuries resulting from warfarin use), potential AWEs (INR [international normalized ratio] >4.5 and management error), and AWE preventability based on physician reviews of medical record abstractions. Potential confounders included nursing home structural characteristics (eg, number of beds and for-profit status), nursing staff time, and nursing home regulatory deficiencies (pharmacy, administrative, quality of care, and all other deficiencies). Multivariable Poisson regression analysis was used to determine the independent association of dementia with potential and preventable AWEs using generalized estimating equations to account for clustering within nursing homes.

RESULTS

Residents with dementia had no difference in the number of INR monitoring tests or percentage of days in the therapeutic range, but did have an increased risk of AWEs (adjusted incidence rate ratio [IRR], 1.47; 95% confidence interval [CI], 1.20-1.82), and preventable or potential AWEs (adjusted IRR, 1.36; 95% CI, 1.06-1.76) after adjustment for patient characteristics, nursing home quality, and case mix. Greater nursing staff time was protective for preventable and potential AWEs (adjusted IRR, 0.66; 95% CI, 0.48-0.90) but not for nonpreventable AWEs.

CONCLUSION

A diagnosis of dementia was associated with increased risk of nonpreventable and preventable or potential AWEs. Greater nursing staff time was associated with lower risk of preventable AWEs. These findings have implications for quality-of-care reporting and patient safety.

A delphi exercise to identify characteristic features of gout - opinions from patients and physicians, the first stage in developing new classification criteria

OBJECTIVE

To identify a comprehensive list of features that might discriminate between gout and other rheumatic musculoskeletal conditions, to be used subsequently for a case-control study to develop and test new classification criteria for gout.

METHODS

Two Delphi exercises were conducted using Web-based questionnaires: one with physicians from several countries who had an interest in gout and one with patients from New Zealand who had gout. Physicians rated a list of potentially discriminating features that were identified by literature review and expert opinion, and patients rated a list of features that they generated themselves. Agreement was defined by the RAND/UCLA disagreement index.

RESULTS

Forty-four experienced physicians and 9 patients responded to all iterations. For physicians, 71 items were identified by literature review and 15 more were suggested by physicians. The physician survey showed agreement for 26 discriminatory features and 15 as not discriminatory. The patients identified 46 features of gout, for which there was agreement on 25 items as being discriminatory and 7 items as not discriminatory.

CONCLUSION

Patients and physicians agreed upon several key features of gout. Physicians emphasized objective findings, imaging, and patterns of symptoms, whereas patients emphasized severity, functional results, and idiographic perception of symptoms.

Association between anti-TNF-α therapy and interstitial lung disease

BACKGROUND

Anti-tumor necrosis factor-α (TNF-α) agents have been hypothesized to increase the risk of interstitial lung disease (ILD), including its most severe manifestation, pulmonary fibrosis.

METHODS

We conducted a cohort study among autoimmune disease patients who were members of Kaiser Permanente Northern California, 1998-2007. We obtained therapies from pharmacy data and diagnoses of ILD from review of X-ray and computed tomography reports. We compared new users of anti-TNF-α agents to new users of non-biologic therapies using Cox proportional hazards analysis to adjust for baseline propensity scores and time-varying use of glucocorticoids. We also made head-to-head comparisons between anti-TNF-α agents.

RESULTS

Among the 8417 persons included in the analysis, 38 (0.4%) received a diagnostic code for ILD by the end of follow-up, including 23 of 4200 (0.5%) who used anti-TNF-α during study follow-up, and 15 of 5423 (0.3%) who used only non-biologic therapies. The age-standardized and gender-standardized incidence rate of ILD, per 100 person-years, was 0.21 [95% confidence interval (CI) 0-0.43] for rheumatoid arthritis and appreciably lower for other autoimmune diseases. Compared with the use of non-biologic therapies, use of anti-TNF-α therapy was not associated with a diagnosis of ILD among patients with rheumatoid arthritis (adjusted hazard ratio, 1.03; 95%CI 0.51-2.07), nor did head-to-head comparisons across anti-TNF-α agents suggest important differences in risk, although the number of cases available for analysis was limited.

