A Novel Approach for Mixed-Methods Research Using Large Language Models: A Report Using Patients' Perspectives on Barriers to Arthroplasty

OBJECTIVE

Mixed-methods research is valuable in health care to gain insights into patient perceptions. However, analyzing textual data from interviews can be time-consuming and require multiple analysts for investigator triangulation. This study aims to explore a novel approach to investigator triangulation in mixed-methods research by employing a large language model (LLM) for analyzing data from patient interviews.

METHODS

This study compared the thematic analysis and survey generation performed by human investigators and ChatGPT-4, which uses GPT-4 as its backbone model, using data from an existing study that explored patient perceptions of barriers to arthroplasty. The human- and ChatGPT-4-generated themes and surveys were compared and evaluated based on their representation of salient themes from a predetermined topic guide.

RESULTS

ChatGPT-4 generated analogous dominant themes and a comprehensive corresponding survey as the human investigators but in significantly less time. The survey questions generated by ChatGPT-4 were less precise than those developed by human investigators. The mixed-methods flowchart proposes integrating LLMs and human investigators as a supplementary tool for the preliminary thematic analysis of qualitative data and survey generation.

CONCLUSION

By utilizing a combination of LLMs and human investigators through investigator triangulation, researchers may be able to conduct more efficient mixed-methods research to better understand patient perspectives. Ethical and qualitative implications of using LLMs should be considered.

Large language models and the future of rheumatology: assessing impact and emerging opportunities

PURPOSE OF REVIEW

Large language models (LLMs) have grown rapidly in size and capabilities as more training data and compute power has become available. Since the release of ChatGPT in late 2022, there has been growing interest and exploration around potential applications of LLM technology. Numerous examples and pilot studies demonstrating the capabilities of these tools have emerged across several domains. For rheumatology professionals and patients, LLMs have the potential to transform current practices in medicine.

RECENT FINDINGS

Recent studies have begun exploring capabilities of LLMs that can assist rheumatologists in clinical practice, research, and medical education, though applications are still emerging. In clinical settings, LLMs have shown promise in assist healthcare professionals enabling more personalized medicine or generating routine documentation like notes and letters. Challenges remain around integrating LLMs into clinical workflows, accuracy of the LLMs and ensuring patient data confidentiality. In research, early experiments demonstrate LLMs can offer analysis of datasets, with quality control as a critical piece. Lastly, LLMs could supplement medical education by providing personalized learning experiences and integration into established curriculums.

SUMMARY

As these powerful tools continue evolving at a rapid pace, rheumatology professionals should stay informed on how they may impact the field.

Healthcare disparities: patients' perspectives on barriers to joint replacement

OBJECTIVE

Racial and ethnic disparities in arthroplasty utilization are evident, but the reasons are not known. We aimed to identify concerns that may contribute to barriers to arthroplasty from the patient's perspective.

METHODS

We identified patients' concerns about arthroplasty by performing a mixed methods study. Themes identified during semi-structured interviews with Black and Hispanic patients with advanced symptomatic hip or knee arthritis were used to develop a questionnaire to quantify and prioritize their concerns. Multiple linear and logistic regression analyses were conducted to determine the association between race/ethnicity and the importance of each theme. Models were adjusted for sex, insurance, education, HOOS, JR/KOOS, JR, and discussion of joint replacement with a doctor.

RESULTS

Interviews with eight participants reached saturation and provided five themes used to develop a survey answered by 738 (24%) participants; 75.5% White, 10.3% Black, 8.7% Hispanic, 3.9% Asian/Other. Responses were significantly different between groups (p < 0.05). Themes identified were "Trust in the surgeon" "Recovery", "Cost/Insurance", "Surgical outcome", and "Personal suitability/timing". Compared to Whites, Blacks were two-fold, Hispanics four-fold more likely to rate "Trust in the surgeon" as very/extremely important. Blacks were almost three times and Hispanics over six times more likely to rate "Recovery" as very/extremely important.

CONCLUSION

We identified factors of importance to patients that may contribute to barriers to arthroplasty, with marked differences between Blacks, Hispanics, and Whites.

Computer Vision Analysis of Rheumatoid Arthritis Synovium Reveals Lymphocytic Inflammation Is Associated With Immunoglobulin Skewing in Blood

OBJECTIVE

We sought to develop computer vision methods to quantify aggregates of cells in synovial tissue and compare these with clinical and gene expression parameters.

METHODS

We assembled a computer vision pipeline to quantify five features encompassing synovial cell density and aggregates and compared these with pathologist scores, disease classification, autoantibody status, and RNA expression in a cohort of 156 patients with rheumatoid arthritis (RA) and 149 patients with osteoarthritis (OA).

RESULTS

All five features were associated with pathologist scores of synovial lymphocytic inflammation (P < 0.0001). Three features that related to the cells per unit of tissue were significantly increased in patients with both seronegative and seropositive RA compared with those with OA; on the other hand, aggregate features (number and diameter) were significantly increased in seropositive, but not seronegative, RA compared with OA. Aggregate diameter was associated with the gene expression of immunoglobulin heavy-chain genes in the synovial tissue. Compared with blood, synovial immunoglobulin isotypes were skewed from IGHM and IGHD to IGHG3 and IGHG1. Further, patients with RA with high levels of lymphocytic infiltrates in the synovium demonstrated parallel skewing in their blood with a relative decrease in IGHGM (P < 0.002) and IGHD (P < 0.03) and an increase in class-switched immunoglobulin genes IGHG3 (P < 0.03) and IGHG1 (P < 0.002).

CONCLUSION

High-resolution automated identification and quantification of synovial immune cell aggregates uncovered skewing in the synovium from naïve IGHD and IGHM to memory IGHG3 and IGHG1 and revealed that this process is reflected in the blood of patients with high inflammatory synovium.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Black Patients are More Likely to Undergo Early Revision Total Knee Arthroplasty in a Matched Cohort Regardless of Surgeon Experience

BACKGROUND

Black patients are at an increased risk of aseptic revision total knee arthroplasty (TKA) when compared to White patients. The goal of this study was to determine whether racial disparities in revision TKA risk are related to surgeon characteristics.

METHODS

This was an observational cohort study. We used inpatient administrative data to identify Black patients who underwent unilateral primary TKA in New York State. There were 21,948 Black patients who were matched 1:1 to White patients on age, sex, ethnicity, and insurance type. The primary outcome was aseptic revision TKA within 2 years of primary TKA. We calculated annual surgeon TKA volume and identified surgeon characteristics such as training in North America, board certification, and years of experience.

RESULTS

Black patients had a higher odds of aseptic revision TKA (odds ratio (OR) 1.32, 95% CI 1.12-1.54, P < .001) and were disproportionately cared for by low volume surgeons (≤12 TKA/year). The relationship between low volume surgeons and risk of aseptic revision was not statistically significant (OR 1.24, 95% CI 0.72-2.11, P = .436). The adjusted odds ratio (aOR) for aseptic revision TKA in Black versus White patients varied across surgeon/hospital TKA volume category pairs, with the greatest aOR when TKA were performed by the highest volume surgeons at the highest volume hospitals (aOR 2.8, 95% CI 0.98- 8.09, P = .055).

CONCLUSION

Black patients were more likely to undergo aseptic TKA revision than matched White patients. This disparity was not explained by surgeon characteristics.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Racial Differences in Patient Satisfaction With the Hospital Experience Undergoing Primary Unilateral Hip and Knee Arthroplasty: A Retrospective Study

Background

Press Ganey (PG) inpatient survey is widely used to track patient satisfaction with the hospital experience. Our aim was to use the PG survey to determine if there are racial differences in overall hospital experience and perception of nurses and surgeons following hip and knee arthroplasty.

Methods

We retrospectively analyzed Black and White patients from hip and knee arthroplasty registries from a single institution between July 2010 and February 2012. The overall assessment score for the hospital experience and perception of the nurse and surgeon questions from the PG inpatient survey were dichotomized as "not completely satisfied" or "completely satisfied". Multivariable logistic regression models were developed to determine the impact of race on the likelihood of being 'completely satisfied' in the hip and knee cohorts.

Results

There were 2517 hip and 2114 knee patients who underwent surgery and completed the PG survey, of whom 3.9% were Black and 96.0% were White. Black patients were less likely to be completely satisfied with their hospital experience compared to White patients in the hip (odds ratio 0.62, confidence interval 0.39-1.00, P = .049) and knee (odds ratio 0.52, confidence interval 0.33-0.82, P = .005) cohorts. Black patients were also less likely to be completely satisfied with multiple aspects of care they received from the nurse and surgeon in both cohorts.

Conclusions

We found that the PG Survey shows Black patients were less likely to be completely satisfied than White patients with the hospital experience, including their interactions with nurses and surgeons. More work is needed to understand this difference.

The Report of the 2022-2023 AACP Professional Affairs Standing Committee: Focused Integration of Community-Based Pharmacy Practice Within the AACP Transformation Center

The 2022-2023 Professional Affairs Committee was charged to (1) Devise a framework and 3-year workplan for the Academia-Community Pharmacy Transformation Pharmacy Collaborative to be integrated within the American Association of Colleges of Pharmacy (AACP) Transformation Center. This plan should include the focus area(s) to be continued and developed by the Center, potential milestone dates or events, and necessary resources; and (2) Provide recommendations on focus areas and/or potential questions for the Pharmacy Workforce Center to consider for the 2024 National Pharmacist Workforce Study. This report provides the background and methodology utilized to develop the framework and 3-year workplan focused on (1) community-based pharmacy pipeline development for recruitment, programming, and retention, (2) programming and resources for community-based pharmacy practice, and (3) research areas for community-based pharmacy practice. The Committee offers suggested revisions for 5 current AACP policy statements, 7 recommendations pertaining to the first charge, and 9 recommendations pertaining to the second charge.

Machine learning identification of thresholds to discriminate osteoarthritis and rheumatoid arthritis synovial inflammation

BACKGROUND

We sought to identify features that distinguish osteoarthritis (OA) and rheumatoid arthritis (RA) hematoxylin and eosin (H&E)-stained synovial tissue samples.

METHODS

We compared fourteen pathologist-scored histology features and computer vision-quantified cell density (147 OA and 60 RA patients) in H&E-stained synovial tissue samples from total knee replacement (TKR) explants. A random forest model was trained using disease state (OA vs RA) as a classifier and histology features and/or computer vision-quantified cell density as inputs.

RESULTS

Synovium from OA patients had increased mast cells and fibrosis (p < 0.001), while synovium from RA patients exhibited increased lymphocytic inflammation, lining hyperplasia, neutrophils, detritus, plasma cells, binucleate plasma cells, sub-lining giant cells, fibrin (all p < 0.001), Russell bodies (p = 0.019), and synovial lining giant cells (p = 0.003). Fourteen pathologist-scored features allowed for discrimination between OA and RA, producing a micro-averaged area under the receiver operating curve (micro-AUC) of 0.85±0.06. This discriminatory ability was comparable to that of computer vision cell density alone (micro-AUC = 0.87±0.04). Combining the pathologist scores with the cell density metric improved the discriminatory power of the model (micro-AUC = 0.92±0.06). The optimal cell density threshold to distinguish OA from RA synovium was 3400 cells/mm2, which yielded a sensitivity of 0.82 and specificity of 0.82.

