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Vina ER, Patel P, Grest CV, Kwoh CK, Jakiela JT, Bye T, White DK. Does Physical Activity Confound Race Differences in Osteoarthritis-Related Functional Limitation? Arthritis Care Res (Hoboken) 2024; 76:200-207. [PMID: 37518677 DOI: 10.1002/acr.25209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/29/2023] [Accepted: 07/19/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE This study sought to determine the extent to which physical activity confounds the relation between race and the incidence of osteoarthritis (OA)-related functional limitation. METHODS OA Initiative study participants with or at increased risk of knee OA who wore an accelerometer were included. Race was self-reported. Average time spent in moderate to vigorous physical activity (minutes per day) based on ActiGraph uniaxial accelerometer data was assessed. Functional limitation was based on the following: (1) inability to achieve a community walking speed (1.2 m/s) standard, (2) slow walking speed (<1.0 m/s), and (3) low physical functioning based on a Western Ontario and McMaster Universities OA Index (WOMAC) physical function score greater than 28 of 68. RESULTS African American (AA) participants (n = 226), compared with White participants (n = 1348), had a higher likelihood of developing functional limitation based on various measures. When adjusted for time in moderate to vigorous physical activity, the association between AA race and inability to walk a community walking speed slightly decreased (from relative risk [RR] 2.15, 95% confidence interval [95% CI] 1.64-2.81, to RR 1.99, 95% CI 1.51-2.61). Association between AA race and other measures of functional limitation mildly decreased (slow walking speed: from RR 2.06, 95% CI 1.40-3.01, to RR 1.82, 95% CI 1.25-2.63; low physical functioning: from RR 3.44, 95% CI 1.96-6.03, to RR 3.10, 95% CI 1.79-5.39). When further adjusted for demographic and other clinical variables, only the association between race and low physical functioning (WOMAC) significantly decreased and no longer met statistical significance. CONCLUSION Greater physical activity is unlikely to completely make up for race differences in OA-related functional limitation, and other barriers to health equity need to be addressed.
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Affiliation(s)
- Ernest R Vina
- Temple University, Philadelphia, Pennsylvania, and University of Arizona, Tucson
| | - Puja Patel
- Temple University, Philadelphia, Pennsylvania
| | | | - C Kent Kwoh
- University of Arizona College of Medicine, Tucson
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Hurst C, Soto M, Vina ER, Rodgers KE. Renin-Angiotensin System-Modifying Antihypertensive Drugs Can Reduce the Risk of Cardiovascular Complications in Lupus: A Retrospective Cohort Study. Am J Med 2023; 136:284-293.e4. [PMID: 36495935 PMCID: PMC9957968 DOI: 10.1016/j.amjmed.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with systemic lupus erythematosus have a higher incidence of cardiovascular disease than the general population. Antihypertensive drugs that modify the renin-angiotensin system (RAS) are used to protect renal function in lupus nephritis and may also have extrarenal effects that lower cardiovascular disease risk due to their anti-inflammatory properties. In this study, we compared the effects of RAS vs non-RAS antihypertensive drugs on cardiovascular disease incidence in patients with lupus. METHODS Using a medical insurance claims dataset, 220,168 patients with lupus were identified, of which 31,647 patients (4018 patients prescribed RAS drugs, 27,629 patients prescribed non-RAS drugs) were eligible for the study. Patients had a mean age of 46.1 years, were 93.0% female, and healthy (96.9% Charlson Comorbidity Index score 0-4). Patients in the 2 drug groups were propensity score matched using demographic data, risk factors, and comorbidities. RESULTS Use of RAS vs non-RAS drugs lowered the relative risk (RR) of diagnosis of cardiovascular disease (RR 0.80; 95% confidence interval [CI], 0.74-0.87), which was more pronounced after propensity score matching (RR 0.62; 95% CI, 0.57-0.68). The decreased risk in cardiovascular disease occurred regardless of lupus nephritis status (with lupus nephritis: RR 0.51; 95% CI, 0.39-0.65; without lupus nephritis: RR 0.65; 95% CI, 0.59-0.72). RAS-modifying therapies significantly increased cardiovascular disease-free survival probability over a 5-year period (86.0% vs 78.3% probability). CONCLUSIONS RAS-modifying drugs reduced the risk of cardiovascular disease in patients with systemic lupus erythematosus in this dataset. These findings have the potential to impact clinical decision-making with regards to hypertension management in patients with lupus.
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Affiliation(s)
- Chelsie Hurst
- Department of Pharmacology, Center for Innovation in Brain Science, College of Medicine, University of Arizona, Tucson
| | - Maira Soto
- Department of Pharmacology, Center for Innovation in Brain Science, College of Medicine, University of Arizona, Tucson
| | - Ernest R Vina
- Section of Rheumatology, Lewis Katz School of Medicine, Temple University, Philadelphia, Pa
| | - Kathleen E Rodgers
- Department of Pharmacology, Center for Innovation in Brain Science, College of Medicine, University of Arizona, Tucson.
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Vina ER, Tsoukas PH, Abdollahi S, Mody N, Roth SC, Redford AH, Kwoh CK. Racial and ethnic differences in the pharmacologic management of osteoarthritis: rapid systematic review. Ther Adv Musculoskelet Dis 2022; 14:1759720X221105011. [PMID: 35794906 PMCID: PMC9251972 DOI: 10.1177/1759720x221105011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 05/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background Racial and ethnic disparities in osteoarthritis (OA) patients' disease experience may be related to marked differences in the utilization and prescription of pharmacologic treatments. Objectives The main objective of this rapid systematic review was to evaluate studies that examined race/ethnic differences in the use of pharmacologic treatments for OA. Data sources and methods A literature search (PubMed and Embase) was ran on 25 February 2022. Studies that evaluated race/ethnic differences in the use of OA pharmacologic treatments were included. Two reviewers independently screened titles and abstracts and abstracted data from full-text articles. Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Results The search yielded 3880 titles, and 17 studies were included in this review. African Americans and Hispanics were more likely than non-Hispanic Whites to use prescription non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for OA. However, compared to non-Hispanic Whites with OA, African Americans and Hispanics with OA were less likely to receive a prescription for cyclooxygenase-2-selective NSAIDs and less likely to report the use of joint health supplements (i.e. glucosamine and chondroitin sulfate). There were minimal/no significant race/ethnic differences in the patient-reported use of the following OA therapies: acetaminophen, opioids, and other complementary/alternative medicines (vitamins, minerals, and herbs). There were also no significant race differences in the receipt of intra-articular therapies (i.e. glucocorticoid or hyaluronic acid). However, there is limited evidence to suggest that African Americans may be less likely than Whites to receive opioids and intra-articular therapies in some OA patient populations. Conclusion This systematic review provides an overview of the current pharmacologic options for OA, with a focus on race and ethnic differences in the use of such medical therapies.
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Affiliation(s)
- Ernest R Vina
- Section of Rheumatology, Lewis Katz School of Medicine, Temple University, 201 MOB, 3322 N. Broad Street, Philadelphia, PA 19140, USA
| | - Philip H Tsoukas
- Section of Rheumatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Shahrzad Abdollahi
- Section of Rheumatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Nidhi Mody
- Section of Rheumatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Stephanie C Roth
- Health Sciences Library, Temple University, Philadelphia, PA, USA
| | - Albert H Redford
- The University of Arizona Arthritis Center and Division of Rheumatology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - C Kent Kwoh
- The University of Arizona Arthritis Center and Division of Rheumatology, College of Medicine, University of Arizona, Tucson, AZ, USA
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Weaver JS, Vina ER, Munk PL, Klauser AS, Elifritz JM, Taljanovic MS. Gouty Arthropathy: Review of Clinical Manifestations and Treatment, with Emphasis on Imaging. J Clin Med 2021; 11:jcm11010166. [PMID: 35011907 PMCID: PMC8745871 DOI: 10.3390/jcm11010166] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/16/2021] [Accepted: 12/26/2021] [Indexed: 12/22/2022] Open
Abstract
Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the articular and periarticular soft tissues, is a frequent cause of painful arthropathy. Imaging has an important role in the initial evaluation as well as the treatment and follow up of gouty arthropathy. The imaging findings of gouty arthropathy on radiography, ultrasonography, computed tomography, dual energy computed tomography, and magnetic resonance imaging are described to include findings of the early, acute and chronic phases of gout. These findings include early monosodium urate deposits, osseous erosions, and tophi, which may involve periarticular tissues, tendons, and bursae. Treatment of gout includes non-steroidal anti-inflammatories, colchicine, glucocorticoids, interleukin-1 inhibitors, xanthine oxidase inhibitors, uricosuric drugs, and recombinant uricase. Imaging is critical in monitoring response to therapy; clinical management can be modulated based on imaging findings. This review article describes the current standard of care in imaging and treatment of gouty arthropathy.