CONCLUSION

The study provides evidence that compared with non-biologic therapies, anti-TNF-α therapy does not increase the occurrence of ILD among patients with autoimmune diseases and informs research design of future safety studies of ILD.

Cost-related medication nonadherence in older patients with rheumatoid arthritis

OBJECTIVE

Economic access to costly medications including biologic agents can be challenging. Our objective was to examine whether patients with rheumatoid arthritis (RA) are at particular risk for cost-related medication nonadherence (CRN) and spending less on basic needs.

METHODS

We identified a nationally representative sample of older adults with RA (n = 1100) in the Medicare Current Beneficiary Survey (2004-2008) and compared them to older adults with other morbidities categorized by chronic disease count: 0 (n = 5898), 1-2 (n = 30,538), and ≥ 3 (n = 34,837). We compared annual rates of self-reported CRN (skipping or reducing medication doses or not obtaining prescriptions because of cost) as well as spending less on basic needs to afford medications and tested for differences using survey-weighted logistic regression analyses adjusted for demographic characteristics, health status, and prescription drug coverage.

RESULTS

In the RA sample, the unadjusted weighted prevalence of CRN ranged from 20.7% in 2004 to 18.4% in 2008 as compared to 18.5% and 11.9%, respectively, in patients with 3 or more non-RA conditions. In adjusted analyses, having RA was associated with a 3.5-fold increase in the risk of CRN (OR 3.52, 95% CI 2.63-4.71) and almost a 2.5-fold risk of spending less on basic needs (OR 2.41, 95% CI 1.78-3.25) as compared to those without a chronic condition.

CONCLUSION

Patients with RA experience a high prevalence of CRN and forgoing of basic needs, more than do older adults with multiple other chronic conditions. The situation did not improve during a period of policy change aimed at alleviating high drug costs.

Heart failure risk among patients with rheumatoid arthritis starting a TNF antagonist

BACKGROUND

While heart failure (HF) is associated with elevations in tumor necrosis factor (TNF)α, several trials of TNF antagonists showed no benefit and possibly worsening of disease in those with known severe HF. We studied the risk of new or recurrent HF among a group of patients receiving these agents to treat rheumatoid arthritis (RA).

METHODS

We used data from four different US healthcare programmes. Subjects with RA receiving methotrexate were eligible to enter the study cohort if they added or switched to a TNF antagonist or another non-biological disease modifying antirheumatic drug (nbDMARD). These groups were compared in Cox regression models stratified by propensity score decile and adjusted for oral glucocorticoid dosage, prior HF hospitalisations, and the use of loop diuretics.

RESULTS

We compared 8656 new users of a nbDMARD with 11 587 new users of a TNF antagonist with similar baseline covariates. The HR for the TNF antagonists compared with nbDMARD was 0.85 (95% CI 0.63 to 1.14). The HR was also not elevated in subjects with a history of HF. But, it was elevated prior to 2002 (HR 2.17, 95% CI 0.45 to 10.50, test for interaction p=0.036). Oral glucocorticoids were associated with a dose-related gradient of HF risk: compared with no use, 1≤5 mg HR 1.30 (95% CI 0.91 to 1.85), ≥5 mg HR 1.54 (95% CI 1.09 to 2.19).

CONCLUSIONS

TNF antagonists were not associated with a risk of HF hospital admissions compared with nbDMARDs in this RA population.

Association between anti-TNF-α therapy and all-cause mortality

PURPOSE

To compare mortality among patients with selected autoimmune diseases treated with anti-tumor necrosis factor alpha (TNF-α) agents with similar patients treated with non-biologic therapies.

METHODS

Cohort study set within several large health care programs, 1998-2007. Autoimmune disease patients were identified using diagnoses from computerized healthcare data. Use of anti-TNF-α agents and comparison of non-biologic therapies were identified from pharmacy data, and mortality was identified from vital records and other sources. We compared new users of anti-TNF-α agents to new users of non-biologic therapies using propensity scores and Cox proportional hazards analysis to adjust for baseline differences. We also made head-to-head comparisons among anti-TNF-α agents.