CONCLUSIONS

H&E-stained images of TKR explant synovium can be correctly classified as OA or RA in 82% of samples. Cell density greater than 3400 cells/mm2 and the presence of mast cells and fibrosis are the most important features for making this distinction.

Fetal and maternal morbidity in pregnant patients with Lupus: a 10-year US nationwide analysis

OBJECTIVE

To evaluate and quantify the indicators of fetal and maternal morbidity in deliveries for patients with systemic lupus erythematosus (SLE) compared with deliveries in patients without SLE.

METHODS

We used retrospective data from the National Inpatient Sample (NIS) to identify all delivery related hospital admissions of patients with and without SLE from 2008 to 2017 using ICD-9/10 codes. Fetal morbidity indicators included pre-term delivery and intrauterine growth restriction (IUGR). 21 indicators of severe maternal morbidity were identified using standard Centers for Disease Control and Prevention (CDC) definitions. Descriptive statistics, including 95% confidence intervals, were calculated using sample weights from the NIS dataset.

RESULTS

Among the 40 million delivery-related admissions, 51 161 patients were reported to have SLE. Patients with SLE had a higher risk of fetal morbidity, including IUGR (8.0% vs 2.7%) and pre-term delivery (14.5% vs 7.3%), than patients without SLE. During delivery, mothers with SLE were nearly four times as likely to require a blood transfusion or develop a cerebrovascular disorder, and 15 times as likely to develop acute renal failure than those without SLE.

CONCLUSION

Our study demonstrates that fetal morbidity and severe maternal morbidity occur at a higher rate in patients with SLE compared with those without. This quantitative work can help inform and counsel patients with SLE during pregnancy and planning.

Burnout and Resilience in the Community-Based Pharmacist Practitioner

Objective: The primary objective was to assess presence of community-based pharmacist practitioner burnout and workplace stress through administration of validated tools. Methods: Pharmacists licensed in Ohio received an invitation to participate in the anonymous online assessment via Qualtrics™ using emails available via the State Board of Pharmacy listserv. The survey assessed emotional exhaustion, depersonalization, and personal accomplishment using a validated tool, the Maslach Burnout Inventory (MBI). The Areas of Worklife Survey (AWS) was used to assess stressors as they relate to burnout and job stress. This study was approved by The Ohio State University Institutional Review Board. Results: There were 1,425 complete responses. Based on the study sample, 67.2% of community-based pharmacists are experiencing burnout. When asked to self-identify workplace stressors, respondents primarily described the Workload, Control, and Reward dimensions of the AWS. The most commonly reported coping mechanisms were self-care strategies (28.4%), mindfulness (17.6%), and personal time/time off (15.3%). Respondents suggested that organizations address staffing (50.2%) and development of a culture of well-being (17.2%) to promote well-being. Conclusion: This study allowed insight into workplace stressors for community-based pharmacists and strategies organizations can employ to improve their well-being. Future studies are needed to assess the efficacy of these interventions.

Are Income-based Differences in TKA Use and Outcomes Reduced in a Single-payer System? A Large-database Comparison of the United States and Canada

BACKGROUND

Income-based differences in the use of and outcomes in TKA have been studied; however, it is not known if different healthcare systems affect this relationship. Although Canada's single-payer healthcare system is assumed to attenuate the wealth-based differences in TKA use observed in the United States, empirical cross-border comparisons are lacking.

QUESTIONS/PURPOSES

(1) Does TKA use differ between Pennsylvania, USA, and Ontario, Canada? (2) Are income-based disparities in TKA use larger in Pennsylvania or Ontario? (3) Are TKA outcomes (90-day mortality, 90-day readmission, and 1-year revision rates) different between Pennsylvania and Ontario? (4) Are income-based disparities in TKA outcomes larger in Pennsylvania or Ontario?

METHODS

We identified all patients hospitalized for primary TKA in this cross-border retrospective analysis, using administrative data for 2012 to 2018, and we found a total of 161,244 primary TKAs in Ontario and 208,016 TKAs in Pennsylvania. We used data from the Pennsylvania Health Care Cost Containment Council, Harrisburg, PA, USA, and the ICES (formally the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada. We linked patient-level data to the respective census data to determine community-level income using ZIP Code or postal code of residence and stratified patients into neighborhood income quintiles. We compared TKA use (age and gender, standardized per 10,000 population per year) for patients residing in the highest-income versus the lowest-income quintile neighborhoods. Similarly secondary outcomes 90-day mortality, 90-day readmission, and 1-year revision rates were compared between the two regions and analyzed by income groups.

RESULTS

TKA use was higher in Pennsylvania than in Ontario overall and for all income quintiles (lowest income quartile: 31 versus 18 procedures per 10,000 population per year; p < 0.001; highest income quartile: 38 versus 23 procedures per 10,000 population per year; p < 0.001). The relative difference in use between the highest-income and lowest-income quintile was larger in Ontario (28% higher) than in Pennsylvania (23% higher); p < 0.001. Patients receiving TKA in Pennsylvania were more likely to be readmitted within 90 days and were more likely to undergo revision within the first year than patients in Ontario, but there was no difference in mortality at 1 year. When comparing income groups, there were no differences between the countries in 90-day mortality, readmission, or 1-year revision rates (p > 0.05).

CONCLUSION

These results suggest that universal health insurance through a single-payer may not reduce the income-based differences in TKA access that are known to exist in the United States. Future studies are needed determine if our results are consistent across other geographic regions and other surgical procedures.

LEVEL OF EVIDENCE

Level III, therapeutic study.

AB1244 TOTAL KNEE ARTHROPLASTY IN PATIENTS UNDER 21 YEARS OF AGE: A U.S. NATIONWIDE ANALYSIS

Background

Total knee arthroplasty (TKA) is a procedure rarely performed in patients under 21 years old. However, the number of patients <21 undergoing TKA in the United States (US) is unknown. In one of the largest US studies of an institutional arthroplasty registry, only 19 TKAs were performed in patients <21 out of ~30,000 primary TKAs over 34 years1. While a few national or multi-national studies have been performed outside the US, these studies have small cohorts (~100), making it difficult to determine the indications for TKA in this age group.

Objectives

We identified the number of patients <21 years of age who underwent TKA in a US nationwide dataset. Additionally, we determined the epidemiological characteristics of patients undergoing TKA, including their age, sex, race, indications for surgery, and in-hospital mortality.

Methods

We analyzed the Kids’ Inpatient Database, which is a national weighted sample of all inpatient hospital admissions in the US in patients <21 years old from ~4,200 hospitals in 46 states. We included all admissions from 2000-2016 with a primary procedural code of TKA determined by ICD-9 and 10 codes. Descriptive statistics such as means and percentages, along with 95% confidence intervals were calculated using appropriate sample weights.

Results

The total number of TKAs performed in patients <21 years old from 2000 to 2016 was 1,331 (Table 1). The majority of TKAs performed (n=936; 70.3%) were for treatment of an oncologic disease. The most common diagnosis was malignant tumor (68.7%), followed by osteoarthritis (7.3%) and inflammatory arthritis or juvenile idiopathic arthritis (JIA) (7.0%) (Figure 1). Osteonecrosis accounted for 3.9% of cases, while mechanical complications accounted for 3.3%. Fewer than 2% of cases had an indication of either benign or uncertain tumor, infection, or trauma. The mean age was 14.8 years, and 48.4% of the cohort was female. A higher proportion of the non-tumor cohort was female (57.1%) than the tumor cohort (44.7%). 57.1% of patients in the overall cohort were White, and this proportion was smaller in the tumor group (53.8%) than the non-tumor group (64.9%). No patients died during the inpatient event. 87.8% of TKAs were performed in urban teaching hospitals.

Table 1.

Characteristics of patients <21 undergoing TKA by diagnosis type

VariableOverallN = 1331Non-tumorN = 395TumorN = 936Age, mean (95% CI)14.8 (14.4, 15.2)15.9 (14.7, 17.1)14.3 (14.1, 14.6)Sex: Female, % (95% CI)48.4 (44.9, 51.9)57.1 (49.1, 64.8)44.7 (41.1, 48.3)Race, % (95% CI) White57.1 (52.3, 61.8)64.9 (55.5, 73.3)53.8 (48.4, 59.2) Black13.1 (10.1, 16.9)16.9 (10.1, 27.2)11.5 (8.7, 14.9) Hispanic19.7 (16.6, 23.3)14.3 (9.9, 20.2)22.0 (18.1, 26.6) Asian or Pacific Islander3.4 (2.1, 5.4)**4.6 (2.9, 7.4) Native American0.9 (0.4, 1.9)**** Other5.8 (4.1, 8.1)2.9 (1.3, 6.4)7.0 (4.8, 10.0)Payor, % (95% CI) Medicare1.4 (0.7, 2.9)4.7 (2.2, 9.7)— Medicaid31.1 (27.5, 35.0)28.0 (21.0, 36.3)32.4 (28.3, 36.7) Private57.8 (53.7, 61.7)60.2 (52.1, 67.8)56.7 (52.2, 61.1) Self-pay3.3 (2.3, 4.9)**4.2 (2.7, 6.2) Other6.1 (4.4, 8.3)5.1 (3.0, 8.6)6.6 (4.5, 9.4)Admission type: elective, % (95% CI)85.9 (81.1, 89.6)81.6 (72.6, 88.2)87.7 (82.2, 91.6)

N represents weighted estimate

CI = Confidence Interval

** Per HCUP guidelines, cell sizes ≤10 have been omitted to protect patient confidentiality

Figure 1.

Most common primary diagnoses for TKA in patients <21 years old

The most common primary diagnosis of 1,331 patients <21 undergoing TKA. Bars represent 95% Confidence Intervals. JIA = juvenile idiopathic arthritis.

Conclusion

TKA is a rarely-performed procedure for patients <21 years old in the US; it is mainly performed in urban teaching centers and has excellent in-hospital survival rates. 70.3% of these procedures are performed for tumors—the vast majority of which are malignant. Also, even with the advent of better treatment options for JIA and inflammatory arthritis, TKA is still performed frequently in this population indicating that better clinical management is needed.

References

[1]Martin JR et al. Adolescent total knee arthroplasty. PMCID: PMC5484984

Acknowledgements

This work was supported by the Kellen Scholar Award supported by the Anna Marie and Stephen Kellen Foundation Total Knee Improvement Program. The authors would like to acknowledge the Healthcare Cost and Utilization Project Data Partners that contribute to Healthcare Cost and Utilization Project: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming.

Disclosure of Interests

J. Alex Gibbons: None declared, Cynthia Kahlenberg: None declared, Deanna Jannat-Khah Shareholder of: AstraZeneca, Cytodyn, and Walgreens, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Peter Sculco Consultant of: Intellijoint Surgical, DePuy Synthes, Lima Corporate, Zimmer Biomet, and EOS Imaging, Grant/research support from: Intellijoint Surgical and Zimmer Biomet, Mark Figgie Shareholder of: HS2, Mekanika, and Wishbone, Consultant of: Lima and Wishbone, Bella Mehta Paid instructor for: Novartis

AB1465 BLACK PATIENTS ARE LESS SATISFIED WITH THE PROCESS OF CARE FOLLOWING PRIMARY HIP AND KNEE ARTHROPLASTY: A RETROSPECTIVE STUDY

Background

Patients’ post-operative satisfaction with their hospital experience is important to patient care, hospital reimbursement, and comparison between hospitals. The Press Ganey (PG) inpatient survey is commonly administered to assess patient satisfaction with the process of care. However, whether patient PG survey scores following primary unilateral hip and knee arthroplasty are associated with a patient’s race and socioeconomic status (SES) is unknown.

