Racial and ethnic disparities in rheumatoid arthritis

The geography of arthritis-attributable pain outcomes: a county-level spatial analysis

ABSTRACT

Research on the geographic distribution of pain and arthritis outcomes, especially at the county level, is limited. This is a high-priority topic, however, given the heterogeneity of subnational and substate regions and the importance of county-level governments in shaping population health. Our study provides the most fine-grained picture to date of the geography of pain in the United States. Combining 2011 Behavioral Risk Factor Surveillance System data with county-level data from the Census and other sources, we examined arthritis and arthritis-attributable joint pain, severe joint pain, and activity limitations in US counties. We used small area estimation to estimate county-level prevalences and spatial analyses to visualize and model these outcomes. Models considering spatial structures show superiority over nonspatial models. Counties with higher prevalences of arthritis and arthritis-related outcomes are mostly clustered in the Deep South and Appalachia, while severe consequences of arthritis are particularly common in counties in the Southwest, Pacific Northwest, Georgia, Florida, and Maine. Net of arthritis, county-level percentages of racial/ethnic minority groups are negatively associated with joint pain prevalence, but positively associated with severe joint pain prevalence. Severe joint pain is also more common in counties with more female individuals, separated or divorced residents, more high school noncompleters, fewer chiropractors, and higher opioid prescribing rates. Activity limitations are more common in counties with higher percentages of uninsured people. Our findings show that different spatial processes shape the distribution of different arthritis-related pain outcomes, which may inform local policies and programs to reduce the risk of arthritis and its consequences.

Therapeutic delivery systems for rheumatoid arthritis based on hydrogel carriers

Rheumatoid arthritis (RA) is an autoimmune disease suffered by millions of people worldwide. It can significantly affect the patient's quality of life by damaging not only the joints but also organs such as the lungs and the heart. RA is normally treated using nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, disease-modifying antirheumatic drugs (DMARDs), and biologics. These active agents often cause side effects and offer low efficacy due to their lack of specificity and limited retention time. In an attempt to improve RA treatments, hydrogel-based systems have been proposed as drug delivery carriers. Due to their exceptional adaptability and biocompatibility, hydrogels have the potential of enhancing the delivery of RA therapy through different administration routes in an efficient and effective manner. In this review, we explore the application of hydrogel systems as potential carriers in RA treatment. Additionally, we discuss recent work in the field and highlight the required hydrogel properties, depending on the administration route. The outstanding potential of hydrogel systems as carriers for RA was demonstrated; however, there is extensive research yet to be done to improve available treatments for RA.

Ideal cardiovascular health metrics have better identification of arthritis

BACKGROUND

This study aimed to explore the association between ideal cardiovascular health metrics (ICVHM) and arthritis (AR), as well as the interactions of various indicators in ICVHM on AR in US adults.

METHODS

We involved 17,041 participants who were interviewed by NHANES from 2011 to 2018. AR included osteoarthritis or degenerative arthritis (OA), rheumatoid arthritis (RA), and psoriatic arthritis and other arthritis (Other AR). Logistic regression was applied to analyze the association between AR and ICVHM. Mixed graphical model (MGM) was used to explore the interaction between variables in ICVHM.

RESULTS

Higher ICVHM scores had a protective effect on AR. Compared to "≤1" score, the ORs of AR in participants with 2, 3, 4, and ≥5 were 0.586, 0.472, 0.259, and 0.130, respectively. Similar results were also found in different types of AR. ICVHM has a maximum area under the curve value of 0.765 and the interaction between blood pressure and total cholesterol was 0.43.

CONCLUSIONS

ICVHM correlates significantly with AR and is better at identifying AR than individual indicators. ICVHM can be better improved by controlling the indicators with stronger interactions. Our findings provide guidance for promoting health factors, which have important implications for identification and prevention of AR.

Racial and Ethnic Distribution of Rheumatic Diseases in Health Systems of the National Patient-Centered Clinical Research Network

OBJECTIVE

To evaluate the relative prevalence of 8 rheumatic and musculoskeletal diseases (RMDs) across racial and ethnic groups within the National Patient-Centered Clinical Research Network (PCORnet).

METHODS

Electronic health records from participating PCORnet institutions and systems from January 1, 2013, to December 31, 2018, were used to identify adult patients with ≥ 2 diagnosis codes for rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoporosis (OP), granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), giant cell arteritis (GCA), and Takayasu arteritis (TAK). Among those with race and ethnicity data available, we compared prevalence of RMDs by race and ethnicity.

RESULTS

Data from 28,059,546 patients were available for analysis. RA was more common in patients who were American Indian or Alaska Native vs White, with a prevalence of 11.57 vs 10.11/1000 (odds ratio [OR] 1.15, 95% CI 1.09-1.22). SLE was more common in patients who were Black or African American (6.73/1000), American Indian or Alaska Native (3.82/1000), and Asian (3.39/1000) vs White (2.80/1000; OR 2.43, 95% CI 2.39-2.46; OR 1.39, 95% CI 1.25-1.53; OR 1.26, 95% CI 1.21-1.31, respectively). SLE was more common in patients who were Hispanic vs non-Hispanic (prevalence 3.93 vs 3.45/1000, OR 1.14, 95% CI 1.12-1.16). TAK was more common in patients who were Asian vs White (prevalence 0.05 vs 0.04/1000, OR 1.43, 95% CI 1.00-2.03). OP, RA, and the vasculitides were all more common in patients who were White vs Black or African American.