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Affiliation(s)
- Jennifer S. Weaver
- Department of Radiology, University of New Mexico, Albuquerque, NM 87131, USA;
- Correspondence:
| | - Ernest R. Vina
- Department of Medicine, University of Arizona Arthritis Center, Tucson, AZ 85724, USA;
| | - Peter L. Munk
- Department of Radiology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
- Department of Radiology, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Andrea S. Klauser
- Radiology Department, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
| | - Jamie M. Elifritz
- Departments of Radiology and Pathology, University of New Mexico, Albuquerque, NM 87131, USA;
- New Mexico Office of the Medical Investigator, Albuquerque, NM 87131, USA
| | - Mihra S. Taljanovic
- Department of Radiology, University of New Mexico, Albuquerque, NM 87131, USA;
- Departments of Medical Imaging and Orthopaedic Surgery, University of Arizona, Tucson, AZ 85721, USA
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Vina ER, Youk AO, Quinones C, Kwoh CK, Ibrahim SA, Hausmann LRM. Use of Complementary and Alternative Therapy for Knee Osteoarthritis: Race and Gender Variations. ACR Open Rheumatol 2021; 3:660-667. [PMID: 34535982 PMCID: PMC8449036 DOI: 10.1002/acr2.11307] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate race and gender variations in complementary and alternative medicine (CAM) use for knee osteoarthritis (OA) (unadjusted and adjusted for demographic and clinical factors). Methods A secondary analysis of cross‐sectional data was conducted. The sample included Veterans Affairs patients 50 years of age or older with symptomatic knee OA. Current use of various CAM therapies was assessed at baseline. Logistic regression models were used to compare race and gender differences in the use of specific CAMs. Results The sample included 517 participants (52.2% identified as African American [AA]; 27.1% identified as female). After adjusting for demographic and clinical factors, AA participants, compared with white participants, were less likely to use joint supplements (odds ratio [OR]: 0.53; 95% confidence interval [CI], 0.31‐0.90]); yoga, tai chi, or pilates (OR: 0.39; 95% CI: 0.19‐0.77); and chiropractic care (OR: 0.51; 95% CI: 0.26‐1.00). However, they were more likely to participate in spiritual activities (OR: 2.02; 95% CI: 1.39‐2.94). Women, compared with men, were more likely to use herbs (OR: 2.42; 95% CI: 1.41‐4.14); yoga, tai chi, or pilates (OR: 2.09; 95% CI: 1.04‐4.19); acupuncture, acupressure, or massage (OR: 2.45; 95% CI: 1.28‐4.67); and spiritual activities (OR: 1.68; 95% CI: 1.09‐2.60). The interactive effects of race and gender were significant in the use of herbs (P = 0.008); yoga, tai chi, or pilates (P = 0.011); acupuncture, acupressure or massage (P = 0.038); and spiritual activities (P < 0.001). Conclusion There are race and gender differences in the use of various CAMs for OA. As benefits and limitations of CAM therapies vary, clinicians must be aware of these differences.
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Affiliation(s)
- Ernest R Vina
- College of Medicine and University of Arizona Arthritis Center, University of Arizona, Tucson
| | - Ada O Youk
- Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cristian Quinones
- College of Medicine and University of Arizona Arthritis Center, University of Arizona, Tucson
| | - C Kent Kwoh
- College of Medicine and University of Arizona Arthritis Center, University of Arizona, Tucson
| | | | - Leslie R M Hausmann
- Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh, Pittsburgh, Pennsylvania
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Tighe CA, Youk A, Ibrahim SA, Weiner DK, Vina ER, Kwoh CK, Gallagher RM, Bramoweth AD, Hausmann LRM. Pain Catastrophizing and Arthritis Self-Efficacy as Mediators of Sleep Disturbance and Osteoarthritis Symptom Severity. Pain Med 2021; 21:501-510. [PMID: 31504838 DOI: 10.1093/pm/pnz187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Sleep and pain-related experiences are consistently associated, but the pathways linking these experiences are not well understood. We evaluated whether pain catastrophizing and arthritis self-efficacy mediate the association between sleep disturbance and osteoarthritis (OA) symptom severity in patients with knee OA. METHODS We analyzed cross-sectional baseline data collected from Veterans Affairs (VA) patients enrolled in a clinical trial examining the effectiveness of a positive psychology intervention in managing pain from knee OA. Participants indicated how often in the past two weeks they were bothered by trouble falling asleep, staying asleep, or sleeping too much. We used validated scales to assess the primary outcome (OA symptom severity) and potential mediators (arthritis self-efficacy and pain catastrophizing). To test the proposed mediation model, we used parallel multiple mediation analyses with bootstrapping, controlling for sociodemographic and clinical characteristics with bivariate associations with OA symptom severity. RESULTS The sample included 517 patients (Mage = 64 years, 72.9% male, 52.2% African American). On average, participants reported experiencing sleep disturbance at least several days in the past two weeks (M = 1.41, SD = 1.18) and reported moderate OA symptom severity (M = 48.22, SD = 16.36). More frequent sleep disturbance was associated with higher OA symptom severity directly (b = 3.08, P <0.001) and indirectly, through higher pain catastrophizing (b = 0.60, 95% confidence interval [CI] = 0.20 to 1.11) and lower arthritis self-efficacy (b = 0.84, 95% CI = 0.42 to 1.42). CONCLUSIONS Pain catastrophizing and arthritis self-efficacy partially mediated the association between sleep disturbance and OA symptom severity. Behavioral interventions that address pain catastrophizing and/or self-efficacy may buffer the association between sleep disturbance and OA symptom severity.
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Affiliation(s)
- Caitlan A Tighe
- VISN 4 Mental Illness Research, Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Said A Ibrahim
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | - Debra K Weiner
- Geriatric Research, Education & Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ernest R Vina
- College of Medicine and University of Arizona Arthritis Center, University of Arizona, Tucson, Arizona
| | - C Kent Kwoh
- College of Medicine and University of Arizona Arthritis Center, University of Arizona, Tucson, Arizona
| | - Rollin M Gallagher
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam D Bramoweth
- VISN 4 Mental Illness Research, Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Geriatric Research, Education & Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Vina ER, Quinones C, Hausmann LRM, Ibrahim SA, Kwoh CK. Association of Patients' Familiarity and Perceptions of Efficacy and Risks With the Use of Opioid Medications in the Management of Osteoarthritis. J Rheumatol 2021; 48:1863-1870. [PMID: 33452165 DOI: 10.3899/jrheum.201133] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE While opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient familiarity and perceptions regarding efficacy and risks with opioid medication use for OA. METHODS A total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients' familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables. RESULTS In this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35.3%), and had higher mean depression (Patient Health Questionnaire [PHQ]-8 7.2 vs 4.9) and OA-related pain (Western Ontario and McMaster Universities Arthritis Index [WOMAC] 54.8 vs 46.8) scores. After adjustment for sociodemographic and clinical variables, the following were associated with opioid medication use: higher perception of medication benefit (OR 1.68, 95% CI 1.18-2.41), lower perception of medication risk (OR 0.67, 95% CI 0.51-0.88), and having family or friends who received the medication for OA (OR 3.88, 95% CI 1.88-8.02). CONCLUSION Among adults with knee/hip OA, opioid use was associated with being familiar with the treatment, as well as believing that the medication was beneficial and low-risk.
