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Jackson LE, Skains RM, Mudano A, Techarukpong N, Booth JS, Saag KG, Fraenkel L, Danila MI. An Emergency Department-based system intervention to improve osteoporosis screening for older adults at high-risk of fracture. JBMR Plus 2024; 8:ziae038. [PMID: 38681999 PMCID: PMC11055962 DOI: 10.1093/jbmrpl/ziae038] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/18/2023] [Accepted: 01/12/2024] [Indexed: 05/01/2024] Open
Abstract
Falls and osteoporosis are risk factors for fragility fractures. Bone mineral density (BMD) assessment is associated with better preventative osteoporosis care, but it is underutilized by those at high fracture risk. We created a novel electronic medical record (EMR) alert-driven protocol to screen patients in the Emergency Department (ED) for fracture risk and tested its feasibility and effectiveness in generating and completing referrals for outpatient BMD testing after discharge. The EMR alert was configured in 2 tertiary-care EDs and triggered by the term "fall" in the chief complaint, age (≥65 years for women, ≥70 years for men), and high fall risk (Morse score ≥ 45). The alert electronically notified ED study staff of potentially eligible patients. Participants received osteoporosis screening education and had BMD testing ordered. From November 15, 2020 to December 4, 2021, there were 2,608 EMR alerts among 2,509 patients. We identified 558 patients at high-risk of fracture who were screened for BMD testing referral. Participants were excluded for: serious illness (N = 141), no documented health insurance to cover BMD testing (N = 97), prior BMD testing/recent osteoporosis care (N = 58), research assistant unavailable to enroll (N = 53), concomitant fracture (N = 43), bedridden status (N = 38), chief complaint of fall documented in error (N = 38), long-term care residence (N = 34), participation refusal (N = 32), or hospitalization (N = 3). Of the 16 participants who had BMD testing ordered, 7 scheduled and 5 completed BMD testing. EMR alerts can help identify subpopulations who may benefit from osteoporosis screening, but there are significant barriers to identifying eligible and willing patients for screening in the ED. In our study targeting an innovative venue for osteoporosis care delivery, only about 1% of patients at high-risk of fracture scheduled BMD testing after an ED visit. Adequate resources during and after an ED visit are needed to ensure that older adults participate in preventative osteoporosis care.
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Affiliation(s)
- Lesley E Jackson
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Rachel M Skains
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
- Geriatrics Research Education and Clinical Center, Birmingham VA Medical Center, Birmingham, AL 35233, United States
| | - Amy Mudano
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Norma Techarukpong
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - James S Booth
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Liana Fraenkel
- Section of Rheumatology, Allergy and Immunology, Yale School of Medicine, New Haven, CT 06510, United States
| | - Maria I Danila
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, United States
- Geriatrics Research Education and Clinical Center, Birmingham VA Medical Center, Birmingham, AL 35233, United States
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Mannion ML, Xie F, FitzGerald JD, Alexander A, Mudano A, Su Y, Saag KG, Curtis JR. Changes in the Workforce Characteristics of Providers Who Care for Adult Patients With Rheumatologic and Musculoskeletal Disease in the United States. Arthritis Rheumatol 2024. [PMID: 38403436 DOI: 10.1002/art.42833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 01/16/2024] [Accepted: 02/20/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE The aim of this study was to describe the adult rheumatology workforce in the United States, assess change in rheumatology providers over time, and identify variation in rheumatology practice characteristics. METHODS Using national Medicare claims data from 2006 to 2020, clinically active rheumatology physicians and advanced practice providers (APPs) were identified. Each calendar year was used for inclusion, exclusion, and analysis, and providers were determined to be entering, exiting, or stable based upon presence or absence in the prior or subsequent years of data. Characteristics (age, gender, practice type, rural, and region) of rheumatologists were determined for 2019 and in mutually exclusive study periods from 2009 to 2011, 2012 to 2015, and 2016 to 2019. The location of rheumatology practice was determined by billing tax identification and mapped. Demographics of physicians exiting or entering the rheumatology workforce were compared separately to those stable by logistic regression. RESULTS The clinically active adult rheumatology workforce identified in US Medicare in 2019 was 5,667 rheumatologists and 379 APPs. From 2009 to 2020, the number of rheumatologists increased 23% and the number of APPs increased 141%. There was an increase in female rheumatologists over time, rising to 43% in 2019. Women and those employed by a health care system were more likely to exit, and those in a small practice or in the South were less likely to exit. CONCLUSION The overall number of clinically active rheumatology providers grew more than 20% over the last decade to a high of 6,036 in 2020, although this rate of growth appears to be flattening off in later years.
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Affiliation(s)
| | | | - John D FitzGerald
- University of California, Los Angeles and VA Greater Los Angeles Healthcare System, Los Angeles
| | | | | | - Yujie Su
- Illumination Health, Hoover, Alabama
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Jackson LE, Annapureddy N, Hansen ME, Saag KG, Booth J, Rosas G, Foster PJ, Mudano A, Sun D, Osborne JD, Bongartz T, Hess E, Lawrence C, Dunkel L, Danila MI. Development and Validation of an Emergency Department Electronic Medical Record Gout Flare Alert. Arthritis Care Res (Hoboken) 2023; 75:1821-1829. [PMID: 36408730 PMCID: PMC10500930 DOI: 10.1002/acr.25061] [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] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 09/21/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Patients with acute gout are frequently treated in the emergency department (ED) and represent a typically underresourced and understudied population. A key limitation for gout research in the ED is the timely ability to identify acute gout patients. Our goal was to refine a multicriteria, electronic medical record alert for gout flares and to determine its diagnostic characteristics in the ED. METHODS The gout flare alert used electronic medical record data from ED nursing notes and was triggered by the term 'gout' preceding past medical history in the chief complaint, the term 'gout' and a musculoskeletal problem in the chief complaint, or the term 'gout' in the problem list and a musculoskeletal chief complaint. We validated its diagnostic properties to assess presence/absence of gout through manual medical record review using adjudicated expert consensus as the gold standard. RESULTS In January 2020, we analyzed 202 patient records from 2 university-based EDs; from these records, 57 patients were identified by our gout flare alert, and 145 were identified by other means as potentially having an acute gout flare. The gout flare alert's positive predictive value was 47% (95% confidence interval [95% CI] 34-60%), negative predictive value was 94% (95% CI 90-98%), sensitivity was 75% (95% CI 61-89%), and specificity was 82% (95% CI 76-88%). The diagnostic properties were similar at both institutions. CONCLUSION Our multicomponent gout flare alert had reasonable sensitivity and specificity, albeit a modest positive predictive value. An electronic gout flare alert may help enable the conduct of gout research in the ED setting.