RESULTS

Among the 46 424 persons included in the analysis, 2924 (6.3%) had died by the end of follow-up, including 1754 (6.1%) of the 28 941 with a dispensing of anti-TNF-α agent and 1170 (6.7%) of the 17 483 who used non-biologic treatment alone. Compared to use of non-biologic therapies, use of anti-TNF-α therapy was not associated with an increased mortality in patients with rheumatoid arthritis (adjusted hazard ratio [aHR] 0.93 with 95% confidence intervals (CI) 0.85-1.03); psoriasis, psoriatic arthritis, or ankylosing spondylitis (combined aHR 0.81 with CI 0.61-1.06; or inflammatory bowel disease (aHR 1.12 with CI 0.85-1.46). Mortality rates did not differ to an important degree between patients treated with etanercept, adalimumab, or infliximab.

CONCLUSION

Anti-TNF-α therapy was not associated with increased mortality among patients with autoimmune diseases.

Patients' knowledge and beliefs concerning gout and its treatment: a population based study

BACKGROUND

For patients to effectively manage gout, they need to be aware of the impact of diet, alcohol use, and medications on their condition. We sought to examine patients' knowledge and beliefs concerning gout and its treatment in order to identify barriers to optimal patient self-management.

METHODS

We identified patients (≥18 years of age) cared for in the setting of a multispecialty group practice with documentation of at least one health care encounter associated with a gout diagnosis during the period 2008-2009 (n = 1346). Patients were sent a questionnaire assessing knowledge with regard to gout, beliefs about prescription medications used to treat gout, and trust in the physician. Administrative electronic health records were used to identify prescription drug use and health care utilization.

RESULTS

Two hundred and forty patients returned surveys out of the 500 contacted for participation. Most were male (80%), white (94%), and aged 65 and older (66%). Only 14 (6%) patients were treated by a rheumatologist. Only a minority of patients were aware of common foods known to trigger gout (e.g., seafood [23%], beef [22%], pork [7%], and beer [43%]). Of those receiving a urate-lowering medication, only 12% were aware of the short-term risks of worsening gout with initiation. These deficits were more common in those with active as compared to inactive gout.

CONCLUSION

Knowledge deficits about dietary triggers and chronic medications were common, but worse in those with active gout. More attention is needed on patient education on gout and self-management training.

Time trends in medication use and expenditures in older patients with rheumatoid arthritis

BACKGROUND

We sought to examine how expansions in insurance coverage of nonbiologic and biologic disease-modifying antirheumatic drugs affected the access, costs, and health status of older patients with rheumatoid arthritis.

METHODS

We identified a nationally representative sample of older adults with rheumatoid arthritis in the 2000-2006 Medicare Current Beneficiary Survey (unweighted n=1051). We examined changes in disease-modifying antirheumatic drug use, self-reported health status, functional status (activities of daily living), and total costs and out-of-pocket costs for medical care and prescription drugs. Tests for time trends were conducted using weighted regressions.

RESULTS

Between 2000 and 2006, the proportion of older adults with rheumatoid arthritis who received biologics tripled (4.6% vs 13.2%, P=.01), whereas the proportion of people who used a nonbiologic did not change. During the same period, the proportion of older patients with rheumatoid arthritis rating their health as excellent/good significantly increased (43.0% in 2000 to 55.6% in 2006; P=.015). Significant improvements occurred in activities of daily living measures of functional status. Total prescription drug costs (in 2006 US dollars) increased from $2645 in 2000 to $4685 in 2006, P=.0001, whereas out-of-pocket prescription costs remained constant ($842 in 2000 vs $832 in 2006; P=.68). Total medical costs did not significantly increase ($16,563 in 2000 vs $19,510 in 2006; P=.07).

CONCLUSION

Receipt of biologics in older adults with rheumatoid arthritis increased over a period of time when insurance coverage was expanded without increasing patients' out-of-pocket costs. During this time period, concurrent improvements in self-reported health status and functional status suggest improved arthritis care.