Objectives

We aimed to determine whether patient PG survey overall assessment scores differ by race and SES.

Methods

We linked data for patients in large institutional hip and knee arthroplasty registries consisting of surgeries from July 2010–February 2012 to their PG survey responses. Patients undergoing primary unilateral surgery of Black or White race who resided in New York, New Jersey, or Connecticut at the time of surgery were included in the analysis. The primary outcome variable was the PG overall assessment score, calculated as the mean of a patient’s ratings for the three questions in the “Overall Assessment” section of the PG survey and dichotomized as either completely satisfied (score of 100) or not completely satisfied (score <100). Primary payor was used as a proxy for patient SES. Multivariable logistic regression was performed for the hip and knee cohorts separately to determine if patient race and primary payor were associated with not being completely satisfied, adjusting for age, sex, and American Society of Anesthesiology (ASA) score.

Results

There were 2,516 hip patients and 2,113 knee patients with PG overall assessment scores included in the analyses (Table 1). Black patients were more likely to be not completely satisfied compared to White patients in both cohorts [hip (odds ratio (OR)=1.64; 95% confidence interval (CI): 1.03, 2.61; p=0.04)]; [knee (OR=1.83; 95% CI: 1.16, 2.88; p=0.01). In the hip cohort, patients between 70-79 years old (OR=1.71; 95% CI: 1.09, 2.67; p=0.02) and older than 80 years (OR=2.00; 95% CI: 1.20, 3.32; p<0.01) were more likely to be not completely satisfied. In the knee cohort, patients 50-59 years old (OR=0.56; 95% CI: 0.33, 0.97; p=0.04) and 60-69 years old (OR=0.57; 95% CI: 0.33, 0.96; p=0.03) were less likely to be not completely satisfied compared to patients <50 years old.

Table 1.

Likelihood of not being completely satisfied with the process of care (PG score <100)

VariableReferenceCategoryHip Cohort (n = 2,516)Knee Cohort (n = 2,113)Odds Ratio95% CIp-valueOdds Ratio95% CIp-valueAge Group<5050-591.02(0.69, 1.50)0.9390.56(0.32, 0.97)0.039<5060-691.04(0.70, 1.54)0.8580.57(0.33, 0.96)0.034<5070-791.71(1.09, 2.67)0.0190.63(0.36, 1.11)0.113<5080+2.00(1.20, 3.32)0.0080.97(0.53, 1.77)0.912SexFemaleMale0.84(0.69, 1.02)0.0821.03(0.83, 1.26)0.816RaceWhiteBlack1.64(1.03, 2.61)0.0381.83(1.16, 2.88)0.010ASA status121.04(0.70, 1.55)0.8321.23(0.60, 2.51)0.580131.45(0.91, 2.29)0.1161.36(0.64, 2.87)0.41914<0.01(0.00, ***)0.968<0.01(0.00, ***)0.977Primary PayorMedicareMedicaid1.35(0.26, 7.01)0.718<0.01(0.00, ***)0.983MedicareOther/Unknown1.24(0.94, 1.64)0.1260.87(0.65, 1.17)0.362MedicarePrivate1.13(0.61, 2.10)0.6881.01(0.57, 1.78)0.983

ASA = American Society of Anesthesiologist (ASA) physical status classification. PG = Press Ganey. CI = Confidence Interval. *** indicates >999.99. Bold indicates p < 0.05

Conclusion

Black patients were less likely to be completely satisfied compared to White patients following total hip and knee arthroplasty. More research is needed to investigate other factors such as perceived staff courtesy and baseline pain and function to understand why these disparities exist.

Acknowledgements

This work was supported by the Stavros Niarchos Complex Joint Reconstruction Center at Hospital for Special Surgery. The content is solely the responsibility of the authors and does not necessarily represent the official views of the center.

Disclosure of Interests

J. Alex Gibbons: None declared, Orett Burke Jr: None declared, Huong Do: None declared, Emily Ying Lai: None declared, Bella Mehta Paid instructor for: Novartis, Letitia Bradford: None declared, Michael Parks Consultant of: ZimmerBiomet, Linda Russell: None declared, Anne Bass: None declared, Mark Figgie Shareholder of: HS2, Mekanika, and Wishbone, Consultant of: Lima and Wishbone, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis

OP0223 DISTINGUISHING OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS SYNOVIUM WITH MACHINE LEARNING USING AUTOMATED CELL DENSITY AND PATHOLOGIST SCORES

Background

Joint damage in the knee can be severe in both rheumatoid arthritis (RA) and osteoarthritis (OA) such that total knee replacement (TKR) is often the only management option. Pathological assessment of the extent or type of synovial tissue inflammation from joint explants or biopsies can be useful. However, an ongoing challenge in using semi-quantitative assessments of synovitis is the disagreement between human pathologist scores of the same sample. We previously developed and validated a computer vision algorithm to automatically count each cell nucleus in an H&E-stained synovial whole slide image and yield a value of cell density, defined as mean nuclei count per mm2 of tissue1.

Objectives

We sought to develop methods to distinguish OA from RA based on machine learning analysis of histologic features on H&E-stained synovial tissue samples.

Methods

We measured 14 pathologist-scored histology features (137 RA and 152 OA patients) and computer vision quantified cell density (60 RA and 147 OA patients) in H&E stained synovial tissue samples from total knee replacement arthroplasty explants. A random forest model was trained using disease state (OA vs RA) as classifier and histology features and/or cell density as inputs, and feature importance scores for the model were calculated.

Results

Synovium from patients with RA exhibited increased lymphocytic inflammation, lining hyperplasia, neutrophils, detritus, plasma cells, Russell bodies, binucleate plasma cells, sub-lining giant cells, synovial lining giant cells, and fibrin (all p<0.001), while synovium from patients with OA had increased mast cells and fibrosis (both p<0.001). Fourteen pathologist-scored features allowed for discrimination between RA and OA samples, producing a macro-averaged area under the receiver operating curve (AUC) of 0.85. This discriminatory ability was comparable to that of the computer vision score of cell density alone (AUC = 0.88). Combining the pathologist scores with the cell density metric improved the discriminatory power of the model (AUC = 0.91). The three most important features in this combined model were mast cells followed by cell density and fibrosis (Figure 1). AUC values for each individual feature are provided in Table 1. The optimal cell density threshold to distinguish RA from OA synovium was 3,400 cells per mm2, which yielded a sensitivity of 0.82 and specificity of 0.82.

Table 1.

Area under receiver operating characteristic curves (AUC) of the synovial features in distinguishing RA and OA patients

FeatureAUCAutomated Cell Density0.88Fibrosis0.84Mast cells0.80Lining hyperplasia0.78Lymphocytic inflammation0.69Fibrin0.68Plasma cells0.66Detritus0.64Binucleate plasma cells0.60Neutrophils0.60Synovial giant cells0.58Sub-lining giant cells0.57Russell bodies0.56Germinal centers0.51Mucoid change0.50Figure 1.

Importance of synovial features in distinguishing RA and OA synovium

Feature importance scores for supervised machine learning model including all 14 pathology scores and the computer vision-generated cell density.

Conclusion

H&E-stained images of RA and OA TKR explant synovium are distinct. We identified cell density, mast cells and fibrosis as the three most important features for making this distinction, with RA being characterized by increased cell density, low mast cells, and low fibrosis. Cell density greater than 3400 per mm2 of tissue yields a sensitivity of 0.82 and a specificity of 0.82 for distinguishing RA from OA. In the future, this can have clinical and research applications as this technique removes the requirement for subjective selection of a certain field of interest, is reproducible, and is scalable as it does not require technical expertise of a pathologist.

References

[1]Guan S, Mehta B…Orange DE. Rheumatoid Arthritis Synovial Inflammation Quantification Using Computer Vision. ACR Open Rheumatology. 2022 Jan 10;acr2.11381.

Acknowledgements

This work was supported by the C. Ronald MacKenzie Young Scientist Endowment Award, the Leon Lowenstein Foundation, and the Kellen Scholar Award supported by the Anna Marie and Stephen Kellen Foundation Total Knee Improvement Program.

Disclosure of Interests

Bella Mehta Paid instructor for: Novartis, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Edward DiCarlo: None declared, Deanna Jannat-Khah Shareholder of: AstraZeneca, Cytodyn, and Walgreens, J. Alex Gibbons: None declared, Miguel Otero Consultant of: Regeneron Pharmaceuticals, Grant/research support from: Tissue Genesis, Laura Donlin Speakers bureau: Stryker, Consultant of: Stryker, Grant/research support from: Karius, Inc, Tania Pannellini: None declared, William Robinson: None declared, Peter Sculco Consultant of: Intellijoint Surgical, DePuy Synthes, Lima Corporate, Zimmer Biomet, and EOS Imaging, Grant/research support from: Intellijoint Surgical and Zimmer Biomet, Mark Figgie Shareholder of: HS2, Mekanika, and Wishbone, Consultant of: Lima and Wishbone, Jose Rodriguez Consultant of: ConforMIS, Medacta, Exactech, Inc, and Smith & Nephew, Grant/research support from: DePuy, Exactech, Inc, and Smith & Nephew, Jessica Kirschmann: None declared, James Thompson: None declared, David Slater: None declared, Damon Frezza: None declared, Zhenxing Xu: None declared, Fei Wang: None declared, Dana Orange: None declared

OP0124 FETAL AND MATERNAL MORBIDITY IN PREGNANT SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) PATIENTS: A 10-YEAR U.S. NATIONAL STUDY

Background

Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects women in their childbearing years. Previously, we demonstrated that fetal and maternal mortality has declined in SLE patients over the years, however little is known about morbidity (1).

Objectives

To determine the proportion of fetal and maternal morbidity in SLE deliveries compared to non-SLE deliveries in a US nationwide study over a decade.

Methods

We used retrospective data from the National Inpatient Sample database to identify all delivery related hospital admissions of patients with and without SLE from 2008 to 2017 using ICD-9 (710.0) and 10 (M32*) codes. Fetal morbidity indicators included preterm delivery and intrauterine growth restriction. 21 indicators of severe maternal morbidity were identified using the standard CDC definition: these are unexpected outcomes of labor and delivery that result in significant short- or long- term consequences to a woman’s health (2). Descriptive statistics and their 95% confidence intervals were calculated using sample weights from the dataset.

Results

Among the 40 million delivery-related admissions, 51,161 patients (10,297 unweighted) were reported to have SLE. SLE patients were more likely to be older and have more comorbidities compared to non-SLE patients (Table 1). Patients with SLE had a higher risk of fetal morbidity, including intrauterine growth restriction (8.0% vs 2.7%) and preterm delivery (14.5% vs 7.3%) than patients without SLE. Amongst the CDC maternal morbidity indicators - SLE patients faced a greater risk of blood transfusion, puerperal cerebrovascular disorders, acute renal failure, eclampsia or DIC, cardiovascular and peripheral vascular disorders, and general medical issues than those without SLE (Figure 1).

Table 1.