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Affiliation(s)
- Lesley E. Jackson
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Narender Annapureddy
- Department of Rheumatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Megan E. Hansen
- Department of Rheumatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kenneth G. Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James Booth
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Giovanna Rosas
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Phillip J. Foster
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amy Mudano
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dongmei Sun
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John D. Osborne
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tim Bongartz
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erik Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colleen Lawrence
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leah Dunkel
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Maria I. Danila
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham VA Medical Center, Birmingham, AL, USA
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Jackson LE, Saag KG, Chiriboga G, Lemon SC, Allison JJ, Mudano A, Rosas G, Foster PJ, Danila MI. A multi-step approach to develop a "storytelling" intervention to improve patient gout knowledge and improve outpatient follow-up. Contemp Clin Trials Commun 2023; 33:101149. [PMID: 37397431 PMCID: PMC10313880 DOI: 10.1016/j.conctc.2023.101149] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/06/2023] [Accepted: 05/13/2023] [Indexed: 07/04/2023] Open
Abstract
Background "Storytelling" interventions influence knowledge, attitudes and behavior to promote chronic disease management. We aimed to describe the development of a video "storytelling" intervention to increase gout knowledge and promote adherence to medications and follow-up care after an acute gout flare visit in the emergency department. Methods We developed a direct-to-patient storytelling intervention to mitigate modifiable barriers to gout care and promote outpatient follow-up and medication adherence. We invited adult patients with gout as storytellers. We utilized a modified Delphi process involving gout experts to identify key themes to guide development of an intervention. Using a conceptual model, we selected stories to ensure delivery of evidence-based concepts and to maintain authenticity. Results Our video-based storytelling intervention consisted of segments addressing modifiable barriers to gout care. Four diverse gout patients were recruited as storytellers and interviewed with questions that covered gout diagnosis and care. Eleven international gout experts from diverse geographic locations generated and ranked items they considered important messages to promote outpatient gout care follow-up and treatment adherence. Filmed videos were truncated into segments and coded thematically. Distinct segments that captured desired messages were combined to form a cohesive narrative story based on gout patient experiences that conveyed evidence-based strategies to manage gout. Conclusions Using the Health Belief Model, we developed a culturally appropriate narrative intervention containing "storytelling" that can be tested as an approach to improve gout outcomes. The methods we describe may be generalizable to other chronic conditions requiring outpatient follow-up and medication adherence to improve outcomes.
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Affiliation(s)
- Lesley E. Jackson
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth G. Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Germán Chiriboga
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | - Stephenie C. Lemon
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | - Jeroan J. Allison
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA
| | - Amy Mudano
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Giovanna Rosas
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Phillip J. Foster
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Maria I. Danila
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
- Geriatrics Research Education and Clinical Center, Birmingham VA Medical Center, Birmingham, AL, USA
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Danila MI, Sun D, Jackson LE, Cutter G, Jackson EA, Ford EW, DeLaney E, Mudano A, Foster PJ, Rosas G, Melnick JA, Curtis JR, Saag KG. Satisfaction with modes of telemedicine delivery during COVID-19: A randomized, single-blind, parallel group, noninferiority trial. Am J Med Sci 2022; 364:538-546. [PMID: 35793732 PMCID: PMC9446840 DOI: 10.1016/j.amjms.2022.06.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 05/09/2022] [Accepted: 06/28/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Little is known about satisfaction with different modes of telemedicine delivery. The objective of this study was to determine whether patient satisfaction with phone-only was noninferior to video visits. METHODS We conducted a parallel group, randomized (1:1), single-blind, noninferiority trial in multispecialty clinics at a tertiary academic medical center. Adults age ≥ 60 years or with Medicare/Medicaid insurance were eligible. Primary outcome was visit satisfaction rate (9 or 10 on a 0-10 satisfaction scale). Noninferiority was determined if satisfaction with phone-only (intervention) versus video visits (comparator) was no worse by a -15% prespecified noninferiority margin. We performed modified intent-to-treat (mITT) and per protocol analyses, after adjusting for age and insurance. RESULTS 200 participants, 43% Black, 68% women completed surveys. Visit satisfaction rates were high. In the mITT analysis, phone-only visits were noninferior by an adjusted difference of 3.2% (95% CI, -7.6% to 14%). In the per protocol analysis, phone-only were noninferior by an adjusted difference of -4.1% (95% CI, -14.8% to 6.6%). The proportion of participants who indicated they preferred the same type of telemedicine visit as their next clinic visit were similar (30.2% vs 27.9% video vs phone-only, p = 0.78) and a majority said their medical concerns were addressed and would recommend a telemedicine visit. CONCLUSIONS Among a group of diverse, established older or underserved patients, the satisfaction rate for phone-only was noninferior to video visits. These findings could impact practice and policies governing telemedicine.