A systematic review of validated methods for identifying cerebrovascular accident or transient ischemic attack using administrative data

PURPOSE

To perform a systematic review of the validity of algorithms for identifying cerebrovascular accidents (CVAs) or transient ischemic attacks (TIAs) using administrative and claims data.

METHODS

PubMed and Iowa Drug Information Service searches of the English language literature were performed to identify studies published between 1990 and 2010 that evaluated the validity of algorithms for identifying CVAs (ischemic and hemorrhagic strokes, intracranial hemorrhage, and subarachnoid hemorrhage) and/or TIAs in administrative data. Two study investigators independently reviewed the abstracts and articles to determine relevant studies according to pre-specified criteria.

RESULTS

A total of 35 articles met the criteria for evaluation. Of these, 26 articles provided data to evaluate the validity of stroke, seven reported the validity of TIA, five reported the validity of intracranial bleeds (intracerebral hemorrhage and subarachnoid hemorrhage), and 10 studies reported the validity of algorithms to identify the composite endpoints of stroke/TIA or cerebrovascular disease. Positive predictive values (PPVs) varied depending on the specific outcomes and algorithms evaluated. Specific algorithms to evaluate the presence of stroke and intracranial bleeds were found to have high PPVs (80% or greater). Algorithms to evaluate TIAs in adult populations were generally found to have PPVs of 70% or greater.

CONCLUSIONS

The algorithms and definitions to identify CVAs and TIAs using administrative and claims data differ greatly in the published literature. The choice of the algorithm employed should be determined by the stroke subtype of interest.

A systematic review of validated methods for identifying heart failure using administrative data

PURPOSE

To identify and describe the validity of algorithms used to detect heart failure (HF) using administrative and claims data sources.

METHODS

A systematic review of PubMed and Iowa Drug Information Service searches of the English language was performed to identify studies published between 1990 and 2010 that evaluated the validity of algorithms for the identification of patients with HF using and claims data. Abstracts and articles were reviewed by two study investigators to determine their relevance on the basis of predetermined criteria.

RESULTS

The initial search strategy identified 887 abstracts. Of these, 499 full articles were reviewed and 35 studies included data to evaluate the validity of identifying patients with HF. Positive predictive values (PPVs) were in the acceptable to high range, with most being very high (>90%). Studies that included patients with a primary hospital discharge diagnosis of International Classification of Diseases, Ninth Revision, code 428.X had the highest PPV and specificity for HF. PPVs for this algorithm ranged from 84% to 100%. This algorithm, however, may compromise sensitivity because many HF patients are managed on an outpatient basis. The most common 'gold standard' for the validation of HF was the Framingham Heart Study criteria.

CONCLUSIONS

The algorithms and definitions used to identify HF using administrative and claims data perform well, particularly when using a primary hospital discharge diagnosis. Attention should be paid to whether patients who are managed on an outpatient basis are included in the study sample. Including outpatient codes in the described algorithms would increase the sensitivity for identifying new cases of HF.

Comparative safety of infliximab and etanercept on the risk of serious infections: does the association vary by patient characteristics?

PURPOSE

Infliximab, a chimeric monoclonal anti-TNFα antibody, has been found to increase the risk of serious infections compared with the TNF receptor fusion protein etanercept in some studies. It is unclear whether the risk varies by patient characteristics. We conducted a study to address this question.

METHODS

We identified members of Kaiser Permanente Northern California who initiated infliximab (n = 793) or etanercept (n = 2692) in 1997-2007. Using a Cox model, we estimated the propensity-score-adjusted hazard ratio (HR) and 95% confidence interval (CI) of serious infections requiring hospitalization or opportunistic infections comparing infliximab initiators to etanercept initiators. We tested whether the adjusted HR differed by age, sex, race/ethnicity, body mass index, and smoking status.

RESULTS

The crude incidence rate of serious infections per 100 person-years was 5.4 (95%CI: 3.8, 7.5) in patients <65 years and 16.0 (95%CI: 10.4, 23.4) in patients ≥ 65 years during the first 3 months following treatment initiation. Compared with etanercept, the adjusted HR during this period was elevated for infliximab in patients <65 years (HR: 3.01; 95%CI: 1.49, 6.07), but not in those ≥ 65 years (HR 0.94; 95%CI: 0.41, 2.13). Findings did not suggest that the HR varied by the other patient characteristics examined.