CONCLUSION

These data provide important information on the prevalence of RMDs by race and ethnicity in the United States. PCORnet can be used as a reliable data source to study RMDs within a large representative population.

Sociocultural and Economic Disparities in Physical Therapy Utilization Among Insured Older Adults With Rheumatoid Arthritis

OBJECTIVE

To examine influences of sociocultural and economic determinants on physical therapy (PT) utilization for older adults with rheumatoid arthritis (RA).

METHODS

In these annual cross-sectional analyses between 2012 and 2016, we accessed Medicare enrollment data and fee-for-service claims. The cohort included Medicare beneficiaries with RA based on 3 diagnosis codes or 2 codes plus a disease-modifying antirheumatic drug medication claim. We defined race and ethnicity and dual Medicare/Medicaid coverage (proxy for income) using enrollment data. Adults with a Current Procedural Terminology code for PT evaluation were classified as utilizing PT services. Associations between race and ethnicity and dual coverage and PT utilization were estimated with logistic regression analyses. Potential interactions between race and ethnicity status and dual coverage were tested using interaction terms.

RESULTS

Of 106,470 adults with RA (75.1% female; aged 75.8 [SD 7.3] years; 83.9% identified as non-Hispanic White, 8.8% as non-Hispanic Black, 7.2% as Hispanic), 9.6-12.5% used PT in a given year. Non-Hispanic Black (adjusted odds ratio [aOR] 0.77, 95% CI 0.73-0.82) and Hispanic (aOR 0.92, 95% CI 0.87-0.98) individuals had lower odds of PT utilization than non-Hispanic White individuals. Adults with dual coverage (lower income) had lower odds of utilization than adults with Medicare only (aOR 0.44, 95% CI 0.43-0.46). There were no significant interactions between race and ethnicity status and dual coverage on utilization.

CONCLUSION

We found sociocultural and economic disparities in PT utilization in older adults with RA. We must identify and address the underlying factors that influence these disparities in order to mitigate them.

Racial and Ethnic Differences in a Biochemical Marker of Rheumatoid Arthritis Disease Activity

OBJECTIVE

Racial and ethnic disparities in rheumatoid arthritis (RA) disease activity measures have been documented. We compared racial and ethnic differences in disease activity using multiple composite measures, including an objective measure, the multi-biochemical disease activity (MBDA) score.

METHODS

Data are derived from the University of California, San Francisco RA Cohort, a longitudinal observational cohort. Participants with at least one MBDA measure and self-reported race and ethnicity were included. Multivariable linear regression evaluated the association between race and ethnicity groups and mean MBDA score, adjusting for potential confounders, including symptom duration and medication use. Sensitivity analyses substituted the Clinical Disease Activity Index (CDAI) and the Disease Activity Score-28 joints with erythrocyte sedimentation rate (DAS28-ESR) for the MBDA in multivariable models.

RESULTS

We included 267 participants (86% female, mean age 52.7 ± 13.3 years). The majority were Latinx (n = 137; 51%), followed by Asian (n = 91; 34%). After adjustment, Latinx participants had the highest mean MBDA score (40.6 ± 2.1) compared with White participants at (32.8 ± 6.7). Black participants had the second highest mean MBDA score, followed by Asian participants (36.3 ± 5.3, 36.0 ± 2.7, respectively), although neither were significantly different from White participants. The trends observed for the CDAI and DAS28-ESR were similar to those for the MBDA.

CONCLUSION

We found significantly higher disease activity measured by the MBDA and DAS28-ESR in Latinx participants compared with White participants. We also found significantly higher disease activity in Asian participants compared with White participants with the DAS28-ESR. Our findings, although limited by the small number of White participants in the referent group, suggest that RA disease activity measures may be influenced by external factors that have differential impacts by racial and ethnic group.

Racial Differences in Multimorbidity and Comorbidities in Rheumatoid Arthritis

OBJECTIVE

To identify differences in multimorbidity and individual comorbidities among individuals with rheumatoid arthritis (RA), separated by race and ethnicity.

METHODS

This case-control study within OptumLabs Data Warehouse from 2010 to 2019 matched RA cases (defined by 2 codes plus prescription of an RA drug) to non-RA controls 1:1 on age, sex, race and ethnicity, region, index date of RA, and insurance coverage duration. We defined multimorbidity as the presence of ≥2 or ≥5 validated comorbidities. Logistic regression models calculated adjusted odds of multimorbidity with 95% confidence intervals (95% CIs) within each race and ethnicity.