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Affiliation(s)
- Maria I Danila
- Department of Medicine, Division of Clinical Immunology and Rheumatology University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA.
| | - Dongmei Sun
- Department of Medicine, Division of Clinical Immunology and Rheumatology University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lesley E Jackson
- Department of Medicine, Division of Clinical Immunology and Rheumatology University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth A Jackson
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Eric W Ford
- Department of Healthcare Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Erin DeLaney
- Department of Family and Community Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amy Mudano
- Department of Medicine, Division of Clinical Immunology and Rheumatology University of Alabama at Birmingham, Birmingham, AL, USA
| | - Phillip J Foster
- Department of Medicine, Division of Clinical Immunology and Rheumatology University of Alabama at Birmingham, Birmingham, AL, USA
| | - Giovanna Rosas
- Department of Medicine, Division of Clinical Immunology and Rheumatology University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joshua A Melnick
- Department of Medicine, Division of Clinical Immunology and Rheumatology University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey R Curtis
- Department of Medicine, Division of Clinical Immunology and Rheumatology University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth G Saag
- Department of Medicine, Division of Clinical Immunology and Rheumatology University of Alabama at Birmingham, Birmingham, AL, USA
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Jackson L, Mcneeley E, Techarukpong NC, Mugeta F, Aaron K, Mudano A, Merchant J, Warren K, Foster J, Saag K, Danila M. POS1147 CHALLENGES IN CONDUCTING PRAGMATIC CARE STRATEGY STUDIES IN OSTEOPOROSIS: PATIENT PERCEPTIONS. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.2473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundLarge pragmatic osteoporosis studies to improve outcomes are needed. Direct-to-patient studies have highest generalizability but achieving sufficient sample size is difficult; recruitment challenges represent an important consideration given limited participant eligibility and interest. The Fracture Liaison Service (FLS), a team approach to post-fracture care, is a secondary fracture prevention method that has significantly improved outcomes internationally.ObjectivesOur goal was to evaluate the interest, barriers, and lessons learned in recruiting participants for a future trial assessing remote FLS approaches for post-fracture care.MethodsWe used ICD10 fracture codes to identify patients > 50 years of age with a documented hip/pelvis, spine, humerus, or wrist fracture in the previous 1 year. We excluded patients with i) prescriptions for osteoporosis medications (e.g., bisphosphonates, parathyroid hormone analogs, denosumab, romosozumab, raloxifene) in the prior 1 year; ii) an ICD10 code for end-stage renal disease, non-osteoporotic metabolic bone disease, malignant neoplasm, or motor vehicle accident. In December 2021, research assistants reviewed electronic health records (EHR) of potentially eligible patients for evidence of additional serious illness limiting life expectancy to < 1 year or non-ambulatory status prior to fracture. Research assistants called preliminary eligible patients that met inclusion and exclusion criteria and asked them to complete a survey by phone. Interest in a FLS future clinical trial was evaluated using a Likert scale (1=“Definitely would not volunteer”, to 5=“Definitely would volunteer”). We used descriptive statistics to analyze baseline demographic, clinical characteristics, and interest. This pilot was approved by the UAB Institutional Review Board (IRB-300008310-005).ResultsWe identified 1,577 patients > 50 years of age with a fracture. After applying exclusion criteria, we identified 869 preliminary eligible patients. Over 3 weeks, we screened the medical records of a random sample of half of the preliminary eligible patient cohort (n=414), of whom we contacted 271 patients determined potentially eligible, and successfully reached 141 (52% of those contacted) by phone. A total of 108 (77% of those reached) persons, mean (SD) age 69.5 (11.5) years, 40% men, 21% Black or non-white Hispanics completed the survey. Among those contacted, 68 (63%, interest rate) said they would be very or highly interested in participating in a future clinical trial evaluating FLS approaches. Among the 40 (37%) people who said they were not sure, unlikely or very unlikely to volunteer the most common reasons cited were “I don’t want to participate in a study” (33%); “I don’t feel well enough to participate” (10%); “I don’t understand what the study is for” (3%). From this pilot, we calculated a refined eligibility/interest rate of 9.1% among those patients preliminarily identified as eligible using administrative data alone.ConclusionBased on our pilot, we estimate that approximately 9% of eligible patients with fractures will be interested in enrolling in a future comparative effectiveness study to prevent recurrent fragility fractures. We identified several potential modifiable barriers to clinical trial recruitment. Patient perceptions collected from this pilot will inform enrollment strategies, which can be incorporated early when planning direct-to-patient pragmatic osteoporosis studies to achieve recruitment goals.Disclosure of InterestsLesley Jackson: None declared, Ellen McNeeley: None declared, Norma C. Techarukpong: None declared, Faith Mugeta: None declared, Kiara Aaron: None declared, Amy Mudano: None declared, Jeanne Merchant: None declared, Kellie Warren: None declared, Jeff Foster: None declared, Kenneth Saag Grant/research support from: Amgen, Horizon, LG Chem, Radius, SOBI, Maria Danila Grant/research support from: Pfizer, Horizon
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Gaffo AL, Saag K, Doyle AJ, Melnick J, Horne A, Foster J, Mudano A, Biggers-Clark S, Redden D, Dalbeth N. Denosumab did not improve computerized tomography erosion scores when added to intensive urate-lowering therapy in gout: Results from a pilot randomized controlled trial. Semin Arthritis Rheum 2021; 51:1218-1223. [PMID: 34706311 DOI: 10.1016/j.semarthrit.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND/PURPOSE Disordered osteoclast activity has been implicated in the pathogenesis of gouty bone erosion. We sought to determine if the addition of denosumab (a monoclonal antibody targeting the receptor activator of nuclear factor kappa-B ligand - RANKL) to intensive urate-lowering therapy (ULT) improves gouty bone erosion. METHODS Open-label, parallel-group pilot randomized controlled trial in which 20 participants with gout with at least one confirmed conventional radiographic foot bone erosion were assigned in a 1:1 allocation to receive denosumab (60 mg subcutaneous every 6 months) added to intensive ULT (serum urate ≤5 mg/dL or 300 µmol/L at the time of randomization and continued for the duration of the study), or intensive ULT alone. The primary outcome was the change in the bilateral foot and ankle computed tomography (CT) bone erosion score from baseline to 12 months, assessed by an experienced musculoskeletal radiologist blinded to study assignment. Secondary outcomes included change in serum C-terminal telopeptide (CTX), and patient reported outcomes of pain and function. RESULTS Although serum CTX declined markedly in the denosumab/ULT group compared with the ULT alone group, there was no interval change in CT erosion score in either the denosumab/ULT or ULT alone group after one year of follow-up. Other secondary outcomes did not differ between groups. There were two severe adverse events: One patient developed atrial fibrillation (on denosumab/ULT) and another atrial flutter (on ULT alone). CONCLUSIONS In this pilot study, denosumab did not offer additional benefit to intensive urate lowering therapy for gouty bone erosion.