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Affiliation(s)
- Ernest R Vina
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Cristian Quinones
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Leslie R M Hausmann
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Said A Ibrahim
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - C Kent Kwoh
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
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Vina ER, Quinones C. Understanding the Role and Challenges of Patient Preferences in Disparities in Rheumatologic Disease Care. Rheum Dis Clin North Am 2020; 47:83-96. [PMID: 34042056 DOI: 10.1016/j.rdc.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Evidence suggests patient preferences, including values and perspectives, have affected clinical outcomes, such as compliance, patient well-being, and satisfaction with care. A literature review was conducted with the purpose of exploring the tools used to elicit patients' treatment preferences and their roles in clinical outcomes. This review revealed racial differences in treatment preferences among patients with rheumatic and musculoskeletal diseases. The use of decision aids is a proactive intervention with potential for reducing race disparities and improving clinical outcomes. The utilization of patient preferences and values can improve outcomes by complementing the shared decision-making approach between patients and rheumatologists.
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Affiliation(s)
- Ernest R Vina
- University of Arizona Arthritis Center, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA; Department of Medicine, Division of Rheumatology, University of Arizona, College of Medicine, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA.
| | - Cristian Quinones
- University of Arizona Arthritis Center, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA; Department of Medicine, Division of Rheumatology, University of Arizona, College of Medicine, 1501 North Campbell Avenue, PO Box 245093, Tucson, AZ 85724-5093, USA
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Vina ER, Hannon MJ, Masood HS, Hausmann LRM, Ibrahim SA, Dagnino J, Arellano A, Kwoh CK. Nonsteroidal Anti-Inflammatory Drug Use in Chronic Arthritis Pain: Variations by Ethnicity. Am J Med 2020; 133:733-740. [PMID: 31862331 PMCID: PMC7293947 DOI: 10.1016/j.amjmed.2019.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/19/2019] [Accepted: 11/26/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Our objective was to determine if there are ethnic differences in the use of over-the-counter (OTC) and prescription oral nonsteroidal anti-inflammatory drugs (NSAIDs) and if observed ethnic differences persist after adjustment for sociodemographic and clinical factors. METHODS Knee and hip osteoarthritis study participants were identified. Surveys were administered to collect sociodemographics, clinical information, and oral treatment methods for arthritis. Multivariable logistic regression models were created using a fully conditional method. RESULTS Hispanics (n = 130), compared to non-Hispanic whites (n = 204), were less likely to have a high school education (26.9% vs 63.2%, P <0.001), less likely to have private medical insurance (P <0.001), and more likely to have worse health (P = 0.004). OTC oral NSAID use was less common (52.9% vs 66.3%, P = 0.019), whereas prescription oral NSAID use was more common (43.4% vs 31.7%, P = 0.042) among Hispanics than non-Hispanic whites in the last 6 months. The ethnic difference in using an OTC NSAID instead of not using any oral NSAID was attenuated and no longer significant when adjusted for age, sex, education, and medical insurance (odds ratio [OR] 0.54 [95% confidence interval [CI]: 0.28-1.02]). The odds of using a prescription instead of an OTC NSAID remained significantly higher among Hispanics than non-Hispanic whites when adjusted for the same variables (odds ratio 2.17 [95% confidence interval: 1.16-4.05]). CONCLUSIONS Among patients with osteoarthritis, OTC NSAIDs were less commonly used but prescription NSAIDs were more commonly used by Hispanics than non-Hispanic whites. Sociodemographic factors partially mediate ethnic differences in the use of oral NSAIDs.
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Affiliation(s)
- Ernest R Vina
- University of Arizona Arthritis Center, Tucson, Arizona; College of Medicine, Department of Medicine, Division of Rheumatology, University of Arizona, Tucson, Arizona.
| | | | - Hana S Masood
- College of Medicine, Department of Medicine, Division of Rheumatology, University of Arizona, Tucson, Arizona
| | - Leslie R M Hausmann
- Pinney Associates, Pittsburgh, Pennsylvania; Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
| | - Said A Ibrahim
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | | | | | - C Kent Kwoh
- University of Arizona Arthritis Center, Tucson, Arizona; College of Medicine, Department of Medicine, Division of Rheumatology, University of Arizona, Tucson, Arizona
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Vina ER, Hannon MJ, Hausmann LRM, Ibrahim SA, Dagnino J, Arellano A, Kwoh CK. Modifiable Determinants of Exercise Use in a Diverse Ethnic Population With Osteoarthritis. Arthritis Care Res (Hoboken) 2019; 71:1495-1503. [PMID: 30762309 DOI: 10.1002/acr.23852] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/12/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the extent of ethnic differences in the use of exercise for therapy and identify relevant modifiable determinants of exercise use among patients with knee/hip osteoarthritis (OA). METHODS Knee/hip OA study participants were identified. Surveys were administered to collect patient sociodemographic and clinical information, and beliefs and attitudes about providers and treatments. Final multivariable logistic regression models were created using a fully conditional method. RESULTS Hispanic participants (n = 130), compared to non-Hispanic participants (n = 232), were less likely to have private medical insurance (9.2% versus 31.0%) or to report having excellent/very good health (40.7% versus 52.6%). They were also less likely to report using exercise for OA treatment in the last 6 months (56% versus 73%; P = 0.003). When adjusted for age and disease severity, the difference in exercise use among ethnicities remained significant (odds ratio [OR] 0.59 [95% confidence interval (95% CI) 0.36-0.99]). In a multivariable logistic regression model designed to determine the most important determinants of exercise use for OA treatment, in the last 6 months the following were all associated with exercise use: having knee instead of hip OA (OR 2.83 [95% CI 1.51-5.29]), having family/friends who exercise (OR 3.20 [95% CI 1.76-5.84]), having a good understanding of what happens after exercise (OR 2.19 [95 CI 1.15-4.19]), and higher perceived benefit of exercise (OR 2.24 [95% CI 1.64-3.04]). CONCLUSION Among patients with knee/hip OA, Hispanics were less likely to exercise for OA treatment. Increased knowledge about the benefits of exercise for treatment and improved familiarity with exercise as treatment for OA may increase exercise use.
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Affiliation(s)
- Ernest R Vina
- University of Arizona, College of Medicine and/or Arthritis Center, Tucson
| | - Michael J Hannon
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Leslie R M Hausmann
- University of Pittsburgh School of Medicine and Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | - Jazmin Dagnino
- University of Arizona, College of Medicine and/or Arthritis Center, Tucson
| | - Andrea Arellano
- University of Arizona, College of Medicine and/or Arthritis Center, Tucson
| | - C Kent Kwoh
- University of Arizona, College of Medicine and/or Arthritis Center, Tucson
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Hausmann LRM, Youk A, Kwoh CK, Gallagher RM, Weiner DK, Vina ER, Obrosky DS, Mauro GT, McInnes S, Ibrahim SA. Effect of a Positive Psychological Intervention on Pain and Functional Difficulty Among Adults With Osteoarthritis: A Randomized Clinical Trial. JAMA Netw Open 2018; 1:e182533. [PMID: 30646170 PMCID: PMC6324470 DOI: 10.1001/jamanetworkopen.2018.2533] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Positive psychological interventions for improving health have received increasing attention recently. Evidence on the impact of such interventions on pain, and racial disparities in pain, is limited. OBJECTIVE To assess the effects of a positive psychological intervention on pain and functional difficulty in veterans with knee osteoarthritis. DESIGN, SETTING, AND PARTICIPANTS The Staying Positive With Arthritis Study is a large, double-blinded randomized clinical trial powered to detect race differences in self-reported pain in response to a positive psychological intervention compared with a neutral control intervention. Data were collected from 2 urban Veterans Affairs medical centers. Participants included non-Hispanic white and non-Hispanic African American patients aged 50 years or older with a diagnosis of osteoarthritis. Mailings were sent to 5111 patients meeting these criteria, of whom 839 were fully screened, 488 were eligible, and 360 were randomized. Enrollment lasted from July 8, 2015, to February 1, 2017, with follow-up through September 6, 2017. INTERVENTIONS The intervention comprised a 6-week series of evidence-based activities to build positive psychological skills (eg, gratitude and kindness). The control program comprised similarly structured neutral activities. Programs were delivered via workbook and weekly telephone calls with interventionists. MAIN OUTCOMES AND MEASURES The primary outcomes were self-reported pain and functional difficulty measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range 0-100). Secondary outcomes included affect balance and life satisfaction. RESULTS The sample included 180 non-Hispanic white patients and 180 non-Hispanic African American patients (mean [SD] age, 64.2 [8.8] years; 76.4% were male). Mean (SD) baseline scores for WOMAC pain and functional difficulty were 48.8 (17.6) and 46.8 (18.1), respectively. Although both decreased significantly over time (pain: χ23 = 49.50, P < .001; functional difficulty: χ23 = 22.11, P < .001), differences were small and did not vary by treatment group or race. Exploratory analyses suggested that the intervention had counterintuitive effects on secondary outcomes. CONCLUSIONS AND RELEVANCE The results of this randomized clinical trial do not support the use of positive psychological interventions as a stand-alone treatment for pain among white or African American veterans with knee osteoarthritis. Adaptations are needed to identify intervention components that resonate with this population, and the additive effect of incorporating positive psychological interventions into more comprehensive pain treatment regimens should be considered. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02223858.