Characteristics for deliveries of patients with and without Systemic Lupus Erythematosus

SLE deliveriesNon-SLE deliveriesPercent (%)(95 %CI)Percent (%)(95 %CI)N51,161* (10,297 unweighted)(49,419.14, 52,903.37)40,000,000* (8,055,025 unweighted)(39,200,000; 40,700,000)Age (years)30.05(29.92, 30.18)28.19(28.14, 28.24)RaceWhite46.15(44.83, 47.47)52.43(51.74, 53.11)African American24.68(23.55, 25.85)15.01(14.62, 15.42)Hispanic18.48(17.40, 19.60)21.45(20.81, 22.10)Other10.69(9.93, 11.50)11.11(10.76, 11.47)InsuranceMedicare5.32(4.83, 5.86)0.7(0.66, 0.75)Medicaid38.2(37.00, 39.41)43.79(43.20, 44.39)private insurance51.84(50.55, 53.13)49.8(49.15, 50.45)self-pay1.39(1.13, 1.70)2.74(2.57, 2.92)no charge0.04(0.02, 0.12)0.13(0.09, 0.18)other3.21(2.84, 3.63)2.84(2.73, 2.95)Elixhauser00(*no obs)80.56(80.32, 80.80)1 to 497.84(97.50, 98.12)19.4(19.16, 19.64)5+2.16(1.88, 2.50)0.04(0.03, 0.04)

*Population weighted values are listed.

Figure 1.

Fetal and severe maternal morbidity outcomes in Systemic Lupus Erythematosus (SLE) and non-SLE patients. Cardiovascular and peripheral vascular disorders include acute myocardial infarction, aneurysm, amniotic fluid embolism, cardiac arrest/ventricular fibrillation, heart failure, pulmonary edema/acute heart failure, sickle cell disease with crisis, air and thrombotic embolism, and conversion of cardiac rhythm. General medical issues include hysterectomy, shock, sepsis, adult respiratory distress syndrome, and severe anesthesia complications, temporary tracheostomy, and ventilation.

Conclusion

Our study demonstrates that fetal morbidity and severe maternal morbidity occur at a higher rate in patients with SLE compared to those without, even in this most recent decade. This work can help inform physicians to counsel and manage patients with SLE during pregnancy and its planning.

References

[1]Mehta B, et al. Trends in Maternal and Fetal Outcomes Among Pregnant Women With Systemic Lupus Erythematosus in the United States: A Cross-sectional Analysis. Ann Intern Med.

[2]https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html

Acknowledgements

This work was supported by the Dean’s Diversity Award at Weill Cornell Medicine.

Disclosure of Interests

Bella Mehta Speakers bureau: Novartis and Jassen, Katharine Kayla J Glaser: None declared, Deanna Jannat-Khah Shareholder of: Cytodyn, AstraZeneca, and Walgreens, Yiming Luo: None declared, Lisa Sammaritano: None declared, Jane E. Salmon: None declared, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Employee of: Current Rheumatology Report (section editor), Fei Wang: None declared

Medicare/Medicaid Insurance Status Is Associated With Reduced Lower Bilateral Knee Arthroplasty Utilization and Higher Complication Rates

Whether to undergo bilateral total knee arthroplasty (BTKA) depends on patient and surgeon preferences. We used the National Inpatient Sample to compare temporal trends in BTKA utilization and in-hospital complication rates among TKA patients ≥50 with Medicare/Medicaid versus private insurance from 2007 to 2016. We used multivariable logistic regression to assess the association between insurance type and trends in utilization and complication rates adjusting for individual-, hospital-, and community-level covariates, using unilateral TKA (UTKA) for reference. Discharge weights were used for nationwide estimates. About 132,400 (49.5%) Medicare/Medicaid patients and 135,046 (50.5%) privately insured patients underwent BTKA. Among UTKA patients, 62.7% had Medicare/Medicaid, and 37.3% had private insurance. Over the study period, BTKA utilization rate decreased from 7.18% to 5.63% among privately insured patients and from 4.59% to 3.13% among Medicaid/Medicare patients (P trend difference <0.0001). In multivariable analysis, Medicare/Medicaid patients were less likely to receive BTKA than privately insured patients. Although Medicare/Medicaid patients were more likely to develop in-hospital complications after UTKA (adjusted odds ratio, 1.06; 95% confidence interval, 1.002 to 1.12; P = 0.04), this relationship was not statistically significant for BTKAs. In this nationwide sample of TKA patients, BTKA utilization rate was higher in privately insured patients compared with Medicare/Medicaid patients. Furthermore, privately insured patients had lower in-hospital complication rates than Medicare/Medicaid patients.

Rheumatoid Arthritis Synovial Inflammation Quantification Using Computer Vision

OBJECTIVE

We quantified inflammatory burden in rheumatoid arthritis (RA) synovial tissue by using computer vision to automate the process of counting individual nuclei in hematoxylin and eosin images.

METHODS

We adapted and applied computer vision algorithms to quantify nuclei density (count of nuclei per unit area of tissue) on synovial tissue from arthroplasty samples. A pathologist validated algorithm results by labeling nuclei in synovial images that were mislabeled or missed by the algorithm. Nuclei density was compared with other measures of RA inflammation such as semiquantitative histology scores, gene-expression data, and clinical measures of disease activity.

RESULTS

The algorithm detected a median of 112,657 (range 8,160-821,717) nuclei per synovial sample. Based on pathologist-validated results, the sensitivity and specificity of the algorithm was 97% and 100%, respectively. The mean nuclei density calculated by the algorithm was significantly higher (P < 0.05) in synovium with increased histology scores for lymphocytic inflammation, plasma cells, and lining hyperplasia. Analysis of RNA sequencing identified 915 significantly differentially expressed genes in correlation with nuclei density (false discovery rate is less than 0.05). Mean nuclei density was significantly higher (P < 0.05) in patients with elevated levels of C-reactive protein, erythrocyte sedimentation rate, rheumatoid factor, and cyclized citrullinated protein antibody.

CONCLUSION

Nuclei density is a robust measurement of inflammatory burden in RA and correlates with multiple orthogonal measurements of inflammation.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Community poverty level influences time to first pediatric rheumatology appointment in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

The impact of social determinants of health on children with polyarticular juvenile idiopathic arthritis (pJIA) is poorly understood. Prompt initiation of treatment for pJIA is important to prevent disease morbidity; however, a potential barrier to early treatment of pJIAs is delayed presentation to a pediatric rheumatologist. We examined the impact of community poverty level, a key social determinant of health, on time from patient reported symptom onset to first pediatric rheumatology visit among pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry.

METHODS

This is a cohort study of pJIA patients in the CARRA registry who lived in the United States from July 2015-February 2020. The primary exposure was community poverty level derived by geocoding patient addresses. The primary outcome was time to first rheumatology appointment. Kaplan-Meier analysis was performed to analyze time to first rheumatologist visit, stratified by community poverty and family income. Log-rank tests were used to identify differences between groups. Adjusted cox proportional-hazards models were used to determine the relationship between community poverty level and time from onset of disease symptoms to date first seen by rheumatologist.

RESULTS

A total of 1684 patients with pJIA meeting study inclusion and exclusion criteria were identified. Median age of onset of pJIA was 7 years (IQR 3, 11), 79% were female, 17.6% identified as minority race and/or ethnicity, and 19% were from communities with ≥20% community poverty level. Kaplan-Meier analysis by community poverty level (< 20% vs ≥20%) yielded no significant differences with time to initial presentation to a pediatric rheumatologist (p = 0.6). The Cox proportional hazards model showed that patients with ≥20% community poverty level were 19% less likely (adjusted HR 0.81, 95% CI 0.67-0.99, p = 0.038) to be seen by a rheumatologist compared to patients with < 20% community poverty level, at the same time point, after adjusting for sex, race/ethnicity, insurance, education level, morning stiffness, RF status, and baseline CHAQ.

CONCLUSION

In this study of pJIA patients in the CARRA registry, increased community poverty level is associated with longer time to presentation to a pediatric rheumatologist after symptom onset.

Primary Care Provider Density and Elective Total Joint Replacement Outcomes

BACKGROUND

Primary care physicians (PCPs) are often gatekeepers to specialist care. This study assessed the relationship between PCP density and total knee (TKA) and total hip arthroplasty (THA) outcomes.

METHODS

We obtained patient-level data from an institutional registry on patients undergoing elective primary TKA and THA for osteoarthritis, including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at baseline and 2 years. Using geocoding, we identified the number of PCPs in the patient's census tract (communities). We used Augmented Inverse Probability Weighting and Cross-validated Targeted Minimum Loss-Based Estimation to compare provider density and outcomes adjusting for potential confounders.

RESULTS

Our sample included 3606 TKA and 4295 THA cases. The median number of PCPs in each community was similar for both procedures: TKA 2 (interquartile range 1, 6) and for THA 2 (interquartile range 1, 7). Baseline and 2-year follow-up WOMAC pain, function, and stiffness scores were not statistically significantly different comparing communities with more than median number of PCPs to those with less than median number of PCPs. In sensitivity analyses, adding 1 PCP to a community with zero PCPs would not have statistically significantly improved baseline or 2-year follow-up WOMAC pain, function, and stiffness scores.

CONCLUSIONS

In this sample of patients who underwent elective TKA or THA for osteoarthritis, we found no statistically significant association between PCP density and pain, function, or stiffness outcomes at baseline or 2 years. Further studies should examine what other provider factors affect access and outcomes in THA and TKA.

Periprosthetic Joint Infection Is Associated with an Increased Risk of Venous Thromboembolism Following Revision Total Knee Replacement: An Analysis of Administrative Discharge Data

BACKGROUND

Little is known about the relationship between infection and the risk of risk of venous thromboembolism (VTE) following orthopaedic surgery. We assessed the 90-day risk of VTE following revision total knee replacement to measure the association between periprosthetic joint infection and the risk of postoperative VTE.

METHODS

We used New York Statewide Planning and Research Cooperative System data to identify all New York State residents undergoing revision total knee replacement from 1998 to 2014. ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes were used to identify comorbidities and to classify the indication for revision total knee replacement as aseptic, infection, or fracture. The primary outcome was any diagnosis code for VTE recorded for the revision surgery and/or subsequent admissions within 90 days. A multivariable logistic regression model that included demographic characteristics and comorbidities was used to estimate the risk of VTE after revision for infection or fracture, with aseptic revision as the reference group.

RESULTS

The present study included 25,441 patients who were managed with revision total knee replacement; the indication for revision was aseptic for 17,563 patients (69%), infection for 7,075 (28%), and fracture for 803 (3%). The mean age (and standard deviation) was 66 ± 12 years, 15,592 (61%) of the patients were female, 3,198 (13%) were Black, 1,192 (5%) were smokers, and 4,222 (17%) were obese. Seven hundred and nineteen patients (2.8%) had VTE within the 90 days after revision total knee replacement, including 387 (1.5%) during the admission for the revision procedure. The 90-day incidence of VTE was 2.1% after aseptic revision, 4.3% after revision for infection, and 5.9% after revision for fracture. The adjusted odds ratio (aOR) for VTE relative to aseptic revision was 2.01 (95% confidence interval [CI], 1.72 to 2.35) for septic revision total knee replacement and 2.62 (95% CI, 1.91 to 3.6) for fracture. A history of VTE was also a strong risk factor for VTE following revision total knee replacement (aOR, 2.01; 95% CI, 1.48 to 2.71).