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Affiliation(s)
- Angelo L Gaffo
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA.
| | - Kenneth Saag
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, AL, USA
| | - Anthony J Doyle
- University of Auckland, Auckland, New Zealand; Auckland District Health Board, Auckland, New Zealand
| | - Joshua Melnick
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, AL, USA
| | - Anne Horne
- University of Auckland, Auckland, New Zealand
| | - Jeffrey Foster
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, AL, USA
| | - Amy Mudano
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, AL, USA
| | - Stephanie Biggers-Clark
- Department of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, AL, USA
| | - David Redden
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, AL, USA
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Shaffer A, Rahn E, Saag K, Mudano A, Gaffo A. Variation in serum urate levels in the absence of gout and urate lowering therapy. BMC Rheumatol 2021; 5:32. [PMID: 34493347 PMCID: PMC8425059 DOI: 10.1186/s41927-021-00202-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 05/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous studies have noted significant variation in serum urate (sUA) levels, and it is unknown how this influences the accuracy of hyperuricemia classification based on single data points. Despite this known variability, hyperuricemic patients are often used as a control group in gout studies. Our objective was to determine the accuracy of hyperuricemia classifications based on single data points versus multiple data points given the degree of variability observed with serial measurements of sUA. METHODS Data was analyzed from a cross-over clinical trial of urate-lowering therapy in young adults without a gout diagnosis. In the control phase, sUA levels used for this analysis were collected at 2-4 week intervals. Mean coefficient of variation for sUA was determined, as were rates of conversion between normouricemia (sUA ≤6.8 mg/dL) and hyperuricemia (sUA > 6.8 mg/dL). RESULTS Mean study participant (n = 85) age was 27.8 ± 7.0 years, with 39% female participants and 41% African-American participants. Mean sUA coefficient of variation was 8.5% ± 4.9% (1 to 23%). There was no significant difference in variation between men and women, or between participants initially normouricemic and those who were initially hyperuricemic. Among those initially normouricemic (n = 72), 21% converted to hyperuricemia during at least one subsequent measurement. The subgroup with initial sUA < 6.0 (n = 54) was much less likely to have future values in the range of hyperuricemia compared to the group with screening sUA values between 6.0-6.8 (n = 18) (7% vs 39%, p = 0.0037). Of the participants initially hyperuricemic (n = 13), 46% were later normouricemic during at least one measurement. CONCLUSION Single sUA measurements were unreliable in hyperuricemia classification due to spontaneous variation. Knowing this, if a single measurement must be used in classification, it is worth noting that those with an sUA of < 6.0 mg/dL were less likely to demonstrate future hyperuricemic measurements and this could be considered a safer threshold to rule out intermittent hyperuricemia based on a single measurement point. TRIAL REGISTRATION Data from parent study ClinicalTrials.gov Identifier: NCT02038179 .
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Affiliation(s)
- Andrew Shaffer
- Division of Rheumatology, University of Utah, 30 N 1900 E, SOM4B200, Salt Lake City, UT, 84132, USA
| | - Elizabeth Rahn
- Division of Rheumatology, University of Alabama at Birmingham, SHEL 306 1530 3rd Ave S, Birmingham, AL, 35294, USA
| | - Kenneth Saag
- Division of Rheumatology, University of Alabama at Birmingham, SHEL 306 1530 3rd Ave S, Birmingham, AL, 35294, USA
| | - Amy Mudano
- Division of Rheumatology, University of Alabama at Birmingham, SHEL 306 1530 3rd Ave S, Birmingham, AL, 35294, USA
| | - Angelo Gaffo
- Division of Rheumatology, University of Alabama at Birmingham, SHEL 306 1530 3rd Ave S, Birmingham, AL, 35294, USA.
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Gaffo AL, Calhoun DA, Rahn EJ, Oparil S, Li P, Dudenbostel T, Feig DI, Redden DT, Muntner P, Foster PJ, Biggers-Clark SR, Mudano A, Sattui SE, Saddekni MB, Bridges SL, Saag KG. Effect of Serum Urate Lowering With Allopurinol on Blood Pressure in Young Adults: A Randomized, Controlled, Crossover Trial. Arthritis Rheumatol 2021; 73:1514-1522. [PMID: 33779064 DOI: 10.1002/art.41749] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 03/25/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine whether serum urate reduction with allopurinol lowers blood pressure (BP) in young adults and the mechanisms mediating this hypothesized effect. METHODS We conducted a single-center, randomized, double-blind, crossover clinical trial. Adults ages 18-40 years with baseline systolic BP ≥120 and <160 mm Hg or diastolic BP ≥80 and <100 mm Hg, and serum urate ≥5.0 mg/dl for men or ≥4.0 mg/dl for women were enrolled. Main exclusion criteria included chronic kidney disease, gout, or past use of urate-lowering therapies. Participants received oral allopurinol (300 mg daily) or placebo for 1 month followed by a 2-4 week washout and then were crossed over. Study outcome measures were change in systolic BP from baseline, endothelial function estimated as flow-mediated dilation (FMD), and high-sensitivity C-reactive protein (hsCRP) levels. Adverse events were assessed. RESULTS Ninety-nine participants were randomized, and 82 completed all visits. The mean ± SD age was 28.0 ± 7.0 years, 62.6% were men, and 40.4% were African American. In the primary intent-to-treat analysis, systolic BP did not change during the allopurinol treatment phase (mean ± SEM -1.39 ± 1.16 mm Hg) or placebo treatment phase (-1.06 ± 1.08 mm Hg). FMD increased during allopurinol treatment periods compared to placebo treatment periods (mean ± SEM 2.5 ± 0.55% versus -0.1 ± 0.42%; P < 0.001). There were no changes in hsCRP level and no serious adverse events. CONCLUSION Our findings indicate that urate-lowering therapy with allopurinol does not lower systolic BP or hsCRP level in young adults when compared with placebo, despite improvements in FMD. These findings do not support urate lowering as a treatment for hypertension in young adults.