RESULTS

We identified 154,391 RA cases and 154,391 controls (mean age 59.6, 76% female). Black enrollees had the most multimorbidity ≥2/≥5 (73.1%, 34.3%); Asian enrollees had the least (52.4%, 17.3%). Adjusted odds of multimorbidity ≥2 and ≥5 in RA cases versus controls was 2.19 (95% CI 2.16-2.23) and 2.06 (95% CI 2.02-2.09), respectively. This increase was similar across race and ethnicity. However, we observed elevated occurrence of certain comorbidities by race and ethnicity versus controls (P < 0.001), including renal disease in White enrollees (4.7% versus 3.2%) and valvular heart disease in Black and White enrollees (3.2% and 2.8% versus 2.6% and 2.2%).

CONCLUSION

Multimorbidity is a problem for all RA patients. Targeted identification of certain comorbidities by race and ethnicity may be a helpful approach to mitigate multimorbidity.

Associations of Rheumatoid Arthritis and Depressive Symptoms Over Time: Are There Differences by Education, Race/Ethnicity, and Gender?

OBJECTIVE

To examine associations between changes in rheumatoid arthritis (RA) symptoms and depressive symptoms adjusted for other time-varying characteristics, and to test if these associations differed by education, race/ethnicity, or gender.

METHODS

Data from the 1988-1998 US National Rheumatoid Arthritis Study were analyzed (n = 854). Time-varying covariates included year of the study, pain, functional ability, household work disability, parental status, marital status, employment status, and social support. The time-invariant covariates included years since diagnosis, education, race/ethnicity, and gender. Multivariate multilevel-model analyses were used to estimate associations within people over time.

RESULTS

Patients with RA experience considerable change in depressive symptoms, pain, functional disability, and household work disability over the study period. Depressive symptoms were driven more by differences between people compared to changes within people over time. Findings show that patients experienced increases in depressive symptoms over the study period. The rate of change in depressive symptoms did not differ by education, race/ethnicity, or gender. Times of worse pain, functional disability, and household disability were associated with worse depressive symptoms. The association of functional disability and depressive symptoms was stronger for men than women.

CONCLUSION

Increases in pain and disability were associated with worse depressive symptoms, adjusted for covariates. It is important to monitor and treat both mental and physical health symptoms. Future research efforts should focus on collecting data reflecting the educational, gender, and racial/ethnic diversity of individuals with RA.

Worse outcomes linked to ethnicity for early inflammatory arthritis in England and Wales: a national cohort study

OBJECTIVE

To assess variability in care quality and treatment outcomes across ethnicities in early inflammatory arthritis (EIA).

METHODS

We conducted an observational cohort study in England and Wales from May 2018 to March 2020, including patients with a suspected/confirmed EIA diagnosis. Care quality was assessed against six metrics defined by national guidelines. Clinical outcomes were measured using DAS28. Outcomes between ethnic groups ('White', 'Black', 'Asian', 'Mixed', 'Other') were compared, and adjusted for confounders.

RESULTS

A total of 35 807 eligible patients were analysed. Of those, 30 643 (85.6%) were White and 5164 (14.6%) were from ethnic minorities: 1035 (2.8%) Black; 2617 (7.3%) Asian; 238 (0.6%) Mixed; 1274 (3.5%) Other. In total, 12 955 patients had confirmed EIA, of whom 11 315 were White and 1640 were from ethnic minorities: 314 (2.4%) Black; 927 (7.1%) Asian; 70 (0.5%) Mixed; 329 (2.5%) Other. A total of 14 803 patients were assessed by rheumatology within three weeks, and 5642 started treatment within six weeks of referral. There were no significant differences by ethnicity. Ethnic minority patients had lower odds of disease remission at three months [adjusted odds ratio 0.79 (95% CI: 0.65, 0.96)] relative to White patients. Ethnic minorities were significantly less likely to receive initial treatment withMTX[0.68 (0.52, 0.90)] or with glucocorticoids [0.63 (0.49, 0.80)].

CONCLUSION

We demonstrate that some ethnic minorities are less likely to achieve disease remission in three months following EIA diagnosis. This is not explained by delays in referral or time to treatment. Our data highlight the need for investigation into the possible drivers of these inequitable outcomes and reappraisal of EIA management pathways.

Patient Empowerment: Apni Jung (Our Fight) against Rheumatoid Arthritis for South Asian Population

Covid-19 has affected many populations in the UK, and ethnic minority communities in particular. People from ethnic minority communities living with long-term chronic diseases have shown to be less engaging with self-management and report having poor medication adherence. The main reason to this problem is the way information is delivered to non-English speaking patients. This editorial discusses an innovation to over this barriers in rheumatology practice.