CONCLUSIONS

We found that the odds of VTE after revision total knee replacement for infection were double those after aseptic revision total knee replacement. Although fracture accounts for a small percentage of revision total knee replacements, the risk of VTE was 2.6-fold higher after these procedures. The indication for revision total knee replacement should be considered when choosing postoperative VTE prophylaxis.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Glucocorticoids in Patients With Rheumatoid Arthritis Having Total Joint Replacements: Help or Harm?

Objective

The optimal strategy for perioperative glucocorticoid (GC) management in patients with rheumatoid arthritis (RA) on chronic GCs is unknown. Although there is a concern for hypotension if inadequate doses are used, higher GC exposure may increase perioperative complications. We aimed to investigate the relationships between perioperative GCs with hemodynamic instability and short‐term postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) in patients with RA.

Methods

This retrospective study included patients with RA who underwent THA and TKA. GC exposure was assessed by the total cumulative dose (in prednisone equivalents) during hospitalization. Perioperative complications and hypotension were assessed.

Results

Of 432 patients, 387 (90%) received supraphysiologic perioperative GC. Thirty percent of patients were using chronic GCs (mean daily dose, 7 ± 4 mg). Half (54%) underwent TKA. The median age was 65 years, and 79% were women. The median cumulative GC dose during hospitalization was 37 mg (interquartile range, 27‐53.3). A lower cumulative dose of GC did not increase odds of hypotension during hospitalization (unadjusted odds ratio, 1.00 [95% confidence interval, 0.99‐1.01]; P = 0.66)]. However, postoperative complications were higher among patients who received higher cumulative doses after adjustment for age, body mass index, home GC use, smoking, and Charlson Comorbidity Index. Risk of short‐term complications increased by 8.4% (P = 0.017) for every 10‐mg increase in GC dose.

Conclusion

A lower GC dose was not associated with increased hypotension. However, patients with higher GC exposure were more likely to have hyperglycemia and other complications. These findings suggest that harms may be associated with high perioperative GC doses. Further research is needed to determine the optimal perioperative regimen for patients with RA.

Assessment of Racial Disparities in the Risks of Septic and Aseptic Revision Total Knee Replacements

IMPORTANCE

Black patients are at higher risk of revision total knee replacement (TKR) than White patients, but whether racial disparities exist for both septic and aseptic revision TKR and the reason for any disparities are unknown.

OBJECTIVE

To assess the risk of septic and aseptic revision TKR in Black and White patients and to examine interactions among race and socioeconomic and hospital-related variables that are associated with revision TKR risk.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included residents of New York, California, and Florida who underwent TKR. Patient-level data were obtained from the New York Statewide Planning and Research Cooperative System, California's Office of Statewide Health Planning and Development Patient Discharge Database, and Florida's Healthcare Utilization Project State Inpatient Database from January 1, 2004, to December 31, 2014. Community characteristics were calculated from the US Census and linked to discharges by patient zip code. American Hospital Association Annual Survey data were linked to discharges using hospital identifiers. The analyses were performed from March 1 to October 30, 2020, with subsequent analyses in April 2021.

MAIN OUTCOMES AND MEASURES

Cox proportional hazards regression modeling was used to measure the association of race with septic and aseptic revision TKR.

RESULTS

A total of 722 492 patients underwent primary TKR, of whom 445 616 (61.68%) were female and 61 092 (8.46%) were Black. Black patients were at higher risk of septic (hazard ratio [HR], 1.11; 95% CI, 1.03-1.20) and aseptic (HR, 1.39; 95% CI, 1.33-1.46) revision TKR compared with White patients. Other risk factors for septic revision TKR were diabetes (HR, 1.24; 95% CI, 1.17-1.30), obesity (HR, 1.13; 95% CI, 1.17-1.30), kidney disease (HR, 1.42; 95% CI, 1.29-1.57), chronic obstructive pulmonary disease (HR, 1.22; 95% CI, 1.15-1.30), inflammatory arthritis (HR, 1.53; 95% CI, 1.39-1.69), surgical site complications during the index TKR (HR, 2.19; 95% CI, 1.87-2.56), Medicaid insurance (HR, 1.17; 95% CI, 1.04-1.31), and low annual TKR volume at the hospital where the index TKR was performed (HR, 1.54; 95% CI, 1.41-1.68). Risk factors for aseptic revision TKR were male sex (HR, 1.03; 95% CI, 1.00-1.06), workers' compensation insurance (HR, 1.61; 95% CI, 1.51-1.72), and low hospital TKR volume (HR, 1.14; 95% CI, 1.07-1.22). Patients with obesity had a lower risk of aseptic TKR revision (HR, 0.81; 95% CI, 0.77-0.84). In an analysis within each category of hospital TKR volume, the HR for aseptic revision among Black vs White patients was 1.20 (95% CI, 1.04-1.37) at very-low-volume hospitals (≤89 TKRs annually) compared with 1.68 (95% CI, 1.48-1.90) at very-high-volume hospitals (≥645 TKRs annually).

CONCLUSIONS AND RELEVANCE

In this cohort study, Black patients were at significantly higher risk of aseptic revision TKR and, to a lesser extent, septic revision TKR compared with White patients. Racial disparities in aseptic revision risk were greatest at hospitals with very high TKR volumes.

POS0480 ASSOCIATION OF NEUTROPHIL LYMPHOCYTE AND PLATELET LYMPHOCYTE RATIOS WITH JOINT INFLAMMATION IN RHEUMATOID ARTHRITIS

Background:

Some patients with rheumatoid arthritis (RA) have high disease activity scores (DAS) and low synovial inflammation, and others have high synovial inflammation and low DAS (subclinical synovitis)[1]. It would be clinically useful to identify blood biomarkers of synovial inflammation. Neutrophil-lymphocyte (NLR) and platelet-lymphocyte ratios (PLR) have been reported to distinguish RA patients with moderate/high DAS28 scores from low DAS28 [2]. However, it is not known if these inexpensive, accessible tests are associated with inflammation in synovial tissue at the histological level.

Objectives:

The objective of this study was to evaluate the relationship of pre-operative NLR and PLR with synovial inflammation of the operative joint in RA patients undergoing arthroplasty.

Methods:

230 patients meeting ACR/EULAR 1987 and/or 2010 criteria were recruited prior to elective total hip, knee, shoulder, and elbow replacement. Demographics, RA characteristics, medications, disease activity, and routine tests including complete blood tests (CBC) were collected pre-operatively. Hematoxylin and eosin (H&E) stains were prepared from the synovium of the operative joint and systematically scored by a pathologist as described previously [3]. Synovial lymphocytic inflammation was graded as none, mild, moderate, marked, or band-like. Linear regression was performed to distinguish differences in the NLR, PLR, and CRP in patients with synovial lymphocytic inflammation (SLI).

Results:

As expected, patients on glucocorticoids (GCs) had higher NLR (mean 5.52 (SD 7.68) vs mean 2.82 (SD 1.66) (p<0.001) and higher PLR (mean 233.73 (SD 237.21) vs (mean 162.93 (SD 65.35)) (p-value=0.04)) and those patients (N=92) were therefore excluded from down-stream analyses. On the remaining 138 patients, we tested for associations of PLR, NLR and CRP with SLI using linear regression. In all the models the highest category for synovial lymphocytic inflammation was found to be statistically significantly associated with NLR, PLR and CRP, separately (Table 1).

Conclusion:

NLR, PLR and CRP are associated with high synovial lymphocytic inflammation of the operative joint. This suggests that these inexpensive, routinely performed blood tests may be a useful blood biomarker of synovial inflammation.

References:

[1]Orange, D.E. et al. Histologic and Transcriptional Evidence of Subclinical Synovial Inflammation in Patients With Rheumatoid Arthritis in Clinical Remission. Arthritis Rheumatol. 71(7): 1034-1041 (2019).

[2]Lee, Y.H. Association between the Neutrophil-to-lymphocyte Ratio, and Platelet-to-lymphocyte Ratio and Rheumatoid Arthritis and their Correlations with the Disease Activity: A Meta-analysis. J Rheum Dis. 25(3):169-178 (2018).

[3]Orange, D. E. et al. Identification of Three Rheumatoid Arthritis Disease Subtypes by Machine Learning Integration of Synovial Histologic Features and RNA Sequencing Data. Arthritis Rheumatol. Hoboken NJ 70: 690–701 (2018).

Table 1.

Results from linear regressions evaluating the association of NLR, PLR, and CRP with synovial lymphocytic inflammation.

Linear regression ResultsNLRPLRCRPSynovial Lymphocytic InflammationCoef (95% CI)Coef (95% CI)Coef (95% CI)NoneReferencereferencereferenceMild0.31 (-0.51, 1.13)26.54 (-8.83, 61.90)-1.00 (-2.37, 0.36)Moderate0.73 (-0.18, 1.64)28.66 (-10.22, 67.53)0.46 (-1.09, 2.01)Marked0.21 (-0.80, 1.22)24.62 (-22.80, 72.05)0.81 (-0.87, 2.49)Band-like1.92 (0.81, 3.02)80.42 (31.46, 129.38)2.32 (0.49, 4.16)

OR= Odds ratio, Coef = Coefficient, NLR= neutrophil lymphocyte, PLR= platelet lymphocyte ratio, CRP= C-reactive protein

All significant associations are bolded.

Disclosure of Interests:

Diyu Pearce-Fisher: None declared, Dana Orange Consultant of: Astra Zeneca/MedImmune and Pfizer, Bella Mehta Consultant of: Novartis, Deanna Jannat-Khah: None declared, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis, Horizon Pharmaceuticals

POS0285 ARE RACIAL DISPARITIES IN REVISION TKA OUTCOMES ASSOCIATED WITH HOSPITAL OR SURGEON VOLUME?

Background:

Total knee arthroplasty (TKA) outcomes are linked to surgical volume,1 despite the increase in TKA utilization, racial disparities in TKA outcomes persist. Blacks in the US are at a higher risk of aseptic revision of TKA (R-TKA) when compared to Whites, yet the reasons for this are not understood.

Objectives:

The objective of this study is to examine the relationship between hospital and surgeon annual TKA volume and R-TKA outcomes by race.

Methods:

This is an observational cohort study. New York Statewide Planning and Research Cooperative System data for 2004 – 2013 was used to identify patients who underwent primary TKA. Data through 2015 was used to identify R-TKA within 2 years of the index TKA. Hospital characteristics were obtained from the AHA Annual Survey. Surgeon data was collected from New York State Education Department and New York State Physician Profile. Surgeon annual TKA volume was categorized based on cutoffs established by Wilson et al1 as </=12, 13-59, 60-145 or >/= 146, and hospital TKA volume as </=89, 90-235, 236-644 and >/=645. We calculated the odds of R-TKA in Whites and Blacks separately and generated crude odds ratios (OR) comparing Blacks to Whites to examine trends across volume categories. A multivariable logistic regression model adjusted for known R-TKA risk factors was also performed.