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Affiliation(s)
- Angelo L Gaffo
- University of Alabama at Birmingham and Birmingham VA Medical Center
| | | | | | | | - Peng Li
- University of Alabama at Birmingham
| | | | | | | | | | | | | | | | - Sebastian E Sattui
- University of Alabama at Birmingham, and Hospital for Special Surgery, New York, New York
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Osborne JD, Booth JS, O'Leary T, Mudano A, Rosas G, Foster PJ, Saag KG, Danila MI. Identification of Gout Flares in Chief Complaint Text Using Natural Language Processing. AMIA Annu Symp Proc 2021; 2020:973-982. [PMID: 33936473 PMCID: PMC8075438] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Many patients with gout flares treated in the Emergency Department (ED) often do not receive optimal continuity of care after an ED visit. Thus, developing methods to identify patients with gout flares in the ED and referring them to appropriate outpatient gout care is required. While Natural Language Processing (NLP) has been used to detect gout flares retrospectively, it is much more challenging to identify patients prospectively during an ED visit where documentation is usually minimal. We annotate a corpus of ED triage nurse chief complaint notes for the presence of gout flares and implement a simple algorithm for gout flare ED alerts. We show that the chief complaint alone has strong predictive power for gout flares. We make available a de-identified version of this corpus annotated for gout mentions, which is to our knowledge the first free text chief complaint clinical corpus available.
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Affiliation(s)
- John D Osborne
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James S Booth
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tobias O'Leary
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Amy Mudano
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Giovanna Rosas
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Kenneth G Saag
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maria I Danila
- University of Alabama at Birmingham, Birmingham, Alabama, USA
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Mrug S, Orihuela C, Rahn E, Mudano A, Foster J, Saag K, Gaffo A. Depressive Symptoms and the Effectiveness of a Urate‐Lowering Therapy in a Clinical Trial. ACR Open Rheumatol 2020; 2:710-714. [PMID: 33216463 PMCID: PMC7738799 DOI: 10.1002/acr2.11192] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/02/2020] [Accepted: 09/30/2020] [Indexed: 11/08/2022] Open
Abstract
Objective Methods Results Conclusion
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Affiliation(s)
| | | | | | | | | | | | - Angelo Gaffo
- University of Alabama at Birmingham and Birmingham VA Medical Center Birmingham Alabama
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12
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Elmagboul N, Coburn BW, Foster J, Mudano A, Melnick J, Bergman D, Yang S, Chen L, Filby C, Mikuls TR, Curtis JR, Saag K. Physical activity measured using wearable activity tracking devices associated with gout flares. Arthritis Res Ther 2020; 22:181. [PMID: 32746893 PMCID: PMC7398057 DOI: 10.1186/s13075-020-02272-2] [Citation(s) in RCA: 11] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 07/20/2020] [Indexed: 02/09/2023] Open
Abstract
Objective To determine the feasibility and validity of using wearable activity trackers to test associations between gout flares with physical activity and sleep. Methods Participants with physician-diagnosed gout, hyperuricemia (≥ 6.8 mg/dl), current smartphone use, and ≥ 2 self-reported flares in the previous 6 months were enrolled. Physical activity, heart rate, and sleep data were obtained from wearable activity trackers (Fitbit Charge HR2). Daily compliance was defined by the availability of sufficiently complete activity data at least 80% of the day. Associations of weekly gout flares with sleep and activity were measured by comparing flare-related values to average sleep and steps per day. We used mixed linear models to account for repeated observations. Results Forty-four participants enrolled; 33 met the criteria for minimal wear time and flare reporting, with activity tracker data available for 60.5% of all total study days. Mean ± SD age was 48.8 ± 14.9 years; 85% were men; 15% were black; 88% were on allopurinol or febuxostat, and 30% reported ≥ 6 flares in the prior 6 months. Activity trackers captured 204 (38%) person-weeks with flares and 340 (62%) person-weeks without flares. Mean ± SD daily step count was significantly lower (p < 0.0001) during weeks with gout flares (5900 ± 4071) than during non-flare periods (6972 ± 5214); sleep however did not differ. Conclusion The pattern of wear in this study illustrates reasonable feasibility of using such devices in future arthritis research. The use of these devices to passively measure changes in physical activity patterns may provide an estimate of gout flare occurrence and duration. Trial registration NCT, NCT02855437. Registered 4 August 2016
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Affiliation(s)
- Nada Elmagboul
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Brian W Coburn
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Jeffrey Foster
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Amy Mudano
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Joshua Melnick
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Debra Bergman
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Shuo Yang
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Lang Chen
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Cooper Filby
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Ted R Mikuls
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Jeffrey R Curtis
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Kenneth Saag
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA.