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Affiliation(s)
- Leslie R. M. Hausmann
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - C. Kent Kwoh
- University of Arizona Arthritis Center, University of Arizona, Tucson
- College of Medicine, University of Arizona, Tucson
| | - Rollin M. Gallagher
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- School of Medicine, University of Pennsylvania, Philadelphia
| | - Debra K. Weiner
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Ernest R. Vina
- University of Arizona Arthritis Center, University of Arizona, Tucson
- College of Medicine, University of Arizona, Tucson
| | - D. Scott Obrosky
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Genna T. Mauro
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Shauna McInnes
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Said A. Ibrahim
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- School of Medicine, University of Pennsylvania, Philadelphia
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
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Kabadi S, Yeaw J, Bacani AK, Tafesse E, Bos K, Karkare S, DeKoven M, Vina ER. Healthcare resource utilization and costs associated with long-term corticosteroid exposure in patients with systemic lupus erythematosus. Lupus 2018; 27:1799-1809. [PMID: 30068254 DOI: 10.1177/0961203318790675] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To evaluate the association between exposure to oral corticosteroids and future healthcare resource utilization and costs for patients with systemic lupus erythematosus. Methods Adults diagnosed with systemic lupus erythematosus (index date) between 1 January 2008 and 30 June 2013 and naive to oral corticosteroids with continuous health plan enrollment for ≥6 months pre- and ≥5 years post-index were identified from a large health plan claims database. Per-patient monthly average daily dose of oral corticosteroids (prednisone or its equivalent) was calculated for the first 2 years post-index to categorize patients into four steroid exposure cohorts: low (≤5 mg/day), medium (6-20 mg/day), high (>20 mg/day) and no steroids. Differences in healthcare resource utilization and total healthcare costs during the third year post-index across corticosteroid exposure cohorts were modeled with adjustment for baseline characteristics. Results The study included 18,618 systemic lupus erythematosus patients (163 high dose, 1127 medium dose, 6717 low dose and 10,611 no steroids). Compared to low-dose corticosteroid users, high-dose corticosteroid users were more likely to have emergency room visits (39.3% vs. 29.7%; p = 0.0085) and to be hospitalized (21.5% vs. 12.3%; p = 0.0005). After adjustment for baseline characteristics, they also had significantly greater average annual total healthcare costs (US$60,366 vs. US$18,777; p < 0.0001). A 1 mg increase in corticosteroid average daily dose was associated with 1.07 times the average annual costs after adjusting for baseline characteristics ( p < 0.0001). Conclusion Long-term high-dose oral corticosteroid use was associated with significantly greater future healthcare resource utilization and costs. Judicious reduction in daily steroid dose may decrease the imminent economic burden associated with high-dose steroid use in systemic lupus erythematosus.
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Affiliation(s)
- S Kabadi
- 1 AstraZeneca, Gaithersburg, Maryland, USA
| | - J Yeaw
- 2 IQVIA, Fairfax, Virginia, USA
| | - A K Bacani
- 1 AstraZeneca, Gaithersburg, Maryland, USA
| | - E Tafesse
- 1 AstraZeneca, Gaithersburg, Maryland, USA
| | - K Bos
- 1 AstraZeneca, Gaithersburg, Maryland, USA
| | | | | | - E R Vina
- 3 University of Arizona Arthritis Center, Banner University Medical Center, Tucson, Arizona, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight recent studies of osteoarthritis epidemiology, including research on prevalence, disease impact, and potential risk factors. RECENT FINDINGS Osteoarthritis is highly prevalent in the United States and around the globe. It is a leading cause of disability and can negatively impact people's physical and mental well being. Healthcare resources and costs associated with managing the disease can be substantial. There is increasing evidence that there are different osteoarthritis phenotypes that reflect different mechanisms of the disease. Various person-level risk factors are recognized, including sociodemographic characteristics (e.g. female sex, African-American race), genetic predispositions, obesity, diet-related factors, and high bone density/mass. Joint-level risk factors include specific bone/joint shapes, thigh flexor muscle weakness, joint malalignment, participation in certain occupational/sports activities, and joint injury. Recent studies have enhanced our understanding of preradiographic lesions associated with osteoarthritis. SUMMARY Application of these new findings may allow us to develop innovative strategies and novel therapies with the purpose of preventing new disease onset and minimizing disease progression.
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Affiliation(s)
- Ernest R. Vina
- Division of Rheumatology, Department of Medicine, University of Arizona, Tucson, Arizona, USA
- Arthritis Center, University of Arizona, Tucson, Arizona, USA
| | - C. Kent Kwoh
- Division of Rheumatology, Department of Medicine, University of Arizona, Tucson, Arizona, USA
- Arthritis Center, University of Arizona, Tucson, Arizona, USA
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Vina ER, Kallan MJ, Collier A, Nelson CL, Ibrahim SA. Race and Rehabilitation Destination After Elective Total Hip Arthroplasty: Analysis of a Large Regional Data Set. Geriatr Orthop Surg Rehabil 2018; 8:192-201. [PMID: 29318080 PMCID: PMC5755837 DOI: 10.1177/2151458517726409] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/22/2017] [Accepted: 07/22/2017] [Indexed: 12/15/2022] Open
Abstract
Background: Three-quarters of patients who undergo total hip replacement (THR) receive postsurgical rehabilitation care in an inpatient rehabilitation facility (IRF), a skilled nursing facility (SNF), or through a home health agency. The objectives of this study are to examine racial differences where THR recipients receive postsurgical rehabilitation care and determine whether discharge destination is associated with hospital readmission. Methods: Using the Pennsylvania Health Care Cost Containment Council database, we selected African American (AA) or white adults who underwent THR surgery (n = 68,016). We used multinomial logistic regression models to assess the relationship between race and postsurgical discharge destination. We calculated 90-day hospital readmission as function of discharge destination. Results: Among patients <65 years, compared to whites, AAs had a higher risk of discharge to an IRF (adjusted relative risk ratio [aRRR]: 2.56, 95% confidence interval [CI]: 1.77-3.71) and a SNF (aRRR 3.37, 95% CI: 2.07-5.49). Among those ≥65 years, AA patients also had a higher risk of discharge to an IRF (aRRR: 1.96, 95% CI: 1.39-2.76) and a SNF (aRRR: 3.66, 95% CI: 2.29-5.84). Discharge to either IRF or SNF, instead of home with self-care, was significantly associated with higher odds of 90-day hospital readmission (<65 years: adjusted odds ratio [aOR]: 4.06, 95% CI: 3.49-4.74; aOR: 2.05, 95% CI: 1.70-2.46, respectively; ≥65 years: aOR: 4.32, 95% CI: 3.67-5.09, respectively; aOR: 1.74, 95% CI: 1.46-2.07, respectively). Conclusions: Compared to whites, AAs who underwent THR were more likely to be discharged to an IRF or SNF. Discharge to either facility was associated with a higher risk of hospital readmission.