Results:

A total of 163,576 patients were included. Mean (SD) age was 66.4 (10.4) years, 107,233 (65.6%) were female, 124,277 (76.6%) were White and 15,990 (9.8%) were Black. 2925 patients underwent aseptic R-TKA. In logistic regression analysis, Blacks had a higher risk of R-TKA (OR 1.42, 95%CI 1.26-1.6) (Table 1). Risk of R-TKA was also higher when surgeon annual volume was </=12 (OR 1.5, 95%CI 1.25-1.8) or 13-59 (OR 1.16, 95%CI 1.04-1.29) TKA compared to the highest volume surgeons (>/=146). Patients who had surgery at a hospital with annual volume of 236-634 TKA were less likely to undergo R-TKA compared to the highest volume hospitals (>/=645) (OR 0.88, 95%CI 0.79-0.98). Other risk factors for R-TKA were younger age and worker’s compensation, while patients with inflammatory arthritis had a lower risk. Figures 1A and 1B show the odds of R-TKA in Whites and Blacks, respectively, by hospital and surgeon volume. Figure 1C shows the crude OR for Blacks to Whites for each category pair. The OR ranged from 0.9 to 2.5, with the largest disparity found in patients who have TKA performed by surgeons with 60-145 annual TKA volume at the highest volume hospitals (>/=645).

Conclusion:

Patients having TKA by a surgeon performing <60 TKA per year have higher risk of R-TKA. Racial disparities in R-TKA risk are highest for TKA by surgeons performing 60-145 TKA per year at hospitals performing >/=645 TKA per year. Future studies should examine factors, such as whether trainees are involved the surgery, that may vary based on social determines of health, such as patient race and payor.

References:

[1]Wilson S. et al Meaningful thresholds for the volume-outcome relationship in total knee arthroplasty. Journal of bone and joint surgery. 2016;98:1683

Table 1.

Logistic regression of risk for R-TKA

Variable (reference)LevelOdds ratio95% CIp-valueAge--0.950.94-0.95<.001Sex (female)Male1.070.99-1.150.108Race (whiteAsian0.650.42-0.960.031Black1.421.26-1.6<.001Unknown0.810.64-1.020.07Other1.050.92-1.210.446Insurance (Medicare)Medicaid0.890.75-1.060.193Other0.890.7-1.130.331Private0.820.74-0.91<.001Work compensation1.561.35-1.8<.001Surgeon volume (>/=146)</=121.51.25-1.8<.00113-591.161.04-1.290.00660-1451.00.91-1.110.957Hospital volume (>/=645)</= 890.980.84-1.150.84890-2350.990.88-1.120.869236-6440.880.79-0.980.018Hospital bed size (>400 beds)6-1991.131.02-1.250.024200-3991.060.96-1.170.262

Other variables in model: diabetes, obesity, renal disease, COPD, osteoarthritis, osteonecrosis, dislocation, inflammatory arthritis, surgical complication, infection, no college, poverty >20%, years since residency, US/Canada medical school, orthopedic board certified, AHA control, teaching, rural hospital

Disclosure of Interests:

Serene Mirza: None declared, Susan Goodman: None declared, Yi Zhang: None declared, Huong Do: None declared, Bella Mehta: None declared, Stephen Lyman: None declared, Lisa A. Mandl: None declared, Mark Figgie: None declared, Michael Parks Consultant of: Zimmer biomet, Grant/research support from: Zimmer biomet, Linda Russell: None declared, Anne Bass: None declared

Community Deprivation Index and Discharge Destination After Elective Hip Replacement

OBJECTIVE

To examine how the deprivation level of the community in which one lives influences discharge disposition and the odds of 90-day readmission after elective total hip arthroplasty (THA).

METHODS

We performed a retrospective cohort study on 84,931 patients who underwent elective THA in the Pennsylvania Health Care Cost Containment Council database from 2012 to 2016. We used adjusted binary logistic regression models to test the association between community Area Deprivation Index (ADI) level and patient discharge destination as well as 90-day readmission. We included an interaction term for community ADI level and patient race in our models to assess the simultaneous effect of both on the outcomes.

RESULTS

After adjusting for patient- and facility-level characteristics, we found that patients from high ADI level communities (most disadvantaged), compared to patients from low ADI level communities (least disadvantaged), were more likely to be discharged to an institution as opposed to home for postoperative care and rehabilitation (age <65 years adjusted odds ratio [OR_adj ] 1.47; age ≥65 years OR_adj 1.31; both P < 0.001). The interaction effect of patient race and ADI level on discharge destination was statistically significant in those patients age ≥65 years, but not in patients age <65 years. The association with ADI level on 90-day readmission was not statistically significant.

CONCLUSION

In this statewide sample of patients who underwent elective THA, the level of deprivation of the community in which patients reside influences their discharge disposition, but not their odds of 90-day readmission to an acute-care facility.

Variables Associated With Perceived Risk of Contracting SARS-CoV-2 Infection During the COVID-19 Pandemic Among Patients With Systemic Rheumatic Diseases

OBJECTIVE

The aim of this study was to assess patients' perceived risk of contracting SARS-CoV-2 at the peak of the pandemic in NYC in terms of their systemic rheumatic disease and medications.

METHODS

With the approval of their rheumatologists, patients were interviewed by telephone and were asked about their perceived risk of contracting SARS-CoV-2 considering their rheumatic condition and whether medications increased this risk. Patients also completed surveys assessing beliefs about medication and multidimensions of physical/mental well-being. Information about current medications and rheumatologist-initiated changes in medications during the pandemic were reported by patients and verified from medical records.

RESULTS

One hundred twelve patients (86% women; mean age, 50 years; 81% White, 15% Latino) with diverse diagnoses were enrolled. Fifty-four percent thought they were at "very much greater risk" of COVID-19 because of their rheumatic condition, and 57% thought medications "definitely" put them at greater risk. In multivariable analysis, the perception of "very much greater risk" was associated with greater belief that rheumatic disease medications were necessary, worse physical function, chronic pulmonary comorbidity, and more anxiety. In a separate model, the perception that medications "definitely" caused greater risk was associated with White race, not taking hydroxychloroquine, rheumatologists initiating change in medications, more anxiety, and taking biologics and corticosteroids.

CONCLUSIONS

Patients' perceived increased risk of contracting SARS-CoV-2 was associated with beliefs about their rheumatic disease, medications, comorbidity, and anxiety. Clinicians should be aware of patients' perceptions and foster self-management practices that will alleviate anxiety, minimize exposure to the virus, and optimize systemic rheumatic disease outcomes.

Medical overuse of therapies and diagnostics in rheumatology

Medical overuse leads to a burden on healthcare costs and potentially is harmful to patients. We wanted to address medical overuse in musculoskeletal disease and rheumatology. We performed a systemic literature review from PubMed and Embase to study medical overuse. On the initial screen, 1499 studies were identified, 839 of them were related to medical overuse. Out of these, 52 were related to overuse in musculoskeletal diseases. Finally, 20 articles were chosen for this systemic review that reported overuse in rheumatology. The article identifies issues with overtesting, including the use of dual-energy X-ray absorptiometry to screen for osteoporosis in women younger than 65 years old and the use of magnetic resonance imaging to evaluate for osteoarthritis. Studies related to overtreatment reported over-prescription of vitamin D supplements resulting in vitamin D toxicity and increased risk of inappropriate prescriptions in patients with osteoarthritis and rheumatoid arthritis. Overtreating osteoporosis was reported after industry-sponsored education. Articles describing methods to reduce overuse included a study showing the reduction of unnecessary dual-energy X-ray absorptiometry scans after the introduction of the Choosing Wisely Campaign. Our findings suggest that there is some evidence that overtesting and overtreatment may be present in the field of rheumatology. This review aims to highlight this and help rheumatologists to be aware of overuse practices and provide appropriate evidence-based healthcare.

Thirty-day hospital readmission in systemic sclerosis associated pulmonary hypertension: A nationwide study

OBJECTIVE

To identify risk-factors for 30-day hospital readmission in systemic sclerosis pulmonary hypertension (SSc-PH) and to compare trends and characteristics of 30-day readmissions in SSc-PH versus non-SSc pulmonary arterial hypertension (non-SSc PAH).

METHODS

In this retrospective study, we identified SSc-PH and non-SSc PAH hospitalizations using ICD-9 codes within the Healthcare Cost and Utilization Project-National Readmission Database. Thirty-day readmission rates were calculated between 2010 and 2015. Characteristics were compared using chi-square, Wilcoxon rank-sum, or two-sample t-tests between (A) SSc-PH patients with versus without readmission and (B) patients with ≥1 readmission with SSc-PH versus non-SSc PAH. Adjusted logistic regression models were generated for readmission in SSc-PH.

RESULTS

4,846 of 22,420 (22%) with SSc-PH and 10,573 of 49,254 (21%) with non-SSc PAH had ≥1 30-day readmission. Between 2010-2015, readmission rate decreased in non-SSc PAH (23% to 20%; p<0.001) and was unchanged in SSc-PH (23% to 23%; p = 0.77). In SSc-PH, independent predictors of 30-day readmission include male sex, age <60, Medicare or Medicaid, higher Charlson/Deyo comorbidity index, and congestive heart failure (CHF). A higher proportion of patients with SSc-PH (vs. non-SSc PAH) died during index hospitalizations (p = 0.001) and readmissions (p <0.001). Readmitted patients with SSc-PH (vs. non-SSc PAH) were younger and less often had CHF. In SSc-PH, the most common readmission primary diagnosis was infection, followed by respiratory and heart failure.

CONCLUSION

In SSc-PH, 30-day readmission is frequent, and in-hospital deaths occur at a higher rate compared to those with non-SSc PAH. This study identifies factors that may characterize those with SSc-PH at highest risk for readmission.

Rheumatic Disease-Related Symptoms During the Height of the COVID-19 Pandemic

BACKGROUND

Systemic rheumatic diseases are characterized by diverse symptoms that are exacerbated by stressors.

QUESTIONS/PURPOSES

Our goal was to identify COVID-19-related stressors that patients associated with worsening rheumatic disease symptoms.

METHODS

With approval of their rheumatologists, patients at an academic medical center were interviewed with open-ended questions about the impact of COVID-19 on daily life. Responses were analyzed with qualitative methods using grounded theory and a comparative analytic approach to generate categories of stressors.

RESULTS

Of 112 patients enrolled (mean age 50 years, 86% women, 34% non-white or Latino, 30% with lupus, 26% with rheumatoid arthritis), 2 patients had SARS-CoV-2 infection. Patients reported that coping with challenges due to the pandemic both directly and indirectly worsened their rheumatic disease symptoms. Categories associated with direct effects were increased fatigue (i.e., from multitasking, physical work, and taking precautions to avoid infection) and worsening musculoskeletal and cognitive function. Categories associated with indirect effects were psychological worry (i.e., about contracting SARS-COV-2, altering medications, impact on family, and impact on job and finances) and psychological stress (i.e., at work, at home, from non-routine family responsibilities, about uncertainty related to SARS-CoV-2, and from the media). Patients often reported several effects coalesced in causing more rheumatic disease symptoms.

CONCLUSION

Coping with the COVID-19 pandemic was associated with rheumatic disease-related physical and psychological effects, even among patients not infected with SARS-CoV-2. According to patients, these effects adversely impacted their rheumatic diseases. Clinicians will need to ascertain the long-term sequelae of these effects and determine what therapeutic and psychological interventions are indicated.

Modifications in Systemic Rheumatic Disease Medications: Patients' Perspectives During the Height of the COVID-19 Pandemic in New York City

OBJECTIVE

Concerns about severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may have led to changes or discontinuation of immunosuppressive medications among patients with systemic rheumatic disease. Our goal was to assess patients' perspectives regarding medication modifications and deviations from planned uses during the height of the pandemic.