Is Rheumatoid Arthritis Related to Coffee Consumption in Korea? A Nationwide Cross-Sectional Observational Study

Coffee consumption is gradually increasing in Korea. As a result, interest in the relationship between coffee consumption and various diseases is growing. Several factors affect the development of rheumatoid arthritis (RA), and coffee consumption may be related. We conducted a nationwide cross-sectional study using data from the Korea National Health and Nutrition Examination Survey (2012–2016). A total of 12,465 eligible participants (4819 men and 7646 women) were included in the study. Participants with RA were defined as those who were diagnosed and currently being treated by physicians. Daily coffee consumption amounts were categorized as none, <1 cup, 1–2 cups, 2–3 cups, and ≥3 cups a day based on a self-report. A multivariable logistic regression model was employed, and we calculated the odds ratios (ORs) and 95% confidence intervals (CIs) for the odds of participants having RA with respect to coffee consumption. Compared to the no-coffee group, the ORs for RA in the <1 cup and 1–2 cups groups were 2.99 (95% CI 0.33–27.28) and 2.63 (95% CI 0.31–22.63) in men, respectively, and the ORs for RA for women in the <1 cup, 1–2 cups, 2–3 cups, and ≥3 cups groups were 0.62 (95% CI 0.31–1.26), 0.67 (95% CI 0.33–1.37), 1.08 (95% CI 0.35–3.36), and 1.43 (95% CI 0.25–8.36), respectively. Our study concludes, therefore, that daily coffee consumption is not related to the prevalence of RA in the general Korean population.

Health Disparities Among Hispanics With Rheumatoid Arthritis: Delay in Presentation to Rheumatologists Contributes to Later Diagnosis and Treatment

OBJECTIVE

The aim of this study was to evaluate referral and treatment delays by ethnicity/race in patients with rheumatoid arthritis (RA) treated at an academic rheumatology center.

METHODS

We reviewed the medical records of all RA patients evaluated at an outpatient clinic between 2011 and 2016 to identify newly diagnosed and naive-to-treatment patients. We determined the durations between symptom onset and first rheumatology visit and time to initiate treatment. Data extraction included referral source, demographics, treatment, and laboratory tests. Routine use of a multidimensional health assessment questionnaire allowed us to calculate baseline RAPID3 (routine assessment of patient index data 3) scores. Comparisons between self-reported ethnicity/race groups were performed. We used logistic regression models to analyze associations between baseline variables and early referral.

RESULTS

Data from 152 disease-modifying antirheumatic drug-naive RA patients were included in the study; 35% were white, 37% black, 20% Hispanic, and 8% other. The range in median time to first rheumatology visit was 6 to 8 months for all patient groups, except Hispanic. This group had a median time of 22.7 months (p = 0.01). The referral pattern was considerably variable between-groups; 40% of Hispanic patients were self-referred (p = 0.01). There were no statistically significant between-group differences for time to treatment initiation according to ethnicity/race. RAPID3 scores (p = 0.04) and erythrocyte sedimentation rates (p = 0.01) were significantly higher in the black and Hispanic groups. A high C-reactive protein value at baseline was associated with earlier referral.

CONCLUSIONS

There is significant delay in initial presentation to a rheumatologist that was associated with a higher disease severity at presentation, especially for Hispanic patients.

Longitudinal assessment of racial disparities in juvenile idiopathic arthritis disease activity in a treat-to-target intervention

BACKGROUND

We sought to evaluate racial disparities in disease outcomes among children with polyarticular juvenile idiopathic arthritis (JIA) during a treat-to-target (TTT) intervention with clinical decision support (CDS).

METHODS

This was a retrospective analysis of a TTT-CDS strategy integrated into clinical practice for children with polyarticular JIA at a single center from 2016 to 2019. The primary outcome was the clinical Juvenile Arthritis Disease Activity Score (cJADAS-10). We used multivariable linear regression to assess racial differences in disease outcomes at the index visit (first visit after implementation). The effect of race on disease outcomes over time was estimated using linear mixed-effects models, stratified by incident or prevalent disease.

RESULTS

We included 159 children with polyarticular JIA, of which 74, 13 and 13% were white, black, and Asian/other, respectively. cJADAS-10 improved significantly over time for all race categories, while the rates of improvement did not differ by race in incident (p = 0.53) or prevalent cases (p = 0.58). cJADAS-10 over time remained higher among black children compared to white children (β 2.5, p < 0.01 and β 1.2, p = 0.08 for incident and prevalent cases, respectively). Provider attestation to CDS use at ≥50% of encounters was associated with a 3.9 greater reduction in cJADAS-10 among black children compared to white children (p = 0.02).

CONCLUSION

Despite similar rates of improvement over time by race, disparities in JIA outcomes persisted throughout implementation of a TTT-CDS approach. More consistent CDS use may have a greater benefit among black children and needs to be explored further.

A comparison of risk factors for osteo- and rheumatoid arthritis using NHANES data

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Both osteo- and rheumatoid arthritis increase with age.

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Osteoarthritis is more common in whites, but rheumatoid arthritis is in blacks.

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Obesity and female sex increase risk of risk of both osteo- and rheumatoid arthritis.

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Smoking increases risk of both forms of arthritis in women.

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These two forms of arthritis have many common risk factors.