CONCLUSIONS

An increased risk of serious infections associated with infliximab relative to etanercept did not appear to be modified by patients' sex, race/ethnicity, body mass index, or smoking status. There was an indication that the increased risk might be limited to patients <65 years. Additional studies are warranted to verify or refute this finding.

Prescribing practices in a US cohort of rheumatoid arthritis patients before and after publication of the American College of Rheumatology treatment recommendations

OBJECTIVE

To examine prescribing practices in the use of biologic and nonbiologic disease-modifying antirheumatic drugs (DMARDs) to treat patients with rheumatoid arthritis (RA), before and after publication of the American College of Rheumatology (ACR) treatment recommendations.

METHODS

Biologics-naive RA patients under the care of a rheumatologist in the US were identified from the Consortium of Rheumatology Researchers of North America registry. Patients were included if their visits occurred prior to and/or at least 6 months after publication of the ACR treatment recommendations (time periods of February 2002-June 2008 versus December 2008-December 2009). The population was divided into 2 mutually exclusive cohorts: 1) methotrexate (MTX) monotherapy users, and 2) multiple nonbiologic DMARD users. Initiation or dose escalation of biologic and nonbiologic DMARDs in response to active disease was assessed cross-sectionally and longitudinally in comparison to the ACR recommendations. The impact of the publication of the ACR recommendations on treatment practices was assessed using logistic regression, stratified by disease activity and adjusted for clustering of physicians and geographic region.

RESULTS

After 1 visit, 24-37% of patients receiving MTX monotherapy who had moderate disease activity and a poor prognosis or high disease activity received care consistent with the ACR recommendations; after 2 visits, 34-56% of the MTX monotherapy group received care consistent with the recommendations. In the patients receiving multiple nonbiologic DMARDs, 31-47% of those with moderate or high disease activity received care consistent with the recommendations after 1 visit, and 43-51% received such care after 2 visits. Publication of the recommendations did not significantly change treatment patterns for those with active disease.

CONCLUSION

Substantial numbers of RA patients with active disease did not receive care consistent with the current ACR treatment recommendations. Innovative approaches to improve care are necessary.

Identifying patients with osteoporosis or at risk for osteoporotic fractures

OBJECTIVES

To test the validity of using administrative data to identify patients with osteoporosis or low bone mineral density (BMD) and high risk for osteoporotic fractures.

STUDY DESIGN

We conducted a retrospective cohort study.

METHODS

We analyzed data from a managed care plan in Massachusetts. We developed 6 case-identification algorithms based on number of osteoporosis (OP) diagnoses, clinical setting of the OP diagnosis, timing of the OP diagnosis relative to BMD test, and clinical fracture risk factors adapted from the World Health Organization Fracture Risk Assessment Tool. We validated the algorithms against BMD results and calculated sensitivity, specificity, and positive predictive value (PPV) against 2 diagnostic criteria (T-score ≤--2.5 and T-score ≤--2.0).

RESULTS

When compared against the first criterion (T-score ≤--2.5), the sensitivity of algorithm (35% to 80%), specificity (65% to 93%), PPV (44% to 63%), and adding fracture risk factors did not improve case identification. When compared against the expanded criterion (T-score ≤--2.0), we found the sensitivity of the algorithms ranged from 23% to 63%, specificity from 72% to 95%, and PPV from 67% to 83%. Including fracture risk in the expanded OP criterion improved case identification, and the algorithms achieved the highest PPV: 70% to 85%.

CONCLUSIONS

Identifying patients with OP or low BMD and high risk for osteoporotic fractures is possible in administrative data if using information about both OP diagnoses and fracture risk profile.

Greater likelihood of remission in rheumatoid arthritis patients treated earlier in the disease course: results from the Consortium of Rheumatology Researchers of North America registry

OBJECTIVE

To examine whether disease duration is an independent predictor of achieving remission in rheumatoid arthritis (RA) patients initiating therapy.