METHODS

Adult patients of 13 rheumatologists at an academic center with physician-diagnosed rheumatic disease and prescribed disease-modifying medications were interviewed by telephone and asked open-ended questions about the impact of SARS-CoV-2 on their medications. Responses were analyzed using content and thematic analyses to generate categories that described patterns of medication modification.

RESULTS

A total of 112 patients (mean age 50 years, 86% women, 34% non-White race or Latino ethnicity) with diverse diagnoses (30% lupus, 26% rheumatoid arthritis, 44% other) who were taking various medications were enrolled. Patients reported clinically relevant issues that were iteratively reviewed to generate unique categories of medication modification: medications and increased or decreased risk of SARS-CoV-2 infection; role of hydroxychloroquine; maintaining medication status quo; role of glucocorticoids; increasing or decreasing existing medications in relation to clinical disease activity; postponing infusions; and medication plan if infected by SARS-CoV-2. Some modifications were suboptimal for disease control but were made to mitigate infection risk and to minimize potential harm when patients were unable to obtain laboratory tests and physical examinations due to cessation of in-person office visits.

CONCLUSION

During the height of the pandemic, substantial medication modifications were made that, in some cases, were temporizing measures and deviations from planned regimens. Future studies will assess short- and long-term sequelae of these medication modifications.

Impact of COVID-19 on vulnerable patients with rheumatic disease: results of a worldwide survey

OBJECTIVE

There is emerging evidence that COVID-19 disproportionately affects people from racial/ethnic minority and low socioeconomic status (SES) groups. Many physicians across the globe are changing practice patterns in response to the COVID-19 pandemic. We sought to examine the practice changes among rheumatologists and what they perceive the impact to be on their most vulnerable patients.

METHODS

We administered an online survey to a convenience sample of rheumatologists worldwide during the initial height of the pandemic (between 8 April and 4 May 2020) via social media and group emails. We surveyed rheumatologists about their opinions regarding patients from low SES and racial/ethnic minority groups in the context of the COVID-19 pandemic. Mainly, what their specific concerns were, including the challenges of medication access; and about specific social factors (health literacy, poverty, food insecurity, access to telehealth video) that may be complicating the management of rheumatologic conditions during this time.

RESULTS

548 rheumatologists responded from 64 countries and shared concerns of food insecurity, low health literacy, poverty and factors that preclude social distancing such as working and dense housing conditions among their patients. Although 82% of rheumatologists had switched to telehealth video, 17% of respondents estimated that about a quarter of their patients did not have access to telehealth video, especially those from below the poverty line. The majority of respondents believed these vulnerable patients, from racial/ethnic minorities and from low SES groups, would do worse, in terms of morbidity and mortality, during the pandemic.

CONCLUSION

In this sample of rheumatologists from 64 countries, there is a clear shift in practice to telehealth video consultations and widespread concern for socially and economically vulnerable patients with rheumatic disease.

Geographical variations in COVID-19 perceptions and patient management: a national survey of rheumatologists

OBJECTIVE

To investigate the perceptions and behaviors of rheumatologists in the United States (US) regarding the risk of COVID-19 for their autoimmune patients and the subsequent management of immunosuppressive and anti-inflammatory medications.

METHODS

We administered an online survey to a convenience sample of rheumatologists in the US from 4/8/20-5/4/20 via social media and group emails. Survey respondents provided demographic information such as, age, gender, state of practice, and practice type. We asked questions about COVID-19 risk in rheumatic patients, as well as their medication management during the pandemic. We conducted descriptive analysis and Multivariable regression models.

RESULTS

271 respondents completed the survey nationally. 48% of respondents either agreed or strongly agreed with the statement "Patients with rheumatic diseases are at a higher risk of COVID-19 irrespective of their immunosuppressive medications". 50% disagreed or strongly disagreed with the statement "The pandemic has led you to reduce the use/dosage/frequency of biologics", while 56% agreed or strongly agreed with the statement "The pandemic has led you to reduce the use/dosage/frequency of steroids". A third of respondents indicated that at least 10% of their patients had self-discontinued or reduced at least one immunosuppressive medication to mitigate their risk of COVID-19. Responses to these questions as well as to questions regarding NSAID prescription patterns were significantly different in the Northeast region of US compared to other regions.

CONCLUSION

In this national sample of rheumatologists, there are variations regarding perceptions of patients' risk of COVID-19, and how to manage medications such as NSAIDs, biologics and steroids during the pandemic. These variations are more pronounced in geographical areas where COVID-19 disease burden was high.

Hydroxychloroquine and Chloroquine in COVID-19: A Survey of Prescription Patterns Among Rheumatologists

OBJECTIVE

With hydroxychloroquine (HCQ) and chloroquine (CQ) emerging as potential therapies for coronavirus disease 2019 (COVID-19), shortages have been reported. We aimed to understand how rheumatologists, one of the most common prescribers of HCQ/CQ, prescribed these medications to manage COVID-19 and to understand if their patients are affected by shortages.

METHODS

Between April 8 and April 27, 2020, an online survey was distributed to a convenience sample of rheumatologists who practice medicine in a diverse range of settings globally, resulting in 506 responses. Adjusted Poisson regression models were calculated.

RESULTS

Only 6% of respondents prescribed HCQ/CQ for COVID-19 prophylaxis, and only 12% for outpatient treatment of COVID-19. Compared to the United States, the likelihood of prescribing HCQ/CQ for prophylaxis was higher in India (adjusted risk ratio [aRR], 6.7; 95% confidence interval [CI], 2.7-16.8; p < 0.001). Further, compared to the United States and those with 1 to 5 years of experience, rheumatologists in Europe (aRR, 2.9; 95% CI, 1.6-5.3; p < 0.001) and those with 10+ years of experience (11-20 years: aRR, 2.5; 95% CI, 1.2-5.3; p = 0.015; 21+ years: aRR = 3.3; 95% CI, 1.4-7.4; p = 0.004) had a higher likelihood of prescribing HCQ/CQ for outpatient treatment. Of note, 71% of all rheumatologists reported that their patients were directly affected by HCQ/CQ shortages.

CONCLUSION

The results suggest that only a small percentage of rheumatologists are prescribing HCQ/CQ for prophylaxis or outpatient treatment of COVID-19. Medication shortages experienced by large numbers of autoimmune disease patients are concerning and should play a role in decisions, especially given poor efficacy data for HCQ/CQ in COVID-19.

Rheumatoid Arthritis Flares After Total Hip and Total Knee Arthroplasty: Outcomes at One Year

OBJECTIVE

Most patients with rheumatoid arthritis (RA) undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) have active RA and report postoperative flares; whether RA disease activity or flares increase the risk of worse pain and function scores 1 year later is unknown.

METHODS

Patients with RA were enrolled before THA/TKA. Patient-reported outcomes, including the Hip disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS) and physician assessments of disease characteristics and activity (Disease Activity Score in 28 joints [DAS28] and Clinical Disease Activity Index), were collected before surgery. Patient-reported outcomes were repeated at 1 year. Postoperative flares were identified using the RA Flare Questionnaire weekly for 6 weeks and were defined by concordance between patient report plus physician assessment. We compared baseline characteristics and HOOS/KOOS scores using 2-sample t-test/Wilcoxon's rank sum test as well as chi-square/Fisher's exact tests. We used multivariate linear and logistic regression to determine the association of baseline characteristics, disease activity, and flares with 1-year outcomes.

RESULTS

One-year HOOS/KOOS scores were available for 122 patients (56 with THA and 66 with TKA). Although HOOS/KOOS pain was worse for patients who experienced a flare within 6 weeks of surgery, absolute improvement was not different. In multivariable models, baseline DAS28 predicted 1-year HOOS/KOOS pain and function; each 1-unit increase in DAS28 worsened 1-year pain by 2.41 (SE 1.05; P = 0.02) and 1-year function by 4.96 (SE 1.17; P = 0.0001). Postoperative flares were not independent risk factors for pain or function scores.

CONCLUSION

Higher disease activity increased the risk of worse pain and function 1 year after arthroplasty, but postoperative flares did not.

Trends in the Inpatient Burden of Coronary Artery Disease in Granulomatosis With Polyangiitis: A Study of a Large National Dataset

OBJECTIVE

Cardiovascular (CV) diseases are serious comorbidities in patients with granulomatosis with polyangiitis (GPA). In a sample of patients hospitalized for GPA, we sought to examine trends in the burden of coronary artery disease (CAD) and its 2 serious manifestations, acute myocardial infarction (AMI) and heart failure (HF).

METHODS

We used the National Inpatient Sample to conduct a retrospective cross-sectional analysis. Our sample consisted of hospitalizations for GPA between 2005 and 2014. We examined trends in the proportion of CAD, AMI, and HF in all hospitalizations with GPA compared to those without GPA. We used logistic regression adjusted for potential confounders and included interaction terms.

RESULTS

Among a total of 103,453 GPA hospitalizations, 20,351 (19.7%) hospitalizations had a concurrent diagnosis of CAD. GPA with CAD was associated with overall lower burden of traditional CV risk factors compared to non-GPA with CAD, with the exception of chronic kidney disease (57% vs 21%). Over the 10-year study period, there were rising trends in the inpatient burden of CAD (16.6% in 2005 to 22.7% in 2014) and CAD with HF (4.3% in 2005 to 9.9% in 2014), but not AMI (1.2% in 2005 to 1.1% in 2014), in GPA hospitalizations compared to non-GPA controls.

CONCLUSION

In this national sample of GPA hospitalizations, we found that the burden of CAD and CAD with HF was on the rise over the 10-year period compared to non-GPA; however, it was not the case for AMI.

FRI0379 VARIATIONS IN THE UTILIZATION OF BILATERAL TOTAL KNEE ARTHROPLASTY IN THE MANAGEMENT OF OSTEOARTHRITIS

Background:

A third of knee osteoarthritis presents with bilateral symptomatic arthritis. In these patients, treatment options include either a staged Unilateral Total knee arthroplasty (UTKA) procedure, or a simultaneous Bilateral TKA (BTKA) procedure. Even though literature regarding outcomes in BTKA procedure has not consistently been favorable, it remains popular in select patients due to use of a single anesthetic, shorter overall surgical time, lower cost and lower overall use of narcotics. African Americans (AAs) have lower utilization and worse outcomes in UTKA literature. It is unclear whether these racial variations extend to BTKA.

Objectives:

We sought to examine BTKA vs UTKA utilization rates and outcomes comparing AA and White patients.

Methods:

National Inpatient Sample (NIS) - Healthcare Cost and Utilization Project (HCUP) database (2007-2016) was used. We identified all patients ≥ 50 years who underwent elective primary TKA using ICD-9-CM code 81.54 for UTKA and BTKA from January 1, 2012 to September 30, 2015, and ICD-10-CM codes 0SRC0x and 0SRD0x thereafter. Patients with inflammatory arthritis, pathologic fractures, metastatic disease and avascular necrosis were excluded. Major in-hospital complications included post-operative myocardial infarction, prosthetic device complication, surgical wound infection, and venous thromboembolism. Differences in temporal trends in utilization and major in-hospital complications of BTKA vs UTKA were compared between AAs and Whites. Multivariable logistic regression models were used to assess differences in both these trends between AAs and Whites after adjusting for individual (age, sex, Elixhauser comorbidity index, and morbid obesity), hospital level (hospital volume, bed size, region and teaching status) and community level (median household income) variables. Discharge weights were used to enable nationwide estimates. Multiple imputation was performed for missing race variable (11.9%).