Osteoarthritis and rheumatoid arthritis are both diseases of joints, but they have very different etiologies. Osteoarthritis is a disease assumed to result from wear and tear over time, whereas rheumatoid arthritis is an autoimmune disease where the body’s immune system attacks joint tissues. Using NHANES data (1999–2015), we have compared the influence of age, sex, ethnicity, body mass index and smoking on these two very different forms of arthritis. Incidence of both increases with age and are more frequent in females than males. There is little apparent difference between osteoarthritis and rheumatoid arthritis in women of normal as comparted to overweight, but both are more frequent in obese women, especially those over the age of 60. While osteoarthritis is more frequent in whites, blacks have more rheumatoid arthritis, and Hispanics show an intermediate prevalence. Smoking significantly increased the incidence of both osteoarthritis and rheumatoid arthritis in women, but increased prevalence of only RA in men. There was no effect of smoking on OA prevalence in males. It is remarkable that two diseases of joints, which have quite different causes, should have so many commonalities. The differences that exist appear to be due to a combination of inflammatory markers and access to health care.

Understanding the Role and Challenges of Patient Preferences in Disparities in Rheumatologic Disease Care

Evidence suggests patient preferences, including values and perspectives, have affected clinical outcomes, such as compliance, patient well-being, and satisfaction with care. A literature review was conducted with the purpose of exploring the tools used to elicit patients' treatment preferences and their roles in clinical outcomes. This review revealed racial differences in treatment preferences among patients with rheumatic and musculoskeletal diseases. The use of decision aids is a proactive intervention with potential for reducing race disparities and improving clinical outcomes. The utilization of patient preferences and values can improve outcomes by complementing the shared decision-making approach between patients and rheumatologists.

Diseases with health disparities as drivers of COVID-19 outcome

The COVID-19 pandemic has forced our society to come face to face with complex issues that were once theoretical but are now being played out in real time. As data from the pandemic accumulates, it is clear that COVID-19 is impacting some parts of society more than others. Unfortunately, there is an almost complete overlap between COVID-19 risk factors and conditions that are already represented as health disparities, such as hypertension, diabetes, heart disease, lung disease and immune disorders. In this review, we discuss our current understanding of the physiological and pathophysiological pathways that link these diseases to COVID-19 outcome. An increased awareness of the factors underlying this issue, both societal and medical, is needed to understand the long-term implications and possible solutions needed going forward.

The role of advanced MRI in the development of treat-to-target therapeutic strategies, patient stratification and phenotyping in rheumatoid arthritis

In this commentary, we discuss the potential of advanced imaging, particularly Dynamic Contrast Enhanced (DCE) magnetic resonance imaging (MRI) for the objective assessment of the inflammatory process in rheumatoid arthritis (RA). We emphasise the potential of DCE-MRI in advancing the field and exploring new areas of research and development in RA. We hypothesize that different grades of bone marrow edema (BME) and synovitis in RA can be examined and monitored in a more sensitive manner with DCE-MRI. Future treatments for RA may benefit from the application of enhanced imaging of BMEs and synovitis. DCE-MRI may also facilitate enhanced stratification and phenotyping of patients enrolled in clinical trials.

Characterizing hand and wrist ultrasound pattern in primary Sjögren's syndrome: a case-control study

INTRODUCTION/OBJECTIVES

To evaluate the clinical relevance of high-resolution hand and wrist ultrasound (US) findings and their possible associations with anti-citrullinated peptide antibodies in primary Sjögren's syndrome (pSS).

METHODS

Ninety-seven consecutive pSS patients (American-European Consensus Group, 2002) without meeting the American College of Rheumatology (ACR) criteria (1987) for rheumatoid arthritis (RA); 20 RA patients (ACR/European League Against Rheumatism (EULAR) criteria, 2010); and 80 healthy individuals with comparable age, gender, and ethnicity were enrolled in a case-control study. Disease activity was assessed by EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI). US was performed by one expert blinded to anti-CCP, anti-MCV, and IgM rheumatoid factor tested by ELISA.

RESULTS

Frequencies of grade 3 synovitis (9.3 vs. 0%, p = 0.004), tenosynovitis (36.1 vs. 3.8%, p < 0.001), and erosions (27.8 vs. 7.5%, p = 0.001) on US were higher in pSS patients than in healthy controls. ESSDAI presented a moderate correlation with the synovitis number (p = 0.001) and tenosynovitis (p < 0.001). Most pSS patients with erosions on US (81.5%) had negative anti-CCP. Nevertheless, anti-CCP ≥ 3× cut-off value was associated with the presence of erosions in pSS (p = 0.026). Erosions in pSS were mainly small size contrasting with moderate/large size in RA (p < 0.001), and positive power Doppler synovitis predominated in RA (p < 0.001).

CONCLUSIONS

US identified significant frequencies of grade 3 synovitis, tenosynovitis, and erosions in pSS. Synovitis and tenosynovitis numbers were correlated with ESSDAI. Association between erosions on US and anti-CCP (high titers) in pSS possibly identifies a subgroup with severe arthritis. These findings suggest that US is a useful method for assessing joint involvement in pSS.Key Points• US identified significant frequencies of grade 3 synovitis, tenosynovitis, and erosions in pSS patients in comparison with age- and race-healthy individuals.• Numbers of synovitis and tenosynovitis on US were correlated with ESSDAI values.• Most pSS patients with erosions on US were negative for anti-CCP, but anti-CCP ≥ 3× cut-off value was associated with the presence of erosions in this disease.• Erosions in pSS were mainly small size contrasting with moderate/large size in RA, and positive power Doppler synovitis predominated in RA.