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Affiliation(s)
- Ernest R Vina
- University of Arizona Arthritis Center, University of Arizona School of Medicine, Tucson, AZ, USA
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Aliya Collier
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles L Nelson
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Said A Ibrahim
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
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Vina ER, Ran D, Ashbeck EL, Ratzlaff C, Kwoh CK. Race, sex, and risk factors in radiographic worsening of knee osteoarthritis. Semin Arthritis Rheum 2017; 47:464-471. [PMID: 28941552 DOI: 10.1016/j.semarthrit.2017.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/20/2017] [Accepted: 08/24/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Characterize radiographic worsening in knee osteoarthritis (KOA) by race and sex over 4 years and evaluate the role of established risk factors in observed race/sex differences. METHODS Whites (WHs) (694 males and 929 females) and African-Americans (AAs) (92 males and 167 females) at risk for radiographic KOA were eligible. Cox shared frailty models were used to estimate race and sex group differences in radiographic worsening, defined by Kellgren-Lawrence (K-L) and OARSI joint space narrowing (JSN). Mixed effect models for repeated measures were used to estimate race- and sex-specific mean medial and lateral fixed joint space width (fJSW) over 4 years of follow-up, as well as annual loss of fJSW. RESULTS Risk of OARSI medial JSN grade worsening was higher among AA males than WH females [HR = 2.28, (95% CI: 1.14-4.57)], though adjustment for KOA risk factors attenuated the association. Compared to WH females, WH males had lower risk of K-L grade worsening [adjusted HR = 0.75 (95% CI: 0.58-0.96)]. Mean baseline medial fJSW (mm) was 6.49 in WH and AA males, 5.42 in WH females, and 5.41 in AA females. Annual change in mean medial fJSW was greater in AA males (-0.19mm/year) than in other subgroups (-0.09 WH males, -0.07 WH females, -0.10 AA females, p < 0.0001). Compared to WHs, AAs had less lateral fJSW at baseline and throughout follow-up. CONCLUSIONS Compared to WHs and AA females, AA males experienced higher risk of medial joint space loss. Controlling for established risk factors attenuated associations between race/sex and disease worsening, suggesting that risk factors such as obesity, history of knee injury, and bony finger joint enlargements largely explain race/sex variations in rates of KOA development and progression.
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Affiliation(s)
- Ernest R Vina
- Division of Rheumatology, Department of Medicine, University of Arizona, Tucson, AZ; Arizona Arthritis Center, University of Arizona, Tucson, AZ.
| | - Di Ran
- Arizona Arthritis Center, University of Arizona, Tucson, AZ; Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
| | - Erin L Ashbeck
- Arizona Arthritis Center, University of Arizona, Tucson, AZ
| | - Charles Ratzlaff
- Division of Rheumatology, Department of Medicine, University of Arizona, Tucson, AZ; Arizona Arthritis Center, University of Arizona, Tucson, AZ
| | - C Kent Kwoh
- Division of Rheumatology, Department of Medicine, University of Arizona, Tucson, AZ; Arizona Arthritis Center, University of Arizona, Tucson, AZ
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Vina ER, Ran D, Ashbeck EL, Kaur M, Kwoh CK. Relationship Between Knee Pain and Patient Preferences for Joint Replacement: Health Care Access Matters. Arthritis Care Res (Hoboken) 2017; 69:95-103. [PMID: 27636123 DOI: 10.1002/acr.23084] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 08/12/2016] [Accepted: 09/06/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To determine if severity of osteoarthritis-related knee pain is associated with a willingness to undergo total knee replacement (TKR) and whether this association is confounded or modified by components of socioeconomic status and health care coverage. METHODS Cross-sectional analysis was conducted among 3,530 Osteoarthritis Initiative study participants. Logistic regression models were used to assess the effect of knee pain severity (where 0 = none, 1-3 = mild, 4-7 = moderate, and 8-10 = severe) on willingness to undergo TKR. Stratified analyses were conducted to evaluate whether socioeconomic status and health care coverage modify the effect of knee pain severity on willingness. RESULTS Participants with severe knee pain, compared to participants without pain, were less willing to undergo TKR (odds ratio [OR] 0.73, 95% confidence interval [95% CI] 0.57-0.93). This association was attenuated when adjusted for age, sex, comorbidity, depression, health insurance coverage, prescription medicine coverage, health care source, education, income, employment, race, and marital status (adjusted OR 0.92, 95% CI 0.68-1.24). The odds of willingness to undergo TKR were significantly lower in those with the highest level of pain, compared to those without pain, among participants without health insurance (adjusted OR 0.08, 95% CI 0.01-0.56), but not among those with health insurance (adjusted OR 1.03, 95% CI 0.73-1.38), when adjusted for demographic, clinical, health care access, and socioeconomic factors (P = 0.015). However, <5% of participants were without health insurance. CONCLUSION Among participants without health insurance, severe knee pain was paradoxically associated with less willingness to undergo TKR. Policies that improve access to quality health care may affect patient preferences and increase utilization of TKR surgery among vulnerable populations.
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Affiliation(s)
| | - Di Ran
- University of Arizona, Tucson
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Vina ER, Richardson D, Medvedeva E, Kent Kwoh C, Collier A, Ibrahim SA. Does a Patient-centered Educational Intervention Affect African-American Access to Knee Replacement? A Randomized Trial. Clin Orthop Relat Res 2016; 474:1755-64. [PMID: 27075333 PMCID: PMC4925413 DOI: 10.1007/s11999-016-4834-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/06/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND A TKA is the most effective and cost-effective surgical option for moderate to severe osteoarthritis (OA) of the knee. Yet, black patients are less willing to undergo knee replacement surgery than white patients. Decision aids help people understand treatment options and consider the personal importance of possible benefits and harms of treatments, including TKA. QUESTIONS/PURPOSES We asked: (1) Does a patient-centered intervention consisting of a decision aid for knee OA and motivational interviewing improve the proportion of referrals of blacks with knee OA to orthopaedic surgery? (2) Does the intervention increase patients' willingness to undergo TKA? METHODS Adults who self-identified as black who were at least 50 years old with moderate to severe knee OA were enrolled from urban primary care clinics in a two-group randomized, controlled trial. A total of 1253 patients were screened for eligibility, and 760 were excluded for not meeting inclusion criteria, declining to participate, or other reasons. Four hundred ninety-three patients were randomized and completed the intervention; three had missing referral data at followup. The mean age of the patients was 61 years, and 51% were women. The majority had an annual household income less than USD 15,000. Participants in the treatment group were shown a decision-aid video and had a brief session with a trained counselor in motivational interviewing. Participants in the control group received an educational booklet about OA that did not mention joint replacement. The two groups had comparable demographic and socioeconomic characteristics. The primary outcome was referral to orthopaedic surgery 12 months after treatment exposure. Receipt of referral was defined as the receipt of a recommendation or prescription from a primary care provider for orthopaedic evaluation. The secondary outcome was change in patient willingness to undergo TKA based on patient self-report. RESULTS The odds of receiving a referral to orthopaedic surgery did not differ between the two study groups (36%, 90 of 253 of the control group; 32%, 76 of 240 of the treatment group; odds ratio [OR], 0.81; 95% CI, 0.56-1.18; p = 0.277). At 2 weeks followup, there was no difference between the treatment and the control groups in terms of increased willingness to consider TKA relative to baseline (34%, 67 of 200 patients in the treatment group; 33%, 68 of 208 patients in the control group; OR, 1.06; p = 0.779). At 12 months followup, the percent increase in willingness to undergo TKA still did not differ between patients in the treatment and control groups (29%, 49 of 174 in the treatment group; 27%, 51 of 191 in the control group; OR, 1.10; p = 0.679). CONCLUSION A combination decision aid and motivational interviewing strategy was no better than an educational pamphlet in improving patients' preferences toward joint replacement surgery for knee OA. The type of intervention treatment also did not affect access to surgical evaluation. Other tools that target patient knowledge, beliefs, and attitudes regarding surgical treatments for OA may be further developed and tested in the future. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Ernest R Vina
- University of Arizona School of Medicine and University of Arizona Arthritis Center, 1501 N. Campbell Avenue, Tucson, AZ, 85724, USA.