METHODS

RA patients in the Consortium of Rheumatology Researchers of North America registry newly prescribed a nonbiologic disease-modifying antirheumatic drug (DMARD) or anti--tumor necrosis factor (anti-TNF) with at least one followup visit were identified. Achievement of remission was defined using the Clinical Disease Activity Index (CDAI; score ≤2.8) and 28-joint Disease Activity Score (DAS28; score <2.6) at any followup visit within one year; sustained remission was defined as remission during any two successive visits. Likelihood of remission was examined through logistic regression based on 5-year increments of disease duration, adjusting for baseline covariates.

RESULTS

Among the 1,646 nonbiologic DMARD initiators, CDAI remission occurred in 21.3% of those with ≤5 years of disease duration, 19.6% with 6-10 years, and 13.5% with ≥11 years (P < 0.001); sustained remission occurred in 10.2%, 8.8%, and 2.5%, respectively (P < 0.001). Results were similar among the 3,179 anti-TNF initiators (CDAI remission in 22.3%, 17.7%, and 12.8%, respectively [P < 0.001]; CDAI sustained remission in 9.7%, 9.5%, and 4.2%, respectively [P < 0.001]). DAS28 results were similar in both groups. In adjusted analyses, an increase of disease duration by 5 years was associated with a reduced likelihood of CDAI remission in nonbiologic DMARD (odds ratio [OR] 0.91, 95% confidence interval [95% CI] 0.83-0.99) and anti-TNF initiators (OR 0.88, 95% CI 0.83-0.94). A similar result was seen for sustained remission using the CDAI (nonbiologic DMARD: OR 0.61, 95% CI 0.48-0.76; anti-TNF: OR 0.85, 95% CI 0.75-0.97).

CONCLUSION

Earlier treatment was associated with a greater likelihood of remission.

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach

BACKGROUND

More than 1.6 million Americans currently reside in nursing homes. As many as 12% of them receive long-term anticoagulant therapy with warfarin. Prior research has demonstrated compelling evidence of safety problems with warfarin therapy in this setting, often associated with suboptimal communication between nursing home staff and prescribing physicians.

METHODS

We conducted a randomized trial of a warfarin management protocol using facilitated telephone communication between nurses and physicians in 26 nursing homes in Connecticut in 2007-2008. Intervention facilities received a warfarin management communication protocol using the approach "Situation, Background, Assessment, and Recommendation" (SBAR). The protocol included an SBAR template to standardize telephone communication about residents on warfarin by requiring information about the situation triggering the call, the background, the nurse's assessment, and recommendations.

RESULTS

There were 435 residents who received warfarin therapy during the study period for 55,167 resident days in the intervention homes and 53,601 in control homes. In intervention homes, residents' international normalized ratio (INR) values were in the therapeutic range a statistically significant 4.50% more time than in control homes (95% confidence interval [CI], 0.31%-8.69%). There was no difference in obtaining a follow-up INR within 3 days after an INR value ≥4.5 (odds ratio 1.02; 95% CI, 0.44-2.4). Rates of preventable adverse warfarin-related events were lower in intervention homes, although this result was not statistically significant: the incident rate ratio for any preventable adverse warfarin-related event was .87 (95% CI, .54-1.4).

CONCLUSION

Facilitated telephone communication between nurses and physicians using the SBAR approach modestly improves the quality of warfarin management for nursing home residents.

Patients and providers view gout differently: a qualitative study

OBJECTIVES

We sought to examine patients' and providers' views on the treatment of gout to better understand why management is suboptimal.

METHODS

In-depth telephone interviews were conducted with gout patients (n = 26) who initiated treatment with a urate-lowering drug (ULD) in the previous 6 months and with providers who care for gout patients (n = 15). The interviews were audiotaped and transcribed verbatim. Using qualitative methods, results were analysed and themes were identified. Interviews focused on the acute management, chronic management and prevention and improvement strategies.