Sociodemographic variation in the oral microbiome

PURPOSE

Variations in the oral microbiome are potentially implicated in social inequalities in oral disease, cancers, and metabolic disease. We describe sociodemographic variation of oral microbiomes in a diverse sample.

METHODS

We performed 16S rRNA sequencing on mouthwash specimens in a subsample (n = 282) of the 2013-2014 population-based New York City Health and Nutrition Examination Study. We examined differential abundance of 216 operational taxonomic units, and alpha and beta diversity by age, sex, income, education, nativity, and race/ethnicity. For comparison, we examined differential abundance by diet, smoking status, and oral health behaviors.

RESULTS

Sixty-nine operational taxonomic units were differentially abundant by any sociodemographic variable (false discovery rate < 0.01), including 27 by race/ethnicity, 21 by family income, 19 by education, 3 by sex. We found 49 differentially abundant by smoking status, 23 by diet, 12 by oral health behaviors. Genera differing for multiple sociodemographic characteristics included Lactobacillus, Prevotella, Porphyromonas, Fusobacterium.

CONCLUSIONS

We identified oral microbiome variation consistent with health inequalities, more taxa differing by race/ethnicity than diet, and more by SES variables than oral health behaviors. Investigation is warranted into possible mediating effects of the oral microbiome in social disparities in oral and metabolic diseases and cancers.

Effects of Language, Insurance, and Race/Ethnicity on Measurement Properties of the PROMIS Physical Function Short Form 10a in Rheumatoid Arthritis

OBJECTIVE

Most studies that have evaluated patient-reported outcomes, such as those utilizing the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a) in rheumatoid arthritis (RA), have been performed in white and English-speaking populations. The aim of our study was to assess the measurement properties of the PF10a in a racially/ethnically diverse population with RA and to determine the effect of non-English language proficiency, insurance status, and race/ethnicity on the validity and responsiveness of the PF10a.

METHODS

Data were abstracted from electronic health records for all RA patients seen in a university-based rheumatology clinic between 2013 and 2017. We evaluated the use of the PF10a, floor and ceiling effects, and construct validity across categories of language preference, insurance, and race/ethnicity. We used standardized response means and linear mixed-effects models to evaluate the responsiveness of the PF10a to longitudinal changes in the Clinical Disease Activity Index (CDAI) across population subgroups.

RESULTS

We included 595 patients in a cross-sectional analysis of validity and 341 patients in longitudinal responsiveness analyses of the PF10a. The PF10a had acceptable floor and ceiling effects and was successfully implemented. We observed good construct validity and responsiveness to changes in CDAI among white subjects, English speakers, and privately insured patients. However, constructs evaluated by the PF10a were less correlated with clinical measures among Chinese speakers and Hispanic subjects, and less sensitive to clinical improvements among Medicaid patients and Spanish speakers.

CONCLUSION

While the PF10a has good measurement properties and is both practical and acceptable for implementation in routine clinical practice, we also found important differences across racial/ethnic groups and those with limited English proficiency that warrant further investigation.

The economic burden of depression among adults with rheumatoid arthritis in the United States

AIMS

Depression is the most frequent comorbidity reported among patients with rheumatoid arthritis (RA). Comorbid depression negatively impacts RA patients' health-related quality-of-life, physical function, mental function, mortality, and experience of pain and symptom severity. The objective of this study was to assess healthcare utilization, expenditures, and work productivity among patients with RA with or without depression.

MATERIALS AND METHODS

Data from adult patients who had at least two visits each related to RA and depression over a 1-year period were extracted from the Truven Health MarketScan research databases. Outcomes comprised healthcare resource utilization, work productivity loss, and direct healthcare costs comparing patients with RA with depression (n = 3,478) vs patients with RA without depression (n = 43,222).

RESULTS

Patients with RA and depression had a significantly greater relative risk of hospitalization and number of all-cause and RA-related hospitalizations, utilization of emergency services, days spent in the hospital, physician visits, and RA-related surgeries compared with RA patients without depression. Patients with RA and depression had a higher risk of and experienced more events and days of short-term disability compared with patients without depression. The incremental adjusted annual all-cause and RA-related direct costs were $8,488 (95% CI = $6,793-$10,223) and $578 (95% CI = -$98-$1,243), respectively, when comparing patients with RA and depression vs RA only.

LIMITATIONS

The current analysis is subject to the known limitations of retrospective studies based on administrative claims data.

CONCLUSIONS

This study suggested increased healthcare utilization, work productivity loss, and economic burden among RA patients due to comorbid depression. These findings emphasize the importance of managing depression and including depression as a factor when devising treatment algorithms for patients with RA.