Results:

From 2007 to 2016, an estimated 276,194 BTKA (unweighted observations 56,675) and 5,528,429 UTKA (unweighted observations 1,131,329) were identified (Table 1). Females had a higher proportion of TKAs performed (62.1% UTKA vs 55.9% BTKA). Patients had fewer comorbidities (measured by the Elixhauser Index) when undergoing BTKA compared to UTKA. The proportion of BTKA amongst all TKAs declined from 5.53% in 2007-08 to 4.03% in 2015-16. AAs continued to have significantly lower proportion of BTKA utilization compared to Whites (4.68% in AAs vs 6.08% in Whites in 2007-08, whereas 3.28% in AAs vs 4.19% in Whites in 2015-16, adjusted p < 0.001) (Figure 1a). In-hospital complication rates for UTKA and BTKA were significantly higher in Whites compared to AAs throughout the study period (0.77% in AAs vs 0.9% in Whites in 2007-08, whereas 0.69% in AAs vs 0.83% in Whites in 2015-16, adjusted p < 0.001) (Figure 1b). The results were similar after imputation of missing race values.

Conclusion:

In this nationwide sample of patients from 2007 to 2016, we found that AAs have lower utilization rate of BKTA compared to Whites, however the in-hospital complication rates were significantly higher in Whites.

References:

N/A

Table 1.

Weighted frequencies and percentages of demographic characteristics among unilateral TKA vs. bilateral TKA (N = 6, 236, 426).

VariableUnilateral TKABilateral TKAPaN = 5,528,429(Unweighted N = 1,131,329)N = 276,194(Unweighted N = 56,675)Patient CharacteristicsAge, mean (SD)67.4 (0.02)65.0 (0.06)<.0001Sex: Female, n(%)3,429,484 (62.1)154,442 (55.9)<.0001Race, n(%): White4,051,648 (50.9)212,468 (76.9)<.0001 African American352,933 (6.4)14,441 (5.2) Other464,407 (8.4)16,443 (6.0) Missing659,439 (11.9)32,842 (11.9)Morbid Obesity, n(%)401,892 (7.3)20,411 (7.4)0.47Elixhauser Indexd, n(%):<.0001 0716,559 (13.0)41,550 (15.0) 1-44,484,941 (81.1)220,638 (80.0) ≥ 5326,928 (5.9)14,007 (5.1)

Disclosure of Interests:

Bella Mehta: None declared, Kaylee Ho: None declared, Jennifer Bido: None declared, Michael Parks Consultant of: Zimmer Biomet, Linda Russell: None declared, Susan Goodman Shareholder of: Reginosine- Investment, Grant/research support from: Novartis, Horizon, Consultant of: Novartis, Celgene, UCB, Said Ibrahim: None declared

0555 The Relationship Between Sleep Efficiency and Apnoea Hypopnoea Index (AHI) in Adult Obese Males

Introduction

Prevalence of obesity is increasing worldwide. According to OECD 2017, the prevalence of obesity is 19.5% worldwide. Obesity leads to disturbed sleep due to complete or partial obstruction of upper airways i.e. obstructive sleep apnoea. This disturbed sleep leads to increased sympathetic discharge & further obesity and thus forms a vicious cycle of obesity disturbing sleep and sleep disturbance increasing obesity. The purpose of the present study was to correlate the sleep efficiency with apnoea hypopnea index (AHI) in adult obese males.

Methods

Nineteen adult obese males (26 years- 60 years), non-smokers were recruited for this cross-sectional study. The obesity criteria was taken as BMI ≥ 25 kg/m2. They underwent an overnight polysomnographic examination with total 68 channels and 32 EEG inputs. The episodes of apnea were defined as complete cessation of airflow for ≥10 s, and hypopnea consisted of a ≥30% reduction in oronasal airflow accompanied by a reduction in oxygen saturation measured by pulse oximetry of at least 4%. AHI was determined by the frequency of these events per hour during sleep time based on the results of the overnight polysomnography. Sleep efficiency index was calculated by dividing total duration of sleep stages (N1+ N2+ N3+ REM) by total time in bed.

Results

We tested for normality through Shapiro Wilk test and our data was found to be non-parametric. Hence Spearman correlation between sleep efficiency and AHI was performed. The correlation was non- significant with p value 0.1245 and r = - 0.365. The correlation of BMI with sleep efficiency was significant (p= 0.0195) with r value= -0.5303.

Conclusion

The results conclude that the sleep efficiency worsens with obesity. Although the correlation between AHI and sleep efficiency was not found significant, a negative r value indicates that the sleep efficiency decreases with increased obstructive events during sleep.

Support

All India Institute of Medical Sciences Jodhpur

0129 Association of Sleep Quality with Serum Lipids in Obese Adults

Introduction

Sleep disturbances have been associated with metabolic dysregulation and have known to contribute to weight gain, obesity, type II diabetes, and cardiovascular disease risk. Obesity due to sleep fragmentation is mediated by multiple pathways like upregulation of orexin neurons and changes in appetite-regulating hormones like Leptin, Ghrelin, which affect food intake and hedonic feeding. Conversely, body mass index (BMI) is associated with alterations in sleep and with high circulating lipids and incidence of coronary heart disease. We hypothesized that poor sleep quality is associated with an adverse serum lipid profile.

Methods

In this cross-sectional study, till date, 27 obese adult participants were recruited after informed consent. The obesity criterion was taken as BMI ≥ 25 kg/m2. Anthropometric parameters, waist circumference, neck circumference, hip circumference, and BP were measured. Sleep quality was assessed by the “Pittsburgh Sleep Quality Index” (PSQI) questionnaire. A score of 5 or more was considered to be adverse sleep. The fasting blood sugar and lipid profile of each participant was determined.

Results

The average age, BMI and waist circumference of the subjects were 48.96 ±13.9 years, 32.41± 6.18 kg/m2 and 107.4 ±12.18 cm respectively. The Spearman correlation test revealed a significant correlation between the PSQI scores and triglyceride levels of the participants (p=0.033, r = 0.420). The correlation with BMI (p=0.33, r=0.192), fasting blood sugar (p=0.26, r=0.241), HDL (p=0.27, r = -0.221) and waist circumference (p=0.69, r = -0.082) were not found to be statistically significant.

Conclusion

We conclude that high triglyceride levels are associated with poor quality of sleep in adults. Although other biochemical parameters did not show a significant correlation, a greater sample size may give us a clear insight into it.

Support

The study is an intramural project supported by AIIMS, Jodhpur.

Validation of the Hip Disability and Osteoarthritis Outcome Score and Knee Injury and Osteoarthritis Outcome Score Pain and Function Subscales for Use in Total Hip Replacement and Total Knee Replacement Clinical Trials

BACKGROUND

Total hip replacement (THR)/total knee replacement (TKR) studies do not uniformly measure patient centered domains, pain, and function. We aim to validate existing measures of pain and function within subscales of standard instruments to facilitate measurement.

METHODS

We evaluated baseline and 2-year pain and function for THR and TKR using Hip disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS), with primary unilateral TKR (4796) and THR (4801). Construct validity was assessed by correlating HOOS/KOOS pain and activities of daily living (ADL), function quality of life (QOL), and satisfaction using Spearman correlation coefficients. Patient relevant thresholds for change in pain and function were anchored to improvement in QOL; minimally clinically important difference (MCID) corresponded to "a little improvement" and a really important difference (RID) to a "moderate improvement." Pain and ADL function scores were compared by quartiles using Kruskal-Wallis.

RESULTS

Two-year HOOS/KOOS pain and ADL function correlated with health-related QOL (KOOS pain and Short Form 12 Physical Component Scale ρ = 0.54; function ρ = 0.63). Comparing QOL by pain and function quartiles, the highest levels of pain relief and function were associated with the most improved QOL. MCID for pain was estimated at ≥20, and the RID ≥29; MCID for function ≥14, and the RID ≥23. The measures were responsive to change with large effect sizes (≥1.8).

CONCLUSION

We confirm that HOOS/KOOS pain and ADL function subscales are valid measures of critical patient centered domains after THR/TKR, and achievable thresholds anchored to improved QOL. Cost-free availability and brevity makes them feasible, to be used in a core measurement set in total joint replacement trials.

The Community Pharmacy Technician's Role in the Changing Pharmacy Practice Space

Purpose:

The practice of pharmacy and role of pharmacists has evolved over the decades but markedly since the introduction of the Affordable Care Act (ACA) in 2010. The ACA allowed patients to have increased access to community pharmacy services, such as medication therapy management, leading to an increase in the clinical services provided by pharmacists. This expansion of pharmacist’s roles has led to pharmacists to feel an increase in workload which negatively impacts the time spent with patients. One way for this shift to occur without continuing to increase the pharmacist’s workload is by using technicians as pharmacist extenders to take on more technical tasks.

Summary:

The role of pharmacy technicians has been slow to expand from fear of public safety due to the lack of required education and training. Today, state requirements to practice as a pharmacy technician have become stricter with state requiring licensing, registration or certification. This increase in requirements as led to the expansion of pharmacy technician duties. Studies show that pharmacy technicians are able to perform technician accuracy checking, provide immunization and perform Clinical Laboratory Improvement Amendments (CLIA)-waived screenings. In addition to these duties, pharmacy technicians are being utilized in more novel ways such as collecting medication information in primary care and telepharmacy settings.

Conclusion:

In order for pharmacy to continue to grow as a profession, pharmacists need to use pharmacy technicians as extenders. As pharmacy technicians begin to take on more of the technical duties, pharmacists are able to increase the time spent with patients.

Assessment of burnout within a health-system pharmacy department

Purpose

Workplace-related burnout is a state of mental and physical exhaustion caused by one’s professional life. Literature demonstrates the link between physician burnout and serious consequences (reduced productivity, medical errors, and clinician suicide), but assessment of burnout in other healthcare professions is limited, especially in pharmacy. A quality improvement study was conducted to quantify burnout in a diverse health-system pharmacy department and identify potential strategies to improve well-being.

Methods

A survey was distributed to assess the perception and drivers of burnout within a health-system pharmacy. All associates received a survey comprised of the Maslach Burnout Inventory (MBI), demographic questions, and items affording respondents the opportunity to list stressors and potential solutions. Email reminders were sent weekly and site visits were conducted to encourage survey completion. Results were analyzed via descriptive statistics.

Results

Two hundred seventy-seven associates completed the survey (response rate, 40.5%). Seventy percent of those participants were experiencing moderate to high levels of burnout, with survey results indicating moderate levels of personal accomplishment and emotional exhaustion and low levels of depersonalization; there were no statistically significant differences in mean MBI scores by shift type, hours worked per week, or years of service. There were statistically significant differences in scores for personal accomplishment between males and females, as well as among positions and regions (P &lt; 0.05). Participants identified issues related to workflow, control, and community as the greatest contributors to stress.

Conclusion

The diverse staff of a health-system pharmacy department reported a moderate amount of burnout, with the greatest variation in the dimension of personal accomplishment. The mitigation strategies most commonly cited were staffing/workflow adjustments and creating a culture of well-being.