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Adami G, Jaleel A, Curtis JR, Delzell E, Chen R, Yun H, Daigle S, Arora T, Danila MI, Wright NC, Cadarette SM, Mudano A, Foster J, Saag KG. Temporal Trends and Factors Associated with Bisphosphonate Discontinuation and Restart. J Bone Miner Res 2020; 35:478-487. [PMID: 31714637 PMCID: PMC7401723 DOI: 10.1002/jbmr.3915] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 08/30/2019] [Revised: 10/23/2019] [Accepted: 11/02/2019] [Indexed: 01/29/2023]
Abstract
Adverse events related to long-term use of bisphosphonates have raised interest in temporary drug discontinuation. Trends in bisphosphonate discontinuation and restart, as well factors associated with these decisions, are not fully understood at a population level. We investigated temporal trends of bisphosphonate discontinuation from 2010 to 2015 and identified factors associated with discontinuation and restart of osteoporosis therapy. Our cohort consisted of long-term bisphosphonate users identified from 2010 to 2015 Medicare data. We defined discontinuation as ≥12 months without bisphosphonate prescription claims. We used conditional logistic regression to compare factors associated with alendronate discontinuation or osteoporosis therapy restart in the 120-day period preceding discontinuation or restart referent to the 120-day preceding control periods. Among 73,800 long-term bisphosphonate users, 59,251 (80.3%) used alendronate, 6806 (9.2%) risedronate, and 7743 (10.5%) zoledronic acid, exclusively. Overall, 26,281 (35.6%) discontinued bisphosphonates for at least 12 months. Discontinuation of bisphosphonates increased from 1.7% in 2010, reaching a peak of 14% in 2012 with levels plateauing through 2015. The factors most strongly associated with discontinuation of alendronate were: benzodiazepine prescription (adjusted odds ratio [aOR] = 2.5; 95% confidence interval [CI] 2.1, 3.0), having a dual-energy X-ray absorptiometry (DXA) scan (aOR = 1.8; 95% CI 1.7, 2.0), and skilled nursing facility care utilization (aOR = 1.8; 95% CI 1.6, 2.1). The factors most strongly associated with restart of osteoporosis therapy were: having a DXA scan (aOR = 9.9; 95% CI 7.7, 12.6), sustaining a fragility fracture (aOR = 2.8; 95% CI 1.8, 4.5), and an osteoporosis or osteopenia diagnosis (aOR = 2.5; 95% CI 2.0, 3.1). Our national evaluation of bisphosphonate discontinuation showed that an increasing proportion of patients on long-term bisphosphonate therapy discontinue medications. The factors associated with discontinuation of alendronate were primarily related to worsening of overall health status, whereas traditional factors associated with worsening bone health were associated with restarting osteoporosis medication. © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
- Giovanni Adami
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA.,Rheumatology Unit, University of Verona, Verona, Italy
| | - Ayesha Jaleel
- Health Primary & Specialty Care Network, Baptist Brookwood Hospital, Birmingham, AL, USA
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth Delzell
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rui Chen
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Huifeng Yun
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shanette Daigle
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tarun Arora
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Maria I Danila
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nicole C Wright
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Suzanne M Cadarette
- Division of Pharmacoepidemiology and Pharmacoeconomics, University of Toronto, Toronto, Canada
| | - Amy Mudano
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey Foster
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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Elmagboul N, Coburn BW, Foster J, Mudano A, Melnick J, Bergman D, Yang S, Redden D, Chen L, Filby C, Curtis JR, Mikuls TR, Saag KG. Comparison of an interactive voice response system and smartphone application in the identification of gout flares. Arthritis Res Ther 2019; 21:160. [PMID: 31255174 PMCID: PMC6599289 DOI: 10.1186/s13075-019-1944-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 02/18/2019] [Accepted: 06/14/2019] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To examine the feasibility, preference, and satisfaction of an interactive voice response (IVR) system versus a customized smartphone application (StudyBuddy) to capture gout flares METHODS: In this 24-week prospective, randomized, crossover, open-label pilot study, 44 gout patients were randomized to IVR vs. StudyBuddy and were crossed over to the other technology after 12 weeks. Flares were reported via weekly (and later daily) scheduled StudyBuddy or IVR queries. Feasibility was ascertained via response rate to scheduled queries. At 12 and 24 weeks, participants completed preference/satisfaction surveys. Preference and satisfaction were assessed using dichotomous or ordinal questions. Sensitivity was assessed by the frequency of flare reporting with each approach. RESULTS Thirty-eight of 44 participants completed the study. Among completers, feasibility was similar for IVR (81%) and StudyBuddy (80%). Conversely, most (74%) preferred StudyBuddy. Measures of satisfaction (ease of use, preference over in-person clinic visits, and willingness for future use) were similar between the IVR and StudyBuddy; however, more participants deemed the StudyBuddy as convenient (95% vs. 73%, P = 0.01) and less disruptive (97% vs. 82%, P = 0.03). Although the per patient number of weeks in flare was not significantly different (mean 3.4 vs. 2.6 weeks/patient, P = 0.15), the StudyBuddy captured more of the total flare weeks (35%) than IVR (27%, P = 0.02). CONCLUSION A smartphone application and IVR demonstrated similar feasibility but overall sensitivity to capture gout flares and participant preference were greater for the smartphone application. Participant preference for the smartphone application appeared to relate to perceptions of greater convenience and lower disruption. TRIAL REGISTRATION NCT, NCT02855437 . Registered 4 August 2016.
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Affiliation(s)
- Nada Elmagboul
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Brian W Coburn
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Jeffrey Foster
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Amy Mudano
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Joshua Melnick
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Debra Bergman
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Shuo Yang
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - David Redden
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Lang Chen
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Cooper Filby
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Jeffrey R Curtis
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Ted R Mikuls
- University of Nebraska Medical Center and VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Kenneth G Saag
- University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL, 35294, USA.