A Randomized, Double-Blind, Placebo-Controlled Clinical Trial of Tocilizumab, An Interleukin-6 Receptor Antibody, For Residual Symptoms in Schizophrenia

Evidence from preclinical, epidemiological, and human studies indicates that inflammation, and in particular elevated interleukin-6 (IL-6) activity, may be related to clinical manifestations and pathophysiology of schizophrenia. Furthermore, studies in preclinical models suggest that decreasing IL-6 activity may mitigate or reverse some of these deficits. The purpose of this trial was to test whether an IL-6 receptor antibody, tocilizumab, would improve residual positive and negative symptoms and cognitive deficits in schizophrenia. We randomized 36 clinically stable, moderately symptomatic (i.e., Positive and Negative Syndrome Scale (PANSS) >60) individuals with schizophrenia to 3 monthly infusions of 8 mg/kg tocilizumab or placebo (normal saline). The primary outcome was effect at week 12 on the PANSS Total Score. Effects on the MATRICS, other PANSS subscales, Clinical Global Impression, and Global Assessment of Functioning were secondary outcomes. There were no observed treatment effects on any behavioral outcome measure. Baseline C-reactive protein (CRP) or cytokine levels did not predict treatment outcome, nor were there correlations between changes in these inflammatory markers and the measured outcomes. As expected, IL-6 and IL-8 increased, while CRP decreased, in the tocilizumab group compared with the placebo group. This study did not reveal any evidence that an IL-6 receptor antibody affects behavioral outcomes in schizophrenia. One potential explanation is the lack of capacity of this agent to penetrate the central nervous system. Additional trials of medications aimed at targeting cytokine overactivity that act directly on brain function and/or treatment in early-stage psychosis populations are needed.

Identification and Treatment Optimization of Comorbid Depression in Rheumatoid Arthritis

Patients with rheumatoid arthritis (RA) suffer from high rates of depression but depression often remains undiagnosed and untreated among RA patients. Because of its high prevalence and its profound impact on functional disability and health-related quality of life, prompt recognition and management of comorbid depression is urgently needed in patients with RA. Rheumatologists face the challenge of addressing depression in their clinical interactions with patients. The purpose of this paper is to present the prevalence of comorbid depression in RA, to delineate the consequences of depression among RA patients, to discuss the barriers to the identification of depression among RA patients, and to outline a set of recommendations to identify and treat comorbid depression that could be implemented within the rheumatology clinic setting. A comprehensive approach to the management of both physical and mental health needs of RA patients can aid in improving patient overall quality of life. New clinical protocols should be developed to include routine depression screening as part of the rheumatology visit. Patient education to address misconceptions, knowledge gaps, and destigmatize depression is also recommended. More counseling resources, including emotional support groups, are necessary to provide treatment for those suffering from depression. Such interventions could help mitigate disability, improve quality of life, patient function, and overall satisfaction.

Use of Low-Literacy Decision Aid to Enhance Knowledge and Reduce Decisional Conflict Among a Diverse Population of Adults With Rheumatoid Arthritis: Results of a Pilot Study

OBJECTIVE

Despite innovations in treatment of rheumatoid arthritis (RA), adherence is poor and disparities persist. Shared decision making (SDM) promotes patient engagement and enhances adherence; however, few tools support SDM in RA. Our objective was to pilot a low-literacy medication guide and decision aid to facilitate patient-clinician conversations about RA medications.

METHODS

RA patients were consecutively enrolled into 1 of 3 arms: 1) control; patients received existing medication guide prior to clinic visit, 2) adapted guide prior to visit, and 3) adapted guide prior to plus decision aid during visit. Outcomes were collected immediately postvisit, at 1-week, and at 3- and 6-month interviews. Eligible adults had to have failed at least 1 disease-modifying antirheumatic drug and fulfill 1 of the following: age >65 years, immigrant, non-English speaker, less than high school education, limited health literacy, and racial/ethnic minority. Primary outcomes were knowledge of RA medications, decisional conflict, and acceptability of interventions.

RESULTS

The majority of 166 patients were immigrants (66%), non-English speakers (54%), and had limited health literacy (71%). Adequate RA knowledge postvisit in arm 3 was higher (78%) than arm 1 (53%; adjusted odds ratio 2.7, 95% confidence interval 1.2, 6.1). Among patients with a medication change, there was lower (better) mean decisional conflict in arms 2 and 3 (P = 0.03). There were no significant differences in acceptability.

CONCLUSION

A low-literacy medication guide and decision aid was acceptable, improved knowledge, and reduced decisional conflict among vulnerable RA patients. Enhancing knowledge and patient engagement with decision support tools may lead to medication choices better aligned with RA patients' values and preferences.

The design of a low literacy decision aid about rheumatoid arthritis medications developed in three languages for use during the clinical encounter

BACKGROUND

Shared decision-making in rheumatoid arthritis (RA) care is a priority among policy makers, clinicians and patients both nationally and internationally. Demands on patients to have basic knowledge of RA, treatment options, and details of risk and benefit when making medication decisions with clinicians can be overwhelming, especially for those with limited literacy or limited English language proficiency. The objective of this study is to describe the development of a medication choice decision aid for patients with rheumatoid arthritis (RA) in three languages using low literacy principles.