RESULTS

Providers viewed the majority of patients as having excellent relief with non-steroidal anti-inflammatories, colchicine and glucocorticoids, while some patients felt these medications were ineffective. Providers felt that most patients had a good understanding of the rationale for ULD therapy and that patients responded well. Some patients felt ULDs triggered, worsened or had no impact on their disease. Most providers thought medication adherence was relatively good. Some patients reported discontinuing medications. Discontinuations were largely purposeful and due to clinical or financial concerns. Most providers thought they had adequate skills to teach disease self-management behaviours. Patients requested more information and longer visit times.

CONCLUSIONS

Providers view gout as easily managed, while patients report challenges and purposeful non-adherence.

Adherence and occurrence of fractures after switching to once-monthly oral bisphophonates

PURPOSE

Reducing dosing demands of medications generally increases adherence, although this relationship has not been demonstrated with the once-monthly oral bisphosphonates (BP). The study aim is to test whether switching from once-weekly BPs to once-monthly BPs improves adherence and fracture risk.

METHODS

This is an interrupted times-series analysis of new users of once-weekly BPs in a nationwide administrative health database from 2003 to 2007. Participants include 1835 individuals who switched to once-monthly BPs and two propensity-matched comparator groups: 1835 individuals who switched to a different once-weekly BP, and 1835 who did not switch. We measured changes in adequate adherence pre- and post-switch as monthly medication possession ratio >0.80, and calculated incidence rate ratios (IRR) of osteoporotic fractures.

RESULTS

All study groups experienced major adherence failure in the first year of therapy: the proportion of adequate adherers was 42% among once-monthly switchers, 47% among once-weekly switchers, and 37% among nonswitchers. However, the once-monthly switch was associated with less adherence failure (4% fewer adherers per month pre-switch vs. 1% fewer adherers per month post-switch, p<0.000). There was no statistically significant change in adherence rates for the other groups. We did not detect significantly reduced fracture risk with once-monthly switch: 1 year post-switch, the fracture incidence risk ratios for once-monthly switchers relative to once-weekly switchers were IRR 0.83, 95% CI: 0.50-1.36, and IRR 0.90, 95% CI: 0.54-1.49, relative to nonswitchers).

CONCLUSIONS

Reducing the dosing demands of oral bisphosphonates from once-weekly to once-monthly decreased adherence failure but had an uncertain impact on fracture risk.

Physician preference motivates the use of anti-tumor necrosis factor therapy independent of clinical disease activity

OBJECTIVE

Physician preference has previously been shown to be an important determinant of prescription patterns, independent of patient-specific factors. We evaluated whether physician preference was important in the decision to select anti-tumor necrosis factor (anti-TNF) therapy rather than nonbiologic disease-modifying antirheumatic drugs (DMARDs) among rheumatoid arthritis (RA) patients initiating a new RA medication.

METHODS

Using data from the Consortium of Rheumatology Researchers of North America, we identified RA patients who had never taken biologics initiating either anti-TNF therapy or a DMARD in 2001-2008. Physician preference for the use of anti-TNF agents was calculated using data from the preceding calendar year for each physician's other RA patients. Multivariable logistic regression with generalized estimating equations accounted for clustering of patients within the physician practice and evaluated the relationship between physician preference and receipt of anti-TNF therapy, controlling for patient-related factors and disease activity using the Clinical Disease Activity Index.

RESULTS

We identified 1,532 RA patients initiating anti-TNF therapy or a DMARD. In models adjusting for tender and swollen joint counts and global disease activity, physician preference for the use of anti-TNF therapy was an independent predictor of receipt of these agents. Patients of physicians in the highest and middle tertiles of physician preference had a 2.50 (95% confidence interval [95% CI] 1.76-3.56) and 1.70 (95% CI 1.22-2.39) greater likelihood of receiving anti-TNF medications, respectively.

CONCLUSION

Physician preference is an important determinant of patients' receipt of anti-TNF therapy and may be useful to examine in future studies of RA treatment patterns, costs, and medication safety.

Adoption of once-monthly oral bisphosphonates and the impact on adherence

BACKGROUND

The extent of the adoption of once-monthly bisphosphonates into general clinical practice is not known, nor is it known if the novel formulation improves adherence.

