Use of protocol-driven medication refills by pharmacists decreases rheumatologist in-basket work and improves rheumatologist satisfaction.

Burn-out among US physicians has been on the rise in the past few decades. Similarly, rheumatologists in the Geisinger Health System have experienced professional dissatisfaction through significant administrative burden and in-basket work. We embedded pharmacists into our rheumatology team in 2019 with the aim of reallocating medication refills to pharmacists, trained professionals in this domain, to help reduce physician workload and burn-out and increase satisfaction. Protocol-driven medication refill parameters per the American College of Rheumatology guidelines and new refill workflows for disease-modifying antirheumatic drugs (DMARDs) and non-DMARDs were created for use by our rheumatology pharmacists. Monthly data on medication refill volume and time saved for rheumatologists were collected from 1 January 2019 to 31 March 2021. Statistical analysis was completed via Shewhart p-charts. The volume of refills by rheumatologists decreased by 73% and the time saved per month for all the rheumatologists increased to 41.5 hours within 6 months. Physicians' feedback was obtained via anonymous electronic surveys preintervention and postintervention. The statistical difference between the presurveys and postsurveys was calculated via two-tailed unpaired t-testing. It demonstrated reduced burn-out and improved workplace satisfaction. This study showed that the integration of rheumatology pharmacists into our practice can help improve the work life of the rheumatologists. It is important for physicians' well-being to practice at the top of their scope and achieve work-life balance.

Hydroxychloroquine Use Is Associated With Decreased Incident Cardiovascular Events in Rheumatoid Arthritis Patients.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in rheumatoid arthritis (RA) patients. This study is the first to report the association of hydroxychloroquine (an antirheumatic medication that has been associated with decreased risk of diabetes, a less atherogenic lipid profile, and antithrombotic properties) with CVD in RA. METHODS AND RESULTS: A retrospective incident RA cohort from January 1, 2001, to October 31, 2013, excluding patients with CVD prior to RA diagnosis, was constructed. Patients were categorized as hydroxychloroquine users versus nonusers and were allowed to contribute time to either group according to hydroxychloroquine exposure. The primary outcome was adjudicated incident CVD defined as a composite of coronary artery disease, stroke, transient ischemic attack, sudden cardiac death, and peripheral artery disease with arterial revascularization procedure. The secondary outcome was a composite of incident coronary artery disease, stroke, and transient ischemic attack. Cox time-varying regression models were used to estimate the association between hydroxychloroquine exposure and development of CVD, after adjusting for propensity score and relevant confounders, including demographics, CVD-related comorbidities, RA severity, and activity indicators and medications. We included 1266 RA patients, 547 hydroxychloroquine users, and 719 nonusers. During the observation period, 102 CVD events occurred, 3 in hydroxychloroquine users and 99 in nonusers. The fully adjusted Cox model showed a hazard ratio of 0.28 (95% CI 0.12-0.63, P=0.002) for incident CVD and 0.30 (95% CI 0.13-0.68, P=0.004) for incident composite coronary artery disease, stroke, and transient ischemic attack for hydroxychloroquine users versus nonusers, respectively. CONCLUSION: In this hypothesis-generating study, hydroxychloroquine use was associated with a 72% decrease in the risk of incident CVD in RA patients. If these preliminary results are confirmed in larger studies, our findings may be used as a rationale for a randomized study of hydroxychloroquine use for primary prevention of CVD in RA or nonrheumatic high-risk patients.

Low vitamin D level is not associated with increased incidence of rheumatoid arthritis.

To evaluate the association of vitamin D level with incident rheumatoid arthritis (RA) in a patient population using electronic health records (EHR). Case-control study with data extracted from EHR from 1/1/2001 to 12/31/2012 in the Geisinger Health System (GHS). Incident RA was defined as International Classification of Disease-9 code 714.0 twice by a GHS rheumatologist. Patients were identified at time of RA diagnoses and were matched 1:5 for age and gender with non-RA controls. Vitamin D levels were identified and extracted prior to RA diagnosis. The subjects were followed retrospectively with regard to their vitamin D levels; the most recent value of vitamin D prior to the RA diagnosis was used in the analysis. Vitamin D levels were treated both as continuous and categorical with two different cutoff values, 30 and 20 ng/ml. The association between vitamin D and RA was presented as the odds ratios with 95 % confidence intervals (OR, 95 % CI) from a conditional logistic regression model adjusting for obesity and smoking status. A total of 270 patients with incident RA and 1,341 matched controls were identified. The RA patients were 83.3 % female with median age at RA diagnosis of 62 years. The adjusted OR (95 % CI) for the association of vitamin D levels with incident RA compared with controls was 1.00 (0.99, 1.01), 0.98 (0.75, 1.29) and 1.12 (0.80, 1.57) for continuous, <30 and <20 ng/ml vitamin D levels, respectively. Subgroup analysis according to gender or rheumatoid factor positivity yielded similar results. In this patient population, vitamin D levels were not associated with the development of RA.

Aspirin use in rheumatoid arthritis patients with increased risk of cardiovascular disease.

Objectives. To examine the patterns of low-dose aspirin use in rheumatoid arthritis (RA) patients with high risk for coronary artery disease (CAD). Methods. Cross-sectional study of 36 consecutive RA patients with a Framingham score ≥10% for CAD. Eligible RA patients were provided with a questionnaire on CAD risk factors and use of low-dose aspirin. For aspirin nonusers, the reason for nonuse was requested by both the patient and rheumatologist. Questions for patients included physician's advice, self-preference, history of gastrointestinal bleeding, allergy to aspirin, or concomitant use of other anti-inflammatory medications. Questions for rheumatologists included awareness of the increased CAD risk, attribution, patient preference, history of gastrointestinal bleeding, allergy to aspirin, and medication interactions. Results. Patients participated in the study; 8 patients reported using daily aspirin, while 23 patients did not. The main reason cited by patients for not taking aspirin was that they were not instructed by their primary care physician (PCP) to do so (n = 16), which was also the main reason cited by rheumatologists (n = 9). Conclusion. This study confirmed underutilization of aspirin in RA patients at high risk for CAD, largely due to the perception that this is an issue which should be handled by the PCP.

Pseudoseptic arthritis: a case series and review of the literature.

Purpose. Pseudoseptic arthritis is an acute inflammatory monoarthritis with a sterile synovial gram stain and culture. Pseudoseptic arthritis has been previously described in the literature in a variety of settings including rheumatoid arthritis and microcrystalline disease. Despite pseudoseptic arthritis being a described entity, there is little published data on this topic with no published reports since 1992. Methods. This paper was a retrospective chart review over a 20-year period that identified all rheumatology inpatient consultations at our tertiary rural hospital for pseudoseptic arthritis. Results. We identified 10 patients with pseudoseptic arthritis and presented 5 of those cases in this paper. Majority of these patients had known autoimmune inflammatory arthritis or microcrystalline inflammatory arthritis. Conclusion. Pseudoseptic arthritis is a syndrome that should be in the differential diagnosis with patients with long standing inflammatory condition who present with an acute monoarthritis with no known bacterial source for septic arthritis.