METHODS

Based on the development of a diabetes decision aid, the RA decision aid (RA Choice) was developed through a collaborative process involving patients, clinicians, designers, decision-aid and health literacy experts. A combination of evidence synthesis and direct observation of clinician-patient interactions generated content and guided an iterative process of prototype development.

RESULTS

Three iterations of RA Choice were developed and field-tested before completion. The final tool organized data using icons and plain language for 12 RA medications across 5 issues: frequency of administration, time to onset, cost, side effects, and special considerations. The tool successfully created a conversation between clinician and patient, and garnered high acceptability from clinicians.

CONCLUSIONS

The process of collaboratively developing an RA decision aid designed to promote shared decision making resulted in a graphically-enhanced, low literacy tool. The use of RA Choice in the clinical encounter has the potential to enhance communication for RA patients, including those with limited health literacy and limited English language proficiency.

Diabetes care and service access among elderly Vietnamese with type 2 diabetes

BACKGROUND

Vietnamese patients are disproportionately represented in type 2 diabetes mellitus statistics and also incur high rates of diabetes complications. This situation is compounded by limited access to health care. The aim of this project was to gain a deeper understanding of the difficulties Vietnamese patients experience when accessing services and managing their type 2 diabetes mellitus, and to identify factors that are important in promoting health service use.

METHODS

Three focus groups with 15 Vietnamese participants with type 2 diabetes mellitus, 60 to >70 years of age, were conducted in Vietnamese. Open-ended questions were used and focussed on experiences of living with diabetes and access to healthcare services in the Inner Northwest Melbourne region. Audio recordings were transcribed and then translated into English. Data were analysed using a thematic analysis framework.

RESULTS

Findings indicate four main themes, which together provide some insight into the experiences of living with diabetes and accessing ongoing care and support, for elderly Vietnamese with type 2 diabetes. Themes included: (1) the value of being healthy; (2) controlling diabetes; (3) staying healthy; and (4) improving services and information access.

CONCLUSIONS

Participants in this study were encouraged to adhere to diabetes self-management principles, based largely on a fear of medical complications. Important aspects of healthcare access were identified as; being treated with respect, having their questions answered and having access to interpreters and information in Vietnamese. Attention to these details is likely to lead to improved access to healthcare services and ultimately to improve glycemic control and overall health status for this community.

Differences in Effectiveness of the Active Living Every Day Program for Older Adults With Arthritis

Objective:

The authors explored whether demographic and psychosocial variables predicted differences in physical activity for participants with arthritis in a trial of Active Living Every Day (ALED).

Method:

Participants (N = 280) from 17 community sites were randomized into ALED or usual care. The authors assessed participant demographic characteristics, self-efficacy, outcome expectations, pain, fatigue, and depressive symptoms at baseline and physical activity frequency at 20-wk follow-up. They conducted linear regression with interaction terms (Baseline Characteristic × Randomization Group).

Results:

Being female (p ≤ .05), less depressed (p ≤ .05), or younger (p ≤ .10) was associated with more frequent posttest physical activity for ALED participants than for those with usual care. Higher education was associated with more physical activity for both ALED and usual-care groups.

Discussion:

ALED was particularly effective for female, younger, and less depressed participants. Further research should determine whether modifications could produce better outcomes in other subgroups.

Race, ethnicity, and disease outcomes in juvenile idiopathic arthritis: a cross-sectional analysis of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry

OBJECTIVE

To measure the associations between self-reported race and ethnicity and disease outcomes, including joint damage, pain, and functional ability, in children with juvenile idiopathic arthritis (JIA).

METHODS

A cross-sectional analysis of children with JIA enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry between May 2010 and March 2012. Mann-Whitney U test and chi-square testing were used to compare patient characteristics between race (white, African American, or Asian) and ethnicity (Non-Hispanic and Non-Latino; Hispanic or Latino) categories. Logistic regression was used to measure the associations between each race or ethnicity category and the outcome of interest.

RESULTS

Race category was available for 4292 of 4682 children (93% white, 5% African American, Asian 3%). Ethnicity data were available for 4644 (11% Hispanic or Latino). African American children with polyarticular-course JIA had an elevated OR for joint damage on radiographic imaging compared to white children (OR 1.9, 95% CI 1.0-3.1; p = 0.04). Hispanic/Latino children had increased odds of having disability scores > 75th percentile (OR 1.5, 95% CI 1.1-2.1; p < 0.01) compared to non-Hispanic/Latino children; however, these odds were no longer significant when the cohort was limited to children with polyarticular-course JIA. Asian children had decreased odds of higher pain and functional disability compared to white children (p < 0.05).

CONCLUSION

Race and ethnicity were variably associated with joint damage, pain, and functional ability. Understanding outcome variation between different race and ethnicity groups may help to optimize care for children with JIA.