| | - Diane Richardson
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Elina Medvedeva
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - C Kent Kwoh
- University of Arizona School of Medicine and University of Arizona Arthritis Center, 1501 N. Campbell Avenue, Tucson, AZ, 85724, USA
| | - Aliya Collier
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Said A Ibrahim
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Vina ER, Ran D, Ashbeck EL, Ibrahim SA, Hannon MJ, Zhou JJ, Kwoh CK. Patient preferences for total knee replacement surgery: Relationship to clinical outcomes and stability of patient preferences over 2 years. Semin Arthritis Rheum 2016; 46:27-33. [PMID: 27132535 DOI: 10.1016/j.semarthrit.2016.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/16/2016] [Accepted: 03/25/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Evaluate the relationship between patient preferences for total knee replacement (TKR) with receipt of TKR, and assess participant characteristics that may influence change in willingness to undergo TKR. METHODS Structured interviews of knee osteoarthritis (OA) patients were conducted. Logistic regression models were conducted to assess the association between baseline willingness and eventual receipt of TKR, adjusted for sociodemographic and clinical variables. Mixed models for repeated measures were used to estimate the effects of sex, race, social support, Δ WOMAC, and orthopedic consult on change in willingness. RESULTS A total of 589 participants were willing, and 215 participants were unwilling to undergo TKR. Willing participants, compared to others, were more often White (69.4% vs. 48.4%), with more than a high school education (60.8% vs. 47.0%) and employed (39.1% vs. 26.5%). At follow-up, the odds of having TKR were twice as high among those who were willing to have the procedure at baseline, but this was no longer significant when adjusted for demographic variables (adjusted OR = 1.82, 95% CI: 0.89-3.69). Willingness to undergo TKR declined over 2 years. Among those who were willing to undergo TKR at baseline but did not obtain one, only 66.5% were still willing at the 2-year follow-up. This decline was less among those who had a greater increase (>median) in WOMAC disability (adjusted Δ = -0.34, 95% CI: -0.47 to -0.20) than those who had minimal change in their WOMAC disability (p = 0.08). The decline in willingness was also less among those who had seen an orthopedic surgeon (adjusted Δ = -0.32, 95% CI: -0.46 to -0.17) than those who did not (p = 0.05). CONCLUSIONS Preference for TKR was consistent with TKR surgery utilization, but not after controlling for patient demographic characteristics. Willingness to undergo TKR declined over time, but this decrease was mitigated by worsening OA-related disability and by consultation with an orthopedic surgeon.
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Affiliation(s)
- Ernest R Vina
- Division of Rheumatology, Department of Medicine, University of Arizona Arthritis Center, University of Arizona, 1501 N Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093.
| | - Di Ran
- Division of Rheumatology, Department of Medicine, University of Arizona Arthritis Center, University of Arizona, 1501 N Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093; Epidemiology and Biostatistics Department, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
| | - Erin L Ashbeck
- Division of Rheumatology, Department of Medicine, University of Arizona Arthritis Center, University of Arizona, 1501 N Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093
| | - Said A Ibrahim
- Department of Medicine, Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, University of Pennsylvania, Philadelphia, PA
| | - Michael J Hannon
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Philadelphia, PA
| | - Jin J Zhou
- Epidemiology and Biostatistics Department, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
| | - C Kent Kwoh
- Division of Rheumatology, Department of Medicine, University of Arizona Arthritis Center, University of Arizona, 1501 N Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093
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Kwoh CK, Vina ER, Cloonan YK, Hannon MJ, Boudreau RM, Ibrahim SA. Determinants of patient preferences for total knee replacement: African-Americans and whites. Arthritis Res Ther 2015; 17:348. [PMID: 26635132 PMCID: PMC4669671 DOI: 10.1186/s13075-015-0864-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 11/17/2015] [Indexed: 11/11/2022] Open
Abstract
Introduction Patient preferences contribute to marked racial disparities in the utilization of total knee replacement (TKR). The objectives of this study were to identify the determinants of knee osteoarthritis (OA) patients’ preferences regarding TKR by race and to identify the variables that may mediate racial differences in willingness to undergo TKR. Methods Five hundred fourteen White (WH) and 285 African-American (AA) patients with chronic knee pain and radiographic evidence of OA participated in the study. Participants were recruited from the community, an academic medical center, and a Veterans Affairs hospital. Structured interviews were conducted to collect socio-demographics, disease severity, socio-cultural determinants, and treatment preferences. Logistic regression was performed, stratified by race, to identify determinants of preferences. Clinical and socio-cultural factors were entered simultaneously into the models. Stepwise selection identified factors for inclusion in the final models (p < 0.20). Results Compared to WHs, AAs were less willing to undergo TKR (80 % vs. 62 %, respectively). Better expectations regarding TKR surgery outcomes determined willingness to undergo surgery in both AAs (odds ratio (OR) 2.08, 95 % confidence interval (CI) 0.91-4.79 for 4th vs. 1st quartile) and WHs (OR 5.11, 95 % CI 2.31-11.30 for 4th vs. 1st quartile). Among AAs, better understanding of the procedure (OR 1.80, 95 % CI 0.97-3.35), perceiving a short hospital course (OR 0.81, 95 % CI 0.58-1.13), and believing in less post-surgical pain (OR 0.73, 95 % CI 0.39-1.35) and walking difficulties (OR 0.66, 95 % CI 0.37-1.16) also determined willingness. Among WHs, having surgical discussion with a physician (OR 1.96, 95 % CI 1.05-3.68), not ever receiving surgical referral (OR 0.56, 95 % CI 0.32-0.99), and higher trust in the healthcare system (OR 1.58, 95 % CI 0.75-3.31 for 4th vs. 1st quartile) additionally determined willingness. Among the variables considered, only knowledge-related matters pertaining to TKR attenuated the racial difference in knee OA patients’ treatment preference. Conclusions Expectations of surgical outcomes influence preference for TKR in all patients, but clinical and socio-cultural factors exist that shape marked racial differences in preferences for TKR. Interventions to reduce or eliminate racial disparities in the utilization of TKR should consider and target these factors. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0864-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C Kent Kwoh
- University of Arizona School of Medicine and University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, Arizona, 85724, USA.
| | - Ernest R Vina
- University of Arizona School of Medicine and University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, Arizona, 85724, USA.
| | - Yona K Cloonan
- University of Pittsburgh School of Public Health, 130 De Soto St., 127 Parran Hall, Pittsburgh, Pennsylvania, 15261, USA.
| | - Michael J Hannon
- University of Pittsburgh School of Medicine, 130 North Bellefield Ave., 4th Floor, Pittsburgh, Pennsylvania, 15213, USA.
| | - Robert M Boudreau
- University of Pittsburgh School of Public Health, 130 De Soto St., 127 Parran Hall, Pittsburgh, Pennsylvania, 15261, USA.
| | - Said A Ibrahim
- University of Pennsylvania Perelman School of Medicine and Philadelphia VA Medical Center, 3900 Woodland Ave., Philadelphia, Pennsylvania, 19104, USA.
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Vina ER, Hannon MJ, Kwoh CK. Improvement following total knee replacement surgery: Exploring preoperative symptoms and change in preoperative symptoms. Semin Arthritis Rheum 2015; 45:547-55. [PMID: 26573377 DOI: 10.1016/j.semarthrit.2015.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/29/2015] [Accepted: 10/07/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine whether changes in preoperative osteoarthritis (OA) symptoms are associated with improvement after total knee replacement (TKR) and to identify predictors of clinically significant improvement. METHODS Data on Osteoarthritis Initiative participants who were annually assessed and underwent TKR were included. T0 was the assessment prior to TKR while T-1 was the assessment prior to that. T+2 was the second assessment after TKR. We compiled data on the Western Ontario and McMaster Universities OA Index (WOMAC), OA-related symptoms, and radiographic severity. We defined clinically significant improvement as improvement in WOMAC total score ≥ to the minimal important difference (MID) (0.5 SD of mean change) between T0 and T+2 and also considered other definitions of improvement. Logistic regression models were performed to evaluate the relationship between improvement and preoperative measures. RESULTS Improved (n = 211) compared to unimproved (n = 58) patients had greater worsening of their WOMAC pain (p = 0.002) and disability (p < 0.001) from T-1 to T0. Preoperative measures as predictors of improvement included higher WOMAC disability (OR = 1.08, p < 0.001), presence of chronic OA symptoms in the surgical knee (OR = 5.77, p = 0.033), absence of OA-related symptoms in the contralateral knee (OR = 9.25, p < 0.001), exposure to frequent knee bending (OR = 3.46, p = 0.040), and having a Kellgren-Lawrence x-ray grade of ≥2 in the contralateral knee (OR = 4.71, p = 0.010). CONCLUSIONS More than 75% of participants had improvement after TKR. Improved patients were more likely to have escalation of OA pain and disability prior to surgery than unimproved patients. Other preoperative measures predicted improvement after TKR.