METHODS

We analyzed administrative claims 2003-2006 from a large employer-based health insurance database for incident use of oral bisphosphonates and stratified users by daily, weekly, and monthly dosing regimen. We measured adherence as the medication possession ratio (MPR) during the first year of therapy. We compared patient characteristics by dosing regimen and evaluated how the dosing regimen influenced the MPR.

RESULTS

We identified 61,125 incident users of bisphosphonates (n=1034 daily, n=56,925 weekly, n=3166 monthly). Monthly bisphosphonate users were, on average, slightly older than the other groups (mean age 66 years for monthly users vs 65 years for weekly users or 66 years for daily users, P<.05) and more often lived in the North Central or South United States (76% vs 72% weekly users or 69% daily users, P<.05). There were no detectable differences among the dosing groups in the history of serious gastrointestinal risk, comorbidity burden, or prior osteoporotic fractures. During the first year of bisphosphonate therapy, 49% of monthly users had MPR> or =80% compared with 49% of weekly users (not significant) or 23% of daily users (P<.0001).

CONCLUSION

We found little evidence of preferential prescribing of monthly bisphosphonates to certain types of patients. Furthermore, we found no evidence of improved bisphosphonate adherence with monthly dosing relative to weekly dosing, although adherence with either weekly or monthly dosing was significantly better than with daily dosing.

Understanding the role of sex differences in work injuries: Implications for primary care practice

PURPOSE

Primary care physicians care for work-injured women and men, yet there is little information on sex differences in outcomes and factors contributing to post-injury outcomes to guide their evaluation and recommendations.

METHODS

Two self-administered questionnaires were sent to a large sample of women and men with work injuries reported to the New Hampshire (USA) Department of Labour between November 2000 and March 2002. Factors associated with the work injury and outcomes were assessed.

RESULTS

A total of 3001 persons (1448 women and 1553 men) completed the first questionnaire and 67% completed the second questionnaire. Work-injured women were significantly younger, more educated, more likely to be single, had more pre-injury comorbidities, and worked in less physically demanding occupations as compared to work-injured men. Women's injuries were more often a result of routine job tasks and of gradual onset. Women had worse long-term outcomes including job stability and post-injury income. In multivariate analyses, being female was independently associated with a negative employer response and greater future work concerns.

CONCLUSIONS

Women and men differ in terms of work injury circumstances and factors contributing to post-injury outcomes. Primary care providers should consider sex when evaluating and treating work-injured adults.

Evaluation of composite measures of treatment response without acute-phase reactants in patients with rheumatoid arthritis

OBJECTIVES

To evaluate composite measures of response without acute-phase reactants in RA patients. Specifically, Clinical Disease Activity Index (CDAI)-derived response criteria were compared with the European League Against Rheumatism (EULAR) response criteria, and the modified ACR (mACR) response criteria were compared to the ACR response criteria.

METHODS

Data from 10 108 RA patients enrolled in the Consortium of Rheumatology Researchers of North America registry were examined, including 649 patients initiating DMARD therapy. CDAI cut-off points for disease activity levels and responses were derived using receiver operating characteristic curves with the DAS28 and EULAR response criteria as gold standards. The kappa-statistics were applied to assess agreement between CDAI-derived and EULAR-defined responses, as well as ACR20 and ACR50 with mACR20- and mACR50-defined responses, respectively.

RESULTS

For the components of the EULAR response, the derived CDAI cut-off points for DAS28 levels of 3.2 and 5.1 were 7.6 and 19.6, respectively. The derived CDAI cut-off points were 4.3 and 10.0 for DAS28 changes of 0.6 and 1.2, respectively. There were moderate to substantial agreements between CDAI-derived and EULAR responses (kappa = 0.57-0.71). Agreement of ACR20 and ACR50 with mACR20 and mACR50 responses, respectively, was excellent (kappa = 0.88-0.95).

CONCLUSIONS

Agreement between composite measures of response without acute-phase reactants and standard measures ranged from moderate to excellent. The mACR20 and mACR50 criteria as well as CDAI-derived response criteria, can serve as composite measures of response in clinical practice and research settings without access to acute-phase reactants.