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Danila MI, Melnick JA, Mudano A, Flood K, Booth K, Kirklin K, Saag KG. A Performing Arts Intervention Improves Cognitive Dysfunction in 50 Hospitalized Older Adults. Innov Aging 2018; 2:igy013. [PMID: 29938231 PMCID: PMC6004786 DOI: 10.1093/geroni/igy013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Indexed: 12/18/2022] Open
Abstract
Background and Objectives Arts in medicine programs have emerged as a patient-centered approach that aims to improve health-related quality of life for patients in U.S. hospitals. Storytelling and poetry/monologue recitation are forms of arts-based experiences designed to enhance healing and are delivered by an artist-in-residence. We evaluated the effect of a storytelling/poetry experience on delirium screening scores and patient satisfaction in hospitalized older adults. Research Design and Methods:
We conducted an observational pre–post study with a control group in the Acute Care for the Elders (ACE) unit at an academic medical center. A convenience sample of 50 participants was recruited to participate and complete two questionnaires measuring pain, anxiety, general well-being, and distress at hospital admission and at hospital discharge. Multivariable regression models were used to compare delirium screening score (primary outcome) between the control and intervention groups and to adjust for the differences in baseline characteristics between groups. Results At baseline participants in the intervention group were younger and had significantly lower cognitive impairment compared with those in the control group. Participants exposed to the storytelling/poetry intervention had a lower delirium screening score at hospital discharge compared with those in the control group. The result remained significant after adjusting for age, baseline cognitive impairment, and general well-being. Participants in the intervention group reported a high level of satisfaction with the interaction with the artist delivering the intervention. Discussion and Implications An artist in residence-delivered storytelling/poetry experience was associated with a lower delirium score at discharge in this pilot study. Further larger studies in diverse inpatient settings are needed to examine whether storytelling/poetry interventions or other types of arts in medicine programs can prevent or reduce delirium in hospitalized older adults.
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Affiliation(s)
- Maria I Danila
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham
| | - Joshua A Melnick
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham
| | - Amy Mudano
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham
| | - Kellie Flood
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | - Katrina Booth
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | | | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham
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Kilgore ML, Outman R, Locher JL, Allison JJ, Mudano A, Kitchin B, Saag KG, Curtis JR. Multimodal intervention to improve osteoporosis care in home health settings: results from a cluster randomized trial. Osteoporos Int 2013; 24:2555-60. [PMID: 23536256 PMCID: PMC4089895 DOI: 10.1007/s00198-013-2340-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 07/23/2012] [Accepted: 03/04/2013] [Indexed: 11/30/2022]
Abstract
SUMMARY We conducted a cluster randomized trial testing the effectiveness of an intervention to increase the use of osteoporosis medications in high-risk patients receiving home health care. The trial did not find a significant difference in medication use in the intervention arm. INTRODUCTION This study aims to test an evidence implementation intervention to improve the quality of care in the home health care setting for patients at high risk for fractures. METHODS We conducted a cluster randomized trial of a multimodal intervention targeted at home care for high-risk patients (prior fracture or physician-diagnosed osteoporosis) receiving care in a statewide home health agency in Alabama. Offices throughout the state were randomized to receive the intervention or to usual care. The primary outcome was the proportion of high-risk home health patients treated with osteoporosis medications. A t test of difference in proportions was conducted between intervention and control arms and constituted the primary analysis. Secondary analyses included logistic regression estimating the effect of individual patients being treated in an intervention arm office on the likelihood of a patient receiving osteoporosis medications. A follow-on analysis examined the effect of an automated alert built into the electronic medical record that prompted the home health care nurses to deploy the intervention for high-risk patients using a pre-post design. RESULTS There were 11 offices randomized to each of the treatment and control arms; these offices treated 337 and 330 eligible patients, respectively. Among the offices in the intervention arm, the average proportion of eligible patients receiving osteoporosis medications post-intervention was 19.1 %, compared with 15.7 % in the usual care arm (difference in proportions 3.4 %, 95 % CI, -2.6 to 9.5 %). The overall rates of osteoporosis medication use increased from 14.8 % prior to activation of the automated alert to 17.6 % afterward, a nonsignificant difference. CONCLUSIONS The home health intervention did not result in a significant improvement in use of osteoporosis medications in high-risk patients.
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Affiliation(s)
- Meredith L. Kilgore
- University of Alabama at Birmingham (UAB), Department of Health Care Organization & Policy, 1665 University Blvd, RPHB 330, Birmingham, AL
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Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, Paulus HE, Mudano A, Pisu M, Elkins-Melton M, Outman R, Allison JJ, Suarez Almazor M, Bridges SL, Chatham WW, Hochberg M, MacLean C, Mikuls T, Moreland LW, O'Dell J, Turkiewicz AM, Furst DE. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008. [PMID: 18512708 DOI: 10.1002/art.2372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, Paulus HE, Mudano A, Pisu M, Elkins-Melton M, Outman R, Allison JJ, Suarez Almazor M, Bridges SL, Chatham WW, Hochberg M, MacLean C, Mikuls T, Moreland LW, O'Dell J, Turkiewicz AM, Furst DE. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. ACTA ACUST UNITED AC 2008; 59:762-84. [PMID: 18512708 DOI: 10.1002/art.23721] [Citation(s) in RCA: 987] [Impact Index Per Article: 61.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kovac SH, Mikuls TR, Mudano A, Saag KG. Health-related quality of life among self-reported arthritis sufferers: effects of race/ethnicity and residence. Qual Life Res 2006; 15:451-60. [PMID: 16547784 DOI: 10.1007/s11136-005-3213-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [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: 11/24/2004] [Accepted: 09/17/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We evaluated differences in health-related quality of life (HRQoL) for African Americans and Caucasians with self-reported arthritis residing in rural and urban areas of a southern state. METHODS 1,191 individuals completed a telephone survey, which included the 12-Item Short Form Health Survey (SF-12). Participants were stratified into groups: African American/rural, Caucasian/rural, African American/urban, and Caucasian/urban. We evaluated differences and associations in HRQoL for the four groups. RESULTS Multivariable linear regression models revealed that being an African American rural resident was associated with worse self-reported mental health on the SF-12 even after adjusting for multiple confounding variables. In contrast, multivariable linear regression models revealed that being a Caucasian rural resident was associated with worse physical health SF-12 scores. CONCLUSIONS The study revealed differences in HRQoL on the mental and physical health functioning scales of the SF-12 for African American rural and Caucasian rural residents. Researchers assessing HRQoL in arthritis patients should consider using a race/residence product term in their analyses.
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Affiliation(s)
- Stacey H Kovac
- Center for Health Services Research in Primary Care, Durham VA Medical Center, 508 Fulton Street (152), Durham, NC 27705, USA.