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Affiliation(s)
- Ernest R Vina
- Department of Medicine, University of Arizona Arthritis Center, University of Arizona, 1501 N Campbell Ave, PO Box 245093, Tucson, AZ 85724-5093.
| | - Michael J Hannon
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - C Kent Kwoh
- Department of Medicine, University of Arizona Arthritis Center, University of Arizona, 1501 N Campbell Ave, PO Box 245093, Tucson, AZ 85724-5093
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Vina ER, Hausmann LRM, Utset TO, Masi CM, Liang KP, Kwoh CK. Perceptions of racism in healthcare among patients with systemic lupus erythematosus: a cross-sectional study. Lupus Sci Med 2015; 2:e000110. [PMID: 26322238 PMCID: PMC4548064 DOI: 10.1136/lupus-2015-000110] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 07/28/2015] [Accepted: 07/30/2015] [Indexed: 11/12/2022]
Abstract
Background Racial disparities in the clinical outcomes of systemic lupus erythematosus (SLE) exist. Perceived racial discrimination may contribute to disparities in health. Objectives To determine if perceived racism in healthcare differs by race among patients with SLE and to evaluate its contribution to racial disparities in SLE-related outcomes. Methods 163 African–American (AA) and 180 white (WH) patients with SLE were enrolled. Structured interviews and chart reviews were done to determine perceptions of racism, SLE-related outcomes (Systemic Lupus International Collaborating Clinics (SLICC) Damage Index, SLE Disease Activity, Center for Epidemiologic Studies-Depression (CES-D)), and other variables that may affect perceptions of racism. Serial hierarchical multivariable logistic regression models were conducted. Race-stratified analyses were also performed. Results 56.0% of AA patients compared with 32.8% of WH patients had high perceptions of discrimination in healthcare (p<0.001). This difference remained (OR 4.75 (95% CI 2.41 to 8.68)) after adjustment for background, identity and healthcare experiences. Female gender (p=0.012) and lower trust in physicians (p<0.001) were also associated with high perceived racism. The odds of having greater disease damage (SLICC damage index ≥2) were higher in AA patients than in WH patients (crude OR 1.55 (95% CI 1.01 to 2.38)). The odds of having moderate to severe depression (CES-D ≥17) were also higher in AA patients than in WH patients (crude OR 1.94 (95% CI 1.26 to 2.98)). When adjusted for sociodemographic and clinical characteristics, racial disparities in disease damage and depression were no longer significant. Among AA patients, higher perceived racism was associated with having moderate to severe depression (adjusted OR 1.23 (95% CI 1.05 to 1.43)) even after adjusting for sociodemographic and clinical variables. Conclusions Perceptions of racism in healthcare were more common in AA patients than in WH patients with SLE and were associated with depression. Interventions aimed at modifiable factors (eg, trust in providers) may reduce higher perceptions of race-based discrimination in SLE.
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Affiliation(s)
- Ernest R Vina
- University of Arizona School of Medicine and University of Arizona Arthritis Center, Tucson, Arizona, USA
| | - Leslie R M Hausmann
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tammy O Utset
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Christopher M Masi
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
- NorthShore University Health System, Evanston, Illinois, USA
| | - Kimberly P Liang
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - C Kent Kwoh
- University of Arizona School of Medicine and University of Arizona Arthritis Center, Tucson, Arizona, USA
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Vina ER, Utset TO, Hannon MJ, Masi CM, Roberts N, Kwoh CK. Racial differences in treatment preferences among lupus patients: a two-site study. Clin Exp Rheumatol 2014; 32:680-688. [PMID: 25084365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 03/20/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To identify the demographic, clinical and psychosocial characteristics associated with racial differences in willingness to receive cyclophosphamide (CYC) or participate in a research clinical trial (RCT) among patients with systemic lupus erythematosus (SLE). METHODS Data from 163 African-American (AA) and 180 white (WH) SLE patients were evaluated. Structured interviews and chart reviews were conducted to determine treatment preferences in hypothetical situations and identify variables that may affect preferences. Logistic regression models were performed to evaluate the relationship between patient preferences and race, adjusted for patient characteristics. RESULTS Among patients who had never received CYC (n=293), 62.9% AAs compared to 87.6% WHs were willing to receive the medication (p<0.001). This difference persisted (OR 0.37 [95% CI, 0.16-0.87]) after adjusting for socio-demographics, clinical characteristics, and perceptions about CYC and physicians. Income and higher perception of CYC effectiveness were other determinants of willingness to receive CYC. Among patients who had never participated in an RCT (n=326), 64.9% AAs compared to 84.3% WHs were willing to do so (p<0.001). This difference persisted (OR 0.41 [95% CI, 0.20-0.83]) after adjusting for socio-demographics, clinical context and patients' perceptions of physicians. SLE damage score, number of immunosuppressive medications and higher trust in physicians were also independently associated with willingness to participate in an RCT. CONCLUSIONS Race remains an independent determinant of treatment preferences after adjustment for income, medications, medication efficacy expectations and trust in physicians. While some factors related to racial differences in preferences are relatively fixed, others that may alleviate these differences also exist, including medication beliefs and provider trust.
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Affiliation(s)
- Ernest R Vina
- University of Pittsburgh and VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
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Vina ER, Cloonan YK, Ibrahim SA, Hannon MJ, Boudreau RM, Kwoh CK. Race, sex, and total knee replacement consideration: role of social support. Arthritis Care Res (Hoboken) 2013; 65:1103-11. [PMID: 23281259 DOI: 10.1002/acr.21925] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 12/05/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine whether there are racial differences in social support among patients with knee osteoarthritis (OA) and whether the impact of social support on patient preferences for total knee replacement (TKR) varies by race and sex. METHODS A total of 514 white and 285 African American patients with knee OA were surveyed. Logistic regression models were performed to determine if the relationship between willingness to undergo TKR and the interaction of patient race and sex was mediated by social support. RESULTS Compared to whites with knee OA, African American patients were less likely to be married (P < 0.001), reported less close friends/relatives (P < 0.001), and had lower Medical Outcomes Study Social Support Scale (MOS-SSS) scores (P < 0.001). African American patients were also less willing to undergo TKR (62% versus 80%; P < 0.001) than whites. The odds of willingness to undergo TKR were less in white females compared to white males when adjusted for recruitment site, age, income, and the Western Ontario and McMaster Universities Osteoarthritis Index score (odds ratio [OR] 0.57, 95% confidence interval [95% CI] 0.34-0.96). This difference was no longer significant when further adjusted for marital status, number of close friends/relatives, and MOS-SSS score, but the effect size remained unchanged (OR 0.60, 95% CI 0.35-1.02). The odds of willingness to undergo TKR remained much less in African American females (OR 0.35, 95% CI 0.19-0.64) and African American males (OR 0.28, 95% CI 0.14-0.54) compared to white males when controlled for sociodemographic, clinical, and social support measures. CONCLUSION African American patients reported less structural and functional social support than whites. Social support is an important determinant of preference for TKR surgery only among whites.
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Affiliation(s)
- Ernest R Vina
- University of Pittsburgh and Pittsburgh, VA Healthcare System, Pittsburgh, Pennsylvania, USA.
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Abstract
Racial and ethnic health disparities are a national health issue. They are well described in other chronic diseases, but in rheumatoid arthritis (RA), research into their causes, outcomes, and elimination is in its early stages. Health disparities occur in a complex milieu, with system-level, provider-level, and individual-level factors playing roles. Dissecting the overlapping aspects of race/ethnicity, socioeconomic variables, and how their individual components combine to explain the magnitude of disparities in RA can be challenging. Recent research has focused on the extent to which treatment preferences, adherence, trust in physicians, patient-physician communication, health literacy, and depression have contributed to observed disparities in RA. Practicing evidence-based medicine, improving patient-physician communication skills, reducing language and literacy barriers, improving adherence to therapies, raising awareness of racial/ethnic disparities, and recognizing comorbidities such as depression are steps clinicians may take to help eliminate racial/ethnic disparities in RA.
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Affiliation(s)
- Christine A McBurney
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, 3500 Terrace St., S720A BST, Pittsburgh, PA 15261, USA.