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Patino FG, Allison J, Olivieri J, Mudano A, Juarez L, Person S, Mikuls TR, Moreland L, Kovac SH, Saag KG. The effects of physician specialty and patient comorbidities on the use and discontinuation of coxibs. Arthritis Rheum 2003; 49:293-9. [PMID: 12794782 DOI: 10.1002/art.11117] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine the effects of physician specialty and comorbidities on cyclooxygenase 2-selective nonsteroidal antiinflammatory drugs (NSAIDs; coxibs) utilization. METHODS Medical records of 452 patients from a regional managed care organization with >/=3 consecutive NSAID prescriptions from June 1998 to April 2001 were abstracted. Multivariable adjusted associations between coxib initiation and discontinuation and patient and provider characteristics were examined. RESULTS A total of 1,142 NSAID prescriptions were written over 9,398 total patient-months of followup. Compared with patients seeing family or general practitioners, patients seeing rheumatologists (odds ratio [OR] 3.4, 95% confidence interval [95% CI] 2.1-5.7) and internists (OR 2.3, 95% CI 1.5-3.6) were significantly more likely to receive a coxib, as well as patients with a history of osteoarthritis (OR 2.6, 95% CI 1.7-3.8), gastrointestinal disease (OR 2.3, 95% CI 1.2-4.5), and congestive heart failure (OR 4.1, 95% CI 1.0-16.4). Although specialists were more likely than generalists to prescribe coxibs, only family or general practitioners were significantly more likely to selectively use coxibs among their patients with a history of gastrointestinal disease. Fifty-four percent of NSAID prescriptions were discontinued, and coxibs were significantly less likely to be discontinued than were traditional NSAIDs (OR 0.6, 95% CI 0.5-0.8). CONCLUSION Our findings suggest significantly greater, but perhaps less selective use of coxibs among specialists, even after accounting for important covariates. The initiation and discontinuation of coxibs was influenced by physician specialty and by patient risk factors.
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Affiliation(s)
- Fausto G Patino
- Center for Education and Research on Therapeutics of Musculoskeletal Disorders, University of Alabama at Birmingham, 35294-3408, USA.
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Mudano A, Allison J, Hill J, Rothermel T, Saag K. Variations in glucocorticoid induced osteoporosis prevention in a managed care cohort. J Rheumatol 2001; 28:1298-305. [PMID: 11409123] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
OBJECTIVE To characterize glucocorticoid use and patterns of osteoporosis prevention therapies among a large US national cohort. METHODS Health maintenance organization (HMO) members who were receiving chronic glucocorticoid therapy (> 90 day supply) within a 3 year observation period were identified along with their prescribing physicians. Receipt of anti-osteoporotic prescription therapies and bone mass measurement was determined. Multivariable analyses were used to define significant predictors of these preventive interventions. RESULTS We identified 2378 HMO members who filled prescriptions for at least a 90 day supply of glucocorticoids, but had not filled a glucocorticoid prescription in the prior 90 days. In women over age 50, use of anti-osteoporotic therapies and bone mass measurement was 41% and 16%, respectively. Glucocorticoid-prescribing physicians were identified for 878 (37%) of these glucocorticoid users, and internal medicine specialists (39%) and rheumatologists (20%) wrote the majority of the prescriptions for glucocorticoids. Women age 50 and over were most likely to receive a prescription anti-osteoporotic preventive therapy (OR 4.0; 95% CI 1.5-10.8). Patients with a rheumatologist prescribing their glucocorticoids were more likely than those of internists to have a bone mass measurement (OR 2.2; 95% CI 1.3-3.6) and receive bisphosphonates (OR 1.9; 95% CI 1.1-3.1), but were not more likely to receive preventive treatment overall. CONCLUSION Although better than in several prior studies, we identified low levels of selected preventive care measures for chronic glucocorticoid users in a large population based cohort. Significant demographic and practice pattern variation suggests opportunities for targeted preventive interventions.
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Affiliation(s)
- A Mudano
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Alabama at Birmingham, 625 MEB, 1813 Sixth Ave. South, Birmingham, AL 35213, USA
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Merlino LA, Bagchi I, Taylor TN, Utrie P, Chrischilles E, Sumner W, Mudano A, Saag KG. Preference for fractures and other glucocorticoid-associated adverse effects among rheumatoid arthritis patients. Med Decis Making 2001; 21:122-32. [PMID: 11310945 DOI: 10.1177/0272989x0102100205] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this study was to determine rheumatoid arthritis (RA) patients' preferences for validated health state scenarios depicting glucocorticoid adverse events, predictors of these preferences, and psychometric properties of different preference techniques in this population. METHODS Preferences were elicited by rating scale and time trade-off methods. Time trade-offs included trading current health for either time spent alive in an adverse health state for chronic conditions (time trade-off) or time spent in a sleeplike state for acute conditions (sleep trade-off). RESULTS A total of 107 subjects with long-standing RA participated in the preference interviews. Mean preference values (rating scale/trade-off) were lowest for serious fracture adverse events, including hip fracture requiring a nursing home stay (0.55+/-0.22/0.76+/-0.36) and vertebral fracture with chronic pain (0.59+/-0.23/0.67+/-0.35), and highest for cataracts (0.84 + 0.17/0.96 0.09) and wrist fracture (0.82+/-0.18/0.81+/-0.29). Rating scales had a stronger correlation (r= 0.88) with physician ranking of scenarios than trade-off methods (r = 0.31). All methods were feasible and demonstrated good reliability, while rating scale method showed better construct validity than trade-off techniques. CONCLUSION Relative to their current health, RA patients assigned low preference values to many glucocorticoid adverse events, particularly those associated with chronic fracture outcomes. Results varied with the preference measure used, indicating that methodological attributes of preference determinations must be considered in clinical decision making.
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Affiliation(s)
- L A Merlino
- Department of Internal Medicine, University of Iowa, Iowa City, USA
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