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Abstract
Objectives. To determine whether there are racial/ethnic differences in the willingness of SLE patients to receive CYC or participate in clinical trials, and whether demographic, psychosocial and clinical characteristics contribute to these differences. Methods. Data from 120 African-American and 62 white lupus patients were evaluated. Structured telephone interviews were conducted to determine treatment preferences, as well as to study characteristics and beliefs that may affect these preferences. Data were analysed using serial hierarchical multivariate logistic regression and deviances were calculated from a saturated model. Results. Compared with their white counterparts, African-American SLE patients expressed less willingness to receive CYC (67.0% vs 84.9%, P = 0.02) if their lupus worsened. This racial/ethnic difference remained significant after adjusting for socioeconomic and psychosocial variables. Logistic regression analysis showed that African-American race [odds ratio (OR) 0.29, 95% CI 0.10, 0.80], physician trust (OR 1.05, 95% CI 1.00, 1.12) and perception of treatment effectiveness (OR 1.40, 95% CI 1.22, 1.61) were the most significant determinants of willingness to receive CYC. A trend in difference by race/ethnicity was also observed in willingness to participate in a clinical trial, but this difference was not significant. Conclusion. This study demonstrated reduced likelihood of accepting CYC in African-American lupus patients compared with white lupus patients. This racial/ethnic variation was associated with belief in medication effectiveness and trust in the medical provider, suggesting that education about therapy and improved trust can influence decision-making among SLE patients.
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Affiliation(s)
- Ernest R Vina
- Arthritis Research Center, 3347 Forbes Ave., Pittsburgh, PA 15213, USA.
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Vina ER, Rhew DC, Weingarten SR, Weingarten JB, Chang JT. Relationship between organizational factors and performance among pay-for-performance hospitals. J Gen Intern Med 2009; 24:833-40. [PMID: 19415390 PMCID: PMC2695536 DOI: 10.1007/s11606-009-0997-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 03/17/2009] [Accepted: 03/23/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services (CMS)/Premier Hospital Quality Incentive Demonstration (HQID) project aims to improve clinical performance through a pay-for-performance program. We conducted this study to identify the key organizational factors associated with higher performance. METHODS An investigator-blinded, structured telephone survey of eligible hospitals' (N = 92) quality improvement (QI) leaders was conducted among HQID hospitals in the top 2 or bottom 2 deciles submitting performance measure data from October 2004 to September 2005. The survey covered topics such as QI interventions, data feedback, physician leadership, support for QI efforts, and organizational culture. RESULTS More top performing hospitals used clinical pathways for the treatment of AMI (49% vs. 15%, p < 0.01), HF (44% vs. 18%, p < 0.01), PN (38% vs. 13%, p < 0.01) and THR/TKR (56% vs. 23%, p < 0.01); organized into multidisciplinary teams to manage patients with AMI (93% vs. 77%, p < 0.05) and HF (93% vs. 69%, p < 0.01); used order sets for the treatment of THR/TKR (91% vs. 64%, p < 0.01); and implemented computerized physician order entry in the hospital (24.4% vs. 7.9%, p < 0.05). Finally, more top performers reported having adequate human resources for QI projects (p < 0.01); support of the nursing staff to increase adherence to quality indicators (p < 0.01); and an organizational culture that supported coordination of care (p < 0.01), pace of change (p < 0.01), willingness to try new projects (p < 0.01), and a focus on identifying system errors rather than blaming individuals (p < 0.05). CONCLUSIONS Organizational structure, support, and culture are associated with high performance among hospitals participating in a pay-for-performance demonstration project. Multiple organizational factors remain important in optimizing clinical care.
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Affiliation(s)
- Ernest R Vina
- Zynx Health, 10880 Wilshire Blvd., Los Angeles, CA 90024, USA
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Vina ER, Fang AJ, Wallace DJ, Weisman MH. Chronic inflammatory demyelinating polyneuropathy in patients with systemic lupus erythematosus: prognosis and outcome. Semin Arthritis Rheum 2006; 35:175-84. [PMID: 16325658 DOI: 10.1016/j.semarthrit.2005.08.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To identify clinical characteristics, laboratory features, approaches to management, and predictors of outcome of chronic inflammatory demyelinating polyneuropathy (CIDP) in patients with systemic lupus erythematosus (SLE). METHODS An analysis of 6 adults with the concurrent diagnosis of CIDP and SLE seen at a SLE Clinic from 1994 to 2004 with a review of 13 patients with SLE and CIDP reported in the medical literature from 1950 through 2004. RESULTS Among our 6 patients with SLE and CIDP, 3 (50%) achieved a substantial clinical response to intravenous immunoglobulin (IVIg) and the remainder had a minimal response. The improved patients were more likely to have received treatment earlier (within 1 year of CIDP onset) and to respond faster (<1 to 3 months) than minimally improved patients. They tended to have CIDP features of weakness of all extremities, hyporeflexia of the upper extremities, and slowed nerve conduction velocity of the motor median nerve. Compared with minimal responders, responders had more serious internal organ manifestations and multiple autoantibodies associated with SLE. Review of the literature identified 13 previously reported CIDP patients with SLE. Many had neurological involvement of all extremities, nerve biopsies showing demyelination, and serious SLE internal organ manifestations. Most were treated with steroids, but the 1 treated with IVIg had similar characteristics to our subset of patients who improved with IVIg. CONCLUSIONS CIDP is an uncommon, but not rare, manifestation of SLE. Certain characteristics including early CIDP diagnosis, involvement of all 4 extremities, hyporeflexia of the upper extremities, and slowed motor nerve conduction velocity of the median nerve in addition to SLE involvement of critical internal organs and the presence of multiple antibodies associated with SLE all appear to predict a good response to IVIg.
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Affiliation(s)
- Ernest R Vina
- Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Abstract
Several attempts have been made to replace aspirin with compounds without gastric toxicity; a cyclooxygenase-2 (COX-2) inhibitor, celecoxib, and a nitric oxide-aspirin, NCX-4016, have been developed for this purpose. This paper compares effects of celecoxib, NCX-4016 and aspirin on production of prostacyclin (PGI2) and thromboxane A2 (TXA2) and activation of the inducible form of nitric oxide synthase (iNOS) in infarcted heart in situ. Aspirin was most effective in reducing myocardial PGI2 synthesis and formation of TXA2. Myocardial effects of celecoxib resemble those of NCX-4016, although the two compounds have different modes of action.
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Affiliation(s)
- T Yamamoto
- Huntington Medical Research Institutes, Department of Experimental Cardiology, Pasadena, Calif 91101, USA
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Abstract
Nitric oxide (NO) donors are heterogeneous substances which release NO, a biologically active compound. NO released by nitric oxide donors has important effects on the circulation by causing vasodilation, diminishing myocardial contractile force, inhibiting platelet aggregation, and counteracting the effects of thromboxane A2. In the infarcted heart, activation of the inducible form of nitric oxide synthase (iNOS) and the formation of prostacyclin and thromboxane A2 by cyclooxygenase (COX) were increased. Myocardial infarction also resulted in increased myocardial NO production. Aspirin (acetylsalicylic acid. ASA) at low concentration (35 mg/kg/day) fails to change iNOS production, in contrast to higher dose (150 mg/kg/day) which, as previously shown, inhibits iNOS activity. ASA at all doses also suppresses myocardial prostanoid formation because of inhibition of COX. Recently, two NO donors have been synthesized: NCX 4016 and Diethylenetriamine/NO (DETA/NO). NCX 4016 combines an NO-releasing moiety with a carboxylic residue via an esteric bond. We describe here that NCX 4016 (65 mg/kg/day) increased prostacyclin and thromboxane A2 production in the infarcted heart muscle, overcoming the inhibitory effects of ASA. As a result of nitric oxide release, oxidation products of NO (NO2- and NO3-; NOx) in arterial blood rose following administration of NCX 4016. On oral administration, NCX 4016 did not change systemic arterial pressure. The effects of a single NO donor, DETA/NO (1.0 mg/kg/day) on the infarcted heart were also investigated On intravenous administration, the compound increased NO concentration in arterial blood slightly but to a lesser degree than NCX 4016. Like NCX 4016, it raised myocardial production of prostacyclin and thromboxane A2 in the infarcted heart. However, it caused a severe fall in blood pressure. These findings demonstrate that newly-synthesized NO donors release nitric oxide in situ and increase myocardial production of prostanoids. NCX 4016 has therapeutic potential because it can be orally administered, lacks hypotensive effects, increases blood levels of nitric oxide and myocardial prostacyclin production.
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Affiliation(s)
- T Yamamoto
- Huntington Medical Research Institutes, Department of Experimental Cardiology, Pasadena, CA 91101, USA
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